Patient case: 72-year-old male with lung adenocarcinoma; genetic feature: EZR-ROS1 fusion

Clinical trial: Nintedanib in Molecularly Selected Patients With Advanced Non-Small Cell Lung Cancer

Summary: There has been limited benefit with angiogenesis inhibitor drugs when used with molecularly selected patients in non-small cell lung cancer (NSCLC). The investigators propose that patients who are molecularly selected for treatment with nintedanib based on the presence of mutations (VEGFR1-3, PDGFR-A, PDGFR-B, and FGFR1-3) will have clinically meaningful benefits in terms of response rate (RR) and progression-free survival (PFS). Furthermore the investigators plan to perform exome sequencing of paired tumor (pre and post treatment) in order to better define molecular marker predictors for response and resistance.


Eligibility: Inclusion Criteria:
  -  Histologically confirmed diagnosis of advanced (metastatic or unresectable) NSCLC with mutations, rearrangement and fusion involving RET oncogene, or abnormalities (non-synonymous SNV or amplification) in the nintedanib target genes VEGFR1-3, TP53, PDGFR-A, PDGFR-B, and FGFR1-3. CLIA certified lab testing for nintedanib target genes using cell free DNA from peripheral blood and/or assays performed on tumor tissues are acceptable.
  -  Patients with EGFR mutations or ALK rearrangements must have disease progression on appropriate FDA-approved therapy for these genomic aberrations prior to enrollment.
  -  Disease progression on platinum-doublet chemotherapy prior to enrollment.
  -  At least one measurable lesion or evaluable disease. Measurable disease is defined as lesions that can be accurately measured in at least one dimension (longest diameter to be recorded) as ≥10 mm with CT scan, as ≥20 mm by chest x-ray, or ≥10 mm with calipers by clinical exam.
  -  Prior treatment of cancer (chemotherapy, radiation therapy, and surgery) is allowed if completed at least 3 weeks prior to start of treatment with nintedanib and if all treatment-related toxicities are resolved.
  -  At least 18 years of age.
  -  ECOG performance status 0-1
  -  Normal bone marrow and organ function as defined below:
  -  Leukocytes ≥ 3,000/mcL
  -  Absolute neutrophil count ≥ 1,500/mcL
  -  Platelets ≥ 100,000/mcL
  -  Hemoglobin ≥ 9.0 g/dL
  -  INR < 2.0
  -  PT and PTT < 50% of deviation from IULN
  -  Total bilirubin ≤ 1.5 x IULN
  -  AST(SGOT)/ALT(SGPT) ≤ 1.5 x IULN for patients without liver metastases and ≤ 2.5 x IULN for patients with liver metastases
  -  Urine protein < 2+
  -  Creatinine within normal institutional limits OR Creatinine clearance > 45 mL/min for patients with creatinine levels above institutional normal
  -  Women of childbearing 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 3 months after the end of treatment. Should a woman become pregnant or suspect she is pregnant while participating in this study, she must inform her treating physician immediately.
  -  Able to understand and willing to sign an IRB approved written informed consent document (or that of legally authorized representative, if applicable).
  Exclusion Criteria:
  -  Prior treatment with VEGFR tyrosine kinase inhibitors.
  -  A history of other malignancy ≤ 5 years previous with the exception of basal cell or squamous cell carcinoma of the skin which were treated with local resection only or carcinoma in situ of the cervix.
  -  Currently receiving any other investigational agents, or received an investigational agent within 3 weeks of the first dose of nintedanib.
  -  Radiotherapy to the target lesion within the past 3 months prior to baseline imaging.
  -  Symptomatic brain metastases. Patients with known brain metastases are eligible if the metastases are asymptomatic and previously treated.
  -  Leptomeningeal disease.
  -  Radiographic evidence of cavitary or necrotic tumors.
  -  Centrally located tumors with radiographic evidence (CT or MRI) of local invasion of major blood vessels.
  -  A history of allergic reactions attributed to compounds of similar chemical or biologic composition to nintedanib or other agents used in the study.
  -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure > NYHA II, active coronary artery disease, unstable angina pectoris, serious cardiac arrhythmia, uncontrolled hypertension (defined as systolic pressures > 150 mmHg or diastolic pressure > 90 mmHg), pericardial effusion, uncontrolled seizure disorder, or psychiatric illness/social situations that would limit compliance with study requirements.
  -  Major injuries and/or surgery with then past 4 weeks prior to the start of study treatment with incomplete wound healing and/or planned surgery during the on-treatment study period.
  -  History of clinically significant hemorrhagic or thromboembolic event in the past 6 months.
  -  Known inherited predisposition to bleeding or thrombosis.
  -  History of cardiac infarction within the past 12 months prior to the start of study treatment.
  -  Receiving therapeutic anticoagulation (except low-dose heparin and/or heparin flush as needed for maintenance of an in-dwelling intravenous device) or anti-platelet therapy (except for low-dose therapy with acetylsalicylic acid < 325 mg QD).
  -  Pregnant and/or breastfeeding. Patients of childbearing potential must have a negative pregnancy test within 14 days of study entry.
  -  Significant weight loss (> 10% of BW) within past 6 months prior to inclusion into the trial.
  -  Known active or chronic hepatitis B or C infection.
  -  Active alcohol or drug abuse.
  -  Gastrointestinal disorder or abnormality that would interfere with absorption of the study drug.
  -  Known HIV-positivity on combination antiretroviral therapy because of the potential for pharmacokinetic interactions with nintedanib. In addition, these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy. Appropriate studies will be undertaken in patients receiving combination antiretroviral therapy when indicated.

Relevance to patient case: not relevant