Patient case: 51-year-old female with papillary thyroid carcinoma; genetic feature: BRAF (V600E)

Clinical trial: CUDC-907 Treatment in People With Metastatic and Locally Advanced Thyroid Cancer

Summary: Background:
  The thyroid is a gland at the base of the throat. Thyroid cancer is a disease that people get when abnormal cells begin to grow in this gland. Researchers believe a new drug called CUDC-907 may be able to help people with thyroid cancer that has spread or has gotten worse.
  Objective:
  To see if CUDC-907 will shrink tumors in people with advanced thyroid cancer.
  Eligibility:
  People at least 18 years old who have been diagnosed with locally advanced and metastatic thyroid cancer.
  Design:
  Participants will be screened with:
  Medical history
  Physical exam
  Blood and urine tests
  Electrocardiogram (ECG) heart test.
  Review of their symptoms and how they perform normal activities
  A scan will be performed. Some will have a computed tomographic scan (CT) that takes pictures of the body using a small amount of radiation. Some will have magnetic resonance imaging (MRI) that uses a magnetic field to take pictures.
  Bone scan (some participants)
  Fludeoxyglucose (FDG) positron emission tomography (PET) scan to produce a tumor image.
  A sample of their tumor from a previous surgery. They may have a biopsy of their tumor if a tumor sample is not available from a previous surgery.
  Participants will be given CUDC-907 in tablet form. They will take it by mouth once a day for 5 days, then take 2 days off, each week.
  While taking the study drug, participants will have study visits that repeat the screening tests.
  After they stop treatment, participants will have 3 follow-up visits over a year. They will repeat some tests. Then participants will be contacted by phone or e-mail every 6 months....

Detailed description: Background:
  -  There are no standard or effective systemic therapies for metastatic or locally advanced poorly differentiated and undifferentiated thyroid cancer.
  -  Poorly differentiated and undifferentiated thyroid cancer are aggressive, with high mortality.
  -  CUDC-907 is a first-in-class dual inhibitor of histone deacetylase (HDAC) and PI3K signaling.
  -  Approximately 80% of poorly differentiated and undifferentiated thyroid cancers have driver mutations in the PI3K/AKT pathway or activation of the pathway.
  -  HDAC2 is upregulated in poorly differentiated and undifferentiated thyroid cancer, and aggressive variants of differentiated thyroid cancer, and CUDC-907 treatment reduces HDAC2 levels in thyroid cancer cells.
  -  CUDC-907 inhibits thyroid cancer cell growth, invasion and migration in vitro.
  -  In addition to inhibiting the PI3K/AKT signaling pathway, CUDC-907 inhibits the EGFR/RAS/RAF/MEK/ERK signaling pathway, which is also activated in poorly differentiated and undifferentiated thyroid cancer.
  -  CUDC-907 inhibits growth and metastases in a mouse model of metastatic thyroid cancer.
  -  We hypothesize that CUDC-907 will cause cancer regression in patients with metastatic and locally advanced poorly differentiated and undifferentiated thyroid cancer, and aggressive variants of differentiated thyroid cancer.
  Objective:
  -To determine response to CUDC-907 treatment by Response Evaluation Criteria in Solid Tumors (RECIST) criteria in patients with locally advanced and metastatic poorly differentiated and undifferentiated thyroid cancer, and aggressive variants of differentiated thyroid cancer.
  Eligibility:
  -  Age greater than or equal to 18 years
  -  Thyroid cancer that is refractory to or relapsed after standard treatment.
  -  Aggressive thyroid cancer confirmed on histology or cytologic analysis.
  -  Measurable disease.
  -  Last dose of chemotherapy or last radiotherapy treatment more than 4 weeks prior to starting treatment with this protocol, except for subjects with anaplastic/undifferentiated thyroid cancer who may enroll immediately after discontinuation of previous therapy.
  Design:
  -  Open label, phase II trial to determine response to CUDC-907 treatment.
  -  Patients will be given 60 mg of CUDC-907 orally for 5 consecutive days followed by 2 days off (5/2 schedule).
  -  One cycle is 21 days. Patients may continue on treatment if there is no disease progression.
  -  Initial anatomic and functional imaging will be performed at enrollment and after 2 cycles of treatment. Thereafter, anatomic imaging will be performed every two cycles of treatment.

Eligibility: -  INCLUSION CRITERIA:
  -  Subjects greater than or equal to 18 years of age.
  -  Thyroid cancer histology or cytology that is aggressive (anaplastic/undifferentiated thyroid cancer, poorly differentiated thyroid cancer, Hurthle cell carcinoma, tall-cell variant of papillary thyroid cancer, sclerosing variant of papillary thyroid cancer).
  -  Measurable disease.
  -  Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2.
  -  Absolute neutrophil count greater than or equal to 1,000/microL
  -  Platelets greater than or equal to 75,000/microL
  -  Creatinine less than or equal to 1.5 times upper limit of normal (ULN) or creatinine clearance > 60ml for patients with creatinine levels 1.5 times above institutional ULN (calculated based on age, weight and sex
  -  Total bilirubin less than or equal to 1.5 times ULN; aspartate aminotransferase (AST)/alanine aminotransferase (ALT) less than or equal to 2.5 times ULN. For subjects with documented liver metastases, the AST/ALT may be less than or equal to 5 times ULN.
  -  Recovery to Grade 1 or baseline of any toxicity due to prior anticancer therapies (excluding alopecia).
  -  Platelet transfusions to help patients meet eligibility criteria are not allowed within 3 days prior to screening complete blood count (CBC) or Cycle 1, Day 1 treatment.
  -  Women of child bearing potential must have a negative serum pregnancy test.
  -  The effects of CUDC-907 on the developing human fetus are unknown. For this reason, 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, for the duration of study participation and for 30 days following the last study treatment.
  Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.
  -Able to provide written informed consent and to follow protocol requirements.
  EXCLUSION CRITERIA:
  -  Systemic anticancer therapy within 4 weeks of study entry, except for subjects with anaplastic/undifferentiated thyroid cancer who may be enrolled immediately after discontinuation of previous therapy.
  -  Other investigational agents within 4 weeks prior to study treatment except for subjects with anaplastic/undifferentiated thyroid cancer who may be enrolled immediately of discontinuation of previous therapy.
  -  Pregnant women are excluded from this study because the potential risk of teratogenic or abortifacient effects of CUDC-907 is unknown. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with CUDC-907, breastfeeding should be discontinued if the mother is treated with CUDC-907. These potential risks may also apply to other agents used in this study.
  -  Diabetes mellitus that is not controlled with medication.
  -  Serious infection requiring intravenous antibiotic therapy within 14 days prior to study treatment.
  -  Evidence of central nervous system metastasis.
  -  Uncontrolled or severe cardiovascular disease, including myocardial infarction, unstable angina, or atrial fibrillation (AFib) within 6 months prior to study treatment, New York Heart Association (NYHA) Class II or greater congestive heart failure, serious arrhythmias requiring medication for treatment, clinically significant pericardial disease, cardiac amyloidosis, or corrected QT interval (QTc) with Fridericia's (QTcF) correction that is unmeasurable or greater than or equal to 480 msec on screening electrocardiogram (ECG). (Note: for QTcF greater than or equal to 480 sec on the screening ECG, the ECG may be repeated twice at least 24 hours apart; the mean QTcF from the three screening ECGs must be < 480 msec in order to meet eligibility for trial participation).
  -  Gastrointestinal disease or disorder that could interfere with the swallowing, oral absorption, or tolerance of CUDC-907. This includes uncontrolled diarrhea (> 1 watery stool/day), major abdominal surgery, significant bowel obstruction and/or gastrointestinal diseases that could alter the assessment of pharmacokinetics or safety, including but not limited to: irritable bowel syndrome, ulcerative colitis, Crohn's disease and hemorrhagic coloproctitis.
  -  Unstable or clinically significant concurrent medical condition that would, in the opinion of the investigator, jeopardize the safety of a subject and/or compliance with the protocol.
  -  Second primary malignancy within 2 years of study entry other than adequately treated non-melanoma skin or superficial bladder cancer, curatively treated carcinoma in situ of the cervix or other curatively treated solid tumor deemed by the investigator to be at low risk for recurrence.

Relevance to patient case: not relevant