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

Clinical trial: Phase II Study of Cobimetinib in Combination With Vemurafenib in Active Melanoma Brain Metastases

Summary: The purpose of this study is to evaluate the effectiveness of the combination of vemurafenib with cobimetinib in patients with active melanoma brain metastases.


Eligibility: Inclusion Criteria:
  -  Signed informed consent
  -  Histologically confirmed metastatic melanoma (Stage IV), carrying BRAF V600-mutation
  -  Melanoma must be documented to contain a BRAFV600 mutation by a CLIA approved laboratory
  -  At least one measurable intracranial target lesion for which all of the following criteria are met:
  1. previously untreated or progressive according to RECIST 1.1 (equal to or greater than 20% increase in longest diameter on baseline scan) after previous local therapy (SRS and/or craniotomy)
  2. immediate local therapy clinically not indicated or patient is not a suitable candidate to receive immediate local therapy (SRS and/or craniotomy)
  3. largest diameter of ≥ 0.5cm but ≤ 4 cm as determined by contrast-enhanced MRI
  -  Prior therapies for extracranial metastatic melanoma including chemo-, cytokine-, immuno-, biological- and vaccine-therapy will be allowed but prior BRAF or MEK not allowed
  -  ECOG PS 0-2
  -  Life expectancy >12 weeks
  -  Age 18 years or older
  -  Adequate bone marrow function as indicated by the following:
  1. ANC > 1500/µL
  2. Platelets ≥ 100,000/µL
  3. Hemoglobin > 9 g/dL
  -  Adequate renal function, as indicated by creatinine =/< 1.5 x the upper limit of normal (ULN)
  -  Adequate liver function, as indicated by bilirubin =/< 1.5 x ULN
  -  AST or ALT < 3 x ULN (patients with documented liver metastases: AST and/or ALT =/< 5 x ULN)
  -  Able to swallow pills
  -  Negative serum pregnancy test within 7 days prior to commencement of dosing in premenopausal women. Women of non-childbearing potential may be included without serum pregnancy test if they are either surgically sterile or have been postmenopausal for ≥ 1 year
  -  Fertile men and women must use an effective method of contraception during treatment and for at least 6 months after completion of treatment as directed by their physician. Effective methods of contraception are defined as those which result in a low failure rate (i.e., less than 1% per year) when used consistently and correctly (for example implants, injectables, combined oral contraception or intra-uterine devices). At the discretion of the Investigator, acceptable methods of contraception may include total abstinence in cases where the lifestyle of the patient ensures compliance. (Periodic abstinence [e.g., calendar, ovulation, symptothermal, post-ovulation methods] and withdrawal are not acceptable methods of contraception.)
  Exclusion Criteria:
  -  Active infection
  -  Prior therapy with BRAFi and/or MEKi
  -  Leptomeningeal disease
  -  Symptomatic brain metastases requiring immediate local interventions such as craniotomy or SRS
  -  Increasing corticosteroid dose in 7 days prior to administration of first dose of study drug. Symptomatic patients that have stable or decreasing corticosteroid use in the past 7 days will be allowed
  -  Current use of therapeutic warfarin
  -  Unresolved toxicity of National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0 (NCI v4.0) [NCI, 2009] Grade 2 or higher from previous anti-cancer therapy, except alopecia
  -  Conditions that will interfere significantly with the absorption of drugs
  -  Inability to undergo MRI secondary to metal, claustrophobia, Gadolinium Contrast allergy
  -  Pregnant, lactating, or breast feeding women
  -  Prior radiation therapy within the last 14 days
  -  Concomitant malignancies or previous malignancies within the last 5 years, with the exception of adequately treated basal or squamous cell carcinoma of the skin or carcinoma in situ of the cervix
  -  Unwillingness or inability to comply with study and follow-up procedures
  -  The following foods/supplements are prohibited at least 7 days prior to initiation of and during study treatment:
  1. St. John's wort or hyperforin
  2. Grapefruit juice
  -  History of or evidence of retinal pathology on ophthalmologic examination that is considered a risk factor for neurosensory retinal detachment, Retinal Vein Occlusion (RVO), or neovascular macular degeneration
  -  Uncontrolled glaucoma with intra-ocular pressures > 21mmHg
  -  Serum cholesterol ≥ Grade 2
  -  Hypertriglyceridemia ≥ Grade 2
  -  Hyperglycemia (fasting) ≥ Grade 2
  -  History of clinically significant cardiac dysfunction, including the following:
  1. Current unstable angina
  2. Current symptomatic congestive heart failure of NYHA class 2 or higher
  3. History of congenital long QT syndrome or mean QTcF > 450 msec at baseline or uncorrectable electrolyte abnormalities
  4. Uncontrolled hypertension ≥ Grade 2 (patients with a history hypertension controlled with anti-hypertensives to ≤ Grade 1 are eligible)
  5. Left ventricular ejection fraction (LVEF) below 50%
  6. Uncontrolled Arrhythmias
  7. Myocardial infarction, severe/unstable angina, symptomatic congestive heart failure, cerebrovascular accident or transient ischemic attack within the previous 6 months

Relevance to patient case: possibly relevant