Testing Treatment With Encorafenib and Binimetinib Before Surgery for Melanoma With Lymph Node Involvement

Study Overview
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Brief Summary
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This phase II trial studies how well encorafenib and binimetinib work before surgery in treating patients with BRAF V600-mutated stage IIIB-D melanoma that has spread to the lymph nodes. Encorafenib and binimetinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. This trial also studies how well 18F-FLT positron emission tomography (PET)/computed tomography (CT) works in predicting the response of melanoma to encorafenib and binimetinib. 18F-FLT is an imaging agent, sometimes called a tracer. PET and CT are types of imaging scans. Using 18F-FLT PET/CT together with encorafenib and binimetinib may provide more information on melanoma over time.

Detailed Description
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PRIMARY CLINICAL OBJECTIVE: I. To evaluate the pathologic complete response (pCR) rate of neoadjuvant treatment with encorafenib and binimetinib. SECONDARY CLINICAL OBJECTIVES: I. To determine response rate (RR) (Response Evaluation Criteria in Solid Tumors [RECIST]), disease-free survival (DFS) and overall survival (OS). II. To describe correlation of pCR with RR, DFS and OS. III. To assess safety and toxicity. CORRELATIVE SCIENCE OBJECTIVES: I. To evaluate CD8 positive (+) T cell infiltration and Ki-67 status in tumor or tumor bed pre, during, and post neoadjuvant treatment and the change in CD8+ tumor infiltrating lymphocyte (TIL) with neoadjuvant treatment and correlate with clinical response. II. To compare local review for pathologic response with central pathology review. III. To assess the correlation between change in fluorothymidine F-18 (18F-FLT) PET/CT uptake and change in Ki-67. IMAGING OBJECTIVES: I. To compare the change in 18F-FLT PET/CT uptake (from baseline to post-neoadjuvant therapy) among patients with and without pathologic complete response. II. To compare post-neoadjuvant 18F-FLT PET/CT uptake among patients with and without pathologic complete response. III. To estimate an optimal threshold for prediction of pathologic complete response using i) change in 18F-FLT PET/CT uptake, and ii) post-neoadjuvant 18F-FLT PET/CT uptake. IV. To assess the correlation between change in 18F-FLT PET/CT uptake and change in Ki-67. OUTLINE: NEOADJUVANT TREATMENT: Patients receive 18F-FLT intravenously (IV) and undergo a PET/CT scan approximately 60 minutes later. Within 2 weeks, patients receive encorafenib orally (PO) once daily (QD) and binimetinib PO twice daily (BID) on days 1-28. Treatment repeats every 28 days for up to 2 cycles in the absence of disease progression or unacceptable toxicity. Patients then receive 18F-FLT IV and undergo a second PET/CT scan approximately 60 minutes later. SURGICAL RESECTION: Within 2 weeks of completing therapy with encorafenib and binimetinib, patients undergo surgery. ADJUVANT TREATMENT: Within 2-7 days after surgery, patients resume treatment with encorafenib PO QD and binimetinib PO BID on days 1-28. Treatment repeats every 28 days for up to 11 cycles in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months for 1 year, then every 6 months for 3 years.

Official Title
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A Phase II Neoadjuvant Study of Encorafenib With Binimetinib in Patients With Resectable Locoregional Metastases From Cutaneous or Unknown Primary Melanoma (Stages III N1B/C/D)

Conditions
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Melanoma of Unknown Primary, Metastatic Malignant Neoplasm in Lymph Node, Pathologic Stage IIIB Cutaneous Melanoma AJCC v8, Pathologic Stage IIIC Cutaneous Melanoma AJCC v8, Pathologic Stage IIID Cutaneous Melanoma AJCC v8, Recurrent Cutaneous Melanoma

Intervention / Treatment
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* Drug: Binimetinib
* Procedure: Computed Tomography
* Procedure: Conventional Surgery
* Drug: Encorafenib
* Other: Fluorothymidine F-18
* Procedure: Positron Emission Tomography


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient must have histologically proven melanoma that is clinically evident (macroscopic lymphadenectomy [LAD]) stage III B/C/D, (American Joint Committee on Cancer [AJCC] 8th edition) of cutaneous origin or unknown primary. Patients must have at least one clinically evident lymph node metastasis (N1c patients are not eligible). Patients with stage IV melanoma are not eligible This may be an initial presentation with primary tumor and nodal metastases or locoregional nodal relapse with history of resected primary melanoma Stage IIIB T0-3a N1b M0 T1a-3a N2b M0 Stage IIIC T0 or T3b-4b N2b M0 T3b-4b N1b M0 Any T N2c M0 (at least 1 clinically evident node) T0-4a N3b M0 Stage IIID T4b N3b/c M0 (if 3c: at least 1 clinically evident node) Patient must have measurable disease on baseline imaging scans, obtained within 4 weeks prior to registration as defined by RECIST and by the following criteria The melanoma target tumor must be completely resectable as determined by a surgical oncologist or experienced melanoma surgeon Extensive satellitosis or in transit metastases are not considered completely resectable Patient must have BRAF V600 mutation positive based on report from Clinical Laboratory Improvement Act (CLIA) certified laboratory Patient must be medically fit to undergo surgery Absolute neutrophil count (ANC) >= 1.5 x 10^9/L (obtained < 14 days prior to registration) Hemoglobin >= 8 g/dL without transfusion (obtained < 14 days prior to registration) Platelets >= 100 x 10^9/L without transfusion (obtained < 14 days prior to registration) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.0 x upper limit of normal (ULN) (obtained < 14 days prior to registration) Total bilirubin =< 1.5 x ULN and < 2 mg/dL; OR total bilirubin > 1.5 x ULN with indirect bilirubin < 1.5 x ULN (obtained < 14 days prior to registration) Serum creatinine =< 1.5 x ULN, or calculated creatinine clearance > 50 mL/min by Cockcroft-Gault formula (obtained < 14 days prior to registration) Prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) =< 1.5 x ULN (obtained < 14 days prior to registration) Patient must have an Eastern Cooperative Oncology Group (ECOG) performance status 0-1 Patient must be able to take oral medications Patient must be able to lie still during the 18F-FLT PET/CT scan for the duration of the imaging study (up to 1.5 hours), have no previous indication of allergic reaction to the radiotracer, and meet the size limits of the qualified PET/CT scanner Patient must be participating in this study at an institution which has completed the ECOG-American College of Radiology Imaging Network (ACRIN) defined PET/CT scanner qualification procedures and received ECOG-ACRIN PET scanner approval Patients known to be human immunodeficiency virus (HIV) positive are eligible if they have undetectable HIV viral load and stable and adequate CD4 counts (>= 500 mm^3) on screening labs provided they meet all other protocol criteria for participation and that there is no high risk drug interactions Women of childbearing potential and sexually active males must use accepted and effective method(s) of contraception or to abstain from sexual intercourse for the duration of their participation in the study and for at least 30 days after the last dose of protocol treatment for female patients, and for at least 90 days after the last dose of protocol treatment for male patients. In addition, female patients must not donate ova from the time of registration until 30 days after the last dose of study treatment. Male patients must not donate sperm from the time of registration until 90 days after the last dose of protocol treatment Patient may be on anticoagulation at prophylactic or therapeutic levels. Patients must not be using anticoagulants at therapeutic levels that may interfere with encorafenib and binimetinib Exclusion Criteria: Patient must not have any prior treatment with BRAF inhibitor (BRAFi) or MEK inhibitor (MEKi) Patient must not have any evidence of distant metastases Patient must not have any prior adjuvant therapy at this disease presentation; prior immune therapy (such as adjuvant interferon or checkpoint inhibitors) is permitted if >= 6 months from last treatment Patient must not have any prior radiation to the site of evaluable disease Patient must not have active infection requiring treatment with parenteral antibiotics Patient must not have active hepatitis B, and/or active hepatitis C infection given concerns for drug interactions or increased toxicities. Testing is not required Patient must not have other significant medical, surgical, or psychiatric conditions that in the opinion of the investigator may interfere with compliance, make the administration of study medications hazardous Patient must not have had previous or concurrent other malignancy with the following exceptions: Adequately treated basal cell or squamous cell carcinoma of the skin, in situ carcinoma of the cervix Other solid tumor: if treated and without evidence of recurrence for at least 2 years prior to study entry Women must not be pregnant or breast-feeding due to potential harm to an unborn fetus and possible risk for adverse events in nursing infants with the systemic antineoplastic medications, as well as surgery and radiation being used. Patients must also not expect to conceive or father children from the time of registration, while on study, treatment, and until at least 30 days after the last dose of study treatment (for female patients) and 90 days after the last dose of study treatment (for male patients). All females of childbearing potential must have a blood test or urine study within 14 days prior to registration to rule out pregnancy. A female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has achieved menarche at some point, 2) has not undergone a hysterectomy or bilateral oophorectomy; or 3) has not been naturally postmenopausal (amenorrhea following cancer therapy does not rule out childbearing potential) for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months) Patient must not have known hypersensitivity or contraindication to any component of binimetinib or encorafenib or their excipients Patient must not have impaired cardiovascular function or clinically significant cardiovascular disease including, but not limited to, any of the following: History of acute coronary syndromes (including myocardial infarction, unstable angina, coronary artery bypass grafting, coronary angioplasty or stenting) < 6 months prior to registration Congestive heart failure requiring treatment (New York Heart Association grade >= 2) Left ventricular ejection fraction (LVEF) < 50% as determined by multigated acquisition scan (MUGA) or echocardiogram (ECHO) Uncontrolled hypertension defined as persistent systolic blood pressure >= 150 mmHg or diastolic blood pressure >= 100 mmHg despite current therapy History or presence of clinically significant cardiac arrhythmias (including resting bradycardia, uncontrolled atrial fibrillation or uncontrolled paroxysmal supraventricular tachycardia) Baseline corrected QT (QTc) interval >= 480 ms Patient must not have impairment of gastrointestinal function or disease which may significantly alter the absorption of study drug (e.g., active ulcerative disease, uncontrolled vomiting or diarrhea, malabsorption syndrome, small bowel resection with decreased intestinal absorption), or recent (=< 3 months) history of a partial or complete bowel obstruction, or other conditions that will interfere significantly with the absorption of oral drugs Patient must not have any known history of acute or chronic pancreatitis Patient must not have any concurrent neuromuscular disorder that is associated with elevated creatine kinase (CK) (e.g., inflammatory myopathies, muscular dystrophy, amyotrophic lateral sclerosis, spinal muscular atrophy Patient must not have any known history or current evidence of retinal vein occlusion (RVO) or current risk factors for RVO (e.g., uncontrolled glaucoma or ocular hypertension, history of hyperviscosity, factor V Leiden or activated protein C resistance); history of retinal degenerative disease Patient must not use any medication (including herbal medications, supplements, or foods), or use of a prohibited medication =< 1 week prior to registration Patient must not have a history of thromboembolic or cerebrovascular events =< 12 weeks prior to registration. Examples include transient ischemic attacks, cerebrovascular accidents, hemodynamically significant (i.e. massive or sub-massive) deep vein thrombosis or pulmonary emboli NOTE: Patients with thromboembolic events related to indwelling catheters or other procedures may be registered NOTE: Patients with either deep vein thrombosis or pulmonary emboli that does not result in hemodynamic instability are allowed to register as long as they are on a stable dose of anticoagulants for at least 4 weeks

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Treatment (18F-FLT, PET/CT, encorafenib, binimetinib, surgery)<br>NEOADJUVANT TREATMENT: Patients receive 18F-FLT IV and undergo a PET/CT scan approximately 60 minutes later. Within 2 weeks, patients receive encorafenib PO QD and binimetinib PO BID on days 1-28. Treatment repeats every 28 days for up to 2 cycles in the absence of disease progression or unacceptable toxicity. Patients then receive 18F-FLT IV and undergo a second PET/CT scan approximately 60 minutes later. SURGICAL RESECTION: Within 2 weeks of completing therapy with encorafenib and binimetinib, patients undergo surgery. ADJUVANT TREATMENT: Within 2-7 days after surgery, patients resume treatment with encorafenib PO QD and binimetinib PO BID on days 1-28. Treatment repeats every 28 days for up to 11 cycles in the absence of disease progression or unacceptable toxicity. | Drug: Binimetinib<br>* Given PO<br>* Other names: Mektovi;Procedure: Computed Tomography<br>* Undergo PET/CT<br>* Other names: tomography;Procedure: Conventional Surgery<br>* Undergo surgery<br>Drug: Encorafenib<br>* Given PO<br>* Other names: LGX818;Other: Fluorothymidine F-18<br>* Given IV<br>* Other names: fluorothymidine F 18;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: proton magnetic resonance spectroscopic imaging;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pathologic complete response (pCR) rate | Will be estimated and 90% confidence intervals (CI) adjusting for the first stage analysis will be provided. | Up to 5 years | 
| Change in fluorothymidine F-18 (18F-FLT) positron emission tomography (PET)/computed tomography (CT) uptake | Will be compared among patients with and without a pCR. Distributional summaries of the continuous percent change in 18F-FLT PET/CT maximum standardized uptake value (SUVmax) will be reported, where percent change is defined as (baseline SUVmax - post-neoadjuvant SUVmax)/(baseline SUVmax)*100%. The comparison of percent change in SUVmax between pCR and non-pCR patients will be performed using a one-sided nonparametric Wilcoxon rank sum test with an alpha level of 0.05. Will also report distributional summaries and comparisons for percent change in 18F-FLT PET/CT peak SUV (SUVpeak); however, the prespecified primary comparison will be based on 18F-FLT PET/CT SUVmax. | Baseline up to 2 cycles of treatment (8 or 9 weeks of neoadjuvant therapy) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall survival (OS) | OS distributions will be estimated using the Kaplan-Meier method. Median OS will be described with 95% confidence intervals. Clinical data from unevaluable patients will be summarized separately. | From time of enrollment to death from any cause, assessed up to 5 years | 
| Disease-free survival (DFS) | DFS distributions will be estimated using the Kaplan-Meier method. Median DFS will be described with 95% confidence intervals. Clinical data from unevaluable patients will be summarized separately. | From complete surgical resection to disease progression or death (whichever comes first), assessed up to 5 years | 
| Response rate | Will be evaluated based on international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors guideline (version 1.1) and estimated with 95% confidence interval. Clinical data from unevaluable patients will be summarized separately. | Up to 5 years | 
| Incidence of adverse events (AEs) | Will be graded using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version(v.) 5.0. All treatment-emergent and baseline adverse events and hematological/biochemical toxicities based on laboratory measurements, as well as drug related AEs, will be summarized by NCI CTCAE v. 5.0 worst grade. The incidence of deaths and treatment-emergent serious adverse events (defined as number of patients experiencing the AE divided by all treated patients) will be summarized. Also, the incidence of adverse events leading to discontinuation of investigational product and/or withdrawal from the study will be summarized and listed. | Up to 5 years | 
| Change in CD8 positive (+) tumor infiltrating lymphocytes | Will be based on the two-sample t-test using two-sided type I error rate of 0.1. If normality assumption is not appropriate, Wilcoxon rank sum test will be used during the analysis. Using the median change value, cases will be divided to high and low change groups. Will be assessed and summarized using the descriptive statistics. Will be compared among patients achieving a pCR versus no pCR. | Baseline up to 2 cycles of treatment (8 or 9 weeks of neoadjuvant therapy) | 
| Change in CD8+ T cell infiltration in tumor or tumor bed | Will be based on the two-sample t-test using two-sided type I error rate of 0.1. If normality assumption is not appropriate, Wilcoxon rank sum test will be used during the analysis. Using the median change value, cases will be divided to high and low change groups. Will be assessed and summarized using the descriptive statistics | Baseline up to 2 cycles of treatment (8 or 9 weeks of neoadjuvant therapy) | 
| Concordance of pCR | The concordance of pCR assessed based on local review versus central pathology review will be evaluated. Kendall's Tau test will be used for this comparison. | Up to 5 years | 
| Post-neoadjuvant 18F-FLT PET/CT uptake | Will be compared among patients with and without a pCR. Distributional summaries of the post-neoadjuvant 18F-FLT PET/CT SUVmax will be reported. The comparison SUVmax between pCR and non-pCR patients will be performed using a one-sided nonparametric Wilcoxon rank sum test with an alpha level of 0.05. Will also report distributional summaries and comparisons for post-neoadjuvant in 18F-FLT PET/CT peakSUV. | Up to 8 weeks of neoadjuvant therapy | 
| Optimal threshold for prediction of pathologic complete response | Will be estimated using change in 18F-FLT PET/CT uptake. Diagnostic performance of percent change in 18F-FLT PET/CT SUVmax (from the baseline scan to the post-neoadjuvant scan) as a marker for pCR status will be assessed using receiver operating characteristic curve (ROC) analysis. In particular, the empirical area. The corresponding performance of the optimal threshold (measured via sensitivity and specificity) will be estimated using cross-validation under the receiver operating characteristic curve (ROC AUC) will be reported, along with corresponding 95% confidence interval. In addition, will formally test if the ROC AUC exceeds 0.5 using a one-sided test with an alpha level of 0.05. The optimal threshold (binary cutpoint) of continuous percent change in SUVmax will be estimated by means of the Youden index. A 95% confidence interval for the optimal threshold will be estimated using the bootstrap technique to properly reflect sampling variability. | Baseline up to 8 weeks of neoadjuvant therapy | 
| Change in 18F-FLT PET/CT uptake | The correlation between percent change in continuous SUVmax and percent change in the continuous Ki67 score will be estimated using the Spearman correlation coefficient. A one-sided correlation test with null hypothesis of zero correlation will be conducted at alpha level of 0.05. The corresponding confidence interval for the estimated Spearman correlation coefficient will also be reported. Correlation between change in 18F-FLT PET/CT and the early change in tumor cell Ki-67 (from baseline to the week 2 interim biopsy) will also be separately estimated. The corresponding correlation with percent change in 18F-FLT PET/CT SUVpeak will also be reported. | Baseline up to 8 weeks of neoadjuvant therapy |