Patient case: 48-year-old female with melanoma; genetic feature: tumor cells with >50% membranous PD-L1 expression

Clinical trial: ACTOplus Met XR in Treating Patients With Stage I-IV Oral Cavity or Oropharynx Cancer Undergoing Definitive Treatment

Summary: This randomized phase IIb trial studies how well ACTOplus met XR works in treating in patients with stage I-IV oral cavity or oropharynx cancer that are undergoing definitive treatment. Chemoprevention is the use of drugs to keep oral cavity or oropharynx cancer from forming or coming back. The use of ACTOplus met XR may slow disease progression in patients with oral cavity or oropharynx cancer.

Detailed description: PRIMARY OBJECTIVES:
  I. To determine whether 14-21 days of treatment with ACTOplus met XR will result in a 50% decrease in proliferation index (Ki-67) expression in oral cavity/oropharyngeal tumor tissue.
  SECONDARY OBJECTIVES:
  I. Compare differences in proliferation index (Ki-67) expression from baseline to post-exposure in visually normal appearing oral cavity/oropharyngeal tissue.
  II. Compare immunohistochemical differences in the apoptosis biomarker cleaved caspase 3 from baseline to post-exposure in oral cavity/oropharyngeal adjacent visually normal appearing tissue and tumor tissue samples.
  III. Compare immunohistochemical differences from baseline to post-exposure in oral cavity/oropharyngeal tumor tissue samples with regard to cyclin D1, p21 and biguanide or PPAR gamma associated pathway biomarkers; prospective biomarkers on the panel will include phosphorylated (p)AKT, pAMPK, pS6 (metformin), and PPAR gamma.
  IV. Compare immunohistochemical differences from baseline to post-exposure of oral cavity/oropharyngeal tumor tissue samples with regard to tumor infiltrating immune cells (effector CD8 [CD8+IFNg+]), regulatory CD4 T regulatory (Treg) (CD4+Foxp3+), tumor associated myeloid cells (CD68), PD1 and PD-L1.
  V. Compare and correlate pre- and post-ACTOplus met XR treatment human ribonucleic acid (RNA)-sequencing (seq) gene analysis on total RNA samples from oral cavity/oropharyngeal adjacent visually normal appearing tissue and tumor tissue pre-and post-study treatment.
  VI. Determine human papillomavirus (HPV) status in pre-treatment tumor tissue using p16 immunohistochemistry.
  VII. Compare pre- and post-study treatment positron emission tomography (PET)/computed tomography (CT) scans to determine any change in tumor fluorodeoxyglucose (FDG) uptake/metabolism.
  OUTLINE: Patients are randomized to 1 of 2 groups.
  GROUP I: Patients receive ACTOplus met XR orally (PO) once daily (QD) for 14-21 days in the absence of disease progression or unacceptable toxicity. Patients may continue ACTOplus met XR PO QD for a maximum of 25 days if end of treatment biopsy/surgical treatment is delayed beyond day 22.
  GROUP II: Patients receive placebo PO QD daily for 14-21 days.

Eligibility: Inclusion Criteria:
  -  Participant has a newly diagnosed, histologically confirmed, stage I-IV squamous cell carcinoma of the oral cavity or oropharynx and will be undergoing definitive surgical, radiotherapy, or chemoradiation treatment OR
  -  Participant has a lesion in the oral cavity or oropharynx that is not yet biopsied but is highly suspicious for cancer; (randomization will be placed on hold until the presence of cancer is histologically confirmed, a standard of care staging PET/CT scan is completed and a treatment plan is established; if the presence of cancer is not confirmed, the participant will be considered a screen failure)
  -  The participant's primary tumor is accessible to biopsy in the outpatient clinic setting and the participant is willing to have baseline and end of study (day 15-26) 4 mm punch biopsies of tumor and adjacent visually normal appearing tissue for biomarker analysis
  -  If the participant has a biopsy-confirmed cancer, the baseline biopsy to collect tissue for biomarker analysis will be in addition to the pre-study diagnostic biopsy
  -  If the participant is having surgical treatment, the end of study biopsies may be collected at the time of surgery unless surgery is delayed beyond day 26
  -  If the participant is not having surgical treatment, the end of study biopsies will be collected prior to initiation of non-surgical treatment
  -  Participant is able to complete a minimum of 14 days of study agent dosing prior to initiation of definitive treatment for their cancer
  -  Participant is scheduled for an end of study biopsy within 22 days of starting study agent and within 36 days of their study screening visit; (if the participant is scheduled for surgical excision of the tumor and the surgery is delayed for any reason after the participant has started taking the study agent, study agent dosing may be extended up to a maximum of 25 days without compromising the evaluability of the end of study biomarkers)
  -  A standard of care staging PET/CT scan has been or will be performed prior to randomization
  -  Participant is willing and able to have another FDG PET/CT performed within 36 hours of their day 15-26 end of study biopsy
  -  Eastern Cooperative Oncology Group (ECOG) performance status = 0 or 1
  -  Life expectancy is > 6 months
  -  Body mass index (BMI) is >= 18.5
  -  Hemoglobin >= 10 g/dl
  -  White blood cells >= 3,000/microliter
  -  Platelets >= 100,000/microliter
  -  Total bilirubin within normal institutional limits
  -  With the exception of candidates with a diagnosis of Gilbert's disease in which case the total bilirubin may extend up to 1.5 x institutional upper limit of normal
  -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) within normal institutional limits
  -  Alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) within normal institutional limits
  -  Glucose, serum < 200 mg/dL
  -  Estimated glomerular filtration rate (eGFR) > 45 mL/min using Cockcroft-Gault calculator
  -  Participant is able to swallow a tablet whole
  -  Participant is willing and able to participate for the duration of the study
  -  Participant of childbearing potential agrees to use adequate contraception (a hormonal method that has been in continual use for a minimum of 3 months prior to the study screening visit, a barrier method, or abstinence) for the duration of their study participation; (should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her study physician immediately)
  -  NOTE: participants should not start hormonal therapy for the purpose of meeting the eligibility criteria for this protocol
  -  Ability to understand and the willingness to sign a written informed consent document
  Exclusion Criteria:
  -  Participant has received or will receive some form of treatment for their cancer prior to completing a minimum of 14 days of study agent dosing; (a biopsy is not considered a form of treatment)
  -  Participant has a concurrent diagnosis of type I or type II diabetes that is being treated with insulin or an oral antidiabetic agent; (participants whose type II diabetes is controlled with diet and/or exercise alone are eligible provided they meet all other eligibility criteria)
  -  Participant has taken any of the following medications within the past 3 months:
  -  A thiazolidinedione (e.g. pioglitazone [Actos] or rosiglitazone [Avandia]),
  -  A biguanide (e.g. metformin [Glucophage, Glumetza, Fortamet, Riomet] or proguanil [Paludrine])
  -  A combination drug containing one of the agents above (brand names include: ACTOplus Met, Avandamet, Avandaryl, Duetact, Glucovance, Invokamet, Janumet, Jentadueto, Komboglyze, Metaglip, PrandiMet, Synjardy, Xigudo)
  -  Participant is currently taking a strong CYP2C8 inhibitor (e.g. gemfibrozil [Lopid])
  -  Participant is currently taking an enzyme inducer of CYP2C8 (carbamazepine [Carbatrol, Epitol, Equetro, Tegretol] cortisol [Hydrocortisone]; dexamethasone [Decadron]; phenobarbital [Luminal Sodium]; phenytoin [Dilantin, Phenytek, Novaplus Phenytoin Sodium]; primidone [Mysoline]; rifampin [Rifadin, Rimactane]; rifapentine [Priftin]; secobarbital [Seconal])
  -  Participant is currently taking topiramate (Topamax) commonly used in epilepsy or to prevent migraines or other carbonic anhydrase inhibitors (e.g. zonisamide [Zonegran]; acetazolamide [Diamox Sequels]; or dichlorphenamide [Keveyis, Daranide])
  -  Participant is currently taking a cationic drug (e.g. amiloride [Midamor]; cimetidine [Tagamet]; digoxin [Lanoxin, Digitek, Digox]; morphine [Roxanol, Duramorph, Kadian, MS Contin]; procainamide [Pronestyl, Procanbid]; quinidine [Quinidex, Cardioquin, Quin-G, Quinora]; quinine [Qualaquin, Quinamm, Quiphile]; ranitidine [Zantac, Deprizine, Gabitidine]; triamterene [Dyrenium]; trimethoprim [Proloprim, Trimpex, Primsol]; or vancomycin [Vancocin, Vancoled])
  -  Participants is taking another investigational agent
  -  Participant has a history of allergic reactions attributed to compounds of similar chemical or biologic composition to ACTOplus Met XR
  -  Participant has a contraindication to biopsy
  -  Participants with a history of congestive heart failure or New York Heart Association (NYHA) class III or IV functional status are excluded
  -  Participant has a history of liver disease
  -  Participant has > Common Terminology Criteria for Adverse Events (CTCAE) grade 1 limb edema (5 - 10% inter-limb discrepancy in volume or circumference at point of greatest visible difference; swelling or obscuration of anatomic architecture on close inspection)
  -  Participant has a history of hypoglycemia
  -  Participant is an active alcoholic or consumes excessive amounts of alcohol per the following definitions:
  -  Female: More than 3 drinks on any day or a total of more than seven drinks in a week
  -  Male: More than 4 drinks on any day or a total of more than 14 drinks in a week
  -  1 drink =
  -  Beer: 12 oz. (1 standard size can or bottle)
  -  Wine: 5 oz. (one standard glass)
  -  Spirits: 6 oz. (one mixed drink or one 1.5 fluid oz. shot)
  -  Participant has a history of macular edema
  -  Participant has a history of bladder cancer (including in situ bladder cancer)
  -  Participant has a history of invasive cancer (other than non-melanoma skin cancer or cervical cancer in situ) active within 18 months prior to the baseline study visit; (participants who have a history of cancer that was curatively treated without evidence of recurrence in the 18 months prior to the baseline study visit are considered eligible)
  -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
  -  Participant is pregnant, breast feeding or planning to become pregnant; (all participants of childbearing potential regardless of method of birth control must have a negative pregnancy test at baseline; a woman is considered not to be of childbearing potential is she has had a hysterectomy, bilateral oophorectomy, or if she is > 55 years of age with >= 2 years of amenorrhea)
  -  Breastfeeding should be discontinued if the mother is treated with ACTOplus met XR

Relevance to patient case: not relevant