Patient case: 70-year-old male with melanoma; genetic feature: NF1 truncation

Clinical trial: NCI-MATCH: Targeted Therapy Directed by Genetic Testing in Treating Patients With Advanced Refractory Solid Tumors, Lymphomas, or Multiple Myeloma

Summary: This phase II trial studies how well treatment that is directed by genetic testing works in patients with solid tumors or lymphomas that have progressed following at least one line of standard treatment or for which no agreed upon treatment approach exists. Genetic tests look at the unique genetic material (genes) of patients' tumor cells. Patients with genetic abnormalities (such as mutations, amplifications, or translocations) may benefit more from treatment which targets their tumor's particular genetic abnormality. Identifying these genetic abnormalities first may help doctors plan better treatment for patients with solid tumors, lymphomas, or multiple myeloma.

Detailed description: PRIMARY OBJECTIVES:
  I. To evaluate the proportion of patients with objective response (OR) to targeted study agent(s) in patients with advanced refractory cancers/lymphomas/multiple myeloma.
  SECONDARY OBJECTIVES:
  I. To evaluate the proportion of patients alive and progression free at 6 months of treatment with targeted study agent in patients with advanced refractory cancers/lymphomas/multiple myeloma.
  II. To evaluate time until death or disease progression. III. To identify potential predictive biomarkers beyond the genomic alteration by which treatment is assigned or resistance mechanisms using additional genomic, ribonucleic acid (RNA), protein and imaging-based assessment platforms.
  IV. To assess whether radiomic phenotypes obtained from pre-treatment imaging and changes from pre- through post-therapy imaging can predict objective response and progression free survival and to evaluate the association between pre-treatment radiomic phenotypes and targeted gene mutation patterns of tumor biopsy specimens.
  OUTLINE:
  STEP 0 (Screening): Patients undergo biopsy along with molecular characterization of the biopsy material for specific, pre-defined mutations, amplifications, or translocations of interest via tumor sequencing and immunohistochemistry. Consenting patients also undergo collection of blood samples for research purposes.
  STEPS 1, 3, 5, 7 (Treatment): Patients are assigned to 1 of 30 treatment subprotocols based on molecularly-defined subgroup. (See Arms Section)
  STEPS 2, 4, 6 (Screening): Patients experiencing disease progression on the prior Step treatment or who could not tolerate the assigned treatment undergo review of their previous biopsy results to determine if another treatment is available or undergo another biopsy. Patients may have a maximum of 2 screening biopsies and 2 treatments per biopsy.
  STEP 8 (Optional Research): Consenting patients undergo end-of-treatment biopsy and collection of blood samples for research purposes.
  After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for 1 year.

Eligibility: Inclusion Criteria:
  -  Women of childbearing potential must have a negative serum pregnancy test within 2 weeks prior to registration; patients that are pregnant or breast feeding are excluded; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria:
  -  Has not undergone a hysterectomy or bilateral oophorectomy; or
  -  Has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
  -  Women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for 4 months after completion of study; should a woman become pregnant or suspect while she or her partner is participating in this study, she should inform her treating physician immediately
  -  Patients must have histologically documented solid tumors or histologically confirmed diagnosis of lymphoma or multiple myeloma requiring therapy and meet one of the following criteria:
  -  Patients must have progressed following at least one line of standard systemic therapy and there must not be other approval/standard therapy available that has been shown to prolong overall survival (i.e. in a randomized trial against another standard treatment or by comparison to historical controls); patients who cannot receive other standard therapy that has been shown to prolonged survival due to medical issues will be eligible, if other eligibility criteria are met; OR
  -  Patients for whose disease no standard treatment exists that has been shown to prolong overall survival
  -  NOTE: No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer; in situ cervical cancer; adequately treated stage I or II cancer from which the patient is currently in complete remission; any other cancer from which the patient has been disease-free for 5 years
  -  Patients must have measurable disease
  -  Patients must meet one of the following criteria:
  -  Patients must have tumor amenable to image guided or direct vision biopsy and be willing and able to undergo a tumor biopsy for molecular profiling; patients with multiple myeloma other than plasmacytomas are to have a bone marrow aspirate to obtain tumor cells; biopsy must not be considered to be more than minimal risk to the patient
  -  NOTE: Registration to screening steps (step 0, 2, 4, 6) must occur after stopping prior therapy; there is no specific duration for which patients must be off treatment prior to registration to the relevant screening step (and subsequently, the biopsy), as long as all other eligibility criteria are met
  -  Patient will be undergoing a procedure due to medical necessity during which the tissue may be collected
  -  NOTE: Registration to screening steps (step 0, 2, 4, 6) must occur after stopping prior therapy; there is no specific duration for which patients must be off treatment prior to registration to the relevant screening step (and subsequently, the biopsy), as long as all other eligibility criteria are met
  -  Formalin-fixed paraffin-embedded tumor tissue block(s) are available for submission following pre-registration (not applicable for bone marrow aspirate specimens); criteria for the submission of formalin-fixed paraffin-embedded (FFPE) tissue are:
  -  Tissue must have been collected within 6 months prior to pre-registration to step 0
  -  Patient may receive treatment after tissue collection; however, lack of response must be documented prior to step 1; the following restrictions apply:
  -  Enrollment onto another investigational study is not permitted
  -  Intervening therapy that constitutes a new, molecularly targeted therapy is not permitted; please note, immunotherapy is not considered molecularly targeted
  -  Continuation of an agent/regimen for which disease progression has been observed prior to biopsy is permitted, including targeted therapy
  -  A new immunotherapy regimen is permitted; but, lack of response must also be documented prior to registration to step 0
  -  Formalin-fixed paraffin-embedded tumor tissue block(s) must meet the minimum requirements
  -  Patient must not require the use of full dose coumarin-derivative anticoagulants such as warfarin; low molecular weight heparin is permitted for prophylactic or therapeutic use; factor X inhibitors are permitted
  -  NOTE: Warfarin may not be started while enrolled in the EAY131 study
  -  Stopping the anticoagulation for biopsy should be per site standard operating procedure (SOP)
  -  Patients must have Eastern Cooperative Oncology Group (ECOG) performance status =< 1 and a life expectancy of at least 3 months
  -  Patients must not currently be receiving any other investigational agents
  -  Patients must not have any uncontrolled intercurrent illness including, but not limited to:
  -  Symptomatic congestive heart failure (New York Heart Association [NYHA] classification of III/IV)
  -  Unstable angina pectoris or coronary angioplasty, or stenting within 6 months prior to registration to step 0, 2, 4, 6
  -  Cardiac arrhythmia (ongoing cardiac dysrhythmias of National Cancer Institute [NCI] Common Terminology Criteria for Adverse Events [CTCAE] version [v]4 grade >= 2)
  -  Psychiatric illness/social situations that would limit compliance with study requirements
  -  Intra-cardiac defibrillators
  -  Known cardiac metastases
  -  Abnormal cardiac valve morphology (>= grade 2) documented by echocardiogram (ECHO) (as clinically indicated); (subjects with grade 1 abnormalities [i.e., mild regurgitation/stenosis] can be entered on study); subjects with moderate valvular thickening should not be entered on study
  -  NOTE: To receive an agent, patient must not have any uncontrolled intercurrent illness such as ongoing or active infection; patients with infections unlikely to be resolved within 2 weeks following screening should not be considered for the trial
  -  Patients must be able to swallow tablets or capsules; a patient with any gastrointestinal disease that would impair ability to swallow, retain, or absorb drug is not eligible
  -  Patients who are human immunodeficiency virus (HIV)-positive are eligible if:
  -  CD4+ cell count greater or equal to 250 cells/mm^3
  -  If patient is on antiretroviral therapy, there must be minimal interactions or overlapping toxicity of the antiretroviral therapy with the experimental cancer treatment; for experimental cancer therapeutics with CYP3A/4 interactions, protease inhibitor therapy is disallowed; suggested regimens to replace protease inhibitor therapy include dolutegravir given with tenofovir/emtricitabine; raltegravir given with tenofovir and emtricitabine; once daily combinations that use pharmacologic boosters may not be used
  -  No history of non-malignancy acquired immune deficiency syndrome (AIDS)-defining conditions other than historical low CD4+ cell counts
  -  Probable long-term survival with HIV if cancer were not present
  -  Any prior therapy, radiotherapy (except palliative radiation therapy of 30 gray [Gy] or less), or major surgery must have been completed >= 4 weeks prior to start of treatment; all adverse events due to prior therapy have resolved to a grade 1 or better (except alopecia and lymphopenia) by start of treatment; palliative radiation therapy must have been completed at least 2 weeks prior to start of treatment; the radiotherapy must not be to a lesion that is included as measurable disease
  -  NOTE: Prostate cancer patients may continue their luteinizing hormone-releasing hormone (LHRH) agonist
  -  NOTE: Patients may receive non-protocol treatment after biopsy (if clinically indicated) until they receive notification of results; however, lack of response must be documented prior to registration to step 1; new non-protocol treatment will NOT be permitted as intervening therapy after registration to step 0; the decision to stop the intervening nonprotocol treatment will be left up to the treating physician if patient has an actionable mutation/amplification of interest (aMOI); however, patients will need to be off such therapy for at least 4 weeks before receiving any MATCH protocol treatment
  -  Patients with brain metastases or primary brain tumors must have completed treatment, surgery or radiation therapy >= 4 weeks prior to start of treatment
  -  Patients must have discontinued steroids >= 1 week prior to registration to step 0 and remain off steroids thereafter, except as permitted (see below); patients with glioblastoma (GBM) must have been on stable dose of steroids, or be off steroids, for one week prior to registration to treatment (step 1, 3, 5, 7)
  -  NOTE: The following steroids are permitted (low dose steroid use is defined as prednisone 10 mg daily or less, or bioequivalent dose of other corticosteroid):
  -  Temporary steroid use for computed tomography (CT) imaging in setting of contrast allergy
  -  Low dose steroid use for appetite
  -  Chronic inhaled steroid use
  -  Steroid injections for joint disease
  -  Stable dose of replacement steroid for adrenal insufficiency or low doses for non-malignant disease
  -  Topical steroid
  -  Steroids required to manage toxicity related to study treatment, as described in the subprotocols
  -  Steroids required as pre- or post-chemotherapy medication for acceptable intervening chemotherapy
  -  NOTE: Steroids must be completed alongside last dose of chemotherapy
  -  Leukocytes >= 3,000/mcL
  -  Absolute neutrophil count >= 1,500/mcL
  -  Platelets >= 100,000/mcL
  -  NOTE: Patients with documented bone marrow involvement by lymphoma are not required to meet the above hematologic parameters, but must have a platelet count of at least 75,000/mcL and neutrophil count of at least 1,000/mcL
  -  Total bilirubin =< 1.5 X institutional upper limit of normal (ULN) (unless documented Gilbert's syndrome, for which bilirubin =< 3 x institutional ULN is permitted)
  -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 X institutional ULN (up to 5 times ULN in presence of liver metastases)
  -  Creatinine clearance >= 45 mL/min/1.73 m^2 for patients with creatinine levels above institutional normal
  -  Patients must have an electrocardiogram (ECG) within 8 weeks prior to registration to screening step and must meet the following cardiac criteria:
  -  Resting corrected QT interval (QTc) =< 480 msec
  -  NOTE: If the first recorded QTc exceeds 480 msec, two additional, consecutive ECGs are required and must result in a mean resting QTc =< 480 msec; it is recommended that there are 10-minute (+/- 5 minutes) breaks between the ECGs
  -  The following only need to be assessed if the mean QTc > 480 msec
  -  Check potassium and magnesium serum levels
  -  Correct any identified hypokalemia and/or hypomagnesemia and may repeat ECG to confirm exclusion of patient due to QTc
  -  For patients with heart rate (HR) 60-100 beats per minute (bpm), no manual read of QTc is required
  -  For patients with baseline HR < 60 or > 100 bpm, manual read of QT by trained personnel is required, with Fridericia correction applied to determine QTc
  -  Patient must not have hypokalemia (value < institutional lower limit of normal)
  -  No factors that increase the risk of QTc prolongation or risk of arrhythmic events such as heart failure, congenital long QT syndrome, family history of long QT syndrome or unexplained sudden death under 40 years of age or any concomitant medication known to prolong the QT interval
  -  NOTE: Patient must be taken off prohibited medication prior to registration to the screening step (step 0, 2, 4, 6) and remain off these medications thereafter, unless permitted on a subprotocol for the management of treatment related toxicity; patient must be off the drug for at least 5 half-lives prior to registration to the treatment step (step 1, 3, 5, 7); the medication half-life can be found in the package insert for Food and Drug Administration (FDA) approved drugs

Relevance to patient case: not relevant