Patient case: 45-year-old female with medullary thyroid carcinoma; genetic feature: RET

Clinical trial: A Targeted Phase I/II Trial of ZD6474 (Vandetanib; ZACTIMA) Plus the Proteasome Inhibitor, Bortezomib (Velcade ), in Adults With Solid Tumors With a Focus on Hereditary or Sporadic, Locally Advanced or Metastatic Medullary Thyroid Cancer (MTC)

Summary: Background:
  -  The combination of anti-cancer drugs vandetanib (given orally) and bortezomib (given intravenously) has not been used in humans. However, both drugs have been studied separately. Bortezomib has been approved by the U.S. Food and Drug Administration (FDA) for treating multiple myeloma and mantle cell lymphoma, while vandetanib is still under investigation pending FDA approval.
  -  Both bortezomib and vandetanib are under investigation for use in treating certain kinds of cancer. Researchers hope that the combination of these two drugs will be more effective than either of them alone.
  Objectives:
  -  To determine if the combination of vandetanib and bortezomib will decrease the amount of the cancer and, if it does, to determine how long the response will last.
  -  To determine any side effects that may occur with this combination of treatments.
  -  To determine what doses of each drug are well tolerated and safe when given together.
  -  To study genetic mutations in tumors to better understand how tumors grow and how these drugs interact with the tumor.
  Eligibility:
  -  Patients 18 years of age and older with solid tumors that cannot be surgically removed and have either recurred or shown further growth. The tumor(s) must be able to be evaluated by X-ray, MRI (magnetic resonance imaging), and CT (computerized tomography) scanning.
  -  Patients who have been diagnosed with medullary thyroid cancer will participate in Phase II of the study.
  Design:
  -  Tumor samples may be taken at the start of the study for research purposes.
  -  Phase I: Patient groups will be treated on an outpatient basis with vandetanib and bortezomib, given at increasing doses over four different levels to determine the maximum tolerated dose calculated by height and weight:
  -  Doses will be given on Days 1, 4, 8, and 11 for each 28-day cycle.
  -  Two additional levels (Level 1A and Level 1B) may be included in the study, depending on side effects at various levels.
  -  Phase II: Patients with medullary thyroid cancer will be divided into two groups, with two patients in Group A for every one patient in Group B. No placebo will be involved in this study.
  -  Group A: Patients will be treated with vandetanib and bortezomib at the maximally tolerated dose of the Phase I study.
  -  Group B: Patients will be treated with bortezomib alone.
  -  A second tumor sample may be taken. In patients with thyroid cancer, the second biopsy will be done at the 6-week evaluation (approximately 42 days after beginning). In patients with cancer other than thyroid cancer, the second biopsy will be obtained on Day 4 of either the first or second cycle, after the bortezomib infusion.
  -  The effects of the drugs will be studied through blood samples and CT scans taken during and after various drug cycles.

Detailed description: Background:
  -  Vandetanib (CAPRELSA; ZD6474) potently inhibits vascular endothelial growth factor receptor-2 (VEGFR-2), and shows additional inhibitory activity at sub-micromolar concentrations against the Rearranged during Transfection (RET) receptor, Flt-4 and EGF receptor tyrosine kinases.
  -  Clinical trials have shown that vandetanib is active against medullary thyroid carcinomas (MTCs), but the activity is characterized by partial responses of variable duration, underscoring the need to develop active combinatorial regimens.
  -  Bortezomib (PS-341, Velcade ), a proteasome inhibitor, has been reported to have several putative mechanisms of action and it is likely that its toxcitiy is mediated by affecting more than one pathway or target. Bortezomib is reported to inhibit the NF-kappaB pathway and regulate NF-kappaB-dependent expression of several other inhibitors of apoptosis.
  -  In vitro studies have shown bortezomib to be active against a broad range of thyroid cancer cell lines. Given this activity of bortezomib and the role of the proteasome in regulating diverse cellular pathways, this study proposes to combine bortezomib with vandetanib to treat patients with advanced solid tumors with a focus on patients with MTC.
  Objectives:
  -  To assess the activity of vandetanib plus bortezomib in adults with MTC, using RECIST and tumor biomarkers including CEA and calcitonin as endpoints.
  -  To assess the safety and tolerance of vandetanib plus bortezomib in dose-seeking cohorts.
  -  To compare the combination bortezomib plus vandetanib versus vandetanib alone in adults with MTC by assessing the response rate and progression-free survival
  -  In exploratory analyses: (a) examine the correlation between genotype and response to therapy in patients with MTC, (b) examine the extent, if any, of RET inhibition in patients with MTC following the administration of vandetanib; and (c) examine the effect, if any, of bortezomib on microtubules.
  Eligibility:
  -  Adults age 18 and older with unresectable, recurrent or metastatic solid tumors, including MTC.
  -  Disease must be evaluable by RECIST.
  Design:
  -  Phase I dose-escalation study followed by randomized phase II trial.
  -  Maximum total number for planned enrollment: 117 - Dose-seeking cohorts of three to 6 patients until MTD/DLT reached (up to 24 patients) followed by a randomized phase II trial comparing the activity of the combination of bortezomib plus vandetanib with vandetanib alone (2:1 randomization 62 plus 31 equals 93 patients).
  -  The MTD and DLT will be determined based on toxicities during the first eight weeks of combined therapy.
  -  Cycle length will be four weeks. Response will be determined by RECIST every 12 weeks.

Eligibility: -INCLUSION CRITERIA:
  1. Pathologic confirmation of cancer by the Laboratory of Pathology, NCI
  2. Phase I: Diagnosis of recurrent, metastatic or primary unresectable solid tumor that does not have curative standard treatment.
  Phase II: Diagnosis of recurrent, metastatic or primary unresectable medullary thyroid cancer (MTC).
  3. Measurable disease at presentation: Either by RECIST or by measurement of serum markers (calcitonin, CEA, PSA or CA-125) in the dose-finding portion of the study; with disease measurable by RECIST required only in the phase II cohort.
  4. A life expectancy of at least 3 months and ECOG performance status 0 1.
  5. Age greater than or equal to 18 years
  6. Last dose of chemotherapy or experimental therapy more than 4 weeks (6 weeks in the case of nitrosourea) prior to enrollment date; unless the last therapy consisted of an oral agent whose average half life is known to be less than 48 hours in which case only 2 weeks need to have elapsed. Regardless of the therapy, any toxicity greater than CTCAE grade 1 from previous anti-cancer therapy must have been resolved.
  7. Last radiotherapy treatment 4 weeks prior to starting treatment with this protocol with the exception of palliative radiotherapy and there must be sites of measurable disease that did not receive radiation.
  8. Organ and marrow function as defined:
  -  total bilirubin less than 1.5 times the upper limit of reference range (ULRR), unless the patient meets the criteria for Gilbert s Syndrome
  -  alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) all three less than 2.5 times the ULRR, or less than 5 times the ULRR if judged by the investigator to be related to liver metastases
  -  serum creatinine less than 1.5 times the ULRR or creatinine clearance greater than or equal to 30 mL/minute (calculated by Cockcroft-Gault formula or measured in a timed urine collection)
  -  serum calcium below the CTCAE grade 1 upper limit (11.5mg/dL or 2.9 mmol/L). In cases where the serum calcium is below the normal range, the calcium adjusted for albumin is calculated and substituted for the measured value.
  -  serum potassium greater than the LLN and less than 5.5 mmol/L.
  -  serum magnesium greater than the LLN and less than 3.0 mg/dL or 1.23 mmol/L.
  -  absolute neutrophil count greater than or equal to 1000/mm(3)
  -  platelet count greater than or equal to 100,000/mm(3)
  -  PT less than or equal to 4 seconds above ULN and PTT less than or equal to 10 seconds above ULN.
  9. Ability to understand and sign an informed consent document.
  10. Provision of informed consent prior to any study-related procedures
  11. Negative pregnancy test for women of childbearing potential
  12. Ability and willingness to follow the guidelines of the clinical protocol including visits to NCI, Bethesda, Maryland for treatment and follow up visits.
  13. Because the effects of chemotherapy on the developing human fetus are potentially harmful, female patients must be one year post-menopausal, surgically sterile, or using an acceptable method of contraception during and continued after the last dose of study medications (oral contraceptives, barrier methods, approved contraceptive implant, long-term injectable contraception, intrauterine device or tubal ligation). Male patients must be surgically sterile or using an acceptable method of contraception during their participation in this study. Contraceptive use will continue for at least four months after the last dose of study medication.
  EXCLUSION CRITERIA:
  1. Patients with cancer potentially curable by surgical excision alone or patients who have not received therapy that might be considered standard and potentially curable.
  2. Evidence of severe or uncontrolled systemic disease or any concurrent condition including, but not limited to symptomatic congestive heart failure, unstable angina pectoris, unstable hypertension, seizure disorder, or psychiatric illness which in the Investigator s opinion makes it undesirable for the patient to participate in the trial or which would jeopardize compliance with the protocol.
  3. Untreated brain metastases (or local treatment of brain metastases within the last 6 months) due to the poor prognosis of these patients and difficulty ascertaining the cause of neurologic toxicities.
  4. During Phase II enrollment: Prior therapy with vandetanib.
  5. Women who are currently pregnant or breast-feeding, due to the possible adverse effects on the developing fetus and infants.
  6. The presence of a second malignancy within the last 2 years, other than squamous cell carcinoma of the skin or in situ cervical cancer because it will complicate the primary objective of the study. Cancer survivors who have been free of disease for at least two years can be enrolled in this study.
  - There is one other exception to the exclusion of secondary malignancies: MEN2 patients with concurrent medullary thyroid cancer and pheochromocytoma may be enrolled at the discretion of the Principal Investigator.
  7. Patients with evidence of a bleeding diathesis that cannot be corrected with standard therapy or factor replacement.
  8. Any unresolved toxicity greater than CTCAE grade 1 (except alopecia) from previous anticancer therapy. Patients with grade 1 neuropathy will be evaluated on a case by case basis for entry into study. Baseline conditions will be taken into consideration.
  9. Major surgery within 4 weeks, or incompletely healed surgical incision before starting study therapy.
  10. Clinically significant cardiovascular event (e.g. myocardial infarction, superior vena cava syndrome (SVC), New York Heart Association (NYHA) classification of heart disease greater than or equal to 2 within 3 months before entry; or presence of cardiac disease that, in the opinion of the Investigator, increases the risk of ventricular arrhythmia.
  11. History of arrhythmia (multifocal premature ventricular contractions PVCs, bigeminy, trigeminy, ventricular tachycardia, or uncontrolled atrial fibrillation) which is symptomatic or requires treatment (CTCAE grade 3) or asymptomatic sustained ventricular tachycardia. Atrial fibrillation controlled on medication is not excluded.
  12. History (within the last 6 months) or presence of stroke/cerebrovascular accident.
  13. QTc prolongation with other medications. If the medication can be discontinued and an alternative medication started that does not cause QTc prolongation, the patient would be eligible. If no alternative medication is available and the medication cannot be discontinued for medical reasons, then the patient would not be eligible.
  14. Congenital long QT syndrome, or 1st degree relative with unexplained sudden death under 40 years of age.
  15. Presence of left bundle branch block (LBBB).
  16. QTc with Bazett s correction that is not measurable, or greater than or equal to 480 msec on screening ECG. (Note: If a patient has a QTc interval greater than or equal to 480 msec on screening ECG, the screen ECG may be repeated twice (at least 24 hours apart). The average QTc from the three screening ECGs must be less than 480 msec in order for the patient to be eligible for the study). Patients who are receiving a drug that has a risk of QTc prolongation are excluded if QTc is greater than or equal to 460 msec.
  17. Concurrent medication that may cause QTc prolongation or induce Torsades de Pointes: Those medications in Group One will not be allowed. Those medications in Group Two will be allowed.
  18. Hypertension not controlled by medical therapy (systolic blood pressure greater than 160 mm Hg or diastolic blood pressure greater than 100 mm Hg)
  19. Currently active (uncontrolled) diarrhea greater than or equal to CTCAE Grade 2 that may affect the ability of the patient to absorb the vandetanib or tolerate diarrhea. Antidiarrhea medications are allowed in patients with chronic diarrhea.
  20. Concomitant medications that are potent inducers (rifampicin, rifabutin, phenytoin, carbamazepine, phenobarbital and St. John s Wort) of CYP3A4 function.
  21. Major surgery within 4-weeks, or incompletely healed surgical incision before starting study medications. Biopsies, port placements, and dental work are examples of acceptable (nonmajor) surgery within the 4 week time frame.
  22. Inability to take oral medications for whatever reason.

Relevance to patient case: definitely relevant