Phase II Study of Combination of Trametinib (MEK Inhibitor) and Hydroxychloroquine (HCQ) (Autophagy Inhibitor) in Patients With KRAS Mutation Refractory Bile Tract Carcinoma (BTC).
Phase: PHASE2
Conditions: Bile Duct Cancer, Biliary Cancer, Biliary Tract Neoplasms, Cholangiocarcinoma
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: Trametinib and HCQ in BTC
Version Date: 04/06/2022
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Abbreviated Title: Trametinib and HCQ in BTC
NIH Protocol: 20C0152
Version Date: 04/06/2022
NCT # NCT04566133 
Title: Phase II Study of combination of Trametinib (MEK inhibitor) and Hydroxychloroquine 
(HCQ) (autophagy inhibitor) in patients with KRAS mutation refractory bile tract carcinoma 
(BTC)
NCI Principal Investigator: 
Tim Greten, MD 
Thoracic & GI Malignancies Branch (TGIB)
National Cancer Institute (NCI)
Building 10, Room 2B38B
9000 Rockville Pike
Bethesda, MD 20892
240-760-6114
gretentf@mail.nih.gov
Investigational Device:
Device Name:
TruSight™ Oncology 500
IDE Number:
Non-significant risk (NSR) device
Sponsor:
CCR/NCI
Manufacturer:
Illumina
Commercial Agents: Hydroxychloroquine (generic), Trametinib (Novartis)

Abbreviated Title: Trametinib and HCQ in BTC
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PRÉCIS
Background:

Among the new cases of bile tract carcinoma (BTC) that are diagnosed every year in the 
United States, there are approximately 6,500 cases of gallbladder carcinoma, 3,000 cases 
of extrahepatic cholangiocarcinoma, and 3,000 cases of intrahepatic cholangiocarcinoma.

Current treatment options for patients with cholangiocarcinoma are limited and take no 
account of the known biological and genetic heterogeneity in these diseases. Median 
survival for advanced disease remains poor at approximately 1 year. 

Activating KRAS mutations are frequently detected in all subtypes of BTC and can be 
found in up to 40% of BTC, predominantly in perihilar and distal cholangiocarcinoma 
(CCA). However, pharmacological inhibition of mutated KRAS has demonstrated little 
clinical benefit in general.

Trametinib is a reversible, highly selective allosteric inhibitor of mitogen-activated 
extracellular signal regulated kinases MEK1 and MEK2. Tumor cells with KRAS 
mutations commonly have hyperactivated extracellular signal-related kinase (ERK) 
pathways in which activated MEK is a critical component. However, tumors are able to 
overcome MEK signaling inhibition by trametinib through upregulation of autophagy 
pathway.

Hydroxychloroquine (HCQ) inhibits lysosomal acidification and prevents the degradation 
of autophagosomes, to suppress autophagy.

Trametinib has been approved by FDA for the treatment of melanoma as a single agent or 
for the treatment of other cancers if tumors carry BRAF mutation. Hydroxychloroquine are 
approved for the treatment of malaria, lupus erythematosus and acute or chronic 
rheumatoid arthritis.

Preclinical studies have shown that combined treatment of trametinib plus HCQ elicited 
striking tumor regression in animal model. 
Objective:

To determine whether the 5-month progression free survival (PFS) of the trametinib plus 
hydroxychloroquine (HCQ) combination in subjects with refractory bile tract carcinoma 
(BTC) with KRAS mutation exceeds 25%.
Eligibility:

Histopathological confirmation of BTC or carcinoma highly suggestive of a diagnosis of 
BTC 

Tumor must have KRAS mutation.

Patients must have disease that is not amenable to potentially curative resection, 
transplantation or ablation. 

Age 18 years

Patients must have measurable lesion by RECIST 1.1. 

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
At least two weeks washout period from previous therapy

ECOG  2 

Adequate renal, hepatic and bone marrow function
Design:

The study is open-labeled phase 2 study. It is designed to enroll total 30 patients with 
refractory BTC, to test the hypothesis that treatment with a combination of HCQ and 
trametinib prevents cancer progression/recurrence. We propose that this combination will 
have relative safety profile and antitumor efficacy in BTC patients with KRAS mutation.

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TABLE OF CONTENTS
PRÉCIS...........................................................................................................................................2
TABLE OF CONTENTS ................................................................................................................4
STATEMENT OF COMPLIANCE ................................................................................................9
1
INTRODUCTION ...................................................................................................................9
1.1
Study Objectives..............................................................................................................9
1.1.1
Primary Objective:.......................................................................................................9
1.1.2
Secondary Objectives: .................................................................................................9
1.1.3
Exploratory Objectives:...............................................................................................9
1.2
Background and Rationale.............................................................................................10
1.2.1
Bile tract carcinoma and KRAS mutation .................................................................10
1.2.2
Challenge of targeting mutant KRAS........................................................................10
1.2.3
Autophagy..................................................................................................................11
1.2.4
Rationale for combining inhibitors of MEK and Autophagy ....................................13
1.2.5
Trametinib..................................................................................................................14
1.2.6
Hydroxychloroquine..................................................................................................18
1.2.7
Drug dose rationale....................................................................................................20
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT .......................................................20
2.1
Eligibility Criteria..........................................................................................................20
2.1.1
Inclusion Criteria .......................................................................................................20
2.1.2
Exclusion Criteria ......................................................................................................22
2.1.3
Recruitment Strategies...............................................................................................23
2.2
Screening Evaluation.....................................................................................................23
2.2.1
Screening activities performed prior to obtaining informed consent ........................23
2.2.2
Screening activities performed after a consent for screening has been signed..........24
2.3
Participant Registration and Status Update Procedures.................................................25
2.3.1
Screen Failures...........................................................................................................25
2.3.2
Treatment Assignment Procedures (for registration purposes only):........................25
2.4
Baseline Evaluation .......................................................................................................25
3
STUDY IMPLEMENTATION .............................................................................................26
3.1
Study Design..................................................................................................................26
3.1.1
Dose Limiting Toxicity (DLT) (Safety Run-In only)................................................27
3.1.2
Safety Run-In:............................................................................................................28
3.2
Drug Administration......................................................................................................29
3.2.1
Trametinib..................................................................................................................29

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3.2.2
Hydroxychloroquine (HCQ)......................................................................................29
3.3
Dose Modifications/Delay.............................................................................................29
3.3.1
Dose reduction...........................................................................................................29
3.3.2
Hydroxychloroquine..................................................................................................30
3.3.3
Trametinib..................................................................................................................32
3.4
Study Calendar...............................................................................................................35
3.5
Costs and Compensation................................................................................................38
3.5.1
Costs ..........................................................................................................................38
3.5.2
Compensation ............................................................................................................38
3.5.3
Reimbursement..........................................................................................................38
3.6
Criteria for Removal from Protocol Therapy ................................................................38
3.6.1
Criteria for Removal from Protocol Therapy ............................................................38
3.6.2
Off Study Criteria ......................................................................................................38
3.6.3
Lost to Follow-up ......................................................................................................39
4
CONCOMITANT MEDICATIONS/MEASURES...............................................................39
4.1
Prohibited Therapy ........................................................................................................39
5
CORRELATIVE STUDIES FOR RESEARCH ...................................................................39
5.1
Biospecimen Collection.................................................................................................39
5.1.1
Correlative studies of blood samples.........................................................................41
5.1.2
Tumor studies (non-genetic analysis)........................................................................41
5.2
Samples for Genetic/Genomic Analysis........................................................................41
5.2.1
KRAS evaluation.......................................................................................................41
5.2.2
RNA Nanostring analysis ..........................................................................................41
5.2.3
Whole exome/Panel (tumor/normal) and RNAseq (tumor).......................................42
5.2.4
Management of Results .............................................................................................42
5.3
Sample Storage, Tracking and Disposition ...................................................................42
5.3.1
Samples Managed by Dr. Figg’s Blood Processing Core (BPC) ..............................43
5.3.2
Protocol Completion/Sample Destruction .................................................................43
6
DATA COLLECTION AND EVALUATION .....................................................................43
6.1
Data Collection ..............................................................................................................43
6.2
Data Sharing Plan ..........................................................................................................44
6.2.1
Human Data Sharing Plan .........................................................................................44
6.2.2
Genomic Data Sharing Plan.......................................................................................44
6.3
Response Criteria...........................................................................................................44

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6.3.1
Disease Parameters ....................................................................................................44
6.3.2
Methods for Evaluation of Measurable Disease........................................................45
6.3.3
Response Criteria.......................................................................................................46
6.4 Toxicity Criteria.......................................................................................................................49
7
NIH REPORTING REQUIREMENTS / DATA SAFETY MONITORING PLAN ............49
7.1
Definitions .....................................................................................................................49
7.2
OHSRP Office of Compliance and Training/IRB Reporting ........................................49
7.2.1
Expedited Reporting ..................................................................................................49
7.2.2
NIH Intramural IRB Requirements for PI Reporting at Continuing Review ............49
7.2.3
NCI Clinical Director Reporting ...............................................................................49
7.3
NIH Required Data and Safety Monitoring Plan...........................................................49
8
SPONSOR PROTOCOL/SAFETY REPORTING................................................................50
8.1
Definitions .....................................................................................................................50
8.1.1
Unanticipated Adverse Device Effect .......................................................................50
8.2
Assessment of Adverse Device Effects .........................................................................50
8.3
Reporting of Unanticipated Adverse Device Effects.....................................................50
8.4
Safety Reporting Criteria to the Pharmaceutical Collaborators ....................................50
8.5
Sponsor Protocol Deviation Reporting..........................................................................51
9
CLINICAL MONITORING..................................................................................................51
10
STATISTICAL CONSIDERATIONS ..................................................................................52
10.1
Statistical hypothesis .....................................................................................................52
10.1.1
Primary Objective..................................................................................................52
10.1.2
Secondary Objectives ............................................................................................52
10.2
Sample Size Determination ...........................................................................................52
10.3
Population for Analysis .................................................................................................53
10.4
Statistical analysis..........................................................................................................53
10.4.1
General approach...................................................................................................53
10.4.2
Analysis of the Primary Endpoints........................................................................53
10.4.3
Analysis of the Secondary Endpoint......................................................................53
10.4.4
Safety analysis .......................................................................................................54
10.4.5
Baseline Descriptive Statistics...............................................................................54
10.4.6
Planned Interim Analyses......................................................................................54
10.4.7
Sub-group analyses................................................................................................54
10.4.8
Tabulations of individual participant data .............................................................54

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10.4.9
Exploratory Analyses.............................................................................................54
11
COLLABORATIVE AGREEMENTS..................................................................................54
11.1
Cooperative Research and Development Agreement (CRADA) ..................................54
12
HUMAN SUBJECTS PROTECTIONS................................................................................55
12.1
Rationale for Subject Selection .....................................................................................55
12.2
Participation of Children................................................................................................55
12.3
Participation of Subjects Unable to Give Consent ........................................................55
12.4
Risk/Benefit Assessment for All Participants................................................................55
12.4.1
Known Potential Risks ..........................................................................................55
12.4.2
Known Potential Benefits......................................................................................57
12.4.3
Assessment of Potential Risks and Benefits..........................................................57
12.5
Consent Process and Documentation.............................................................................57
12.5.1
Consent Process for Adults Who Lack Capacity to Consent to Research 
Participation...........................................................................................................................58
13
REGULATORY AND OPERATIONAL CONSIDERATIONS..........................................58
13.1
Study Discontinuation and Closure ...............................................................................58
13.2
Quality Assurance and Quality Control.........................................................................58
13.3
Conflict of Interest Policy..............................................................................................59
13.4
Confidentiality and Privacy ...........................................................................................59
14
PHARMACEUTICAL INFORMATION .............................................................................60
14.1
Trametinib......................................................................................................................60
14.1.1
Source ....................................................................................................................60
14.1.2
Acquisition and Accountability .............................................................................60
14.1.3
Formulation, Appearance, Packaging, and Labeling.............................................60
14.1.4
Product Storage and Stability ................................................................................60
14.1.5
Preparation.............................................................................................................60
14.2
HYDROXYCHLOROQUINE (generic).......................................................................60
14.2.1
Source ....................................................................................................................60
14.2.2
Acquisition and Accountability .............................................................................60
14.2.3
Formulation, Appearance, Packaging, and Labeling.............................................60
14.2.4
Product Storage and Stability ................................................................................61
14.2.5
Preparation.............................................................................................................61
14.3
TruSight™ Oncology 500 panel....................................................................................61
15
REFERENCES ......................................................................................................................62
16
APPENDICES .......................................................................................................................65

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16.1
Appendix A - Performance Status Criteria....................................................................65
16.2
Appendix B Child-Pugh Classification System.............................................................66
16.3
Appendix C - Patient’s Medication Diary .....................................................................67
16.4
Appendix D: Modified immune-related response criteria (irRC)..................................69

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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval. Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled. Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study. In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.
1
INTRODUCTION
1.1
Study Objectives
1.1.1
Primary Objective:

To determine whether the 5-month PFS of the trametinib plus hydroxychloroquine (HCQ) 
combination in subjects with refractory bile tract carcinoma (BTC) with KRAS mutation 
exceeds 25%.
1.1.2
Secondary Objectives:

To determine the safety, tolerability and feasibility of the trametinib plus HCQ combination 
in subjects with refractory BTC with KRAS mutation. 

To evaluate the response rate (RR) (CR+PR) in patients with refractory BTC with KRAS 
mutation treated with the combination of trametinib plus HCQ 

To access overall survival (OS). 
1.1.3
Exploratory Objectives:

To evaluate the bioactivity of the combination of trametinib plus HCQ against the MEK1/2 
and autophagy pathways.

To measure changes in immune parameters in the peripheral blood and tumors of patients 
with refractory KRAS mutation BTC treated with the combination of trametinib plus HCQ. 

To explore mechanism of primary and secondary resistance to the combination of 
trametinib plus HCQ in patients with refractory KRAS mutation BTC.

To evaluate the relationship between the RR, OS and immune parameters, in patients with 
refractory KRAS mutation BTC treated with the combination of trametinib plus HCQ.

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1.2
Background and Rationale
1.2.1
Bile tract carcinoma and KRAS mutation
BTC is a hepatobiliary malignancy and incidence has been steadily increasing [1]. Among the new 
cases of BTC that are diagnosed every year in the United States, there are approximately 6,500 
cases of gallbladder carcinoma, 3,000 cases of extrahepatic cholangiocarcinoma, and 3,000 cases 
of intrahepatic cholangiocarcinoma[2]. Surgical resection is the only curative approach for patients 
with local disease, however, the majority of patients present with advanced unresectable disease 
limiting the success of curative surgery [3-5]. The combination of gemcitabine and cisplatin 
chemotherapy has become the standard first-line treatment regimen for advanced BTC with a 
median survival of 9 months [6, 7]. For patients who progress on first-line therapy, there is no 
standard second-line option [8]. RAS genes include HRAS, KRAS, and NRAS. The 
three RAS genes encode four 188–189 amino acid proteins that share 82%–90% amino acid 
sequence identity and share near-identical structural and biochemical properties[9]. However, they 
are differentially expressed and mutated with different frequencies in cancer[10, 11]. KRAS is the 
predominant mutated RAS gene in cancers (84% of all RAS missense mutations), followed by 
NRAS (12%), with HRAS rarely mutated (4%) (COSMIC v80)[9]. Activating KRAS mutations 
are frequently detected in all subtypes of BTC and can be found in up to 40% of BTC [12, 
13]. Notably, the incidence of KRAS mutations increases with disease stage[14]. KRAS has been 
associated with perineural invasion and poor prognosis [15]. 
Newly developed targeted therapies have shown promising clinical efficacy against chemotherapy 
refractory CCA. In a phase II study of patients with FGFR-altered advanced biliary tract cancer, a 
selective pan-FGFR kinase inhibitor showed impressive anti-tumor activity and a disease-control 
rate (DCR) of 82% [16]. Additionally, in a phase I study of patients with IDH1-positive CCA, 
which represents approximately 25% of all CCA cases, IDH1 inhibitor, ivosidenib exhibited a 
well-tolerated safety profile with an overall response rate (ORR) of 5% and an OS of 13.8 months 
[17]. Unfortunately, these promising targeted therapies only apply to a relatively small percentage 
of CCA patients with specific mutations. 
Within the last decade, immunotherapy has become a major pillar of cancer therapy. Immune 
checkpoint inhibitors (ICIs) act by targeting dysregulated immune checkpoints such as 
programmed death protein 1 (PD-1) and programmed death ligand 1 (PD-L1), which are present 
in many types of cancers. Accumulating data suggest encouraging results with ICIs alone in 
hepatocellular carcinoma (HCC), with response rates as high as 15-20% [18, 19]. However, there 
is minimal efficacy of ICIs in the treatment of CCA [20, 21]. In our recent study of advanced BTCs 
that were treated with a combination of an ICI and microwave ablation, the ORR was 12.5% [22]. 
Novel strategies to combat CCA progression are thus urgently needed.
1.2.2
Challenge of targeting mutant KRAS 
Despite the recognized frequency and significance of KRAS mutations, targeting this pathway 
remains challenging and a clinically effective anti-RAS therapy remains elusive. The main current 
strategies for developing therapeutics to block mutant KRAS function have focused on indirect 
approaches: to target proteins that support KRAS function and promote KRAS-driven cancer 
growth, including inhibition of activated downstream signaling molecules such as MEK, AKT or 
mTOR [23]. Early evidence of efficacy of MEK inhibitor (MEKi) was reported in a single arm 
study of selumetinib in advanced bile duct cancer[24]. Of the 28 patients enrolled, 3 patients had 
confirmed partial responses. In this study, no BRAF V600E mutations were found. Recently, the 

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ABC-04 study of selumetinib in combination with gemcitabine and cisplatin in advanced or 
metastatic bile duct cancer (9/13 CCA) demonstrated a RR of 37.5%, a median PFS of 6.4 months 
and manageable toxicities [25]. 
However, it is likely that KRAS drives tumorigenesis by the integrated result of multiple effector 
signaling pathways, with multiple KRAS effector pathways contributing to the tumor etiology, 
that likely contributes to treatment resistance to MEKi. Given the intense crosstalk between the 
signaling pathways downstream of KRAS and possible resistance mechanisms, combination of 
inhibitors targeting different redundant signaling pathways seems to be the most promising 
strategy. Co-targeting with a MEKi and the multi-kinase inhibitor ponatinib for example has 
shown promising effects in pancreatic cancer cells and in-vivo models[26]. Further trials targeting 
the KRAS signaling pathway with MEKi combined with other therapeutics are ongoing 
(NCT02042443; NCT01438554). The other interesting target strategy to be combined with MEKi 
is to interfere autophagy process.
In this protocol for confirmation of KRAS mutations we plan to use TruSight™ Oncology 500 
panel assay performed by NCI Laboratory of Pathology or use results of tests approved by FDA 
to evaluate KRAS mutation status. There is a list of next generation sequencing-based in-vitro 
diagnostic tests developed and approved by FDA for tumor genetic profiling (see Study Instrument 
submitted with this amendment), including KRAS mutation, which is one of most commonly 
detected mutations in various tumor types.  These approvals were based on the analytical validity 
of the tests for specific biomarkers and clinical evidence. Since they all detect mutation profiling 
with next generation sequencing method, the results derived from different companies or kits are 
expected similar though different kits cover various detected gene panels. 
1.2.3
Autophagy
1.2.3.1
Autophagy with bile tract carcinoma
Progressive cancer growth requires reprogramming energy and nutrient metabolism to support 
their elevated proliferative state [27]. These increased needs are met by reprogramming various 
metabolic processes to either recycle intracellular fuel sources or to scavenge extracellular 
components. 
Autophagy is one of critical process that provides this refuel. It is a cellular degradation or “self-
eating” pathway highly conserved throughout all life kingdoms [28]. This multistep and fine-tuned 
process is regulated by autophagy-(ATG-) related proteins originally discovered in autophagy-
defective yeast mutants [29]. It is a tightly orchestrated process that sequesters proteins, and 
damaged or aged organelles in double‐membrane vesicles called autophagosomes, which 
ultimately fuse to lysosomes, leading to the degradation of the sequestered components [30]. 
Autophagy plays an important role in maintaining cellular homeostasis and is therefore 
constitutively active at a basal level in most cell types. However, during different stress conditions, 
such as those induced by nutrient starvation, organelle damage, accumulation of abnormal proteins, 
or during development and cell differentiation [31], autophagy is additionally enhanced to meet 
the cellular needs. 
In the last two decades, accumulating evidence pointed to the importance of autophagy in various 
human diseases [32]. Studies have indicated that autophagy impairments are root causes of 
numerous diseases such as cancer, neurodegenerative disorders (Alzheimer disease, Parkinson 
disease), infectious and inflammatory diseases (Crohn's disease), diabetes, obesity, and 

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cardiovascular and muscular diseases [33]. Therefore, the number of studies focusing on the 
autophagy modulation as a perspective and promising therapeutic target is constantly increasing.
The complex and paradoxical role of autophagy in modulating cancer progression has been widely 
studied. The determination of tumor cell fate by autophagy depends on the cancer type, stage, and 
genetic context [34]. As a physiological quality control process, autophagy exerts a cytoprotective 
effect by removing misfolded proteins, damaged organelles and reactive oxygen species (ROS), 
hence limiting the genomic damage that leads to aberrant mutations and ultimately cancer. 
However, as cancer progresses, the stress-mitigating properties of autophagy are hijacked by tumor 
cells to meet the heightened metabolic requirements necessary for tumor survival and rapid 
proliferation [35, 36]. 
Cholangiocarcinoma (CCA) reportedly follows a stepwise carcinogenesis process via the 
precursor lesion biliary intraepithelial neoplasia (BilIN). The involvement of autophagy in 
multistep cholangiocarcinogenesis was evaluated by testing expression of beclin-1, and 
p62/sequestosome-1, as well as tumor suppressor gene product p53 [37]. The status of KRAS 
mutations at codons 12 and 13 was examined in selected cases of BilIN-1/2. The results showed 
the expression of LC3 (a component of the autophagosome), beclin-1, and p62 was significantly 
higher in BilIN-1/2, BilIN-3, intraductal papillary neoplasm, and invasive carcinoma than in large 
bile duct and peribiliary gland. The results suggest deregulation of autophagy is associated with 
BTC tumorigenesis. Genetically engineered mouse model of intrahepatic cholangiocarcinoma 
(iCCA) with somatic activation of KRAS G12D and deletion of TP53 has been established[38]. In 
nutrient-rich conditions, cell lines derived from KRAS-TP53 iCCAs have elevated LC3, a marker 
of autophagy, compared with normal and KRAS-TP53 mutant liver. Visualization of GFP-LC3 
autophagic puncta and chloroquine (CQ) inhibition of autophagic flux confirmed this biochemical 
observation [39]. Furthermore, CQ treatment inhibits the growth of four separate cell lines from 
both well and poorly differentiated iCCA[39]. There is no clinical trial available to directly study 
the effect of autophagy on BTC. However, abovementioned preclinical data indicates that the 
inhibition of this metabolic pathway may provide a new therapeutic option in the treatment of 
BTC.
1.2.3.2
KRAS Regulates Autophagy
Recent studies have implicated mutant KRAS in the regulation of autophagy [40, 41]. It has been 
established that KRAS signaling leads to the scavenging of extracellular proteins and lipids and 
activates self-eating and recycling of proteins through autophagy [42]. The role of autophagy in 
cancer is extremely complex[43] and while it appears clear that cancer cells depend on autophagy 
for growth, the role of oncogenic KRAS in this dependence remains unclear. When tissue samples 
from 71 patients with pancreatic ductal adenocarcinoma (PDAC) were analyzed via 
immunohistochemical staining for LC3 protein, it was determined that high expression of LC3 
was correlated with large tumor size, short-disease free period, and overall poor clinical outcome 
[44]. Genetic or pharmacological inhibition of autophagy results in increased reactive oxygen 
species, elevated DNA damage, and mitochondrial defects that lead to decreased proliferation of 
pancreatic cancer cell lines in vitro, as well as substantial tumor regression and sustained survival 
in in vivo models of pancreatic cancer [45, 46]. In support of a cooperative role 
between RAS expression and proliferation fueled by autophagy, immortal, non-tumorigenic baby 
mouse kidney epithelial cells ectopically expressing oncogenic HRAS or KRAS experienced 
defects in mitochondrial respiration upon autophagy inhibition [45]. A recent study has shown the 
inhibitor of KRASRAFMEKERK signaling in cancer cell lines elicits autophagy, which 

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protects cancer cells from the potentially cytotoxic effects of pathway inhibition[47]. This 
indicates the antitumor efficacy of the combination of MEK blockade with autophagy inhibitor.
1.2.4
Rationale for combining inhibitors of MEK and Autophagy
Current clinical trials have shown that autophagy inhibition by HCQ as a monotherapy is not 
sufficient [48]. One possible explanation as to why the combined therapies work better than HCQ 
monotherapy is because the autophagy could be required to degrade harmful material generated as 
a result of chemotherapeutic drug insults to the cancer cells. The other reason could be because 
the inhibition of a single possible pathway is simply not sufficient. In the other words, combination 
of autophagy inhibition with other modality would be a logical strategy. For instance, sorafenib is 
a multi-kinase inhibitor, including MEK pathway. Earlier studies have demonstrated that sorafenib 
treatment led to accumulation of autophagosomes due to activation of autophagic flux. 
Pharmacological inhibition of autophagic flux by CQ increased apoptosis and decreased cell 
viability in hepatoma cells. Furthermore, sorafenib induced autophagy in Huh7 xenograft tumors 
in nude mice and co-administration with CQ significantly suppressed tumor growth compared with 
sorafenib alone[49]. Additionally, it was found autophagy inhibitor rapamycin induced the 
apoptosis of malignancy cell line from uterus, and this apoptosis was enhanced by MEKi 
U0126[50].
1.2.4.1
Preclinical experience of combining inhibitors of MEK and autophagy
Recent publication has shown combined inhibition of MEK1/2 and autophagy with CQ displays 
synergistic anti-proliferative effects against PDAC cell lines in vitro [47]. Most strikingly, whereas 
single agent therapy had modest effects, combined treatment of xenografted patient derived PDAC 
tumors with trametinib plus CQ/HCQ elicited striking tumor regression. The regression elicited 
by trametinib plus CQ/HCQ was superior to gemcitabine/ nab-paclitaxel standard of care 
chemotherapy in preclinical models. These finding suggest that combination of trametinib and 
CQ/HCQ may be efficacious in patients with KRAS mutant bearing cancer.
Figure 1 Antitumor effect trametinib/HCQ in human CCA cell line TFK-1 (KRAS WT, left panel) 
and EGI (KRAS Mutant right panel) cells. Cholangiocarcinoma cell growth curve of the TFK-1 cell line 

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(RAS Wild Type) and of the EGI-1 cell line (RAS mutated) treated with chloroquine (20uM), trametinib 
(450 nM) and chloroquine /trametinib (20uM/450 nM). The cells with KRAS WT show reduced 
proliferation with chloroquine, trametinib or the combination, whereas cells with KRAS mutant exhibit cell 
death starting by 50 hour of treatment with trametinib or the combination. 
In our lab, combined treatment of trametinib plus CQ shows significantly antitumor effect in 
human CCA cell lines with KRAS mutant (Figure 1). These data indicate this combination has 
antitumor efficacy in CCA with KRAS mutant
1.2.4.2
Clinical experience of combining inhibitors of MEK and autophagy
More recently, a study showed the elicits autophagy in pancreatic ductal adenocarcinoma (PDAC) 
cell lines by activation of the LKB1→AMPK→ULK1 signaling axis, a key regulator of autophagy. 
Furthermore, combined inhibition of MEK1/2 plus autophagy displays synergistic anti-
proliferative effects against PDAC cell lines in vitro and promotes regression of xenografted 
patient-derived PDA tumors in mice. The observed effect of combination trametinib plus 
chloroquine was not restricted to PDAC as other tumors, including patient-derived xenografts 
(PDX) of NRAS-mutated melanoma and BRAF-mutated colorectal cancer displayed similar 
responses[47]. Interestingly, treatment of a patient with PDAC with the combination of trametinib 
plus HCQ resulted in a partial, but nonetheless striking disease response[47]. So far, 10 patients 
(7 patients with PDAC and 3 patients with KRAS mutated malignancies) have been treated at 
Huntsman Cancer Institute with trametinib plus HCQ. All patients were heavily pretreated and out 
of standard options. All patients were treated with 1200 mg HCQ and 2 mg of trametinib. Common 
toxicities observed in these patients and attributed to the drug combination have been grade 1-2: 
rash, fatigue, nausea, and diarrhea. However, most patients have seen dramatic decline in tumor 
marker values and tumor burden with the eventual development resistance.
Our GI oncology team in NIH CC also treated a heavily treated PDAC patient with KRAS 
mutation indicating stable tumor control and decline of tumor specific marker (Figure 2).
Figure 2. Antitumor effect of trametinib/HCQ in PDAC patient with KRAS mutation. 
1.2.5
Trametinib
1.2.5.1
Mechanism of action
Trametinib is a reversible inhibitor of mitogen-activated extracellular signal-regulated kinase 1 
(MEK1) and MEK2 activation and of MEK1 and MEK2 kinase activity. MEK proteins are 

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upstream regulators of the extracellular signal-related kinase (ERK) pathway, which promotes 
cellular proliferation. BRAF V600E mutations result in constitutive activation of the BRAF 
pathway which includes MEK1 and MEK2. Trametinib inhibits cell growth of various BRAF 
V600 mutation-positive tumors in vitro and in vivo. 
1.2.5.2
Toxicity
Cardiomyopathy
METRIC clinical trial is an international multicenter randomized (2:1), open-label, active-
controlled trial in 322 patients with BRAF V600 E or V600 K mutation-positive, unresectable or 
metastatic melanoma trial. Cardiomyopathy [defined as cardiac failure, left ventricular 
dysfunction, or decreased left ventricular ejection fraction (LVEF)] occurred in 7% (14/211) of 
patients treated with trametinib; no chemotherapy-treated patient in Trial 1 developed 
cardiomyopathy. The median time to onset of cardiomyopathy in patients treated with trametinib 
was 63 days (range 16 to 156 days); cardiomyopathy was identified within the first month of 
treatment with trametinib in five of these 14 patients. Four percent of patients in METRIC trial 
required discontinuation (4/211) and/or dose reduction (7/211) of trametinib. Cardiomyopathy 
resolved in 10 of these 14 (71%) patients.
Across clinical trials of trametinib at the recommended dose (N = 329), 11% of patients developed 
evidence of cardiomyopathy (decrease in LVEF below institutional lower limits of normal with an 
absolute decrease in LVEF ≥10% below baseline) and 5% demonstrated a decrease in LVEF below 
institutional lower limits of normal with an absolute decrease in LVEF of ≥20% below baseline. 
Assess LVEF by echocardiogram or multigated acquisition (MUGA) scan before initiation of 
trametinib, one month after initiation of trametinib, and then at 2- to 3-month intervals while on 
treatment. Withhold treatment if absolute LVEF value decreases by 10% from pre-treatment values 
and is less than the lower limit of normal. Permanently discontinue trametinib for symptomatic 
cardiomyopathy or persistent, asymptomatic LVEF dysfunction that does not resolve within 4 
weeks.
Retinal pigment Epithelial Detachment (RPED)
RPED can occur during treatment with trametinib. In the METRIC trial, where ophthalmologic 
examinations including retinal evaluation were performed pretreatment and at regular intervals 
during treatment, one patient (0.5%) receiving trametinib developed RPED and no cases of RPED 
were identified in chemotherapy-treated patients. Across all clinical trials of trametinib, the 
incidence of RPED was 0.8% (14/1749). Retinal detachments were often bilateral and multifocal, 
occurring in the macular region of the retina. RPED led to reduction in visual acuity that resolved 
after a median of 11.5 days (range: 3 to 71 days) following the interruption of dosing with 
trametinib, although Ocular Coherence Tomography (OCT) abnormalities persisted beyond a 
month in at least several cases. Perform ophthalmological evaluation at any time a patient reports 
visual disturbances and compare to baseline, if available. Withhold trametinib if RPED is 
diagnosed. If resolution of the RPED is documented on repeat ophthalmological evaluation within 
3 weeks, resume trametinib at a reduced dose.
Retinal Vein Occlusion (RVO) 
Across all clinical trials of trametinib, the incidence of RVO was 0.2% (4/1749). An RVO may 
lead to macular edema, decreased visual function, neovascularization, and glaucoma. Urgently 
(within 24 hours) perform ophthalmological evaluation for patient-reported loss of vision or other 

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visual disturbances. Permanently discontinue trametinib in patients with documented retinal vein 
occlusion.
Interstitial Lung Disease
In clinical trials of trametinib at the recommended dose (N = 329), interstitial lung disease (ILD) 
or pneumonitis occurred in 1.8% of patients. In Trial 1, 2.4% (5/211) of patients treated with 
trametinib developed ILD or pneumonitis; all five patients required hospitalization. The median 
time to first presentation of ILD or pneumonitis was 160 days (range: 60 to 172 days). Withhold 
trametinib in patients presenting with new or progressive pulmonary symptoms and findings 
including cough, dyspnea, hypoxia, pleural effusion, or infiltrates, pending clinical investigations. 
Permanently discontinue trametinib for patients diagnosed with treatment related ILD or 
pneumonitis.
Serious Skin Toxicity
In this trial, the overall incidence of skin toxicity including rash, dermatitis, acneiform rash, 
palmar-plantar erythrodysesthesia syndrome, and erythema was 87% in patients treated with 
trametinib and 13% in chemotherapy-treated patients. Severe skin toxicity occurred in 12% of 
patients treated with trametinib. Skin toxicity requiring hospitalization occurred in 6% of patients 
treated with trametinib, most commonly for secondary infections of the skin requiring intravenous 
antibiotics or severe skin toxicity without secondary infection. In comparison, no patients treated 
with chemotherapy required hospitalization for severe skin toxicity or infections of the skin. The 
median time to onset of skin toxicity in patients treated with trametinib was 15 days (range: 1 to 
221 days) and median time to resolution of skin toxicity was 48 days (range: 1 to 282 days). 
Reductions in the dose of trametinib were required in 12% and permanent discontinuation of 
trametinib was required in 1% of patients with skin toxicity. Monitor patients receiving trametinib 
for skin toxicities and for secondary infections.
Embryofetal Toxicity
Based on its mechanism of action, trametinib can cause fetal harm when administered to a pregnant 
woman. trametinib was embryotoxic and abortifacient in rabbits at doses greater than or equal to 
those resulting in exposures approximately 0.3 times the human exposure at the recommended 
clinical dose. If this drug is used during pregnancy, or if the patient becomes pregnant while taking 
this drug, the patient should be apprised of the potential hazard to a fetus. 
Advise female patients of reproductive potential to use highly effective contraception during 
treatment with trametinib and for 4 months after treatment. Advise patients to contact their 
healthcare provider if they become pregnant, or if pregnancy is suspected, while taking trametinib.
1.2.5.3
Clinical trial experience 
Trametinib as a single agent was evaluated in 329 patients including 107 (33%) exposed for ≥ 6 
months and 30 (9%) exposed for ≥ one year. Trametinib as a single agent was studied in open-
label, single-arm trials (N = 118) and in an open- label, randomized, active-controlled trial (N = 
211; the METRIC study, a randomized, open-label trial of patients with BRAF V600E or V600K 
mutation-positive unresectable or metastatic melanoma). The median age was 54 years, 60% were 
male, > 99% were White, and all patients had unresectable or metastatic melanoma. All patients 
received 2 mg once-daily doses of trametinib or chemotherapy (N = 99) (either dacarbazine 1,000 
mg/m2 every 3 weeks or paclitaxel 175 mg/m2 every 3 weeks). Patients with abnormal LVEF, 
history of acute coronary syndrome within 6 months, or current evidence of Class II or greater 

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17
congestive heart failure (New York Heart Association) were excluded. The median duration of 
treatment with trametinib was 4.3 months. 
In this study, 9% of patients receiving trametinib experienced adverse reactions resulting in 
permanent discontinuation of trial medication. The most frequent adverse reactions resulting in 
permanent discontinuation of trametinib were decreased left ventricular ejection fraction (LVEF), 
pneumonitis, renal failure, diarrhea, and rash. Adverse reactions led to dose reductions in 27% of 
patients treated with trametinib. Rash and decreased LVEF were the most frequent reasons cited 
for dose reductions of trametinib. Table 1 and Table 2 present adverse reactions and laboratory 
abnormalities, respectively, of trametinib as a single agent in the METRIC study.
Table 1. Select Adverse Reactions Occurring in ≥ 10% of Patients Receiving Trametinib and at a 
Higher Incidence (≥ 5%) than in the Chemotherapy Arm or ≥ 2% (Grades 3 or 4) Adverse Reactions 
in METRIC
Trametinib N = 211 
Chemotherapy N = 99 
Adverse Reactions 
All Grades a, b Grades 3 b and 4 c, b All Gradesa Grades 3 and 4 c, b 
Skin and subcutaneous tissue 
Rash 
57 
8 
10 
0 
Acneiform dermatitis 
19 
<1 
1 
0 
Dry skin 
11 
0 
0 
0 
Pruritus 
10 
2 
1 
0 
Paronychia 
10 
0 
1 
0 
Gastrointestinal 
Diarrhea 
43 
0 
16 
2 
Stomatitis d 
15 
2 
2 
0 
Abdominal pain e 
13 
1 
5 
1 
Vascular 
Lymphedema f 
32 
1 
4 
0 
Hypertension 
15 
12 
7 
3 
Hemorrhage g 
13 
<1 
0 
0 
aEvents included are higher in the trametinib arm compared with chemotherapy by ≥5% in 141 overall incidence or 
by ≥2% Grade 3-4 adverse reactions higher in trametinib arm compared 142 with chemotherapy.
bNational 
Cancer 
Institute 
Common 
Terminology 
Criteria 
for 
Adverse 
Events, 
version 
4.0.
cGrade 4 adverse reactions were limited to rash (n = 1) in trametinib arm and diarrhea (n = 1) in the chemotherapy 
arm. 
dIncludes the following terms: stomatitis, aphthous stomatitis, mouth ulceration, and mucosal inflammation. 
eIncludes the following terms: abdominal pain, abdominal pain lower, abdominal pain upper, and abdominal 
tenderness. 
fIncludes 
the 
following 
terms: 
lymphedema, 
edema, 
and 
peripheral 
edema. 
gIncludes the following terms: epistaxis, gingival bleeding, hematochezia, rectal hemorrhage, melena, vaginal 
hemorrhage, hemorrhoidal hemorrhage, hematuria, and conjunctival hemorrhage.
Other clinically important adverse reactions observed in ≤ 10% of patients (N = 329) receiving 
trametinib were: bradycardia, dry mouth, folliculitis, rash pustular, cellulitis, rhabdomyolysis, 
dizziness, dysgeusia, blurred vision, dry eye 

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Table 2. Laboratory Abnormalities Occurring at a Higher Incidence in Patients Treated with 
Trametinib in the METRIC Study [Between-arm Difference of ≥ 5% (All Grades) or ≥ 2% (Grades 
3 or 4)a] 
Trametinib N = 211 
Chemotherapy N = 99 
Laboratory Abnormality 
All Grades Grades 3 and 4 All Grades Grades 3 and 4 
Increased aspartate aminotransferase (AST) 
60
2
16
1
Hypoalbuminemia 
42
2
23
1
Increased alanine aminotransferase (ALT) 
39
3
20
3
Anemia 
38
2
26
3
Increased alkaline phosphatase 
24
2
18
3
aOnly grade 3 adverse reactions were reported in either treatment arm
Further information on these risks (e.g. presenting symptoms) can be found in the current version 
of the trametinib package insert.
1.2.6
Hydroxychloroquine
1.2.6.1
Mechanism of Action 
HCQ can inhibit lysosomal acidification and prevent the degradation of autophagosomes, thereby 
suppressing autophagy. The mechanism by which chloroquine derivatives interfere with 
autophagy is still not very well understood.
1.2.6.2
 Toxicity
Ocular:
Irreversible retinal damage has been observed in some patients who had received HCQ sulfate. 
Significant risk factors for retinal damage include daily doses of HCQ sulfate greater than 6.5 
mg/kg (5 mg/kg base) of actual body weight, durations of use greater than five years, subnormal 
glomerular filtration, use of some concomitant drug products such as tamoxifen citrate and 
concurrent macular disease. A baseline ocular examination is recommended within the first year 
of starting HCQ. The baseline exam should include best corrected distance visual acuity (BCVA), 
an automated threshold visual field (VF) of the central 10 degrees (with retesting if an abnormality 
is noted), and spectral domain ocular coherence tomography (SD-OCT). For individuals with 
significant risk factors (daily dose of HCQ sulfate greater than 5.0 mg/kg base of actual body 
weight, subnormal glomerular filtration use of tamoxifen citrate or concurrent macular disease) 
monitoring should include annual examinations which include BCVA, VF and SD-OCT.
For individuals without significant risk factors, annual exams can usually be deferred until five 
years of treatment. In individuals of Asian descent, retinal toxicity may first be noticed outside the 
macula. In patients of Asian descent, it is recommended that visual field testing be performed in 
the central 24 degrees instead of the central 10 degrees. It is recommended that HCQ be 
discontinued if ocular toxicity is suspected and the patient should be closely observed given that 
retinal changes (and visual disturbances) may progress even after cessation of therapy.
 Cardiac Effects, including Cardiomyopathy and QT prolongation:

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Post marketing cases of life-threatening and fatal cardiomyopathy have been reported with use of 
HCQ as well as with use of chloroquine. Patients may present with atrioventricular block, 
pulmonary hypertension, sick sinus syndrome or with cardiac complications. ECG findings may 
include atrioventricular, right or left bundle branch block. Signs or symptoms of cardiac 
compromise have appeared during acute and chronic treatment. Clinical monitoring for signs and 
symptoms of cardiomyopathy is advised, including use of appropriate diagnostic tools such as 
ECG to monitor patients for cardiomyopathy during HCQ therapy. Chronic toxicity should be 
considered when conduction disorders (bundle branch block/atrio-ventricular heart block) or 
biventricular hypertrophy are diagnosed. If cardiotoxicity is suspected, prompt discontinuation of 
HCQ may prevent life-threatening complications. HCQ prolongs the QT interval. Ventricular 
arrhythmias and torsade’s de pointes have been reported in patients taking HCQ. Therefore, HCQ 
should not be administered with other drugs that have the potential to prolong the QT interval
Worsening of psoriasis and porphyria: 
Use of HCQ in patients with psoriasis may precipitate a severe attack of psoriasis. When used in 
patients with porphyria the condition may be exacerbated. The preparation should not be used in 
these conditions unless in the judgment of the physician the benefit to the patient outweighs the 
possible hazard.
 Proximal Myopathy and Neuropathy:
Skeletal muscle myopathy or neuropathy leading to progressive weakness and atrophy of proximal 
muscle groups, depressed tendon reflexes, and abnormal nerve conduction, have been reported. 
Muscle and nerve biopsies have been associated with curvilinear bodies and muscle fiber atrophy 
with vacuolar changes. Assess muscle strength and deep tendon reflexes periodically in patients 
on long-term therapy with HCQ.
Neuropsychiatric events, including suicidality:
Suicidal behavior has been rarely reported in patients treated with HCQ.
Hypoglycemia:
HCQ has been shown to cause severe hypoglycemia including loss of consciousness that could be 
life threatening in patients treated with or without antidiabetic medications. Patients treated with 
HCQ should be warned about the risk of hypoglycemia and the associated clinical signs and 
symptoms. Patients presenting with clinical symptoms suggestive of hypoglycemia during 
treatment with HCQ should have their blood glucose checked and treatment reviewed as necessary.
1.2.6.3
Toxicities of the combination of trametinib and HCQ
There is no data available in terms of this combination though there should have this information 
accessible in the near future since several trials involved with this combination is ongoing. 
However, there is safety data from the BAMM trial (NCT02257424), that is designed for patients 
with advanced BRAF mutant melanoma treated with dabrafenib, trametinib, and 
hydroxychloroquine. The doses of trametinib and hydroxychloroquine used in the BAMM trial is 
the exact same as we plan in our trial except that we are not planning BRAF inhibitor dabrafenib. 
Therefore, this precious data will provide important reference for our trial. From personal 
communication with Dr. Ravi Amaravadi (Primary Investigator of BAMM trial, University of 
Pennsylvania), we summarize the safety profile from BAMM trial as showed in the following 
Table 3. 

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Table 3. Safety profile in the BAMM Study 
Dabrafenib + trametinib + HCQ (BAMM)
 Adverse Event
Grade 1-2
Grade 3
Chills
14 (56%)
1 (4%)
Diarrhea
13 (52%)
0
Fever
13 (52%)
1 (4%)
Nausea
12 (48%)
1 (4%)
Fatigue
11 (44%)
0
Headache
9 (36%)
0
Myalgia
9 (36%)
0
Rash
9 (36%)
3 (12%)
Anorexia
8 (32%)
0
Dry mouth
7 (28%)
0
Pruritus
7 (28%)
0
Arthralgia
6 (24%)
0
Abdominal pain
5 (20%)
0
Vomiting
5 (20%)
0
Constipation
4 (16%)
0
Dysgeusia
4 (16%)
0
Creatinine increased
3 (12%)
0
Dehydration
3 (12%)
2 (8%)
QTc prolonged
3 (12%)
1 (4%)
Increased alanine aminotransferase
1 (4%)
2 (8%)
Ejection fraction decreased
0
1 (4%)
With the triplet combination, the most common adverse effects are chills, diarrhea, fever, nausea, 
rash, and fatigue with grade 1-2. No grade 4 AEs are reported. This information indicates the less 
adverse effects we foresee with trametinib and hydroxychloroquine in our trial.
1.2.7
Drug dose rationale
Given there is a previously described efficacious dosing for trametinib at 2 mg once daily for 
metastatic melanoma with described de-escalation for trametinib associated side-effects, we will 
keep this dosing static and only de-escalate if trametinib specific, dose limiting side effects are 
encountered. As we do not know the dosing of HCQ needed to inhibit trametinib-induced 
autophagy, we will use flat dose as 600 mg twice daily used in previous mentioned PDAC trial 
and de-escalate if HCQ specific, dose limiting side effects are encountered. Both drugs are orally 
bioavailable and will be dosed orally. Drug-drug interactions between trametinib and HCQ are not 
expected due to separate metabolism and transporter pathways.
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT
2.1
Eligibility Criteria
2.1.1
Inclusion Criteria

Histopathological confirmation of:
biliary tract carcinoma (BTC)
OR

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carcinoma in the setting of clinical and radiological characteristics which, together with 
the pathology, are highly suggestive of a diagnosis of BTC
Note: The term BTC includes intra- or extra- hepatic cholangiocarcinoma (CCA), 
gallbladder cancer or ampullary cancer.

The tumor must have KRAS mutation(s) of clinical significance, confirmed by NCI 
Laboratory of Pathology or by FDA approved test.

Patients must have received or been intolerant of at least one line of chemotherapy.

Patients must have at least 1 measurable lesion by RECIST version 1.1 (see section 6.3) 

Patients must have disease that is not amenable to potentially curative resection, ablation 
or transplantation.

Age  18 years. 

Performance status (ECOG) 0-2 (see Appendix A)

If liver cirrhosis is present, patient must have a Child-Pugh score <7 (Class A) (Section 
Appendix B)

Patients must have adequate organ and marrow function as defined below:
ANC
> 1,500/mcL
platelets
≥ 100,000/mcL
hemoglobin
  9 g/dL
total bilirubin
If cirrhosis present: Part of Child Pugh 
requirement
If no cirrhosis: bilirubin should be ≤ 1.5 x ULN
ALT or AST 
 5 x ULN.
Creatinine OR
Measured or calculated creatinine 
clearance (CrCl) (eGFR may also 
be used in place of CrCl) A
< 1.5x institution upper limit of normal OR
> 30 mL/min/1.73 m2 for participant with 
creatinine levels > 1.5 X institutional ULN
ALT (SGPT)=alanine aminotransferase (serum glutamic pyruvic transaminase); 
AST (SGOT)=aspartate aminotransferase (serum glutamic oxaloacetic transaminase); GFR=glomerular 
filtration rate; ULN=upper limit of normal.
A Creatinine clearance (CrCl) or eGFR should be calculated per institutional standard.

Patients must have at least 1 focus of disease that is amenable to mandatory tumor biopsies 
and be willing to undergo this. Ideally, the biopsied lesion should not be one of the target 
measurable lesions, although this can be up to the discretion of the investigators. 

The study drugs are harmful for developing human fetus. For this reason, women of child-
bearing potential and men must agree to use adequate contraception (hormonal or barrier 

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22
method of birth control; abstinence) at the study entry, for the duration of study treatment 
and up to 4 months after the last dose of the study drug(s). 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.

Patients must be able to understand and be willing to sign a written informed consent. 
2.1.2
Exclusion Criteria

Patients who have had standard-of-care anti-cancer therapy within 2 weeks of treatment 
initiation or therapy with investigational agents (e.g. chemotherapy, immunotherapy, 
endocrine therapy, targeted therapy, biologic therapy, tumor embolization, monoclonal 
antibodies or other investigation agents), large field radiotherapy, or major surgery within 
4 weeks of treatment initiation. 

Any unresolved toxicity NCI CTCAE v.5 Grade ≥2 from previous anticancer therapy with 
the exception of alopecia, vitiligo, and the laboratory values defined in the inclusion 
criteria. Patients with Grade ≥2 neuropathy will be evaluated on a case-by-case basis.

Has biliary duct obstruction, unless a treatable, clinically relevant obstruction has been 
relieved by internal endoscopic drainage/stenting, palliative by-pass surgery or 
percutaneous drainage prior to treatment initiation. 

Patients with known brain metastases are excluded from this clinical trial because of their 
poor prognosis and because they often develop progressive neurologic dysfunction that 
would confound the evaluation of neurologic and other adverse events.

Patients with signs of liver failure, e.g. clinically significant ascites, encephalopathy, or 
variceal bleeding within six months before treatment initiation.

History or current evidence of retinal vein occlusion (RVO) or current risk factors for RVO 
(e.g. uncontrolled glaucoma or ocular hypertension, history of hyper viscosity or 
hypercoagulability syndromes)

Current evidence of uncontrolled, significant intercurrent illness including, but not limited 
to, the following conditions:
Cardiovascular disorders: Congestive heart failure New York Heart Association class 
3 or 4, unstable angina pectoris, serious cardiac arrhythmias, stroke (including transient 
ischemic attack [TIA]), myocardial infarction (MI), or other ischemic event, or 
thromboembolic event (e.g., deep venous thrombosis, pulmonary embolism) within 3 
months before treatment initiation
History of glucose-6-phosphate dehydrogenase (G6PD) deficiency
History of seizures
Patients who are planning on embarking on a new strenuous exercise regimen after first 
dose of study treatment. Muscular activities, such as strenuous exercise, that can result 
in significant increases in plasma creatine kinase (CK) levels should be avoided while 
on study treatment

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23
Patients who have neuromuscular disorders that are associated with elevated CK (e.g., 
inflammatory myopathies, muscular dystrophy, amyotrophic lateral sclerosis, spinal 
muscular atrophy)
Impairment of gastrointestinal function or gastrointestinal disease (e.g., ulcerative 
disease, uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome, or small 
bowel resection that under the judgment of the principal investigator (PI) may impair 
absorption of study drugs)
Any other condition that would, in the Investigator’s judgment, contraindicate the 
patient’s participation in the clinical study due to safety concerns or compliance with 
clinical study procedures, e.g., infection/inflammation, intestinal obstruction, unable to 
swallow medication (patients may not receive drug through a feeding tube), social/ 
psychological issues, etc.

Screening corrected QT interval by Fridericia’s (QTcF) > 500 msec

Known infection with human immunodeficiency virus (HIV), unless patient is on effective 
anti-retroviral therapy with undetectable viral load within 6 months of treatment initiation 

Known chronic hepatitis B virus, unless hepatitis B virus (HBV) viral load is undetectable.

Known history of hepatitis C virus (HCV) infection, unless completed treatment and cured 
with undetectable HCV viral load.

Known prior severe hypersensitivity to study drugs or any component in its formulations 
(CTCAE v5.0 grade >= 3).

Pregnant women are excluded from this study because study therapy can cause fetal harm. 
Because there is potential risk for adverse events in nursing infants secondary to treatment 
of the mother with study therapy, breastfeeding should be discontinued if the mother is 
treated with study drugs.
2.1.3
Recruitment Strategies 
This protocol may be abstracted into a plain language announcement posted on NIH websites, 
including www.clinicaltrials.gov and the CCR website, and on NIH social media platforms. 
Outside providers and colleagues may directly refer patients for screening into this study.
2.2
Screening Evaluation 
2.2.1
Screening activities performed prior to obtaining informed consent
Minimal risk activities that may be performed before the subject has signed a consent include the 
following: 

Email, written, in person or telephone communications with prospective subjects 

Review of existing medical records to include H&P, laboratory studies, etc. 

Review of existing MRI, x-ray, or CT images

Review of existing photographs or videos

Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes.

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2.2.2
Screening activities performed after a consent for screening has been signed
The following activities will be performed only after the subject has signed the study consent OR 
the consent for study 01-C-0129 (provided the procedure is permitted on that study) on which 
screening activities may also be performed. Assessments performed at outside facilities or on 
another NIH protocol within the timeframes below may also be used to determine eligibility once 
a patient has signed the consent.
The following must be completed within 28 days prior to initiation of study treatment unless 
otherwise noted below:

Complete Medical History and Physical Evaluation (including height, weight, vital signs, 
and ECOG performance status).

EKG

Echocardiogram

Cardiology Consultation (if clinically indicated)

Ophthalmological evaluation

CT scan of chest, abdomen and pelvis (or MRI of chest, abdomen and pelvis if clinically 
indicated)

MRI of brain (if clinically indicated)

Laboratory Evaluation
o
Hematological Profile: CBC with differential and platelet count.
o
Biochemical Profile: electrolytes, BUN, creatinine, AST, ALT, total and direct 
bilirubin, calcium, phosphorus, albumin, magnesium. 
o
24-hour urine collection (if clinically indicated)
o
Serum or urine pregnancy test for female participants of childbearing potential (within 
2 weeks of enrollment). 
o
HIV, Hepatitis B and C serology and/or viral load (if clinically indicated)
o
TB testing (if clinically indicated)
o
Troponin I (if clinically indicated)

Documentation of histologic confirmation of BTC or carcinoma highly suggestive of a 
diagnosis of BTC (at any time point prior to enrollment). If there is no available 
documentation, biopsy will be performed to confirm the diagnosis.

KRAS mutation status will be confirmed by NCI Laboratory of Pathology with TruSight™ 
Oncology 500 panel (at any time point prior to enrollment). If there is no available tumor 
sample, biopsy will be performed to confirm KRAS mutational status. Note: if participant 
has documentation of KRAS mutation status performed with FDA approved test (see Study 
Instrument) from certified laboratory, confirmation with TruSight™ Oncology 500 panel 
can be omitted. 

Abbreviated Title: Trametinib and HCQ in BTC
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2.3
Participant Registration and Status Update Procedures
Registration and status updates (e.g. when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant 
Registration & Status Updates found here.
2.3.1
Screen Failures 
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered in the study. A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure participants, to meet 
the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, screen 
failure details, eligibility criteria, and any serious adverse event (SAE).
Individuals who do not meet the criteria for participation in this trial (screen failure) because of a 
not definite KRAS status may be rescreened. Rescreened participants should be assigned the same 
participant number as for the initial screening
2.3.2
Treatment Assignment Procedures (for registration purposes only):
Cohorts
Number
Name
Description
1
Cohort 1
Subjects with BTC or carcinoma in the setting of clinical and 
radiological characteristics which, together with the pathology, 
are highly suggestive of a diagnosis of BTC. 
Arms
Number
Name
Description
1
Arm 1
Trametinib + hydroxychloroquine (HCQ)
Patients in Cohort 1 will be directly assigned to treatment in Arm 1. 
2.4
Baseline Evaluation
Tests done at screening do not need to be repeated on baseline if performed in designated time 
frame prior to start of study treatment.
Within 28 days prior to study treatment initiation:

CT scan of chest, abdomen and pelvis (or MRI of chest, abdomen and pelvis if clinically 
indicated) 

Baseline research biopsy (does not need to be repeated if biopsy was done during 
screening) 

Concomitant medications

Baseline signs and symptoms

Urinalysis

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3
STUDY IMPLEMENTATION
3.1
Study Design
The proposed study is an open label, single-arm phase II study of trametinib in combination with 
hydroxychloroquine (HCQ) in BTC patients (Schema 1).
Initially, 6 patients will be enrolled into safety run-in portion of the trial (section 3.1.2). If safe, we 
will continue enrollment as planned, if not, we will submit next amendment with new study design.
Initially, 10 patients will be enrolled and evaluated for progression. Enrollment will be temporarily 
halted after the 10th patient has been accrued, unless we know that 3 patients have passed the 5-
month point without progression. If 3 or more of the first 10 patients enrolled have not progressed 
at the 5-month evaluation, then accrual will continue until a total of 17 patients have been entered. 
If, among the first 10 patients accrued, 0 to 2 are able to be progression-free at the 5-month 
evaluation, then no further patients will be enrolled after such a determination has been made. If 6 
or more of the total cohort of 17 patients have been found to be progression-free at 5 months, then 
this will indicate an adequate progression free probability to justify further consideration of 
trametinib in combination with hydroxychloroquine in this population of patients. On the other 
hand, if 3 to 5 of 17 are progression-free at 5 months, this will be considered insufficient.
Treatment with trametinib and HCQ will be delivered in cycles consisting of 4 weeks (+/- 3 days) 
and start on cycle 1 day 1. 
Both drugs will be given orally on daily basis: trametinib (2 mg once a day) and HCQ (600 mg 
twice a day – 1,200 mg total dose).
Treatment with study drugs will continue until off treatment criteria are met (see section 3.6.1). 
If one of the study drugs is permanently discontinued because of toxicity, per PI discretion the 
patient may continue the other study drug. It is unclear in terms of the attitude and duration of 
antitumor efficacy with this drug combination in BTC. If patient’s disease is controlled with the 
combination but the treatment is held because of AEs from one of the agents, we think it would be 
beneficial for participants to continue the other agent and continue monitoring the disease progress 
accordingly.
Patients will be monitored every 8 (+/- 1) weeks with imaging studies.
Patients will be evaluated for toxicity and malignancy per Study Calendar 3.4. 
Patients will undergo mandatory research biopsies at the baseline and any day during week 3 of 
cycle 2. If patient disease progresses before C3D1, post-treatment biopsy might be performed per 
PI discretion at the time of progression.

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Schema 1. Treatment and monitoring schedule
3.1.1
Dose Limiting Toxicity (DLT) (Safety Run-In only) 
The DLT period is one cycle, 28 days, starting on Day 1 of cycle 1 after study drugs administration. 
The following events will be considered DLTs (CTCAE v5.0) if attributable (definite, probable, 
possible) to the combination of study drugs:  
Toxicity Category
DLT Criteria (grade per CTCAE 5.0)
Grade ≥ 4 neutropenia lasting ≥ 7 consecutive days and/or not 
resolving within 48 hours to a grade 2 or less toxicity after correctible 
treatment 
Grade ≥ 4 thrombocytopenia lasting ≥ 7 consecutive days and/or not 
resolving within 48 hours to a grade 2 or less toxicity after correctible 
treatment
Hematology
Grade ≥ 3 neutropenia with fever (temperature ≥ 38.5 °C), not 
correctible within 48 hours to a grade 2 or less toxicity
Skin and subcutaneous 
tissue disorders
Grade ≥ 3 rash, hand-foot skin reaction or photosensitivity lasting > 
7 consecutive days and/or not resolving within 48 hours to a grade 2 
or less toxicity after correctible treatment 
Grade ≥ 2 retinal events lasting > 14 consecutive days confirmed by 
ophthalmologic examination
Eye disorders
Grade ≥ 3 retinal events confirmed by ophthalmologic examination, 
not correctible within 48 hours to a grade 2 or less toxicity
Grade ≥ 3 nausea or vomiting lasting ≥ 7 days and/or not resolving 
within 48 hours to a grade 2 or less toxicity after correctible 
treatment
Gastrointestinal
Grade ≥ 3 diarrhea lasting ≥ 7 days and/or not resolving within 48 
hours to a grade 2 or less toxicity after correctible treatment

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Grade ≥ 3 total bilirubin not related to progression of disease, not 
correctible within 48 hours to a grade 2 or less toxicity
Grade ≥ 3 AST or ALT (isolated increases in AST without 
concomitant increases in ALT will not be considered DLT because 
of the non-specific nature of AST), not correctible within 48 hours 
to a grade 2 or less toxicity.
Patients with liver metastases will require AST or ALT levels 10 x 
ULN (isolated increases in AST without concomitant increases in 
ALT will not be considered DLT because of the nonspecific nature 
of AST).
Hepatic
Grade ≥ 4 alkaline phosphatase lasting ≥ 7 consecutive days and/or 
not resolving within 48 hours to a grade 2 or less toxicity after 
correctible treatment
ECG QT Interval
QTcF interval ≥ 501 ms on at least two separate ECGs, not 
correctible within 48 hours to a grade 2 or less toxicity
Renal
Serum creatinine > 2 × ULN, not correctible within 48 hours to a 
grade 2 or less toxicity
Grade 3 alopecia
< 5 days of Grade 3 fatigue
< 5 days of Grade 3 edema
Grade ≤ 4 lymphopenia
Exceptions 
to 
DLT 
criteria
Grade ≤ 4 laboratory abnormalities that are responsive to oral 
supplementation or deemed by the investigator to be clinically 
insignificant.
3.1.2
Safety Run-In:
Six patients will be enrolled in a staggered fashion with at least 7 days minimum between each 
patient enrolled. If < 2 patients experience DLTs, as defined in section 3.1.1, we will proceed to 
the following portion of the trial. If ≥ 2 patients experience DLT, we will stop enrollment and will 
submit next amendment with new study design.
Subjects who do not start or do not complete the DLT observation period for reasons other than a 
DLT will be replaced and not included in the evaluation. 
In case of DLT, DLT will be documented and patient, per PI discretion, may continue study 
treatment if toxicity could be managed by interruption of study treatment or dose reductions (See 
Section 3.3).
Patient will be eligible for the DLT evaluation if at least ≥80 percent of trametinib and HCQ 
scheduled doses were taken within the DLT period. 

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3.2
Drug Administration
3.2.1
Trametinib
Trametinib will be given orally at designated dose once a day on every day of every 28-day cycle. 
Trametinib should be taken orally at least 1 hour before and 2 hours after a meal with 
approximately 200 mL of water. If a subject vomits after taking study treatment, the subject should 
be instructed not to retake the dose but should be instructed to take the next scheduled dose. If a 
subject misses a dose of trametinib, the subject may take the dose immediately if the next dose is 
scheduled for at least 12 hours later. If the next scheduled dose is due in less than 12 hours, the 
subject should skip the dose and resume dosing at the next scheduled dose.
Missing of 20% of the doses for any given cycle is allowed. 
Patients will complete and return Patient’s Diary (Appendix C).
3.2.2
Hydroxychloroquine (HCQ)
Hydroxychloroquine will be given orally at designated dose twice a day on every day of every 28-
day cycle. 
Hydroxychloroquine should be taken at approximately the same times each day. Doses should be 
taken within 2 hours of the scheduled time. 
In case of a missed dose (more than 2 hours late) or vomiting after taking hydroxychloroquine, 
patients will be instructed not to make up the missed dose.
Hydroxychloroquine will be taken orally with a meal or a glass of milk.
Missing of 20% of the doses for any given cycle is allowed. 
Patients will complete and return Patient’s Diary (Appendix C).
3.3
Dose Modifications/Delay
In case of unbearable toxicity definitely attributed to one of the study drugs, patient will be taken 
off this drug and per PI discretion may continue treatment with the other drug only.
When, at the beginning of a treatment cycle, treatment delay related to one of the drugs is indicated, 
both study drugs should be held and resumed concurrently. 
If, in the opinion of the investigator, a toxicity is considered to be due solely to one drug, the dose 
of the other drug may not require modification per PI discretion.
Dose interruptions for study treatment-related AEs are allowed as per the dose modification 
recommendations. Doses of any investigational product that were not administered due to toxicity 
will not be replaced within the same cycle. In addition to dose interruption, the need for a dose 
reduction at the time of treatment resumption should also be considered based on the dose 
modifications recommendations. If a toxicity-related dose delay of HCQ and trametinib for >28 
days  is required, treatment will be discontinued permanently, and the patient should be removed 
from study treatment.
3.3.1
Dose reduction
Following dosing interruption due to treatment related toxicity, the offending agent may need to 
be resumed at a reduced dose as per the dose modification recommendations as following. Dose 

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reduction should proceed by decreasing the administered dose by 0.5 mg of original dose of 
trametinib or 400 mg of original dose of HCQ.
3.3.2
Hydroxychloroquine
Table 4 Guidelines for hydroxychloroquine-related toxicities
Adverse Event
1st Occurrence
2nd Occurrence
Hematology
Grade 4 neutropenia lasting ≥ 7 
consecutive days
Grade 4 thrombocytopenia ≥ 7 
consecutive days
Grade ≥ 3 neutropenia with fever 
(temperature ≥ 38.5 °C)
Hold HCQ and trametinib. Continue 
weekly hematologic monitoring. 
Once AE resolves to ≤Grade 1, 
restart study drugs, with HCQ at next 
lower dose level.
Discontinue HCQ 
and trametinib 
Skin and subcutaneous tissue disorders
Grade ≥ 3 rash, hand-foot skin reaction or 
photosensitivity lasting > 7 consecutive 
days despite skin toxicity treatment
See Table 5
Discontinue HCQ 
and trametinib
Eye disorders
Grade 2 retinal events lasting > 14 
consecutive days confirmed by 
ophthalmologic examination
Grade ≥ 3 retinal events confirmed by 
ophthalmologic examination
Hold HCQ and trametinib. Monitor 
until AE resolves to Grade ≤ 1. 
Patients should be referred for 
ophthalmologic exam. Restart study 
drugs, with HCQ at next lower dose 
level. 
Discontinue HCQ 
and trametinib
Gastrointestinal
Grade ≥ 3 nausea or vomiting lasting ≥ 7 
days despite optimal anti-emetic therapy
Hold HCQ and trametinib. Monitor 
until AE resolves to Grade ≤ 1. 
Restart study drugs, with HCQ at 
next lower dose level.
Discontinue HCQ 
and trametinib 
Grade ≥ 3 diarrhea lasting ≥ 7 days 
despite optimal anti-diarrhea treatment
See Table 6
Discontinue HCQ 
and trametinib 
Hepato-biliary
Grade ≥ 3 total bilirubin felt to be not 
related to progression of disease
Grade ≥ 3 ALT (isolated increases in AST 
without concomitant increases in ALT 
will not be considered dose-limiting 
because of the non-specific nature of 
AST)
Grade 4 alkaline phosphatase lasting ≥ 7 
consecutive days felt to be not related to 
progression of disease
Hold HCQ and trametinib. Monitor 
with weekly CMP until AE resolves 
to Grade ≤ 1. Restart study drugs, 
with HCQ at next lower dose level.
Discontinue HCQ 
and trametinib 
ECG QT Interval
Hold HCQ and trametinib. Monitor 
Discontinue HCQ 

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Adverse Event
1st Occurrence
2nd Occurrence
QTcF interval ≥ 501 ms on at least two 
separate ECGs
with ECG until AE resolves to Grade 
≤ 1. Restart study drugs, with HCQ 
at next lower dose level.
and trametinib 
Renal
Serum creatinine ≥ Grade 2
Check cystatin-C levels.
If GFR calculated by cystatin C is ≥ 
30 mL/min/1.73 m2, continue HCQ 
and trametinib.
If GFR calculated by cystatin C is ≤ 
30 mL/min/1.73 m2, hold HCQ and 
trametinib. Monitor with weekly 
CMP and cystatin C until AE 
resolves to ≤Grade 1. Restart study 
drugs, with HCQ at next lower dose 
level.
Check cystatin-C 
levels.
If GFR calculated 
by cystatin C is 
≥30 mL/min/1.73 
m2, continue HCQ 
and trametinib. 
If GFR calculated 
by cystatin C is 
≤30 mL/min/1.73 
m2, discontinue 
HCQ and 
trametinib.*
*2nd occurrence 
of elevated serum 
creatinine will 
only be 
determined if 1st 
occurrence 
included elevated 
cystatin C and 
dose reduction.
Hypoglycemia
Hold HCQ if Grade 2. Monitor AE 
until resolution to Grade ≤ 1. Restart 
study drugs, with HCQ at next lower 
dose level.
Hold HCQ if Grade 3. Monitor AE 
until resolution to Grade ≤ 1. Restart 
study drugs HCQ at next lower dose 
level.
Discontinue HCQ permanently if 
Grade 4
Discontinue HCQ 
and trametinib 
Non-hematologic events
Grade ≥3, except for the exclusions noted 
below:
Grade 3 alopecia
< 5 days of Grade 3 fatigue
< 5 days of Grade 3 edema
Grade 3 laboratory abnormalities that 
are responsive to oral supplementation 
Hold HCQ and trametinib. Monitor 
AE until resolution to Grade ≤ 1. 
Restart study drugs, with HCQ at 
next lower dose level.
Discontinue HCQ 
and trametinib 

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Adverse Event
1st Occurrence
2nd Occurrence
or deemed by the investigator to be 
clinically insignificant
3.3.3
Trametinib
Dose reductions for adverse reactions associated with trametinib are presented in Table 5
Table 5:Recommended Dose Reductions for Trametinib for Adverse Reactions
Action
Recommended Dose
First Dose Reduction
1.5 mg orally once daily
Second Dose Reduction
1 mg orally once daily
Subsequent Modification
Permanently discontinue if unable to tolerate 
trametinib 1 mg orally once daily
Dosage modifications for adverse reactions associated with trametinib are presented in Table 6.
Table 6 Recommended Dosage Modifications for Trametinib for Adverse Reactions
Severity of Adverse Reactiona
Dosage Modification for 
Trametinib b
Venous Thromboembolism 
Uncomplicated deep venous thrombosis (DVT) 
or pulmonary embolism (PE)
Withhold trametinib for up to 3 weeks.
If improved to Grade 0-1, resume 
trametinib at lower dose.
If not improved, permanently 
discontinue trametinib.
Life threatening PE
Permanently discontinue trametinib.
Cardiomyopathy 
Asymptomatic, absolute decrease in left 
ventricular ejection fraction (LVEF) of 10% or 
greater from baseline and is below institutional 
lower limit of normal (LLN) from pretreatment 
value
Withhold trametinib for up to 4 weeks.
If improved to normal 
LVEF value, resume 
trametinib at lower dose.
If not improved to normal LVEF 
value, permanently discontinue 

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Severity of Adverse Reactiona
Dosage Modification for 
Trametinib b
trametinib.
Symptomatic cardiomyopathy
Absolute decrease in LVEF of greater than 20% 
from baseline that is below LLN
Permanently discontinue trametinib.
Ocular Toxicities 
Retinal pigment epithelial detachments (RPED)
Withhold trametinib for up to 3 weeks.
If improved, resume 
trametinib at same or lower 
dose.
If not improved, permanently 
discontinue trametinib or resume 
trametinib at lower dose.
Retinal vein occlusion (RVO)
Permanently discontinue trametinib.
Pulmonary
Interstitial lung disease (ILD)/pneumonitis
Permanently discontinue trametinib.
Febrile Reactions 
Fever higher than 104°F
Fever complicated by rigors, hypotension, 
dehydration, or renal failure
Withhold trametinib until fever 
resolves, then resume trametinib at 
same or lower dose.
Skin Toxicities 
Intolerable Grade 2
Grade 3 or 4
Withhold trametinib for up to 3 weeks.
If improved, resume trametinib at 
lower dose.
If not improved, permanently 
discontinue.
Severe cutaneous adverse reactions (SCARs)
Permanently discontinue trametinib.
Other Adverse Reactions, including Hemorrhage 

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Severity of Adverse Reactiona
Dosage Modification for 
Trametinib b
Intolerable Grade 2
Any Grade 3
Withhold trametinib
If improved to Grade 0-1, resume at 
lower dose.
If not improved, permanently 
discontinue.
First occurrence of any Grade 4
Withhold trametinib until 
improves to Grade 0-1, then 
resume at lower dose.
Or
Permanently discontinue trametinib.
Recurrent Grade 4
Permanently discontinue trametinib.
a National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) 
version 5.0.
b See Table 5 for recommended dose reductions of trametinib.

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3.4
Study Calendar 
Screening
Baseline1 
Day 1 of 
every 
cycle1
Weekly2
28 
Days 
Safety 
FU13, 15
Long 
Term 
FU14,15
Trametinib3
X
X
Hydroxychloroquine4
X
X
Medical History
X
Height
X
Histologic confirmation of 
disease 
X
KRAS mutational status
X
Ophthalmology consult5
X
X
Cardiology evaluations6 
X
X
24-hour urine (if indicated)
X
Infectious diseases testing 7 
X
Physical exam, weight and 
ECOG
X
X
X
X
Vital Signs
X
X
X
CBC w/differential, Platelets 
X
X
X
X
X
Biochemical profile8
X
X
X
X
X
CK 
X
Urinalysis
X
Pregnancy test9
X
X
Thyroid tests TSH, T3, T4
X
X
Uric acid, amylase and lipase
X
X
X
PT, INR, PTT, fibrinogen
X
X
X
Tumor marker CEA, AFP, 
CA19-9
X
X
Baseline signs and symptoms
X
Concomitant medications
X
X
X
Adverse event evaluation
X
X

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Screening
Baseline1 
Day 1 of 
every 
cycle1
Weekly2
28 
Days 
Safety 
FU13, 15
Long 
Term 
FU14,15
Radiologic Evaluation10
X
X
X
X
Tumor biopsy11
X
 
X
Research blood for whole 
exome/panel
X
Research blood for Immune 
monitoring12
X
Research blood for serum p62 
12
X
Phone call or e-mail for 
survival every 6 month
X
1 Baseline and C1D1 evaluations do not need to be repeated if performed on screening or baseline 
in designated time frame. Cycle=28+/-3 days. All evaluations will be done within 3 days before 
Day 1 of every cycle. Screening evaluations will be repeated if treatment does not start within 28 
days after screening. 
2 Weekly until first restaging, after that every two weeks during treatment. Outside labs are 
acceptable.
3 2 mg of trametinib daily every day of every cycle. 
4 600 mg of HCQ PO twice daily every day of every cycle. 
5 A standard ophthalmologic exam must be completed at screening, C2D1, and every 3 cycles 
thereafter (i.e. C5D1, C8D1, etc.) and as clinically indicated to assess for retinopathies. The 
screening ophthalmologic exam should include: best corrected distance visual acuity (BCVA), an 
automated threshold visual field (VF) of the central 10 degrees (with retesting if an abnormality is 
noted), and spectral domain ocular coherence tomography (SD-OCT). Outside evaluations are 
acceptable.
6 EKG must be performed at screening and on Day 1 of every cycle. Echocardiogram must be 
completed at screening, C2D1, and every 3 cycles thereafter (i.e. C5D1, C8D1, etc.) and as 
clinically indicated. Troponin I test and cardiology consult only if clinically indicated. 
7 HIV, Hepatitis B and C serology. If screening serology results indicate potential HBV or HCV 
infection, viral load will be tested before starting investigational agents. TB testing will be 
performed only if clinically indicated.
8 Biochemical Profile: electrolytes, BUN, creatinine, AST, ALT, total and direct bilirubin, calcium, 
phosphorus, albumin, magnesium. 
9 Pregnancy test for female participants of childbearing potential (serum or urine; if urine is 
positive it must be confirmed with serum test 

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10 CT scan of chest, abdomen and pelvis (or MRI of chest, abdomen and pelvis if clinically 
indicated) every 8 (+/-1) weeks after start of study therapy. If patient taken off treatment for reason 
other than progression, CT scans will continue until progression or 5 months have passed since the 
start of study therapy whatever comes earlier. MRI of brain can be done at screening if clinically 
indicated.
11 Mandatory tumor biopsies will be performed at baseline and any day during week 3 of cycle 2. 
If patient disease progresses before this, post-treatment biopsy might be performed per PI 
discretion at the time of progression.
12 On Day 1 of cycles 1-4, then every 12 weeks until PD
13 +/- 1 week
14 After Safety Follow Up visit, subjects will be followed for adverse events by phone call or e-
mail at 60 (+/- 14 days) and 90 (+/- 14 days) days. After that every 6 (± 1) months by phone call 
or e-mail for survival. If patient is taken off treatment for reason other than disease progression 
before 5 months have passed since the start of study therapy, we will continue to invite patient 
every 8 (+/-1) weeks for imaging studies until disease progression or 5 months have passed since 
the start of study therapy whatever comes earlier. Outside scans are acceptable. 
15 If patients are not willing to come to the NIH Clinical Center, they may be followed by phone 
call or e-mail.

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3.5
Costs and Compensation
3.5.1
Costs
NIH does not bill health insurance companies or participants for any research or related clinical 
care that participants receive at the NIH Clinical Center. If some tests and procedures performed 
outside the NIH Clinical Center, participants may have to pay for these costs if they are not covered 
by insurance company. Medicines that are not part of the study treatment will not be provided or 
paid for by the NIH Clinical Center.
3.5.2
Compensation
No compensation is offered on this study.
3.5.3
Reimbursement 
The NCI will cover the costs of some expenses associated with protocol participation. Some of 
these costs may be paid directly by the NIH and some may be reimbursed to the 
participant/guardian as appropriate. The amount and form of these payments are determined by 
the NCI Travel and Lodging Reimbursement Policy.
3.6
Criteria for Removal from Protocol Therapy 
Prior to removal from the study, effort must be made to have all subjects complete a safety visits 
approximately 30 days following the last dose of study therapy. 
3.6.1
Criteria for Removal from Protocol Therapy

Participant requests to be withdrawn from active therapy 

Unacceptable toxicity (both drugs) as described in Section 3.3

PI discretion

Positive pregnancy test or intent to become pregnant

Drugs become unavailable

Initiation of therapy that prevents further administration of study treatment 

Confirmed disease progression based on radiographic progression per RECIST 1.1. 

Permanent loss of capacity to consent, per requirements of section 12.3
3.6.2
Off Study Criteria 

Death

Patient request to be withdrawn from study

PI discretion

Lost to follow up

PI decision to end the study

Screen failure.

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3.6.3
Lost to Follow-up
A participant will be considered lost to follow-up if he or she fails to return for 3 scheduled visits 
and is unable to be contacted by the study site staff. 
The following actions must be taken if a participant fails to return to the clinic for a required study 
visit:

The site will attempt to contact the participant and reschedule the missed visits and counsel 
the participant on the importance of maintaining the assigned visit schedule and ascertain 
if the participant wishes to and/or should continue in the study.

Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible, 3 telephone calls and, if 
necessary, an IRB approved certified letter to the participant’s last known mailing address 
or local equivalent methods). These contact attempts should be documented in the 
participant’s medical record or study file. 

Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up
4
CONCOMITANT MEDICATIONS/MEASURES 
All routine and appropriate supportive care (including blood products) will be provided during this 
study, as clinically indicated, and in accordance with the standard of care practices. Clinical 
judgment should be utilized in the treatment of any adverse event experienced by the patient. 
4.1
Prohibited Therapy
The following medications are not permitted to be taken concurrently with study therapy.

Any other anti-cancer systemic therapy.

Other investigational agents.

Any live vaccines (Inactivated vaccines are allowed).

The following QT prolonging agents: mesoridazine, thioridazine, pimozide, terfenadine, 
cisapride, sparfloxacin, saquinavir, ziprasidone, dronedarone, piperaquine, amisulpride 
(Other agents with the possibility of QT prolongation should be used with caution).

Non-steroid anti-inflammatory medications (i.e. naproxen, ibuprofen, piroxicam, 
diclofenac, meloxicam).

Anti-platelet agents (i.e. clopidogrel, prasugrel, dipyridamole).

Serotonin reuptake inhibitors (SSRIs) should be used with caution.

Tamoxifen.
5
CORRELATIVE STUDIES FOR RESEARCH
5.1
Biospecimen Collection
A description of correlative studies including a brief statement of rationale and processing 
information is made below.

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Test/assay
Sample 
volume 
(approx.)
Type of tube/ 
tissue sample a
Collection 
point 
Location of specimen 
analysis
Blood Samples
Immune- 
monitoring by 
FACS
Blood, 100 
ml
EDTA (Purple 
top tubes)
See Study 
Calendar 3.4
BPC (Figg Lab)
Serum p62 by 
ELISA
4 ml
SST tube 
See Study 
Calendar 3.4
BPC (Figg Lab)
Whole 
exome/panel
Blood, 2.5 
mL
1 PAX gene 
DNA tube
See Study 
Calendar 3.4
BPC (Figg Lab)
Tumor Samples
IHC for immune 
cell infiltration
Tumor 
sample
At time of 
biopsies
Laboratory of Pathology
RNA seq
Tumor 
sample
At time of 
biopsies
Laboratory of Pathology 
Whole 
exome/panel
Tumor 
sample
At time of 
biopsies
Laboratory of Pathology 
Proteomics
Tumor 
sample
At time of 
biopsies
Greten Laboratory
Metabolomics
Tumor 
sample
At time of 
biopsies
Greten Laboratory
RNA Nanostring 
analysis 
Tumor 
sample
At time of 
biopsies
Greten Laboratory
IHC
Tumor 
sample
At time of 
biopsies
Greten Laboratory
a.
Please note that tubes and media may be substituted based on availability with the permission of the 
PI or laboratory investigator.
5.1.1
Correlative studies of blood samples
Blood samples will be collected at time points indicated in the Study Calendar. Blood samples will 
be initially sent to the Blood Processing Core (BPC) for barcoding, storage and analysis.
5.1.1.1
Immune monitoring
We will analyze PBMC for quantitative and functional changes of effector cells by FACS. The 
effect on (i) CD4 T cell number and activity, (ii) CD8 T cell number and activity, (iii) NK cell 
number and activity, (iv) Treg number, (v) MDSC: frequency + functional assay, and (vi) the 
detection of tumor-associated antigens using tetramer assay. These data will provide further 

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information in terms of potential immune modulation effect with the combination therapy of 
trametinib/HCQ. These experiments will be done in BPC.
5.1.1.2
Serum p62 level
We predict that p62 levels may be elevated in serum with treatment as this has been demonstrated 
to be a biomarker for impaired autophagy [51]. We will test this hypothesis by obtaining blood 
samples from patients during routine blood collection and utilizing a commercially available 
ELISA assay to determine the concentration of p62 in the bloodstream. This study may also lead 
to a predictive biomarker for response to trametinib plus HCQ. These experiments will be done in 
BPC.
5.1.2
Tumor studies (non-genetic analysis)
Mandatory tumor biopsies will be performed at baseline and anytime during week 3 of Cycle 2. If 
patient disease progresses before week 3 of Cycle 2, post-treatment biopsy might be performed 
per PI discretion at the time of progression. It is preferred that at least two core biopsies ≥18 
gauge in diameter and ≥1 cm in length will be obtained. 
5.1.2.1
IHC
IHC will be performed on tumor tissue for assessment of immune cell infiltration (e.g. CD3+ 
CD4/8 cells, PDL1 etc.). Immunohistochemistry will be performed in the Laboratory of Pathology 
under the direction of Dr. David Kleiner.
5.1.2.2
Omics study
Tumor samples will be collected for proteomics and metabolomics studies to investigate the 
differential expression of protein and metabolite that might be associated with the treatment 
outcome or efficacy. These experiments will be done in Dr. Greten lab.
5.2
Samples for Genetic/Genomic Analysis
5.2.1
KRAS evaluation
KRAS mutation detection will be formed with TruSight™ Oncology 500 panel in Lab of 
Pathology.
5.2.2
RNA Nanostring analysis
Tumor samples will be used for gene expression profiling with Nanostring analysis (nCounterPan 
Cancer Immunology Profile) in BPC.
5.2.3
Whole exome/Panel (tumor/normal) and RNAseq (tumor)
Whole exome will be done on tumor and blood sample. RNAseq will be done on tumor for 
expressed somatic mutations and neoantigen discovery. Tumor material for these analyses will be 
sent to the Laboratory of Pathology, the laboratory of Drs. Javed Khan and Paul Meltzer (NCI 
Genetics Branch). Specifically, the expression of different signaling pathway, including interferon 
gamma signaling, immune cell functional molecular, e.g. perforin and granzyme, will be 
investigated
5.2.4
Management of Results
Subjects will be contacted if a clinically actionable gene variant is discovered. Clinically 
actionable findings for the purpose of this study are defined as disorders appearing in the 

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American College of Medical Genetics and Genomics recommendations for the return of 
incidental findings that is current at the time of primary analysis. (A list of current guidelines is 
maintained 
on 
the 
CCR 
intranet: 
https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists). 
Subjects 
will be contacted at this time with a request to provide a blood sample to be sent to a CLIA 
certified laboratory. If the research findings are verified in the CLIA certified lab, the subject 
will be offered the opportunity to come to NIH (at our expense) to have genetic education and 
counseling to explain this result. If the subject does not want to come to NIH, a referral to a local 
genetic healthcare provider will be provided (at their expense).
This is the only time during the course of the study that incidental findings will be returned. No 
interrogations regarding clinically actionable findings will be made after the primary analysis.
5.3
Sample Storage, Tracking and Disposition
Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system. 
Should a CRIS screen not be available, the CRIS downtime procedures will be followed. Samples 
will not be sent outside the National Institutes for Health (NIH) without appropriate approvals 
and/or agreements, if required.
All samples will be barcoded, with data entered and stored in the secure databases. These databases 
create a unique barcode ID for every sample and sample box, which cannot be traced back to 
patients without database access. The data recorded for each sample includes the patient ID, name, 
trial name/protocol number, time drawn, cycle time point, dose, material type, as well as box and 
freezer location. Patient demographics associated with the clinical center patient number are 
provided in the system. For each sample, there are notes associated with the processing method 
(delay in sample processing, storage conditions on the ward, etc.).
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -800C according 
to stability requirements. 
Access to stored clinical samples is restricted. Samples will be stored until requested by a 
researcher named on the protocol. All requests are monitored and tracked in database. All 
researchers are required to sign a form stating that the samples are only to be used for research 
purposes associated with this trial (as per the IRB approved protocol) and that any unused samples 
must be returned. It is the responsibility of the NCI Principal Investigator to ensure that the samples 
requested are being used in a manner consistent with IRB approval. 
5.3.1
Samples Managed by Dr. Figg’s Blood Processing Core (BPC) 
BPC contact information 
Please e-mail at NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the 
Friday before is preferred).
For sample pickup, page 102-11964.
For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 
240-760-6190 (main clinical pharmacology lab number).
For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov.

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5.3.2
Protocol Completion/Sample Destruction
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are 
remaining at the completion of the protocol will be stored in the conditions described in sections 
above. The study will remain open so long as sample or data analysis continues. Samples from 
consenting subjects will be stored until they are no longer of scientific value or if a subject 
withdraws consent for their continued use, at which time they will be destroyed. The PI will record 
any loss or unanticipated destruction of samples as a deviation. Reports will be made per the 
requirements of section 7.2.
If the patient withdraws consent the participant’s data will be excluded from future distributions, 
but data that have already been distributed for approved research use will not be able to be 
retrieved.
6
DATA COLLECTION AND EVALUATION 
6.1
Data Collection
The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-compliant data 
capture system provided by the NCI CCR and ensuring data accuracy, consistency and timeliness. 
The principal investigator, associate investigators/research nurses and/or a contracted data 
manager will assist with the data management efforts. Primary and final analyzed data will have 
identifiers so that research data can be attributed to an individual human subject participant.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. 
Document AEs from the first study intervention, day 1 of cycle 1 through 90 days after the study 
agent (s) was/were last administered. Beyond 90 days after the last intervention, only adverse 
events which are serious and related to the study intervention need to be recorded. 
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following: 

Results in discontinuation from the study 

Is associated with clinical signs or symptoms 

Requires treatment or any other therapeutic intervention 

Is associated with death or another serious adverse event, including hospitalization 

Is judged by the Investigator to be of significant clinical impact 
If any abnormal laboratory result is considered clinically significant, the investigator will provide 
details about the action taken with respect to the test drug and about the patient’s outcome. 
Information on all concomitant medications, administered blood products, as well as interventions 
occurring during the study must be recorded on the patient’s eCRF.
End of study procedures: Data will be stored according to HHS, FDA, and NIH Intramural 
Records Retention Schedule regulations as applicable. 
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in section 7.2.1. 

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6.2
Data Sharing Plan 
6.2.1
Human Data Sharing Plan 
The PI will share coded linked human data generated in this research for future research 
in a NIH-funded or approved public repository clinicaltrials.gov and dbGaP
in BTRIS 
in publication and/or public presentations
at the time of publication or shortly thereafter. 
6.2.2
Genomic Data Sharing Plan 
Unlinked genomic data will be deposited in public genomic databases such as dbGaP in 
compliance with the NIH Genomic Data Sharing Policy 
6.3
Response Criteria 
For the purposes of this study, patients should be re-evaluated every 8 (+/-1) weeks. In addition, 
confirmatory scans should also be obtained 4-8 weeks following initial documentation of objective 
response. 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1). Changes in the largest diameter (unidimensional measurement) of the tumor lesions 
and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. 
6.3.1
Disease Parameters
Measurable disease: Measurable lesions are defined as those that can be accurately measured in at 
least one dimension (longest diameter to be recorded) as: 

By chest x-ray: >20 mm; 

By CT scan: 
o
Scan slice thickness 5 mm or under as >10 mm 
o
Scan slice thickness >5 mm: double the slice thickness 

With calipers on clinical exam: >10 mm. 
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters).
Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph node 
must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended 
to be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured 
and followed.
Non-measurable disease: All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pneumonitis, inflammatory breast disease, and abdominal masses 
(not followed by CT or MRI), are considered as non-measurable.

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Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts.
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, if 
they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions.
Target lesions: All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded and 
measured at baseline. Target lesions should be selected on the basis of their size (lesions with the 
longest diameter), be representative of all involved organs, but in addition should be those that 
lend themselves to reproducible repeated measurements. It may be the case that, on occasion, the 
largest lesion does not lend itself to reproducible measurement in which circumstance the next 
largest lesion which can be measured reproducibly should be selected. A sum of the diameters 
(longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated 
and reported as the baseline sum diameters. If lymph nodes are to be included in the sum, then 
only the short axis is added into the sum. The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the disease.
Non-target lesions: All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline. Measurements of these lesions are not required, but the presence, absence, or 
in rare cases unequivocal progression of each should be noted throughout follow-up.
6.3.2
Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or calipers. All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment.
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam.
Clinical lesions: Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers 
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a 
ruler to estimate the size of the lesion, is recommended. 
Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung. However, CT is preferable. 
Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater 
than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is 
also acceptable in certain situations (e.g. for body scans). 
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; 
however, there are many image acquisition variables involved in MRI, which greatly impact image 
quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable 

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globally. As with CT, if an MRI is performed, the technical specifications of the scanning 
sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, 
as with CT, the modality used at follow-up should be the same as was used at baseline and the 
lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the 
RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases. Ideally, the same type of scanner should be used, and the image acquisition 
protocol should be followed as closely as possible to prior scans. Body scans should be performed 
with breath-hold scanning techniques, if possible.
Ultrasound: Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement. Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next. If new lesions are identified by ultrasound during the study, confirmation by CT or MRI is 
advised. If there is concern about radiation exposure at CT, MRI may be used instead of CT in 
selected instances.
Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor evaluation is not 
advised. However, such techniques may be useful to confirm complete pathological response when 
biopsies are obtained or to determine relapse in trials where recurrence following complete 
response (CR) or surgical resection is an endpoint.
Cytology, Histology: These techniques can be used to differentiate between partial responses (PR) 
and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell 
tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease.
6.3.3
Response Criteria
6.3.3.1
Evaluation of Target Lesions
Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm.
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking 
as reference the baseline sum of diameters.
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest 
on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute 
increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered 
progression).
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum of diameters while on study.

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6.3.3.2
Evaluation of Non-Target Lesions
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level. All lymph nodes must be non-pathological in size (<10 mm short axis).
Note: If tumor markers are initially above the upper normal limit, they must normalize for a patient 
to be considered in complete clinical response.
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression 
of existing non-target lesions. Unequivocal progression should not normally trump target lesion 
status. It must be representative of overall disease status change, not a single lesion increase. 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances, and the progression status should be confirmed at 
a later time by the review panel (or Principal Investigator).
6.3.3.3
Evaluation of Best Overall Response (BOR)
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started). The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria.
For Patients with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Respons
e
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
>4 wks. Confirmation**
CR
Non-CR/Non-PD
No
PR
CR
Not evaluated
No
PR
PR
Non-CR/Non-
PD/not evaluated
No
PR
>4 wks. Confirmation**
SD
Non-CR/Non-
PD/not evaluated
No
SD
Documented at least once >4 
wks. from baseline**
PD
Any
Yes or No
PD
Any
PD***
Yes or No
PD
Any
Any
Yes
PD
no prior SD, PR or CR
*
See RECIST 1.1 manuscript for further details.
**
Only for non-randomized trials with response as primary endpoint.
***
In exceptional circumstances, unequivocal progression in non-target lesions may 
be accepted as disease progression.
Note: Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.” Every effort should be made to 
document the objective progression even after discontinuation of treatment.
For Patients with Non-Measurable Disease (i.e., Non-Target Disease)

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Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD
* ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised
6.3.3.4
Duration of Response
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented.
Duration of stable disease: Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements. 
6.3.3.5
Modified Immune-mediated response criteria (imRC)
Modified immune-mediated response criteria (imRC) will also be employed in this study. This 
new classification is based on the recent learning from clinical studies with cancer 
immunotherapies that even if some new lesions appear at the beginning of a treatment or if the 
total tumor burden does not increase substantially, tumor regressions or stabilizations might still 
occur later. The irRC were created using bi-dimensional measurements (as previously widely used 
in the World Health Organization criteria). For this trial, the concepts of the irRC are combined 
with RECIST 1.1 to come up with the modified imRC. Please refer to Appendix D for further 
details.
Progression-Free Survival: PFS is defined as the duration of time from start of treatment to time 
of progression or death, whichever occurs first.
Overall Survival: Overall survival is defined as the duration of time from the start of treatment to 
time of death of any cause. 
6.4 Toxicity Criteria 
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study. The descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. 
All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy 
of 
the 
CTCAE 
version 
5.0 
can 
be 
downloaded 
from 
the 
CTEP 
web 
site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_50). 
All 
appropriate treatment areas should have access to a copy of the CTEP Active Version of CTCAE). 

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7
NIH REPORTING REQUIREMENTS / DATA SAFETY MONITORING PLAN
7.1
Definitions
Please refer to definitions provided in Policy 801: Reporting Research Events found here.
7.2
OHSRP Office of Compliance and Training/IRB Reporting
7.2.1
Expedited Reporting
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802: Non-Compliance Human Subjects Research found here. Note: Only IND Safety Reports that 
meet the definition of an unanticipated problem will need to be reported per these policies.
7.2.2
NIH Intramural IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here. 
7.2.3
NCI Clinical Director Reporting 
Problems expeditiously reported to the OHSRP in iRIS will also be reported to the NCI Clinical 
Director. A separate submission is not necessary as reports in iRIS will be available to the Clinical 
Director.
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to progressive 
disease. 
To report these deaths, please send an email describing the circumstances of the death to Dr. Dahut 
at NCICCRQA@mail.nih.gov within one business day of learning of the death.
7.3
NIH Required Data and Safety Monitoring Plan
The clinical research team will meet on a weekly basis when patients are being actively treated on 
the trial to discuss each patient. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in section 
7.2.1 will be submitted within the appropriate timelines. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff.
8
SPONSOR PROTOCOL/SAFETY REPORTING
8.1
Definitions
8.1.1
Unanticipated Adverse Device Effect 
Unanticipated adverse device effect is any serious adverse effect on health or safety, any life-
threatening problem or death caused by, or associated with a device, if that effect, problem, or 
death was not previously identified in nature, severity, or degree of incidence in the application; 
or any other unanticipated serious problem associated with a device that relates to the rights, safety, 
or welfare of subjects.

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8.2
Assessment of Adverse Device Effects
AE information collected will include event description, date of onset, assessment of severity and 
relationship to study product and alternate etiology (if not related to study product), date of 
resolution of the event, seriousness and outcome. The assessment of severity and relationship to 
the study product will be done only by those with the training and authority to make a diagnosis 
and listed on the Investigator or Record Form as the site principal investigator or sub-investigator. 
AEs occurring during the collection and reporting period will be documented appropriately 
regardless of relationship. AEs will be followed through resolution.
UADEs will be:

Assessed for severity and relationship to study product and alternate etiology (if not related 
to study product) by a licensed study physician listed on the Investigator or Record Form 
as the site principal investigator or sub-investigator.

Recorded on the appropriate SAE report form, the medical record and captured in the 
clinical database.

Followed through resolution by a licensed study physician listed on the Investigator or 
Record Form as the site principal investigator or sub-investigator.
8.3
Reporting of Unanticipated Adverse Device Effects
Any UADE must be submitted immediately (within 24 hours of awareness) to OSRO Safety using 
the CCR SAE report form. 
All UADE reporting must include the elements described in Section 8.2. 
UADE reports will be submitted to the Center for Cancer Research (CCR) at: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. CCR SAE report form and 
instructions can be found at: 
https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions 
Following the assessment of the SAE by OSRO, other supporting documentation of the event may 
be requested by the OSRO Safety and should be provided as soon as possible.
8.4
Safety Reporting Criteria to the Pharmaceutical Collaborators
Reporting will be per the collaborative agreement.
8.5
Sponsor Protocol Deviation Reporting
A Protocol Deviation is defined as any non-compliance with the clinical trial Protocol, Manual of 
Operational Procedures (MOP) and other Sponsor approved study related documents, GCP, or 
protocol-specific procedural requirements on the part of the participant, the Investigator, or the 
study site staff inclusive of site personnel performing procedures or providing services in support 
of the clinical trial.
It is the responsibility of the study Staff to document any protocol deviation identified by the Staff 
or the site Monitor in the CCR Protocol Deviation Tracking System (PDTS) online application. 
The entries into the PDTS online application should be timely, complete, and maintained per CCR 
PDTS user requirements. 

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In addition, any deviation to the protocol should be documented in the participant’s source records 
and reported to the reviewing IRB per their guidelines. OSRO required protocol deviation 
reporting is consistent with E6(R2) GCP: Integrated Addendum to ICH E6(R1): 4.5 Compliance 
with Protocol; 5.18.3 (a), and 5.20 Noncompliance; and ICH E3 16.2.2 Protocol deviations.
9
CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights of the participants are protected, that 
the study is implemented per the approved protocol, Good Clinical Practice and standard operating 
procedures, and that the quality and integrity of study data and data collection methods are 
maintained. 
Monitoring for this study will be performed by NCI CCR Office of Sponsor and Regulatory 
Oversight (OSRO) Sponsor and Regulatory Oversight Support (SROS) Services contractor. 
Clinical site monitoring activities will be based on OSRO standards, FDA Guidance E6(R2) Good 
Clinical Practice: Integrated Addendum to ICH E6(R1) March 2018, and applicable regulatory 
requirements.
Details of clinical site monitoring will be documented in a Clinical Monitoring Plan (CMP) 
developed by OSRO. CMPs will be protocol-specific, risk-based and tailored to address human 
subject protections and integrity of the study data. OSRO will determine the intensity and 
frequency of monitoring based on several factors, including study type, phase, risk, complexity, 
expected enrollment rate, and any unique attributes of the study and the site. The Sponsor will 
conduct a periodic review of the CMP to confirm the plan's continued appropriateness. A change 
to the protocol, significant or pervasive non-compliance with GCP, or the protocol may trigger 
CMP updates.
OSRO SROS Monitoring visits and related activities will be conducted throughout the life cycle 
of each protocol. The first activity is before the study starts to conduct a Site Assessment Visit 
(SAV) (as warranted), followed by a Site Initiation Visit (SIV), Interim Monitoring Visit(s) 
(IMVs), and a study Close-Out Visit (COV).
Some monitoring activities may be performed remotely, while others will take place at the study 
site(s). Monitoring visit reports will describe visit activities, observations, findings of protocol 
non-adherence and associated action items or follow-up required for resolution of findings. 
Monitoring reports will be distributed to the study PI, NCI CCR QA, coordinating center (if 
applicable) and the OSRO regulatory file.
The site Monitor will inform the study team of any deviations observed during monitoring visits. 
If unresolved, the Monitor will request that the site Staff enter the deviations in the CCR Protocol 
Deviation Tracking System (PDTS) for deviation reporting to the Sponsor and as applicable per 
institutional and IRB guidance.
10 STATISTICAL CONSIDERATIONS 
10.1 Statistical hypothesis 
10.1.1 Primary Objective 

To determine whether the 5-month PFS of the trametinib plus hydroxychloroquine (HCQ) 
combination in subjects with refractory bile tract carcinoma (BTC) with KRAS mutation 
exceeds 25%.

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10.1.2 Secondary Objectives 

To determine the safety, tolerability and feasibility of the combination with trametinib plus 
HCQ in refractory BTC with KRAS mutation. 

To evaluate the response rate and overall survival the combination with trametinib plus 
HCQ in patients with refractory BTC with KRAS mutation.
10.2 Sample Size Determination
The primary objective of this study is to determine in a preliminary, limited size trial whether 
trametinib in combination with HCQ is associated with a 5-month progression free probability, 
which exceeds 25% when used to treat patients with cholangiocarcinoma. 
Based on our analysis of data from previous trials of patients with similar eligibility requirements 
the median progression free survival in BTC is 2.5 months[8]. This translates to 25% without 
progressive disease at 5 months following an exponential failure model. Based on these results, it 
would be useful to demonstrate whether trametinib in combination with hydroxychloroquine is 
able to be associated with a median PFS of 5 months, which would correspond to 50% of patients 
having stable disease at 5 months. The trial will be conducted using a two-stage optimal design 
[52]. In order to attempt to determine if the agent offers any improvement, using alpha=0.10 and 
beta =0.10 as acceptable error probabilities, the trial will target 50% as the desirable proportion of 
patients who are still without progression at the five-month evaluation (p1=0.50), and will be 
considered inadequate if only a fraction consistent with 20% are without progression by the same 
evaluation time (p0=0.20).
Initially, 10 patients will be enrolled and evaluated for progression. Enrollment will be temporarily 
halted after the 10th patient has been accrued, unless we know that 3 patients have passed the 5-
month point without progression. If 3 or more of the first 10 patients enrolled have not progressed 
at the 5-month evaluation, then accrual will continue until a total of 17 patients have been entered. 
If, among the first 10 patients accrued, 0 to 2 are able to be progression-free at the 5-month 
evaluation, then no further patients will be enrolled after such a determination has been made. If 6 
or more of the total cohort of 17 patients have been found to be progression-free at 5 months, then 
this will indicate an adequate progression free probability to justify further consideration of 
trametinib in combination with hydroxychloroquine in this population of patients. On the other 
hand, if 3 to 5 of 17 are progression-free at 5 months, this will be considered insufficient. Under 
the null hypothesis (20% progression free at 5 months), the probability of being able to stop accrual 
after 10 patients have been evaluated at 5 months is 68%. 
In addition to evaluation of the proportion of patients that are progression-free at 5 months, the 
progression-free survival for patients will also be analyzed via a Kaplan-Meier curve. This curve 
will be compared informally to other published results in similar patients. As well, the overall 
response rate will be reported, and the overall survival will be reported using a Kaplan-Meier curve. 
It is anticipated that up to 10 patients per year will be able to enroll onto this protocol. Thus, it is 
expected that accrual of up to 17 total patients can be completed in approximately 2 years. In order 
to allow for a small number of unevaluable patients and screen failures, the accrual ceiling will be 
set at 30 patients. 
To evaluate the response rate, proportion of patients obtaining CR and PR per RECIST 1.1 criteria 
of all evaluable patients will be analyzed. 

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To address safety, tolerability and feasibility of trametinib in combination with 
hydroxychloroquine, adverse events will be tabulated by grade according to CTCAE and analyzed 
and reported descriptively. The fraction of patients who experience a response will be reported 
along with confidence intervals.
10.3  Population for Analysis 
Any patient who receives at least one dose of both agents will be included in the efficacy 
evaluations.
Any patients who receive at least one dose of either agent will be included in the safety evaluations.
10.4 Statistical analysis
10.4.1 General approach
The fraction of patients who do not have progressive disease by 5 months will be reported.
10.4.2 Analysis of the Primary Endpoints 
The fraction of patients who are able to not have progressive disease at 5 months will be reported 
along with a 95% confidence interval. A Kaplan-Meier curve of PFS will also be created and 
reported along with the 5-month PFS probability and its 95% confidence interval.
10.4.3 Analysis of the Secondary Endpoint
The safety of the treatment will be monitored, and any toxicities identified will be reported by type 
and grade. The feasibility and tolerability will be assessed and reported descriptively.
In each cohort, the fraction of patients who experience a response (PR + CR) will be reported along 
with 80% and 95% two-sided confidence intervals.
Overall survival will be calculated from the on-study date using the Kaplan-Meier method.
10.4.4 Safety analysis
The safety of the treatment will be monitored, and any toxicities identified will be reported by type 
and grade. 
10.4.5 Baseline Descriptive Statistics
Baseline demographic characteristics will be reported.
10.4.6 Planned Interim Analyses
There are no planned interim analyses for efficacy.
10.4.7 Sub-group analyses
None are planned.
10.4.8 Tabulations of individual participant data
None.
10.4.9 Exploratory Analyses
The following objectives will result in descriptive or comparative analyses when adequate data 
exist to perform them:

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To evaluate the bioactivity of the combination of trametinib plus HCQ against the MEK1/2 
and autophagy pathways by immunohistochemistry.
To measure changes in immune parameters in the peripheral blood and tumors of patients 
with refractory KRAS mutation BTC treated with the combination of trametinib plus HCQ. 
To explore mechanism of primary and secondary resistance to the combination of trametinib 
plus HCQ in patients with refractory KRAS mutation BTC.
To evaluate the relationship between the RR, OS and immune parameters, in patients with 
refractory KRAS mutation BTC treated with the combination of trametinib plus HCQ. 
Any exploratory evaluations which generate quantitative measures will be done using 
descriptive statistics including confidence intervals when appropriate. Any statistical tests 
performed for evaluation of exploratory objectives will be done without formal adjustment 
for multiple comparisons, but in the context of the number of tests performed.
11 COLLABORATIVE AGREEMENTS
11.1 Cooperative Research and Development Agreement (CRADA) 
CRADA for this protocol is currently being negotiated between Thoracic & GI Malignancy 
Branch, NCI, NIH and Novartis, the manufacturer of trametinib.
12 HUMAN SUBJECTS PROTECTIONS 
12.1 Rationale for Subject Selection
No individual who meets the criteria for eligibility will be excluded from participation based on 
their race, ethnicity, gender, or socioeconomic status. Particular attention will be made to acquire 
a broad and diversified population.
12.2 Participation of Children
Children (younger than 18 years) will not be included in this protocol due to the limited data on 
this combination in children and the different biology of childhood malignancy.
12.3 Participation of Subjects Unable to Give Consent
Adults unable to consent are excluded from enrolling in the protocol. However, it is possible that 
subjects enrolled in the protocol may permanently lose the capacity to consent for themselves 
during the course of this study. If a subject loses the capacity to consent during the course of the 
study for reasons unrelated to protocol participation and is receiving direct benefit from the study 
therapy in the opinion of the PI, the subject may be retained on the study therapy with the 
permission of the alternate decision maker. If the permanent loss of capacity is due to toxicity from 
the study therapy or disease progression, the participant will be removed from study therapy as 
required per protocol, but may be retained on study to be followed for safety reasons and/or overall 
survival as described in the Study Calendar 3.4. The follow-up procedures involve non-invasive, 
low risk studies, with the exception of scanning. Scanning during follow-up will be performed 
only in participants who are taken of treatment for reasons other than disease progression and only 
within 5 months of study initiation. These scans are clinically indicated. The benefit of a safety 
follow up would outweigh the risks of such procedures. All subjects will be offered the opportunity 
to fill in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 

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person can make decisions about their medical care in the event that they become incapacitated or 
cognitively impaired during the course of the study. Please see section 12.5 for the consent 
procedure.
12.4 Risk/Benefit Assessment for All Participants
12.4.1 Known Potential Risks
The primary risk to patients participating in this research study is from the toxicity of study drugs.
All care will be taken to minimize study treatment side effects, but they can be unpredictable in 
nature and severity.
12.4.1.1 Risk of Biopsy
All care will be taken to minimize risks that may be incurred by tumor sampling. However, there 
are procedure-related risks (such as bleeding, infection, visceral injury, hematoma and death) that 
will be explained fully during informed consent. However, it may be noted that we have not 
experienced a single bleeding event in approximately 250 patients who have undergone liver 
biopsy procedures recently for other standard of care or research testing. The biopsies will be 
performed in interventional radiology.
12.4.1.2 Risks of Exposure to Ionizing Radiation 
The study will involve radiation from the following sources:

Up to 7 CT scans per year for disease assessment

2 CT scans for the collection of 2 mandatory biopsies
Subjects in this study may be exposed to approximately 9.3 rem per year. This amount is more 
than would be expected from everyday background radiation. Being exposed to excess radiation 
can increase the risk of cancer. The risk of getting cancer from the radiation exposure in this study 
is 0.9 out of 100 (0.9%) and of getting a fatal cancer is 0.5 out of 100 (0.5%). 
12.4.1.3 Risks of CT Scans
In addition to the radiation risks discussed above, CT scans may include the risks of an allergic 
reaction to the contrast. Participants might experience hives, itching, headache, difficulty 
breathing, increased heartrate and swelling.
12.4.1.4 Risks of sedation
Biopsies will be done under sedation. Potential side effects of sedation include headache, nausea 
and drowsiness. These side effects usually go away quickly.
12.4.1.5 Risks of ophthalmologic exam
Risks of ophthalmologic exam include discomfort, blurry vision and light sensitivity.
12.4.1.6 Risks of Blood Collection 
Risks of blood draws include pain and bruising in the area where the needle is placed, 
lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood 
cell count (anemia) can develop. Up to the 170 ml of blood may be collected at any visit, but no 
more than 550 ml per 8 weeks period.

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12.4.1.7 Risks of EKG
Risks include some minor skin irritation from the electrodes.
12.4.1.8 Risks of Echocardiogram
Risks include mild discomfort during the test.
12.4.1.9 Other Risks
Risks include the possible occurrence of any of a range of side effects which are listed in the 
Consent Document or this protocol document. Frequent monitoring for adverse effects will help 
to minimize the risks associated with administration of the study agents.
12.4.1.10
Risk of losing data 
This includes the risk that data obtained during this study, including data related to genotype, DNA 
sequencing or risk for disease tendency or trait can be released to members of the public, insurers, 
employers, or law enforcement agencies. Although there are no plans to release results to the 
patients, family members or health care providers, this risk will be included in the informed 
consent document.
12.4.1.11
Risk of receiving unwanted information
Anxiety and stress may arise as a result of the anticipation that unwanted information regarding 
disease related DNA sequencing or disease tendencies, or misattributed paternity. Patients will be 
clearly informed that the data related to DNA sequencing and genetic analysis is coded, 
investigational and will not be shared with patients, family members or health care providers.
12.4.2 Known Potential Benefits
The study drug may help to control the disease. The results may help the investigators learn more 
about the disease and develop new treatments for patients with this disease
12.4.3 Assessment of Potential Risks and Benefits
BTC treatment needs improved therapy options. Preclinical studies suggest that study therapy may 
have tremendous anti-tumor efficacy. 
A number of clinically appropriate strategies to minimize risks to patients have been built into the 
protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management 
guidelines. Overall, the potential benefit of the study treatment in subjects with BTC outweigh the 
risks associated with study drugs.
The potential benefit to a patient that participates in this study is better control of their tumor 
growth and disease recurrence which may or may not have a favorable impact on symptoms and/or 
survival.
Potential adverse reactions attributable to the administration of the study drug utilized in this trial 
are discussed in Sections 1.2.5.2 and 1.2.6.2. All care will be taken to minimize side effects, but 
they can be unpredictable in nature and severity.
12.5 Consent Process and Documentation
The informed consent document will be provided as a physical or electronic document to the 
participant or consent designee(s) as applicable for review prior to consenting. A designated study 
investigator will carefully explain the procedures and tests involved in this study, and the 

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associated risks, discomforts and benefits. In order to minimize potential coercion, as much time 
as is needed to review the document will be given, including an opportunity to discuss it with 
friends, family members and/or other advisors, and to ask questions of any designated study 
investigator. A signed informed consent document will be obtained prior to entry onto the study.
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms used in compliance with 
policy, including HRPP Policy 303) per discretion of the designated study investigator and with 
the agreement of the participant/consent designee(s). Whether in person or remote, the privacy of 
the subject will be maintained. Consenting investigators (and participant/consent designee, when 
in person) will be located in a private area (e.g., clinic consult room). When consent is conducted 
remotely, the participant/consent designee will be informed of the private nature of the discussion 
and will be encouraged to relocate to a more private setting if needed.
Consent will be documented with required signatures on the physical document (which includes 
the printout of an electronic document sent to participant) or as described below, with a manual 
(non-electronic) signature on the electronic document.  When required, witness signature will be 
obtained similarly as described for the investigator and participant.
Manual (non-electronic) signature on electronic document:
When a manual signature on an electronic document is used for the documentation of consent at 
the NIH Clinical Center, this study will use the following to obtain the required signatures:

Adobe platform (which is not 21 CFR Part 11 compliant); or,  

iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of the 
approved consent document on screens at their respective locations (if remote consent); the same 
screen may be used when in the same location but is not required.  
Both the investigator and the subject will sign the document using a finger, stylus or mouse. 
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent Process 
for additional information (e.g., verification of participant identity when obtaining consent 
remotely) found here.
12.5.1 Consent Process for Adults Who Lack Capacity to Consent to Research Participation
For participants addressed in section 12.3, an LAR will be identified consistent with Policy 403 
and informed consent obtained from the LAR, as described in Section 12.5
13 REGULATORY AND OPERATIONAL CONSIDERATIONS
13.1 Study Discontinuation and Closure
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants. If the 
study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform 
study participants, the Institutional Review Board (IRB), and sponsor and will provide the 
reason(s) for the termination or suspension. Study participants will be contacted, as applicable, 
and be informed of changes to study visit schedule.

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 Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants

Demonstration of efficacy that would warrant stopping 

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
13.2 Quality Assurance and Quality Control
The clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion. An individualized quality management plan 
will be developed to describe a site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical 
trial is conducted and data are generated and biological specimens are collected, documented 
(recorded), and reported in compliance with the protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., 
Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source data/documents, 
and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities.
13.3 Conflict of Interest Policy
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. The study leadership in conjunction with the NCI has established policies and 
procedures for all study group members to disclose all conflicts of interest and will establish a 
mechanism for the management of all reported dualities of interest.
13.4 Confidentiality and Privacy
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor. This confidentiality is extended to cover testing of biological samples 
and genetic tests in addition to the clinical information relating to participants. Therefore, the study 
protocol, documentation, data, and all other information generated will be held in strict confidence. 

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No information concerning the study or the data will be released to any unauthorized third party 
without prior written approval of the sponsor. 
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records.
The study participant’s contact information will be securely stored at each clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements.
Study participant research data will not include the participant’s contact or identifying information. 
Rather, individual participants and their research data will be identified by a unique study 
identification number. The study data entry and study management systems used by clinical sites 
will be secured and password protected. At the end of the study, all study databases will be 
archived at the NIH Clinical Center.
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued 
by the National Institutes of Health (NIH). This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that 
would identify research participants, Certificates of Confidentiality help achieve the research 
objectives and promote participation in studies by helping assure confidentiality and privacy to 
participants.
14 PHARMACEUTICAL INFORMATION 
14.1 Trametinib 
14.1.1 Source
Commercial supplies of trametinib will be supplied by Novartis
14.1.2 Acquisition and Accountability
Trametinib will be provided by Novartis and delivered directly to the NIH Pharmacy. Individual 
bottles with tablets will be prepared for each study participant according to assigned dose by NIH 
Pharmacy personnel. Patients will pick up bottles at NIH Pharmacy and will return bottles and not-
used tablets after completion of every cycle together with Medication Diary to Study Coordinator. 
After review of leftover tablets and Medication Diary, unused tablets will be returned to pharmacy 
and disposed by pharmacy personnel.
14.1.3 Formulation, Appearance, Packaging, and Labeling
Please refer to the package insert for additional information.

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14.1.4 Product Storage and Stability
Please refer to the package insert for additional information.
14.1.5 Preparation
N/A. 
14.2 HYDROXYCHLOROQUINE (generic)
14.2.1 Source
Hydroxychloroquine will be provided by the NIH Clinical Center Pharmacy according to standard 
pharmacy procedures
14.2.2 Acquisition and Accountability
Hydroxychloroquine will be delivered directly to the NIH Pharmacy. Individual bottles with 
tablets will be prepared for each study participant according to assigned dose by NIH Pharmacy 
personnel. Patients will pick up bottles at NIH Pharmacy and will return bottles and not-used 
tablets after completion of every cycle together with Medication Diary to Study Coordinator. After 
review of leftover tablets and Medication Diary, unused tablets will be returned to pharmacy and 
disposed by pharmacy personnel.
14.2.3 Formulation, Appearance, Packaging, and Labeling
Please refer to the package insert for additional information.
14.2.4 Product Storage and Stability
Please refer to the package insert for additional information.
14.2.5 Preparation
N/A.
14.3 TruSight™ Oncology 500 panel
TruSight™ Oncology 500 panel assay is not FDA approved; it is being used as a treatment 
determining in-vitro diagnostic device in this study. According to 21 CFR 812.3(m), a significant 
risk device presents a potential for serious risk to the health, safety and welfare of a subject and 
meets the significant risk criteria listed in the table below along with the sponsor’s conclusions 
with regard to the applicability of these criteria to the current study. The device has been assessed 
by the sponsor as non-significant risk (NSR) per the below.
Significant Risk Criteria
Applicable 
to current 
study
Justification
Is an implant
No
TruSight™ Oncology 500 panel is not 
introduced into the subject
Is used in supporting or 
sustaining human life
No
The device is diagnostic
Is of substantial importance 
in diagnosing mitigating or 
No
While the device is diagnostic, we do not 
believe in presents a potential for serious risk 
to the health and welfare of the subject. The 

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Significant Risk Criteria
Applicable 
to current 
study
Justification
treating disease or preventing 
impairment of human health
assessment of KRAS mutation status is only 
used to help to increase the possibility that all 
persons enrolling on the study might derive 
benefit from therapy. Persons that are deemed 
ineligible to enroll on the basis of this test are 
eligible for studies within TGMB that are not 
reliant on this test. 
Otherwise poses a risk
No
Testing will be performed on fresh sample 
that is collected at screening for confirmation 
of diagnosis. No additional collection of 
sample will occur for purposes of KRAS 
testing.

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16 APPENDICES
16.1 Appendix A - Performance Status Criteria 
ECOG Performance Status Scale
Grade
Descriptions
0
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction.
1
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work).
2
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours.
3
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours.
4
100% bedridden. Completely 
disabled. Cannot carry on any 
self-care. Totally confined to bed 
or chair.
5
Dead.

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16.2 Appendix B Child-Pugh Classification System 

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16.3 Appendix C - Patient’s Medication Diary
Cycle___________________   Patient’s ID ___________________
INSTRUCTIONS TO THE PATIENT:
1.
Complete one form for each cycle of treatment
2.
You will take trametinib once a day and HCQ twice a day every day during 28-day cycle
3.
HCQ should be taken every 12 hours at approximately the same times each day. Doses should be 
taken within 2 hours of the scheduled time. 
4.
In case of a missed dose (more than 2 hours late) or vomiting after taking HCQ, do not make up 
the missed dose of HCQ.
5.
Take trametinib on empty stomach: at least 1 hour before or 2 hours after a meal with a glass of 
water. Take HCQ with a meal or a glass of milk.
6.
Record the date, the number of tablets that you took, and when you took them.
7.
If you have any comments or notice any side effects, please record them in the comment’s 
column.
8.
Please bring this form and your bottles (even it is empty) when you come for your clinic visits.
# of Oral HCQ Tablets 
taken
(every 12 hours)
Day
Date
AM
PM
# of Oral 
trametinib 
Tablets taken
Comments (side effects or 
missed doses)
1
2
3
4
5
6
7
8
9
10
11
12
13

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# of Oral HCQ Tablets 
taken
(every 12 hours)
Day
Date
AM
PM
# of Oral 
trametinib 
Tablets taken
Comments (side effects or 
missed doses)
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Patient’s signature: ___________________________________________________

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16.4 Appendix D: Modified immune-related response criteria (irRC)
This new classification is based on the recent learning from clinical studies with cancer 
immunotherapies that even if some new lesions appear at the beginning of a treatment or if the 
total tumor burden does not increase substantially, tumor regressions or stabilizations might still 
occur later. The irRC were created using bi-dimensional measurements (as previously widely used 
in the World Health Organization criteria). For this trial, the concepts of the irRC are combined 
with RECIST 1.1 to come up with the modified irRC. 
For modified irRC, only target and measurable lesions are taken into account. In contrast to the 
RECIST 1.1 criteria, the modified irRC criteria (a) require confirmation of both progression and 
response by imaging at 6 weeks after initial imaging and (b) do not necessarily score the 
appearance of new lesions as progressive disease if the sum of lesion diameters of target lesions 
(minimum of 10 mm per lesion, maximum of 5 target lesions, maximum of 2 per organ) and 
measurable new lesions does not increase by ≥ 20%. 
The same method of assessment and the same technique should be used to characterize each 
identified and reported target lesion(s) at baseline, during the trial, and at the end of trial visit. 
All measurements should be recorded in metric notation. The modified irRC based on RECIST 
1.1 are displayed below.