Conditions: BRAF V600E Mutation Present BRAF V600K Mutation Present Metastatic Malignant Solid Neoplasm Metastatic Melanoma Stage III Cutaneous Melanoma AJCC v7 Stage IIIA Cutaneous Melanoma AJCC v7 Stage IIIB Cutaneous Melanoma AJCC v7 Stage IIIC Cutaneous Melanoma AJCC v7 Stage IV Cutaneous Melanoma AJCC v6 and v7 Unresectable Solid Neoplasm
Allocation: NON_RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 22
Healthy volunteers: no

Brief summary:
This phase I trial studies the side effects and best dose of onalespib when given together with dabrafenib and trametinib in treating patients with BRAF-mutant melanoma or solid tumors that have spread to another place in the body (metastatic) or cannot be removed by surgery. Onalespib, dabrafenib, and trametinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the maximum tolerated dose (MTD), toxicity, and safety profile of onalespib (AT13387) given weekly in combination with dabrafenib and trametinib in patients with BRAF-mutant metastatic or unresectable solid tumors.

SECONDARY OBJECTIVES:

I. To obtain preliminary estimates of the objective response rate (ORR) and progression-free survival (PFS) and document the 6-month PFS and 1-year overall survival (OS) of patients with BRAF-mutant metastatic or unresectable melanoma treated with AT13387 given weekly in combination with dabrafenib and trametinib.

II. To describe the pharmacokinetics of treatment with dabrafenib, trametinib, and AT13387.

OUTLINE: This is a dose-escalation study of onalespib. Four dose levels, plus a fallback dose, are specified in the protocol and are summarized below. The trial is based on a standard 3+3 design with dose escalation beginning in dose level 1 (DL1). In a 3+3 design," three patients are initially enrolled into a given dose cohort. If there is no dose limiting toxicity (DLT) observed in any of these subjects, the trial proceeds to enroll additional subjects into the next higher dose cohort. If one subject develops a DLT at a specific dose, an additional three subjects are enrolled into that same dose cohort. Development of DLTs in more than 1 of 6 subjects in a specific dose cohort suggests that the maximum total dose (MTD) has been exceeded, and further dose escalation is not pursued. Fallback dose level -1 is initiated if more than 1 of 6 subjects in dose level 1 (starting dose) develop DLTs.

Patients receive dabrafenib orally (PO) twice daily (BID), trametinib PO once daily (QD) on days 1-28, and onalespib intravenously (IV) over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

Dose Level -1 (fallback dose):

* Dabrafenib = 75 mg
* Trametinib = 1 mg
* Onalespib = 180 mg/m\^2

Dose Level 1 (starting dose):

* Dabrafenib = 150 mg
* Trametinib = 1 mg
* Onalespib = 180 mg/m\^2

Dose Level 2:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 180 mg/m\^2

Dose Level 3:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 220 mg/m\^2

Dose Level 4:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 260 mg/m\^2

After completion of study treatment, patients are followed up at 28 days and every 6 months for up to 2 years.

Arms:
arm 1: Patients receive dabrafenib PO BID and trametinib PO QD on days 1-28, and onalespib IV over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

There are four dose levels, plus a fallback dose. Dose escalation begins at dose level 1 (starting dose). Fallback dose level -1 is initiated if more than 1 of 6 subjects in dose level 1 (starting dose) develop DLTs.

Dose Level -1 (fallback dose):

* Dabrafenib = 75 mg
* Trametinib = 1 mg
* Onalespib = 180 mg/m\^2 arm 2: Patients receive dabrafenib PO BID and trametinib PO QD on days 1-28, and onalespib IV over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

There are four dose levels, plus a fallback dose. Dose escalation begins at dose level 1 (starting dose).

Dose Level 1 (starting dose):

* Dabrafenib = 150 mg
* Trametinib = 1 mg
* Onalespib = 180 mg/m\^2 arm 3: Patients receive dabrafenib PO BID and trametinib PO QD on days 1-28, and onalespib IV over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

There are four dose levels, plus a fallback dose. Dose escalation begins at dose level 1 (starting dose).

Dose Level 2:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 180 mg/m\^2 arm 4: Patients receive dabrafenib PO BID and trametinib PO QD on days 1-28, and onalespib IV over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

There are four dose levels, plus a fallback dose. Dose escalation begins at dose level 1 (starting dose).

Dose Level 3:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 220 mg/m\^2 arm 5: Patients receive dabrafenib PO BID and trametinib PO QD on days 1-28, and onalespib IV over 1 hour on days 1, 8, and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

There are four dose levels, plus a fallback dose. Dose escalation begins at dose level 1 (starting dose).

Dose Level 4:

* Dabrafenib = 150 mg
* Trametinib = 2 mg
* Onalespib = 260 mg/m\^2

Interventions: intervention 1: Dabrafenib intervention 2: Laboratory Biomarker Analysis intervention 3: Onalespib intervention 4: Pharmacological Study intervention 5: Trametinib
Intervention descriptions: intervention 1: Given PO intervention 2: Correlative studies intervention 3: Given IV intervention 4: Correlative studies intervention 5: Given PO

Protocol document:
Prot_SAP_000.pdf: 
i 
 
For Protocol Amendment #18 submission to: 
 
NCI Protocol #:  9557 
Local Protocol #: 14-186 
 
NCI Version Date:   February 15, 2018 
Protocol Date:  February 15, 2018 
 
Summary of Changes 
 
#  
Section  
Change  
1.  Front Page 
Editortial updates to protocol amendment number and version date  
2.  2.2.2.4 
Revised CTCAE V.4 to V.5 
3.  3.1.4  
Eligibility criteria revised to change the CTCAE v4.0 to v5.0. 
 
4.  7.2 
Edited to state CTCAE V5.0 will be utilized starting April 1, 2018. A 
link to the new version was also provided. 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
 
 
 
1 
NCI Protocol #: 
CTEP#9557 
 
Local Protocol #: 
14-186 
 
TITLE: Phase I study of AT13387 in combination with dabrafenib and trametinib in patients 
with BRAF-mutant melanoma and other solid tumors. 
 
 
Coordinating Center: 
 
 
Massachusetts General Hospital 
Cancer Center Protocol Office 
Massachusetts General Hospital 
326 Cambridge Street 
Boston, MA, 02114 
Fax: 617-726-3810 
ccpo-mcgroup@partners.org 
 
*Principal Investigator: 
Ryan J. Sullivan, MD 
 
Massachusetts General Hospital Cancer Center 
 
55 Fruit Street, Yawkey Center 9E 
 
Boston, MA 02114 
 
Phone - 617-724-4000 
 
Fax - 617-726-1949 
 
rsullivan7@partners.org 
 
Co-Investigators: 
Dana Farber Cancer Institute 
 
James M. Cleary, MD, PhD 
 
Early Drug Development Center 
 
450 Brookline Avenue 
 
Boston, MA 02215 
 
jcleary@partners.org 
 
 
 
 
Moffitt Cancer Center 
 
Geoffrey T. Gibney, MD 
 
12902 Magnolia Drive 
 
Tampa, FL 33612 
 
Phone – 813-745-8581 
 
Fax – 813-745-5725 
 
Geoffrey.Gibney@moffitt.org 
 
 
 
 
 
 
 
 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
2 
Statistician: 
 
 
 
 
Anita Giobbie-Hurder 
 
450 Brookline Avenue 
 
Boston, MA 02115 
 
Phone – 617-632-2193 
 
Fax – 617-632-5444 
 
agiohur@jimmy.harvard.edu  
 
 
NCI Supplied Agent(s):  
Trametinib (GSK1120212), NSC# - 763093 
Dabrafenib (GSK2118436), NSC# - 763760 
AT13387, NSC# - 749712 
 
 
IND Sponsor:  DCTD, NCI 
 
Protocol Type / Version # / Version Date: 
Amendment /Version #18 / February 15, 2018 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
3 
  
SCHEMA 
 
Dose Escalation 
 
Dose Level 
Dabrafenib  
[BID/PO] 
Trametinib 
[QD/PO] 
AT13387 
[D1,8,15/IV] 
-1 
75 mg  
1 mg 
180 mg/m2  
1 
150 mg 
1 mg 
180 mg/m2  
2 
150 mg 
2 mg 
180 mg/m2  
3 
150 mg 
2 mg 
220 mg/m2  
4 
150 mg 
2 mg 
260 mg/m2 
 
The preceding table summarizes the planned dose levels. The primary objective of the dose 
escalation component of the study is to define the maximum tolerated dose (MTD) of the triple 
combination of dabrafenib, trametinib, and AT13387.  Dose escalation will follow a standard 
3+3 design beginning in dose level 1.  The doses of dabrafenib and trametinib for Dose Level 1 
were selected based upon the results of the phase I study showing excellent tolerability and 
safety, and that this combination appears to be associated with a reduced incidence and severity 
of some of the toxic effects of monotherapy with either a BRAF or MEK inhibitor., as well as 
excellent clinical activity. (Flaherty et al. 2012) Of note, the first dose cohort (dose level 1) 
incorporates a trametinib dose of 1 mg daily as opposed to the FDA-approved dose of 2 mg 
daily.  This dose was chosen due to the theoretical overlapping ocular toxicity of trametinib and 
AT13387. 
It is conceivable that additional cohorts may be necessary to pick an optimal treatment regimen 
with the three agents. As such, if toxicity is seen at a dose level where dose modification is 
necessary and the prior, lower dose level was treated without DLT, then additional dose cohorts 
between the two dose levels will be considered (see section 5 for details of this process). If the 
toxicity is determined to be related to dabrafenib (i.e. palmar-plantar erythrodysesthesia 
syndrome, arthralgia) then the dose of dabrafenib will be reduced first to 75 mg BID and then 
increased to 100 mg BID if that first dose level is tolerated.  If the toxicity is determined to be 
related to trametinib, then the dose of trametinib will be reduced to 1 mg QD (if a dose higher 
than 1 mg QD is being evaluated in the dose cohort) and then increased to 1.5 mg QD if that first 
dose level is tolerated.  If the toxicity is determined to be related to AT13387 then the dose will 
be reduced by 1 dose cohort.  At the end of the planned enrollment to the phase 1 portion of the 
study, a complete review of the PK data and safety will occur before cohort expansion at the 
MTD.  
 
 
 
 


NCI Protocol #: 9557 
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4 
 
 
TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................3 
1. 
OBJECTIVES ......................................................................................................................6 
1.1 
Phase I Objectives ....................................................................................................6 
2. 
BACKGROUND .................................................................................................................6 
2.1 
BRAF mutant melanoma .........................................................................................6 
2.2 
CTEP Agents ...........................................................................................................7 
2.3 
Rationale ................................................................................................................37 
2.4 
Correlative Studies Background ............................................................................39 
3. 
PATIENT SELECTION ....................................................................................................40 
3.1 
Eligibility Criteria ..................................................................................................40 
3.2 
Exclusion Criteria ..................................................................................................42 
3.3 
Inclusion of Women and Minorities ......................................................................45 
4. 
REGISTRATION PROCEDURES ...................................................................................46 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ...................................46 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions .................................46 
4.3 
General Guidelines For Other Participating Institutions ............................................46 
4.4 
Registration Process For Other Participating Institutions ..........................................47 
5. 
TREATMENT PLAN ........................................................................................................47 
5.1 
Agent Administration .............................................................................................47 
5.2 
Definition of Dose Limiting Toxicity ....................................................................49 
5.3 
General Concomitant Medication and Supportive Care Guidelines ......................50 
5.4 
Duration of Therapy ...............................................................................................51 
5.5 
Duration of Follow Up ...........................................................................................52 
5.6 
Criteria for Removal from Study ...........................................................................52 
6. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................52 
6.1 
Dabrafenib or Dabrafenib + Trametinib Dose Modifications ................................52 
6.2 
AT13387 Dose modifications ................................................................................69 
7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................71 
7.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) .................71 
7.2 
Adverse Event Characteristics ...............................................................................82 
7.3 
Expedited Adverse Event Reporting ......................................................................84 
7.4 
Routine Adverse Event Reporting .........................................................................85 
7.5 
Secondary Malignancy ...........................................................................................85 
7.6 
Second Malignancy ................................................................................................86 


NCI Protocol #: 9557 
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5 
7.7 
Pregnancy, Fetal Death, and Death Neonatal ........................................................86 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................87 
8.1 
CTEP IND Agent(s) ...............................................................................................87 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................93 
9.1 
Biomarker Studies ..................................................................................................93 
9.2 
Laboratory Correlative Studies ..............................................................................95 
 
10. 
STUDY CALENDAR .....................................................................................................100 
11. 
MEASUREMENT OF EFFECT......................................................................................101 
11.1 
Antitumor Effect – Solid Tumors ........................................................................101 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS .........................................107 
12.1 
Data Reporting .....................................................................................................107 
12.2 
CTEP Multicenter Guidelines ..............................................................................108 
12.3 
Collaborative Agreements Language ...................................................................108 
13. 
STATISTICAL CONSIDERATIONS.............................................................................110 
13.1 
Study Design/Endpoints.......................................................................................110 
13.2 
Sample Size/Accrual Rate ....................................................................................112 
13.3 
Analysis of Secondary, Correlative, and Exploratory Endpoints ........................112 
REFERENCES ............................................................................................................................115 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ................................................120 
APPENDIX B 
CTEP MULTICENTER GUIDELINES ..................................................121 
APPENDIX C 
INFORMATION ON POSSIBLE DRUG INTERACTIONS .................123 
APPENDIX D 
DRUG DIARY........................................... Error! Bookmark not defined. 
APPENDIX E 
PREGNANCY REPORT FORM ............................................................127 
APPENDIX F 
Concomitant Medications and Non-Drug Therapies ...............................128 
 
APPENDIX G 
BIOASSAY TEMPLATES 1………………………………………......132 
 
APPENDIX H 
BIOASSAY TEMPLATES 2…………………………………………..133 
 
APPENDIX I 
BIOASSAY TEMPLATES 3…………………………………………..134 
 
APPENDIX J 
BIOASSAY TEMPLATES 4…………………………………………..145 
 
 


NCI Protocol #: 9557 
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6 
 
 
 
1. OBJECTIVES 
 
1.1 
Phase I Objectives 
 
1.1.1 Primary Objective 
 
1.1.1.1 
To determine the maximum tolerated dose (MTD), toxicity, and safety profile of 
AT13387 given weekly in combination with dabrafenib and trametinib in patients 
with BRAF-mutant metastatic or unresectable solid tumors. 
 
1.1.2 Secondary Objectives 
 
1.1.2.1 
To obtain preliminary estimates of the objective response rate (ORR) and 
progression-free survival (PFS) and document the 6-month PFS and 1-year overall 
survival (OS) of patients with BRAF-mutant metastatic or unresectable melanoma 
treated with AT13387 given weekly in combination with dabrafenib and trametinib. 
 
1.1.2.2 
To describe the pharmacokinetics of treatment with dabrafenib, trametinib, and 
AT13387. 
 
2. BACKGROUND 
 
2.1 
BRAF mutant melanoma and other solid tumors 
The incidence of melanoma has dramatically risen over the past several decades and in 2013, an 
estimated 76,690 new cases and 9,480 deaths are expected in the United States.  (Seigel et al., 
2013)  As a result, melanoma is now the 5th and 7th most common malignancy in the US among 
men and women, respectively.  The prognosis for patients with metastatic melanoma is poor, 
though is dramatically different if the disease is limited to subcutaneous and/or lymph nodes 
(M1a), if the lungs are the only site of visceral metastasis (M1b), or if other sites of visceral 
metastasis are identified and/or if the lactate dehydrogenase (LDH) level is elevated (M1c).  In 
particular, the 1-year survival rates of M1a, M1b, and M1c are 68%, 58%, and 38% respectively. 
(Balch et al., 2009) Still, melanoma typically disseminates widely, and frequently involves sites 
that are uncommon in other cancers, such as the GI tract and the skin. Treatment options for 
stage IV melanoma have traditionally been extremely limited, with only dacarbazine (DTIC) and 
high-dose interleukin 2 (HD IL-2) receiving FDA-approval from 1976-2011.  In 2011, however, 
two new agents were FDA-approved for use in metastatic melanoma; ipilimumab, an anti-
cytotoxic T-lymphocyte 4 monoclonal antibody, and vemurafenib, a BRAF inhibitor.   
Melanoma harbour oncogenic BRAF mutations in 40-50% of cases. (Davies et al., 2002) These 
mutations lead to constitutive activation of the BRAF kinase that then hyperactivates mediators 
of the mitogen activated protein kinase (MAPK) pathway including MEK and ERK. The 
ramifications of constitutive activation of the MAPK pathway include cell cycle dysregulation, 


NCI Protocol #: 9557 
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7 
apoptosis resistance, immune evasion, and increased invasion and metastases.  Further, patients 
with BRAF mutant melanoma have a worse prognosis than those without BRAF mutations. 
(Long et al., 2012)  Since the discovery that BRAF mutations are present in nearly half of all 
melanomas, strategies to develop therapeutic inhibitors have been underway.  The first such 
agent to be associated with substantial clinical activity was vemurafenib.  In the phase I study, it 
became clear early that treatment of patients with BRAF-mutant melanoma was associated with 
remarkable responses. (Flaherty et al., 2010) In subsequent phase II and III studies, the activity 
of vemurafenib has been clearly established, objective response rates of approximately 50% and 
progression free survival of 6-7 months, and shown to be superior to treatment with 
chemotherapy in terms of response rate, PFS, and overall survival. (Chapman et al., 2011; 
Sosman et al., 2012)  In May 2013, two additional agents, the BRAF inhibitor dabrafenib and the 
MEK inhibitor trametinib, were approved by the FDA for the treatment of melanoma based on 
Phase III studies showing superiority of single-agent treatment of each agent compared with 
chemotherapy. (Hauschild et al., 2012; Flaherty et al., 2012 #1)  In January 2014, the 
combination of dabrafenib plus trametinib was approved based on data suggesting that 
combination therapy is better than single-agent BRAF inhibitor therapy. (Flaherty et al., 2012 
#2) 
Oncogenic BRAF mutations are also seen across a number of other malignancies including 40-
50% of papillary thyroid cancer, 10% of colorectal cancer, less than 5% of non-small cell lung 
cancer, and in lower percentages of other malignancies.  BRAF inhibitor therapy has been tested 
widely in these diseases with variable results, and now dual BRAF/MEK inhibitor targeting is 
being tested.  Specifically, responses have been seen with vemurafenib (Dadu et al. 2014) in 
nearly half of patients with BRAF-mutant papillary thyroid cancer, and there is an ongoing study 
evaluating the effectiveness of dabrafenib with or without trametinib in recurrent, BRAF-mutant 
recurrent thyroid cancer (NCT01723202).  Additionally, there is a 12% response rate in BRAF-
mutant colon cancer with the combination of dabrafenib and trametinib (Corcoran et al. 2014), 
and a number of clinical trials are looking to improve the efficacy of BRAF-targeted therapy in 
this subset of colon cancer patients (NCT01719380, NCT01750918, NCT01791309).  Lastly, a 
number of reports are emerging detailing the responsiveness of BRAF-mutant lung cancer to 
single-agent BRAF inhibition. (Peters et al. 2013, Robinson et al. 2014)  
2.2 
CTEP Agents 
 
2.2.1 Trametinib Dimethyl Sulfoxide (GSK1120212B) 
 
The RAF-MEK-ERK pathway plays a critical role in multiple cellular functions.  
Activation of the pathway can result from activation/mutations of the upstream receptor 
tyrosine kinases (RTKs) and RAS, or upregulation/mutations in RAF and MEK.  Upon 
activation, RAF acts as the MAPK kinase kinase and activates MAPKK (MEK1/2), 
which in turn catalyze activation of the effectors ERK1/ERK2.  Once activated, ERK1/2 
translocate into the nucleus and phosphorylate a number of effector proteins and 
transcriptional factors that regulate cell proliferation, motility, differentiation, and 
survival.  Trametinib is one of the several MEK inhibitors in clinical development.   
Experience to date indicates that MEK is a valid target.  In a phase III trial comparing 
trametinib with dacarbazine or paclitaxel in patients with BRAF V600E or V600K 


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8 
mutant metastatic melanoma, trametinib demonstrated a significantly better response rate, 
progression-free survival, and overall survival (Flaherty et al., 2012 #1).  However, 
single agent activities are limited.  Extensive research is underway to identify the patient 
selection markers and develop rational combination strategies.  Preclinical studies have 
provided strong rationale and proof of principle for combination of MEK inhibitors with 
RTK inhibitors (EGFR or IGF-1R) (Gopal et al., 2010; Ebi et al., 2011), PI3K/AKT 
inhibitors (Engelman et al., 2008; Hoeflich et al., 2009), and mTOR inhibitors.  On the 
other hand, the optimal dose/schedule and patient selection criteria for combination 
regimens have not been defined.  Phase 1 results for a number of combinations have been 
reported, including AZD6244 + MK2206 (Tolcher et al., 2011) and GDC-0973 + GDC-
094 (MEK + PI3K inhibitor) (Bendell et al., 2011). 
 
2.2.1.1 
Mechanisms of Action and Preclinical Data with Trametinib 
 
Trametinib is a dimethyl sulfoxide (DMSO) solvate compound (ratio 1:1) with potent, 
allosteric and ATP non-competitive inhibition of MEK1/2 (IC50 of 0.7 and 0.9 nM 
against MEK1 and MEK2, respectively) (Gilmartin et al., 2011).  Trametinib inhibited 
MEK1/2 kinase activity and prevented RAF-dependent MEK phosphorylation (S217 for 
MEK1), producing prolonged pERK1/2 inhibition.  Trametinib showed better potency 
against unphosphorylated MEK1/2 (u-MEK1/2) when compared with preactivated 
diphosphorylated MEK (pp-MEK), suggesting that u-MEK affords a higher affinity 
binding site for trametinib than does pp-MEK. 
 
The specificity of trametinib was confirmed against a panel of 183 kinases, including 
MEK5 (the closet kinase homolog to MEK1/2), CRAF, BRAF, ERK1, and ERK2 
(Yamaguchi et al., 2011).  Trametinib demonstrated equal potency against activated 
MEK1- and MEK2-mediated phosphorylation of ERK (sequence identity of 85% across 
the whole protein and 100% in the active site for humans).  Trametinib demonstrated 
preferential inhibition of RAF-mediated MEK1 activation (IC50 = 0.60 nM) over pMEK1 
kinase activity (IC50 = 13 nM) (Investigator’s Brochure, 2012a). 
 
BRAF-mutant Colo205, A375P F11s, and HT-29 human tumor xenograft mouse models 
showed the most significant mean tumor growth inhibition (TGI) (80% to 87%) at 3.0 
mg/kg trametinib, with multiple complete and partial tumor regressions.  In the Colo205 
model, tumor regression was observed even at a dose of 0.3 mg/kg (Yamaguchi et al., 
2011).  Two KRAS-mutant xenograft models, HCT-116 and A549, also showed 
significant TGI (83% and 75%) but without significant tumor regressions (Gilmartin et 
al., 2011).  As predicted by cell proliferation assays, tumor xenograft lines with wild-type 
(wt) RAF/RAS (PC3, BxPC3, and BT474) were much less sensitive, showing only 
modest TGI (44-46%) with no tumor regressions. 
 
Pharmacodynamic studies were performed in mice treated with trametinib for 14 days 
(Gilmartin et al., 2011).  In the A375P F11s xenograft model, the first dose of trametinib 
(3 mg/kg) significantly reduced pERK for more than 8 hours on Day 1.  pERK inhibition 
was more sustained (over 24 hours) after the Day 7 dose, probably due to an increase in 
the steady-state levels of trametinib after repeated doses.  The average Cmax in blood was 


NCI Protocol #: 9557 
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9 
1,410 nM on Day 7, with an estimated half-life (t1/2) of 33 hours.  In addition, 
immunohistochemistry (IHC) also confirmed inhibition of cell proliferation (reduced 
Ki67) and G1 cell cycle arrest (elevated p27Kip1/CDKN1B) following 4 days of 
treatment. 
 
2.2.1.2 
Clinical Pharmacokinetics (PK) and Activity of Trametinib 
 
FTIH Phase 1 Trial of Trametinib Monotherapy (MEK111054) 
There are 3 parts in this ongoing study.  Part 1:  The dose-escalation portion involves 
administration of trametinib (repeat doses of 0.125 mg to 4.0 mg) to patients with solid 
tumors or lymphoma in one of three schedules - (1) QD for 21 days followed by 7 days 
without drug, (2) loading dose on Day 1 or Day 1-2, followed by QD with the designated 
dose, or (3) QD dosing without a drug holiday.  Part 2:  cohort expansion at the 
recommended phase 2 dose (RP2D) for pancreatic cancer, melanoma, NSCLC, CRC, or 
any BRAF mutation-positive cancer.  Part 3:  expansion to characterize the biologically 
active range of trametinib via analysis of pharmacodynamic biomarkers (biopsies or 
FDG-PET). 
 
The dose escalation part and some of the cohort expansion components have been 
completed.  The MTD of trametinib was established as 3 mg QD, but the recommended 
phase 2 dose (RP2D) was chosen at 2 mg QD based on tolerability of repeated cycles 
(Infante et al., 2010). 
 
PK and metabolism of trametinib: 
PK measurements were conducted under fasting conditions.  After a single dose (Day 1), 
AUC0-24 and Cmax values were dose-proportional up to 6 mg, lower than dose 
proportional following 8 mg, and greater than dose proportional following the 10 mg 
dose.  Median Tmax was 1.5 hours. 
 
After repeat doses (Day 15), trametinib accumulated with a mean accumulation ratio of 
6.6 at the RP2D of 2 mg QD.  Between-subject variability in exposure ranged from 27-
50% for Cmax and 20-41% for AUC0-24 across all dosing regimens.  The effective t1/2 was 
approximately 4.5 days, and steady state was reached by approximately Day 15.  
Trametinib had a small peak:trough ratio of ~2 (Infante et al., 2010).  At 2 mg QD on 
Day 15, mean AUC0-24 was 376 ng•h/mL and Cmax 23 ng/mL, and the mean trough 
concentrations ranged from 10.0 to18.9 ng/mL.  The long half-life and small peak:trough 
ratio of trametinib allowed constant target inhibition within a narrow range of exposure. 
 
Drug-drug interactions: 
Trametinib is metabolized predominantly via deacetylation (non-cytochrome P450 
[CYP450]-mediated) with secondary oxidation or in combination with glucuronidation 
biotransformation pathways (Investigator’s Brochure, 2012a).  The deacetylation is likely 
mediated by hydrolytic esterases, such as carboxylesterases, or amidases.  Based on in 
vitro studies, trametinib is not an inhibitor of CYP1A2, CYP2A6, CYP2B6, CYP2D6, 
and CYP3A4.  Although trametinib was found to be an in vitro inhibitor of CYP2C8, 
CYP2C9, and 2C19; inducer of CYP3A4; and inhibitor of transporters (OATP1B1, 


NCI Protocol #: 9557 
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10 
OATP1B3, P-glycoprotein [P-gp], and breast cancer resistance protein [BCRP]), its low 
efficacious dose, and low clinical systemic concentration (22.2 ng/mL or 0.04 mcM at 2 
mg) relative to the in vitro inhibition/induction potency suggests an overall low potential 
for drug-drug interactions. 
 
Pharmacodynamic effect and biomarkers: 
The relationship between dose and tumor biomarkers such as pERK, Ki67, and p27, were 
evaluated in patients with BRAF or NRAS mutation-positive metastatic melanoma 
(Investigator's Brochure, 2012a).  In general, increasing exposures and/or doses provided 
greater pharmacodynamic effects.  The median change observed at a dose of 2 mg QD 
was 62% inhibition of pERK, 83% inhibition of Ki67, and a 175% increase in p27. 
 
Antitumor Activity of Trametinib Monotherapy 
In the FTIH phase 1 trial, 14 patients with BRAF-mutant melanoma received trametinib 
at 2 mg QD (2 mg/day continuously, or 2 mg for 21 days followed by a 1 week break).  
The overall objective response rate (ORR) was 43% (6/14), including 2 complete 
responses (CRs) (Investigator's Brochure, 2012a).  In 9 patients with BRAF wt 
melanoma, 2 patients achieved a partial response (PR), and 3 stable disease (SD) (Infante 
et al., 2010).  In 26 evaluable pancreatic cancer patients, there were 2 PRs (1 PR was 
KRAS mutation-positive) and 11 SD (2 achieved ≥20% tumor reduction) (Messersmith et 
al., 2011).  Among the 27 CRC patients (without selection of RAS or RAF mutations), 8 
SD were observed. 
 
In a phase 3 trial, patients with unresectable stage IIIC or IV cutaneous melanoma with a 
BRAF V600E or V600K mutation were randomized (2:1) to trametinib (2 mg, PO, QD) 
or chemotherapy (dacarbazine or paclitaxel) (Flaherty et al., 2012).  There were 322 
patients in the intention-to-treat (ITT) population, of whom 273 (85%) were in the 
primary efficacy population (patients with BRAFV600E-positive cancer who did not have 
brain metastases at baseline).  In the ITT analyses, the ORR was 22% in the trametinib 
group and 8% in the chemotherapy group; the median duration of PFS was 4.8 months in 
the trametinib group as compared with 1.5 months in the chemotherapy group; and the 6-
month OS rate was 81% in the trametinib group and 67% in the chemotherapy group. 
 
Antitumor Activity of Trametinib in Cancer Other Than Melanoma 
In a phase 1/2 monotherapy study, acute myeloid leukemia (AML) or myelodysplastic 
syndrome (MDS) patients were given trametinib at dose levels from 1-2 mg QD.  Drug-
related AEs in 45 patients were similar to that observed in patients with solid tumors, and 
2 mg PO QD was selected for further investigation in this patient population.  Twelve 
patients (23%) withdrew due to an AE, including cardiac failure (2) and infection (2).  
Efficacy was reported in 39 patients (Borthakur et al., 2010).  The best response in 13 
patients with KRAS or NRAS mutations included 3 CRs (23%), 7 SD (54%), and 1 PD 
(progressive disease) (5%).  In 26 patients with wild-type RAS or an unknown mutation, 
there were 2 PRs (8%). 
 
2.2.1.3 
Trametinib Safety Profile 
 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
11 
A Comprehensive Adverse Events and Potential Risks (CAEPR) list using NCI 
Common Terminology Criteria for Adverse Events (CTCAE) terms is included in 
Section 7.1 of the protocol. 
 
Due to limited experience in human subjects, there is currently incomplete information 
available about the relationship of AEs and administration of trametinib.  Based on 
available AE data from clinical studies involving trametinib to date, the most common 
toxicities are rash and diarrhea.  Rash and diarrhea are common, class-effect toxicities for 
MEK inhibitors. In addition, visual impairment and left ventricular ejection fraction 
(LVEF) reduction, although observed at lower frequencies, are also considered class-
effect toxicities as they have been observed with trametinib as well as other MEK 
inhibitors. 
 
AEs of special interest: 
Rash, diarrhea, visual disorders, hepatic disorders, cardiac-related AEs, and pneumonitis 
are considered AEs of special interest because they are either known class effects (i.e., 
have been observed with other MEK inhibitors) or are potentially life-threatening 
(Investigator’s Brochure, 2012a). 
 
Rash:  Rash was a common AE observed across different dose levels and in different 
combinations.  The majority of rash observed with trametinib was acneiform and 
appeared to occur most frequently on the face, scalp, chest, and upper back.  At the 2 mg 
dose, rash was seen in 48% to 91% of patients in different trials.  The majority of rash 
AEs were grades 1 or 2 (68% to 80%); 1% to 18% of patients experienced grade 3 rash 
AEs, and one patient had a grade 4 rash AE. 
 
Diarrhea:  At the 2 mg monotherapy dose, 28% to 58% of patients in three trials had 
diarrhea.  Of 219 patients with diarrhea at this dose, the majority of diarrhea AEs were 
grade 1 or 2 in severity (28% to 56% of all study patients); 6 patients had grade 3 
diarrhea, and none had grade 4 diarrhea. 
 
Visual disorders:  At the 2 mg monotherapy dose, 6% to 21% of the patients in three 
trials experienced visual disorders.  Of the 62 total patients experiencing visual disorders 
at this dose level, the majority of visual disorders were grades 1 or 2 (6% to 20% of all 
study patients); five patients experienced grade 3 visual disorders, and one patient 
experienced a grade 4 visual disorder. 
− 
Retinal pigment epithelial detachment (RPED):  RPED is a class side effect of MEK 
inhibitors.  As of 22 May 2012, 13 cases of RPED have been reported amongst 
approximately 1,600 patients treated with trametinib, either as monotherapy or in 
combination with other anti-cancer agents:  two cases of grade 1, eight cases of grade 
2, and three cases of grade 3.  All 13 resolved. 
− 
Retinal vein occlusion (RVO):  As of 22 May 2012, four cases of RVO have been 
observed with trametinib.  All four cases occurred in one eye only, and study drug 
was stopped at time of diagnosis in all cases.  There was a decrease in visual acuity in 
two patients with central RVO (CRVO), while the other two patients experienced no 
meaningful decrease in visual acuity.  Three of the four cases were considered related 


NCI Protocol #: 9557 
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12 
to study treatment by the investigators. 
 
Hepatic disorders:  Abnormalities of liver enzymes and bilirubin have been observed with 
administration of trametinib.  However, assessment of these cases was often confounded 
by co-morbid conditions (such as biliary obstruction), concomitant use of other 
potentially hepatotoxic drugs, and liver metastases.  At the 2 mg monotherapy dose, 10% 
to 19% of patients in three trials had hepatic disorders.  Of the 56 total patients 
experiencing hepatic disorders, the majority were grade 1 or 2 in severity (7% to 15% of 
all study patients); 12 patients had grade 3 hepatic disorders, and 3 patients had grade 4 
hepatic disorders. 
 
Cardiac-related AEs:  At the 2 mg monotherapy dose in three trials, 3% to 21% of 
patients had cardiac-related AEs.  Of the 43 total patients experiencing cardiac-related 
AEs, the majority were grade 1 or 2 in severity (4% to 16% of all study patients); six 
patients at this trametinib dose level had grade 3 cardiac-related AEs (three left 
ventricular dysfunction, two decreased LVEF, and one ventricular dilatation), and one 
patient experienced a grade 4 cardiac-related AE (cardiogenic shock).  One patient died 
of acute cardiac failure, with evidence of massive tumor invasion of the heart; this AE 
was considered not drug-related by the investigator. 
In the phase 3 trial of trametinib vs. chemotherapy in patients with melanoma 
(MEK114267), patients were monitored by serial echocardiogram or MUGA scans.  As 
of 23 June 2012, among 211 patients on the trametinib arm, 17 cardiac-related AEs were 
reported and included:  decreased LVEF (ten grade 1-2, and two grade 3), left ventricular 
dysfunction (two grade 2, and two grade 3), and one grade 3 cardiac failure.  No cardiac-
related AEs have been observed on the chemotherapy arm of the study.  Cardiac-related 
AEs leading to permanent discontinuation of study drug included decreased LVEF (n=2), 
left ventricular dysfunction (n=2), cardiac failure (n=1), myocardial infarction (n=1), and 
tachycardia (n=1).  There was also one death due to cardiogenic shock secondary to 
ischemic heart disease, but it was not considered related to trametinib. 
 
Pneumonitis:  As of the Investigator Brochure’s cut-off date, 20 cases of pneumonitis 
were reported in subjects treated with trametinib, either as monotherapy or in 
combination with other anti-cancer agents, in six studies:  five cases of grade 1, five cases 
of grade 2, nine cases of grade 3, and one case of grade 4. 
 
2.2.1.4 
Clinical Experience with the Combination of Trametinib + Dabrafenib 
 
Preliminary data on 45 patients participating in the phase 1/2 study of dabrafenib and 
trametinib, BRF113220, have been reported (Infante et al., 2011). 
 
PK: 
The plasma levels of dabrafenib were higher in combination with trametinib as compared 
to that with monotherapy.  Geometric mean Day 15 AUC of dabrafenib in combination 
ranged from 3539 to 5187 ng•hr/mL, and the AUC observed in the monotherapy study 
was 2619 ng•hr/mL.  Further data are required to understand this difference. 
 


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13 
PK of trametinib did not appear to be affected by the addition of dabrafenib.  Preliminary 
results showed that the geometric mean dose-normalized AUC0-τ (CV%) for trametinib 
(dose normalized for the 2.0 mg QD dose) in combination with dabrafenib at 150 mg BID 
was 302 ng•hr/mL (n=17; 35%) on Day 15.  Historical PK data from the trametinib FTIH 
study (MEK111054) indicated a mean Day 15 AUC0-τ (CV%) of 360 ng•hr/mL (31%). 
 
Safety and the RP2D for the combination of trametinib and dabrafenib 
One DLT of a recurrent grade 2 neutrophilic panniculitis occurred, and pyrexia was 
common (51%).  The RP2D was 150 mg BID dabrafenib plus 2 mg QD trametinib (both 
agents at the RP2D for single agent).  Of the 137 patients enrolled, 32 patients were 
treated at the RP2D.  SAEs experienced by more than one patient include:  pyrexia (5%), 
hypotension (4%), nausea (3%), and 2% of patients had a constellation of AEs including 
vomiting, dehydration, or renal failure.  The only grade 4 AE was a sepsis-like syndrome 
with fever/hypotension.  Grade 3 AEs included generalized rash (n=2, 4%) and 
neutropenia (n=2, 4%).  Skin toxicity (rash) occurred in 9 (20%) patients.  Of note, the 
rate of SCC was 2% in this study.  A single case of grade 5 hyponatremia was reported.   
 
Activity 
Among 77 evaluable patients with melanoma who had not received prior BRAF 
inhibitors, there were 43 responses (56%), including 4 CRs (5%) and 39 PRs (51%) 
(Weber et al., 2012).  Twenty-nine patients experienced SD, and three patients 
experienced PD.  Patients were treated on four escalating dose levels of 
dabrafenib/trametinib (mg BID/mg QD):  75/1, 150/1, 150/1.5, 150/2.  The confirmed RR 
for each dose level, respectively, was 67% (n=6), 64% (n=22), 48% (n=25), and 54% 
(n=24).  Median PFS (months) for each of the first three dose levels, respectively, was 
8.7, 8.3, and 5.5; PFS data are not mature for the fourth (150/2) dose level.  Overall PFS 
was 7.4 months. 
 
Currently, the randomized phase 2 portion (Part C) of the study of dabrafenib with or 
without trametinib has enrolled 162 patients as of September 1, 2011 (Investigator’s 
Brochure, 2012b). 
 
2.2.1.5 
Clinical Experience with the Combination of Trametinib + GSK2141795 (AKT 
inhibitor) (TAC113886) 
 
Twenty-three patients with advanced solid tumors received the combination using a zone-
based escalation procedure enabling evaluation of multiple combination doses in parallel 
cohorts (Kurzrock et al., 2011).  While the RP2D for single agent trametinib and 
GSK2141795 are 2 mg/d and 75 mg/d, dose reductions were required for the 
combination.  DLTs include grade 2 AST and ALT elevation, and grade 3 chest pain with 
sustained ventricular tachycardia; all DLTs were reversible with drug interruption.  The 
most common AEs (≥10%) included nausea (26%), AST elevation (22%; grade 3/4, 9%), 
fatigue (22%) and rash (22%).  Three MTDs were defined for variable dose ratios:  2 mg 
trametinib + 25 mg GSK2141795; 0.5 mg trametinib + 75 mg GSK2141795; and 1.5 mg 
trametinib + 50 mg GSK2141795.  Three of 13 evaluable patients (unselected) had tumor 
shrinkage of 8% (ovarian), 16% (endometrial), and 17% (ovarian) after 8 weeks on study.  


NCI Protocol #: 9557 
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14 
The dose regime of 1.5 mg trametinib + 50 mg GSK2141795 will be considered for 
further development.  Additional trials to explore alternate schedules (e.g., intermittent) 
and pharmacodynamic markers are ongoing. 
 
2.2.2 Dabrafenib Mesylate (GSK2118436B) 
 
The RAS/RAF/MEK/ERK pathway is a critical proliferation pathway in many human 
cancers.  This pathway can be constitutively activated by molecular alterations including 
BRAF activating mutations.  Approximately 90% of all identified BRAF mutations in 
human cancer consist of a T1799 transversion mutation in exon 15, which results in a 
V600 E/D/K(T1799A) amino acid substitution.  This mutation appears to mimic 
regulatory phosphorylation and increases BRAF activity approximately 10-fold compared 
to wild type (wt).  RAF is a validated target in BRAF V600E-containing melanoma.  In 
August 2011, the FDA approved vemurafenib (PLX4032, Zelboraf®), an ATP-
competitive selective RAF inhibitor for the treatment of late-stage BRAFV600E melanoma.  
In the pivotal phase III trial of vemurafenib vs. dacabazine (Chapman et al., 2011), 
vemurafenib demonstrated significant improvement in overall survival (OS) (6-month OS 
of 84% vs. 64%, hazard ratio [HR]=0.37; P<0.001), progression-free survival (PFS) 
(estimated median PFS of 5.3 months vs. 1.6 months (HR=0.26; P<0.001]), and overall 
response rate (ORR) (48% vs. 5%).  However, in patients with colorectal cancer (CRC) 
bearing the BRAF V600E mutation, there was only one partial response (PR) among 20 
patients treated (ORR 5%) and four minor responses (Kopetz et al., 2010). 
 
Dabrafenib mesylate (GSK2118436B, Tafinlar®; referred to as dabrafenib hereafter), a 4-
(3-aminosulfonylphenyl)-5-(pyrimidin-3-yl) thiazole, is an ATP-competitive, selective 
inhibitor of RAF kinase currently in clinical development.  On May 29, 2013, the U.S. 
FDA approved dabrafenib for the treatment of patients with unresectable or metastatic 
melanoma with BRAFV600E mutation as detected by an FDA-approved test (FDA, 2013).  
On January 10, 2014, the FDA granted accelerated approval to dabrafenib and MEK 
inhibitor trametinib for use in combination to treat patients with unresectable or 
metastatic melanoma with either BRAFV600E or BRAFV600K mutation as detected by an 
FDA-approved test (FDA, 2014). 
 
2.2.2.1 
Mechanisms of Action and Preclinical Data with Dabrafenib 
 
Dabrafenib potently inhibits all RAF isoforms, with the strongest potency against the 
V600 mutant, as compared to its activity against wt BRAF and CRAF (see below).  In a 
panel of more than 270 kinases tested outside RAF isoforms, only 10 kinases were 
inhibited at a 50% inhibitory concentration (IC50) <100 nM:  LIM domain kinase 1 
(LIMK1), activin receptor-like kinase 5 (ALK5)/ transforming growth factor (TGF)-beta 
receptor type-1 (TGFβ1R), Never In Mitosis Gene A (NIMA)-related kinase 11 
(NEK11), salt-inducible kinase 1 (SIK1), salt-inducible kinase 2 (SIK2), polycystin-2 
(PKD2), protein tyrosine kinase 6/breast tumor kinase (BRK), pancreatic eukaryotic 
initiation factor-2 alpha (eIF2α) kinase (PEK)/eIF2α kinase (PERK), endothelium-
specific receptor tyrosine kinase 2 (TIE2) (R849W), and yeast casein kinase 1 (CK1) (IB, 
2013a). 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
15 
 
 
 
Inhibitory activity of dabrafenib on RAF 
 
BRAFV600E 
BRAFV600K 
BRAFV600D 
wt BRAF 
CRAF 
IC50 
0.65 nM 
0.50 nM 
1.84 nM 
3.2 nM 
5.0 nM 
 
In a panel of >110 human tumor cell lines with known BRAF mutational status, 
dabrafenib potently inhibited proliferation of a majority (73%) of BRAFV600E mutant cell 
lines with growth IC50 (gIC50) <100 nM (IB, 2013a).  In contrast, there was poor or no 
activity in other BRAF mutants or wt BRAF cell lines. 
 
Dabrafenib given orally (PO) for 14 days at doses ranging from 0.1-300 mg/kg 
administered once daily (QD), twice daily (BID), or three times daily (TID) inhibited 
tumor growth in mice bearing BRAFV600E A375P F11s or Colo205 tumor xenografts.  
The effect was generally dose dependent up to 10 mg/kg/day (A375P F11s) or 30 
mg/kg/day (Colo205), yielding 90-120% tumor reduction relative to untreated animals.  
However, cessation of treatment was associated with regrowth of the tumors.  In A375P 
F11s melanoma xenografts, inhibition of pERK by >50% in the tumor was seen at doses 
of ≥3 mg/kg.  Based on the single-dose studies, ~100 nM (52 ng/mL) dabrafenib in blood 
at 6 h post-dosing was needed for effective pharmacodynamic biomarker inhibition in the 
tumor.  At repeated dosing of 30 mg/kg/day, the tumor pERK levels were reduced by 
>50% at 8 h after dosing (69% on Day 1 and 53% on Day 14).  Levels of pERK returned 
to baseline 24 h post-dosing.  Similar ↓pERK effects were seen in the ES-2 ovarian 
xenograft model, but pERK inhibition was weaker in the Colo205 xenograft model.  Of 
note, concentrations of dabrafenib showing pharmacodynamic activity in xenografts did 
not cause a reduction in pERK/tERK levels in the normal intact brain.  
 
2.2.2.2 
Clinical Pharmacokinetics (PK) and Pharmacokinetics of Dabrafenib 
 
Following single-dose oral administration of dabrafenib HPMC capsules, plasma 
concentrations peaked approximately 2.0 hours post-dose.  Oral bioavailability is near 
complete (94.5%) relative to an intravenous (IV) microdose.   
 
Dabrafenib is highly bound to plasma proteins (99.6%).  Its volume of distribution after 
IV dosing is 45.5 L.  Intravenous plasma clearance (12.0 L/hr) is low relative to liver 
blood flow, suggesting a low hepatic extraction ratio drug.  Median terminal half-life is 
approximately 8 hours after a single oral dose.  
 
Three metabolites of dabrafenib were characterized and may contribute to activity.  
GSK2285403 (hydroxy-metabolite [M7]) PK paralleled that of dabrafenib, while the 
carboxy- (GSK2298683 [M4]) and desmethyl- (GSK2167542 [M8]) metabolites 
exhibited a longer t1/2 (21-22 hours) and accumulated following repeat dosing.  M7 is the 
most abundant, accounting for 54% of the three metabolites.  Similar to dabrafenib 
concentrations, exposure for all metabolites showed a less than dose proportional increase 
with repeat dosing. 
 


NCI Protocol #: 9557 
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16 
Fecal excretion was a major route of dabrafenib elimination in humans, accounting for 
71.1% of the dose administered, and renal excretion accounted for about 20% of drug 
elimination. 
 
Administration of dabrafenib with a high-fat, high-calorie meal reduced the oral 
bioavailability of dabrafenib when compared to the fasted state with a decrease in Cmax 
and AUC of 51% and 31%, respectively, and delayed its absorption.  Therefore, the 
current recommendation is to administer dabrafenib under fasting conditions, either 1 h 
before or 2 h after a meal. 
 
Drug-drug interactions for dabrafenib: 
Dabrafenib induces CYP3A4 and CYP2C9.  Dabrafenib decreased the systemic 
exposures of midazolam (a CYP3A4 substrate), S-warfarin (a CYP2C9 substrate), and R-
warfarin (a CYP3A4/CYP1A2 substrate).  Co-administration of dabrafenib 150 mg twice 
daily for 15 days and a single dose of midazolam 3 mg (a CYP3A4 substrate) decreased 
midazolam AUC by 74%. Co-administration of dabrafenib 150 mg twice daily for 15 
days and a single dose of warfarin 15 mg decreased the AUC of S-warfarin (a CYP2C9 
substrate) by 37% and the AUC of R-warfarin (a CYP3A4/CYP1A2 substrate) by 33%.  
 
In vitro studies show that dabrafenib is a substrate of CYP3A4 and CYP2C8 while 
hydroxy-dabrafenib and desmethyl-dabrafenib are CYP3A4 substrates. Co-administration 
of dabrafenib 75 mg twice daily and ketoconazole 400 mg once daily (a strong CYP3A4 
inhibitor) for 4 days increased dabrafenib AUC by 71%, hydroxy-dabrafenib AUC by 
82%, and desmethyl-dabrafenib AUC by 68%. Co-administration of dabrafenib 75 mg 
twice daily and gemfibrozil 600 mg twice daily (a strong CYP2C8 inhibitor) for 4 days 
increased dabrafenib AUC by 47%, with no change in the AUC of dabrafenib 
metabolites. Dabrafenib is a substrate of human P-glycoprotein (P-gp) and breast cancer 
resistance protein (BCRP) in vitro.   
 
Pharmacodynamic effect of dabrafenib: 
Median tumor pERK inhibition was 83.9% (range:  38.0 to 93.3%) in BRAF mutant 
melanoma subjects receiving doses of 70 to 200 mg BID.  The relationship between 
exposure and % pERK inhibition was characterized using a maximum response (Emax) 
model with 100% maximum inhibition and IC50 of 134 ng/mL (95% CI:  92.7, 155) based 
on the sum of the potency-adjusted parent and active metabolite concentrations.  A dose-
related decrease in pERK was predicted with total daily doses <200 mg (100 mg BID) 
dabrafenib, with a plateau occurring beyond total daily doses of 200 mg thereafter. 
 
Selection of the RP2D for dabrafenib monotherapy: 
The single-agent MTD for dabrafenib was not reached.  A dose of 150 mg BID was 
selected for further single-agent development, based on the following 
PK/pharmacodynamics, safety, and activity:  a) dose increases beyond 150 mg BID 
yielded no increase in Cmax and <50% increase in AUC; b) incidence and severity of AEs 
was similar at 100-300 mg BID; c) pERK target suppression was >80%; and d) the tumor 
response rate (RR) was 50% at 150 mg BID. 
 


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17 
 
 
Antitumor Activity of Dabrafenib Monotherapy  
 
Activity in patients with BRAF V600E or V600K melanoma in the FTIH monotherapy 
study (BRF112680).  The study enrolled 114 patients with BRAFV600 mutant melanoma 
in the dose escalation phase (Part 1), and 70 patients at the RP2D (150 mg BID) in Part 2.  
Within this study, a cohort of 10 patients with previously untreated asymptomatic brain 
metastasis was evaluated for intracranial response to dabrafenib (Long et al., 2011).  All 
patients had decreases in the size of the brain metastasis; three patients achieved 
complete radiographic resolution of brain lesions as well as reduction in extracranial 
disease.  The response rates in patients treated at 150 mg BID are shown below. 
 
FTIH monotherapy study (BRF112680) response rates in melanoma patients 
 
Subgroup 
Patient # 
ORR 
Part 1 
V600E 
77 
50% 
 V600K 
14 
20% 
Part 2, Cohort A 
V600E/K with brain mets 
10 
40% 
 V600E/K without brain 
mets 
20 
55% 
 
When dabrafenib was used at 50 mg BID (Part 2, Cohort C) in patients with BRAFV600E 
mutant melanoma, the response rate was only 17%. 
 
Correlative studies in the phase 1 monotherapy trial: 
Preliminary genomic analysis was performed on 37 patients with melanoma, using a 
Sequenom mutation analysis for 11 genes (AKT, BRAF, CDK4, CDKN2A, GNAQ, 
GNA11, Kit, MEK1, MEK2, and NRAS), and PTEN analysis by sequencing, 
comparative genomic hybridization (CGH), and multiplex ligation-dependent probe 
amplification (MPLA) (Nathanson et al., 2011).  Nine patients (24%) had PTEN genetic 
alterations including mutation, hemi-/homozygous deletion.  PTEN deficiency was 
associated with lower responses (ORR of 11% and 54% in patients with and without 
PTEN alteration, respectively). 
 
Phase III trial of dabrafenib versus chemotherapy in patients with advanced BRAFV600 
mutant melanoma (BREAK3 Trial): 
Patients with previously untreated, unresectable stage III or IV BRAFV600E-mutated 
melanoma were randomized (3:1) and stratified by stage to dabrafenib (150 mg PO BID) 
or dacarbazine (DTIC) (1000 mg/m2, IV, every 3 weeks [Q3W]).  Of 250 patients, 187 
received dabrafenib and 63 received DTIC from February to September 2011.  The 
hazard ratio for PFS was 0.30 (95% CI:  0.18-0.53; P<0.0001), with median PFS of 5.1 
months for dabrafenib and 2.7 for DTIC.  OS data were immature, with 30 deaths 
reported.  Confirmed RR was 53% for dabrafenib and 19% for DTIC.  Benefits in PFS 
and RR were observed in all subgroups evaluated. 
 
Activity in BRAFV600E mutant tumors other than melanoma: 
In phase 1 trial, 18 patients had cancers other than melanoma: CRC (7), papillary thyroid 


NCI Protocol #: 9557 
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18 
cancer (PTC) (13), NSCLC (1) and ovarian cancer (1).  Confirmed PRs were seen in one 
patient with CRC, and in 5 patients with PTC; the patient with NSCLC had an 
unconfirmed PR at 6 weeks.  Eleven patients (6 with PTC and 5 with CRC) had stable 
disease (SD) as their best response; the ovarian cancer patient had SD for approximately 
36 weeks. 
 
2.2.2.3 
Clinical Experience with the Combination of Dabrafenib + Trametinib 
 
Data on 247 patients with metastatic melanoma and BRAFV600 mutations participating in 
the phase 1/2 study of dabrafenib and trametinib, BRF113220, have been published 
(Flaherty et al., 2012). 
 
PK 
Coadministration of dabrafenib 150 mg twice daily and trametinib 2 mg once daily 
resulted in no clinically relevant pharmacokinetic drug interactions.   
 
RP2D for the combination of trametinib and dabrafenib 
In the dose escalation portion (Part B) of study BRF113220, the MTD of the combination 
was not reached, and the RP2D was therefore 150/2.  (Flaherty et al., 2012).  Pyrexia, 
chills, and nausea were the most common reasons cited for dose reductions; pyrexia, 
chills, and decreased ejection fraction were the most common reasons cited for dose 
interruptions.  Comprehensive safety data for the combination of dabrafenib and 
trametinib are presented in Section 2.2.2.4. 
 
Activity of dabrafenib + trametinib 
In the phase 2 portion of study BRF113220, among 162 patients with BRAFV600E or 
BRAFV600K mutation-positive melanoma, were randomized to 3 arms: dabrafenib 150 mg 
BID + trametinib 2 mg QD, dabrafenib 150 mg BID + trametinib 1 mg QD, and single-
agent dabrafenib 150 mg BID, efficacy analyses were performed in the intention-to-treat 
population, with a median follow-up of 14.1 months (Flaherty et al., 2012).  All major 
efficacy endpoints were improved, including PFS, 12-month PFS, ORR, and duration of 
response (see table below). 
 
End Point 
(as assessed by the investigators) 
Dabrafenib 
Monotherapy 
(n=54) 
Combination 
150/1 
(n=54) 
Combination 
150/2 
(n=54) 
Progression-free Survival – months 
Median (95% CI) 
5.8 (4.6-7.4) 
9.2 (6.4-11.0) 
9.4 (8.6-16.7) 
Progression-free Survival at 12 mo. 
% (95% CI) 
9 (3-20) 
26 (15-39) 
41 (27-54) 
CR or PR 
Patients (% [95% CI]) 
29 (54 [40-67]) 
27 (50 [36-64]) 
41 (76 [62-86]) 
Duration of response 
Median months (95% CI) 
5.6 (4.5-7.4) 
9.5 (7.4-NA) 
10.5 (7.4-14.9) 
 
2.2.2.4 
Safety profile of Dabrafenib or Dabrafenib-Trametinib Combination 
 
Comprehensive Adverse Events and Potential Risks (CAEPR) lists using NCI 


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19 
Common Terminology Criteria for Adverse Events (CTCAE) terms for dabrafenib and 
for trametinib are included in Section 7.1 of the protocol. 
 
Based on available AE data from clinical studies involving dabrafenib to date, the most 
common drug-related AE was hyperkeratosis (29%). Other commonly reported (>15%) 
drug-related AEs included alopecia, arthralgia, fatigue, skin papilloma, 
pyrexia, and rash (IB, 2013). 
 
Based on available AE data from clinical studies involving trametinib to date, the most 
common toxicities are rash and diarrhea.  Rash and diarrhea are common, class-effect 
toxicities for MEK inhibitors.  In addition, visual impairment and left ventricular 
ejection fraction (LVEF) reduction, although observed at lower frequencies, are also 
considered class-effect toxicities as they have been observed with trametinib as well as 
other MEK inhibitors. 
Common Adverse Events of Dabrafenib Monotherapy Based on Phase III Trial of 
Dabrafenib vs. Dacarbazine in Patients with Advanced Melanoma (adapted from 
Dabrafenib Package Insert) 
Adverse Reaction or Laboratory 
Abnormality 
Dabrafenib 
(n=187) 
Dacarbazine 
(n=59) 
All 
Gradesa 
Grades 
3 and 4b 
All Gradesa 
Grades 
3 and 4 
Skin and subcutaneous tissue disorders 
Hyperkeratosis 
37 
1 
0 
0 
Alopecia 
22 
NAf 
2 
NA 
Palmar-plantar erythrodysesthesia 
syndrome 
20 
2 
2 
0 
Rash 
17 
0 
0 
0 
Nervous system disorders 
Headache 
32 
0 
8 
0 
General disorders and administration site conditions 
Pyrexia 
28 
3 
10 
0 
Musculoskeletal and connective tissue disorders 
Arthralgia 
27 
1 
2 
0 
Back pain 
12 
3 
7 
0 
Myalgia 
11 
0 
0 
0 
Neoplasm benign, malignant, and unspecified (including cysts and polyps) 
Papillomac 
27 
0 
2 
0 
cuSCCd, e 
7 
4 
0 
0 
Respiratory, thoracic, and mediastinal  
Cough 
12 
0 
5 
0 
Gastrointestinal disorders 
Constipation 
11 
2 
14 
0 
Infections and infestations 


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20 
Common Adverse Events of Dabrafenib Monotherapy Based on Phase III Trial of 
Dabrafenib vs. Dacarbazine in Patients with Advanced Melanoma (adapted from 
Dabrafenib Package Insert) 
Adverse Reaction or Laboratory 
Abnormality 
Dabrafenib 
(n=187) 
Dacarbazine 
(n=59) 
All 
Gradesa 
Grades 
3 and 4b 
All Gradesa 
Grades 
3 and 4 
Nasopharyngitis 
10 
0 
3 
0 
a NCI CTCAE v5. 
b Gade 4 adverse reactions limited to hyperkeratosis (n=1) and constipation (n=1). 
c Includes skin pappiloma and papilloma. 
d Includes squamous cell carcinoma of the skin and keratoacanthoma. 
e Cases of cutaneous squamous cell carcinoma were required to be reported as Grade 3 per protocol. 
f NA = not applicable.. 
Common Adverse Events of Dabrafenib-Trametinib Combination vs. Dabrafenib 
Monotherapy.  The phase 2 portion of study BRF113220 (referred to as Part C) included 
3 arms:  dabrafenib 150 mg BID + trametinib 2 mg QD, dabrafenib 150 mg BID + 
trametinib 1 mg QD, and single-agent dabrafenib 150 mg BID.  The most common AE 
resulting in permanent discontinuation was pyrexia (4%).  AEs led to dose reductions in 
49% and dose interruptions in 67% of patients treated with dabrafenib in combination with 
trametinib.  The table below presents selected adverse reactions and treatment-emergent 
laboratory abnormalities in this study. 
Selected AEs and Laboratory Abnormalities Occurring in ≥10% at (All Grades) 
or ≥5% (Grades 3 or 4) of Patients Treated With Dabrafenib in Combination 
With Trametinib 
Adverse Reaction or 
Laboratory Abnormality 
Dabrafenib + 
Trametinib 2mg 
(n=55) 
Dabrafenib + 
Trametinib 1mg 
(n=54) 
Dabrafenib 
(n=53) 
All 
Gradesa 
Grades 
3 and 4 
All 
Gradesa 
Grades 
3 and 4 
All 
Gradesa 
Grades 
3 and 4 
General disorders and administrative site conditions 
Pyrexia 
71 
5 
69 
9 
26 
0 
Chills 
58 
2 
50 
2 
17 
0 
Fatigue 
53 
4 
57 
2 
40 
6 
Edema peripheralb 
31 
0 
28 
0 
17 
0 
Skin and subcutaneous tissue disorders 
Rashc 
45 
0 
43 
2 
53 
0 
Night sweats 
24 
0 
15 
0 
6 
0 
Dry skin 
18 
0 
9 
0 
6 
0 
Dermatitis acneiform 
16 
0 
11 
0 
4 
0 
Actinic keratosis 
15 
0 
7 
0 
9 
0 
Erythema 
15 
0 
6 
0 
2 
0 
Pruritis 
11 
0 
11 
0 
13 
0 
Gastrointestinal disorders 


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Selected AEs and Laboratory Abnormalities Occurring in ≥10% at (All Grades) 
or ≥5% (Grades 3 or 4) of Patients Treated With Dabrafenib in Combination 
With Trametinib 
Adverse Reaction or 
Laboratory Abnormality 
Dabrafenib + 
Trametinib 2mg 
(n=55) 
Dabrafenib + 
Trametinib 1mg 
(n=54) 
Dabrafenib 
(n=53) 
All 
Gradesa 
Grades 
3 and 4 
All 
Gradesa 
Grades 
3 and 4 
All 
Gradesa 
Grades 
3 and 4 
Nausea 
44 
2 
46 
6 
21 
0 
Vomiting 
40 
2 
43 
4 
15 
0 
Diarrhea 
36 
2 
26 
0 
28 
0 
Metabolism and nutritional disorders 
Decreased appetite 
22 
0 
30 
0 
19 
0 
Dehydration 
11 
0 
6 
2 
2 
0 
Vascular disorders 
Hemorrhaged 
16 
5 
11 
0 
8 
2 
Renal and urinary disorders 
Renal failuree 
7 
7 
2 
0 
0 
0 
Hematology 
Leukopenia 
62 
5 
46 
4 
21 
0 
Neutropenia 
55 
13 
37 
2 
9 
2 
Liver function tests 
Increased AST 
60 
5 
54 
0 
15 
0 
Increased alkaline 
phosphatase 
60 
2 
67 
6 
26 
2 
Increased ALT 
42 
4 
35 
4 
11 
0 
Hyperbilirubinemia 
15 
0 
7 
4 
0 
0 
Chemistry 
Hyperglycemia 
58 
5 
67 
6 
49 
2 
Hyponatremia 
55 
11 
48 
15 
36 
2 
Hypophosphatemia 
47 
5 
41 
11 
40 
0 
Increased creatinine 
24 
5 
20 
2 
9 
0 
a NCI CTCAE v5. 
b Includes the following terms:  peripheral edema, edema, and lymphedema. 
c Includes the following terms:  rash, rash generalized, rash pruritic, rash erythematous, rash popular, 
rash vesicular, rash macular, rash maculo-papular. 
d Includes the following terms:  brain stem hemorrhage, cerebral hemorrhage, gastric hemorrhage, 
epistaxis, gingival hemorrhage, hematuria, vaginal hemorrhage, hemorrhage intracranial, eye 
hemorrhage, and vitreous hemorrhage. 
e Includes the following terms:  renal failure and renal failure acute. 
 
AEs of special interest: 
 
The following events observed with dabrafenib monotherapy and for dabrafenib plus 
trametinib are discussed in further detail because they may represent a class effect of 
BRAF and/or MEK inhibitor compounds, and/or are potentially life-threatening.  AEs of 
special interest associated with dabrafenib or trametinib individually are listed in the table 
below: 
AEs of special interest that are 
AEs of special interest that are associated with trametinib 


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associated with dabrafenib (BRAF 
category AEs) are: 
• 
Skin-related toxicities 
• 
Pyrexia 
• 
Malignancies 
• 
Renal failure (renal failure, renal 
failure acute) 
• 
Uveitis 
• 
Hyperglycemia 
• 
Pancreatitis 
 
(MEK category AEs) 
• 
Skin-related toxicities (e.g., rash – generalized, macular, 
maculopapular, 
pruritic, erythematous, etc; dermatitis acneiform; 
erythema; skin exfoliation 
• 
Diarrhea 
• 
Ocular events (e.g., RVO, RPED (previously termed 
CSR)) 
• 
Hepatic events (e.g., aspartate aminotransferase [AST], 
ALT, and blood 
bilirubin increased) 
• 
Cardiac-related events (e.g., LVEF decreased and left 
ventricular dysfunction) 
• 
Hypertension 
• 
Pneumonitis (pneumonitis, interstitial lung disease) 
• 
Hemorrhages 
 
In general, the overall profile of “AEs of special interest” observed with the combination 
of trametinib-dabrafenib is consistent with the known profiles of each separate drug, the 
most notable differences being the increase in pyrexia and the decrease in skin-related 
toxicities with combination therapy relative to monotherapy.    
 
For “MEK-related AEs of special interest,” the overall incidence in the dabrafenib-
trametinib combination arm in trial BRF113220 was 91%, which was similar to the 
incidence reported with trametinib ISS monotherapy  (94%), but higher than the 
incidence in the dabrafenib alone arm.  However, MEK-related skin toxicities, diarrhea 
and hypertension appeared to be lower in the combination arm, as compared with the 
trametinib-only treated population.  The incidence rate of ocular events was higher 
relative to the trametinib ISS population.  
 
For “BRAF-related AEs of special interest,” the incidence of any event in combination 
arm was higher (84%) than either the Dabrafenib ISS population (49%) or the trametinib 
ISS population (19%).  This increase is predominantly due to the increased incidence of 
pyrexia observed with combination treatment.  Also noted were an increase in renal 
failure and a decrease in cuSCC and PPES when comparing the combination to 
dabrafenib ISS population. 
 
The following sections provide more detailed description of the AEs of Special Interest. 
 
Dermatologic toxicities (dabrafenib or dabrafenib-trametinib):   
 
Dabrafenib monotherapy has been associated with skin-related toxicities including 
hyperkeratosis, skin papilloma, rash, seborrheic keratosis, acrochordon as well as rash 
and pruritis and cutaneous squamous cell carcinoma.    
 
With the combination of dabrafenib-trametinib at 150/2 (Part C of the phase II trial), 
skin-related toxicity occurred in 65% of subjects (IB, 2013). This incidence was lower 
than observed in the trametinib ISS population (88%, 288 out of 329 subjects).  The most 
frequent skin-related toxicities (affecting >10% treated with combination) were rash, 


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dermatitis acneiform, erythema, and rash generalized.  The incidence and severity of the 
majority of skin-related toxicities and especially those most often seen with either 
trametinib- or dabrafenib therapy alone appear to be reduced when both compounds are 
combined. 
 
Malignancies (dabrafenib or dabrafenib-trametinib): 
 
Cutaneous SCC and keratoacanthomas:  SCC and proliferative skin toxicities are 
considered a class effect of BRAF inhibitors such as vemurafenib and sorafenib (Long et 
al., 2011).  SCC was treated with local excision, and treatment with dabrafenib was 
continued.  Most SCCs of the skin have been localized and generally treated with 
curettage, and have been without significant clinical sequelae. 
 
Across clinical trials of dabrafenib monotherapy (n=586), the incidence of cutaneous 
SCC was 11%.  Of those patients who developed new SCC, approximately 33% 
developed one or more SCC with continued administration of dabrafenib.   
 
In randomized trial with dabrafenib vs. dabrafenib-trametinib combination (BRF113220), 
the incidence of cutaneous SCC/keratocanthoma was statistically lower with150/2 
combination therapy relative to dabrafenib alone (7 vs. 19%).  The median time to the 
first occurrence of keratoacanthoma/cuSCC was 152 days in the combination treatment 
group as compared to 30.5 days in the dabrafenib alone arm. 
 
New primary malignant melanoma:  In the randomized trial for dabrafenib-trametinib 
combination (BRF113220), new primary melanoma occurred in 2% (1/53) on dabrafenib 
monotherapy [similar to the dabrafenib ISS population (1%)] and in none of 55 patients 
receiving dabrafenib + trametinib (IB, 2013).  The overall frequency of new primary 
melanomas observed with dabrafenib treatment approximates that expected for untreated 
subjects with antecedent melanoma. 
 
Other treatment-emergent malignancies:  Non-cutaneous secondary malignancies have 
also been reported in patients receiving dabrafenib or dabrafenib-trametinib combination.  
In patients receiving dabrafenib-trametinib combination, five cases out of 365 subjects 
(1%) were identified as having non-cutaneous malignancies:  KRAS mutation-positive 
pancreatic adenocarcinoma (n=1), recurrent NRAS mutation-positive CRC (n=1), head 
and neck carcinoma (n=1), glioblastoma (n=1), and pre-existing renal cell carcinoma 
(n=1) (FDA label).  No increase was detected in the overall frequency of treatment 
emergent malignancies in melanoma subjects receiving dabrafenib and trametinib 
treatment in Study BRF113220 as compared to the dabrafenib safety population.  
Dabrafenib should be permanently discontinued for RAS mutation-positive non-
cutaneous malignancies. 
 
Pyrexia (dabrafenib or dabrafenib-trametinib):  Pyrexia and pyrexia-related events, 
including influenza-like illness, cytokine release syndrome, and systemic inflammatory 
response syndrome are common side effects associated with dabrafenib.  In dabrafenib- 
trametinib combination study BRAF113220 Part C, pyrexia and related events in the 


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combination arm (150/2) were increased in frequency and severity (76%; 5% grade 3, no 
grade 4), as compared with dabrafenib monotherapy ISS population (33%; 2% grade 3, 
no grade 4).  Eleven percent of subjects in the combination group required hospitalization 
for episodes of serious pyrexia (IB, 2013).  Approximately 50% of the pyrexia-related 
events in the Part C 150/2 arm resulted in dose interruption and/or dose reduction, a 
higher proportion than in the dabrafenib ISS population (15% to 30%).  The majority of 
subjects (>80%) who dose-reduced dabrafenib due to AEs were able to be dose re-
escalated.  
 
All SAEs of pyrexia-related events (pyrexia, influenza-like illness, cytokine release 
syndrome, and systemic inflammatory response syndrome) were manually reviewed to 
identify cases described as having experienced serious non-infectious febrile events 
with complications of hypotension, dehydration, severe rigors/chills, or renal failure in 
the absence of another identifiable etiology (e.g., infection).  Ten such subjects were 
identified among 404 subjects (2.5%) in the entire combination therapy population as 
compared to 1% in the dabrafenib ISS population; 9 of these subjects were hospitalized.  
All of these subjects required dose interruption(s) and/or dose modification(s); one 
subject permanently discontinued study drug after experiencing fever, muscle weakness, 
dehydration, and hyponatremia.  All subjects responded to symptomatic therapy with 
either NSAIDs, paracetamol, or corticosteroids and best supportive care including IV 
fluids. 
 
Renal failure (dabrafenib or dabrafenib-trametinib):  Renal failure was observed in 
the dabrafenib ISS population (<1%; <1% grade 3/4) and trametinib ISS population (2%; 
no grade 3, <1% grade 4), and was increased in incidence and severity in the combination 
arm in study BRF113220 (7%, all grade 3) (IB, 2013).  Most cases of acute renal failure 
presented as a secondary event in the setting of pyrexia where dehydration appeared to be 
a contributing factor and/or in concert with other risk factors such as hemolytic uremic 
syndrome (HUS), antibiotic toxicity, or hypercalcemia.  There was one case of advanced 
renal failure which may have been drug-induced but whose precise etiology was not 
clear.  The renal events led to permanent discontinuation of study drugs in one subject, 
and to dose interruptions in three subjects. 
 
Hypertension (dabrafenib-trametinib): Hypertension has been associated with 
trametinib therapy.  In the combination study of dabrafenib-trametinib, the combination 
arm had a higher rate of hypertension compared to the dabrafenib ISS population (9% vs. 
2%); however, this rate was lower than that in the trametinib ISS population (15%) (IB, 
2013).   
 
In either the combination or the dabrafenib monotherapy population, there were no SAEs 
related to hypertension, and hypertension did not lead to treatment discontinuation, dose 
reduction or dose interruption in any of the patients.   
 
Cardiac valvular abnormalities (dabrafenib or dabrafenib-trametinib):  Data from 
preclinical studies suggested that dabrafenib has the potential to cause cardiac valve 
abnormalities.  In a 28-day dog toxicology study, high doses (50 mg/kg/day; 


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approximately 40-fold over the therapeutic dose) of dabrafenib in 1 dog (n=10) resulted 
in hypertrophy of the right atrio-ventricular valve (tricuspid valve).  Therefore, this was 
monitored in clinical trials with echocardiograms. 
 
Cardiomyopathy (dabrafenib-trametinib):  Cardiomyopathy has been associated with 
trametinib use and therefore the incidence was increased in the dabrafenib-trametinib 
combination compared to dabrafenib alone.  Cardiac-related AEs occurred in 9% of 
subjects in the Part C 150/2 group, which is the same incidence as in the Trametinib ISS 
population (9%), but a higher incidence compared with the Dabrafenib ISS population 
(2%) (IB, 2013).  Decreased ejection fraction was the only AE reported in the Part C 
150/2 group, and all reports were either grade 1 or 2. 
 
Ocular adverse events:  Ocular events occurred at a higher frequency in study 
BRF113220 Part C 150/2 combination group (25%) compared to trametinib (13%) and 
dabrafenib (8%) monotherapy ISS populations (IB, 2013).  Blurred vision, dry eye, and 
visual impairment were the most commonly reported ocular events in the Part C 150/2 
group.  All ocular events in Part C 150/2 were grade 1 to 2 with the exception of one case 
of grade 3 retinal pigment epithelial detachment (RPED).  
 
RPED and RVO (dabrafenib-trametinib):  These two events are associated with 
trametinib therapy and therefore were observed in the combination of dabrafenib and 
trametinib.  Of 365 subjects in Study BRF113220, the incidence of RPED remained at 
1% and is thus similar to the frequency observed in the overall trametinib development 
program so far. Thus, the addition of dabrafenib appears to have no impact on the 
frequency or severity of RPED previously reported for trametinib.  
 
RVO has not been reported as an AE in the dabrafenib ISS population of 586 subjects. 
Addition of dabrafenib to trametinib in the combination treatment regimen in Study 
BRF113220 did not increase the frequency of RVO observed thus far with trametinib 
monotherapy.  
 
Uveitis, iritis, and iridocyclitis (dabrafenib or dabrafenib-trametinib):  Uveitis and 
iritis can occur when dabrafenib is administered as a single agent or in combination with 
trametinib.  In the 365 subjects with melanoma treated on the dabrafenib-trametinib 
combination arm in Study BRF113220, the incidence of ocular events including uveitis, 
iritis, or iridocyclitis was 2%, and responded to symptomatic therapy, which included 
primarily the use of topical corticosteroids.  This rate is slightly higher than in the 
dabrafenib ISS population (1%).  In addition, the severity of the inflammatory ocular 
events also appeared to be slightly increased, with 2 cases of uveitis Grade 3 and 1 case 
of Grade 4. 
 
Hyperglycemia (dabrafenib or dabrafenib-trametinib):  Hyperglycemia can occur 
when dabrafenib is used as a monotherapy or in combination with trametinib.  In study 
BRF112680 (dabrafenib monotherapy), 5/12 patients with a history of diabetes required 
more intensive hypoglycemic therapy while taking dabrafenib; the incidence of grade 3 
hyperglycemia was 6% (12/187) in patients treated with dabrafenib compared with none 


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26 
of the dacarbazine-treated patients.  In study BRF113220 (combination with trametinib), 
the incidence of hyperglycemia was 5% (3/55) in patients treated with dabrafenib-
trametinib compared with 2% (1/53) in patients treated with dabrafenib (FDA label).  
 
Pancreatitis (dabrafenib or dabrafenib-trametinib):  Pancreatitis (<1%) and/or 
increased lipase/amylase (2%) have been reported at low frequency with dabrafenib.  In 
the phase 2 combination study BRAF113229, AEs of acute pancreatitis or pancreatitis 
occurred in six (1%) subjects on the dabrafenib-trametinib arm (IB, 2013), and none with 
dabrafenib monotherapy.  The time to onset of pancreatitis ranged from Study Day 21 to 
292 (median:  138 days).  At the data cut-off, 4 subjects had recovered from the event of 
pancreatitis.  Discontinuation of study drugs due to pancreatitis was not deemed 
necessary by the investigators in any of the 6 cases.  The incidence of pancreatitis was 
<1% in the dabrafenib ISS population (2 subjects) and in the trametinib ISS population (1 
subject). 
 
Hepatic events (dabrafenib-trametinib combination):  In the Part C 150/2 group, 15% 
of subjects experienced hepatic AEs as compared to 13% of subjects in the trametinib ISS 
population and 6% of subjects in the dabrafenib ISS population (IB, 2013).  Of the 
hepatic AEs, increased ALT and AST were the most common events in all groups, and 
most were either grade 1 or 2.  No cases of Hy’s law were observed among any of the 
subjects in the BRF113220 study. 
 
Diarrhea (dabrafenib-trametinib combination):  The proportion of subjects in the Part 
C 150/2 group who experienced diarrhea was 36% compared with 49% in the trametinib 
ISS population and 16% in the dabrafenib ISS population (IB, 2013).  Most subjects 
across the monotherapy and combination therapy dabrafenib and trametinib clinical 
programs reported grade 1 or grade 2 diarrhea. 
 
Pneumonitis (dabrafenib-trametinib combination):  Pneumonitis was not reported as 
an AE in the 365 subjects enrolled in Study BRF113220 (Investigators Brochure, 2013).  
However, pneumonitis was the most common drug-related SAE (1% of subjects) 
Trametinib ISS population.  Overall, the addition of dabrafenib to trametinib does not 
appear to increase the frequency or severity of pneumonitis previously observed with 
trametinib monotherapy. 
 
Hypersensitivity:  There has been a single report of hypersensitivity (blisters) to 
dabrafenib, occurring on the same day as the 1st dose of study drug as well as upon 
rechallenge (IB, 2013).  The subject recovered after interruption and then discontinuation 
of dabrafenib.  Grade 1 AEs of blisters on limbs (4 subjects) and drug hypersensitivity 
(rash, 1 subject) have been reported in previous studies with dabrafenib.  However, the 
precise etiology of these events is unclear. 
 
Hypersensitivity to trametinib was reported by one subject 7 days after starting trametinib 
who experienced fever, asthenia, visual disturbance, and symptoms suggestive of a 
hypersensitivity reaction described by the investigator as “vascularity.”  This subject also 
developed LFT elevations, lower limb nodules that by biopsy showed “dermo-


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27 
hypodermatitis with plasmocyte and lymphocyte infiltrate.”  The subject recovered after 
discontinuation of trametinib. 
 
Hemorrhages (dabrafenib-trametinib combination):  Hemorrahge is an AE identified 
with the dabrafenib-trametinib combination therapy.  Hemorrhages, including major 
hemorrhages defined as symptomatic bleeding in a critical area or organ, can occur with 
dabrafenib plus trametinib combination therapy (FDA label).  In study BRF113220, 
treatment with dabrafenib in combination with trametinib resulted in an increased 
incidence and severity of any hemorrhagic event:  16% (9/55) of patients treated with 
trametinib in combination with dabrafenib compared with 2% (1/53) of patients treated 
with dabrafenib as a single agent.  The major hemorrhagic events of intracranial or 
gastric hemorrhage occurred in 5% (3/55) of patients treated with trametinib in 
combination with dabrafenib compared with none of the 53 patients treated with 
dabrafenib as a single agent.  Intracranial hemorrhage was fatal in two (4%) patients 
receiving the combination of trametinib and dabrafenib.  
 
Glucose-6-phosphate dehydrogenase (G6PD) deficiency (dabrafenib or dabrafenib-
trametinib combination):  Dabrafenib, which contains a sulfonamide moiety, confers a 
potential risk of hemolytic anemia in patients with G6PD deficiency; these patients 
should be closely observed for signs of hemolytic anemia.   
 
Embryofetal toxicity:  Based on the mechanisms of action, dabrafenib and/or trametinib 
can cause fetal harm when administered to a pregnant woman.  Dabrafenib was 
teratogenic and embryotoxic in rats at doses three times greater than the human exposure 
at the recommended clinical dose.  Trametinib was embryotoxic and abortifacient in 
rabbits at doses greater than or equal to those resulting in exposures approximately 0.3 
times the human exposure at the recommended clinical dose.  
 
2.2.3 AT13387 
 
AT13387AU (2,4-dihydroxy-5-isopropyl-phenyl)-[5-(4-methyl-piperazin-1-ylmethyl)-
1,3-dihydro-isoindol-2-yl]-methanone) is the L-lactic acid salt of AT13387 and is the 
active pharmaceutical ingredient in AT13387.  
 
2.2.3.1 
Mechanisms of Action and Preclinical Data with AT13387 
 
HSP90 is a ubiquitously expressed and highly abundant molecular chaperone, accounting 
for as much as 1-2% of total cell protein. Both HSP90 and heat shock protein 70 
(HSP70) are induced under conditions of cellular stress to ensure the cell has an increased 
capacity to maintain proper protein folding. Heat shock factor-1 (HSF-1) is bound by 
HSP90 under non-stressed conditions. In response to a variety of cellular stresses, or 
direct inhibition of HSP90, HSF-1 dissociates from HSP90 and as a consequence 
upregulates HSP90, HSP70, and HSP40 gene transcription. In contrast to other 
chaperones, which generally act to aid the folding and refolding of proteins, HSP90 is 


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28 
only involved in the final maturation of a distinct set of “client” proteins. The precise 
manner in which HSP90 influences the folding of these proteins is not fully understood, 
but the process is known to be adenosine triphosphate (ATP)-dependent. HSP90 is 
required for the functional stabilization of numerous client proteins. Inhibition of the 
binding of ATP to HSP90 induces the degradation of these client proteins, growth arrest, 
and apoptosis. HSP90 client degradation profoundly inhibits multiple cell signaling 
pathways known to be critical for cell growth and survival. 
 
In vitro studies with AT13387 have shown that the compound binds to the N-terminal 
ATP site on HSP90 with sub-nanomolar affinity.  
 
AT13387 inhibits the growth of a variety of tumor cell lines including melanoma cell 
lines. AT13387 has single agent activity in BRAF-mutant cell lines, including those that 
are sensitive (A375, SkMel-28) and those that are resistant (A2058, RPMI-7951) to 
BRAF inhibitors.  AT13387 depleted BRAF and CRAF levels as well as AKT.  In the 
RPMI-7951 cell line, levels of the client protein COT, which is overexpressed and leads 
to resistance in this cell line, were also depleted. In addition, levels of pERK and 
phospho-S6 Ribosomal protein (pS6) were ablated in all cell lines, indicating an 
inhibition of AKT and ERK signaling, which are the key pathways in the majority of 
vemurafenib resistance mechanisms.  
 
Activity of AT13387 in a Panel of Melanoma Cell Lines 
Melanoma Cell line Vemurafenib IC50 (nM) AT13387 IC50 (nM) 
Mutation status 
A375 
87 
22 
BRAFV600E 
SK-MEL-28 
340 
73 
BRAFV600E 
SK-Mel-5 
370 
190 
BRAFV600E 
A2058 
1700 
34 
BRAFV600E/PTEN-null 
RPMI-7951 
>10000 
30 
BRAFV600E/COT 
SK-Mel-2 
> 10000 
45 
BRAFWT/N-RasQ61R 
   IC50 values are the mean of at least 2 individual experiments 
 
AT13387 has also been evaluated in both vemurafenib-sensitive (A375, SK-MEL-28) 
and vemurafenib-resistant (A2058) xenograft mouse models. AT13387 significantly 
inhibited the growth of all three xenografts.  As expected, oral administration of 
vemurafenib at 50 mg/kg twice a day caused significant regression of the A375 and SK-
MEL-28 tumors over the period of dosing but not in A2058. Combination of vemurafenib 
and AT13387 enhanced tumor growth inhibition over either of the monotherapies in the 
A2058 xenograft. The combination of AT13387 and vemurafenib was well tolerated (no 
major adverse effects on body weight) and not antagonistic. 


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The effects of AT13387 treatment on modulation of HSP90 clients and signaling 
pathways were also evaluated in the tumor xenografts models. Mice bearing A375 tumors 
were treated with a single dose of AT13387 and tumors were removed at various 
timepoints up to 72 hrs. Levels of the clients, BRAF, AKT, CRAF and cyclin dependent 
kinase 4 (CDK4) were depleted over this timecourse, whilst levels of HSP70, an indicator 
of HSP90 inhibition, were induced. Depletion of HSP90 clients and induction of HSP70 
was also observed in vemurafenib resistant RPMI-7951 xenograft tumors 24 hrs after 
treatment. In addition an ablation of pAKT, pS6 and pERK indicated that signaling 
through the ERK and AKT pathways was inhibited at this time point. 
 
2.2.3.2 
Nonclinical safety of AT13387 
 
Further information on the nonclinical program of AT13387 is provided in the AT13387 
investigator’s brochure (March 2013). 
 
A CNS safety pharmacology study in rats demonstrated no adverse CNS effects.  
A cardiovascular safety pharmacology study was conducted in Beagle dogs. A dose-
related increase in heart rate was observed at 4 mg/kg and above from 10 minutes after 
the start of infusion which peaked at the end of infusion and returned to control levels by 
approximately 5 hrs after the end of infusion. The increased heart rate observed at 
15 mg/kg was associated with a concomitant decrease in blood pressure (systolic, 
diastolic and mean arterial). AT13387 did not have any significant effect on QT interval 
or QTc at any dose level tested. 
 
Toxicity studies were conducted by 1-hr IV infusion in rodent (rat) and non-rodent (dog) 
species.  Both species exhibited decreased body weight and food consumption, and 
decreases in white blood cell counts. While clinical pathology changes suggestive of 
adverse effects in the bone marrow, kidney and liver were observed for both species, 
histopathologic changes were only seen in dogs and included testes, gallbladder, bone 
marrow (sternum), kidneys and thymus. The overall effects observed in surviving rats 
and dogs were transient and reversible, with the exception of the testicular lesions 
observed in dogs at high doses, for which the recovery period of 14 days was not 
sufficient.  No microscopic ophthalmic changes were seen in either species. The 
histological changes in the testes seen in dogs indicate that treatment with AT13387 may 
be associated with impaired fertility, which may be only slowly reversible or permanent. 
 
2.2.3.3 
Clinical Pharmacokinetics (PK) and Activity of AT13387 
 
As detailed in the AT13387 March 2013 Investigator Brochure five studies have been 
initiated with AT13387; two Phase 1 clinical studies of AT13387 monotherapy and 3 
Phase 2 combination studies;  
 
• AT13387-01; a phase 1 monotherapy study in adults with metastatic solid tumors  
• AT13387-03, a phase 1 monotherapy study sponsored by the National Cancer 
Institute (NCI) in adults with refractory solid tumors  


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• AT13387-02 a phase 2 study in adults with gastrointestinal stromal tumor (GIST) 
who receive AT13387 in combination with imatinib  
• AT13387-04; a Phase 2 study of AT13387 alone or in combination with abiraterone 
acetate in the treatment of castration-resistant prostate cancer (CRPC) no longer 
responding to abiraterone 
• AT13387-05;  AT13387 alone and in combination with crizotinib in the treatment of 
non-small cell lung cancer (NSCLC) 
 
AT13387-01 Study (data from AT13387/01 Clinical Study Report Version 2 signed 
January 2014) 
 
AT13387-01 was the FTIH study designed to determine the safety, tolerability, 
pharmacokinetics, and preliminary efficacy of AT13387, administered as a 1-hour 
infusion either twice-weekly or once-weekly for 3 weeks in a 4-week cycle, in subjects 
with advanced malignancies. Sixty-two subjects were treated with AT13387 in 10 
cohorts;  5 with the twice-weekly regimen (ranging from 10 mg/m2 to 120 mg/m2) and 5 
with the once-weekly regimen (ranging from 150 mg/m2 to 310 mg/m2).  
PK and metabolism of AT13387 
 
In study AT13387/01 blood samples for PK analysis were collected either on Day 1 and 
Day 18 of Cycle 1, for the twice-weekly regimen or Cycle 1, Day 1 and Cycle 2, Day 15 
for the once-weekly regimen. The PK evaluable population was 61. 
 
The PK of AT13387 showed a dose-proportional increase in AUC0-t and Cmax from 10 to 
120 mg/m2 (twice-weekly) and then from 150 to 310 mg/m2 (once-weekly) with 
relatively low inter-individual variability. The elimination half-life (t1/2) was dose-
independent and ranged from 6.6 to 11.5 hrs between cohorts. There was no notable 
accumulation or reduction in exposures between Cycle 1, Day 1 and Day 18 in the twice-
weekly regimen or Cycle 1, Day 1 and Cycle 2, Day 15 in the once-weekly regimen. 
From urine data available, the urinary excretion of AT13387 appeared to be low. The 
maximum rate of excretion was observed within 3.50 to 11.9 hours (mean Tmax) 
following the IV infusion for the 10 to 120 mg/m2 cohorts. The percent of the dose 
recovered in urine ranged from 0.92 to 2.98%.  
 
AT13387 clearance or volume of distribution was independent of sex, race (albeit with 
significant variability) or previous treatment (radiotherapy, chemotherapy or surgery). 
However, AT13387 exposures (AUC) were higher and clearance was lower in two 
subjects with high baseline bilirubin levels, which may be indicative of reduced UGT 
enzyme activity in these subjects as glucuronidation constitutes the main pathway for 
metabolic clearance of AT13387. 
 
As detailed in the March 2013 AT13387 Investigator Brochure in Study AT13387-02, 
subjects received once weekly IV infusion doses of AT13387 in combination with daily 
oral doses of imatinib. The plasma PK of AT13387 was assessed on Day 8 of the study 
(second dose of AT13387); as it was considered that the imatinib plasma concentrations 
would be close to steady state. Subjects in Cohort 1 of Study AT13387-02 received doses 


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31 
of 180 mg/m2: the principal mean PK parameters derived from 6 subjects are summarized 
in the Table below. The mean AUC0-t value obtained in Study AT13387-02 was greater, 
and showed wider inter-subject variability, than the mean AUC0-t for the same dose level 
in Study AT13387-01: values for t1/2 and Cmax of AT13387 were similar in the 2 studies. 
A relatively sparse PK sampling schedule was adopted for Study AT13387-02 and this 
may have contributed to the higher AUC0-t values obtained. On balance, there is no clear 
evidence of imatinib affecting the PK of AT13387 on the data obtained so far. 
 
Plasma samples from 5 subjects in Cohort 1 of Study AT13387-02 were analyzed for the 
presence of the isomeric glucuronide metabolites, AT17219 and AT17220. The semi-
quantitative (non-validated) LCMS method confirmed that AT17220 was the  
predominant metabolite in the systemic circulation. Estimated concentrations of 
AT17220 were >25x those of metabolite AT17219 and >40x the concentrations of 
AT13387 itself, in all 3 hrs to 24 hrs postdose samples. 
 
Drug-drug interactions 
 
No drug drug interaction studies have been performed with AT13387.  However, the 
potential for AT13387 to inhibit cytochrome P450 (CYP) 1A2, 3A4, 2D6, 2C9, and 2C19 
was assessed in vivo and the results indicated a concentration resulting in IC50 >10 µM, 
suggesting a low potential for clinically significant drug-drug interactions mediated by 
these enzymes.  The potential of AT13387 to induce liver cytochrome P450 (CYP) 
enzymes 1A2, 2B6, and 3A4 was also assessed in cultured human hepatocytes (n=3 
donors) by measuring changes in mRNA expression.  No induction of CYP1A2, 
CYP2B6, and CYP3A4 was seen at concentrations up to 30 μM.  
 
In addition, studies have been performed to assess if AT13387 inhibits UGT isoforms.  A 
small amount of inhibition (~14%) of probe substrate metabolism was observed with 
UGT1A1, UGT1A3 and UGT1A9 when AT13387AU was tested at 20 μM. Isoforms 
UGT1A6 AND UGT2B7 showed no inhibition at 20 μM. These data suggests that 
AT13387 has a relatively low affinity for UGT isoforms and thus it has a low risk of 
reducing the clearance of co-administered compounds cleared primarily by this enzyme 
family 
 
Pharmacodynamic effect of AT13387 
 
The pharmacodynamics effect of AT13387 was assessed in the FTIH study AT13387-01.  
HSP70 expression was assessed in plasma and PBMC lysates from samples collected for 
upto 24 hrs after the start of infusion in Cycle 1 and before the start of the first infusion in 
Cycle 2.  Tumor biopsy samples were collected in screening and in Cycle 1.  
 
Increased levels of HSP70 were detected in plasma in all dosing cohorts in the study. 
HSP70 induction in plasma was dose-dependent until Cohort 5 (120 mg/m2; ~2- to 6-fold 
increase) in the twice-weekly regimen. In the once-weekly regimen, HSP70 induction 
appeared to be dose-dependent until Cohort 8 (220 mg/m2).  
 


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32 
HSP90 client protein levels (AKT, phospho-AKT, S6, phospho-S6, CDK4, LCK and C-
Raf) were also measured in PBMCs. Due to large variability in HSP90 client knockdown 
in PBMCs, no meaningful conclusions could be drawn.  
 
Pre- and post-treatment tumor biopsy samples were taken and successfully analyzed from 
4 subjects treated at the MTD (120 mg/m2) for the twice-weekly regimen. Pre-treatment 
samples were taken at Screening or before the start of infusion on Cycle 1, Day 1. Post-
treatment samples were taken approximately 24 hrs after the end of infusion on Cycle 1, 
Day 18 for subjects on the twice-weekly regimen and on Cycle 1, Day 16 (+7 days) for 
subjects on the once-weekly regimen. HSP90 client protein depletion (B-Raf, CDK4, 
phospho-S6 and caspase-3) was very variable in the tumor biopsies. For paired tumor 
samples suitable for analysis, a consistent increase in HSP70 staining was detected in the 
majority of the samples.  
 
PD analysis of samples for study AT13387-02 to AT13387-05 is ongoing.  
 
Selection of the RP2D 
 
The RP2D for once weekly treatment was determined to be 260mg/m2 in study AT13387-
01.  No DLTs were observed in the once-weekly regimen; however, the MTD was 
defined based on a series of moderate toxicities (mostly Grade 2 diarrhea, nausea, 
vomiting, fatigue and systemic infusion reactions) observed in the 310 mg/m2 cohort.  
 
Antitumor Activity of AT13387 Monotherapy  
 
The antitumor activity of AT13387 in the FTIH study AT13387 has been reported in the 
AT13387-01 RPED.  No subjects in this study had complete response (CR) as best 
response to therapy. One (1) subject (2%) had partial response (PR) as best response to 
therapy. The PR occurred in the 220 mg/m2 once-weekly cohort after 6 months of 
treatment, for a duration of 113 days (~3.8 months), in a subject with GIST who had 3 
prior treatments with imatinib and who had acquired a mutation conferring resistance to 
imatinib prior to treatment, and was on treatment for a total of approximately 10 months.   
 
Twenty-one (21) subjects (34%) had stable disease (SD) as best response to therapy.  
Of the 10 subjects with NSCLC all of whom had been heavily pretreated, 4 subjects 
(40%) had SD with a duration of 47-102 days. Of the 7 subjects with GIST, there was 1 
subject with PR and 3 subjects (43%) with SD, two of whom had SD for 231 (~7.7 
months) and 335 days (~11.2 months). 
 
As described in the AT13387 Investigator Brochure dated March 2013 no objective 
responses have been reported for the Phase I monotherapy study AT13387-03. In study 
AT13387-02 the best responses were 1 PR (180 mg/m2/dose) and 4 subjects with SD (1 
with 150 mg/m2/dose and 3 with 180 mg/m2/dose).  Collection of additional efficacy data 
from these studies and studies AT13387-04 and 05 is ongoing.  
 
2.2.3.4 
AT13387 Safety Profile 
 


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33 
A Comprehensive Adverse Events and Potential Risks (CAEPR) list using NCI 
Common Terminology Criteria for Adverse Events (CTCAE) terms is included in Section 
7.1 of the protocol. 
 
The safety data is taken from the AT13387 March 2013 Investigator brochure. SAE data 
is based on information from all Astex-sponsored AT13387 studies in the Safety database 
as of 9 January 2013 (i.e., studies AT13387-01 and AT13387-02). All AE data are based 
on Astex-sponsored studies AT13387-01 and AT13387-02, which represent the studies 
with the most subjects treated and most substantial safety information available to date 
(database of 87 subjects treated).  
The table below summarizes SAE data based on safety database information as of 9 
January 2013. 
Overview of SAEs 
 
SAE 
Number (%) of Subjects with SAEs 
AT13387-01 (N=62) 
AT13387-02 (N=25) 
Total (N=87) 
Any SAE 
22 (35) 
7 (28) 
29 (33) 
SAEs that led to death 
6 (10) 
0 
6 (7) 
Other SAEs (i.e., those not leading 
to death) 
16 (26) 
7 (28) 
23 (26) 
 
 
  Source: Safety database (9 Jan 2013) 
 
SAEs were reported for 29 of 87 subjects (33%) in Astex-sponsored studies. Most of the 
subjects with SAEs (22 of 29) were in Study AT13387-01.  
A total of 6 deaths were reported as SAEs in AT13387 studies as of 9 January 2013. Half 
(3 of 6) were due to disease progression. The other 3 were due to pneumonia (2 subjects) 
and metastatic colon cancer (1 subject). SAEs that led to death were considered not 
related to study treatment by both the Investigator and the Sponsor, except for metastatic 
colon cancer, for which the Investigator assessed causality as possible. This subject had 
rapidly worsening colorectal cancer and deteriorating liver function; he died at home 
shortly after starting AT13387 treatment. The investigator reported the death as possibly 
due to progressive disease but could not exclude a contribution from AT13387. The 
subject’s ECG was normal throughout treatment. 
Other SAEs (those that did not lead to death) were reported for 23 of 87 subjects (26%). 
The only SAEs that were reported for >1 subject were blood CPK increased and 
electrocardiogram QT prolonged (2 subjects for each event, 2%).  
Other SAEs (those that did not lead to death) that were considered related to study 
treatment were reported for 11 of 87 subjects (13%). No related SAE was reported from 
subjects receiving less than 120 mg/m2/dose of AT13387. All of the related SAEs were 
reversible other than muscular weakness (Study AT13387-01), asthenia (Study AT13387-


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34 
01), and blood creatine phosphokinase increased (Study AT3387-02), which were 
ongoing at last follow up or death. 
As of 31 December 2012, the most common AEs (≥10 subjects), regardless of 
relationship, reported in decreasing order of frequency, from Studies AT13387-01 and -
02, are shown below.  
Summary of AEs with Highest Incidence (≥10 Subjects) in Decreasing Order of 
Frequency, Regardless of Relationship or Grade, for Studies AT13387-01 and -02 (as of 
31 December 2012) 
Adverse Event 
MedDRA Preferred Term 
Number (%) of Subjects 
AT-13387-01 
AT-13387-02 
(n=24b) 
Overall Total AT-13387-01 + 
AT-13387-02 (N=86) 
2x/week 
(n=28) 
1x/week 
(n=34) 
Total 
(n=62a) 
All AEs 
CTCAE  
Grade 3+4 AEs 
Diarrhoea 
20 (71) 
27 (79) 
47 (76) 
16 (67) 
63 (73) 
4 (5) 
Fatigue 
15 (54) 
19 (56) 
34 (55) 
8 (33) 
42 (49) 
0 
Nausea 
8 (29) 
19 (56) 
27 (44) 
11 (46) 
38 (44) 
0 
Abdominal pain 
9 (32) 
12 (35) 
21 (34) 
5 (21) 
26 (30) 
2 (2) 
Decreased appetite 
7 (25) 
12 (35) 
19 (31) 
7 (29) 
26 (30) 
0 
Dizziness 
5 (18) 
15 (44) 
20 (32) 
6 (25) 
26 (30) 
1 (1) 
Anaemia 
9 (32) 
7 (21) 
16 (26) 
8 (33) 
24 (28) 
4 (5) 
Vomiting 
8 (29) 
7 (21) 
15 (24) 
9 (38) 
24 (28) 
0 
Dry mouth 
7 (25) 
11 (32) 
18 (29) 
5 (21) 
23 (27) 
0 
Headache 
4 (14) 
10 (29) 
14 (23) 
5 (21) 
19 (22) 
0 
Muscle spasms 
3 (11) 
11 (32) 
14 (23) 
5 (21) 
19 (22) 
0 
Injection site reaction 
1 (4) 
12 (35) 
13 (21) 
5 (21) 
18 (21) 
0 
Insomnia 
3 (11) 
9 (26) 
12 (19) 
4 (17) 
16 (19) 
0 
Visual impairment 
1 (4) 
13 (38) 
14 (23) 
2 (8) 
16 (19) 
0 
Weight decreased 
3 (11) 
10 (29) 
13 (21) 
3 (13) 
16 (19) 
0 
Chills 
2 (7) 
11 (32) 
13 (21) 
2 (8) 
15 (17) 
0 
Constipation 
4 (14) 
8 (24) 
12 (19) 
2 (8) 
14 (16) 
0 
Dehydration 
3 (11) 
7 (21) 
10 (16) 
4 (17) 
14 (16) 
3 (3) 
Hyperhidrosis 
2 (7) 
9 (26) 
11 (17) 
3 (13) 
14 (16) 
0 
Oedema peripheral 
4 (14) 
2 (6) 
6 (10) 
7 (29) 
13 (15) 
0 


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Activity of AT13387 in a Panel of Melanoma Cell Lines (Cont'd) 
Adverse 
Event 
MedDRA 
Preferred 
Term 
Number (%) of Subjects 
AT-13387-01 
AT-13387-02 
(n=24b) 
Overall Total AT-13387-01 + 
AT-13387-02 (N=86) 
2x/week 
(n=28) 
1x/week 
(n=34) 
Total 
(n=62a) 
All AEs 
CTCAE  
Grade 3+4 AEs 
Aspartate 
aminotransfer
ase increased 
8 (29) 
0 
8 (13) 
4 (17) 
12 (14) 
2 (2) 
Cough 
6 (21) 
6 (18) 
12 (19) 
0 
12 (14) 
0 
Infusion 
5 (18) 
6 (18) 
11 (17) 
1 (4) 
12 (14) 
0 
Blood 
creatine 
7 (25) 
1 (3) 
8 (13) 
2 (8) 
11 (13) 
1 (1) 
Hypokalaemi
1 (4) 
4 (12) 
5 (8) 
5 (21) 
10 (12) 
1 (1) 
Pruritus 
1 (4) 
5 (15) 
6 (10) 
4 (17) 
10 (12) 
0 
Rash 
4 (14) 
5 (15) 
9 (15) 
1 (4) 
10 (12) 
0 
Vision 
6 (21) 
3 (9) 
9 (15) 
1 (4) 
10 (12) 
1 (1) 
a  The safety dataset includes subjects who received study treatment (i.e., 1 less than the number enrolled). 
 b  Study treatment for 1 subject was missing from this preliminary database; that subject is not included in the 
safety data set. 
 
The most common individual events (occurring in >25% of subjects) were diarrhea 
(63 subjects, 73%); fatigue (42 subjects, 49%); nausea (38 subjects, 44%); abdominal 
pain, decreased appetite, and dizziness (26 subjects each, 30%); anemia and vomiting 
(24 subjects each, 28%); and dry mouth (23 subjects, 27%). Note that under the preferred 
term of Visual Impairment several visual symptoms were reported, such as blurred 
vision, color changes, flashes, floaters, light/dark accommodation difficulties, and 
moving objects. Most AEs were reported as Grade 1 or 2 and were reversible. 
In Studies AT13387-01 and -02, the most common related AEs (occurring in >25% of 
subjects) were diarrhea (58 subjects, 67%), nausea (32 subjects, 37%), and fatigue (30 
subjects, 35%). Most related AEs were reported as Grade 1 or 2. 
AEs of Special Interest 
The following events are discussed in detail as they describe the most commonly reported 
class of AEs or provide more detailed information about particular types of adverse 
events.  
Gastrointestinal (GI toxicity)  
The most commonly reported GI toxicities (>15% incidence) include diarrhea, nausea, 
abdominal pain, vomiting, dry mouth, and constipation. These AEs are mostly Grade 1 to 
2 and manageable with available supportive medications. 


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36 
Infusion-Related Reactions 
Treatment with AT13387 may be associated with local infusion-related irritation, as well 
as systemic infusion reactions, which occur either during the infusion or shortly 
afterwards. The local infusion site events may be formulation-related (pH of current 
formulation ~4.2). Systemic reactions are reversible and are often characterized by 
flushing, itching, rigors, chills, nausea, tachycardia/bradycardia, alterations in blood 
pressure and dizziness. The incidence of these reactions increases at higher dose levels 
and the severity of their effects may be reduced by slowing the infusion or with additional 
hydration or premedication with dexamethasone, antihistamines and 5HT3 antagonists.  
Visual Disturbances and Ocular Adverse Events  
A range of visual disturbances (collectively grouped under the MedDRA preferred term 
of Visual Impairment) have been reported in subjects receiving AT13387 in phase 1-2 
trials. These include peripheral flashes (photopsia), blurred or double vision, floaters, 
color distortion and dimness, difficulties with light/dark accommodation, tunnel vision or 
other field defects, halos, apparent movement of stationary objects, and complex 
disturbances. The symptoms were generally Grade 1 in severity, intermittent, reversible 
and transient, lasting a few seconds to a few minutes and occurring on 1 to 3 days per 
cycle. The onset was generally in the first cycle, although in some subjects, the onset was 
in the first half of the second cycle.  The symptoms were more frequent in the evening or 
at night and generally did not interfere with activities of daily living. Visual symptoms 
were dose-related and most frequently reported in subjects treated with 120 mg/m2 twice-
weekly in the AT13387-01 trial (11/13 subjects; 85%), compared with around half the 
subjects treated with 150 mg/m2 or 180 mg/m2 weekly and 5 of 7 subjects (71%) treated 
with 220 mg/m2 weekly. Dry eyes, eye pain and keratitis have been reported but these 
events appear to be much less frequent with AT13387 than visual disturbances (and also 
less frequent than xerostomia).  
 
Visual disturbances have been reported as side effects of treatment with a range of HSP90 
inhibitors and thus appear to be a class effect. The mechanism is not well understood but 
nonclinical data suggest that it may be due to effects on retinal pigment epithelial cells, 
which are essential for the physiological function of adjacent photoreceptors. Normal 
conjunctival epithelium expresses abundant HSP90, and HSP90 inhibition has also been 
associated with dry eyes, conjunctivitis, keratitis and ocular surface disease. 
Other Toxicities 
Other common AEs (>15% incidence) with AT13387 include fatigue, decreased appetite, 
dizziness, anemia, headache, muscle spasms, insomnia, chills, dehydration, and 
hyperhidrosis. Two cases of renal adverse events (1 Grade 4 and another Grade 2) were 
reported in combination with imatinib. The subjects had borderline serum creatinine at 
baseline and other concomitant conditions/medications that might have contributed to 
these events including dehydration as a result of vomiting and diarrhea. Finally, 1 subject 
had asymptomatic Grade 2 QTc prolongation (in combination with imatinib), and another 
subject had reversible decreased LVEF, Grade 2.  
 
2.3 
Rationale 
 


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Vemurafenib is FDA approved for the treatment of advanced, BRAF-mutant melanoma after it 
was shown to improve overall survival when compared with dacarbazine in patients with 
advanced melanoma. (Chapman et al., 2011) Dabrafenib, a selective BRAF inhibitor structurally 
unrelated to vemurafenib, also achieves significant improvements in clinical response rate and 
progression-free survival compared to chemotherapy; findings that led to its FDA-approval in 
2013. (Hauschild et al., 2012)  While these results have been significant, there remain critical 
limitations to the activity of these agents.  Specifically, clinical resistance develops in most 
patients within one year, and the median progression free survival in these patients is 
approximately six months and durable remissions are uncommon. (Sosman et al., 2012; 
Chapman et al., 2011; Hauschild et al., 2012).  
 
Studies suggest that resistance to BRAF inhibitors is mediated by multiple mechanisms, 
including reactivation of the mitogen activated protein kinase (MAPK) pathway in many 
patients, while others show evidence of upregulation of other pro-survival signaling pathways 
[i.e. phosphoinositide-3-kinase (PI3K) pathway]. (Bollag et al., 2010; Johannessen et al., 2010; 
Nazarian et al., 2010; Montagut et al., 2008; Poulikakos et al., 2011; Shi et al., 2012; Villanueva 
et al., 2010; Emery et al., 2009; Wagle et al., 2011) Recently, promising clinical results have 
been observed with the combination of BRAF and MEK inhibitors. (Flaherty et al., 2012 #2) In 
a randomized phase II trial, 162 patients were randomized to receive either single-agent 
dabrafenib, the combination of dabrafenib 150 mg twice daily and trametinib 1 mg daily, or the 
combination of dabrafenib 150 mg twice daily and trametinib 2 mg daily.  At the highest dose 
level, the response rate was significantly higher (76%) than the combination with the lower 
trametinib dose (50%) and monotherapy (54%).  Interestingly, the median PFS for both 
combination arms was significantly longer than monotherapy (9.4 v 9.2 v 5.8 months).  
Supporting this proof of concept, two additional BRAF/MEK inhibitor combinations that have 
been evaluated in phase I clinical trials and shown promising results.  The first is the 
combination of vemurafenib with the MEK inhibitor cobimetinib.  In this phase I/II study, 
combination therapy has been associated with a response rate of 86% in patients with BRAF 
mutant melanoma.  Similarly, the combination of the BRAF inhibitor LGX818 and the MEK 
inhibitor MEK162 is associated with a high response rate in BRAF inhibitor naïve patients (8 of 
9 responders), though relatively few patients have been treated with this combination. Still, many 
patients develop resistance, and the median PFS on combination therapy is only a few months 
longer than BRAF inhibitor monotherapy. 
 
Unfortunately, there is no known effective, standard of care treatment for patients with BRAF 
inhibitor resistant melanoma. In particular, the use of the other recently approved therapy, 
ipilumumab, appears to be uniquely ineffective in patients who have developed disease 
progression on vemurafenib,  (Ascierto et al 2012. Ackerman et al. 2014)  In addition, it is very 
difficult to enroll these patients onto clinic trials that require BRAF inhibitor washout periods 
due to the accelerated progression and short survival following BRAF inhibitor discontinuations.  
As a result, determining therapy for this hard-to-treat population of patients has become one of 
the most unmet clinical needs in the field. 
 


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38 
The described mechanisms of resistance to BRAF inhibitor therapy include both reactivation of 
the mitogen activated protein kinase (MAPK) pathway and activation of parallel growth 
signaling pathways [such as the phosphoinositide-3-kinase (PI3K) pathway].   Heat shock 
protein 90 (HSP90) serves as a molecular chaperone to a number of mediators these growth 
factor pathways and is a potential therapeutic target in the setting BRAF inhibitor resistance.  
Included among its client proteins are insulin-like growth factor 1 receptor (IGF1R), BRAF, 
CRAF, AKT, cyclin D, and cyclin dependent kinase 
4 (CDK4), all of which have been implicated in 
BRAF inhibitor resistance.  Supporting this is 
recently published data showing that the HSP 
inhibitor (HSPi) XL888 blocks growth and survival, 
in vitro and in vivo, in BRAF-mutant melanoma cell 
lines that harbor acquired resistance mechanisms to 
BRAF inhibitor including COT overexpression, 
platelet derived growth factor receptor beta 
(PDGFR-b) overexpression, concomitant BRAF and 
NRAS mutations, and cyclin D amplifications 
(Paraiso et al. 2012).  Additionally, a reduction in 
levels of a number of both client proteins and growth 
pathway mediators was seen, as was a favorable 
change in the pro- and anti-apoptotic molecules 
respectively, BIM and MCL1. 
 
AT13387 is a small molecule inhibitor of HSP90 that has been shown to be safe given both 
weekly and twice weekly (either days 1 and 4 or days 1 and 2) in patients with advanced solid 
tumors.  In melanoma cell lines, AT13387 has single agent activity in vitro in BRAF-mutant cell 
lines, including those that are sensitive and those that are resistant to a BRAF inhibitor, and 
effectively reduces HSP90 client proteins. (Figure 2.3.1) In xenograft studies, single-agent 
AT13387 has modest activity against 
BRAF-mutant melanoma cell lines. 
(Figure 2.3.2).  In combination with a 
BRAF inhibitor, AT13387 is well 
tolerated, is neither associated with 
additive activity nor antagonism in 
BRAFi sensitive cell lines, and shows 
enhanced growth inhibition compared 
to both single-agent therapies in a 
BRAF inhibitor resistant cell line. 
(Fig 2.3.2 (B))  Lastly, a reduction in 
the HSP90 client proteins BRAF, 
CRAF, AKT, cyclin D, CDK4 was 
seen with AT13387 treatment in the 
above and additional xenograft 
models using BRAF-mutant 
melanoma cell lines (Figure 2.3.3).   
 


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39 
AT13387 can overcome multiple mechanisms of BRAF inhibitor resistance, including acquired 
resistance, through its inhibitory effect on the AKT and ERK signalling pathways.  Based on this 
preclinical data with AT13387 and the published data with XL888, it is clear that HSP inhibition 
is a rational strategy for patients with BRAFi-
resistant, BRAF mutant melanoma.  
Importantly, in patients who are progressing 
on BRAF inhibitor therapy, there tends to be 
continued regression of some disease sites 
while other sites are progressing. (Long SMR)  
Ongoing BRAF inhibitor therapy in these 
patients tends to lead to continued control of 
some disease and can be effectively used as 
palliative therapy even when patients are 
dying of their disease.  Thus, it may to be 
useful to continue BRAF inhibitor therapy 
after progression. Therefore, we propose to 
study the combination of dabrafenib and 
trametinib with AT13387 in patients who have 
disease progression on BRAF inhibitor 
therapy.  Additionally, based on the xenograft 
data in 2.3.2 D showing that concomitant 
BRAF-targeted therapy with AT13387 may 
suppress the emergence of BRAF inhibitor 
resistance in tumors treated from the outset of therapy, we believe that upfront BRAF-targeted 
therapy plus AT13397 is a potentially useful strategy for BRAF targeted therapy naïve patients.   
 
2.4 
Correlative Studies Background 
 
2.4.1 Pharmacokinetic Studies 
While the pharmacokinetic data of weekly AT13387 and the combination of dabrafenib and 
trametinib are known, PK data of the triple combination will be investigated as part of the Phase 
I portion of this study. Clinically observed toxicities will be correlated with the possibility of 
delayed clearance of the individual agents.  
The PK sampling regimen for this study is based on the following observations; steady state for 
trametinib was reached by approximately Day 15 and the Cmax and AUC for dabrafenib at the 
RP2D are about 40% lower on Day 15 versus Day 8.  In addition, accumulation of trametinib 
was observed in the combination study of trametinib and dabrafenib.   
Measurement of drug levels of AT13387, dabrafenib, and trametinib will be performed on Cycle 
1 day 15 of three-drug treatment (pre-, 1, 2, 4, 6, and 8 hours after dosing), and Cycle 1 day 16 
(24 hours after AT13387 day 15 dosing). Samples for trough level PK analysis will then be 
planned for each patient on day 1 of cycles 2, 4, 8, and 12. 
 
2.4.2 Biomarkers of Drug Effect 
 


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Although we do not yet know which HSP90 client proteins must be degraded in order for long 
term anti-tumor responses to be seen to the BRAF/MEK/HSP90 inhibitor combination, 
preliminary studies from our group and others suggests that the PI3K/AKT/mTOR pathway may 
be critical for the short-term adaptive responses to BRAF inhibition and that prolonged inhibition 
of the Raf/MEK/ERK/CDK4/Cyclin D1 pathway is required for durable anti-tumor response. 
Levels of HSP90 client proteins, HSP chaperones and other proteins involved in adaptive 
signaling responses will be measured using LC-MRM from FNAs taken from accessible 
melanoma lesions before therapy initiation and after 7-10 days of BRAF/MEK/HSP90 treatment. 
 
Additionally, biopsy specimens will be evaluated by Reverse Phase Protein Array (RPPA) at 
RPPA Core Facility, Functional Proteomics, MD Anderson Cancer Center (Texas, USA). 
Primary targets of interest for analysis of AT13387 effect on relevant HSP90 client proteins in 
tumor biopsy tissue will be evaluated. Frozen biopsy specimens obtained during collection will 
be sent for analysis of relevant proteins, protein post-translational modifications 
(phosphorylation and other modifications) and effects on relevant signaling pathways.  
 
2.4.3 Blood Based BRAF Assay 
Our group has developed a blood-based assay that can measure circulating BRAF levels in 
patients with BRAF mutant melanoma. (Panka et al., 2010; Panka et al., 2014) Our data shows 
that the BRAF level is reduced in patients treated with BRAF-directed therapy (both single-agent 
vemurafenib and the combination of DT) and, in some patients, increases in advanced of clinical 
or radiographic progression by 40-60 days. (Panka et al., 2014) As this assay remains under 
clinical development, we plan to measure serial values (pre-treatment and at the beginning of 
each cycle) to further interrogate the utility of this assay.  All samples will be initially processed 
in the Translational Research Laboratory at MGH and then subsequently assayed at the BIDMC. 
 
3. PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have histologically confirmed, BRAF-mutant (V600E/K) solid tumor  
(molecularly confirmed using Cobas assay or a comparable FDA-approved assay) that is 
metastatic or unresectable, have received and tolerated prior BRAF or BRAF and MEK 
inhibitor (BRAF targeted) therapy at full dose or not previously received BRAF targeted 
therapy, and for which standard curative measures do not exist or are no longer effective.   
 
• If test at CLIA-certified lab used a non-FDA approved method, information about the 
assay must be provided.  (FDA approved tests for BRAF V600 mutations in melanoma 
include:  THxID BRAF Detection Kit and Cobas 4800 BRAF V600 Mutation Test). 
 
3.1.2 Patients must have measurable disease, defined as at least one lesion that can be 
accurately measured in at least one dimension (longest diameter to be recorded for non-
nodal lesions and short axis for nodal lesions) as ≥20 mm with conventional techniques 
or as ≥10 mm with spiral CT scan, MRI, or calipers by clinical exam.  See Section 11 for 
the evaluation of measurable disease. 
 


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41 
3.1.3 Prior therapy is allowed. Patients may have received any number of prior lines of therapy, 
including treatment with a BRAF and/or MEK inhibitor.   
 
3.1.4 All prior anti-cancer treatment-related toxicities must be less than or equal to Grade 1 
according to the Common Terminology Criteria for Adverse Events version 5 (CTCAE 
version 5.0; NCI,2017) at the time of enrollment. A notable exception are 
endocrinopathies caused by immune checkpoint inhibitors that are appropriately treated 
with medical management (e.g. hormone replacement therapy, anti-diabetic agents) 
 
3.1.5 Age ≥18 years.  Because no dosing or adverse event data are currently available on the 
use of AT13387 in combination with dabrafenib and trametinib in patients <18 years of 
age, children are excluded from this study, but will be eligible for future pediatric trials. 
 
3.1.6 ECOG performance status ≤1 (Karnofsky ≥70%, see Appendix A). 
 
3.1.7 Life expectancy of greater than 3 months. 
 
3.1.8 Patients must have normal organ and marrow function as defined below: 
 
− 
leukocytes 
≥3,000/mcL 
− 
absolute neutrophil count 
≥1,200/mcL 
− 
hemoglobin 
 
 
> 9 g/dl (patients may be transfused to this level) 
− 
platelets 
≥ 100,000/mcL 
− 
total bilirubin 
< 1.5 x institutional upper limit of normal 
 
 
 
 
 
 
 
 
 
 
OR 
> 1.5 x institutional upper limit of normal allowed if 
direct bilirubin is within normal range. 
− 
AST(SGOT)/ALT(SGPT) 
≤ 2.5 x institutional upper limit of normal 
− 
PT/INR and PTT  
 
< 1.3 x ULN 
− 
Serum creatinine 
≤1.5 mg/dL 
OR 
− 
creatinine clearance 
≥50 mL/min/1.73 m2  
− 
Potassium  
 
 
>3 and <5.5mEq/L 
− 
Magnesium  
 
 
>1.2 and <2.5mEq/L 
− 
Left ventricular   
≥ institutional lower limit of normal (LLN) by ECHO 
   ejection fraction  
 


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3.1.9 The effects of AT13387, dabrafenib, and trametinib on the developing human fetus are 
unknown.  For this reason, women of child-bearing potential must have a negative serum 
pregnancy test within 14 days prior to randomization and agree to use effective 
contraception (barrier method of birth control, or abstinence; hormonal contraception is 
not allowed due to drug-drug interactions which can render hormonal contraceptives 
ineffective) from 14 days prior to randomization, throughout the treatment period, and 
for 4 months after the last dose of study treatment.  Should a woman become pregnant or 
suspect she is pregnant while she is participating in this study, she should inform her 
treating physician immediately.   
 
Based on studies in animals, it is also known that dabrafenib may cause damage to the 
tissue that makes sperm.  This may cause sperm to be abnormal in shape and size and 
could lead to infertility, which may be irreversible. 
 
Safety and efficacy of the combination of dabrafenib and trametinib in pediatric 
populations have not been investigated.  Dabrafenib or trametinib-dabrafenib 
combination should not be administered to pediatric populations outside clinical trials. 
 
3.1.10 Therapeutic level dosing of warfarin can be used with close monitoring of PT/INR by the 
site.  Exposure may be decreased due to enzyme induction when on treatment, thus 
warfarin dosing may need to be adjusted based upon PT/INR.  Consequently, when 
discontinuing dabrafenib, warfarin exposure may be increased and thus close monitoring 
via PT/INR and warfarin dose adjustments must be made as clinically appropriate.  
Prophylactic low dose warfarin may be given to maintain central catheter patency. 
 
3.1.11 Ability to understand and the willingness to sign a written informed consent document. 
 
3.1.12 Able to swallow and retain oral medication, and must not have any clinically significant 
gastrointestinal abnormalities that may alter absorption such as malabsorption syndrome 
or major resection of the stomach or bowels 
 
3.2 
 Exclusion Criteria 
 
3.2.1 Patients who received prior systemic anti-cancer therapy (chemotherapy with delayed 
toxicity, extensive radiation therapy, immunotherapy, biologic therapy, or vaccine 
therapy) within the last 3 weeks prior to Day 1 of Cycle 1. Patients are permitted to be on 
dabrafenib and trametinib standard of care at start of therapy without wash-out period 
prior to Day 1 of Cycle 1. Dosing will change to protocol determined dose levels on Day 
1 of Cycle 1.  
 
3.2.2 Patients must not have received prior HSP90 inhibitor therapy.  
 
3.2.3 Patients who are receiving any other investigational agents. Patients who have taken an 
investigational drug within 28 days or 5 half-lives (minimum 14 days), whichever is 
shorter, prior to randomization.  
 


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43 
3.2.4 Patients with history of RAS mutation positive tumors regardless of interval from current 
study. However, patients may have concurrent BRAFV600 and RAS mutations in the 
tuor to be treated with protocol therapy. 
 
3.2.5 Patients must have no clinical evidence of leptomeningeal or brain metastasis causing 
spinal cord compression that are symptomatic or untreated or not stable for ≥ 4 weeks 
(must be documented by imaging) or requiring corticosteroids.  Subjects on a stable dose 
of corticosteroids >1 month or who have been off of corticosteroids for at least 2 weeks 
can be enrolled with approval of the CTEP medical monitor.  Subjects must also be off of 
enzyme-inducing anticonvulsants for >4 weeks.  
 
3.2.6 History of known immediate or delayed hypersensitivity reactions reactions attributed to 
compounds of similar chemical or biologic composition to AT13387, dabrafenib, or 
trametinib, or excipients or to dimethyl sulfoxide (DMSO). 
 
3.2.7 Uncontrolled intercurrent illness including, but not limited to, ongoing or active serious 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia, uncontrolled diabetes, or psychiatric illness/social situations that would limit 
compliance with study requirements. 
 
3.2.8 Pregnant women are excluded from this study because AT13387, dabrafenib, and 
trametinib may have teratogenic or abortifacient effects.  Because there is an unknown 
but potential risk for adverse events in nursing infants secondary to treatment of the 
mother with the study drugs, breastfeeding should be discontinued prior to the mother 
being treated with the study drugs.   
 
3.2.9 Patients known to be HIV-positive patients and on combination antiretroviral therapy are 
ineligible because of the potential for pharmacokinetic interactions with the study drugs.  
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. 
 
 
3.2.10 History of another malignancy other than the study indication under this trial within 5 
years of study enrollment. Does not apply to subjects who underwent successful 
definititive resection of basal or squamous cell carcinoma of the skin, superficial bladder 
cancer, in situ cervical cancer, in situ breast cancer, or other in situ cancers.   
 
Exception:  Patients with history of RAS mutation-positive tumors are not eligible 
regardless of interval from the current study.   Prospective RAS testing is not required. 
However, if the results of previous RAS testing are known, they must be used in 
assessing eligibility.  
 
3.2.11 History of interstitial lung disease or pneumonitis. 
 
3.2.12 History or current evidence/risk of retinal vein occlusion (RVO) or retinal pigment 
epithelial detachment (RPED): 
 


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44 
− 
History of RVO or RPED, or predisposing factors to RVO or RPED (e.g., 
uncontrolled glaucoma or ocular hypertension, uncontrolled systemic disease such as 
hypertension, diabetes mellitus, or history of hyperviscosity or hypercoagulability 
syndromes). 
− 
Visible retinal pathology as assessed by ophthalmic exam that is considered a risk 
factor for RVO or RPED such as evidence of new optic disc cupping, evidence of 
new visual field defects, and intraocular pressure >21 mm Hg. 
 
3.2.13 History or evidence of cardiovascular risk including any of the following: 
− 
An average of the three most recent QT intervals corrected for heart rate using the 
Bazett’s formula QTcB ≥460 msec. 
− 
History or evidence of current clinically significant uncontrolled arrhythmias 
(exception:  patients with controlled atrial fibrillation for >30 days prior to 
randomization are eligible). 
− 
History of acute coronary syndromes (including myocardial infarction and unstable 
angina), coronary angioplasty, or stenting within 6 months prior to randomization. 
− 
History or evidence of current ≥ Class II congestive heart failure as defined by the 
New York Heart Association (NYHA) functional classification system 
− 
Treatment-refractory hypertension defined as a blood pressure of systolic >140 
mmHg and/or diastolic >90 mmHg which cannot be controlled by anti-hypertensive 
therapy. 
− 
Abnormal cardiac valve morphology (≥grade 2) documented by echocardiogram 
(subjects with grade 1 abnormalities [i.e., mild regurgitation/stenosis] can be entered 
on study).  Subjects with moderate valvular thickening should not be entered on 
study. 
− 
Prior placement of an implantable defibrillator 
− 
History of or identification on screening imaging of intracardiac metastases 
 
3.2.14 No known active infection with Hepatitis B Virus (HBV), or Hepatitis C Virus (HCV).  
Patients with chronic or cleared HBV infection and HCV infection are eligible.   
 
3.2.15 Current use of a prohibited medication.  The following medications or non-drug therapies 
are prohibited (Please refer to Appendix F for complete list): 
− 
Other anti-cancer therapy while on study treatment.  (note:  megestrol [Megace] if 
used as an appetite stimulant is allowed). 
− 
Concurrent treatment with bisphosphonates is permitted; however, treatment must be 
initiated prior to the first dose of study therapy.  Prophylactic use of bisphosphonates 
in patients without bone disease is not permitted, except for the treatment of 
osteoporosis. 
− 
Because the composition, PK, and metabolism of many herbal supplements are 
unknown, the concurrent use of all herbal supplements is prohibited during the study 
(including, but not limited to, St. John’s wort, kava, ephedra [ma huang], ginkgo 
biloba, dehydroepiandrosterone [DHEA], yohimbe, saw palmetto, or ginseng). 


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45 
 
Current use of a prohibited medication.  Patients receiving any medications or substances 
that are strong inhibitors or inducers of CYP3A or CYP2C8 are ineligible.  Current use 
of, or intended ongoing treatment with:  herbal remedies (e.g., St. John’s wort), or strong 
inhibitors or inducers of P-glycoprotein (Pgp) or breast cancer resistance protein 1 
(Bcrp1) should also be excluded.  Below are a few examples of the agents. 
 
PROHIBITED – strong inducers of CYP3A or CYP2C8, since concentrations of dabrafenib may be 
decreased 
Class/Therapeutic Area 
Drugs/Agents 
Antibiotics 
Rifamycin class agents (e.g.,  rifampin, rifabutin, rifapentine),  
Anticonvulsant 
Carbamazepine, oxcarbazepine phenobarbital, phenytoin, s-mephenytoin  
Miscellaneous 
bosentan, St. John’s wort 
PROHIBITED – Strong inhibitors of CYP3A, or CYP2C8 since concentrations of dabrafenib may 
be increased 
Class/Therapeutic Area 
Drugs/Agents 
Antibiotics 
Clarithromycin, telithromycin, troleandomycin 
Antidepressant 
Nefazodone 
Antifungals 
Itraconazole, ketoconazole, posaconazole, voriconazole 
Hyperlipidemia 
Gemfibrozil  
Antiretroviral 
ritonavir, saquinavir, atazanavir 
Miscellaneous 
Conivaptan  
 
Because the lists of these agents are constantly changing, it is important to regularly 
consult a frequently-updated list such as http://medicine.iupui.edu/clinpharm/ddis/main-
table/; medical reference texts such as the Physicians’ Desk Reference may also provide 
this information.  As part of the enrollment/informed consent procedures, the patient will 
be counseled on the risk of interactions with other agents, and what to do if new 
medications need to be prescribed or if the patient is considering a new over-the-counter 
medicine or herbal product.  Appendix C is a patient information sheet that can be used 
for this specific protocol and presented to the patient. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial.  BRAF mutant 
melanoma is more common in Caucasians and women, though metastatic melanoma is more 
common in men. 
 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
 
Males 
 
Total 
Hispanic or Latino 
1 
+ 
1 
= 
2 
Not Hispanic or Latino 
18 
+ 
18 
= 
36 
Ethnic Category: Total of all subjects 
19 
(A1) + 
19 
(B1) = 
38 
(C1) 


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46 
Racial Category 
 
American Indian or Alaskan Native 
0 
+ 
0 
= 
0 
Asian 
1 
+ 
1 
= 
2 
Black or African American 
0 
+ 
0 
= 
0 
Native Hawaiian or other Pacific 
Islander 
0 
+ 
0 
= 
0 
White 
18 
+ 
18 
= 
36 
Racial Category: Total of all subjects 
19 
(A2) + 
19 
(B2) = 
38 
(C2) 
 
(A1 = A2) 
 
(B1 = B2) 
 
(C1 = C2) 
 
 
4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Any laboratory values 
(chemistry and hematology) that are taken on C1D1 must re-meet eligibility in order for 
participants to receive treatment. Issues that would cause treatment delays should be discussed 
with the Overall Principal Investigator (PI). If a participant does not receive protocol therapy 
following registration, the participant’s registration on the study must be canceled. Registration 
cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
 
 
4.3 
General Guidelines For Other Participating Institutions 
 
Eligible participants will NOT be registered on study by the Coordinating Center.  A designee 
from the institution will register patients with Theradex via the online slot reservation system, 
Interactive Web Response System (IWRS). 
 
Prior to registration, a Site Investigator will confirm eligibility of prospectives participants for all 
inclusion/exclusion criteria.   
 


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Following registration, participants should begin protocol treatment. Any laboratory values 
(chemistry and hematology) that are taken on C1D1 must re-meet eligibility in order for 
participants to receive treatment. Issues that would cause treatment delays should be discussed 
with the Principal Investigator/Sponsor. If a participant does not receive protocol therapy 
following registration, the participant’s protocol status must be changed. The Coordinating 
Center should be notified of participant status changes as soon as possible. 
 
4.4 
Registration Process For Other Participating Institutions 
 
External sites will only be registering patients to the protocol with Theradex via IWRS and not 
with with DF/HCC.  Sites will follow any site-specific processes as applicable. 
The registration procedures are as follows: 
 
• Obtain written informed consent from the participant prior to the performance of any 
protocol specific procedures or assessments.  
 
• Verify all protocol eligibility criteria. To be eligible for registration to the protocol, the 
participant must meet all inclusion and exclusion criterion as described in the 
protocol.  
 
Reminder: Confirm eligibility for ancillary studies at the same time as eligibility for the 
treatment protocol. Registration to both treatment and ancillary protocols will not be 
completed if eligibility requirements are not met for all studies.  
 
• Designeed will register patient with Theradex via IWRS. 
 
5. TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis.  A cycle of treatment will be 28 days in 
length. IV administration will begin approximately the same time oral agents are dosed, but not 
more than 10 minutes after oral agents are taken.  For Cycle days 8 and 15, patients will be 
instructed to bring oral agents with them to be given in the clinic.  Patients are asked to maintain 
a medication diary for recording each dose of Dabrafenib and Trametinib (Appendix D). 
Reported adverse events and potential risks are described in Section 7.  Appropriate dose 
modifications are described in Section 6.  No investigational or commercial agents or therapies 
other than those described below may be administered with the intent to treat the patient's 
malignancy. The patient will be requested to maintain a medication diary of each dose of 
medication.  The medication diary (Appendix D) and pill bottles will be returned to clinic staff at 
the end of each course.  To document compliance, a pill count will be performed of all unused 
pills. 
Dosing levels for the study are listed below in Table 5.1. Dose level 1 will be the first dose level. 
Intrapatient dose escalation will be allowed when safe and feasible once the next higher dose 
level has been cleared. Additional, intermediate dose levels may be enrolled under the following 


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conditions:  
1) Toxicity is seen at a dose level where dose modification is necessary and the prior, lower 
dose level was treated without DLT or analysis of the PK data suggests that an 
intermediate dose would be appropriate;  
2) An intermediate dose is conceivable based on the size of pills and nature of the toxicity at 
the higher dose;  
3) Consensus agreement is made between investigators, industry sponsors, and CTEP;  
4) CTEP and IRB approval of an amendment to the protocol that clearly describes the 
rationale for and the logistics of the intermediate dose level.   
 
Table 5.1 Dose Escalation Levels for Phase I Study 
Dose Level 
Dabrafenib 
[BID/PO] 
Trametinib 
[QD/PO] 
AT13387 
[D1,8,15/IV] 
-1 
75 mg 
1 mg  
180 mg/m2  
1 
150 mg 
1 mg  
180 mg/m2  
2 
150 mg 
2 mg  
180 mg/m2  
3 
150 mg  
2 mg  
220 mg/m2  
4 
150 mg  
2 mg  
260 mg/m2  
 
5.1.1 Trametinib 
The effect of food on trametinib absorption is unknown.  The current recommendation is 
to administer trametinib on an empty stomach, either 1 hour before or 2 hours after a 
meal; the recommendation to administer trametinib fasting may change based on 
emerging data.  Missed doses of trametinib should not be made up if there is less than 12 
hours until the next scheduled dose. Vomited doses of trametinib should not be made up. 
 
In the event that dabrafenib, AT13387, or both agents need to be discontinued due to 
toxicity reasons, treatment with trametinib may continue at the discretion of the 
investigator until time of disease progression. 
 
5.1.2 Dabrafenib 
Patients should take dabrafenib at least 1 hour prior to or 2 hours after a meal due to a 
potential food effect on dabrafenib absorption.  Doses should be taken every 12 hours. 
Missed doses of dabrafenib should not be made up if it is less than 6 hours until the next 
scheduled dose (section 8.1.2). Vomited doses of dabrafenib should not be made up. 
 
In the event that trametinib, AT13387, or both agents need to be discontinued due to 
toxicity reasons, treatment with dabrafenib may continue at the discretion of the 
investigator until time of disease progression. 
 
5.1.3 AT13387 
AT13387 is dosed in mg/m^2 using institutional standard of practice for dose 
calculations. AT13387 is administered via Infusion. Infuse over 1 hour through a central 
line or a well-defined peripheral vein (Note: an in-line filter is NOT required). If use a 
peripheral line, be sure to aspirate venous blood prior to starting the infusion.  Check the 


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infusion site every 15 minutes and change the site of infusion should evidence of swelling 
or discoloration is observed. If AT13387 cannot be administered on Cycle Day 8 or 15, 
the dose will be skipped and not delayed. 
 
If patient experiences pain along the infusion site, slow the infusion rate (i.e. > 1 hour 
duration) and/or infuse D5W through a “Y” connector.  The additional volume of D5W 
dilutes AT13387 concentration at the local site of the infusion and alleviates the irritation. 
 
In the event that trametinib, dabrafenib, or both agents need to be discontinued due to 
toxicity reasons, treatment with AT13387 may continue at the discretion of the 
investigator until time of disease progression. 
 
5.2 
Definition of Dose Limiting Toxicity 
 
Dose-limiting toxicity (DLT) is based on the CTEP Active Version 5 of the NCI Common 
Terminology Criteria for Adverse Events (CTCAE). DLT refers to toxicities experienced during 
the first cycle of treatment between days 1-28. A DLT must 
be considered to be at least possibly related to study drug(s) will be defined as follows: 
• Any grade 4 toxicity 
• Grade 3 (or grade 2 intolerable) non-hematologic toxicity 
• Grade ≥ 3 neutropenia with fever > 38.5°C 
• Grade 3 thrombocytopenia with clinically significant bleeding 
• Furthermore, grade 2 intolerable/grade 3 fatigue that results in hospitalization should be 
considered a DLT.  
• Intolerable AEs are toxicities deemed to lead to a missing dose of AT13387 or more than 
25% of dabrafenib/trametinib in the first cycle. 
 
In general, all Grade 3 or intolerable grade 2, non-hematological toxicities regardless of duration 
are considered DLT. However, the following Grade 3 toxicities will not be considered a DLT. 
• The appearance of cutaneous squamous cell carcinoma or keratoacanthoma will not be 
considered a dose limiting toxicity as these are commonly observed with dabrafenib. 
• Grade 3 fatigue persistent for < 7 days 
• Grade 3 nausea, vomiting, or diarrhea persisting < 72 hours with maximum supportive 
care 
• Grade 3 electrolyte events if they are resolved with replacement within 24 hours   
• Lymphopenia regardless of grade  
• The following grade 3 laboratory abnormalities will not be considered dose limiting if 
they return to baseline within 7 days: elevated bilirubin, AST, ALT, cholesterol, amylase, 
lipase, creatinine and hypertriglyceridemia 
Management and dose modifications associated with the above adverse events are outlined in 
Section 6. 
 
Dose escalation will proceed within each cohort according to the following scheme.  Dose-
limiting toxicity (DLT) is defined above. 
 


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50 
 
Table  5.2. Dose escalation table 
 
 
 
 
 
 
 
 
 
 
 
5.3 
General Concomitant Medication and Supportive Care Guidelines 
 
5.3.1 Trametinib 
 
Because there is a potential for interaction of trametinib with other concomitantly administered 
drugs through the cytochrome P450 system, the case report form must capture the concurrent use 
of all other drugs, over-the-counter medications, or alternative therapies.  The Principal 
Investigator should be alerted if the patient is taking any agent known to affect or with the 
potential to affect selected CYP450 isoenzymes.   
 
5.3.2 Dabrafenib 
 
Because there is a potential for interaction of dabrafenib with other concomitantly administered 
drugs through the cytochrome P450 system, the case report form must capture the concurrent use 
of all other drugs, over-the-counter medications, or alternative therapies.  The Principal 
Investigator should be alerted if the patient is taking any agent known to affect or with the 
potential to affect selected CYP450 isoenzymes.  Appendix C is a patient information sheet that 
can be used for this specific protocol and presented to the patient. 
 
Dabrafenib mesylate is a substrate for CYP 3A4, 2C8, p-glycoprotein (Pgp), and breast 
carcinoma resistance protein (Bcrp). Strong inhibitors/inducers of these enzymes and 
transporters are prohibited for eligibility and during the study. 
 
Mild or moderate inhibitors/inducers of CYP 3A4, 2C8, Pgp, and Bcrp should be used with 
caution as dabrafenib serum concentrations may be altered. Because the lists of these agents are 
constantly changing, it is important to regularly consult a frequently-updated list such as 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical reference texts such as the 
Physicians’ Desk Reference may also provide this information.   
 
Number of Patients with DLT 
at a Given Dose Level 
 
Dose Escalation Rule 
 
0 out of 3 
 
Proceed to the next dose level and enroll 3 patients 
1 out of 3 
Enroll and treat 3 additional patients at this dose level. 
 
> 2 out of 3 
Dose escalation will be stopped.  The MTD will be one dose 
below this dose level. Three (3) additional patients will be 
entered at the next lower dose level if only 3 patients were 
treated previously at that dose.  
1 out of 6 
oceed to the next dose level. 
≥ 2 out of 6 
Dose escalation will be stopped.  The MTD will be one dose 
below this dose level. Three (3) additional patients will be 
entered at the next lower dose level if only 3 patients were 
treated previously at that dose. 
If ≥2/3 or ≥2/6 patients at dose level 1 experience dose limiting toxicities, dose level -1 will be 
enrolled.  If dose level -1 proves too toxic, the study will stop. 


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Dabrafenib may induce CYP 3A4, 2B6, and possibly 2C8/9 and 2C19.  Use concomitant 
medications that are substrates of these isoenzymes with caution as there may be loss of efficacy. 
Substitute with other medications that are not affected if possible. 
 
5.3.3 AT13387 
 
AT13387 does not induce of inhibit the cytochrome P450 system, however the concurrent use of 
all other drugs, over-the-counter medications, or alternative therapies must be captured in the 
case report form. AT13387 is a substrate of UGT with a relatively low affinity for UGT 
isoforms. In vitro data demonstrate that AT13387 is a weak inhibitor of UGT1A1, UGT1A3 and 
UGT1A9. AT13387 is also a weak inhibitor of CYP1A2, -3A4, -2D6, -2C9 and -2C19. 
AT13387 metabolizes primary via the glucuronidation, sulphation and N-oxidation. Use caution 
in patients taking CYP1A2, -3A4, -2D6, -2C9, -2C19 and UGT1A1, -3,-9 substrates with narrow 
therapeutic ranges. Caution should be exercised with all medications known to cause QTc 
prolongation or renal impairment since these events have been reported in previous studies with 
AT13387. 
 
Supportive treatment should be given as per the institution standards and at the Investigator’s 
discretion. In the presence of systemic infusion reactions, the infusion may be diluted to 500 mL 
and/or premedication given before subsequent infusions based on the systemic reaction 
symptoms (acetaminophen/paracetamol; antihistamines, dexamethasone, or similar agents for 
allergic manifestations; IV ondansetron or similar agents for nausea/vomiting).  Antiemetics, 
anti-diarrheal agents, etc. may be given to treat or prevent gastrointestinal toxicities.  
 
Subjects are advised not to drive or operate heavy machinery until they see how they react to the 
injections in terms of development of visual changes (i.e., at least during the first cycle of 
treatment).  
 
5.4 
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue until one of 
the following criteria applies: 
 
• 
Disease progression, 
 
• 
Intercurrent illness that prevents further administration of treatment, 
 
• 
Unacceptable adverse event(s), 
 
• 
Patient decides to withdraw from the study, or 
 
• 
General or specific changes in the patient's condition render the patient unacceptable 
for further treatment in the judgment of the investigator. 
 
The reason for removal from study treatment will be documented in the Case Report Form. 


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5.5 
Duration of Follow Up 
 
Patients removed from study treatment due to progressive disease will be followed for 4 weeks 
(28 days) after removal from study treatment or until death, whichever occurs first.  Patients 
removed from study treatment for any reason other than progressive disease will be followed 
until disease progression or death, whichever occurs first. Patients removed from study for 
unacceptable adverse event(s) will be followed until resolution or stabilization of the adverse 
event or progressive disease, whichever occurs last. All patients will be asked to come to clinic 
for a follow-up visit 28 days (+/- 3 days) after last study treatment. 
 
5.6 
Criteria for Removal from Study 
 
Patients will be removed from study upon completion of the follow-up phase (section 5.5), death 
or withdrawal of consent.  The reason for study removal and the date the patient was removed 
must be documented in the Case Report Form. 
 
6. DOSING DELAYS/DOSE MODIFICATIONS 
 
The criteria for dose modification of dabrafenib, trametinib, and AT13387 are detailed below.  In 
the setting of toxicities of sufficient severity justifying dose modification, every effort will be 
made to identify the related medication.  In the setting where the offending agent is difficult to 
determine, dose modification will occur with each agent. 
 
6.1 
Dabrafenib or Dabrafenib + Trametinib Dose Modifications 
 
The tables below outline the dose levels to be used for any necessary dabrafenib and trametinib 
dose modifications in studies which include the combination: 
 
Current Dose Dabrafenib 
If Dose Reduction Required 
Reduce To 
150mg BID 
→ 
100mg BID 
100mg BID 
→ 
75mg BID 
75mg BID 
→ 
50 mg BID 
50 mg BID 
→ 
Discontinue dabrafenib 
 
Current Dose Trametinib 
If Dose Reduction Required 
Reduce To 
2mg QD 
→ 
1.5mg QD 
1.5mg QD 
→ 
1.0mg QD 
1.0mg QD 
→ 
Discontinue trametinib 
 
 
Dabrafenib + Trametinib Dose Modification Guidelines 
 
If an AE resolves to grade 1 or baseline at the reduced dose level, and no additional toxicities are 
seen after 4 weeks of study treatment at the reduced dose, the dose may be increased to the 
previous dose level.  A dose reduction below 50 mg BID for dabrafenib is not allowed.  For 


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dabrafenib-trametinib combination, dose below 1 mg once daily for trametinib is not allowed; 
however, if dabrafenib will be permanently discontinued for dabrafenib-related toxicities, the 
patients will be allowed to continue trametinib and AT13387 Conversely, if trametinib is 
permanently discontinued for trametinib-related toxicities,  patients will be allowed to continue 
dabrafenib and AT13387. 
 
CTEP Medical Monitor approval is required to restart study treatment after ≥28 days of dose 
interruption. 
 
The dose modifications may involve one or both agents, and should be based on the nature, 
severity and attributions of the AEs.  General guidelines are provided below, with details 
stipulated in subsequent sections.  CTEP drug monitors should be consulted if there are questions 
about the attribution of AEs and how the doses should be modified.     
 
In the event that AT13387 needs to be discontinued due to toxicity reasons, treatment with 
dabrafenib and trametinib may continue at the discretion of the investigator until time of disease 
progression. 
 
In the event that dabrafenib and AT13387 need to be discontinued due to toxicity reasons, 
treatment with trametinib may continue at the discretion of the investigator until time of disease 
progression. 
 
In the event that trametinib and AT13387 need to be discontinued due to toxicity reasons, 
treatment with dabrafenib may continue at the discretion of the investigator until time of disease 
progression. 
 
6.1.1 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Toxicities Not Specified 
in Subsequent Sections 
 


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Table 6-1:  Dabrafenib or Dabrafenib + Trametinib Dose Modification for 
ToxicitiesNot Specified in Subsequent Sections* 
CTCAE Grade 
Action and Dose Modification 
Grade 1  
Grade 2 (Tolerable) 
• Continue study treatment at same dose level (no dose modification). 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
Grade 2 (Intolerable) 
Grade 3 
• Interrupt study treatment. 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
• When toxicity resolves to grade 1 or baseline, restart study treatment 
reduced by one dose level. 
• If the grade 2 (intolerable) or grade 3 toxicity recurs, interrupt study 
treatment. 
• When toxicity resolves to grade 1 or baseline, restart study treatment 
reduced by another dose level. 
Grade 4 
• Permanently discontinue, or interrupt, study treatment. 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
• If study treatment was interrupted, restart with study treatment reduced 
by one dose level once toxicity resolves to grade 1 or baseline. 
•  
*If the AEs are thought to be due to one of the two agents, resumption of the other agents may be 
considered if the first agent is discontinued due to toxicities and treatment interruption is <28 days.  
CTEP monitor should be consulted for resumption of single agent.   
 
6.1.2 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Pyrexia 
 
• Pyrexia is defined as a body temperature equal to or above 38.5○ Celsius or 101.3○ 
Fahrenheit  
• Pyrexia is an adverse event associated with dabrafenib, and is increased in frequency and 
severity in subjects receiving dabrafenib in combination with trametinib.  In a minority of 
cases, pyrexia was accompanied by symptoms such as severe chills/rigors, dehydration, 
hypotension, dizziness or weakness and required hospitalization.  
Subjects should be instructed on the importance of immediately reporting febrile 
episodes.  In the event of a fever, the subject should be instructed to take anti-pyretics 
(e.g. ibuprofen or acetaminophen/paracetamol) as appropriate to control fever.  The use 
of oral corticosteroids should be considered in those instances in which anti-pyretics are 
insufficient. Monitor serum creatinine and other evidence of renal function during and 
following severe events of pyrexia. 
 
Table 6-2:  Dabrafenib or Dabrafenib + Trametinib dose Modification and 
Management Guidelines for Pyrexiaa 
Event 
Management Guideline 
Dose Modification 


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Table 6-2:  Dabrafenib or Dabrafenib + Trametinib dose Modification and 
Management Guidelines for Pyrexiaa 
Event 
Management Guideline 
Dose Modification 
Work up: 
• Clinical evaluation for infection and hypersensitivity, especially if pyrexia is complicated by rigors, severe 
chills, dehydration, etc.  
• Laboratory work-up (should include full-blood-count, electrolytes, creatinine, BUN, CRP, liver-function 
tests, blood and urine culture). 
 
Management:  
• Anti-pyretic treatment should be started immediately at the first occurrence.  Anti-pyretic treatment may 
include acetaminophen (paracetamol), ibuprofen, or suitable anti-pyretic medication per institutional 
standards.  
• Oral hydration is encouraged in subjects without evidence of dehydration.  Intravenous hydration is 
recommended if pyrexia is complicated by dehydration/hypotension. 
• In subject experiencing pyrexia complicated by rigors, severe chills, etc., which cannot be controlled with 
anti-pyretic medication, oral corticosteroids should be started. 
• Prophylactic anti-pyretic treatment is recommended after the 2nd event if pyrexia , or after the 1st event if 
complicated by rigors or severe chills. Prophylactic anti-pyretics may be discontinued after three days in 
absence of pyrexia.   
1st Eventb: 
• Clinical evaluation for infection and 
hypersensitivityc 
• Laboratory work-upc 
• Hydration as requiredd 
• Administer anti-pyretic treatment if 
clinically indicated and continue 
prophylactic treatmentf 
• Interrupt dabrafenib. 
• Continue trametinib. 
• Once pyrexia resolves to baseline, restart 
dabrafenib at the same dose level. If fever was 
associated with rigors, dehydration, hypotension, 
or renal insufficiency, reduce dabrafenib by 
one dose level. 
 
2nd Event 
• Clinical evaluation for infection and 
hypersensitivityc 
• Laboratory work-upc 
• Hydration as requiredd 
• Within 3 days of onset of pyrexia: 
− Optimize anti-pyretic therapy. 
− Consider oral corticosteroids (i.e., 
prednisone 10 mg) for at least 5 
days or as clinically indicated.f 
• Interrupt dabrafenib. 
• Continue trametinib. 
• Once pyrexia resolves to baseline, restart 
dabrafenib at the same dose level. If fever was 
associated with rigors, dehydration, hypotension, 
or renal insufficiency, reduce dabrafenib by 
one dose level. 
Subsequent 
Events:  
 
• Clinical evaluation for infection and 
hypersensitivityc 
• Laboratory work-upc 
• Hydration as requiredd 
• Blood sample for cytokine analysise 
• Within 3 days of onset of pyrexia: 
− Optimize oral corticosteroid dose 
as clinically indicated for 
recalcitrant pyrexia.g 
− If corticosteroids have been 
tapered and pyrexia recurs, restart 
steroids. 
− If corticosteroids cannot be 
tapered, consult medical monitor. 
• Interrupt dabrafenib. 
• Continue trametinib. 
• Once pyrexia resolves to baseline, restart 
dabrafenib reduced by one dose level.h 
• If dabrafenib must be reduced to <50 mg BID, 
permanently discontinue dabrafenib. 


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Table 6-2:  Dabrafenib or Dabrafenib + Trametinib dose Modification and 
Management Guidelines for Pyrexiaa 
Event 
Management Guideline 
Dose Modification 
h  Dabrafenib should be reduced by one dose level after three episodes of pyrexia which cannot be managed by 
best supportive care and increasing doses of oral steroids.  Escalation of dabrafenib is allowed if no episode of 
pyrexia is observed in the 4 weeks subsequent to dose reduction.  
 
 
6.1.3 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Rash 
 
Rash is a frequent AE observed in patients receiving trametinib, dabrafenib, or the combination 
of both therapies.  Recommendations for supportive care and guidelines for dose modifications 
for rash are based on experience with other MEK inhibitors and EGFR inhibitors (Balagula et 
al., 2010; Lacouture et al., 2011). 
 
The institutional standards for the management of skin-related AEs can differ from these 
guidelines.  In this case, best clinical judgment should be applied and a consultation with the 
study chair or the CTEP Medical Monitor may be required. 
 


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Table 6-3:  Dabrafenib or Dabrafenib + Trametinib Supportive care and Dose 
Modification for Rash 
CTCAE Grade 
Adverse Event Management 
Action and Dose Modification 
Supportive care: 
• Avoid unnecessary sun light 
• Apply broad-spectrum sunscreen (containing titanium dioxide or zinc oxide) with a skin protection factor 
(SPF) ≥15 at least twice daily. 
• Use thick, alcohol-free emollient cream (e.g., glycerine and cetomacrogol cream) on dry areas of the body at 
least twice daily. 
• Topical steroids and antibiotics should be applied at least twice daily starting on Day 1 of study treatment, to 
body areas such as face, chest, and upper back. 
• Use mild-strength topical steroid  (hydrocortisone 1% cream) or topical antibiotic (e.g., clindamycin) or oral 
antibiotics (e.g., doxycycline 100 mg BID, minocycline 100 mg BID) 
Symptom Management 
• Pruritic lesions:  cool compresses and oral antihistamines therapies. 
• Fissuring lesions:  Monsel’s solution, silver nitrate, or zinc oxide cream. 
• Desquamation:  thick emollients and mild soap. 
• Paronychia:  antiseptic bath, local potent corticosteroids in addition to oral antibiotics; if no improvement, 
consult dermatoligist or surgeon 
• Infected lesions:  appropriate bacterial/fungal culture-driven systemic or topical antibiotics. 
 
*Rash prophylaxis is recommended for the first 6 weeks of study treatment  
* Subjects who develop rash/skin toxicities should be seen by a qualified physician and should receive 
evaluation for symptomatic/supportive care management 
Grade 1 
 
• Initiate prophylactic and symptomatic 
treatment measures.1 
• Use moderate strength topical steroid.2 
• Reassess after 2 weeks. 
• Continue study treatment. 
• If rash does not recover to baseline within 2 
weeks despite best supportive care, reduce 
study treatment by one dose level.3 
Grade 2 
(tolerable) 
 
• Initiate prophylactic and symptomatic 
treatment measures.1 
• Use moderate strength topical steroid.2 
• Reassess after 2 weeks. 
• Reduce study treatment by one dose level. 
• If rash recovers to ≤ grade 1 within 2 weeks, 
increase dose to previous dose level. 
• If no recovery to ≤ grade 1 within 2 weeks, 
interrupt study treatment until recovery to ≤ 
grade 1. 
• Restart study treatment at reduced dose 
level.3 
Grade ≥3 or 
intolerable 
Grade 2 
• Use moderate strength topical steroids 
PLUS oral methyl-prednisolone dose 
pack.2 
• Consult dermatologist. 
• Interrupt study treatment until rash recovers to 
≤ grade 1. 
• Restart with study treatment reduced by one 
dose level.3,4 
If no recovery to ≤ grade 2 within 28 days, 
permanently discontinue study treatment. 
1.  Rash prophylaxis is recommended for the first 6 weeks of study treatment. 
2.  Moderate-strength topical steroids:  Hydrocortisone 2.5% cream or fluticasone priopionate 0.5% cream. 
3.  Approval of CTEP Medical Monitor is required to restart study treatment after >28 days of interruption. 
4.  Study treatment may be escalated to previous dose level if no rash is evident 4 weeks after restarting study 
treatment. 
 


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6.1.4 Dabrafenib or Dabrafenib + Trametinib Dose Modification for palmar-plantar 
erythrodysesthesia syndrome (PPES)  
 
• Lifestyle modification:  avoidance of hot water, traumatic activity, constrictive footwear, 
or excessive friction on the skin and the use of thick cotton socks and gloves, and shoes 
with padded insoles 
• Symptomatic treatments:  apply moisturizing creams frequently, topical keratolytics (e.g. 
urea 20-40 % cream, salicylic acid 6%, tazarotene 0.1% cream, fluorouracil 5% cream), 
clobetasol propionate 0.05% ointment for erythematous areas, topical lidocaine 2%, and / 
or systemic pain medication such as nonsteroidal anti-inflammatory drugs, codeine, and 
pregabalin for pain. 
 
Dose modification may also be required. – Refer to table for dose modification for non-
specific AEs 
 
6.1.5 Dabrafenib or Dabrafenib + Trametinib Dose Modification for New Primary/ Recurrent 
Malignancies: 
 
6.1.5.1 Cutaneous SCC and New Primary Melanoma 
 
Dermatologic skin assessments for subjects on treatment should be performed 
before initiation of dabrafenib, then every 2 months through treatment.  For 
protocols that start after June 2014, it is also recommended that skin exams 
should continue every 2-3 months for 6 months after discontinuation of 
dabrafenib or initiation of another anti-neoplastic therapy.  Report any new 
primary/recurrent malignancies as SAE through CTEP-AERS.       
 
Cutaneous SCC 
Cases of cuSCC (which include those classified as keratoacanthoma or mixed 
keratoacanthoma subtype) have been observed in subjects treated with 
dabrafenib.  Approximately 70 % of events occurred within the first 12 weeks of 
treatment with a median time to onset of 8 weeks. 
 
These should be surgically removed according to institutional practices.  Dose 
modification or interruption of study treatment is not required for cuSCC or KA, 
however cuSCC should be reported as an SAE (refer to Section 7.6).  In addition, 
a biopsy of the lesion should be taken, where possible, and a summary of the 
results submitted to CTEP through the SAE reporting.   
 
Patients should be instructed to immediately inform their physician if new 
lesions develop.  
 
New Primary Melanoma 
 
New primary melanomas have been reported in patients treated with dabrafenib. 
These were identified primarily within the first 5 months of therapy and did not 


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require treatment modification other than excision.  New primary melanoma 
should be reported as SAE through CTEP-AERS. 
 
6.1.5.2 Non-Cutaneous Malignancies 
In vitro experiments have demonstrated paradoxical activation of MAP-kinase 
signalling in BRAF wild type cells with RAS mutations when exposed to BRAF 
inhibitors, which may lead to increased risk of non-cutaneous malignancies in 
patients treated with dabrafenib.  Cases of RAS-driven malignancies have been 
seen with BRAF inhibitors.  Patients should be monitored as clinically 
appropriate. 
 
Permanently discontinue dabrafenib in patients who develop RAS mutation-
positive non-cutaneous malignancies.  If used in combination with trametinib, 
trametinib may continue.   
 
Following discontinuation of dabrafenib, monitoring for non-cutaneous 
secondary/recurrent malignancies should continue for up to 6 months or until 
initiation of another anti-neoplastic therapy. 
 
New non-cutaneous malignancies should be reported as a SAE. A biopsy of the 
new malignancy should be taken, where possible, and submitted for further 
analyses with the results provided to CTEP via SAE reporting.  Testing of these 
biopsies should include RAS mutation analysis and may include analysis of 
genomic alterations, which include but not limited to DNA, RNA and protein 
analysis of these biopsy specimens, and would analyze the biological pathways 
known to be associated with, and relevant to, BRAF-mutant tumor activation. 
 
         
6.1.6 Dabrafenib-Trametinib Dose Modification for Hemorrhages 
 
Table 6-4:  Dabrafenib or Dabrafenib-Trametinib Treatment Modifications for 
Hemorrhage 
Grade 3 
• Hold dabrafenib or dabrafenib-trametinib for up to 3 weeks 
• If improved, resume the drugs at one dose reduction 
• If no improvement, permanently discontinue dabrafenib or dabrafenib-
trametinib 
Grade 4 
• Permanently discontinue dabrafenib or dabrafenib-trametinib 
 
6.1.7 Dabrafenib  or Dabrafenib-Trametinib Dose Modification for Pancreatitis  
 
In the event of abdominal pain or suspected pancreatitis, amylase and lipase laboratory 
samples should be collected for confirmation of the diagnosis.  Patients should be closely 
monitored when re-starting dabrafenib after an episode of pancreatitis. 


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6.1.8 Dabrafenib  or Dabrafenib-Trametinib Dose Modification for Hyperglycemia 
 
Hyperglycemia requiring an increase in the dose of, or initiation of insulin or oral therapy 
can occur with dabrafenib. Monitor serum glucose levels as clinically appropriate during 
treatment with dabrafenib in subjects with pre-existing diabetes or hyperglycemia. 
Advise patients to report symptoms of severe hyperglycemia such as excessive thirst or 
any increase in the volume or frequency of urination. 
 
6.1.9 Dabrafenib + Trametinib Dose Modification for Renal Insufficiency 
 
Cases of renal insufficiency have occurred in patients receiving the combination of dabrafenib 
and trametinib.  Prior to start of study treatment, concomitant medications should be reviewed 
for the potential risk of inducing nephrotoxicity and modified if clinically possible. 
 
Table 6-5: Dabrafenib or Dabrafenib + Trametinib Dose Modification for Renal 
Insufficiency 
Serum Creatinine Level 
Management Guideline 
Action and Dose 
Modification 
Serum creatinine increase 
>0.2 mg/dL (18 mcmol/L) 
BUT 
≤0.5 mg/dL (44 mcmol/L) 
above baseline 
• Recheck serum creatinine within 1 week. 
• Serum creatinine increase >1 week:  contact 
CTEP Medical Monitor. If elevation 
persists beyond 4 weeks, recommend 
evaluation (consider renal biopsy) for 
etiology; consider nephrology consultation. 
• If pyrexia is present, treat pyrexia as per 
guidelines.a 
Continue study treatment at 
the same dose level. 
Serum creatinine increase 
>0.5 mg/dL (44 mcmol/L) 
OR 
>2 mg/dL (>177 mcmol/L) 
• Monitor serum creatinine ≥2-times per 
week. 
• Hospitalization may be necessary if serum 
creatinine cannot be monitored frequently. 
• If pyrexia is present, treat pyrexia per 
guidelines. a 
• Consult nephrologist if clinically indicated. 
• Perform renal biopsy if clinically indicated, 
for example: 
− Renal insufficiency persists despite 
volume repletion. 
− Patient has new rash or signs of 
hypersensitivity (such as elevated 
eosinophil count). 
• Interrupt study treatment 
until serum creatinine 
recovers to baseline. 
• Restart study treatment.b 
  
a  NSAIDs can induce renal insufficiency, especially in patients with dehydration; ;encourage oral fluids or 
consider IV fluids as clinically indicated. See guidelines for pyrexia Section 6.1.2. 
b  Investigator may restart at either the same or a reduced dose level.  Escalation of study treatment to previous 
dose level is allowed if another episode of renal insufficiency does not occur after 4 weeks of dose reduction.  
Consultation with the CTEP Medical Monitor is required before restarting study treatment if there is evidence 
of thrombotic microangiopathy. 
 


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6.1.10 Dabrafenib + Trametinib Dose Modification for Reduced Left Ventricular Ejection 
Fraction 
 
Decreases of the left ventricular ejection fraction (LVEF) have been observed in patients 
receiving dabrafenic plus trametinib.  Therefore, ECHOs/MUGAs must be performed in regular 
intervals outlined in the Study Calendar.  The same procedure (either ECHO or MUGA, although 
ECHO is preferred) should be performed at baseline and at follow-up visit(s).   
 
 
Table 6-6:  Dabrafenib + Trametinib Treatment Modification and Management 
Guidelines for LVEF Decrease 
Clinic 
LVEF-drop (%) or 
CTCAE grade 
Dose Modification 
Asymptomatic 
 
Absolute decrease of >10% in 
LVEF compared to baseline and 
ejection fraction below the 
institution’s LLN. 
• Interrupt study trametinib and repeat ECHO within 2 
weeks.a, dabrafenib may continue 
• If the LVEF recovers within 4 weeks (defined as 
LVEF ≥LLN and absolute decrease ≤10% compared 
to baseline): 
− Consult with the CTEP Medical Monitor and 
request approval for restart. 
− Restart trametinib at reduced doses by one dose 
level. Continue dabrafenib at current dose. 
− Repeat ECHO 2, 4, 8, and 12 weeks after re-start; 
continue in intervals of 12 weeks thereafter. 
• If LVEF does not recover within 4 weeks: 
− Consult with cardiologist. 
− Permanently discontinue trametinib.  
− Once LVEF recovers, resumption of dabrafenib 
may be considered after consultation with CTEP. 
− Repeat ECHO after 2, 4, 8, 12, and 16 weeks or 
until resolution. 
− Report as SAE 
Symptomaticb 
 
• Grade 3:  resting LVEF 39-20% 
or >20% absolute reduction from 
baseline 
• Grade 4:  Resting LVEF ≤20%. 
• Permanently discontinue trametinib.  Report as 
SAE   
• Hold dabrafenib until LVEF improves.  Consult 
CTEP drug monitor for resumption of 
dabrafenib.  
• Consult with cardiologist. 
• Repeat ECHO after 2, 4, 8, 12, and 16 weeks or 
until resolution. 
a If ECHO does not show LVEF recovery after 2 weeks, repeat ECHO 2 weeks later. 
b Symptoms may include:  dyspnea, orthopenea, and other signs and symptoms of pulmonary congestion and 
edema. 
 
6.1.11 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Hypertension 
 
Increases in blood pressure (BP) have been observed in patients receiving dabrafenib plus 
trametinib.  Recommendations for BP monitoring and management are provided below. 
 
Monitoring:  All BP assessments should be performed under the following optimal conditions: 
 


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• The subject has been seated with back support, ensuring that legs are uncrossed and flat 
on the floor. 
• The subject is relaxed comfortably for at least 5 minutes. 
• Restrictive clothing has been removed from the cuff area, and the right cuff has been 
selected. 
• The subject’s arm is supported so that the middle of the cuff is at heart level. 
• The subject remains quiet during the measurement. 
• In subjects with an initial BP reading within the hypertensive range, a second reading 
should be taken at least 1 minute later, with the two readings averaged to obtain a final 
BP measurement.  The averaged value should be recorded in the eCRF. 
• Visits to monitor increased blood pressure can be scheduled independently from the per-
protocol visits outlined in the study calendar.  Ideally, subsequent blood pressure 
assessments should be performed within 1 week. 
• Persistent hypertension is defined as an increase of systolic BP (SBP) >140 mmHg and/or 
diastolic BP (DBP) >90 mmHg in three consecutive visits with blood pressure 
assessments from two readings collected as described above. 
• Asympomatic hypertension is defined as an increase of SBP >140 mmHg and/or diastolic 
BP (DBP) >90 mmHg in the absence of headache, light-headedness, vertigo, tinnitus, 
episodes of fainting, or other symptoms indicative of hypertension. 
 
Table 6-7:  Dabrafenib or Dabrafenib + Trametinib Treatment Modification and 
Management Guidelines for Hypertension 
Event 
Management Guideline 
Dose Modification 
(Scenario A) 
Asymptomatic and persistenta SBP 
of ≥140 and <160 mmHg, or DBP 
≥90 and <100 mmHg 
OR 
linically significant increase in 
DBP of 20 mmHg (but still below 
100 mmHg) 
• Adjust current or initiate new 
antihypertensive medication(s). 
• Titrate antihypertensive 
medication(s) during the next 2 
weeks to achieve well-
controlledb BP.   
• If BP is not well-controlled 
within 2 weeks, consider 
referral to a specialist and go to 
scenario (B). 
• Continue protocol therapy. 
 
(Scenario B) 
Asymptomatic SBP ≥160 mmHg, 
or DBP ≥100 mmHg,  
OR 
Failure to achieve well-controlled 
BP within 2 weeks in Scenario A. 
• Adjust current or initiate new 
antihypertensive medication(s). 
• Titrate antihypertensive 
medication(s) during the next 2 
weeks to achieve well-
controlled BP. 
• Interrupt study treatment if clinically 
indicated. 
• Once BP is well-controlledb, restart study 
treatment reduced by one dose level. 
 
(Scenario C) 
Symptomatic hypertension  
OR 
Persistent SBP ≥160 mmHg, or 
DBP ≥100 mmHg, despite 
antihypertensive medication and 
dose reduction of study treatment 
• Adjust current or initiate new 
antihypertensive medication(s). 
• Titrate antihypertensive 
medication(s) during the next 2 
weeks to achieve well-
controlled BP. 
• Referral to a specialist for 
further evaluation and follow-
up is recommended. 
• Interrupt study treatment if clinically 
indicated. 
• Once BP is well controlled, restart study 
treatment reduced by one dose level.c 
 


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Table 6-7:  Dabrafenib or Dabrafenib + Trametinib Treatment Modification and 
Management Guidelines for Hypertension 
Event 
Management Guideline 
Dose Modification 
(Scenario D) 
Refractory hypertension 
unresponsive to above 
interventions or hypertensive 
crisis. 
• Continue follow-up per 
protocol. 
• Permanently discontinue study treatment. 
a. Hypertension detected in two separate readings during up to three consecutive visits 
b. Well-controlled blood pressure defined as SBP ≤140 mm Hg and DBP ≤90 mm Hg in two separate readings 
during up to three consecutive visits. 
c. Escalation of trametinib to previous dose level can be considered if BPs remain well-controlled for 4 weeks after 
restarting of trametinib.  Approval from CTEP Medical Monitor is required. 
• d. Symptomatic hypertension defined as hypertension aggravated by symptoms (e.g., headache, light-headedness, 
vertigo, tinnitus, episodes of fainting) that resolve after the blood pressure is controlled within the normal range 
 
 
6.1.12 Dabrafenib or Dabrafenib  + Trametinib Dose Modification for QTc Prolongation 
 
Table 6-8:  Dabrafenib + Trametinib modification for QTc Prolongation 
Prolongation 
Action and Dose Modification 
• QTcB ≥501 msec 
• Interrupt study treatment until QTcB prolongation resolves to grade 1 or 
baseline. 
• Test serum potassium, calcium, phosphorus and magnesium. If abnormal, 
correct per routine clinical practice to within normal limits.   
• Review concomitant medication usage for agents that prolonged QTc. 
• If the event resolves, restart study treatment at current dose level.b 
• If the event does not resolve, permanently discontinue study treatment. 
Consider evaluation with cardiologist. 
• If the event recurs, permanently discontinue study treatment. Consider 
evaluation with cardiologist. 
Abbreviations:  msec = milliseconds; QTcB = QT interval on electrocardiogram corrected using the Bazett’s 
formula 
a. Based on average QTc value of triplicate ECGs.  For example, if an ECG demonstrates a prolonged QT interval, 
obtain two or more ECGs over a brief period, and then use the averaged QTc values of the three ECGs to determine 
if study treatments should be interrupted or discontinued. 
b. If the QTc prolongation resolves to grade 1 or baseline, the subject may resume study treatment if the investigator 
and CTEP medical monitor agree that the subject will benefit from further treatment. 
 
6.1.13 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Diarrhea 
 
Episodes of diarrhea have been observed in patients receiving dabrafenib, trametinib, or both 
therapies in combination.  Other, frequent causes for diarrhea including concomitant medications 
(e.g., stool softeners, laxatives, antacids, etc.), infections caused by C. difficile or other 
pathogens, partial bowel obstruction, etc., should be clinically excluded. 
 


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Table 6-9:  Dabrafenib or Dabrafenib + Trametinib Treatment Modification and 
Management Guidelines for Diarrhea 
CTCAE Grade 
Management Guideline 
Action and Dose Modification 
Uncomplicated 
Diarrhea,1 
Grade 1 or 2 
(tolerable) 
• Diet:  Stop all lactose containing products; eat 
small meals, BRAT-diet (banana, rice, apples, 
toast) recommended. 
• Hydration:  8-10 large glasses of clear liquids 
per day (e.g., Gatorade or broth). 
• Loperamide3:  Initially 4 mg, followed by 2 mg 
every 4 hours or after every unformed stool; 
maximum 16 mg/day.  Continue until diarrhea-
free for 12 hours. 
• Diarrhea >24 hours:  Loperamide 2 mg every 2 
hours; maximum 16 mg/day.  Consider adding 
oral antibiotics. 
• Diarrhea >48 hous:  Loperamide 2 mg every 2 
hours; maximum 16 mg/day.  Add budesonide 
or other second-line therapies (otreotide, or 
tincture of opium) and oral antibiotics. 
• Continue study treatment. 
• If diarrhea is grade 2 for > 48 
hours, interrupt study treatment 
until diarrhea resolves to grade ≤1. 
• Restart study treatment at the same 
dose level. 
 
Uncomplicated 
Diarrhea,1 
Grade 2 
(intolerable), 3, or 
4 
 
Any Complicated 
Diarrhea2 
 
• Clinical evaluation mandatory. 
• Loperamide3:  Initially 4 mg, followed by 2 mg 
every 4 hours or after every unformed stool; 
maximum 16 mg/day.  Continue until diarrhea-
free for 12 hours. 
• Oral antibiotics and second-line therapies if 
clinically indicated 
• Hydration:  Intravenous fluids if clinically 
indicated. 
• Antibiotics (oral or intravenous) if clinically 
indicated. 
• Intervention should be continued until the 
subject is diarrhea-free for ≥24 hours. 
• Intervention may require hospitalization for 
subjects at risk of life-threatening 
complications. 
• Interrupt study treatment until 
diarrhea resolves to ≤ grade 1. 
• Restart with study treatment 
reduced by one dose level.4 
• If 3 dose reductions of study 
treatment are clinically indicated, 
permanently discontinue study 
treatment. 
1.  Uncomplicated diarrhea defined by the absence of symptoms such as cramping, nausea/vomiting, ≥ grade 
2, decreased performance status, pyrexia, sepsis, neutropenia ≥ grade 3, frank bleeding, and/or dehydration 
requiring intravenous fluid substitution. 
2.  Complicated diarrhea defined by the presence of symptoms such as cramping, nausea/vomiting, ≥ grade 2, 
decreased performance status, pyrexia, sepsis, neutropenia ≥ grade 3, frank bleeding, and/or dehydration 
requiring intravenous fluid substitution. 
3.  Loperamide should be made available prior to start of study treatment so loperamide administration can 
begin at the first signs of diarrhea. 
4.  Escalation of study treatment to previous dose level is allowed after consultation with the medical monitor 
and in the absence of another episode of complicated or severe diarrhea in the 4 weeks subsequent to dose 
reduction. 
 
 
6.1.14 Dabrafenib or Dabrafenib  + Trametinib Dose Modification for Vision Changes 
 
Episodes of vision changes have been observed in patients receiving dabrafenib, trametinib, or 
the combination of both therapies.   An ophthalmologist should be consulted if changes in vision 


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develop.  However, if the visual changes are clearly unrelated to study treatment (e.g., allergic 
conjunctivitis), then monitor closely as it may be reasonable to defer ophthalmic examination. 
 
Uveitis and iritis have been associated with dabrafenib, while RPED and RVO have been 
associated with trametinib therapy.  Monitor patients for visual signs and symptoms (such as 
change in vision, photophobia, and eye pain) during therapy. Special attention should be given to 
retinal findings (e.g., retinal pigment epithelial detachment (RPED) or retinovascular 
abnormalities (i.e., branch or central retinal vein occlusions [RVO]).  For events of visual 
changes regardless of severity but for which an ophthalmic examination is conducted, a blood 
sample for PK analysis is encouraged when feasible, and the blood sample should be drawn as 
close as possible to the time of the event. 
 
The ophthalmology exam will include best corrected visual acuity, visual field examination, 
tonometry, slit lamp biomicroscopic examination of the anterior segment (with special attention 
to inflammation) and the posterior segment, and dilated indirect fundoscopy with special 
attention to retinal abnormalities.  Optical coherence tomography is strongly recommended at 
scheduled visits and if retinal abnormalities are suspected.  Other types of ancillary testing 
including color fundus photography, and fluorescein angiography may also be indicated as 
determined by clinical exam. 
 
Guidelines regarding event management and dose reduction for visual changes considered to be 
related to study treatment are provided in the table below. 
 
Table 6-10: Dabrafenib or Dabrafenib-Trametinib Treatment Modification for Visual 
Changes  
CTCAE Grade 
Management Guideline 
Action and Dose Modification 
Grade 1 
 
• Consult ophthalmologist 
immediately. 
 
 
• If dilated fundus examination cannot be 
performed within 7 days of onset, hold 
trametinib until RPED and RVO can be 
excluded by retina specialist/ 
ophthalmologist. Dabrafenib may be 
continued. 
• If RPED and RVO excluded, continue (or 
restart) trametinib at same dose level 
• If Uveitis/Iritis, refer to table below for 
Iritis/Uveitis 
• If RPED suspected or diagnosed, refer to 
RPED dose modification table below; 
report as SAE if diagnosed. 
• If RVO suspected or diagnosed:  
Permanently discontinue trametinib 
and report as SAE if diagnosed. 
 


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66 
CTCAE Grade 
Management Guideline 
Action and Dose Modification 
Grade 2 and 3 
 
• Consult ophthalmologist 
immediately. 
• Hold trametinib.  Dabrafenib may be 
continued. 
• If RPED and RVO excluded, restart 
trametinib at same dose level 
• If Uveitis/Iritis, refer to table below for 
Uveitis/Iritis 
• If RPED diagnosed, see RPED dose 
modification table below; report as SAE. 
• If RVO diagnosed:  Permanently 
discontinue trametinib and report as 
SAE. 
Grade 4 
 
• Consult ophthalmologist 
immediately. 
• Interrupt trametinib.  Dabrafenib may be 
continued. 
• If RPED and RVO excluded, may 
consider restarting trametinib at same or 
reduced dose after discussion with study 
medical monitor. 
• If Uveitis/Iritis, refer to table below 
• If RVO or RPED diagnosed, 
permanently discontinue trametinib and 
report as SAE. 
Abbreviations: RPED = retinal pigment epithelial detachments; RVO = retinal vein occlusion; SAE = serious 
adverse event 
*If visual changes are clearly unrelated to study treatment (e.g., allergic conjunctivitis), monitor closely but 
ophthalmic examination is not required 
 
 
Table 6-11: Dose Modification for RPED 
Event 
CTCAE Grade 
Action and Dose Modification 
Grade 1 RPED (Asymptomatic; 
clinical or diagnostic observations 
only) 
• Continue trametinib with retinal evaluation monthly until resolution.  If 
RPED worsens, follow instructions below. 
• Dabrafenib treatment is not affected 
Grade 2-3 RPED (Symptomatic 
with mild to moderate decrease in 
visual acuity; limiting instrumental 
ADL) 
• Interrupt trametinib.  Continue dabrafenib 
• Retinal evaluation monthly. 
• If improved to ≤ Grade 1, restart trametinib with one dose level 
reduction (reduced by 0.5 mg) or discontinue in patients taking 
trametinib 1 mg daily. 
• If no recovery within 4 weeks permanently discontinue trametinib 


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Table 6-12: Dabrafenib or Dabrafenib-Trametinib Dose Modification for Uveitis and 
Iritis 
CTCAE Grade 
Action and Dose Modification 
Uveitis and Iritis 
• Continue study treatment 
• Control ocular inflammation with local therapies  
• If not improved to grade ≤1 within 1 week, interrupt dabrafenib until 
resolution of ocular inflammation and then restart dabrafenib reduced by one 
dose level 
• If no recover within 4 weeks, permanently discontinue dabrafenib.  
Trametinib may be continued. 
 
6.1.15 Dabrafenib + Trametinib Dose Modification for Pneumonitis 
 
Pneumonitis has been observed in patients receiving trametinib in combination with dabrafenib.  
To reduce the risk of pneumonitis, patients will be monitored closely for symptoms, evaluated 
with imaging and functional tests when appropriate.   
 
Table 6-13: Dabrafenib-Trametinib Treatment Modification for Pneumonitis 
CTCAE Grade 
Adverse Event Management 
Action and Dose Modification 
Grade 1 
• CT scan (high-resolution with lung windows) 
recommended. 
• Clinical evaluation and laboratory work-up for 
infection. 
• Monitoring of oxygenation via pulse-oximetry 
recommended. 
• Consultation with pulmonologist recommended. 
Continue study treatment at current 
dose 
Grade 2 
• CT scan (high-resolution with lung windows). 
• Clinical evaluation and laboratory work-up for 
infection. 
• Consult pulmonologist. 
• Pulmonary function tests:  If < normal, repeat 
every 8 weeks until ≥ normal. 
• Bronchoscopy with biopsy and/or BAL 
recommended 
•  Symptomatic therapy including corticosteroids if 
clinically indicated. 
• Interrupt trametinib until recovery 
to grade ≤1. 
• Restart with trametinibreduced by 
one dose level. 
• Escalation to previous dose level 
after 4 weeks and consultation with 
the CTEP Medical Monitor may be 
considered. 
• If no recovery to grade ≤1 within 4 
weeks, permanently discontinue 
trametinib. 
Grade 3 
• Same as grade 2 
• Interrupt study treatment until 
recovery to grade ≤1. 
• Resumption of trametinib at one 
dose level reduction may be 
considered after consultation with 
the CTEP Medical Monitor 
• If no recovery to grade ≤1 within 4 
weeks, permanently discontinue 
trametinib. 
Grade 4 
• Same as grade 2 
Permanently discontinue trametinib. 


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6.1.16 Dabrafenib or Dabrafenib + Trametinib Dose Modification for Liver Chemistry 
Changes 
 
Table 6-14:  Dabrafenib or Dabrafenib-Trametinib Dose Modification for Liver Chemistry 
Changes 
Event 
Treatment modifications and assessment/monitoring 
• ALT ≥3x ULN but <5x ULN 
and TB <2x ULN, without 
symptoms considered related to 
liver injury or hypersensitivity 
and who can be monitored 
weekly for 4 weeks 
 
• May continue study treatment. 
• Report as SAE if CTEP-AERS reporting criteria is met. 
• If liver chemistry stopping criteria are met any time, proceed as 
described below. 
 
MONITORING: 
Repeat LFT (ALT, AST, ALK, bilirubin) until they return to 
normal/baseline or stabilise (LFT may be every 2 weeks after 4 weeks if 
ALT <3x ULN and TB <2 ULN). 
Criteria for discontinuing study 
drug:  When any of the liver 
stopping  criteria below is met, 
discontinue trametinib and 
dabrafenib 
 
1. ALT ≥3xULN and bilirubin 
≥2x ULN  or >35% direct 
bilirubin1, 2 
2. ALT  3xULN and INR >1.5, 
if INR measured2  (INR 
threshold does not apply if 
subject is on anticoagulant) 
3. ALT ≥5x ULN 
4. ALT ≥3x ULN persists for 4 
weeks 
5. ALT ≥3x ULN and cannot be 
monitored weekly for 4 weeks 
6. ALT  ≥3x ULN associated with 
symptoms3  (new or worsening) 
believed to be related to  liver 
injury or hypersensitivity 
 
 
• Immediately discontinue study treatment. 
• Do not restart/rechallenge unless approved by CTEP  medical 
monitor.  [Do not include for single-dose studies.] 
• Report as SAE if:  1) CTEP-AERS reporting criteria are met, or 2) 
patients meet criteria 1-2. 
• Perform liver event ASSESSMENT AND WORKUP (see below). 
• Monitor the subject until liver chemistries  resolve, stabilize, or return 
to baseline (see MONITORING below). 
If applicable, provide details on required follow up assessments (e.g., 
follow up for overall survival or disease recurrence or progression). [Do 
not include for single-dose studies] 
 
MONITORING: 
In patients stopping for criteria 1-2 (with abnormal TB and INR, indicating 
potentially more significant liver toxicities): 
• Repeat liver chemistries (ALT, AST, ALK, bilirubin) and perform liver 
event follow-up assessments within 24 hours. 
• Monitor subjects twice weekly until LFT return to normal/baseline or 
stabilize. 
• A specialist or hepatology consultation is recommended. 
In patients stopping for criteria 2-6: 
• Repeat LFT and perform liver event follow up assessments within  24-
72 hours  
• Monitor subjects weekly until LFTs return to normal/baseline or 
stabilize. 
 
ASSESSMENT and WORKUP: 
• Viral hepatitis serology.4 
• If possible, obtain blood sample for PK analysis.5 
• Serum CPK and LDH. 
• Fractionate bilirubin, if total bilirubin ≥2x ULN. 
• CBC with differential to assess eosinophilia. 
• Record clinical symptoms of liver injury, or hypersensitivity on AE 
CRF. 
• Record concomitant medications (including acetaminophen, herbal 


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Event 
Treatment modifications and assessment/monitoring 
remedies, other over the counter medications). 
• Record alcohol use. 
Additional work up for patient stopping for criteria 1-2 (with abnormal TB 
and INR, indicating potentially more significant liver toxicities): 
• Anti-nuclear antibody, anti-smooth muscle antibody, Type 1 anti-liver 
kidney microsomal antibodies, and quantitative total immunoglobulin G 
(IgG or gamma globulins). 
• Serum acetaminophen adduct HPLC assay (in subjects with likely 
acetaminophen use in the preceding). 
• If there is underlying chronic hepatitis B (e.g. positive hepatitis B 
surface antigen):  quantitative hepatitis B DNA and hepatitis delta 
antibody.6 
• Liver imaging (ultrasound, MRI, CT) and /or liver biopsy. 
 
6.1.17 Dabrafenib or Dabrafenib-Trametinib Dose Modification for Venous Thromembolism 
(VTE) 
 
Dabrafenib 
Trametinib 
(When Used in Combination) 
Uncomplicated DVT or 
PE 
Do not modify the dose. 
 
Withhold trametinib for up to 3 weeks. 
• If improved to Grade 0-1, resume at a lower 
dose level. 
• If not improved, permanently discontinue. 
Life Threatening PE 
Permanently discontinue 
dabrafenib 
Permanently discontinue trametinib. 
 
6.2 
AT13387 Dose modifications 
 
AT13387 dosing may be reduced in the setting of toxicity.  The below table denotes the possible 
dose levels based on the dose escalation schema.   
 
  
Current Dose 
If Dose Reduction Required 
Reduce To 
260 mg/m2 days1, 8, and 15 
→ 
220 mg/m2 days 1, 8, and 15 
220 mg/m2 days 1, 8, and 15 
→ 
180 mg/m2 days 1, 8, and 15 
180 mg/m2 days 1, 8, and 15 
→ 
150 mg/m2 days 1, 8, and 15 
150 mg/m2 days 1, 8, and 15 
→ 
Discontinue AT13387 
 
 
Further dose modifications to 120 mg days 1, 8, and 15 are permitted at the discretion of the 
Investigator but should be discussed with CTEP and the study sponsors.  In the event that 
dabrafenib, trametinib, or both agents need to be discontinued due to toxicity reasons, treatment 
with AT13387 may continue at the discretion of the investigator until time of disease 
progression.   
 


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6.2.1 Management of AT13387 toxicity 
 
Dexamethasone and/or antihistamines could be given to treat or prevent the systemic infusion 
reactions. Antiemetics, anti-diarrheal agents, etc. may be given to treat or prevent gastrointestinal 
toxicities.  
 
6.2.1.1 
Dose Reduction and Interruption 
 
Table 6-15:  AT13387 Dose Modification for Toxicities 
Not Specified in Subsequent Sections 
CTCAE Grade 
Action and Dose Modification 
Grade 1  
• Continue study treatment at same dose level (no dose modification). 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
Grade 2 (Tolerable) 
• Interrupt study treatment if clinically indicated. 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
• When toxicity resolves to grade 1 or baseline, restart study treatment at 
current dose level. 
Grade 2 (Intolerable) 
Grade 3 
• Interrupt study treatment. 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
• When toxicity resolves to grade 1 or baseline, restart study treatment 
reduced by one dose level. 
• If the grade 3 toxicity recurs, interrupt study treatment. 
• When toxicity resolves to grade 1 or baseline, restart study treatment 
reduced by another dose level. 
Grade 4 
• Interrupt study treatment. 
• Monitor closely. 
• Provide supportive care according to institutional standards. 
• Restart with study treatment reduced by one dose level once toxicity 
resolves to grade 1 or baseline. 
• If the grade 4 toxicity recurs, either permanently discontinue study 
treatment or, if the patient is clinically benefiting, discuss continuation 
of study treatment with the CTEP Medical Monitor. 
 
In the event of abdominal pain or suspected pancreatitis, amylase and lipase laboratory samples should 
be collected for confirmation of the diagnosis. 
 
Dose reductions for QTc elevations 
 
A 12-lead EKG will be performed in triplicate prior to the start of each AT13387 infusion. If a 
subject’s QTc is >480 msec but ≤500 msec, the infusion will be withheld until the subject’s QTc 
has decreased to 480 msec and then the subject may be dosed at the same dose level. If a 
subject’s QTc is ≥500 msec, the treatment will be withheld until the subject’s QTc has decreased 
to <480 msec and then the subject will be dosed at one dose level below their assigned treatment. 
 
Dose modifications for ocular toxicity 
While ocular toxicity is an adverse event of special interest, dose reductions and modifications 
will be made based on the table above (Table 6-13).  Additionally, patients will be required to 


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have an ophthalmology visit within 24 hours of first event of visual disturbance. 
 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will 
determine whether the event requires expedited reporting (via CTEP-AERS) in addition to 
routine reporting. 
 
7.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) 
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system.  In addition to the comprehensive list, a subset of AEs, 
the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column 
and is identified with bold and italicized text.  The SPEER is a list of events that are protocol-
specific exceptions to expedited reporting to NCI via CTEP-AERS (except as noted below).   
 
Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification.  
 
The CAEPR may not provide frequency data; if not, refer to the Investigator’s Brochure for this 
information. 
 
NOTE:  Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next 
to the AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple 
investigational agents and has an AE listed on different SPEERs, use the lower of the grades to 
determine if expedited reporting is required 
 
 
7.1.1.1 
CAEPR for Trametinib 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR)  
for 
Trametinib dimethyl sulfoxide (GSK1120212B, NSC 763093) 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 1111 patients. Below is the CAEPR for 
Trametinib dimethyl sulfoxide (GSK1120212B). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 


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AE in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
 
Version 2.4, October 7, 20161 
 
 Adverse Events with Possible  
 Relationship to Trametinib dimethyl sulfoxide (GSK1120212B) 
 (CTCAE 4.0 Term) 
[n= 1111] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
 Anemia (Gr 2) 
CARDIAC DISORDERS 
  
 
 
Heart failure 
  
 
 
Left ventricular systolic 
dysfunction 
  
 
Sinus bradycardia 
 
  
EYE DISORDERS 
  
 
Blurred vision 
 
  
 
Dry eye 
 
  
 
 
Eye disorders - Other 
(chorioretinopathy also 
known as retinal pigment 
epithelial detachment) 
  
 
 
Eye disorders - Other 
(retinal vein occlusion) 
  
 
Eye disorders - Other (visual 
disorders)2  
 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
 
 Colitis 
  
 
 
 Colonic perforation 
  
 
Constipation 
 
 Constipation (Gr 2) 
Diarrhea 
 
 
 Diarrhea (Gr 3) 
 
Dry mouth 
 
 Dry mouth (Gr 2) 
 
Dyspepsia 
 
 Dyspepsia (Gr 2) 
 
Mucositis oral 
 
 Mucositis oral (Gr 2) 
Nausea 
 
 
 Nausea (Gr 3) 
 
Vomiting 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills 
 
 Chills (Gr 2) 
 
Edema face 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
IMMUNE SYSTEM DISORDERS 
  
 
Allergic reaction3 
 
  
INFECTIONS AND INFESTATIONS 
  
 
Lung infection 
 
  
 
Paronychia 
 
 Paronychia (Gr 2) 
 
Skin infection 
 
 Skin infection (Gr 2) 
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased 
 
 Alanine aminotransferase 
increased (Gr 2) 


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73 
 
 Adverse Events with Possible  
 Relationship to Trametinib dimethyl sulfoxide (GSK1120212B) 
 (CTCAE 4.0 Term) 
[n= 1111] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
Alkaline phosphatase 
increased 
 
 Alkaline phosphatase increased 
(Gr 2) 
 
Aspartate aminotransferase 
increased 
 
 Aspartate aminotransferase 
increased (Gr 2) 
 
CPK increased 
 
  
 
Ejection fraction decreased 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 2) 
 
Dehydration 
 
 Dehydration (Gr 3) 
 
Hypoalbuminemia 
 
  
 
Hypomagnesemia 
 
 Hypomagnesemia (Gr 2) 
 
Hyponatremia 
 
 Hyponatremia (Gr 3) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
Back pain 
 
 Back pain (Gr 2) 
 
 
Musculoskeletal and 
connective tissue disorder - 
Other (rhabdomyolysis) 
  
 
Pain in extremity 
 
 Pain in extremity (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
 Dizziness (Gr 2) 
 
Headache 
 
 Headache (Gr 2) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 2) 
 
 
Pneumonitis 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Alopecia 
 
 Alopecia (Gr 2) 
 
Dry skin 
 
 Dry skin (Gr 2) 
 
 
Palmar-plantar 
erythrodysesthesia 
syndrome 
  
 
Periorbital edema 
 
  
 
Pruritus 
 
 Pruritus (Gr 2) 
 
Skin and subcutaneous 
tissue disorders - Other 
(folliculitis) 
 
 Skin and subcutaneous tissue 
disorders - Other (folliculitis) (Gr 
2) 
Skin and subcutaneous 
tissue disorders - Other 
(rash)4 
 
 
 Skin and subcutaneous tissue 
disorders - Other (rash)4 (Gr 3) 
VASCULAR DISORDERS 
  
 
Hypertension 
 
 Hypertension (Gr 2) 
Vascular disorders - Other 
(edema)5 
 
 
 Vascular disorders - Other 
(edema)5 (Gr 2) 
 
Vascular disorders - Other 
(hemorrhage)6 
 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
74 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
 
2Visual disorders include visual disturbance that can be associated with conjunctival hemorrhage, corneal 
graft rejection, cyclitis, eye nevus, halo vision, iritis, macular edema, retinal hemorrhage, visual acuity 
reduced, visual impairment, and vitreous detachment. 
 
3Hypersensitivity (allergic reactions) may present with symptoms such as fever, rash, increased liver 
function tests, and visual disturbances. 
 
4Skin and subcutaneous tissue disorders - Other (rash) may include rash, rash acneiform, rosacea, 
erythematous rash, genital rash, rash macular, exfoliative rash, rash generalized, erythema, rash papular, 
seborrhoeic dermatitis, dermatitis psoriasiform, rash follicular, and skin fissures. 
 
5Edema includes edema, lymphedema, and edema limbs. 
 
6The majority of hemorrhage events were mild.  Major events, defined as symptomatic bleeding in a 
critical area or organ (e.g., eye, GI hemorrhage, GU hemorrhage, respiratory hemorrhage), and fatal 
intracranial hemorrhages have been reported. 
 
 
Adverse events reported on Trametinib dimethyl sulfoxide (GSK1120212B) trials, but for which 
there is insufficient evidence to suggest that there was a reasonable possibility that Trametinib 
dimethyl sulfoxide (GSK1120212B) caused the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Disseminated intravascular coagulation; Febrile 
neutropenia; Leukocytosis 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac arrest; Myocardial infarction; Restrictive 
cardiomyopathy; Sinus tachycardia 
EYE DISORDERS - Corneal ulcer; Eyelid function disorder; Flashing lights; Floaters; Glaucoma; 
Papilledema; Photophobia; Retinal detachment 
GASTROINTESTINAL DISORDERS - Anal hemorrhage; Ascites; Duodenal ulcer; Enterocolitis; 
Esophageal necrosis; Esophageal ulcer; Esophagitis; Gastric hemorrhage; Gastric ulcer; Gastritis; 
Gastrointestinal disorders - Other (intestinal obstruction); Gastrointestinal disorders - Other 
(oropharyngeal pain); Gastrointestinal disorders - Other (pneumatosis intestinalis); Gastrointestinal fistula; 
Gingival pain; Hemorrhoidal hemorrhage; Ileus; Lower gastrointestinal hemorrhage; Obstruction gastric; 
Pancreatitis; Rectal hemorrhage; Small intestinal obstruction; Upper gastrointestinal hemorrhage 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Flu like symptoms; General 
disorders and administration site conditions - Other (axillary pain); Localized edema; Malaise; Non-
cardiac chest pain; Pain 
HEPATOBILIARY DISORDERS - Cholecystitis; Hepatic failure; Hepatic pain; Hepatobiliary disorders - 
Other (hepatic encephalopathy) 
INFECTIONS AND INFESTATIONS - Biliary tract infection; Catheter related infection; Device related 
infection; Endocarditis infective; Enterocolitis infectious; Hepatitis viral; Infections and infestations - Other 
(abscess limb); Infections and infestations - Other (necrotizing fasciitis); Infections and infestations - Other 
(oral infection); Pharyngitis; Rash pustular; Sepsis; Upper respiratory infection; Urinary tract infection 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising 
INVESTIGATIONS - Blood bilirubin increased; Creatinine increased; Electrocardiogram QT corrected 
interval prolonged; GGT increased; Investigations - Other (blood lactate dehydrogenase increased); 
Lipase increased; Lymphocyte count decreased; Platelet count decreased; Serum amylase increased; 
White blood cell decreased 
METABOLISM AND NUTRITION DISORDERS - Hyperglycemia; Hyperkalemia; Hyperuricemia; 
Hypocalcemia; Hypoglycemia; Hypokalemia; Metabolism and nutrition disorders - Other 
(hyperphosphatemia) 


NCI Protocol #: 9557 
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75 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Generalized muscle weakness; 
Musculoskeletal and connective tissue disorder - Other (compression fracture); Musculoskeletal and 
connective tissue disorder - Other (muscle spasm); Myalgia; Neck pain 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms 
benign, malignant and unspecified (incl cysts and polyps) - Other (tumor hemorrhage); Tumor pain 
NERVOUS SYSTEM DISORDERS - Dysgeusia; Encephalopathy; Intracranial hemorrhage; Lethargy; 
Nervous system disorders - Other (diplopia); Seizure; Somnolence; Stroke; Syncope; Transient ischemic 
attacks 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Delirium; Depression; Hallucinations; Insomnia; 
Personality change 
RENAL AND URINARY DISORDERS - Acute kidney injury; Cystitis noninfective; Hematuria; Proteinuria; 
Renal and urinary disorders - Other (dysuria); Urinary incontinence 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Vaginal fistula; Vaginal hemorrhage 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; 
Epistaxis; Hypoxia; Laryngeal edema; Pleural effusion; Pneumothorax; Productive cough; Pulmonary 
hypertension; Respiratory failure; Sinus disorder 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Bullous dermatitis; Photosensitivity; Purpura; Skin 
and subcutaneous tissue disorders - Other (erythema nodosum); Skin and subcutaneous tissue disorders 
- Other (nail disorder); Skin and subcutaneous tissue disorders - Other (skin fissures); Skin ulceration; 
Urticaria 
VASCULAR DISORDERS - Hematoma; Hot flashes; Hypotension; Thromboembolic event (venous) 
 
 
Note: Trametinib dimethyl sulfoxide (GSK1120212B) in combination with other agents could cause an 
exacerbation of any adverse event currently known to be caused by the other agent, or the combination 
may result in events never previously associated with either agent. 
 
 
 
 
 
 
7.1.1.2 
CAEPR for Dabrafenib 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR)  
for 
Dabrafenib mesylate (GSK2118436B, NSC 763760) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 1291 patients. Below is the CAEPR for 
Dabrafenib mesylate (GSK2118436B). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
Version 2.3, May 20, 20161 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
76 
 
 Adverse Events with Possible  
 Relationship to Dabrafenib mesylate (GSK2118436B) 
 (CTCAE 4.0 Term) 
[n= 1291] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER) 
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia2,3  
 
 Anemia2,3 (Gr 2) 
EYE DISORDERS 
  
 
 
Eye disorders - Other (iritis)4 
  
 
 
Uveitis4 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 3) 
 
Constipation 
 
 Constipation (Gr 3) 
 
Diarrhea 
 
 Diarrhea (Gr 3) 
Nausea 
 
 
 Nausea (Gr 3) 
 
 
Pancreatitis 
  
 
Vomiting 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills 
 
 Chills (Gr 2) 
 
Edema limbs5 
 
 Edema limbs5 (Gr 2) 
Fatigue 
 
 
 Fatigue (Gr 3) 
Fever6 
 
 
 Fever6 (Gr 2) 
 
Flu like symptoms 
 
 Flu like symptoms (Gr 2) 
 
General disorders and 
administration site conditions - 
Other (hemorrhage)7 
 
  
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction8 
  
INFECTIONS AND INFESTATIONS 
  
 
Infections and infestations - 
Other (nasopharyngitis) 
 
  
INVESTIGATIONS 
  
 
Creatinine increased3 
 
 Creatinine increased3 (Gr 2) 
 
Neutrophil count decreased3 
 
 Neutrophil count decreased3  
(Gr 2) 
 
Platelet count decreased3 
 
 Platelet count decreased3 (Gr 2) 
 
White blood cell decreased3 
 
 White blood cell decreased3  
(Gr 2) 
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 2) 
Hyperglycemia3 
 
 
 Hyperglycemia3 (Gr 2) 
 
Hypokalemia3 
 
 Hypokalemia3 (Gr 2) 
 
Hyponatremia3 
 
 Hyponatremia3 (Gr 2) 
Hypophosphatemia3 
 
 
 Hypophosphatemia3 (Gr 2) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
Arthralgia 
 
 
 Arthralgia (Gr 3) 
 
Back pain 
 
 Back pain (Gr 3) 
 
Myalgia 
 
 Myalgia (Gr 3) 
 
Pain in extremity 
 
 Pain in extremity (Gr 3) 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND 
POLYPS) 
  


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
77 
 
 Adverse Events with Possible  
 Relationship to Dabrafenib mesylate (GSK2118436B) 
 (CTCAE 4.0 Term) 
[n= 1291] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER) 
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
Neoplasms benign, malignant 
and unspecified (incl cysts and 
polyps) - Other (squamous cell 
carcinoma or keratoacanthoma)9 
 
 Neoplasms benign, malignant 
and unspecified (incl cysts and 
polyps) - Other (squamous cell 
carcinoma or keratoacanthoma)9 
(Gr 2) 
 
Treatment related secondary 
malignancy (non-SCC)10 
 
  
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
 Dizziness (Gr 2) 
Headache 
 
 
 Headache (Gr 2) 
 
 
Syncope 
  
RENAL AND URINARY DISORDERS 
  
 
 
Renal and urinary disorders - 
Other (renal failure) 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
Alopecia 
 
 
 Alopecia (Gr 2) 
 
Dry skin 
 
 Dry skin (Gr 2) 
 
Hyperhidrosis 
 
 Hyperhidrosis (Gr 2) 
 
Palmar-plantar 
erythrodysesthesia syndrome 
 
 Palmar-plantar 
erythrodysesthesia syndrome 
(Gr 2) 
 
Pruritus 
 
 Pruritus (Gr 3) 
Rash11 
 
 
 Rash11 (Gr 2) 
 
Skin and subcutaneous tissue 
disorders - Other (abnormal hair 
texture) 
 
 Skin and subcutaneous tissue 
disorders - Other (abnormal hair 
texture) (Gr 2) 
Skin and subcutaneous tissue 
disorders - Other 
(hyperkeratosis) 
 
 
 Skin and subcutaneous tissue 
disorders - Other 
(hyperkeratosis) (Gr 2) 
 
 
Skin and subcutaneous tissue 
disorders - Other (neutrophilic 
panniculitis)12 
  
Skin and subcutaneous tissue 
disorders - Other (skin 
papilloma) 
 
 
 Skin and subcutaneous tissue 
disorders - Other (skin 
papilloma) (Gr 2) 
VASCULAR DISORDERS 
  
 
Vascular disorders - Other 
(venous thromboembolic event)13 
 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2The incidence of anemia is increased when dabrafenib mesylate (GSK2118436B) is used in combination 
with trametinib dimethyl sulfoxide (GSK1120212B). 
 
3The frequencies of these events are based upon laboratory findings rather than being due to patient-


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
78 
reported outcomes. 
 
4Dabrafenib mesylate (GSK2118436B) has been associated with ocular toxicities including chorioretinitis, 
retinitis, iridocyclitis, iritis, and uveitis. 
 
5Edema limbs (peripheral edema) is a risk associated when dabrafenib mesylate (GSK2118436B) is used 
in combination with trametinib dimethyl sulfoxide (GSK1120212B) compared to dabrafenib mesylate 
(GSK2118436B) alone. 
 
6Fever (pyrexia) can be associated with hypotension and/or (in rare cases) syncope. The frequency of 
fever and serious febrile events is increased when dabrafenib mesylate (GSK2118436B) is used in 
combination with trametinib dimethyl sulfoxide (GSK1120212B). 
 
7Treatment with dabrafenib mesylate (GSK2118436B) in combination with trametinib dimethyl sulfoxide 
(GSK1120212B) resulted in an increased incidence and severity of hemorrhagic events compared to 
patients treated with dabrafenib mesylate (GSK2118436B) as a single agent.  Sites of hemorrhage may 
include, but are not limited to, intracranial, reproductive tract, respiratory tract, and gastrointestinal 
hemorrhage. 
 
8Manifestations of allergic reactions (hypersensitivity) to dabrafenib mesylate (GSK2118436B) may 
include bullous rash (bullous dermatitis). 
 
9Squamous cell carcinoma (SCC), including SCC of the skin, SCC in situ (Bowen’s disease), and 
keratoacanthoma have been observed. 
 
10New non-SCC malignancies have been reported including primary melanoma, basal cell carcinoma, 
and non-cutaneous malignancies. 
 
11Rash includes the terms: rash, rash acneiform, rash papular, rash maculo-papular, and erythema. 
 
12Recurrent neutrophilic panniculitis has been observed in at least one patient treated with dabrafenib 
mesylate (GSK2118436B) in combination with the MEK inhibitor trametinib dimethyl sulfoxide 
(GSK1120212B). 
 
13Venous thromboembolic events (including deep vein thrombosis and pulmonary embolism) is a risk 
associated when dabrafenib mesylate (GSK2118436B) is used in combination with trametinib dimethyl 
sulfoxide (GSK1120212B). 
 
 
Adverse events reported on Dabrafenib mesylate (GSK2118436B) trials, but for which there is 
insufficient evidence to suggest that there was a reasonable possibility that Dabrafenib mesylate 
(GSK2118436B) caused the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(agranulocytosis); Blood and lymphatic system disorders - Other (pancytopenia); Disseminated 
intravascular coagulation; Febrile neutropenia; Hemolysis 
CARDIAC DISORDERS - Acute coronary syndrome; Atrial fibrillation; Atrial flutter; Heart failure; Left 
ventricular systolic dysfunction; Mitral valve disease; Myocardial infarction; Sinus tachycardia 
ENDOCRINE DISORDERS - Hyperthyroidism; Hypothyroidism 
EYE DISORDERS - Blurred vision; Eye disorders - Other (amaurosis fugax); Eye disorders - Other (visual 
acuity reduced); Eye disorders - Other (visual impairment); Eye disorders - Other (vitreous detachment); 
Floaters; Photophobia; Retinopathy 
GASTROINTESTINAL DISORDERS - Colitis; Colonic perforation; Dry mouth; Dyspepsia; Gastritis; 
Stomach pain 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Localized edema; Non-cardiac 
chest pain; Pain 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
79 
HEPATOBILIARY DISORDERS - Cholecystitis; Hepatic pain 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising 
INVESTIGATIONS - Alanine aminotransferase increased; Alkaline phosphatase increased; Aspartate 
aminotransferase increased; Blood bilirubin increased; CD4 lymphocytes decreased; Ejection fraction 
decreased; Electrocardiogram QT corrected interval prolonged; GGT increased; Lipase increased; 
Lymphocyte count decreased; Weight loss 
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hypercalcemia; Hypernatremia; 
Hypocalcemia; Hypoglycemia; Hypomagnesemia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Generalized muscle 
weakness; Musculoskeletal and connective tissue disorder - Other (muscle spasms); Neck pain 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Leukemia 
secondary to oncology chemotherapy; Myelodysplastic syndrome; Neoplasms benign, malignant and 
unspecified (incl cysts and polyps) - Other (mycosis fungoides) 
NERVOUS SYSTEM DISORDERS - Ataxia; Cognitive disturbance; Dysgeusia; Intracranial hemorrhage; 
Lethargy; Nervous system disorders - Other (intracranial pressure increased); Paresthesia; Seizure; 
Somnolence 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Depression 
RENAL AND URINARY DISORDERS - Hematuria; Renal calculi; Urinary frequency 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Menorrhagia; Reproductive system and breast 
disorders - Other (hematospermia) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Nasal congestion; Respiratory, 
thoracic and mediastinal disorders - Other (oropharyngeal pain); Sore throat; Stridor; Voice alteration 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Photosensitivity; Purpura; Skin and subcutaneous 
tissue disorders - Other (palmoplantar keratoderma) 
VASCULAR DISORDERS - Flushing; Hot flashes; Hypertension; Hypotension 
 
Note: Dabrafenib mesylate (GSK2118436B) in combination with other agents could cause an 
exacerbation of any adverse event currently known to be caused by the other agent, or the combination 
may result in events never previously associated with either agent. 
 
 
 
 
7.1.1.3 
CAEPR for AT13387 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
AT13387 (Onalespib, NSC 749712) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 119 patients. Below is the CAEPR for AT13387 
(Onalespib). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
 
Version 2.0, April 6, 20171 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
80 
 
 Adverse Events with Possible  
 Relationship to AT13387 (Onalespib) 
 (CTCAE 4.0 Term) 
[n= 119] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 2) 
EYE DISORDERS 
  
 
Blurred vision 
 
  
 
Eye disorders - Other (visual 
impairment) 
 
 Eye disorders - Other (visual 
impairment) (Gr 2) 
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Constipation 
 
 Constipation (Gr 2) 
Diarrhea 
 
 
 Diarrhea (Gr 2) 
 
Dry mouth 
 
 Dry mouth (Gr 2) 
 
Dyspepsia 
 
 Dyspepsia (Gr 2) 
 
Flatulence 
 
 Flatulence (Gr 2) 
 
Gastrointestinal hemorrhage2 
 
  
 
Hemorrhoids 
 
 
 Hemorrhoids (Gr 2) 
Nausea 
 
 
 Nausea (Gr 2) 
 
Vomiting 
 
 Vomiting (Gr 2) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Edema limbs 
 
  
Fatigue 
 
 
 Fatigue (Gr 2) 
 
Fever3 
 
 Fever3 (Gr 2) 
 
Infusion related reaction3 
 
 Infusion related reaction3 (Gr 2) 
Injection site reaction4 
 
 
 Injection site reaction4 (Gr 2) 
 
Malaise 
 
 Malaise (Gr 2) 
INFECTIONS AND INFESTATIONS 
  
 
Infection5 
 
 Infection5 (Gr 2) 
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased 
 
 Alanine aminotransferase 
increased (Gr 2) 
 
Alkaline phosphatase increased  
 Alkaline phosphatase increased 
(Gr 2) 
 
Aspartate aminotransferase 
increased 
 
 Aspartate aminotransferase 
increased (Gr 2) 
 
CPK increased 
 
 CPK increased (Gr 2) 
 
Electrocardiogram QT corrected 
interval prolonged 
 
  
 
Lymphocyte count decreased 
 
 Lymphocyte count decreased 
(Gr 2) 
 
Platelet count decreased 
 
 Platelet count decreased (Gr 2) 
 
Weight loss 
 
 Weight loss (Gr 2) 
 
White blood cell decreased 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 2) 
 
Dehydration 
 
 Dehydration (Gr 2) 
 
Hypocalcemia 
 
 Hypocalcemia (Gr 2) 
 
Hypokalemia 
 
  
 
Hypomagnesemia 
 
  
 
Hyponatremia 
 
 Hyponatremia (Gr 2) 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
81 
 
 Adverse Events with Possible  
 Relationship to AT13387 (Onalespib) 
 (CTCAE 4.0 Term) 
[n= 119] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Musculoskeletal and connective 
tissue disorder - Other (muscle 
spasms) 
 
 Musculoskeletal and connective 
tissue disorder - Other (muscle 
spasms) (Gr 2) 
 
Myalgia 
 
 Myalgia (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
 Dizziness (Gr 2) 
 
Dysgeusia 
 
  
 
Headache 
 
 Headache (Gr 2) 
PSYCHIATRIC DISORDERS 
  
 
Insomnia 
 
 Insomnia (Gr 2) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 2) 
 
Hiccups 
 
 Hiccups (Gr 2) 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Dry skin 
 
 Dry skin (Gr 2) 
 
Hyperhidrosis3 
 
 Hyperhidrosis3 (Gr 2) 
 
Rash acneiform 
 
  
 
Rash maculo-papular 
 
 Rash maculo-papular (Gr 2) 
VASCULAR DISORDERS 
  
 
Flushing 
 
 Flushing (Gr 2) 
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Gastrointestinal hemorrhage includes Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, 
Duodenal hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, 
Hemorrhoidal hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal hemorrhage, Lower 
gastrointestinal hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal hemorrhage, 
Retroperitoneal hemorrhage, and Upper gastrointestinal hemorrhage under the GASTROINTESTINAL 
DISORDERS SOC. 
 
3Infusion-related reactions may include, tachycardia/bradycardia, hypotension/hypertension, flushing, 
chills, fever, hyperhidrosis, itching, rigors, and abdominal cramps. 
 
4Injection site reaction may include injection site irritation, injection site pain, injection site inflammation or 
redness, or erythema. 
 
5Infection may include all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
 
Adverse events reported on AT13387 (Onalespib) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that AT13387 (Onalespib) caused the 
adverse event: 
 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
82 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Febrile neutropenia 
CARDIAC DISORDERS - Cardiac disorders - Other (atrioventricular block NOS); Left ventricular systolic 
dysfunction; Palpitations 
EYE DISORDERS - Dry eye; Eye disorders - Other (color distortion); Eye disorders - Other (diplopia); Eye 
disorders - Other (halos); Eye disorders - Other (loss of visual acuity during changes in ambient light 
levels); Eye disorders - Other (tunnel vision); Eye disorders - Other (visual color darkening); Eye disorders 
- Other (visual disturbances); Eye pain; Flashing lights; Floaters; Keratitis; Night blindness; Papilledema; 
Photophobia; Retinopathy 
GASTROINTESTINAL DISORDERS - Colitis; Mucositis oral; Oral dysesthesia; Oral pain; Salivary duct 
inflammation 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills3; Flu like symptoms 
HEPATOBILIARY DISORDERS - Hepatic hemorrhage 
INVESTIGATIONS - Activated partial thromboplastin time prolonged; Blood bilirubin increased; Creatinine 
increased; Ejection fraction decreased; Neutrophil count decreased 
METABOLISM AND NUTRITION DISORDERS - Hyperglycemia; Hypoalbuminemia; Hypophosphatemia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Bone pain; Generalized 
muscle weakness 
NERVOUS SYSTEM DISORDERS - Seizure; Syncope; Tremor 
PSYCHIATRIC DISORDERS - Anxiety 
RENAL AND URINARY DISORDERS - Acute kidney injury; Proteinuria 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Pneumonitis 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Palmar-plantar erythrodysesthesia syndrome; 
Pruritus; Skin hyperpigmentation 
VASCULAR DISORDERS - Hypertension3 
 
 
Note: AT13387 (Onalespib) in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events never 
previously associated with either agent. 
 
 
 
 
7.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade: The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting beginning April 1, 2018. All appropriate treatment 
areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE 
version 5.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 7.1.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are addressed in 
section 7.4. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 


NCI Protocol #: 9557 
Version Date:  February 15, 2018 
 
83 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 


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7.3 
Expedited Adverse Event Reporting 
 
7.3.1 Expedited AE reporting for this study must use CTEP-AERS (Adverse Event Expedited 
Reporting System), accessed via the CTEP Web site (https://eapps-
ctep.nci.nih.gov/ctepaers).  The reporting procedures to be followed are presented in the 
“NCI Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD 
(CTEP and CIP) and DCP INDs and IDEs” which can be downloaded from the CTEP 
Web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm.  
These requirements are briefly outlined in the tables below (Section 7.3.3). 
 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 
24-hour notification phoned in must be entered electronically into CTEP-AERS by the 
original submitter at the site. 
 
7.3.2 CTEP-AERS is programmed for automatic electronic distribution of reports to the 
following individuals:  Study Coordinator of the Lead Organization, Principal 
Investigator, and the local treating physician, and the Reporter and Submitter.  CTEP-
AERS provides a copy feature for other e-mail recipients.  
 
7.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting regardless of 
causality, unless as noted below.  Attribution to treatment or other cause must be 
provided. 
 
Death due to progressive disease should be reported as Grade 5 “Disease progression” 
in the system organ class (SOC) “General disorders and administration site conditions.” 
Evidence that the death was a manifestation of underlying disease (e.g., radiological 
changes suggesting tumor growth or progression: clinical deterioration associated with a 
disease process) should be submitted.  
 
Expedited Reporting Requirements for Adverse Events that Occur on Studies under an 
IND/IDE within 30 Days of the Last Administration of the Investigational 
Agent/Intervention 1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not they are considered related to 
the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:   
1) 
Death 
2) 
A life-threatening adverse event  
3) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 hours  


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4) 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) 
A congenital anomaly/birth defect.  
6) 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization may be considered serious 
when, based upon medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via electronic submission within the 
timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be electronically submitted within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational agent/intervention 
and have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
• 
All Grade 3, 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
• 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, rounded 
UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above applies after this 
reporting period. 
Effective Date:  May 5, 2011 
 
7.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave. For this trial the Adverse Event Case Report Form is used 
for routine AE reporting in Rave. 
 
7.5 
Secondary Malignancy 
 


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A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary 
malignancy is not considered a metastasis of the initial neoplasm.  
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS. Three options are available to 
describe the event:  
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML])  
• Myelodysplastic syndrome (MDS)  
• Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
7.6 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine reporting 
unless otherwise specified.  For dabrafenib-containing protocols, all second malignancies should 
be reported through CTEP-AERS. 
 
7.7 
Pregnancy, Fetal Death, and Death Neonatal 
NOTE:  When submitting CTEP-AERS reports for “Pregnancy”, “Pregnancy 
loss”, or “Neonatal loss”, the Pregnancy Information Form should be 
completed and faxed along with any additional medical information to 301-230-
0159 (see Appendix F).  The potential risk of exposure of the fetus to the 
investigational agent(s) or chemotherapy agent(s) should be documented in the 
“Description of Event” section of the CTEP-AERS report. 
 
7.7.1.1 
Pregnancy 
• Because patients who become pregnant on study risk intrauterine exposure of 
the fetus to agents which may be teratogenic, DCTD/DCP is requesting that 
pregnancy should be reported in an expedited manner via CTEP-AERS as 
Grade 3 “Pregnancy, puerperium and perinatal conditions - Other 
(pregnancy)” under the Pregnancy, puerperium and perinatal conditions 
SOC.  
• The pregnancy outcome for patients on study should be reported via CTEP-
AERS at the time the outcome becomes known, accompanied by the same 
Pregnancy Report Form used for the initial report.  
 
7.7.1.2 
 Pregnancy Loss 
• Pregnancy loss is defined in CTCAE as “Death in utero.” 


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87 
• Any Pregnancy loss should be reported expeditiously, as Grade 4 
“Pregnancy loss” under the Pregnancy, puerperium and perinatal 
conditions SOC. 
• A Pregnancy loss should NOT be reported as a Grade 5 event under 
• the Pregnancy, puerperium and perinatal conditions SOC, as currently 
CTEPAERS 
• recognizes this event as a patient death. 
 
7.7.1.3 
Death Neonatal 
• Neonatal death, defined in CTCAE as “A disorder characterized by 
cessation of life occurring during the first 28 days of life” that is felt by 
the investigator to be at least possibly due to the investigational 
agent/intervention, should be reported expeditiously. 
▪ A neonatal death should be reported expeditiously as Grade 4 “Death 
neonatal” under the General disorders and administration SOC. 
• Neonatal death should NOT be reported as “Death neonatal” under the 
General disorders and administration SOC, a Grade 5 event.  If reported as 
such, the CTEP-AERS interprets this as a death of the patient being treated. 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agents 
administered in this study can be found in Section 7.1. 
 
8.1 
CTEP IND Agent(s) 
 
8.1.1 Trametinib dimethyl sulfoxide (GSK1120212B) (NSC 763093) 
 
Chemical Name (IUPAC): equimolecular combination of N-(3-{3-cyclopropyl-5-[(2-
fluoro-4-iodophenyl)amino]-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-
d]pyrimidin-1(2H)-yl}phenyl)acetamide with (methylsulfinyl)methane 
 
Other Names:  trametinib, GSK1120212, JTP-74057, JTP-78296, JTP-75303, Mekinist 
 
CAS Registry Number:  1187431-43-1 
 
Classification:  MEK inhibitor 
 
Molecular Formula:  C26H23FIN5O4 • C2H6OS 
 
M.W.:  693.54 (dimethyl sulfoxide solvate), 615.41 (anhydrous parent) 
 
Approximate Solubility:  Trametinib dimethyl sulfoxide is almost insoluble in water 


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88 
(<0.0001 mg/mL at 25° C) 
 
Mode of Action:  Trametinib dimethyl sulfoxide is a reversible, highly selective, 
allosteric inhibitor of mitogen-activated extracellular signal regulated kinase 1 (MEK1) 
and MEK2.  Tumor cells commonly have hyperactivated extracellular signal-related 
kinase (ERK) pathways in which MEK is a critical component.  Trametinib dimethyl 
sulfoxide inhibits activation of MEK by RAF kinases and MEK kinases. 
 
Description:  Trametinib dimethyl sulfoxide is a white to almost white powder. 
 
How Supplied:  Novartis supplies and CTEP, NCI, DCTD distributes 0.5 mg and 2 mg 
(as free base) tablets.   
 
Each commercially-labeled bottle contains 30 tablets with a desiccant. 
 
The tablet core contains mannitol, microcrystalline cellulose, hypromellose, 
croscarmellose sodium, magnesium stearate (non-animal), colloidal silicon dioxide and 
sodium lauryl sulfate.  
 
• 0.5 mg tablets are yellow, modified oval, biconvex and film-coated with ‘GS’ debossed 
on one face and ‘TFC’ on the opposing face. Aqueous film coating consists of 
hypromellose, titanium dioxide, polyethylene glycol, iron oxide yellow. 
 
• 2 mg tablets are pink, round, biconvex and film-coated with ‘GS’ debossed on one face 
and ‘HMJ’ on the opposing face. Aqueous film coating consists of hypromellose, 
titanium dioxide, polyethylene glycol, polysorbate 80, iron oxide red. 
 
Storage:  Store tablets at 2°C - 8°C in the original bottle.  Do not repackage tablets or 
remove desiccant.  Bottles should be protected from light and moisture.   
 
If a storage temperature excursion is identified, promptly return trametinib to 2°C -8°C 
and quarantine the supplies.  Provide a detailed report of the excursion (including 
documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:  Shelf life studies of trametinib dimethyl sulfoxide are ongoing. Refer to the 
package label for expiration. 
 
Route of Administration:  Oral. Take by mouth on an empty stomach, either 1 hour 
before or 2 hours after a meal. If a dose of trametinib is missed, the dose can be taken if it is 
more than 12 hours until the next scheduled dose. 
 
Potential Drug Interactions 
 
In vitro studies suggest that trametinib dimethyl sulfoxide is not a substrate of CYP 
enzymes or of human BCRP, MRP2, OATP1B1, OATP1B3, OATP2B1, OCT1 or 


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89 
MATE1 transporters. Trametinib elimination by deacetylation to metabolite M5 is 
dependent on carboxylesterases (CES1b, CES1c and CES2). M5 is eliminated by 
CYP3A4 and other pathways, presenting the clinically relevant, albeit low, potential for 
drug-drug interaction. Trametinib is a substrate for P-gp and BSEP, but this is not 
expected to be clinically relevant due to trametinib’s high permeability.  
 
Trametinib dimethyl sulfoxide is an in vitro inhibitor of CYP 2C8, and is anticipated to 
have overall low potential for drug interactions as a perpetrator. It is also a weak 
CYP3A4 inducer and expected to have little clinical effect on sensitive substrates. 
Trametinib is not an inhibitor of CYP 1A2, 2A6, 2B6, 2C9, 2C19, 2D6 and 3A4 and not 
an inhibitor of P-gp, BCRP, OATP1B1, OATP1B3, OAT1, OAT3, OCT2 MRP2 and 
MATE1.  
 
Availability 
 
Trametinib dimethyl sulfoxide (GSK1120212B) is  FDA-approved for the treatment of 
unresectable or metastatic BRAF-mutant melanoma.  It will be supplied to investigators 
by the Division of Cancer Treatment and Diagnosis (DCTD), NCI. 
 
Trametinib dimethyl sulfoxide (GSK1120212B) is provided to the NCI under a 
Collaborative Agreement between the Pharmaceutical Collaborator and the DCTD, NCI 
(see Section 12.3). 
 
8.1.2 Dabrafenib mesylate (GSK2118436B) (NSC 763760) 
 
Chemical Name:  N-{3-[5-(2-Amino-4-pyrimidinyl)-2-(1,1-dimethylethyl)-1,3-thiazol-
4-yl]-2-fluorophenyl}-2,6-difluorobenzene sulfonamide, methanesulfonate salt 
 
Other Names:  GSK2118436, GSK2118436A (free base), Tafinlar 
 
Classification:  BRAF inhibitor 
 
CAS Registry Number:  1195768-06-9 
 
Molecular Formula:  C23H20F3N5O2S2 • CH4O3S 
 
M.W.:  615.68 (mesylate salt) 
 
Mode of Action:  Dabrafenib mesylate (GSK2118436B) is a potent and selective BRAF 
kinase inhibitor.  This inhibition suppresses downstream activity of pERK, a biomarker, 
and has antiproliferative activity against BRAF mutant tumors.  The mode of action is 
consistent with ATP-competitive inhibition. 
 
How Supplied:  Dabrafenib mesylate (GSK2118436B) capsules are supplied by Novartis 
and distributed by the DCTD, NCI, as 50 mg and 75 mg capsules (equivalent to the free-
base) for oral administration.  


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90 
 
 
Each commercially-labeled bottle contains 120 capsules and a silica gel desiccant. 
 
• 50 mg capsule is dark red and imprinted with ‘GS TEW’ and ‘50 mg.’  
 
• 75 mg capsule is dark pink and imprinted with ‘GS LHF’ and ‘75 mg.’  
 
Capsule excipients include microcrystalline cellulose, magnesium stearate (vegetable 
source), and colloidal silicon dioxide. Capsule shells contain hypromellose, red iron 
oxide (E172), and titanium dioxide (E171). 
 
Storage:  Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see 
USP Controlled Room Temperature]. 
 
Stability:  Shelf-life studies of dabrafenib mesylate (GSK2118436B) are ongoing. Refer 
to the package label for expiration. 
 
If a storage temperature excursion is identified, promptly return dabrafenib mesylate 
(GSK2118436B) to room temperature and quarantine the supplies.  Provide a detailed 
report of the excursion (including documentation of temperature monitoring and duration 
of the excursion) to PMBAfterHours@mail.nih.gov for determination of suitability.   
 
Route of Administration:  Oral administration.  Take dabrafenib mesylate 
(GSK2118436B ) 1 hour prior or 2 hours after a meal. If a dose is missed, it should not be 
taken if it is less than 6 hours until the next dose. 
 
Potential Drug Interactions:  In vivo data shows that metabolism of dabrafenib mesylate 
(GSK2118436B) and its metabolites is mediated by CYP3A4 and CYP2C8. Use caution if 
strong inducers or inhibitors of CYP2C8 or 3A4 are co-administered with dabrafenib. 
Although in vitro studies indicate dabrafenib mesylate and its metabolites are substrates for 
P-glycoprotein (P-gp) and BCRP transporters, the apparent high oral bioavailability and 
permeability indicate modulation of efflux transporters will have minimal impact on 
dabrafenib pharmacokinetics. 
 
Dabrafenib mesylate (GSK2118436B) and its metabolites showed moderate inhibition of 
CYP 2C8, 2C9, 2C19 and 3A4 in human microsomes studies. Use caution in patients 
who are taking sensitive substrates of these enzymes. Additionally, dabrafenib and its 
metabolites showed inhibition of OATP1B1, OATP1B3, OAT1, OAT3 and OCT2 
transporter systems and weak to moderate inhibition of BCRP.  Neither dabrafenib nor its 
metabolites show inhibition of P-gp in vitro. 
 
Dabrafenib mesylate (GSK2118436B) induces CYP3A4, 2C9 and possibly 2B6, 2C8, 2C19 
enzymes, UDP glucuronosyltransferase and P-gp. Use caution in patients who are taking 
substrates of these pathways, such as warfarin or hormonal contraceptives. 
 


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91 
Dabrafenib solubility is pH-dependent and experiences decreased solubility at higher pH. 
Use caution in patients who are taking drugs that elevate gastric pH due to the theoretical 
risk of decreasing oral bioavailability of dabrafenib.  
 
Patient Care Implications: In the case of overdose, patients should be treated 
symptomatically since there is no specific antidote. Hemodialysis is likely to be 
ineffective since dabrafenib mesylate is highly bound to plasma proteins.  
 
Availability 
 
Dabrafenib mesylate (GSK2118436B) is FDA-approved for the treatment of unresectable 
or metastatic BRAF-mutant melanoma. It is supplied to investigators by the Division of 
Cancer Treatment and Diagnosis (DCTD), NCI. 
 
Dabrafenib mesylate (GSK2118436B) is provided to the NCI under a Collaborative 
Agreement between the Pharmaceutical Collaborator and the DCTD, NCI (see Section 
12.3). 
 
8.1.3 AT13387 
 
Chemical Name: (2,4-dihydroxy-5-isopropyl-phenyl)-[5-(4-methyl-piperazin-1-ylmethyl)-1,3- 
dihydro-isoindol-2-yl]-methanone, L-lactic acid salt 
 
Other Name: 
AT13387AU, Onalespib 
 
Classification:   
   Heat shock protein 90 (HSP90) inhibitor 
 
Molecular Formula:   C24H31N3O3.C3H6O3  
 
M.W.:  499.61 
 
Mode of Action:  AT13387 is a synthetic non-ansamycin small molecule that inhibits heat shock 
protein 90 (HSP90.  HSP90 seems to affect multiple aberrant signaling pathways and therefore 
may be of clinical benefit in several cancer treatments.  
  
How Supplied:  AT13387 is supplied by Astex Pharmaceuticals Inc. and distributed by CTEP, 
NCI as a 265-mg free base equivalent (L-lactic acid salt) vial, containing white to off-white 
lyophilized powder.  The agent is formulated in pH 5.0 (red cap). 
 
Preparation:  Reconstitute the 265-mg lyophilized powder with 10 mL of Sterile Water for 
Injection (SWFI) resulting in 25.7 mg/mL concentration (10.3 mL total volume).  A sticky mass 
will be formed. Vigorously shake the vial. Agitate until the contents are fully dissolved (about 5 
minutes).  Leave the diluted vial at ambient temperature for 15-30 minutes to allow any foam to 
dissipate. If not used immediately, store the reconstituted vial(s) at 20 to 80 C not to exceed 8 
hours.  
 
Withdraw the calculated dose of AT13387 and further dilute it in 250 mL of D5W or 0.9% NS. 
The prepared IV solution is compatible in PVC or non-PVC infusion bags.   


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92 
 
Store the prepared IV solution at 20 to 80 C (not to exceed 8 hours) if not used immediately.  
When removed from the refrigerator, allows the prepared IV solution to sit at room temperature 
between 15 to 30 minutes before administering to patients. The prepared IV solution must be used 
within 8 hours -i.e., from the time the drug vial is diluted to the time the IV administration is 
complete. Protection from light during the infusion period is not required. 
 
Storage:     Store the intact vials at 150 to 25ºC (59 to 77ºF).  Protect from light. 
 
If a storage temperature excursion is identified, promptly return AT13387 to 150 to 25ºC (59 to 
77ºF) and quarantine the supplies.  Provide a detailed report of the excursion (including 
documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:     Shelf life surveillance of the intact vials is ongoing.  
Route of Administration:     Intravenous 
 
Method of Administration:  Infuse over 1 hour through a central line or a well-defined peripheral 
vein (Note: an in-line filter is NOT required).  If use a peripheral line, be sure to aspirate venous 
blood prior to starting the infusion.  Check the infusion site every 15 minutes. Change infusion site 
should evidence of swelling or discoloration is observed.   
 
Potential Drug Interactions:   AT13387 is a substrate of UGT with a relatively low affinity for 
UGT isoforms. In vitro data demonstrate that AT13387 is a weak inhibitor of UGT1A1, UGT1A3 
and UGT1A9.   AT13387 is also a weak inhibitor of CYP1A2, -3A4, -2D6, -2C9 and -2C19.  
AT13387 appears to metabolize via the glucuronidation, sulphation and N-oxidation. 
 
Pre-clinical studies suggest that AT13387 is a substrate of P-gp, the efflux ratios was above 2 
(ranging from 3.4 to 4.6); a moderate inhibitor of BCRP (35.9% +/- 2%, p=0.0001) and P-gp 
(31.3% +/- 1.2%, p= 0.0009), and a strong inhibitor of MATE1 (94.6% +/- 0.2%, p=0.0001) and 
MATE2-K (91.2% +/- 1.2%, p= 0.0002). 
 
Patient Care Implications:  There are no genotoxicity, carcinogenicity, developmental and 
reproductive studies conducted with AT13387.  Women of childbearing potential should not 
become pregnant or breastfeed and men should not father a child during the study.  All subjects 
must use acceptable contraceptive measures during the treatment of AT13387 and 3 months after 
the last dose of the investigational drug. 
 
Systemic infusion reactions (e.g., vomiting, itching skin, or swelling), slow the infusion and/or 
administer NS or D5W through a “Y” connector in parallel to AT13387 IV infusion.  Pre-
medication (e.g., dexamethasone, H-1 and H-2 antagonist) may be given before subsequent 
infusions and/or administer additional volume of 500 mL over 1 hour if medically appropriate.   
 
Avoid extravasation. For local irritation, apply cold compress or topical pain medication. Change 
infusion site if any evidence of swelling or discoloring is observed. 
 
 


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93 
 
8.1.4 Agent Ordering and Agent Accountability 
 
8.1.4.1 
NCI-supplied agents may be requested by the Principal Investigator (or their 
authorized designee) at each participating institution.  Pharmaceutical Management 
Branch (PMB) policy requires that agent be shipped directly to the institution where 
the patient is to be treated.  PMB does not permit the transfer of agents between 
institutions (unless prior approval from PMB is obtained).  The CTEP-assigned 
protocol number must be used for ordering all CTEP-supplied investigational agents.  
The responsible investigator at each participating institution must be registered with 
CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and 
Financial Disclosure Form (FDF).  If there are several participating investigators at 
one institution, CTEP-supplied investigational agents for the study should be ordered 
under the name of one lead investigator at that institution. 
 
Active CTEP-registered investigators and investigator-designated shipping designees 
and ordering designees can submit agent requests through the PMB Online Agent 
Order Processing (OAOP) application (https://eapps-
ctep.nci.nih.gov/OAOP/pages/login.jspx).  Access to OAOP requires the 
establishment of a CTEP Identity and Access Management (IAM) account 
(https://eapps-ctep.nci.nih.gov/iam/) and the maintenance of an “active” account 
status and a “current” password.  
 
For questions about drug orders, transfers, returns, or accountability, call (240) 276-
6575 Monday through Friday between 8:30 am and 4:30 pm (ET) or email 
PMBAfterHours@mail.nih.gov anytime. 
 
8.1.4.2 
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the inventory and disposition of all 
agents received from DCTD using the NCI Drug Accountability Record Form 
(DARF).  (See the NCI Investigator’s Handbook for Procedures for Drug 
Accountability and Storage. 
 
8.1.4.3  
Investigator Brochure Availablilty— The current versions of the IBs for PMB-
supplied agents will be accessible to site investigators and research staff through the 
PMB Online Agent Order Processing (OAOP) application.  Access to OAOP requires 
the establishment of a CTEP Identity and Access Management (IAM) account and the 
maintenance of an “active” account status and a “current” password.  Questions about 
IB access may be directed to the PMB IB coordinator at IBCoordinator@mail.nih.gov 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Biomarker Studies 
 


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9.1.1 PK Analysis 
Little is known about the potential for drug-drug interactions (DDI) of the triple 
combination of dabrafenib, trametinib, and AT13387. For this reason, extensive PK 
analysis will be performed during this study. 
 
9.1.2 
Tissue anaysis of HSP90 inhibition 
 
Subjects enrolled into the trial that have tumor tissue which is accessible for biopsy via 
FNA, core, or excisional will have tumor biopsies at the timepoints described in the study 
calendar. Specimens (approximately 50-100 mg/wet weight) will be analyzed in the lab 
of Keiran Smalley, PhD at the Moffitt Cancer Center, 12902 Tampa, FL 33602. Biopsy 
specimens and blood specimens will be evaluated via a novel mass spectrometry based 
assay to validate the role of increased HSP70 expression as a pharmacodynamic marker 
of HSP90 inhibition. Correlative studies will address whether HSP90 inhibition blocks 
the signaling pathways implicated in therapeutic escape including receptor tyrosine 
kinases, components of the mitogen activated protein kinase (MAPK) and PI3K/AKT 
signaling pathways.  
 
Correlative studies will be performed to assess how changes in the expression of the key 
signaling proteins relate to patient response. The HSP client proteins and compensatory 
signaling molecules to be studied in the proteomic assay include Pathways and processes 
involved in the cell cycle (CDK1, CDK2, CDK4, cyclin D1, CHK1), receptor tyrosine 
kinases (ERBB2, IGF1R,), RAS/MAPK signaling (NRAS, HRAS, KRAS, SOS1, SHC1, 
BRAF, ARAF, CRAF, MEK1/2, c-Myc), PI3K/AKT signaling (AKT1, AKT2, AKT3, 
mTOR, CSK, FAK1, GSK3β), B-catenin/WNT signaling (APC, Axin, β-catenin, α-
catenin), NFκB, Src and MITF. In parallel, pre and post-treatment tumor biopsy 
specimens will be processed for immunohistochemistry and stained for HSP client 
proteins implicated in therapeutic escape including BRAF, CRAF, AKT, phospho-AKT 
and phospho-ERK. All IHC work will be performed in Dr. Sullivan’s laboratory. 
 
Additionally, biopsy specimens will be evaluated by Reverse Phase Protein Array 
(RPPA) at RPPA Core Facility, Functional Proteomics, MD Anderson Cancer Center 
(Texas, USA). Primary targets of interest for analysis of AT13387 effect on relevant 
HSP90 client proteins in tumor biopsy tissue will be evaluated. Frozen biopsy specimens 
obtained during collection will be sent for analysis of relevant proteins, protein post-
translational modifications (phosphorylation and other modifications) and effects on 
relevant signaling pathways.  
 
For FNA specimens, an 18-gauge needle should be used to perform multiple passes per 
needle, per sample under sterile conditions. For each pass, negative pressure was applied 
via the plunger on a 10 ml syringe to introduce adequate amounts of tissue into the needle 
bore. Following sampling, ~500 uL of preservcyt was aspirated into the syringe and the 
contents of the syringe were expelled into a sterile 1.5 ml eppindorf tube. Samples were 
kept on dry ice for transport. Then the sample is centrifuged at 0.2 rcf to form a pellet, 
aspirated off the preservcyt using a 200 uL pipet and a 200 uL capillary/gel-loading 


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95 
pipette tip. Aspirated preservcyt will be re-spun at 0.2 rcf, pelleting any remaining 
tissue/cells and remaining liquid was again aspirated off as waste. All samples are then 
placed at -20C for undergoing urea lysis the following day. For excisional specimens the 
same process will take place except 10-20 passes with a 18 gauge needle will be 
performed on the same in sterile conditions.  Specimens will then be snap frozen in liquid 
nitrogen and stored in cryotubes before being transported to Dr. Smalley’s lab at Moffitt. 
 
It is not necessary to do FNAs if core needle biopsies or excisions can be performed 
instead. Furthermore, while liquid nitrogen is the preferred method of freezing 
specimens, using dry ice is allowable if it improves the chances of getting biopsies. 
Samples can also be transferred t oSullivan Lab at Massachusetts General Hospital for 
freezing and storing. 
 
9.1.3 
Blood BRAF test 
 
Our group has developed a blood-based assay that can measure circulating BRAF levels 
in patients with BRAF mutant melanoma. (Panka et al., 2010; Panka et al., 2014) Our 
data shows that the BRAF level is reduced in patients treated with BRAF-directed 
therapy (both single-agent vemurafenib and the combination of DT) and, in some 
patients, increases in advanced of clinical or radiographic progression by 40-60 days. 
(Panka et al., 2014) As this assay remains under clinical development, we plan to 
measure serial values (pre-treatment and at the beginning of each cycle) to further 
interrogate the utility of this assay.  All samples will be initially processed in the 
Translational Research Laboratory at MGH and then subsequently assayed at the 
BIDMC. 
9.2 
Laboratory Correlative Studies 
 
9.2.1 PK Analysis 
 
9.2.1.1 
Collection of Specimen(s) 
 
Specimens will be collected as follows: 
While the pharmacokinetic data of single-agent AT13387 and the combination of 
dabrafenib and trametinib are known, PK data of the triple combination will be done 
during this study. Clinically observed toxicities will be correlated with the possibility of 
delayed clearance of individual agents. Drug levels of AT13387, dabrafenib, and 
trametinib will be performed on day 1 of three-drug treatment (pre-, 1, 2, 4, 6, and 8 
hours after dosing), day 2 (24 hours after day 1 dosing) as well as day 15 (pre-, 1, 2, 4, 6, 
and 8 hours after dosing), day 16 (24 hours after day 1 dosing). For the purpose of this 
study, post-treatment refers to post-infusions.  All PK samples, inclusive of those drawn 
for oral agents, will be drawn at the same time relative to the end of infusion (+ 10 min). 
 
Samples for trough level PK analysis will then be planned for each patient on day 1 of 
cycles 2, 4, 8, and 12. 


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96 
 
Cycle(s) 
Day of Collection 
Planned Collection Time 
1 
1 
Pre-treatment 
1 
1.0 hr. post treatment 
1 
2.0 hr. post treatment 
1 
4.0 hr. post treatment 
1 
6.0 hr. post treatment 
1 
8.0 hr. post treatment 
2 
24.0 hr. post treatment (C1D1) 
15 
Pre-treatment 
15 
1.0 hr. post treatment 
15 
2.0 hr. post treatment 
15 
4.0 hr. post treatment 
15 
6.0 hr. post treatment 
15 
8.0 hr. post treatment 
16 
24.0 hr. post treatment (C1D15) 
2, 4, 8, 12 
1 
Pre-treatment 
 
9.2.1.2 
Handling of Specimens(s) 
 
For each sample, the date and time of the dose and the date and time of the PK 
sample draw will be recorded and keep as Source Documentation in each individual 
patients chart. 
 
Details for AT13387 PK collection and process are provided in the “AT13387 
Pharmacokinetic Laboratory Manual.”.  Note:  This manual will be disseminated with 
the clinical protocol and is also available to investigators on request from the 
coordinating center. 
 
AT13387 PK Samples 
 
If AT13387 was not administered at Cycle day 8 or 15, PK samples will only be 
drawn for dabrafenib/trametinib for that time point. 
 
1. At each time point, collect 4 mL whole blood PK sample into a properly labeled 4 
mL Lithium Heparin blood collection tube.  Record the date and time each sample 
is collected.  Note the sampling time and volume of blood collection may 
differ with specific protocols and/or regimens.   
 
2. Immediately after collection, gently invert (do not shake) the evacuated blood 
collection tube for 30 seconds, then place on a standard roller for a minimum of 5 
minutes.  If a blood roller is not available, continue to invert the tube a further 8 – 
10 times. Blood samples should be processed into plasma within 1 hour of sample 
collection  
 
3. Centrifuge the tube at 1100 - 1500g for 10-15 minutes at 4-8° C within 1 hour of 


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97 
sample collection. 
 
4. Immediately transfer plasma into two 2.0 mL Matrix TrackMate ScrewTop tubes, 
each containing approximately 0.75 mL of plasma. 
 
5. Store at -20°C until shipped.   
 
6. Ship all frozen plasma samples on dry ice 
 
Details for dabrafenib and trametinib PK collection and process are provided in the 
“Pharmacokinetic Laboratory Manual”.  Note:  This manual will be disseminated 
with the clinical protocol and is also available to investigators on request from the 
coordinating center.Dabrafenib/Trametinib PK Samples 
 
Due to the potential instability of trametinib, pharmacokinetic blood samples collected for the 
determination of trametinib/dabrafenib concentration in plasma will be collected in 2 mL K2-
EDTA blood tubes.   
 
1. At each time point, collect 2 mL whole blood PK sample into a properly labeled 
2mL K2EDTA evacuated blood collection tube. Record the date and time the 
sample is collected.  (Note the sampling time and volume of blood collection 
may differ with specific protocols and/or regimens.)   
 
2. Immediately after collection, gently invert (DO NOT SHAKE) the evacuated 
blood collection tube 8-10 times to mix the K2EDTA anticoagulant with the 
whole blood.  Blood samples MUST be placed on wet ice immediately after 
mixing the blood with the anticoagulant.  Blood samples should be processed into 
plasma within 15 minutes of collection (30 minutes maximum). 
 
3. Centrifuge the sample at 2500 to 3000 rpm for 10 to 15 minutes in refrigerated 
centrifuge to achieve a clear plasma layer over the red cells. The speed and time 
may be varied according to the make and model of centrifuge used.   
 
4. Immediately transfer plasma into a corresponding pre-labeled 1.8 mL NUNC 
tubes (each containing approximately 0.75 mL of plasma). 
 
5. Store at -20 °C until shipped. 
 
6. Ship all frozen plasma samples on dry ice, overnight. 
 
9.2.1.3 
Shipping of Specimen(s) 
 
 
AT13387 PK Samples 
 
The frozen plasma samples for AT13387 will be packed in dry ice sufficient to last 
during transport for 3 days and shipped to: 


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98 
 
BASi Sample Management 
2701 Kent Avenue 
West Lafayette, IN 47906 
USA 
 
An inventory of the samples shipped will accompany the package.  Samples should be 
shipped so they arrive before 4pm, Monday to Friday only. Weekend deliveries are not 
permitted.  
  
Dabrafenib/Trametinib PK Samples 
 
The frozen plasma samples for dabrafenib/trametinib will be packed in dry ice 
(sufficient to last during transport for 3 days) and shipped to:   
 
Carolyn Dugan 
Covance Laboratories Inc. 
Bioanalytical Chemistry Sample Accession Room, 1S - 160 
3301 Kinsman Boulevard 
Madison, WI  53704 
Phone:  608-242-2720   
Fax:  608-242-2735 
Carolyn.Dugan@covance.com 
Madison.SA@covance.com 
Also cc Mark Hoffmann at mark.hoffmann@covance.com 
 
An inventory of the samples shipped will accompany the package.  Samples should be 
shipped so they arrive before 4pm, Monday to Friday only. Weekend deliveries are not 
permitted.  
  
9.2.1.4 
Site(s) Performing Correlative Study 
 
All study sites involved in the study will perform PK analysis. 
 
9.2.2 Tissue analysis of HSP90 clients 
 
9.2.2.1 
Collection of Specimen(s) 
 
Optional tumor biopsies will be performed pretreatment and one week (+/- 3 days) 
after commencing therapy with the combination as part of the phase I dose escalation 
and dose expansion cohorts. Only lesions that are deemed biopsiable through minimal 
risk procedures will be selected.  For each biopsy, if possible, four core biopsy passes 
will be made.  The first and third cores of tissue will be placed in formalin and then 
fixed in paraffin.  The second and fourth cores of tissue will be flash frozen in liquid 
nitrogen and embedded in OCT.  The first core will be used for IHC and primary 
outcome assessment.  The second core will be used for gene and protein expression 
analysis.  The third and fourth cores will be used to augment testing of cores 1 and 2, 
should the first and/or second cores be exhausted, and will be stored for future 


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99 
analysis. 
 
9.2.2.2 
Handling of Specimens(s) 
 
As described above, four cores will be obtained and fixed.  The SOP for collection, 
handling, and processing is attached (Appendix I). Samples will either be stored at the 
individual sites and sent in batch at the time of planned correlative study analysis or 
sent to and stored at the Sullivan Laboratory at MGH. FFPE samples will be stored at 
room temperature.  Frozen samples will be stored in a -80 degree freezer. 
 
9.2.2.3 
Shipping of Specimen(s) 
 
Samples may be sent at the time of collection or in batches via overnight shipping.  
Frozen samples should be sent on dry ice; paraffin blocks may be sent at room 
temperature conditions.  One flash frozen sample will be sent on dry ice to Dr. 
Smalley’s laboratory and the remainder of samples sent to Dr. Sullivan’s laboratory.  
If only one frozen sample is available, this will be sent to Dr. Smalley’s laboratory. 
 
The addresses of the laboratories are: 
 
Sullivan Laboratory 
c/o Mark Hammond 
55 Fruit Street; Jackson 9th Floor 
Boston, MA 02114 
 
Smalley Laboratory 
Moffitt Cancer Center 
12902 Magnolia Drive 
Tampa, FL 33602 
 
 
 
9.2.2.4 
Site(s) Performing Correlative Study   
All sites are expected to participate in these correlative studies. 
 
9.2.3. 
Blood-BRAF Assay 
 
9.2.3.1 
Collection of Specimen(s) 
 
Samples will be obtained via venipuncture at the time of safety lab collection.  One 
10 mL green top (heparinized) tube and 1 serum separator will be required to be 
collected at the following time points: 
• Pretreatment 
• Following the one week lead-in of AT13387 
• Cycle 1, day 15 (in phase I study) 
• Day 1 of every cycle of therapy 


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100 
• At the time of progression 
 
9.2.3.2 
Handling of Specimens(s) 
 
Specimens will either be processed on site using the collection and processing SOP 
(Appendix I) or shipped to the Sullivan Laboratory overnight for processing and 
storage.  Following processing, samples will be stored in a -80 degree freezer until 
batch analysis is performed. 
 
9.2.3.3 
Shipping of Specimen(s) 
 
Unprocessed specimens should be shipped overnight on wet ice (i.e. Freezer packs).  
Previously processed samples may be sent in batches on dry ice via overnight 
shipping.  The address of the laboratory is: 
 
Sullivan Laboratory 
c/o Mark Hammond 
55 Fruit Street; Jackson 9th Floor 
Boston, MA 02114 
 
9.2.3.4 
Site(s) Performing Correlative Study   
 
All study sites are expected to participate in this correlative study. 
 
10. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 14 days prior to start of protocol therapy.  Scans 
and x-rays must be done <4 weeks (28 days) prior to the start of therapy.  Patients who are not 
being treated with AT13387 do not need to have Day 8 and Day 15 assessments done. In the 
event that the patient’s condition is deteriorating, laboratory evaluations should be repeated 
within 48 hours prior to initiation of the next cycle of therapy.  Participants will be required to 
maintain a diary (Appendix D) during each cycle and to bring the diary, unused pills, and all 
medication bottles to the day 1 visit of each cycle. 
 
 


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99 
 
Procedure 
Pre-Study 
Cycle 1 
Cycles 2+ 
End of 
Txt Visit 
28 Day F-U 
Visit 3 
Baseline 1 
Day 12,b 
Day 84 
Day 
154 
Day 12 
Day 8 
Day 15 
 
 
Dabrafenib and Trametinib A 
 
DT --------------------------------------------------------- DT 
 
 
AT13387 B 
 
X 
X 
X 
X 
X 
X 
 
 
Informed Consent a 
X 
 
 
 
 
 
 
 
 
Demographic 
X 
 
 
 
 
 
 
 
 
Medical History 
X 
X 
X 
X 
X 
 
 
 
 
Concurrent Medication 
X 
X 
X 
X 
X 
 
 
 
 
Serum pregnancy test (B-Hcg) c 
X 
 
 
 
 
 
 
 
 
Physical Examination  
X 
X 
X 
X 
X 
 
 
X 
 
Vital Signs (BP, HR, body temperature) 
X 
X 
X 
X 
X 
X 
X 
X 
 
ECOG Performance Status 
X 
X 
X 
X 
X 
X 
X 
X 
 
Dermatology Examination d 
X 
 
 
 
X 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
 
X 
 
 
X 
 
Ophthalmology Examination e 
X 
 
 
 
X 
 
 
 
 
12 Lead EKG f 
X 
X 
X 
X 
X 
X 
X 
 
 
Hematology/Clinical Chemistry g, p 
X 
X 
X 
X 
X 
Xp 
Xp 
X 
 
Echo/MUGA h 
X 
 
 
 
X 
 
 
 
 
Coagulation i 
X 
 
 
 
 
 
 
 
 
Tumor Measurements j 
X 
 
 
 
 
 
 
   
 
Radiological Examination j 
X 
 
 
 
 
 
 
  X j 
 
PK Analysis k 
 
X 
 
X 
 
 
 
 
 
Biopsiesl 
X 
 
X 
 
 
 
 
X 
 
Blood BRAF testingm 
 
X 
 
X 
X 
 
 
X 
 
AE assessment n 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Long term Follow up o 
 
 
 
 
 
 
 
 
 
 
A. Dabrafenib and Tramatinib: doses as assigned; Dabrafenib BID and Trametinib QD. 
B. AT13387: dosing as assigned per dose level. 
1. All Prestudy assessments must be completed within 14 days prior to first dose, except for Scans and Echo that must be done within 28 days prior to first 
dose. 


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100 
2. Assessment throughout the study is calendar based starting from first day of dosing (Day 1) in the first cycle of treatment. Dose interruptions should not alter 
the assessment schedule for any subsequent treatment cycle. Assessments and administration of study medication for each visit can be done within 3 days of 
the projected visit date. However, there must always be at least 6 days between AT13387 infusions. 
3. Follow up visits should be 28 days from last dose of study drugs (± 3 days).  
a. 
Informed Consent can be obtained 28 days prior to the first dose 
b. If within 3 days of screening, this assessment does not need to be repeated on Day 1 of the first dose 
c. 
Serum Pregnancy test (Woman of childbearing potential only) done within 72 hours of first dose. 
d. Dermatological Examination done at screening and then every 8 weeks (2 cycles) 
e. 
Ophthalmological examination is done at screening, week 4, and annually; additional ophthalmic exams will be performed only as symptomatically 
warranted 
f. 
Triple EKG will be collected at at intervals according to the treating institution’s standards prior to each AT13387 infusion 
g. sodium, potassium, carbon dioxide/bicarbonate, BUN creatinine, glucose, calcium, magnesium, phosphorus, AST, ALT, total Bilirubin, Alkaline 
phosphatase, total protein and albumin, LDH, hematology includes CBC with differentials and platelets 
h. Echo/MUGA is done at  screening,  week 4, week 12, week 24 and every 12 weeks thereafter. 
i. 
Includes PT, PT-INR, PTT, repeated as indicated 
j. 
Tumor measurements and radiological exam done every other (odd) cycle within 7 days of day 1 treatment. Documentation (radiologic) must be provided 
for patients removed from the study for progressive disease. Brain CT/MRI is required at baseline for patients with melanoma. 
k. PK for phase 1: Cycle 1 Days 1 and 15; pre, 1, 2, 4, 6, 8, 24 hour post dose, Day 1 in Cycles 2, 4, 8, and 12. 
l. 
In patients with biopsiable disease; pre treatment, Cycle 1 Day 8 (+/- 3 days), at disease progression (if possible) 
m. Blood BRAF analysis performed C1 D1, C1 D15, at the beginning of each subsequent cycle and at disease progression. 
n. AE assessment starting from the day 1 of dosing throughout the study 
o. After 28 day follow up visit, patient is followed for survival only. Survival status is to be collected every 6 months (+/- 2 weeks) for up to 2 years and can be 
completed by phone. Patients removed from study treatment for any reason other than progressive disease will be followed until disease progression or 
death, whichever occurs first. 
p. After cycle 6, hematology/clinical chemistry are collected on Day 8 and Day 15 at the investigator’s discretion. 
4. Physical Exam, Medical History, Concurrent Medications, Vital Signs, ECOG Status, Hematology and Blood Chemistry panels will be completed prior to 
Day 8 and Day 15 treatment. Day 8 and Day 15 assessments are not required for patients who are not receiving AT13387 infusions.


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101
 
11. MEASUREMENT OF EFFECT 
 
Although response is not the primary endpoint of the phase I portion of this trial, patients with 
measurable disease will be assessed by standard criteria.  For the purposes of this study, patients 
should be re-evaluated every 8 weeks.  In addition to a baseline scan, confirmatory scans will 
also be obtained at least 4 weeks following initial documentation of an objective response.  
Every attempt should be made to use a consistent imaging modality for each individual 
participant. 
 
11.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 8 weeks.  In 
addition to a baseline scan, confirmatory scans should also be obtained not less than 4 weeks 
following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
11.1.1 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their 
first treatment with trametinib, dabrafenib, and AT13387. 
 
Evaluable for objective response.  Only those patients who have measurable disease 
present at baseline, have received at least one cycle of therapy, and have had their disease 
re-evaluated will be considered evaluable for response.  These patients will have their 
response classified according to the definitions stated below.  (Note:  Patients who exhibit 
objective disease progression prior to the end of cycle 1 will also be considered 
evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline 
that are evaluable but do not meet the definitions of measurable disease, have received at 
least one cycle of therapy, and have had their disease re-evaluated will be considered 
evaluable for non-target disease.  The response assessment is based on the presence, 
absence, or unequivocal progression of the lesions.  
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥20 mm by chest 
x-ray or as ≥10 mm with CT scan, MRI, or calipers by clinical exam.  All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 


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102 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might not 
be considered measurable.  If the investigator thinks it appropriate to include them, the 
conditions under which such lesions should be considered must be defined in the 
protocol. 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a 
lymph node must be ≥15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor non-measurable) 
since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same patient, these are preferred for selection as target 
lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 
lesions in total, representative of all involved organs, should be identified as target 
lesions and recorded and measured at baseline.  Target lesions should be selected on the 
basis of their size (lesions with the longest diameter), be representative of all involved 
organs, but in addition should be those that lend themselves to reproducible repeated 
measurements.  It may be the case that, on occasion, the largest lesion does not lend itself 
to reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected.  A sum of the diameters (longest for non-
nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and 
reported as the baseline sum diameters.  If lymph nodes are to be included in the sum, 
then only the short axis is added into the sum.  The baseline sum diameters will be used 
as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable 
lesions over and above the 5 target lesions should be identified as non-target lesions and 
should also be recorded at baseline.  Measurements of these lesions are not required, but 
the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 


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103 
11.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers.  All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks before the beginning of the 
treatment. 
 
The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination unless the lesion(s) being 
followed cannot be imaged but are assessable by clinical exam. 
 
Clinical lesions  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm diameter as 
assessed using calipers (e.g., skin nodules).  In the case of skin lesions, documentation by 
color photography, including a ruler to estimate the size of the lesion, is recommended.  
In the case that skin lesions are followed, documentation of pathologic CR of that lesion 
will be made via biopsy in the event that a previously raised lesion becomes flat.  
 
Chest x-ray  Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI  This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have 
slice thickness greater than 5 mm, the minimum size for a measurable lesion should be 
twice the slice thickness.  MRI is also acceptable in certain situations (e.g. for body 
scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement.  Furthermore, the 
availability of MRI is variable globally.  As with CT, if an MRI is performed, the 
technical specifications of the scanning sequences used should be optimized for the 
evaluation of the type and site of disease.  Furthermore, as with CT, the modality used at 
follow-up should be the same as was used at baseline and the lesions should be 
measured/assessed on the same pulse sequence.  It is beyond the scope of the RECIST 
guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases.  Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT  At present, the low dose or attenuation correction CT portion of a combined 
PET-CT is not always of optimal diagnostic CT quality for use with RECIST 
measurements.  However, if the site can document that the CT performed as part of a 
PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), 
then the CT portion of the PET-CT can be used for RECIST measurements and can be 


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104 
used interchangeably with conventional CT in accurately measuring cancer lesions over 
time.  Note, however, that the PET portion of the CT introduces additional data which 
may bias an investigator if it is not routinely or serially performed.   
 
Ultrasound  Ultrasound is not useful in assessment of lesion size and should not be used 
as a method of measurement.  Ultrasound examinations cannot be reproduced in their 
entirety for independent review at a later date and, because they are operator dependent, it 
cannot be guaranteed that the same technique and measurements will be taken from one 
assessment to the next.  If new lesions are identified by ultrasound in the course of the 
study, confirmation by CT or MRI is advised.  If there is concern about radiation 
exposure at CT, MRI may be used instead of CT in selected instances. 
 
Endoscopy, Laparoscopy  The utilization of these techniques for objective tumor 
evaluation is not advised.  However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers  Tumor markers alone cannot be used to assess response.  If markers are 
initially above the upper normal limit, they must normalize for a patient to be considered 
in complete clinical response.  Specific guidelines for both CA-125 response (in recurrent 
ovarian cancer) and PSA response (in recurrent prostate cancer) have been published 
[JNCI 96:487-488, 2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 
2008].  In addition, the Gynecologic Cancer Intergroup has developed CA-125 
progression criteria which are to be integrated with objective tumor assessment for use in 
first-line trials in ovarian cancer [JNCI 92:1534-1535, 2000]. 
 
Cytology, Histology  These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease. 
 
FDG-PET  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis 
of FDG-PET imaging can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If 
the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT  scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal 
FDG-PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing 


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105 
site of disease on CT that is not progressing on the basis of the anatomic images, this 
is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy 
in cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively 
described in the protocol and supported by disease-specific medical literature for the 
indication.  However, it must be acknowledged that both approaches may lead to false 
positive CR due to limitations of FDG-PET and biopsy resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image. 
 
11.1.4 Response Criteria 
 
11.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (Note:  
the appearance of one or more new lesions is also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study. 
 
11.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization 
of tumor marker level.  All lymph nodes must be non-pathological in size (<10 mm 
short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or 


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106 
unequivocal progression of existing non-target lesions.  Unequivocal progression 
should not normally trump target lesion status.  It must be representative of overall 
disease status change, not a single lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion 
of the treating physician should prevail in such circumstances, and the progression 
status should be confirmed at a later time by the review panel (or Principal 
Investigator). 
 
11.1.4.3 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
>4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
>4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once >4 
wks. from baseline** 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**        Only for non-randomized trials with response as primary endpoint. 
***      In exceptional circumstances, unequivocal progression in non-target lesions may be 
            accepted as disease progression. 
 
Note:  Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.”  Every effort should be made to document the 
objective progression even after discontinuation of treatment. 
 
 
 


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107 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
 
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign 
this category when no lesions can be measured is not advised 
 
11.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first 
date that recurrent or progressive disease is objectively documented (taking as reference 
for progressive disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met 
for CR until the first date that progressive disease is objectively documented. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 
11.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or 
death, whichever occurs first. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting 
 
12.1.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  
Information on CTMS reporting is available at http://www.theradex.com/CTMS.  Data 
collection for this study will be done exclusively through Medidata Rave.  Data will be 
submitted by all participating institutions to CTMS at least once every two weeks via 
Medidata Rave. 
 


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108 
Users that have not previously activated their iMedidata/Rave account will receive a 
separate invitation from iMedidata to activate their account.  Account activation 
instructions are located on the CTSU web site, Rave tab under Rave resource materials 
(Medidata Account Activation and Study Invitation Acceptance).  Additional information 
on iMedidata/Rave is available on the CTSU website under the Rave tab at 
http://www.ctsucontact@westat.com.  For CTMS monitored stuidies, after users have 
activated their accounts, please contact the Theradex Help Desk at (609) 799-7580 or by 
email at ctms@theradex.com for additional support with Rave and completion of CRFs. 
 
12.1.2 Responsibility for Data Submission 
Study participants are responsible for submitting data every two weeks to CTMS via 
Medidata Rave.  
12.2 
CTEP Multicenter Guidelines 
 
This protocol will adhere to the policies and requirements of the CTEP Multicenter Guidelines.  
The specific responsibilities of the Principal Investigator and the Coordinating Center (Study 
Coordinator) and the procedures for auditing are presented in Appendix B. 
• The Principal Investigator/Coordinating Center is responsible for distributing all IND 
Action Letters or Safety Reports received from CTEP to all participating institutions for 
submission to their individual IRBs for action as required. 
 
• Except in very unusual circumstances, each participating institution will order DCTD-
supplied agents directly from CTEP.  Agents may be ordered by a participating site only 
after the initial IRB approval for the site has been forwarded by the Coordinating Center 
to the CTEP PIO (PIO@ctep.nci.nih.gov) except for Group studies. 
 
12.3 
Collaborative Agreements Language 
 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI 
under a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical 
Company(ies) (hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer 
Treatment and Diagnosis.  Therefore, the following obligations/guidelines, in addition to the 
provisions in the “Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can 
Agent(s) be transferred or licensed to any party not participating in the clinical study.  
Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall 
be maintained as such by the investigators.  The protocol documents for studies utilizing 
Agents contain confidential information and should not be shared or distributed without the 
permission of the NCI.  If a copy of this protocol is requested by a patient or patient’s family 
member participating on the study, the individual should sign a confidentiality agreement.  A 


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109 
suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and 
use of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the 
date of receipt for review.  Collaborator shall have the right to request that publication be 
delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected.  
Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy 


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110 
review as soon as possible and preferably at least three (3) days prior to submission, but in 
any case, prior to presentation at the meeting or publication in the proceedings.  Press 
releases and other media presentations must also be forwarded to CTEP prior to release.  
Copies of any manuscript, abstract and/or press release/ media presentation should be sent to: 
 
Email:  ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information. 
 
13. STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
This is a phase I trial of the combination of dabrafenib, trametinib, and AT13387 in patients with 
BRAF-mutant advanced solid tumors.  The primary objective of the study is to determine the 
maximum tolerated dose (MTD) of the combination; secondary objectives will provide 
preliminary estimates of efficacy and toxicity.  The escalation and stopping rules imply that the 
incidence rate for DLT will be less than 33% at the MTD.   Following the identification of the 
MTD, an additional 14 patients will be enrolled in a dose expansion cohort at the MTD. 
 
Toxicities and lab values will be graded according to the NCI Common Toxicity Criteria for 
Adverse Events (v4.0).   Dose-limiting toxicities will be scored and will be defined as in Section 
5.2.  
 
Dose escalation will use a standard “3+3” approach, beginning in dose level 1, with dosing and 
rules for escalation and de-escalation described in the tables below. Tolerability assessments will 
be based on cycle 1 alone. The MTD is defined as the highest dose level at which 0 or 1 of six 
patients has experienced a DLT.  If an excessive number of toxicities occur at the initial dose 
level 1, the dose will be reduced to the fall-back dose of -1.  If dose level -1 has excessive 
toxicity, the study will stop. 
 
Dose Level 
Dabrafenib 
[BID/PO] 
Trametinib 
[QD/PO] 
AT13387 
[D1,8,15/IV] 
-1 
75 mg 
1 mg 
180 mg/m2  
1 
150 mg 
1 mg 
180 mg/m2  
2 
150 mg 
2 mg 
180 mg/m2  
3 
150 mg 
2 mg 
220 mg/m2 
4 
150 mg 
2 mg 
260 mg/m2  
 
 
Number of Patients with DLT 
at a Given Dose Level 
 
Dose Escalation Rule 
0 out of 3 
Proceed to the next dose level and enroll 3 patients 
1 out of 3 
Enroll and treat 3 additional patients at this dose level 
 
Dose escalation will be stopped.  The MTD will be one dose below this dose 


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111 
 
The following table shows the probability of escalating the dose for various true, but unknown, 
rates of unacceptable toxicity. 
 
True DLT Rate 
Probability of Dose Escalation 
0.10 
0.91 
0.20 
0.71 
0.30 
0.49 
0.40 
0.31 
0.50 
0.17 
0.60 
0.08 
 
A patient will be replaced if determination of DLT cannot be adequately assessed because of 
rapid disease progression or if treatment is stopped during the first cycle of therapy for reasons 
other than toxicity. 
 
When the MTD had been determined, a total of 14 patients will be enrolled in an expansion 
cohort of patients with BRAF-mutant advanced solid tumors to obtain preliminary toxicity and 
efficacy estimates.  Patients treated at the MTD during the dose escalation phase may be 
included in the expansion cohort.  Toxicity and efficacy rates will be summarized with 90% 
exact binomial confidence intervals.  For a sample of size 14, the confidence intervals will be no 
wider than 0.48. 
The table below summarizes the probabilities of observing at least one patient with a severe or 
unexpected toxicity in the expansion cohort for a range of incidence rates. 
 
True Incidence of Unexpected or Severe Toxicity 
Probability of Observing One or More Patients 
with Toxicity among 14 
0.01 
0.13 
0.03 
0.35 
0.05 
0.51 
0.08 
0.69 
0.09 
0.73 
0.10 
0.77 
0.15 
0.90 
 
> 2 out of 3 
level. Three (3) additional patients will be entered at the next lower dose level if 
only 3 patients were treated previously at that dose.  
1 out of 6 
Proceed to the next dose level. 
≥ 2 out of 6 
se escalation will be stopped.  The MTD will be one dose below this dose level. 
Three (3) additional patients will be entered at the next lower dose level if only 3 
patients were treated previously at that dose. 
If ≥2/3 or ≥2/6 patients at dose 
level 1 experience dose limiting 
toxicities, dose level -1 will be 
enrolled.  If dose level -1 
proves too toxic, the study will 
stop. 
Dose escalation will be stopped.  The MTD will be one dose below this dose 
level. Three (3) additional patients will be entered at the next lower dose level if 
only 3 patients were treated previously at that dose. 
 


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112 
Secondary endpoints that will be assessed for the 14 patients treated at the MTD are: objective 
response rate, progression-free survival (PFS), 6-month PFS, and 1-year overall survival (OS).   
 
Objective response rate is defined as the proportion of patients with complete or partial response 
as their best response to therapy.  At the time of each restaging, patients will be classified as 
achieving complete response (CR), partial response (PR), stable disease (SD), progressive 
disease (PD), or non-evaluable for response according to RECIST (Version 1.1) criteria.  
Objective response will be determined by the best overall response designation recorded between 
the date of first dose of trial therapy and the date of objectively documented disease progression 
or cessation of trial therapy, whichever occurs first.  For patients without documented 
progression or cessation of trial therapy, all available response designations will contribute to the 
objective response determination.   
 
The distributions of progression-free survival (PFS) and overall survival (OS) will each be 
summarized using the product-limit method of Kaplan-Meier. Median times for each endpoint 
will be presented with two-sided, 90% confidence intervals estimated using log(-log(survival)) 
methodology.  Kaplan-Meier estimates of 6-month PFS and 1-year OS will also be presented 
with two-sided, 90% confidence intervals. 
 
13.2 
Sample Size/Accrual Rate 
 
The total enrollment of this trial will be between 4 and 32 evaluable patients. The minimum 
would occur if the triple combination proved too toxic at dose levels 1 and -1 and the trial was 
stopped during the dose escalation phase.  A maximum enrollment of 32 patients reflects four 
complete dose escalation cohorts of 6 patients each and the expansion cohort of 14 total patients 
at the MTD.  Assuming an accrual rate of 2-3 patients per month, we estimate a maximum 
enrollment period of 20 months. 
 
13.3 
Analysis of Secondary, Correlative, and Exploratory Endpoints 
 
The response rate will be presented as a point estimate with a 90% exact binomial confidence 
interval. The one-year disease-free and overall survival after treatment will be estimated using 
the product-limit methods of Kaplan-Meier, and presented with 90% confidence intervals.  
Standard errors will be estimated using log(-log(survival)) methodology. 
 
Correlatives and exploratory endpoints 
 
Pharmacokinetics  
Pharmacokinetic parameters, including maximal plasma or serum concentration (Cmax), area 
under the curve to the last collection point (AUClast), area under the curve for dose interval 
(AUC0-t), and time of maximal concentration (Tmax), will be determined.   Descriptive statistics 
including mean, standard deviation, coefficient of variation, geometric mean, median, minimum 
and maximum will be computed for each pharmacokinetic variable; descriptive statistics for 
natural-log transformed pharmacokinetic variables will also be provided.  
 
 


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113 
 
Exploratory Analyses 
Factors related to prior therapy and features of therapy will be collected and explored with 
respect to efficacy outcomes.  These include whether or not participants had prior treatment with 
any of the following agents – ipilimumab, lambrolizumab, MPDL-3280, or nivolumab – and the 
time of last dose for each.  Subset analyses will be performed to assess for indications of 
differential outcomes.  Additionally, on-study features such as dose reductions or 
discontinuations (of any or all study drugs) will also be taken into consideration. 
 
Evaluation of HSP90 clients 
Correlative studies will be performed to assess how changes in the expression of the key 
signaling proteins relate to patient response. The HSP client proteins and compensatory signaling 
molecules to be studied in the proteomic assay include Pathways and processes involved in the 
cell cycle (CDK1, CDK2, CDK4, cyclin D1, CHK1), receptor tyrosine kinases (ERBB2, 
IGF1R,), RAS/MAPK signaling (NRAS, HRAS, KRAS, SOS1, SHC1, BRAF, ARAF, CRAF, 
MEK1/2, c-Myc), PI3K/AKT signaling (AKT1, AKT2, AKT3, mTOR, CSK, FAK1, GSK3β), 
B-catenin/WNT signaling (APC, Axin, β-catenin, α-catenin), NFκB, Src and MITF.  
 
Furthermore, biopsy specimens will be evaluated by Reverse Phase Protein Array (RPPA) at 
RPPA Core Facility, Functional Proteomics, MD Anderson Cancer Center (Texas, USA). 
Primary targets of interest for analysis of AT13387 effect on relevant HSP90 client proteins in 
tumor biopsy tissue will be evaluated. Frozen biopsy specimens obtained during collection will 
be sent for analysis of protein expression, protein phosphorylation and effects on relevant 
signaling pathways. 10-15 mg of tumor tissue should be provided for protein extraction and all 
tumor tissue must be supplied in Precellys tubes with Precellys beads for homogenization. 
Evaluation will depend upon availability of validated antibodies at MD Anderson Cancer Center. 
Equivalent biopsy speciments embedded in OCT will be evaluated for tumor and necrotic 
content. 
 
In parallel, pre and post-treatment tumor biopsy specimens will be processed for 
immunohistochemistry and stained for HSP client proteins implicated in therapeutic escape 
including BRAF, CRAF, AKT, phospho-AKT and phospho-ERK.  
 
Skyline version 1.3 will used for data evaluation.  Peaks will be evaluated by comparison of their 
elution time and fragment ion signal ratios to their matched internal standards.  All transitions 
above 10% of the base peak were used for quantification.  Data will be exported to Excel for 
calculations of protein quantity, standard deviation, and CV (%).  
 
Adverse Events and Toxicity Data 
 
Adverse events (AEs):  All adverse events recorded during the trial will be summarized. The 
incidence of treatment-emergent adverse events will be summarized according to primary system 
organ class, severity (based on the National Cancer Institute’s Common Terminology Criteria for 
Adverse Events (CTCAE) version5.0), type of adverse event, and relationship to treatment. 
Deaths reportable as SAEs and non-fatal serious adverse events will be listed by patient and 
tabulated by primary system organ class, and type of adverse event.  Any other information 


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114 
collected (e.g. start/end dates, cumulative dose/number of cycles of therapy, duration of adverse 
event, severity, or relatedness to trial medication) will be listed, as appropriate. 
Laboratory abnormalities:  The frequency of notable lab abnormalities (i.e., newly occurring 
CTCAE grade-3 or -4 laboratory toxicities), will be displayed by parameter and treatment cycle. 
Similarly, the frequency of all laboratory abnormalities will be displayed by parameter, worst 
CTCAE grade experienced, and treatment cycle. A separate listing will display notable 
laboratory abnormalities (i.e., newly occurring CTCAE grade-3 or -4 laboratory toxicities).  
 


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the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities.  Support 
Care Cancer.  19:1079-1095. 
 
Long, G.V., A.M. Menzies, A.M. Nagrial, et al.  (2011).  Prognostic and clinicopathologic 
associations of oncogenic BRAF in metastatic melanoma.  J Clin Oncol.  29:1239-1246. 
 
Long GV, Wilmott JS, Haydu LE, et al. (2013) Effects of BRAF inhibitors on human tissue 
before treatment, early during treatment, and on progression. Pigment Cell Melanoma Res. 
Doi :10.1111/pcmr.12098. [Epub ahead of print] 
 
McArthur GA, Young RJ, Sheppard KE, et al. (2012) Clinical significance of genomic 
alterations of the CDK4-pathway and sensitivity to the CDK4 inhibitor PD 0332991 in 
melanoma. J Clin Oncol. 30. 
 
Messersmith, W.A., G.S. Falchook, L.A. Fecher, et al.  (2011).  Clinical activity of the oral 
MEK1/MEK2 inhibitor GSK1120212 in pancreatic and colorectal cancer.  J Clin Oncol.  
29:Abstract 246. 
 
Montagut C, Sharma SV, Shioda T, et al. (2008) Elevated CRAF as a potential mechanism of 
acquired resistance to BRAF inhibition in melanoma. Cancer Res. 68: 4853-61. 
 
Nathanson, K.L., A. Martin, R. Letrero, et al. (2011).  Tumor genetic analyses of patients with 
metastatic melanoma treated with the BRAF inhibitor GSK2118436 (GSK436).  J Clin Oncol.  
29:Abstract 8501. 
 


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Nazarian R, Shi H, Wang Q, et al. (2010) Melanomas acquire resistance to B-RAF(V600E) 
inhibition by RTK or N-RAS upregulation. Nature. 468: 973-7. 
 
Paraiso KH, Xiang Y, Rebecca VW, et al. (2011) PTEN loss confers BRAF inhibitor resistance 
to melanoma cells through the suppression of BIM expression. Cancer Res. 71: 2750-60. 
 
Paraiso KH, Haarberg HE, Wood E, et al. (2012) The HSP90 inhibitor XL888 overcomes BRAF 
inhibitor resistance mediated through diverse mechansims. Clin Cancer Res. 18:2502-14. 
 
Poulikakos PI, Persaud Y, Janakiramam M, et al. (2011) RAF inhibitor resistance is mediated by 
dimerization of aberrantly spliced BRAF (V600E). Nature. doi: 10. 108/nature 10662. [Epub 
ahead of print]  
 
Siegel R, Naishadham D, Jemal A. (2013) Cancer statistics 2013. CA Cancer J Clin. 63(1):11-
30. 
 
Shi H, Moriceau G, Kong X, Lee MK, Lee H, Koya RC, et al. (2012) Melanoma whole-exome 
sequencing identifies (V600E)B-RAF amplification-mediated acquired B-RAF inhibitor 
resistance. Nat Commun.3:724. 
 
Smalley KS, Lioni M, Dalla Palma M, et al. (2008) Increased cyclin D1 expression can mediate 
BRAF inhibitor resistance in BRAF V600E-mutated melanomas. Mol Cancer Ther. 7: 2876-83. 
 
Sosman JA, Kim KB, Schuchter LM, et al. (2012) Survival in BRAF V600-mutant advanced 
melanoma treated with vemurafenib. N Engl J Med. 366(8):707-14. 
 
Sosman, J., K. Kim, L. Schuchter, et al.  (2010).  An open-label, multicenter Phase II study of 
continuous oral dosing of RG7204 (PLX4032) in previously treated patients with BRAF V600E 
mutation-positive metastatic melanoma.  Pigment Cell Melanoma Res.  23:886. 
 
Tap WD, Gong KW, Dering J, et al. (2010) Pharmacodynamic characterization of the efficacy 
signals due to selective BRAF inhibition with PLX4032 in malignant melanoma. Neoplasia. 12: 
637-49. 
 
Tolcher, A.W., J.C. Bendell, A. Patnaik, et al.  (2011).  A phase Ib study of the MEK inhibitor 
GSK1120212 combined with gemcitabine in patients with solid tumors: Interim results.  J Clin 
Oncol.  29:Abstract 278. 
 
Villanueva J, Vultur A, Lee JT, et al. (2010) Acquired resistance to BRAF inhibitors mediated 
by a RAF kinase switch in melanoma can be overcome by cotargeting MEK and IGF-1R/PI3K. 
Cancer Cell. 18: 683-95. 
 
Wagle N, Emery C, Berger MF, et al. Dissecting therapeutic resistance to RAF inhibition in 
melanoma by tumor genomic profiling. J Clin Oncol 2011; 29: 3085-96. 
 
Wang H, Daouti S, Li WH, et al. (2011) Identification of the MEK1(F129L) activating mutation 
as a potential mechanism of acquired resistance to MEK inhibition in human cancers carrying the 
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Weber, J.S., K.T. Flaherty, J.R. Infante, et al.  (2012).  Updated safety and efficacy results from 
a phase I/II study of the oral BRAF inhibitor dabrafenib (GSK2118436) combined with the oral 
MEK 1/2 inhibitor trametinib (GSK1120212) in patients with BRAFi-naïve metastatic 
melanoma.  J Clin Oncol.  30:Abstract 8510. 
 
Wei, M.C., W.X. Zong, E.H. Cheng, et al.  (2001).  Pro-apoptotic BAX and BAK: a requisite 
gateway to mitochondrial dysfunction and death.  Science.  292:727-730. 
 
Willis, S., C.L. Day, M.G. Hinds, and D.C. Huang.  (2003).  The Bcl-2-regulated apoptotic 
pathway.  J Cell Sci.  116:4053-4056. 
 
Yamaguchi, T., R. Kakefuda, N. Tajima, et al.  (2011).  Antitumor activities of JTP-74057 
(GSK1120212), a novel MEK1/2 inhibitor, on colorectal cancer cell lines in vitro and in vivo.  
Int J Oncol.  39:23-31. 
 
Zelboraf.  (2011).  
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202429s000lbl.pdf  (last accessed 26 
April 2013). 
 
Zingone, A., N. Korde, J. Chen, et al.  (2011).  Molecular characterization and clinical 
correlations of MEK1/2 inhibition (AZD6244) in relapse or refractory multiple myeloma:  
analysis from a phase II study.  Blood (ASH Annual Meeting Abstracts).  118:Abstract 306. 


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120 
 
APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 


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121 
 
APPENDIX B 
CTEP MULTICENTER GUIDELINES 
 
If an institution wishes to collaborate with other participating institutions in performing a 
CTEP sponsored research protocol, then the following guidelines must be followed. 
 
Responsibility of the Protocol Chair  
• The Protocol Chair will be the single liaison with the CTEP Protocol and Information 
Office (PIO).  The Protocol Chair is responsible for the coordination, development, 
submission, and approval of the protocol as well as its subsequent amendments.  The 
protocol must not be rewritten or modified by anyone other than the Protocol Chair.  
There will be only one version of the protocol, and each participating institution will use 
that document.  The Protocol Chair is responsible for assuring that all participating 
institutions are using the correct version of the protocol. 
• The Protocol Chair is responsible for the overall conduct of the study at all participating 
institutions and for monitoring its progress.  All reporting requirements to CTEP are the 
responsibility of the Protocol Chair.  
• The Protocol Chair is responsible for the timely review of Adverse Events (AE) to assure 
safety of the patients. 
• The Protocol Chair will be responsible for the review of and timely submission of data 
for study analysis. 
 
Responsibilities of the Coordinating Center 
• Each participating institution will have an appropriate assurance on file with the Office 
for Human Research Protection (OHRP), NIH.  The Coordinating Center is responsible 
for assuring that each participating institution has an OHRP assurance and must maintain 
copies of IRB approvals from each participating site.  
• Prior to the activation of the protocol at each participating institution, an OHRP form 310 
(documentation of IRB approval) must be submitted to the CTEP PIO. 
• The Coordinating Center is responsible for central patient registration.  The Coordinating 
Center is responsible for assuring that IRB approval has been obtained at each 
participating site prior to the first patient registration from that site. 
• The Coordinating Center is responsible for the preparation of all submitted data for 
review by the Protocol Chair. 
• The Coordinating Center will maintain documentation of AE reports.  There are two 
options for AE reporting: (1) participating institutions may report directly to CTEP with a 
copy to the Coordinating Center, or (2) participating institutions report to the 
Coordinating Center who in turn report to CTEP.  The Coordinating Center will submit 
AE reports to the Protocol Chair for timely review. 
• Audits may be accomplished in one of two ways:  (1) source documents and research 
records for selected patients are brought from participating sites to the Coordinating 
Center for audit, or (2) selected patient records may be audited on-site at participating 
sites.  If the NCI chooses to have an audit at the Coordinating Center, then the 
Coordinating Center is responsible for having all source documents, research records, all 
IRB approval documents, NCI Drug Accountability Record forms, patient registration 
lists, response assessments scans, x-rays, etc. available for the audit. 


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Inclusion of Multicenter Guidelines in the Protocol 
• The protocol must include the following minimum information:  
➢ The title page must include the name and address of each participating institution and 
the name, telephone number and e-mail address of the responsible investigator at each 
participating institution. 
➢ The Coordinating Center must be designated on the title page. 
➢ Central registration of patients is required.  The procedures for registration must be 
stated in the protocol. 
➢ Data collection forms should be of a common format.  Sample forms should be 
submitted with the protocol.  The frequency and timing of data submission forms to 
the Coordinating Center should be stated. 
➢ Describe how AEs will be reported from the participating institutions, either directly 
to CTEP or through the Coordinating Center. 
➢ Describe how Safety Reports and Action Letters from CTEP will be distributed to 
participating institutions. 
 
Agent Ordering 
• Except in very unusual circumstances, each participating institution will order DCTD-
supplied investigational agents directly from CTEP.  Investigational agents may be 
ordered by a participating site only after the initial IRB approval for the site has been 
forwarded by the Coordinating Center to the CTEP PIO.  
 
 
 


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APPENDIX C 
INFORMATION ON POSSIBLE DRUG INTERACTIONS 
 
Information on Possible Interactions with Other Agents for Patients and Their Caregivers 
and Non-Study Healthcare Team 
 
The patient ____________________________ is enrolled on a clinical trial using the 
experimental agents AT13387, Dabrafenib mesylate and trametinib dimethyl sulfoxide.  This 
clinical trial is sponsored by the National Cancer Institute.  This form is addressed to the patient, 
but includes important information for others who care for this patient.  
 
AT13387, dabrafenib mesylate, and trametinib dimethyl sulfoxide interact with many drugs that 
are processed by your liver.  Because of this, it is very important to tell your study doctors about 
all of your medicine before you start this study.  It is also very important to tell them if you stop 
taking any regular medicine, or if you start taking a new medicine while you take part in this 
study.  When you talk about your medicine with your study doctor, include medicine you buy 
without a prescription at the drug store (over-the-counter remedy), or herbal supplements such as 
St. John’s wort.  
 
Many health care prescribers can write prescriptions.  You must also tell your other prescribers 
(doctors, physicians’ assistants or nurse practitioners) that you are taking part in a clinical trial. 
Bring this paper with you and keep the attached information card in your wallet.  These are 
the things that you and they need to know:  
 
Dabrafenib mesylate interacts with certain specific enzymes in your liver.  
• The enzymes in question are CYP450 3A4, 2C8, 2C9, 2C19, 2B6.  Dabrafenib mesylate 
levels are affected by some of these enzymes and can lower the levels of other medicines 
you take. 
• Dabrafenib mesylate must be used very carefully with other medicines that need these liver 
enzymes to be effective or to be cleared from your system. 
• Other medicines may also affect the activity of the enzyme. 
o Substances that increase the enzyme’s activity (“inducers”) could reduce the 
effectiveness of the drug, while substances that decrease the enzyme’s activity 
(“inhibitors”) could result in high levels of the active drug, increasing the chance 
of harmful side effects.  Dabrafenib mesylate should not be taken with any other 
drugs that are strong inducers or inhibitors of CYP 3A4 or 2C8.  Prohibited 
medications include azole antifungals, some antiepileptic drugs, some antibiotics 
and some immunosuppressants.  Please check with the study investigator before 
prescribing or dispensing strong inhibitors/inducers of CYP 3A4 or 2C8. 
Mild/moderate inhibitors/inducers should be used with caution. 
o Dabrafenib mesylate is considered an inducer of CYP 3A4, CYP2C8/9, 2B6 and 
possibly and 2C19, meaning that it can decrease the levels of other drugs that are 
processed by these enzymes.  This can lead to harmful side effects and/or reduce 
the effectiveness of those medications.    
• You and healthcare providers who prescribe drugs for you must be careful about adding or 
removing any drug in this category. 
• Before you start the study, your study doctor will work with your regular prescriber to 


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124 
switch any prohibited medicines that are considered “strong inducers/inhibitors or 
substrates of CYP 3A4 and 2C8.” 
• Your prescribers should look at this web site 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx 
•  or consult a medical reference to see if any medicine they want to prescribe is on a list of 
drugs to avoid. 
• Please be very careful!  Over-the-counter drugs have a brand name on the label—it’s 
usually big and catches your eye.  They also have a generic name—it’s usually small and 
located above or below the brand name, and printed in the ingredient list.  Find the 
generic name and determine, with the pharmacist’s help, whether there could be an 
adverse interaction. 
• Be careful: 
o If you take acetaminophen regularly:  You should not take more than 3 grams a 
day if you are an adult or 2.4 grams a day if you are older than 65 years of age.  
Read labels carefully!  Acetaminophen is an ingredient in many medicines for 
pain, flu, and cold. 
o If you take herbal medicine regularly:  You should not take St. John’s wort while 
you are taking dabrafenib mesylate 
 
 
Other medicines can be a problem with your study drugs.  
 
• You should check with your doctor or pharmacist whenever you need to 
use an over-the-counter medicine or herbal supplement.  
 
• Your regular prescriber should check a medical reference or call your 
study doctor before prescribing any new medicine for you.  Your study 
doctor’s name is  
 
 
_____________________________________  
 
and he or she can be contacted at  
 
_____________________________________ 


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125 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INFORMATION ON POSSIBLE DRUG INTERACTIONS  
You are enrolled on a clinical trial using the experimental agents 
AT13387, dabrafenib mesylate, and trametinib dimethyl sulfoxide.  
This clinical trial is sponsored by the NCI. Dabrafenib mesylate 
interacts with drugs that are processed by your liver.  Because of this, 
it is very important to: 
➢ Tell your doctors if you stop taking regular medicine or if you start 
taking a new medicine. 
➢ Tell all of your prescribers (doctor, physicians’ assistant, nurse 
practitioner, pharmacist) that you are taking part in a clinical trial. 
➢ Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement. 
 
 
 
 
Dabrafenib mesylate interact with specific liver enzymes called 
CYP 3A4, CYP2C9, and CYP 2C8, and must be used very carefully with 
other medicines that interact with these enzymes. 
➢ Before you start the study, your study doctor will work with your 
regular prescriber to switch any prohibited medicines that are 
considered “strong inducers/inhibitors or substrates of CYP 3A4 
and 2C8.” 
➢ Before prescribing new medicines, your regular prescribers should 
go to http://medicine.iupui.edu/clinpharm/ddis/table.aspx for a 
list of drugs to avoid, or contact your study doctor.   
➢ Your study doctor’s name is _____________________________ 
and can be contacted at _____________________________.  
 


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126
APPENDIX D DRUG DIARY 
 
 
 
 
 
Participant Name: __________________________ 
Your Doctor_____________________ Phone___________________ 
Your Nurse______________________ Phone___________________ 
Dosing Instructions for Dabrafenib: 
Your dose of dabrafenib is ______ mg made up of ______ - ______ mg tablets. You take two doses of dabrafenib each day. 
Dosing Instructions for Trametinib: 
Your dose of trametinib is ______ mg made up of ______ - ______ mg tablets. You take one dose of trametinib each day. 
• You will take trametinib once per day. You will take dabrafenib twice per day.  
• You should take your first dose of dabrafenib and your dose of trametinib in the morning.  
• You should not eat for two hours before taking dabrafinib and trametinib.  
• You should not eat for one hour after taking dabrafenib and trametinib. 
• Approximately 12 hours after your morning dose of dabrafenib, you should take an evening dose of dabrafenib. You again 
should not eat two hours before and one hour after taking dabrafenib.  
• Dabrafenib should be stored at room temperature. Trametinib should be refrigerated. 
• Vomited doses should not be made up. Missed doses of trametinib should not be made up if more than 6 hours have lapsed 
from the scheduled/planned dose time (i.e. no more than 30 hours from the previous dose). Missed doses of dabrafenib should 
not be made up if it is less than 6 hours until the next scheduled dose. 
• Please contact your study staff immediately if you develop a fever, which is defined as a temperature of 38.5° Celsius or 
101.3° Fahrenheit 
• Each of the study drugs must be kept in the original container they are distributed in 
• Please remember to bring back any unused study drug, all empty containers, and your diary to the next clinic visit 
• Wash your hands with soap and water after taking your dose 
 
Diary Page 126 of 3 
 
Study Participant Self-Administration Drug Diary 
DFCI Study Number: 14-186 


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127 
 
DOSING LOG: Cycle ____ Date of Day 1: ___________ 
Dosing Log Instructions 
• Make sure to indicate the date, time, amount taken and any comments immediately following each dose. 
• Bring your study drug containing all remaining medication, including empty bottles, to each visit. 
• Once complete, provide this signed or initialed and dated dosing log to your study doctor or nurse. 
 
Day  
Date 
Time of Dose 
 
Dabrafenib 
Dose (mg) 
Time of Dose 
 
Dabrafenib 
Dose (mg) 
Time of Dose 
 
Trametinib 
Dose (mg) 
Comments 
If dose was 
vomited, missed 
or skipped, 
indicate reason 
below. 
1 
 
am 
 
pm 
 
am 
 
 
2 
 
am 
 
pm 
 
am 
 
 
3 
 
am 
 
pm 
 
am 
 
 
4 
 
am 
 
pm 
 
am 
 
 
5 
 
am 
 
pm 
 
am 
 
 
6 
 
am 
 
pm 
 
am 
 
 
7 
 
am 
 
pm 
 
am 
 
 
8 
 
am 
 
pm 
 
am 
 
 
9 
 
am 
 
pm 
 
am 
 
 
10 
 
am 
 
pm 
 
am 
 
 
11 
 
am 
 
pm 
 
am 
 
 
12 
 
am 
 
pm 
 
am 
 
 
13 
 
am 
 
pm 
 
am 
 
 
 
Diary Page 2 of 3 


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128 
 
Day  
Date 
Time of Dose 
 
Dabrafenib 
Dose (mg) 
Time of Dose 
 
Dabrafenib 
Dose (mg) 
Time of Dose 
 
Trametinib 
Dose (mg) 
Comments 
If dose was 
vomited, missed 
or skipped, 
indicate reason 
below. 
14 
 
am 
 
pm 
 
am 
 
 
15 
 
am 
 
pm 
 
am 
 
 
16 
 
am 
 
pm 
 
am 
 
 
17 
 
am 
 
pm 
 
am 
 
 
18 
 
am 
 
pm 
 
am 
 
 
19 
 
am 
 
pm 
 
am 
 
 
20 
 
am 
 
pm 
 
am 
 
 
21 
 
am 
 
pm 
 
am 
 
 
22 
 
am 
 
pm 
 
am 
 
 
23 
 
am 
 
pm 
 
am 
 
 
24 
 
am 
 
pm 
 
am 
 
 
25 
 
am 
 
pm 
 
am 
 
 
26 
 
am 
 
pm 
 
am 
 
 
27 
 
am 
 
pm 
 
am 
 
 
28 
 
am 
 
pm 
 
am 
 
 
 
 
 
 
 
 
 
Diary Page 3 of 3 
Participant Signature or Initials 
 
Date 


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127
APPENDIX E            PREGNANCY REPORT FORM 
 
 
SAE FAX NO:  (301) 230-0159
Alternate Phone FAX NO:  (301) 897-7404
    ALTERNATE
Ticket Number:_______________
Attach to AdEERS Report
NOTE:  The patient should have appropriate follow-up as deemed necessary by their physician. 
 
If the the baby is born with a birth defect or anomaly, then a second AdEERS report is required.
 
 
 


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APPENDIX F 
CONCOMITANT MEDICATIONS AND NON-DRUG THERAPIES 
1.1. 
Permitted Medications and Non-Drug Therapies 
The investigator must be informed as soon as possible about any medication taken from the time 
of screening until 30 days after the last dose of study treatment.  Any concomitant medication(s), 
including dietary supplements, taken during the study will be recorded in the eCRF.  The 
minimum requirement is that drug name, dose, and the dates of administration are to be recorded.  
Additionally, a complete list of all prior surgical procedures will be recorded in the eCRF.   
Subjects should receive full supportive care during the study, including transfusions of blood and 
blood products, and treatment with antibiotics, anti-emetics, anti-diarrheals, and analgesics, and 
other care as deemed appropriate, and in accordance with their institutional guidelines.  Use of 
anticoagulants such as warfarin is permitted provided that INR is monitored in accordance with 
local institutional practice.   
1.2. 
Prohibited Medications and Non-Drug Therapies 
The use of certain medications and illicit drugs within 28 days or 5 half lives, whichever is 
shorter, prior to randomization and for the duration of the study will not be allowed.  
The following medications or non-drug therapies are also prohibited while on treatment in this 
study: 
• 
Other anti-cancer therapies; 
• 
Other investigational drugs; 
• 
Antiretroviral drugs (Note: Subjects with known HIV are ineligible for study 
participation); 
• 
Herbal remedies (e.g., St. John’s wort); 
• 
Dabrafenib is metabolized primarily by Cytochrome P450 (CYP) 2C8 and CYP3A4.  
Co-administration of dabrafenib with ketoconazole, a CYP3A4 inhibition, or with 
gemfibrozil, a CYP2C8 inhibitor, resulted in increases in dabrafenib AUC of 71% and 
47%, respectively.  Drugs that are strong inhibitors or inducers of CYP3A and CYP2C8 
(see list in Table 1) may only be used under special circumstances (e.g. as a single use 
for a procedure) while treatment with study drug is interrupted as they may alter 
dabrafenib concentrations; consider therapeutic substitutions for these medications.  
Approval of the CTEP medical monitor is required in these situations. The list may be 
modified based on emerging data. Refer to the SPM for the most current list.  


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129 
Table 1 
Prohibited Medications 
PROHIBITED – strong inducers of CYP3A or CYP2C8, since concentrations of dabrafenib may be 
decreased 
Class/Therapeutic Area 
Drugs/Agents 
Antibiotics 
Rifamycin class agents (e.g.,  rifampin, rifabutin, rifapentine),  
Anticonvulsant 
Carbamazepine, oxcarbazepine phenobarbital, phenytoin, s-mephenytoin  
Miscellaneous 
bosentan, St. John’s wort 
PROHIBITED – Strong inhibitors of CYP3A, or CYP2C8 since concentrations of dabrafenib may 
be increased 
Class/Therapeutic Area 
Drugs/Agents 
Antibiotics 
Clarithromycin, telithromycin, troleandomycin 
Antidepressant 
Nefazodone 
Antifungals 
Itraconazole, ketoconazole, posaconazole, voriconazole 
Hyperlipidemia 
Gemfibrozil  
Antiretroviral 
ritonavir, saquinavir, atazanavir 
Miscellaneous 
Conivaptan  
 
1.3. 
Medications to be Used with Caution 
The following medications should be used with caution as their concentrations may be altered by 
dabrafenib or they may alter dabrafenib concentrations: 
• 
Drugs that are moderate inhibitors or inducers of CYP3A and CYP2C8 as they may 
alter concentrations of dabrafenib. 
• 
Dabrafenib has been shown to induce CYP3A4 and CYP2C9 in vivo using midazolam  
(CYP3A4 substrate) and S-warfarin (CYP2C9 substrate).  Dabrafenib is an in vitro 
inducer of CYP2B6 and other enzymes such as CYP2C8, CYP2C19, UDP-glucuronyl 
transferases. Transporters may also be affected.  Co-administration of dabrafenib and 
medications which are affected by the induction of these enzymes (including warfarin) 
and transporters may result in loss of efficacy.  If co-administration of these 
medications is necessary, investigators should monitor subjects for loss of efficacy or 
consider substitutions of these medications. A partial list of these medications is 
provided in Table 2 and in the SPM. 
• 
Therapeutic level dosing of warfarin can be used with approval by the CTEP Medical 
Monitor and close monitoring of PT/INR by the site. Exposure decreased by 37% due to 
enzyme induction when on treatment, thus warfarin dosing may need to be adjusted 
based upon PT/INR. Consequently, when discontinuing dabrafenib, warfarin exposure 
may be increased and thus close monitoring via PT/INR and warfarin dose adjustments 
must be made as clinically appropriate. Prophylactic low dose warfarin may be given to 
maintain central catheter patency.  
Dabrafenib solubility is pH-dependent with decreased solubility at higher pH. Drugs such as proton 
pump inhibitors that inhibit gastric acid secretion to elevate gastric pH may decrease the solubility 
of dabrafenib and reduce its bioavailability. No clinical study has been conducted to evaluate the 


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130 
effect of pH on dabrafenib pharmacokinetics. In an ad-hoc analysis, no differences in Cmax and 
AUC were noted between subjects who reported taking pH-elevating products relative to other 
subjects. Due to the theoretical risk that pH-elevating agents may decrease oral bioavailability and 
exposure to dabrafenib, these medicinal products that increase gastric pH should be used with 
caution when administered with dabrafenibTable 2 
Medications to be used with Caution 
USE WITH CAUTION:  Moderate  inhibitors of CYP3A, or CYP2C8 since concentrations 
of dabrafenib may be increased 
Class/Therapeutic Area 
Moderate CYP3A and CYP2C8 Inhibitors 
Antiarrhythmics 
Diltiazem, verapamil 
Antibiotic 
Erythromycin 
Antifungal 
Fluconazole 
Miscellaneous 
Aprepitant 
USE WITH CAUTION: Co-administration of these drugs with study treatment may result 
in loss of efficacy.  Monitor subjects for loss of efficacy or substitute with another 
medication. 
Class/Therapeutic Area 
CYP3A4, CYP2B6, CYP2C8, CYP2C9, or CYP2C19 
Substrates that May be Affected by Induction  
Analgesics 
Alfentanil, buprenorphine, celecoxib, codeine, fentanyl, methadone, 
oxycodone 
Antiarrhythmics 
Disopyramide, dronedarone, mexiletine, propafenone, quinidine 
Antibiotics 
Chloramphenicol, doxycycline, erythromycin, moxifloxacin  
Anticoagulants/ 
Antiplatelets 
Cilostazole, warfarin 
Anticonvulsants 
Divalproex, lamotrigine, valproate, zonisamide 
Antidepressants and 
Antipsychotics 
Aripiprazole, bupropion, buspirone, desipramine, haloperidol, 
mirtazapine, pimozide, quetiapine, trazodone, amitriptyline, 
clomipramine, imipramine 
Antidiabetics 
Glyburide, saxagliptin, tolbutamide, nateglinide, pioglitazone, repaglinide, 
rosiglitazone 
Antifungals 
Caspofungin, fluconazole, terbinafine 
Antihistamines 
Astemizole, chlorpheniramine, ebastine 
Antihypertensives 
Amlodipine, diltiazem, felodipine, nifedipine, nilvadipine, nisoldipine, 
verapamil 
Antimigraine Agents 
Diergotamine, eletriptan, ergotamine 
Corticosteroids 
Dexamethasone, methylprednisolone, oral budesonide 
Erectile Dysfunction Agents 
Sildenafil, tadalafil, vardenafil 
HMG-CoA Reductase 
Inhibitors 
Atorvastatin, lovastatin, simvastatin 
Hypnotics and Sedatives 
Alprazolam, brotizolam, diazepam, estazolam, midazolam, triazolam, 
zolpidem, zopiclone 
Immunosuppressants 
Everolimus, sirolimus, tacrolimus 
Miscellaneous 
Aprepitant, cisapride, darifenacin, disopyramide, leflunomide, 
methohexital, oral contraceptives, quinine, ranitidine, solifenacin, 
sulfasalazine, tramadol, tolvaptan, chloroquine, zopiclone 
Selective Aldosterone 
Blockers 
Eplerenone 


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USE WITH CAUTION: Co-administration of drugs that increase gastric pH should be 
used with caution when administered with dabrafenib.. 
pH altering agents 
dexlansoprazole. esomeprazole, famotidine, ilaprazole, lansoprazole, 
omeprazole, pantoprazole, rabeprazole, ranitidine 
Abbreviations: CYP = cytochrome P450; HMG-CoA = 3-hydroxy-3-methylglutaryl-coenzyme A. 
 
Questions regarding concomitant medications should be directed to the CTEP Medical Monitor 
for clarification. 


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APPENDIX G 
BIOASSAY TEMPLATES 1 
 
ISOLATION OF PERIPHERAL BLOOD LYMPHOCYTES 
 
Materials. 
1. Histopaque 1077 (Sigma)-for creating Ficoll gradients for cell separation. 
2. 10X Phosphate buffered saline (PBS) 
3. Fetal bovine serum (FBS)-for making freezing media. 
4. Dimethyl sulfoxide (DMSO)-for making freezing media. 
5.Freezing media: 5% DMSO, 95% fetal bovine serum. 
6. Polypropylene centrifuge tubes (50cc). 
7. Nunc freezing vials (1.5 ml). 
Method for the isolation of peripheral blood lymphocytes 
 
Peripheral blood lymphocytes are isolated by Ficoll density centrifugation (47) in a laminar flow hood (BL2).  If a 
BL2 cabinet is not available can be done on the lab bench but try to remove Histopaque and freezing media under 
sterile conditions to avoid bacterial contamination. 
 
1. 
Wearing gloves pour contents of green top heparinized blood collection tube into a 50 cc centrifuge tube. 
2. 
Add 10 ml of  PBS to green top tubes and pool with the blood in the 50 cc centrifuge tube.  If there are two 
green tops pool the blood and PBS into a single 50 cc centrifuge tube. 
3. 
Add 10 ml Histopaque to a new 50 cc centrifuge tube. 
4. 
Carefully layer the blood on top of the Histopaque (Hold the tube with the Histopaque as horizontal as 
possible as you slowly layer the blood, trying not to mix the layers. Alternately you can try to underlay the 
Histopaque below the blood but this can be messy). 
5. 
Centrifuge at 700 x g at room temperature for 12 min. 
6. 
At the interface of the layers will be the PBLs (should be a white layer of cells). At the bottom of the tube will 
be the red cells. Remove some of the plasma above the interface with a 10 ml pipette. Remove the cells at the 
interface with the same pipette, trying not to remove anything below the interface. Transfer to a new 
centrifuge tube. 
7. 
Add enough PBS to fill the 50 cc tube. 
8. 
Centrifuge at 400 x g at room temperature for 5 min. 
9. 
Aspirate the liquid above the cellular pellet. 
10. 
Add 2 ml freezing media to the pellet. Gently pipette up and down and aliquot into two Nunc freezing vials. 
11. 
Store at -80 short term or in liquid nitrogen long term. 
 
 


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APPENDIX H 
BIOASSAY TEMPLATES 2 
 
BLOOD BRAF ASSAY PROTOCOL 
 
RNA from ficoll purified PBMCs is isolated by the trizol method (Invitrogen) (46) and (1 g) reverse 
transcribed to cDNA by standard methods using M-MLV reverse transcriptase (Invitrogen) and oligo 
(dt)15 (Promega). The cDNA is subjected to real time PCR for 18S RNA in order to normalize the 
quantity, as well as quality of the input RNA prior to the next step (ABI for oligo/probe set).   
 
The equilibrated cDNA is PCR amplified using PCR master mix (Promega) and oligonucleotides 
[5(CCATATCATTGAGACCAAATTTGAGATG)3 
and 
5(GGCACTCTGCCATTAATCTCTTCATGG)3] that produces a product of 466 bp including the 
mutation site at position 600. The PCR conditions are 94 for 2 min followed by 40 cycles of 94 for 1 
min, 60 for 2 min and 72 for 2 min with a final incubation of 72 for 7 min.  
 
After cleanup using a nucleospin extract column (Clontech), a portion of the PCR product is digested with 
TSPR1 (restriction site=NNCASTGNN, New England Biolabs, Beverly, Massachusetts, USA) at 65 for 
16h. Only wild-type Braf and not V600E mutant Braf PCR product is digested by this enzyme. This 
digestion is added to reduce the amount of contaminating normal Braf from surrounding and infiltrating 
normal tissue in the blood samples. The TspR1 digestion is not complete resulting in some PCR product 
containing wild-type sequence at position 600.  
 
A 1/100 dilution of the TSPR1 digested material is then PCR amplified a second time using nested 
oligonucleotides 
5(ACGCCAAGTCAATCATCCACAGAG)3 
and 
5(CCGTACCTTACTGAGATCTGGAGACAGG)3 producing a product of 331 bp, which is enriched in 
PCR products containing the position 600 mutation. The conditions of the PCR are the same as the first 
PCR except instead of 40 cycles, the amplification is 45 cycles for PBLs.  
 
After a second cleanup using a nucleo-spin extract column, the DNA (1/1000 dilution) is subjected to a 
BRAF V600E real time PCR as described (german group).   
 
Purified Braf V600E first round PCR product with a known concentration is also run through the assay 
and is used to create a standard curve.  Using the standard curve the amount of end product is determined. 


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APPENDIX I 
BIOASSAY TEMPLATES 3 
 
PROCESSING OF TISSUE SPECIMENS 
 
Adapted from: 
1. Leyland-Jones, B.R. et al.  Recommendations for collection and handling of specimens from 
group breast cancer clinical trials.  J Clinical Oncology, 26 (34): 5638-5644, 2008. 
-Full guidelines from that manuscript are referenced on the World Wide Web at 
http://ctep.cancer.gov/guidelines/spec_bc_grptrials.html  
 
2. University of Texas MD Anderson Cancer Center Institutional Tissue Bank Standard 
Operating Procedures, Version 7.0 
 
 
MATERIALS/EQUIPMENT 
 
 
Liquid Nitrogen in approved LN2 transport carrier 
Surgical mask/eye protection 
Safety glasses or face shield 
Clean Laboratory coat 
Freezer gloves 
Clean protective shoes 
Disposable latex gloves 
Cryovials 
Disposable scalpels or scalpel blades (or single edge 
razor blade) 
Racks for cryovials 
Forceps 
Petri dish 
Histoprep Marker 
OCT cyro-compound 
TissueTek cryomold 
Kimwipes 
10% Neutral Buffered formalin 
100% Isopropanol  
95% Ethanol (alcohol) 
 
 
 
HAZARDOUS MATERIALS 
 
1. 10% Neutral Buffered Formalin 
Formaldehyde : severe eye and skin irritant. Sensitizes by skin and respiratory contact. Toxic 
by ingestion and inhalation. Target organs effects on respiratory system. Corrosive. 
Carcinogen. 
 
Emergency First Aid Procedures:   
Eye: Irrigate immediately with large quantity of 
water for a least 15 minutes. Get medical attention 
immediately 
Skin: Flush with water for at least 15 minutes 
Ingestion: Dilute immediately with water or milk. 
Induce vomiting. Call physician. 
Inhalation:  Remove to fresh air. Give artificial 


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respiration if necessary. 
If released or spilled:  
Use formaldehyde spill kit for small spills of 
1000ml; For larger spills contact Environmental 
Health & Safety 
Waste Disposal Method  
Whatever cannot be saved for recovery or recycled 
should be disposed of according to local, state, and 
federal regulations. 
Respiratory Protection  
If the exposure level is exceeded, wear a full 
facepiece respirator equipped with a formaldehyde 
cartridge. 
Ventilation  
Work in well ventilated areas 
Precautionary Labeling  
Label with formaldehyde label 
Handling and Storage Considerations  
Wash hands thoroughly after handling. Avoid eye 
contact. Protect from freezing and physical damage.  
Store at controlled room temperature, 15-30 C. 
 
 
2. Liquid Nitrogen 
Emergency First Aid 
Procedures:  
For Cold Liquid Frostbite: 
If any liquefied atmosphere gas contacts the skin or eyes, 
remove any clothing that may constrict blood circulation to 
the frozen area. Immediately flood or submerge the affected 
body area with large quantities of clean, unheated water and 
then apply cold compresses. A source of water should be 
nearby and easily accessible wherever liquid nitrogen 
activities are being conducted. If the skin is blistered, or there 
is any chance that the eyes have been affected, get the patient 
to a physician immediately for treatment. 
 
 
For Grogginess or Unconsciousness While Handling Liquid 
Nitrogen: 
If a person seems to become groggy or loses consciousness 
while working with liquid nitrogen, get him to a well-
ventilated area immediately. Use a self-contained breathing 
apparatus if necessary. If breathing has stopped, apply 
artificial respiration. Whenever a person loses consciousness, 
call 911 immediately. 
If released or spilled:  
 
Waste Disposal Method  
 
Respiratory Protection  
 
Ventilation  
 
Precautionary Labeling  
 
Handling and Storage 
Considerations  
Use only containers specifically designed for holding 
liquefied gases 
 
 


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FRESH/FROZEN TISSUE PROCESSING 
 
Processing Options for Fresh/Frozen Tissue: 
• OCT is especially useful for preserving histology, and may improve RNA recovery, and 
thus is recommended. A frozen section resulting from an OCT-embedded specimen will 
provide important information on the presence and quantity of tumor. Moreover, OCT 
prevents the tissue from desiccation and crumbling and also acts as an insulator from 
thermal change and limits ice crystal formation.  If tissue samples are obtained by core 
(punch or needle) biopsies, each core should be separately embedded in the OCT. 
• If OCT processing is not possible, controlled snap-freezing in cooled isopentane or with a 
heat extractor is recommended over simple dry-ice freezing.  Snap-frozen specimens 
should be placed in an appropriate container (e.g., cryovial or cassette) and transferred to 
-80°C or colder for storage 
 
Some guiding principles for fresh/frozen tissue collection include the following 
• Do not slow-freeze. Samples should be snap-frozen. Slow freezing promotes the 
formation of ice crystals, which damage the nucleic acids (e.g., RNA) in the specimen. 
The slower a sample freezes, the larger the ice crystals. Older models of cryostats 
(bath/dewar or vacuum type) that require > one minute to freeze a specimen should be 
avoided. 
• Do not place the specimen directly in liquid nitrogen.  Instead, place the OCT-filled 
cryomold onto a stable structure (i.e. Petri dish) that is on the surface of the liquid 
nitrogen. 
• If only dry ice is available, adding alcohol (e.g., isopropanol or ethanol) to the dry ice can 
make a slurry that will help freeze the specimen more effectively (the alcohol will 
increase the thermal conductivity of the dry ice). This, however, is not a preferred over 
liquid nitrogen for snap-freezing. 
• Do not add serum to the specimen 
• Do not touch the biopsy without sterile gloves 
• Sterile or disposable equipment should be used, including for dissection and for snap-
freezing. 
• Instruments should be changed or cleaned between dissecting normal and tumor tissue. 
• If a pen is used to label cryovials or other receptacles that will be stored in freezing 
conditions, ensure that the pen is waterproof/solvent-proof and can withstand long-term 
freezing conditions. 
• Copies of any relevant pathology reports and material submission forms should be sent 
along with the specimens to the central bank. Reports should be coded in a way they can 
be matched to the specimen(s) while also protecting patient confidentiality requirements. 
• If possible, representative adjacent normal tissue should be provided in addition to the 
tumor tissue. Normal tissue should be maximally distant from the tumor (minimum 2 


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cm).  Collection of germline DNA (i.e. from PBMCs) should be considered in all 
protocols that include the collection of tumor tissue for DNA isolation.  
 
Size/Number of fresh/frozen biopsies 
Punch biopsies (4-6 mm preferred, 2 mm minimum) of cutaneous and subcutaneous lesions are 
preferable to core needle biopsies.  A single biopsy is generally sufficient for research purposes. 
 
Core needle biopsies: It should be stressed that core biopsy – whether collected as fresh/frozen or 
FFPE – is superior to fine needle aspiration (FNA) (Singh, 2007). Cores are more representative 
than FNA, providing more accurate diagnostic information – including invasive versus in situ, 
grade, percent tumor, and other important histopathologic information.  The minimum size for 
fresh/frozen tissue collection is generally 0.25 cubic cm, which is generally achieved with 
approximately four passes of a 14-gauge needle. In the diagnostic setting, the collection of 2-4 
fresh/frozen cores for research is recommended, in addition to 2 cores for diagnosis.  The 
fraction of cores that will contain viable tumor will decrease if/as the tumor shrinks in response 
to therapy. Therefore, fewer cores may be obtainable as lesions grow smaller.   
 
If a previous biopsy site is noted in the specimen to be sampled, biopsies should not be taken 
from near that site. Core biopsies alter the biology of tissue – e.g., they introduce inflammatory 
material from wound reaction and biomolecules involved in wound healing – which can be 
problematic if a subsequent core taken from that tissue is used for assay development. Notably, 
genes involved in wound healing are very similar to those involved in cancer progression (Riss et 
al., 2006). 
 
Fresh/Frozen Tissue Collection in the Surgical Setting 
During surgery, fresh/frozen tissue may be acquired by the transfer of the surgical specimen 
from the operating room to the pathology department in a tumor container without fixatives. 
Once it arrives in the pathology department, the sample may be sectioned, and then cores taken 
with a punch biopsy instrument and snap-frozen. This method is preferred if ischemia time can 
be limited to 30 minutes or less.  Note: use a sterile RNAse free container if RNA work will be 
done with any of the tissue. 
• Alternative: Taking cores and immediately freezing them in the operating room – i.e., a 
core biopsy is taken from the specimen immediately after the specimen is removed from 
the patient. Operating room acquisition of cores from the specimen right after excision 
helps keep ischemia time under 10 minutes, especially in situations where pathologists 
are some distance from the operating room. 
 
Time to Freezing and Storage Temperature for Fresh/Frozen Samples 
• Fresh tissue samples should be frozen as soon as possible. If they cannot be frozen 
immediately, they should be frozen within 30 minutes. 
• Once snap-frozen, samples should be immediately transferred either to liquid nitrogen 
(preferred) or to a -80°C freezer. Specimens should be carried to such freezers on dry ice. 
• Frozen samples should be stored long-term either in liquid nitrogen or in a locked freezer 
with a temperature of -80°C or colder. The freezer should be on electrical emergency 
power line and alarmed. If future uses of the tissue are unknown, storing the tissue in the 
vapor phase of liquid nitrogen will help to ensure long-term viability. 


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• Storage equipment may include small (2x3 inch) plastic, zip-top bags; mega-cassettes 
(for example, with each tissue or cryomold wrapped in aluminum foil); and cryoboxes 
and plastic racks (cryovial storage). 
 
Quality Assurance for Fresh/Frozen Samples 
A frozen section should be cut from the OCT block and stained with H&E to confirm tumor 
presence, percent of tumor cells, preservation of morphology, and the presence of any 
undesirable material, such as necrotic or inflammatory material.  The H&E slide may be used as 
a guide to isolate specific portions of the sample for molecular analyses (i.e. viable tumor; 
adjacent normal tissue; etc). 
 
Database Annotation for Fresh/Frozen Tissue Collection 
When possible, the following should be recorded on the specimen submission form with respect 
to fresh/frozen tissue collection: 
• Time before freezing:  if >30 minutes, note time in 15-minute increments beyond 30 
minutes.  
• Freezing temperature 
• If previous punch biopsy(ies) were performed on the patient or noted in the specimen 
• Time point of sample – e.g., after which cycle of therapy 
 
LABELING 
Vials, including cryovials, should be labeled with the study name or number, a specimen ID 
number that is linked to the subject’s study ID, contents of the vial, and date of collection. The 
subject’s study ID should not be on the vial unless patient confidentiality is determined to be 
secure according to the clinical trial protocol.  Specific procedures for labeling specimens should 
clearly be defined in the protocol. The central bank itself should have standardized labeling 
(printed or written) for archiving samples, such as unique sample IDs and or barcodes.  The 
information included on a sample label must not include patient-identifying information, and 
should be compliant with the Health Insurance Portability and Accountability Act (HIPAA). The 
information should be sufficiently specific such that the encoded information (e.g., tracking 
number) can be linked to the sample in the database. 
 
 
 


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Recommended Procedures for OCT Embedding and Snap-Freezing 
Specimen Preparation Prior to Fixation 
- 
Using universal precautions, remove any excess blood from the tissue using a paper towel 
or kimwipe.  
- 
Tissue should be cut on a dissection board using a razor blade or scissors with at least one 
dimension at a maximum thickness of 0.5 cm.  
- 
Discard any unused tissue according to procedures for disposing of biological waste 
material. 
- 
Discard the blade according to procedures for disposing of contaminating sharps. 
- 
Weigh each section of the specimen prior to fixation 
- 
For labeling, Markers specifically made for cryo temperatures are recommended 
(alcohol-based permanent markers will smudge). 
- 
Note: if any of the tissue will be used for RNA work later use RNAse free technique. 
 
1. OCT Embedding 
a. Pre-Procedure Preparation: label cryomolds with permanent marker or printed 
cryolabel, and prepare (preferably print) sticker labels for foil wrappers.  Labels 
should include sample ID number, tissue type, and date.  Place cryomolds on a flat 
surface in a manner that will allow for easy differentiation of those intended for 
normal tissue and those for tumor tissue. 
b. When sample is available, fill the bottom of each cryomold with a thin layer (less 
then 1 mm) of OCT by slowly and carefully filling the mold. It is important to avoid 
formation of bubbles and avoid uneven surfaces. 
c. Weigh each section of the specimen prior to placing it in a cryoomold. Record the 
weight in appropriate log and database 
d. If possible, pre-chill the prepared cryomold (step b). This can be done by: (1) setting 
on ice for 2-5 minutes, or (2) just prior to transferring specimen (step e) partially 
freezing by holding over liquid nitrogen until OCT starts to become cloudy. 
e. Transfer the specimen to the OCT-filled cyromold using forceps. 
f. Cover the tissue with OCT; ensure the top surface of the OCT compound completely 
covers the tissue and is level.  
g. The OCT can be hardened by placing a Petri dish on the surface of liquid nitrogen 
and, using forceps, place the filled cryomold in the Petri dish. Avoid allowing the 
cryomold to come in direct contact with the liquid nitrogen.  Specimen(s) are 
sufficiently frozen when the OCT has become completely white and hard. 
h. After the OCT has hardened, place the mold in pre-labeled aluminum foil (heavy duty 
is best) with the appropriate label with the sample identification information. 
i. Place samples on dry ice until transferred to -80° freezer for storage. 
2. Snap Freezing 
a. Pre-Procedure Preparation: Label 1.8 ml cryovials using a permanent cryo-marker 
(EtOH- and freezer-resistant). 
b. To determine specimen weight: record weight of the empty vial, add tissue, then re-
weigh.  Subtract weights to determine the weight of the specimen, and record. 
c. Place specimen in a 1.8ml cryovials using forceps. Use separate forceps for each type 
(tumor, normal) of specimen to avoid cross contamination. 


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d. Tightly secure the cap and submerged in liquid nitrogen for “snap freezing”. Use 
freezer gloves and a face shield during this procedure. Take precautions to avoid 
accidental spillage or spattering of liquid nitrogen. 
e. Place samples on dry ice until transferred to -80° freezer for storage. 
 
FFPE TISSUE PROCESSING 
 
Fixation and paraffin infiltration 
 
One fixative and one buffer type should be used across participating centers. All tissue samples 
should be fixed in 10% neutral phosphate-buffered formalin (i.e., 3.7% formaldehyde), pH 7.  
Resection specimens should be grossly dissected (macrosectioned) prior to fixation, to ensure 
adequate penetration of the fixative; ideally, the sections should be approximately 3 to 5 mm 
thick prior to placement in tissue cassettes for fixation. It is essential that surgical margins are 
appropriately marked and that these steps are carried out by a pathologist or their designate. 
Different blades should be used when dissecting normal tissue vs. tumor tissue.  The time that 
elapses from resection to dissection and formalin fixation (the warm ischemia time) should be 
minimized, and typically should be no longer than 4 hours. Placing the specimen in fixative 
without dissection for overnight or longer is NOT adequate. 
 
The following are recommended acceptable ranges of duration of fixation for FFPE specimens: 
• Biopsies (core, needle, and skin biopsies): 8-24 hours  
• Excision specimens: 12-24 hours in formalin (36 hours -  absolute maximum) 
• Tissue sections (0.25-1.0 grams): Overnight-24 hours in formalin (36 hours -  absolute 
maximum) 
• Weekend specimens:  Although fixing and shipping of specimens over the weekend (i.e., 
Friday-Monday) is discouraged, if specimens must be left in formalin over the weekend, 
they should be oriented, “blocked”, bread-loaf sectioned and placed in a large amount of 
formalin in closed containers. 
 
If the collecting center is not associated with a pathology group and does not have access to a 
tissue processor, then the specimen should be either 1) shipped in formalin on the day of 
collection for next-day delivery to the central bank, or 2) fixed in formalin for no more than 24 
hours and then transferred to 70% ethanol, then shipped to the central bank within a few days.  
Samples should be protected from excessive heat when appropriate by packaging them in a 
styrofoam container (without ice packs).  See Shipping section for more detailed information 
about appropriate packaging of samples. 
 
The following are recommended ranges of time from formalin to paraffin on the processor 
(variable according to the specific manufacturer): 
• 5-8 hrs for biopsies 
• 6-14 hrs for other specimens (time depending on the instrumentation and tissue size) 
 
Completion of the processes of dehydration with alcohols, clearing with xylene, and 
impregnation with paraffin is important. Some findings have suggested that extended processor 


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times may result in higher-quality analytes, although which step should be prolonged has not yet 
been determined (Stephen Hewitt, personal communication, 2006). Use of low-melt paraffins has 
been recommended. Contamination with beeswax should be avoided (Hewitt et al., 2008). 
 
Storage of FFPE tissue 
 
FFPE blocks should be stored at temperatures below 80ºF (below 26ºC) in an “office-like” 
environment – i.e., a controlled-temperature environment with room temperature typical for an 
office, and protected from excessive heat (>28C), humidity (>70%), and dryness (<30% 
humidity). FFPE tissue should not be stored in basements (danger of water) or warehouses 
(danger of insects). Light exposure for FFPE tissue is a key problem and should be minimized.  
Storage of unstained FFPE slides (whether from a single block or from a TMA block) should be 
discouraged due to antigen loss (DiVito et al., 2004; Fergenbaum et al., 2004). Biomarker 
analyses may best be carried out on freshly cut FFPE sections.  
 
Annotation of Laboratory Methods for FFPE samples 
 
We recommend that fixative type, buffer type, and time from resection to dissection and formalin 
fixation should be reported and recorded in the central bank’s database. 
 
 
Recommended Procedures for Formalin-Fixation of Tissues 
 
1. Preserving the tissue in formalin enables the embedding of specimens into paraffin blocks. 
Neutral buffered formalin is used to stabilize protein in fresh tissue, and prevent autolysis 
and putrefaction.  
a. Specimens intended for formalin fixation should be processed after the completion of 
other fresh tissue procedures such as snap freezing, embedding in OCT compound, 
and submersion in RNA stabilizing reagent. 
b. Minimize time interval 
i. The time interval from of removal of tissues to fixation is very important in 
this procedure. The faster the tissue is placed in fixative, the better. Artifact 
will be introduced by drying, so if tissue is left out, please keep it moist with 
saline. The longer the interval between excision and fixation, the more cellular 
organelles will be lost and the more nuclear shrinkage and artifactual 
clumping will occur. 
c. The volume of formalin should be a minimum of 15-20 times the volume of the tissue 
sample – e.g., 20ml of formalin per 1cm3 of tissue. 
d. Sectioning tissue for better penetration  
i. Penetration of tissues depends upon the diffusibility of each individual 
fixative, which is a constant. One way to get around this problem is sectioning 
the tissues thinly (3 to 5 mm). To preserve tissue and process for paraffin 
embedding, cut fresh tissue into appropriate size pieces.  
ii. NOTE: Tissues to be fixed and processed should be cut to a size no larger 
than 3-5 mm in thickness. Larger sized tissues will not permeate well with 
formaldehyde and will result in poor fixation and poor cellular morphology. 


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e. Record weight of each section 
i. Weigh the specimen prior to placing it in a tissue cassette. Record the weight 
in appropriate log and database 
f. Labeling  
i. Place specimen in tissue cassette using proper orientation. Be sure to label the 
cassette using the cassette labeler. Include the tissue ID number and the tissue 
type on the cassette. 
ii. Note: If the tissue is for a primary investigator, include their last name and 
protocol number on the side of the cassette. 
g. Fixation 
i. Place cassette in a specimen cup containing a 10:1 ratio of 10% Neutral 
buffered formalin to tissue. Let tissue fix in the 10% formalin at room 
temperature from a minimum of 16 hours up to 24 hr.  
ii. Note: If unable to embed after 24 hours of 10% formalin fixation, transfer 
specimen in specimen cassette to 70% alcohol and embed within 72 hrs. 
 
SHIPPING 
 
Shipping personnel must receive training and be current in certification for biological specimen 
shipping. International Air Transport Authority (IATA) requires recertification every 2 years.  
For international studies, each country should consider identifying a tissue bank where tissue can 
be held before final shipping to a central bank across borders.  A site should consult the central 
bank to determine the best times to ship samples that are frozen. This will help to avoid 
inadvertent thawing due to the evaporation of dry ice. 
 
Batch shipping of samples will help to reduce the time required for organizing shipments and, in 
the case of frozen samples, dry-ice shipping costs (see “Note on Nucleic Acid Extraction”, 
below.) A good guideline for the interval of time between procurement and shipment is one 
month. 
 
Packaging for All Specimens 
Packaging should comply with International Air Transport Association (IATA) criteria (please 
see http://www.iata.org).  If ground overnight is used for FFPE samples, then shipment should 
conform to ground transportation standards (e.g., Department of Transportation packaging 
standards if in the US).  The shipping box should be secured and appropriate stickers should be 
placed, such as “Biological Substance, Category B UN 3373”, and the type of shipment, e.g., 
next-day. The IATA shipping category appropriate to the specimens collected should be used, 
both in labeling and in the training required for packaging. In addition to “Biological Substance, 
Category B, other IATA categories include “Exempt Human Specimens” and “Infectious 
Substance, Category A”. 
 
Packaging for Shipping FFPE Specimens 
Shipment of FFPE blocks requires that the blocks be protected from excessive heat. High 
outdoor temperatures are only one hazard: placement of an unprotected paraffin block on a warm 
surface can result in significant damage that could require re-embedding.  Blocks should be 
individually wrapped or placed in small, jewelry-size, labeled plastic zip-top bags (not 2-10 


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blocks in a single sandwich bag). Blocks should then be placed in a Styrofoam shipping 
container, without dry ice or cold packs. Additional space should be filled with packing peanuts 
and other filler. Use of sealed bags with a desiccant can be used, if deemed necessary, to help 
control humidity. 
 
Slides should be placed in appropriate slide carriers after the Permount has dried. At a minimum, 
the slide container should be wrapped in bubble wrap or placed in a padded envelope. 
 
If alternative tissue block punchers are sent to a site for FFPE tissue collection, they should be 
shipped packed into a sleeve and in secured Styrofoam. 
 
Packaging for Shipping Frozen Specimens 
Multi-level, watertight packaging with the appropriate biohazard and dry ice labels should be 
used to ship frozen solid tissue and aliquoted serum or plasma. These specimens should be 
contained in non-breakable – i.e., non-glass – cryovials or tube containers. 
 
For example: 
• Cryovial is placed into bubble-wrap, then into a plastic zip-top bag containing a sheet of 
absorbent material, for biohazard protection, then the bag and documentation into a 
watertight Styrofoam container packed with dry ice, the content list placed on top of 
Styrofoam container, then the Styrofoam container into a cardboard box with a biohazard 
label and a dry ice label. 
 
Absorbent material, such as cotton balls, paper towels, or bubble wrap, should be used for 
additional cushioning as needed. Fragile containers should be wrapped with cushioning material. 
Again, though, plastic (not glass) vials should be used. 
 
Shipping containers should not be sealed airtight so that CO2 gas created from the evaporation of 
dry ice can escape the container. Pack dry ice and samples with paper, cardboard, or Styrofoam 
so that as the dry ice sublimates the samples will not move freely inside of the insulated box. The 
volume of air to which the dry ice is exposed should be minimized in order to slow the rate of 
sublimation. If there is any air space after filling the package with dry ice, it should be filled with 
packing peanuts or other material to reduce the volume of air space. 
 
Temperature control for blood and fresh/frozen samples 
• Samples should be shipped overnight, and shipped only Monday through Thursday to 
ensure delivery on a workday. If shipment cannot be made immediately, the samples can 
be stored at the appropriate temperature (e.g., -80°C for frozen tissue) until shipment can 
be made. 
• Notification of shipment to the central repository is encouraged to ensure that specimens 
are properly received and processed. Communication can avoid mishaps due to absence 
or closure of the repository or variations from region to region. Tracking numbers and 
carrier information should be included in the communications. 
• Dry ice should be used for shipping fresh/frozen tissue and aliquoted serum or plasma. 
The amount of dry ice needed will depend on the length of the trip and surrounding 
outside temperature, and should allow for a 24-hour delay in delivery. Discuss the 


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amount required with the shipper in order to ensure that enough dry ice is added in order 
to maintain frozen specimens sufficiently to the destination. 
• EDTA tubes containing blood for germline DNA extraction should be shipped on the 
same day as the blood draw (if possible), unfrozen, on a cold pack conditioned to 
maintain refrigerated temperatures during shipment. Blood should NOT be transported 
frozen, and particularly not at -20ºC. 
• The amount of refrigerant or dry ice (depending on which type of specimen is being 
shipped) should allow for a 24-hour delay in transport. 
• A consideration for larger sites is the inclusion of temperature monitors within the 
shipping containers of frozen specimens to validate that temperature has been maintained 
and indicate if significant warming has taken place. 
 
The “NCI Best Practices for Biospecimens Resources” (June 2007) provides further information 
on specimen storage, under Section B.1.4, “Biospecimen Storage”, pages 4-5 of that document 
(Research, 2007).  
 
 
REFERENCES 
 
 
Divito, K. A., Charette, L. A., Rimm, D. L., and Camp, R. L. (2004). Long-term preservation of 
antigenicity on tissue microarrays. Lab Invest 84, 1071-8. 
Fergenbaum, J. H., Garcia-Closas, M., Hewitt, S. M., Lissowska, J., Sakoda, L. C., and Sherman, 
M. E. (2004). Loss of antigenicity in stored sections of breast cancer tissue microarrays. 
Cancer Epidemiol Biomarkers Prev 13, 667-72. 
Hewitt, S. M., Lewis, F. A., Cao, Y., Conrad, R. C., Cronin, M., Danenberg, K. D., Goralski, T. 
J., Langmore, J. P., Raja, R. G., Williams, P. M., et al. (2008). Tissue handling and 
specimen preparation in surgical pathology: issues concerning the recovery of nucleic 
acids from formalin-fixed, paraffin-embedded tissue. Arch Pathol Lab Med 132, 1929-35. 
Research, N. C. I. O. O. B. a. B. (2007). National Cancer Institute Best Practices for 
Biospecimen Resources  
Riss, J., Khanna, C., Koo, S., Chandramouli, G. V., Yang, H. H., Hu, Y., Kleiner, D. E., 
Rosenwald, A., Schaefer, C. F., Ben-Sasson, S. A., et al. (2006). Cancers as wounds that 
do not heal: differences and similarities between renal regeneration/repair and renal cell 
carcinoma. Cancer Res 66, 7216-24. 
Singh, B. (2007). Initial pathology assessment prior to preoperative therapy. In Preoperative 
Therapy in Invasive Breast Cancer: Reviewing the State of the Science and Exploring 
New Research Directions,  (Bethesda, Maryland). 
 
 


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APPENDIX J 
BIOASSAY TEMPLATES 4 
 
RPPA ANALYSIS 
 
Preparation of tumor lysates for reverse phase protein array (RPPA) analysis 
1. Reagents and materials:  
a. Frozen tumor tissue set on dry ice, scalpel, weighing dish, tweezers, lysis buffer with 
protease inhibitors set on ice, 5ml tubes (round bottom) labeled with sample number 
and set on ice.  
 
b. Lysis Buffer: 1% Triton X-100, 50mM HEPES, pH 7.4, 150mM NaCl, 1.5mM 
MgCl2, 1mM EGTA, 100mM NaF, 10mM Na pyrophosphate, 1mM Na3VO4, 10% 
glycerol, containing freshly added protease and phosphatase inhibitors from Roche 
Applied Science Cat. # 04693116001 and 04906845001, respectively. 
 
c. 4  SDS Sample Buffer: 40% Glycerol, 8% SDS, 0.25M Tris-HCL, pH 6.8. Before 
use, add 2-mercaptoehtanol at 1/10 of volume. 
 
2. Preparation of tumor: 
a. OCT-embedded tumor tissue 
i. Review H&E slide of OCT-embedded tumor with pathologist to select area for 
protein extraction.   
ii. Using the H&E slide as a guide, macrodissect the desired region, keeping the 
OCT base intact.  Submit to histology for preparation of tumor shears, which 
should be cut using a DNAse/RNAse-free blade at -30°C.  The number and 
thickness of shears must be determined by review of the available surface area 
of the tumor (i.e. 4 X 20 um shears).  Shears should be transferred into a sterile 
tube on dry ice, and stored at -80°C until use. 
iii. Add ice-cold lysis buffer to the tube. The volume of lysis buffer is 200 ul per 5 
mg of tumor tissue  
b. Snap-frozen tumor tissue 
i. Remove the tumor tissue from cryovials and set in weighing dish at room 
temperature for a short while (Do not wait for complete thaw). Cut a small piece 
of the tumor and weigh by analytical balance. Try to put the remaining tumor 
tissue back on dry ice as soon as possible. 
ii. Put the small piece of tumor tissue into a 5ml tube on ice. Add ice-cold lysis 
buffer to the tube. The volume of lysis buffer is 200 ul per 5 mg of tumor tissue 
 
3. Generation of protein lysate 
a. 
Homogenize the tumor tissue by electric homogenizer for 8 seconds. The 
tumor tissue should be set on ice while homogenizing to prevent heating. Wash the 
homogenizer probe twice with ice-cold water in between samples and dry the probe 
with Kimwipe.  
 


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b. 
Optional: Set the samples on ice for 10 minutes. 
 
c. 
Transfer the samples to microcentrifuge tubes and centrifuge at 4 C, 
14,000rpm for 10 minutes.  
 
d. 
Collect supernatant (tumor lysates) and transfer to another set of 
microcentrifuge tubes.  
 
e. 
Determine protein concentration by BCA or Bradford reaction and adjust 
protein concentration to 1.3 mg/ml by lysis buffer. 
 
f. 
Mix the cell lysate with 4  SDS sample buffer without bromophenol blue 
(3 parts of cell lysate plus one part of 4  SDS sample buffer). Boil the samples for 5 
minutes. The samples are ready for RPPA processing. If the samples need to be stored 
for later use, store them in –80 C.  
 
4. Submit samples for RPPA analysis at the MD Anderson Functional Proteomics Core Facility.  
Provide at least 35 l of the denatured protein lysate for each sample.  Each tube should be 
clearly labeled.  Also include a Microsoft Excel file list of the sample names, sample order, 
protein concentration and sample volume.  Results for each sample will be reported as load-
corrected, log2 relative protein concentrations for each protein.