Patient case: 62-year-old male with cholangiocarcinoma; genetic feature: PIK3CA (1047H)

Clinical trial: Akt Inhibitor MK-2206 and Anastrozole With or Without Goserelin Acetate in Treating Patients With Stage II-III Breast Cancer

Summary: This phase II trial studies how well Akt inhibitor MK-2206 (MK-2206) and anastrozole with or without goserelin acetate works in treating patients with stage II-III breast cancer. MK-2206 may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Estrogen can cause the growth of breast cancer cells. Hormone therapy using anastrozole and goserelin acetate may fight breast cancer by blocking the use of estrogen by the tumor cells. Giving MK-2206, anastrozole, and goserelin acetate together may kill more tumor cells.

Detailed description: PRIMARY OBJECTIVES:
  I. To determine the pathologic complete response (pCR) rate of neoadjuvant MK-2206 (Akt inhibitor MK-2206) in combination with anastrozole (goserelin [goserelin acetate] is added if premenopausal) in women with clinical stage II or III phosphatidlinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) mutated estrogen receptor (ER)+/human epidermal growth factor receptor 2 (HER2)- breast cancer.
  SECONDARY OBJECTIVES:
  I. To determine the safety profile of neoadjuvant MK-2206 in combination with anastrozole (goserelin is added if premenopausal) in women with clinical stage II or III PIK3CA mutated ER+/HER2- breast cancer.
  II. To estimate the rate of clinical response and radiologic response using the World Health Organization (WHO) criteria.
  TERTIARY OBJECTIVES:
  I. For pre and post-menopausal women separately, to examine serum estradiol levels prior to pre-registration, prior to registration, after 2 cycles of anastrozole plus MK-2206 (cycle 3 day 1) and pre surgery.
  II. To examine the percent change in the apoptotic index after 2 weeks of combination therapy with MK-2206 and anastrozole (cycle 1 day 17) relative to apoptotic index after 4 weeks of treatment with anastrozole alone (pre MK-2206).
  III. To examine the change in Ki67 levels after 2 weeks of combination therapy with MK-2206 and anastrozole (cycle 1 day 17) relative to that after 4 weeks of treatment with anastrozole alone (pre MK-2206).
  IV. To estimate the proportion of patients whose Ki67 values is at most 10% after 2 weeks of combination therapy with MK-2206 and anastrozole (cycle 1 day 17) among those whose Ki67 was more than 10% or more after 4 weeks of treatment with anastrozole alone (pre MK-2206).
  V. To examine the pharmacodynamic effect of MK-2206 in combination with anastrozole (or anastrozole in combination with goserelin) on PI3K pathway signaling using serially collected tumor specimens.
  VI. To explore molecular mechanisms which could affect tumor response to combination MK-2206 and anastrozole (or anastrozole in combination with goserelin) in PIK3CA mutant ER+ breast cancer.
  VII. To examine the PIK3CA mutation status in circulating plasma deoxyribonucleic acid (DNA) prior to and following therapy on serially collected peripheral blood (pre anastrozole, pre MK-2206, cycle 1 day 17, and at the time of surgery) and to correlate with tumor tissue PIK3CA status.
  VIII. To examine PIK3CA mutation status of the residual cancer collected at the time of surgery post 4 cycles of neoadjuvant MK-2206 and anastrozole.
  OUTLINE:
  Patients receive Akt inhibitor MK-2206 orally (PO) on days 2, 9, 16, and 23; anastrozole PO daily on days 1-28; and goserelin acetate subcutaneously (SC) on day 1 (premenopausal patients only). Treatment repeats every 28 days for 4 courses in the absence of disease progression or unacceptable toxicity.
  Standard of care surgery (breast and axillary lymph node surgery) is performed 1-3 weeks following the last dose of Akt inhibitor MK-2206.
  After completion of study treatment, patients are followed up for 30-60 days.

Eligibility: Inclusion Criteria:
  -  Clinical T2-T4c, any N, M0 invasive ER+ (Allred score of 6-8) and HER2 negative (0 or 1+ by immunohistochemistry [IHC] or fluorescence in situ hybridization [FISH] negative for amplification) breast cancer, by American Joint Committee on Cancer (AJCC) 7th edition clinical staging, with the goal being surgery to completely excise the tumor in the breast and the lymph node;
  -  Note: if the patient has invasive or ductal carcinoma in situ (DCIS) in the contralateral breast the patient is not eligible for this study
  -  >= 1 measurable lesion that is palpable, its size can be measured by bi-dimensional tape, ruler or caliper technique, and the minimum size of the largest tumor diameter is greater than 2.0 cm by imaging or physical examination
  -  Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1 or 2
  -  Life expectancy > 4 months
  -  Leukocytes >= 3,000/mcL
  -  Absolute neutrophil count >= 1,500/mcL
  -  Platelets >= 100,000/mcL
  -  Total bilirubin =< upper limit of normal (ULN)
  -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT])/and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 x institutional ULN
  -  Creatinine =< ULN OR creatinine clearance >= 60 mL/min/1.73 m^2 for patients with creatinine above institutional normal
  -  Patient with diabetes mellitus: fasting glucose =< 120 mg/dL and hemoglobin A1c (HbA1c) =< 8%
  -  Negative serum pregnancy test =< 7 days prior to pre-registration for women of childbearing potential
  -  Ability to understand and the willingness to sign a written informed consent document
  -  Patient is postmenopausal or premenopausal
  -  NOTE: postmenopausal women, verified by
  -  Bilateral surgical oophorectomy, or
  -  No spontaneous menses >= 1 year or
  -  No menses for < 1 year with follicle stimulating hormone (FSH) and estradiol levels in postmenopausal range, according to institutional standards or
  -  Premenopausal women, verified by:
  -  Regular menses or
  -  FSH and estradiol levels in premenopausal range, according to institutional standards
  -  Willingness to provide biologic samples for PIK3CA sequencing and correlative studies
  -  Positive for PIK3CA mutation based on central laboratory testing
  -  In premenopausal women, serum estradiol level in postmenopausal range =< 7 days prior to registration
  Exclusion Criteria:
  -  Any of the following for treatment of this cancer including:
  -  Surgery
  -  Radiation therapy
  -  Chemotherapy
  -  Biotherapy
  -  Hormonal therapy
  -  Investigational agent prior to study entry
  -  Receiving any other investigational agents
  -  History of allergic reactions attributed to compounds of similar chemical or biologic composition to MK-2206 or other agents used in this study
  -  Prior axillary lymph node sampling (sentinel lymph node biopsy or axillary lymph node dissection); NOTE: fine needle aspiration (FNA) of axillary lymph node is acceptable
  -  Invasive cancer or DCIS in the contralateral breast
  -  Receiving any medications or substances that are strong inhibitors or inducers of cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP450 3A4);
  -  NOTE: oxidative metabolism of MK-2206 in human liver microsomes is catalyzed primarily by CYP3A4, although direct glucuronidation also occurs; at least 7 days washout period is required in patients who were previously taking strong inhibitors or inducers of CYP.450 3A4; patients who are currently taking moderate inhibitors or inducers of CYP450 3A4 are encouraged to switch to other medications that do not interact with CYP450 3A4
  -  Corrected QT interval (QTc) prolongation (defined as a QTc interval > 480 msec) or other significant electrocardiogram (ECG) abnormalities
  -  Receiving any medications or substances with risk of torsades de pointes; Note: medications or substances on the list "Drugs with Risk of Torsades de Pointes" are prohibited; medications or substances on the list "Drugs with Possible or Conditional Risk of Torsades de Pointes" may be used while on study with extreme caution and careful monitoring
  -  Uncontrolled intercurrent illness including, but not limited to:
  -  Ongoing or active infection
  -  Symptomatic congestive heart failure
  -  Unstable angina pectoris
  -  Uncontrolled symptomatic cardiac arrhythmia
  -  Psychiatric illness/social situations that would limit compliance with study requirements
  -  Any of the following:
  -  Pregnant women
  -  Nursing women
  -  Women of childbearing potential who are unwilling to employ adequate contraception
  -  NOTE: breastfeeding should be discontinued if the mother is treated with MK-2206; women of childbearing potential must use two forms of contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation
  -  Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy; NOTE: HIV-positive patients on combination antiretroviral therapy are ineligible; in addition, these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy
  -  Evidence of inflammatory cancer (clinical presentation of skin erythema involving more than one third of the breast or pathological evidence of dermal lymphatic involvement)
  -  Patients with known metastatic disease are excluded
  -  Current use of therapeutic anticoagulation therapy
  -  Previous excisional biopsy of the breast cancer
  -  Any condition (e.g., gastrointestinal tract disease resulting in an inability to take oral medication or a requirement for intravenous [IV] alimentation, prior surgical procedures affecting absorption) that impairs patients ability to swallow MK-2206 tablets

Relevance to patient case: not relevant