Patient case: 84-year-old male with glioblastoma; genetic feature: CDK6

Clinical trial: Sorafenib Combined With Erlotinib, Tipifarnib, or Temsirolimus in Treating Patients With Recurrent Glioblastoma Multiforme or Gliosarcoma

Summary: This phase I/II trial is studying the side effects and best dose of erlotinib, tipifarnib, and temsirolimus when given together with sorafenib and to see how well they work in treating patients with recurrent glioblastoma multiforme or gliosarcoma. Sorafenib, erlotinib, tipifarnib, and temsirolimus may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Sorafenib and tipifarnib may also stop the growth of tumor cells by blocking blood flow to the tumor. Giving sorafenib together with erlotinib, tipifarnib, or temsirolimus may kill more tumor cells.

Detailed description: PRIMARY OBJECTIVES:
  I Determine the maximum tolerated dose (MTD) of tipifarnib, erlotinib hydrochloride, or temsirolimus in combination with a fixed dose of sorafenib in patients with recurrent glioblastoma mutiforme or gliosarcoma who are not taking enzyme-inducing antiepileptic drugs. (Phase I)
  SECONDARY OBJECTIVES:
  I. Characterize the safety profile of the doublet combinations of tipifarnib-sorafenib, erlotinib hydrochloride-sorafenib, and temsirolimus-sorafenib in patients with recurrent glioblastoma multiforme or gliosarcoma. (Phase I and II) II. Characterize the pharmacokinetics of these doublet combinations, evaluating single-agent pharmacokinetics of each agent and the combination pharmacokinetics to determine drug-drug interactions. (Phase I and II) III. Determine the efficacy of each of the doublet combinations, in terms of 6-month progression-free survival, in patients with recurrent glioblastoma multiforme or gliosarcoma. (Phase II) IV. Determine the efficacy of each of the doublet combinations, in terms of 12-month survival and objective tumor response, in patients with recurrent glioblastoma multiforme or gliosarcoma. (Phase II)
  TERTIARY OBJECTIVES:
  I. Perform exploratory correlative laboratory studies by examining tissue markers of signal transduction pathways by immunohistochemical analysis using tissue blocks obtained prior to initiation of protocol therapy, either from the time of diagnosis or subsequent tumor resection. (Phase II) II. Determine the relationship between tumor and blood biomarkers and clinical outcome of patients treated with the combination of targeted agents. (Phase II)
  OUTLINE: This is a multicenter, phase I, dose-escalation study of tipifarnib, erlotinib hydrochloride, and temsirolimus followed by a phase II open-label study.
  PHASE I: Patients are sequentially assigned to 1 of 3 treatment groups.
  GROUP 1: Patients receive oral sorafenib twice daily and oral erlotinib hydrochloride once daily on days 1-28.
  GROUP 2: Patients receive sorafenib as in group 1. Patients also receive temsirolimus IV over 30 minutes on days 1, 8, 15, and 22.
  GROUP 3: Patients receive sorafenib as in group 1. Patients also receive oral tipifarnib twice daily on days 1-21.
  In all groups, treatment repeats every 28 days for up to 24 courses in the absence of disease progression or unacceptable toxicity.
  In each treatment group, cohorts of 3-6 patients receive escalating doses of erlotinib hydrochloride (group 1), temsirolimus (group 2), or tipifarnib (group 3) sequentially until the maximum tolerated dose (MTD) is determined for each group. The MTD is defined as the dose preceding that at which 2 of 3 or 2 of 6 patients experience dose-limiting toxicity during the first course of therapy.
  PHASE II: Patients receive sorafenib as in phase I. Patients also receive erlotinib hydrochloride, temsirolimus, or tipifarnib as in phase I at the MTD determined in phase I.
  Tissue that was collected during a prior surgery is examined for biomarkers by immunohistochemistry (in patients enrolled in the phase II portion of the study). Biomarkers examined include epidermal growth factor receptor, HER-2, AKT, S6 ribosomal protein, and Erk.
  After completion of study treatment, patients are followed every 3 months.

Eligibility: Inclusion Criteria:
  -  Histologically confirmed intracranial glioblastoma multiforme or gliosarcoma
  -  Evidence of tumor progression by MRI or CT scan within the past 14 days AND on a steroid dose that has been stable for ≥ 5 days
  -  Patients who underwent prior therapy that included interstitial brachytherapy or stereotactic radiosurgery must have confirmation of true progressive disease rather than radiation necrosis by either positron emission tomography or thallium scanning, MR spectroscopy, or surgical documentation of disease
  -  Recent resection of recurrent or progressive tumor allowed
  -  Residual disease is not required
  -  Treatment for any number of prior relapses, defined as disease progression after initial therapy (i.e., radiotherapy with or without chemotherapy if used as initial treatment), allowed (phase I)
  -  No more than 3 prior therapies (initial therapy and therapy for 2 relapses) (phase II)
  -  Each of the following is considered 1 relapse:
  -  Disease progression after initial therapy (i.e., radiotherapy with or without chemotherapy if used as initial therapy)
  -  Underwent a surgical resection for relapsed disease and received no anticancer therapy for up to 12 weeks after surgical resection AND then underwent a subsequent surgical resection
  -  Received prior therapy for a low-grade glioma, followed by a surgical diagnosis of glioblastoma
  -  Failed prior radiotherapy
  -  15 unstained paraffin slides or 1 tissue block must be available from original surgery, definitive surgery, or surgery closest to the initiation of this study (phase II)
  -  Karnofsky performance status 60-100%
  -  WBC ≥ 3,000/mm^3
  -  Absolute neutrophil count ≥ 1,500/mm^3
  -  Platelet count ≥ 100,000/mm^3
  -  Hemoglobin ≥ 10 g/dL (transfusion allowed)
  -  AST/ALT ≤ 2.5 times upper limit of normal (ULN)
  -  Total bilirubin normal
  -  Creatinine < 1.5 mg/dL
  -  PT/INR ≤ 1.5 (INR < 3.0 for patients on anticoagulation therapy)
  -  INR < 1.1 times ULN (for patients on prophylactic anticoagulation therapy [low-dose warfarin])
  -  Fasting cholesterol < 350 mg/dL (for patients receiving temsirolimus and sorafenib)
  -  Fasting triglycerides < 400 mg/dL (for patients receiving temsirolimus and sorafenib)
  -  Well-controlled hypertension (e.g., systolic blood pressure ≤ 140 mm Hg or diastolic pressure ≤ 90 mm Hg) allowed
  -  Not pregnant or nursing
  -  Negative pregnancy test
  -  Fertile patients must use effective barrier contraception during and for at least 2 weeks (women) or 3 months (men) after completion of study treatment
  -  No peripheral neuropathy > grade 1 (for patients receiving sorafenib and tipifarnib)
  -  No evidence of bleeding diathesis or coagulopathy
  -  No history of any other cancer (except nonmelanoma skin cancer or carcinoma in situ of the cervix), unless in complete remission and off all therapy for that disease for ≥ 3 years
  -  No significant traumatic injury within the past 21 days
  -  No active infection or serious medical illness that would preclude study treatment
  -  No condition that would impair ability to swallow pills (e.g., gastrointestinal tract disease resulting in an inability to take oral medication or a requirement for IV alimentation or active peptic ulcer disease)
  -  No HIV disease
  -  No allergies to imidazoles (e.g., clotrimazole, ketoconazole, miconazole or econazole) or a history of allergic reactions attributed to any compound of similar chemical or biological composition to tipifarnib (for patients receiving sorafenib and tipifarnib)
  -  No other disease that would obscure toxicity or dangerously alter drug metabolism
  -  Recovered from prior therapy
  -  At least 7 days since prior noncytotoxic agents (e.g., interferon, tamoxifen, thalidomide, or isotretinoin) (radiosensitizer does not count)
  -  At least 14 days since prior vincristine
  -  At least 21 days since prior procarbazine or major surgery
  -  At least 28 days since prior investigational agent or cytotoxic therapy
  -  At least 42 days since prior nitrosoureas or radiotherapy
  -  No prior sorafenib, AEE788, or vatalanib
  -  No prior surgical procedures affecting absorption
  -  No prior tipifarnib, lonafarnib, or other agents targeting farnesyl transferase (for patients receiving sorafenib and tipifarnib)
  -  No prior temsirolimus or mTOR-targeting agent (phase II), rapamycin or everolimus, or Akt-pathway inhibitors (for patients receiving sorafenib and temsirolimus)
  -  No prior erlotinib hydrochloride, AEE788, or other epidermal growth factor receptor targeting agents (phase II) (for patients receiving sorafenib and erlotinib hydrochloride)
  -  No concurrent enzyme-inducing antiepileptic drugs (e.g., carbamazepine, oxcarbazepine, phenytoin, fosphenytoin, phenobarbital, or primidone)
  -  Dexamethasone allowed
  -  No concurrent hepatic cytochrome p450 enzyme-inducing anticonvulsants
  -  No other concurrent investigational agents or anticancer therapies, including chemotherapy, radiotherapy, hormonal therapy, or immunotherapy
  -  No concurrent prophylactic filgrastim (G-CSF) or other hematopoietic colony-stimulating factors
  -  Full-dose anticoagulants allowed provided both of the following criteria are met:
  -  In-range INR (between 2-3) on a stable dose of oral anticoagulant or on a stable dose of low molecular weight heparin
  -  No active bleeding or pathological condition that carries a high risk of bleeding (e.g., tumor involving major vessels or known varices)

Relevance to patient case: not relevant