Patient case: 67-year-old male with melanoma; genetic feature: BRAF (V600E), NRAS (Q61R)

Clinical trial: Selumetinib and Akt Inhibitor MK2206 in Treating Patients With Stage III or Stage IV Melanoma Who Failed Prior Therapy With Vemurafenib or Dabrafenib

Summary: This phase II trial studies how well selumetinib and Akt inhibitor MK2206 works in treating patients with stage III or stage IV melanoma who failed prior therapy with vemurafenib or dabrafenib. Selumetinib and Akt inhibitor MK2206 stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet know whether giving selumetinib and Akt inhibitor MK2206 together is an effective treatment for advanced melanoma.

Detailed description: PRIMARY OBJECTIVES:
  I. To determine the frequency of objective clinical responses by RECIST 1.1 for these melanoma patients who have previously progressed on selective BRAF inhibitors when treated with MEK inhibitor, AZD6244 hydrogen sulfate plus Akt inhibitor, MK-2206.
  II. To further characterize toxicities of both regimens in these patients who have progressed after BRAF inhibitor therapy.
  SECONDARY OBJECTIVES:
  I. With required fresh pretreatment biopsies on all patients, we plan to characterize the molecular state (genetic and proteomic) associated with BRAF inhibitor resistance. This may include an analysis of pathway activation, PI3/Akt or MAP kinase pathway; loss of expression of PTEN, secondary mutations in BRAF, other mutations in the MAP kinase pathway (NRAS, KRAS, HRAS, CRAF, MEK), activation of other RTKs (amplification, over expression, phosphorylation).
  OUTLINE:
  Patients receive selumetinib orally (PO) twice daily (BID) on days 1-21 and Akt inhibitor MK2206 PO once weekly.
  After completion of study treatment, patients are followed up every 12 weeks.

Eligibility: Inclusion Criteria:
  -  Patients must have incurable unresectable stage III or IV histologically confirmed Melanoma with V600-mutant BRAF disease and must have progressed after therapy on selective BRAF inhibitor; all patients must have biopsiable tumor and a biopsy must be performed with the collection of FFPE and if possible FF prior to initiation of treatment on this protocol; archival tumor tissue must also be obtained if at all available; this required biopsy will not be necessary if a previous biopsy of progressing tumor after selective BRAF therapy had already been obtained and is adequate
  -  Patients must have measurable disease, defined as at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded for non-nodal lesions and short axis for nodal lesions) as ≥ 20 mm with conventional techniques or as ≥ 10 mm with spiral computed tomography (CT) scan
  -  Patients must have received prior therapy and progressed following a selective BRAF inhibitor (i.e., vemurafenib, dabrafenib, LGX818, etc.); patients must have completed prior therapy a minimum of 4 weeks previously (6 weeks for BCNU and/or mitomycin C), 4 weeks for prior biologic therapy, and 2 weeks for localized radiation therapy; all treatment related toxicity must have resolved to grade 2 or less as well; patients may initiate the protocol treatment at 48 hours following the completion of BRAF inhibitor; patients must have had no more than 2 prior chemotherapy regimens; patients cannot receive chemotherapy after the BRAF inhibitor treatment and prior to enrollment on this protocol; up to two prior immunotherapy regimens for advanced disease are allowed and one may be given between BRAF inhibitor therapy and this trial
  -  Patients must not be refractory to the BRAF inhibitor; patients must demonstrate some degree of tumor regression initially on BRAF inhibitor prior to progression; (tumor regression does not require RECIST objective response); they cannot have progressive disease at the time of first evaluation (4 or 8 weeks) on the BRAF inhibitor
  -  Baseline Ophthalmologic exam must be done at screening to include slit lamp exam and fundoscopy; an OCT scan should be considered in case of retinal abnormality at exam
  -  Life expectancy of greater than or equal to 3 months
  -  Eastern Cooperative Oncology Group (ECOG) performance status ≤1 (Karnofsky ≥ 70%)
  -  Absolute neutrophil count ≥ 1,500 mm³
  -  Hemoglobin ≥ 9.0 g/dL (patients may be transfused to achieve level)
  -  Platelet count ≥ 100,000/μL
  -  Serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvate transaminase(SGPT) < 2.5 X upper limit of normal (ULN)
  -  Total bilirubin < 1.5 mg/dL
  -  Serum creatinine ≤ 2.0 mg/dL OR creatinine clearance > 50 mL/min, determined by 24-hour urine collection
  -  Fasting blood glucose < 160 mg/dL OR
  -  HgbA1C < 8% disease (uncontrolled diabetes)
  -  Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation
  -  Patients must have a negative serum pregnancy test prior to being eligible to take part in the study
  -  Pregnant women are excluded from this study; breastfeeding should be discontinued if the mother is treated with AZD6244 hydrogen sulfate and MK-2206
  -  Baseline echocardiogram or MUGA must be performed at screening and patients must have LVEF > 55%; additionally baseline EKG must be performed and corrected QTc must be < 480 milliseconds
  -  Baseline electrocardiogram(EKG) must be performed and corrected QTc must be < 480 milliseconds
  -  Patients must be able to swallow tablets and capsules to participate in the study
  -  No history of allergic reactions attributed to compounds of similar chemical or biologic composition to AZD6244 hydrogen sulfate, MK-2206, or other agents used in the study
  -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, psychiatric illness/social situations that would limit compliance with study requirements, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, uncontrolled hypertension (BP >= 150/95 despite optimal therapy), baseline ejection fraction < 55% or the lower limit of institutional normal, heart failure NYHA Class II or above, prior or current cardiomyopathy, atrial fibrillation with heart rate > 100 bpm, and uncontrolled angina (Canadian Cardiovascular society grade II-IV despite medical therapy); acute coronary syndrome within 6 months from starting therapy
  -  Patients must have completed prior therapy a minimum of 4 weeks previously (6 weeks for BCNU and/or mitomycin C), 4 weeks for prior biologic therapy, and 2 weeks for localized radiation therapy
  -  All treatment-related toxicity must have resolved to grade 2 or less
  -  No patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier
  -  Patients must have had no more than 2 prior chemotherapy regimens
  -  Patients cannot receive chemotherapy after the BRAF-inhibitor treatment and prior to enrollment on this protocol
  -  Up to two prior immunotherapy regimens for advanced disease are allowed and one may be given between BRAF-inhibitor therapy and this trial
  -  Patients may not be receiving any other investigational agents at the same time as study treatment
  -  Patients receiving medications or substances that are strong inhibitors or inducers of cytochrome P450 3A4 (CYP3A4) are ineligible
  -  Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy are ineligible
  -  Patients must not have received chemotherapy in the time between the failure of BRAF inhibitor and the enrollment onto the present trial

Relevance to patient case: possibly relevant