Conditions: Melanoma
Keywords: Melanoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 1
Healthy volunteers: no

Brief summary:
This research study is studying a combination of drugs as a possible treatment for BRAF-mutant melanoma.

The drugs involved in this study are:

* Itacitinib (INCB039110)
* Dabrafenib
* Trametinib

Detailed description:
This research study is a Phase I clinical trial, which tests the safety of the investigational drugs and also tries to define the appropriate doses of the investigational drugs to use for further studies. "Investigational" means that the drugs are being studied.

The FDA (the U.S. Food and Drug Administration) has not approved itacitinib as a treatment for any disease.

The FDA has approved dabrafenib and trametinib as a treatment option for Melanoma.

In this research study, the investigators are studying the combination of itacitinib, dabrafenib, and trametinib. The investigators believe this combination of study drugs may stop the participant's cancer cells from growing and spreading. All three of the study drugs are inhibitors. Trametinib may work by binding to the participant's cancer cells to inhibit the cancer cells' signals to decrease cell growth, dabrafenib may work by stopping the participant's cancer cells from duplicating, and itacitinib may work by stopping the participant's tumor cells from living and growing.

Arms:
arm 1: * Dabrafenib is administered orally every 12 hours
* Trametinib is administered orally once a day
* INCB039110 is administered orally once a day

Interventions: intervention 1: Trametinib intervention 2: Dabrafenib intervention 3: INCB039110
Intervention descriptions: intervention 1: Trametinib may work by binding to your cancer cells to inhibit the cancer cells' signals to decrease cell growth. intervention 2: Dabrafenib may work by stopping your cancer cells from duplicating. intervention 3: Itacitinib may work by stopping your tumor cells from living and growing.

Protocol document:
Prot_SAP_000.pdf: 
Protocol Version / Version Date: Amendment 3, Date June 10, 2020
Page 1
DF/HCC Protocol #:
17-380
TITLE:  Phase I study of INCB039110 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 (PI):
David M. Miller, MD, PhD
Massachusetts General Hospital Cancer Center
55 Fruit Street
Boston, MA 02114
Phone - 617-724-4000
Fax - 617-726-1949
Statistician:
      Anita Giobbie-Hurder
450 Brookline Avenue
       Boston, MA 02115
Phone – 617-632-2193
Fax – 617-632-5444
agiohur@jimmy.harvard.edu 
Study Drug: 
INCB039110, Incyte Corporation
IND #:  
136558
IND Sponsor:  
David M. Miller, MD, PhD
Protocol Version / Version Date: Amendment 3, Dated June 10, 2020
NCT03272464


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2
SCHEMA
Phase I Dose Escalation portion 
Expansion portion
*See section 10 for additional information on serial biopsies
Diseases: 
BRAF mutant melanoma
 
R
E
G
I
S
T
E
R
Treatment
  
Dabrafenib/trametinib/INCB039110
  
Start at 
dose level 1
Treat cohort
(3 participants)
Number 
of DLTs
No further 
escalation
Recruit 3 more 
participants
Further 
DLTs?
Stop
Escalate dose
Yes
No
<1
2 or 3
Treat until 
progression
Serial 
biopsy*


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TABLE OF CONTENTS
SCHEMA.......................................................................................................................................................2
1.
OBJECTIVES...................................................................................................................................5
1.1
Phase I Objectives................................................................................................................5
1.2
Study Design........................................................................................................................5
2.
BACKGROUND ..............................................................................................................................6
2.1
Study Disease.......................................................................................................................6
2.2
IND Agent – INCB039110..................................................................................................7
2.3
Other Agents......................................................................................................................16
2.4
Rationale ............................................................................................................................32
2.5
Correlative Studies Background ........................................................................................33
3.
PARTICIPANT SELECTION........................................................................................................34
3.1
Eligibility Criteria..............................................................................................................34
3.2
Exclusion Criteria ..............................................................................................................36
3.3
Inclusion of Women and Minorities ..................................................................................39
4.
REGISTRATION PROCEDURES ................................................................................................39
4.1
General Guidelines for DF/HCC Institutions ....................................................................40
4.2
Registration Process for DF/HCC Institutions...................................................................40
5.
TREATMENT PLAN.....................................................................................................................40
5.1
Pre-Treatment Criteria .......................................................................................................41
5.2
Agent Administration.........................................................................................................42
5.3
Definition of Dose Limiting Toxicity................................................................................43
5.4
General Concomitant Medication and Supportive Care Guidelines..................................44
5.5
Duration of Therapy...........................................................................................................45
5.6
Duration of Follow Up.......................................................................................................45
5.7
Criteria for Removal from Study.......................................................................................45
6.
DOSING DELAYS/DOSE MODIFICATIONS.............................................................................46
6.1
Dabrafenib or Dabrafenib + Trametinib Dose Modifications ...........................................46
6.2
INCB039110 Dose modifications......................................................................................63
7.
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS .........................................64
7.1
Adverse Event Characteristics...........................................................................................65
7.2
Expedited Adverse Event Reporting..................................................................................65
7.3
DF/HCC Expedited Reporting Guidelines.........................................................................66
7.4
Expedited Reporting to the Food and Drug Administration (FDA) ..................................66
7.5
Expedited Reporting to the company Supplying Drug (Incyte) ........................................66
Reporting of Pregnancy ..................................................................................................................67
7.6
Expedited Reporting to Hospital Risk Management .........................................................67
7.7
Routine Adverse Event Reporting .....................................................................................67
8.
PHARMACEUTICAL INFORMATION.......................................................................................67
8.1
Dabrafenib mesylate (GSK2118436B) (NSC 763760)......................................................67
8.2
Trametinib dimethyl sulfoxide (GSK1120212B) (NSC 763093)......................................69


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8.3
INCB039110......................................................................................................................70
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES .....................................................70
9.1
Biomarker Studies..............................................................................................................70
9.2
Pharmacokinetics...............................................................................................................71
10.
STUDY CALENDAR ....................................................................................................................73
11.
MEASUREMENT OF EFFECT.....................................................................................................75
11.1
Antitumor Effect – Solid Tumors ......................................................................................75
12.
DATA REPORTING / REGULATORY REQUIREMENTS........................................................80
12.1
Data Reporting...................................................................................................................81
12.2
Data Safety Monitoring......................................................................................................81
13.
STATISTICAL CONSIDERATIONS............................................................................................81
13.1
Study Design/Endpoints ....................................................................................................81
13.2
Sample Size/Accrual Rate..................................................................................................83
13.3
Analysis of Secondary, Correlative, and Exploratory Endpoints ......................................83
14.
PUBLICATION PLAN ..................................................................................................................85
REFERENCES.............................................................................................................................................86
APPENDIX A
PERFORMANCE STATUS CRITERIA .............................................................91
APPENDIX B
INFORMATION ON POSSIBLE DRUG INTERACTIONS..............................92
APPENDIX C ..............................................................................................................................................95
APPENDIX D
PREGNANCY REPORT FORM .........................................................................98
APPENDIX E
Concomitant Medications and Non-Drug Therapies............................................99
1.1.
Permitted Medications and Non-Drug Therapies ..............................................................99
1.2.
Prohibited Medications and Non-Drug Therapies.............................................................99
1.3.
Medications to be Used with Caution..............................................................................100
APPENDIX F
BIOASSAY TEMPLATES 1 .............................................................................103
APPENDIX G
BIOASSAY TEMPLATES 2 .............................................................................104
APPENDIX H
BIOASSAY TEMPLATES 3 .............................................................................105
APPENDIX I
BIOASSAY TEMPLATES 4 ..........................................................................................116


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1.
OBJECTIVES
1.1
Phase I Objectives
Primary Objective
To determine the maximum tolerated dose (MTD), toxicity, and safety profile of 
INCB039110 given daily in combination with dabrafenib and trametinib in patients with 
BRAF-mutant unresectable or metastatic melanoma and other solid tumors.
Secondary Objectives
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 INCB039110 given 
daily in combination with dabrafenib and trametinib.
To describe the pharmacokinetics of treatment with dabrafenib, trametinib, and INCB039110.
1.2
Study Design
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 INCB039110. The table below 
summarizes the planned dose levels. 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).
Dose Level
Dabrafenib 
[BID/PO]
Trametinib 
[QD/PO]
INCB039110 (mg QD)
-2
75 mg
1 mg
100 mg
-1
150 mg
2 mg
100 mg
1
150 mg
2 mg
200 mg
2
150 mg
2 mg
300 mg
3
150 mg
2 mg
400 mg
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 6 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. Please see section 6.1 for dose modifications of dabrafenib and 
trametinib. If the toxicity is determined to be related to INCB039110 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. 


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2.
BACKGROUND
2.1
Study Disease
The incidence of melanoma has dramatically risen over the past several decades and in 2016, an estimated 
76,380 new cases and 10,130 deaths are expected in the United States.  (American Cancer Society, 2016) 
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, 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).


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2.2
IND Agent – INCB039110
2.2.1
Mechanisms of Action and Preclinical Data with INCB039110
INCB039110 is a potent inhibitor of JAK1 (IC50 value = 3.6 ± 2.3 nM), with 22-fold to > 500-fold 
selectivity over the other JAK family members (Table 1). INCB039110 does not significantly inhibit 
(< 30% inhibition) a broad panel of 60 other kinases, suggesting that it is a selective inhibitor of 
JAK1.
Since INCB039110 has demonstrated selectivity for the JAK1 enzyme compared with JAK2 in 
biochemical assays, its selectivity was examined in cell-based assay systems that measured signaling 
in response to stimulation with TPO or prolactin, since both have been shown to signal through a 
JAK2 homodimer (Murray 2007). In both systems, INCB039110 showed weak inhibition with IC50 
values of approximately 1 μM or greater (Table 2), suggesting that INCB039110 is JAK2-sparing in 
cells.
Despite the reduced potency of INCB039110 against JAK2, INCB039110 was potent (IC50 values of 
approximately 10 nM to 350 nM) in cell-based assays relevant to the pathogenesis of RA, such as IL-
2–stimulated phosphorylation of JAKs and STATs and IL-2–induced proliferation of T cells. This 
effect was not because of general cytotoxicity, as INCB039110 showed no effect on the survival of 
naïve T cells cultured in the absence of cytokine stimulation and did not affect the proliferation of 
non–JAK-dependent cell lines (< 20% inhibition at 5 μM). INCB039110 also potently inhibited the 
phosphorylation of STAT proteins and the production of proinflammatory factors (eg, IL-17, MCP-1) 
induced by other cytokines, such as IL-23 and IL-6, with IC50 values in the range of approximately 
30 nM to 100 nM. These data are summarized in Table 2.


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In addition, the human INA-6 multiple myeloma cell line was used to establish a cell-based assay 
system to investigate the effects of JAK1 inhibition on cell proliferation because this cancer cell line 
requires exogenous IL-6 for in vitro growth and survival (Burger et al 2001). IL-6 has been 
demonstrated to signal through both JAK1 and JAK2, leading to activation of STAT3. It has been 
previously demonstrated that activation of JAK/STAT3 in these cells is dependent on the presence of 
IL-6 and that inactivation of JAK/STAT3 by either withdrawal of IL-6 or inhibition of IL-6 binding 
to the IL-6 receptor induces cell death via apoptosis (Burger et al 2001). In this assay system, 
INCB039110 inhibited INA-6 cell growth with an IC50 of 352 ± 112 nM (Table 2).
In order to estimate INCB039110 potency in blocking JAK activity in hematopoietic cells in vivo, 
where serum protein binding can be a significant factor, a whole blood assay was established that 
measures pSTAT3 in response to cytokine stimulation. In this assay system, pSTAT3 levels in 
response to stimulation with IL-6 or TPO were examined, since JAK1 was shown to have a dominant 
role in IL-6 signaling (Guschin et al 1995) and TPO has been shown to signal through a JAK2 
homodimer (Murray 2007). INCB039110 blocked IL-6– induced STAT3 phosphorylation in human 
whole blood, with an IC50 value of 292 ± 16 nM (n = 27), whereas the potency of INCB039110 in 
blocking TPO-induced pSTAT3 was significantly reduced (2322 ± 178 nM; n = 23), consistent with 
the JAK1 selectivity measured in the biochemical assays. No effects on total STAT3 levels were 
observed at any concentration tested. Similar results were obtained using whole blood from dogs and 
rats, confirming the species cross-reactivity and selectivity of the compound (Table 3).


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2.2.2
Nonclinical safety of INCB039110
INCB039110 was evaluated in vivo in rat adjuvant-induced arthritis (rAIA), as this model is an aggressive 
polyarthritis that shares characteristics with human RA (Waksman 2002). Moreover, multiple cytokines 
are upregulated in this model, including IL-1, IL-6, and TNF-α, and JAK1 phosphorylation has been 
described in the synovial lining cells and macrophages in affected rats (Shahrara et al 2003). In these 
experiments, administration of INCB039110 was initiated in the therapeutic mode after a robust 
inflammatory response was observed.
In aggregate, INCB039110 demonstrated dose-dependent effects on multiple endpoints in the rAIA 
model, including PD suppression of STAT3 phosphorylation and clinical and histological signs of 
disease. Oral doses of 1 mg/kg BID or 3 mg/kg QD are predicted to provide an AUC of approximately 
0.67 to 1.0 μM∙h (based on Sprague Dawley rat PK data). For comparison, the NOAEL from the 28-day 
rat toxicology study was 225 mg/kg, with an associated AUC of 73.6 μM∙h. These data are consistent 
with a therapeutic margin of > 100-fold for BID administration and > 70-fold for QD administration. 
Significant histological improvements were observed at a dose with a predicted AUC of 2.0 μM∙h, 
resulting in a margin of > 35-fold. The data presented above demonstrate the ability of INCB039110 to 
reduce joint inflammation and bone resorption in this relevant preclinical model of RA.
In the INA-6 cytokine-dependent (ie, WT JAK-dependent) model of myeloma, INCB039110 reduced 
tumor growth by a maximum of 6%, 45%, and 57% when continuously infused, achieving plasma 
concentrations of 220 nM, 470 nM, and 783 nM, respectively. Twice-daily oral administration of 
INCB039110 also reduced splenomegaly in a model of JAK2 V617F-driven hematological malignancy – 
BaF/JAK2 V617F. A BID dose of 90 mg/kg reduced splenomegaly by 67% compared with vehicle-
treated mice. Plasma samples collected 1-hour postdose (near tmax) exhibited INCB039110 levels well 
below the concentration required to significantly inhibit JAK2 signaling in rodent whole blood samples 
(Table 3). In summary, pharmacological data obtained in both in vitro and in vivo model systems support 
the potential utility of orally administered INCB039110 in the treatment of MF and RA.
Safety Pharmacology
INCB039110 was studied in a variety of in vitro binding assays against panels of receptors, channels, 
transporters, and other kinases to evaluate specificity for the JAK family of kinases. To assess central 
nervous system (CNS) effects, the gross behavioral and physiological state of rats administered oral doses 
of INCB039110 was evaluated using parameters described in Irwin's functional observational assessment. 
For assessment of respiratory effects, INCB039110 was administered orally to rats followed by the 
measurement of respiratory rate and tidal volume. INCB039110 was also administered orally to 
conscious, telemetered beagle dogs to study the effects of the drug on blood pressure, heart rate, and ECG 
measures.
INCB039110 did not demonstrate inhibition of binding for any of 55 different receptors, channels, and 
transporters evaluated at 0.1 μM and 1 μM; or against approximately 60 non-JAK family kinases 
evaluated at 0.1 μM. Adverse findings in safety pharmacology nonclinical assessments included transient 
decreased motor activity in male and female rats administered a single oral dose of 1000 mg/kg, 
decreased respiratory function in rats administered a single oral dose of 1000 mg/kg, decreased blood 
pressure with a compensatory higher heart rate, and an increase in core body temperature after a single 
oral dose of ≥ 60 mg/kg in the dog cardiovascular evaluation. Administration of ≥ 60 mg/kg INCB039110 
resulted in significantly lower arterial blood pressure (up to 5 hours postdose), compensatory higher heart 
rate (up to 8 hours postdose), and increased core body temperature (up to 12 hours postdose). The 
magnitude of change in pulse pressure was small despite INCB039110-related changes in systolic and 
diastolic blood pressure, suggesting no effect of INCB039110 on myocardial contractility. Although 


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10
changes in arterial blood pressure were noted at 30 mg/kg, the small magnitude and short duration of 
effect led to the determination of the NOAEL to be 30 mg/kg. There were no effects on ventricular 
repolarization at any dose in this study. The IC50 for inhibition of the hERG channel was determined to 
be 65.3 μM.
The toxicologic and toxicokinetic profiles of orally administered INCB039110 were characterized in 
single- and multiple-dose studies of up to 6 months in duration in rats and 9 months in dogs. Embryo-fetal 
developmental toxicity studies were conducted in rats and rabbits, and the potential genetic toxicity of 
INCB039110 was also assessed.
JAKs play an important role in the signaling of a number of cytokines and hematopoietic growth factors. 
Multiple cytokines, including IL-2 and IL-6, signal via JAK enzymes and play an important role in 
lymphocyte differentiation, survival, and function, and JAK2 plays a central role in erythropoiesis and 
thrombopoiesis in humans. INCB039110 is a potent inhibitor of JAK1 with reduced potency for JAK2. 
Therefore, bone marrow and the lymphoid system are the predicted target organs for INCB039110 
pharmacological effects.
Two single-dose studies of orally administered INCB039110 were conducted in rats; the NOAEL was 
defined at the highest dose used in each study, 1200 mg/kg and 2000 mg/kg. In a single-dose study in 
dogs, dose levels were ≤ 1000 mg/kg. Nonadverse clinical signs, including injected sclera, prominent 
nictitating membrane, and emesis were noted at 1000 mg/kg.
Multiple-dose toxicity and toxicokinetic studies of INCB039110 were conducted in rats for up to 6 
months and dogs for up to 9 months. A 4- or 6-week recovery group was included in the GLP studies to 
determine the reversibility of INCB039110-related findings.
Immunophenotyping data revealed that the cell subtypes most affected by INCB039110 administration 
were cytotoxic (CD8+) T cells and natural killer (NK) cells. Consistent with the lower peripheral blood 
lymphocyte counts, a lower proportion of bone marrow lymphoid cells was also observed. In serum 
chemistry evaluations, slight elevations in the liver enzymes alkaline phosphatase (ALP), aspartate 
aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT) were noted and were more prevalent 
in females. In the 6-month study, where dose levels of 0 mg/kg, 30 mg/kg, 100 mg/kg, 300 mg/kg, and 
1000 mg/kg daily were evaluated, increased ALP was noted for females administered ≥ 100 mg/kg daily, 
and increased GGT was noted in females administered 1000 mg/kg daily. There were no liver enzyme 
alterations in male rats in the 3- or 6-month studies. Elevations in AST were observed only in the 28-day 
study. These liver enzyme changes lacked a histological correlate and were deemed nonadverse. All 
clinical pathology and immunophenotyping changes demonstrated reversibility. Histologically, 
INCB039110-related alterations were similar across rat multiple-dose studies and were pharmacological 
in nature. Reversible lymphoid depletion of the thymus, spleen, and lymph nodes, and a reduction in bone 
marrow cellularity were noted. Reversible lower spleen and thymus weights correlated with the lymphoid 
depletion in these tissues. A reduction in adrenal gland weight was also noted in rat multiple-dose studies; 
however, this finding lacked a microscopic correlate and thus was considered nonadverse. Based on body 
weight decreases in males and the magnitude of reduction in circulating lymphocyte counts, the NOAEL 
for male and female rats administered INCB039110 for 6 months was determined to be 300 mg/kg daily, 
corresponding to AUC0-24 values of 28.8 and 86.0 μM·h for males and females, respectively, on Day 
181.
In a 28-day GLP study of orally administered INCB039110 in rats, increased incidences of luteal ovarian 
cysts and epididymal sperm granulomas were observed. These findings were not observed in either the 3-
month or 6–month study at similar plasma exposures to those in the 28-day study and, therefore, are 
determined to be unrelated to INCB039110 administration.


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Four multiple-dose studies of orally administered INCB039110 were conducted in the dog: a 10-day non-
GLP study, and 28-day, 3-month, 6-month, and 9-month GLP studies. In the 10-day, 28-day, and 3-month 
studies, severe clinical signs related to GI toxicity occurred in the higher dose groups, resulting in 
unscheduled terminations. In the 6-month GLP study in dogs, dose levels evaluated were 0 mg/kg, 10 
mg/kg, 20 mg/kg, 30 mg/kg, and 60 mg/kg daily. Despite a lowering of the high-dose level to 50 mg/kg 
daily on Day 45, adverse clinical signs consistent with the immunosuppressive effects of INCB039110 
persisted, and dose administration was subsequently terminated for this dose group during Week 17. In 
the 9-month study, dose levels were 10, 20, 30, and 40 mg/kg per day. A dose-related lowering of CD8+ 
T cells was noted in the immunophenotyping evaluations after at least 17 weeks of dose administration. 
INCB039110-related microscopic findings that were related to the pharmacology included decreased 
lymphocytes in multiply lymphoid organs (white pulp of the spleen, various lymph nodes, gut-associated 
lymphoid tissue) and extramedullary hematopoiesis in the spleen, at doses ≥ 30 mg/kg per day, and bone 
marrow hypocellularity in the sternum, at doses ≥ 20 mg/kg per day. Additional microscopic findings 
were observed in a few animals that were considered secondary to effects on the immune/inflammatory 
response. Based on the adverse findings associated with immunosuppression and development of clinical 
demodicosis, the NOAEL in the 9-month study was determined to be 10 mg/kg daily. At the end of the 
administration phase (Day 269), the NOAEL corresponded to AUC0-24 values of 3.04 μM·h and 5.00 
μM·h, respectively, for males and females.
Using the exposures at the NOAELs from the 6-month toxicology studies in the rat and dog, the estimated 
safety margins associated with the therapeutic dose levels of 600 mg QD (estimated unbound AUC0-24 
of 3.99 μM∙h) and 200 mg BID (estimated unbound AUC0-24 of 2.83 μM∙h) are calculated.
2.2.3
Clinical Pharmacokinetics (PK) and Activity of INCB039110
PK and metabolism of INCB039110
Study INCB 39110-101 was a single, ascending-dose escalation study of INCB039110 IR administered 
orally to healthy adult subjects. Pharmacokinetic data for single doses of 10 mg to 1000 mg are provided 
in Table 4. Curves of plasma concentration versus time are presented in Figure 1. INCB039110 was 
quickly absorbed when administered as IR capsules, attaining plasma Cmax within 1.5 hours after 
administration, and the compound was subsequently eliminated with a mean terminal-phase t½ ranging 
from 1.7 to 2.8 hours. Exposures were greater than dose-proportional over most of the dose range, but 
were dose-proportional between 500 mg and 1000 mg. For the 1000 mg dose, mean Cmax and AUC0-∞ 
were 7.4 μM and 20.7 μM∙h, respectively. There was prolonged absorption seen after 16 hours with an 
apparent t½ of 9.8 hours for the higher doses.
Study INCB 39110-103 was a multiple-dose, double-blind, randomized, ascending-dose escalation study 
of INCB039110 administered orally over a 10-day period to healthy adult subjects. The mean t½ values 
ranged from 6.6 to 13 hours for SR1 (fasted or fed), and 6.5 to 8.1 hours for SR3 (fed only). The extent of 
systemic accumulation was similar among the 6 BID dose regimens, and on average, geometric mean 
Cmax, Cmin, and AUC0–τ increased by approximately 2-fold at the PK steady-state versus after the first 
dose. For the only QD regimen studied (800 mg SR3 fed), the geometric mean Cmax and AUC0–τ 
increased by 9.6% and 15%, respectively.


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Drug-drug interactions
In vitro studies indicate that CYP3A4 is the major isozyme responsible for the metabolism of 
INCB039110 in human liver microsomes. In the human pregnane X receptor (hPXR) reporter gene assay, 
INCB039110 did not induce gene activity, suggesting that the potential for INCB039110 to induce 
CYP3A4 in clinical studies is low. In addition, INCB039110 did not significantly inhibit the activity of 
CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4, suggesting that the potential 
for INCB039110 to cause clinical drug-drug interactions through CYP inhibition is low.
Pharmacodynamic effect of INCB039110
The efficacy of INCB039110 was characterized after continuous administration using subcutaneous 
pumps (Table 5) or when administered orally QD or BID (Table 6). Significant dose-dependent 
improvements in clinical signs of disease as well as histological assessment of inflammation, pannus, 
bone resorption, and cartilage damage in the rat paws were achieved with continuous infusion at plasma 
concentrations of approximately 50 nM, with near maximal effects on clinical scores seen at 
approximately 95 nM. For comparison, the IC50 of INCB039110 for inhibition of IL-6–stimulated 
pSTAT3 is 274 nM (Table 3), suggesting modest inhibition of JAK1 can be efficacious in this model. In 
contrast, similar compound exposures were nearly ineffective in a JAK2-driven pharmacodynamic (PD) 
model in which recombinant EPO induces reticulocytogenesis. This is consistent with the enzymatic and 
cellular selectivity for JAK1 relative to JAK2 described above.


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Selection of the RP2D
Study INCB 39110-250 was a double-blind, placebo-controlled, sequential, dose-escalation study of 
INCB039110 administered for 28 days to subjects with chronic plaque psoriasis characterized by Static 
Physician's Global Assessment (sPGA) ≥ 3, PASI score > 5, and BSA of psoriatic involvement ≥ 5%. 
INCB039110 was evaluated in parallel with placebo in 4 treatment groups (100 mg QD, 200 mg QD, 200 
mg BID, and 600 mg QD). Subjects were randomized to INCB039110 in a 3:1 ratio with placebo. 
The primary efficacy endpoint was the mean percent change from baseline in sPGA at the Day 28 visit. 
The study met its primary endpoint, demonstrating a dose-dependent improvement in sPGA score at the 
Day 28 visit. At the Day 28 visit, all treatment groups had mean percent reductions in sPGA score, with 
22.2%, 29.4%, 35.2%, and 42.4% reductions in the 100 mg QD, 200 mg QD, 200 mg BID, and 600 mg 
QD groups, respectively, compared with a reduction of 12.5% in the placebo group. The difference 
between the 600 mg QD group and the placebo group was statistically significant (p = 0.003, without 
adjustment for multiplicity). Similar improvement was also noted in secondary endpoints. The 
proportions of sPGA responders and subjects achieving 50% improvement in PASI score (PASI 50) were 
also dose-dependent, reaching statistical significance at 200 mg QD (PASI 50 only) and 600 mg QD 
(sPGA and PASI 50). Improvement in mean sPGA and PASI scores was noted as early as the first 
assessment (Day 8). Responses in sPGA score were observed in all INCB039110-treated groups and no 
placebo-treated subjects. A dose-dependent increase in the proportion of subjects achieving an sPGA 


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score of 1 (minimal) was seen at the Day 28 visit. The proportion of responders was statistically 
significant for the 600 mg QD group (p = 0.014, without adjustment for multiplicity). Overall, more than 
half of the INCB039110-treated subjects achieved at least a 50% improvement in PASI score (PASI 50) 
at the Day 28 visit. At the Day 28 visit, the proportion of subjects achieving PASI 50 was dose-dependent 
and was statistically significant for the 200 mg and 600 mg QD groups (p = 0.016 and p < 0.001, 
respectively). Among INCB039110 groups, 6 subjects (15.8%) achieved PASI 75 overall at the Day 28 
visit compared with no subjects in the placebo group.
Antitumor Activity of INCB039110 Monotherapy 
Data from INCB 39110-230, a Phase 2a, open label, multiple Simon 2-stage study of INCB039110 
administered orally to subjects with PMF, PPV MF, and PET MF, were presented at the 2014 American 
Society of Hematology Annual Meeting in New Orleans. In brief, results showed that meaningful 
reductions in MF-related symptoms were achieved by Week 12 in the 200 mg BID and 600 mg QD dose 
groups, and symptom improvements were largely maintained through Week 24. Modest reductions in 
spleen volume were attained in these 2 treatment groups. Hemoglobin levels were preserved in the 
majority of subjects who entered the study without transfusion requirements, and subjects requiring 
transfusions prior to study entry achieved meaningful reductions in transfusion requirements during the 
study (Mascarenhas et al 2014).
2.2.4
INCB039110 Safety Profile
Summary of Treatment-Emergent Adverse Events Occurring in ≥ 5 Subjects in Study INCB 39110-230 
by MedDRA Preferred Term in Decreasing Order of Frequency (Safety Population)


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Summary of Treatment-Emergent Adverse Events Occurring in ≥ 5 Subjects in Study INCB 
39110-230 by MedDRA Preferred Term in Decreasing Order of Frequency (Safety Population) 
(Continued)
2.3
Other Agents
2.3.1
Trametinib Dimethyl Sulfoxide (GSK1120212B)

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 


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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 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.

Clinical Pharmacokinetics (PK) and Activity of Trametinib
FTIH Phase 1 Trial of Trametinib Monotherapy (MEK111054)
There were 3 parts in this 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, OATP1B3, 


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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%).

Trametinib Safety Profile
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).


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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 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.


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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.

Clinical Experience with the Combination of Trametinib + Dabrafenib
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.
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).
2.3.2
Dabrafenib Mesylate (GSK2118436B)
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 


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metastatic melanoma with either BRAFV600E or BRAFV600K mutation as detected by an FDA-approved test 
(FDA, 2014).

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).
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. 

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 


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to dabrafenib concentrations, exposure for all metabolites showed a less than dose proportional increase 
with repeat dosing.
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.
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.


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
23
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 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.

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 


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
24
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)
2.3.2.4
Safety profile of Dabrafenib or Dabrafenib-Trametinib Combination
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)
Dabrafenib
(n=187)
Dacarbazine
(n=59)
Adverse Reaction or Laboratory 
Abnormality
All 
Gradesa
Grades
3 and 4b
All 
Gradesa
Grades
3 and 4
Skin and subcutaneous tissue disorders


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
25
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)
Dabrafenib
(n=187)
Dacarbazine
(n=59)
Adverse Reaction or Laboratory 
Abnormality
All 
Gradesa
Grades
3 and 4b
All 
Gradesa
Grades
3 and 4
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
Nasopharyngitis
10
0
3
0
NCI CTCAE v4.
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.


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26
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
Dabrafenib +
Trametinib 2mg
(n=55)
Dabrafenib +
Trametinib 1mg
(n=54)
Dabrafenib
(n=53)
Adverse Reaction or 
Laboratory 
Abnormality
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
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


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
27
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
Dabrafenib +
Trametinib 2mg
(n=55)
Dabrafenib +
Trametinib 1mg
(n=54)
Dabrafenib
(n=53)
Adverse Reaction or 
Laboratory 
Abnormality
All 
Gradesa
Grades
3 and 4
All 
Gradesa
Grades
3 and 4
All 
Gradesa
Grades
3 and 4
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
NCI CTCAE v4.
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.
ncludes 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 
associated with dabrafenib (BRAF 
category AEs) are:
Skin-related toxicities
Pyrexia
Malignancies
Renal failure (renal failure, renal 
failure acute)
Uveitis
Hyperglycemia
Pancreatitis
AEs of special interest that are associated with 
trametinib (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.   


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
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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, 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 


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
29
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 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 


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suggested that dabrafenib has the potential to cause cardiac valve abnormalities.  In a 28-day dog 
toxicology study, high doses (50 mg/kg/day; 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 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 


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
31
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-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 


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32
approximately 0.3 times the human exposure at the recommended clinical dose. 
2.4
Rationale
Vemurafenib was 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. 
Importantly, these early results have been corroborated by larger randomized phase 3 studies. In the 
coBRIM trial of 495 randomly assigned patients with unresectable locally advanced or metastatic BRAF 
V600 mutation–positive melanoma, the combination of 960mg vemurafenib twice daily and 60mg 
combimetinib daily produced a PFS of 9.9 months vs. 6.2 months with vemurafenib alone (Larkin et al. 
2014). In 2014, Long et al demonstrated a benefit in progression-free survival and overall response rate in 
patients taking the combination of dabrafenib and trametinib vs. dabrafenib alone (9.3 vs. 8.3 month PFS 
and 67% vs. 51% overall response rate). Furthermore, an advantage in overall survival was recently 
reported with the combination of dabrafenib and trametinib vs. dabrafenib alone in a phase 3 randomized 
trial of 704 patients (Robert et al 2015). Those patients receiving 2mg of trametinib daily and 150mg of 
dabrafenib twice daily exhibited a 31% reduction in the risk of death. Consequently the FDA approved 
both doublet therapies – dabrafenib/trametinib and vemurafenib/combimetinib – as combination 
treatments for advanced BRAF-mutant melanoma November 2015.  
Nevertheless, despite these exciting advances, the majority of patients on BRAF/MEK combined inhibitor 
therapy develop resistance, and the median PFS on combination therapy is only a few months longer than 
BRAF inhibitor monotherapy. Unfortunately, there is no known reliably effective, standard of care 
treatment for patients with BRAF inhibitor resistant melanoma. In addition, it is very difficult to enroll 
these patients onto clinic trials that require BRAF inhibitor washout periods due to the accelerated 


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33
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.
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. 
Recent studies have identified the role of JAK1 in V600-BRAF mutant melanoma resistance to BRAFi-
based therapy (Kim et al., 2015). JAK1, a member of the Janus kinase family of proteins, plays a critical 
and nonredundant role in biological responses downstream of a select subset of cytokine receptors, as 
evidenced by perinatal lethality in JAK1 knockout mice (Rodig et al 1998). Although the link between the 
Janus Kinases and the Raf/MAPK signaling pathways has been known for many years (Stancato et al., 
1997), the connection between JAK signaling and BRAFi-resistance has only been recently illuminated 
(Kim et al., 2015). In these studies, JAK1 was found to be upregulated in BRAFi-resistant melanomas, 
due to attenuated expression of the ubiquitin ligase RNF125. Upregulated JAK1 was found to contribute 
to elevated RTK (receptor tyrosine kinase) expression, including AXL, EGFR and PDGFR. Interestingly, 
increased expression of these RTKs have been implicated in melanoma resistance to MAPK-directed 
therapies (Muller et al 2014., Sun et al 2014). 
The newly identified regulatory axis – RNF125-JAK1-AXL/EGFR offers a unique opportunity for 
therapy, which was evaluated in initial preclinical assessments in these studies (Kim et al., 2015). First, 
administration of commercially available JAK inhibitors, AZD1480 or Pyridone 6, effectively attenuated 
growth of BRAFi-resistant melanoma in 3D soft agar culture. The effect of JAK inhibitors was 
pronounced on its own, although enhanced in the presence of EGFR inhibitor, Gefitinib. In vivo, growth 
of BRAFi-resistant melanoma was not affected by PLX4720 but when combined with JAK and EGFR 
inhibitors the growth of these tumors was largely attenuated. These observations provide the rationale for 
assessment of JAK1 inhibitors in preclinical and clinical settings in combination with dabrafenib and 
trametinib in BRAF-mutant melanoma specifically and, perhaps more generally, BRAF-mutant solid 
tumors.   
2.5
Correlative Studies Background
2.5.1
Pharmacokinetic Studies
While the pharmacokinetic data of single-agent INCB039110 and the combination of dabrafenib and 
trametinib are known, PK data of the triple combination have not been previously studied. The lack of 
evidence for drug-drug interactions with INCB039110 poses little risk that the clearance of dabrafenib 
and/or trametinib will be altered. We will collect trough samples on the first day of certain cycles in the 
protocol in order to measure drug concentrations of each agent if we encounter a rate of toxicity with the 
combination regimen that is higher than expected 
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. Therefore, sampling of trough levels on day 1 of cycle 2 
and cycle 4 and 6 will provide value that correspond to steady-state concentrations of dabrafenib and 
trametinib.
2.5.2
Biomarkers of Drug Effect
Although we do not yet know which JAK1 targets must be modulated in order for long term anti-tumor 
responses to be seen to the BRAF/MEK/JAK1 inhibitor combination, preliminary studies from our group 


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34
and others suggests that the RNF125-JAK1-AXL/EGFR and EGFR-SRC family kinase–STAT3 pathways 
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. Thus, levels of 
JAK1 protein, downstream targets such as STAT1 and STAT3 and other proteins involved in adaptive 
signaling responses (EGFR, PDGR, MITF, NF-kB) will be measured via immunohistochemistry, 
immunofluorescence or immunoblots from FNAs taken from accessible melanoma lesions before therapy 
initiation and following BRAF/MEK/JAK1 inhibitor treatment. The preferred time point for on-treatment 
biopsies is Cycle 1 Day 7 (± 3 days). Biopsies may be also taken at any time, including at the time of 
clinically meaningful events such as response, disease progression or adverse events of interest.
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 INCB039110 effect on relevant JAK1 target 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. 
2.5.3
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.
2.5.4   Expanded Genetic/Genomic Analysis 
A number of mutations in oncogenes and tumor suppressor genes have been described in melanoma 
(McArthur et al,. 2012; TCGA). We will plan to perform expanded genomic analysis on pretreatment 
samples (either from pretreatment biopsies or from archived, formalin-fixed paraffin-embedded tumor 
blocks [FFPE]). The exact methodology for analysis has not yet been selected, though the options include 
NGS for mutations/deletions, nanostring for mRNA, and IHC and RPPA for protein. As it becomes 
clearer which methodology is best suited for the analysis as part of this protocol, a protocol amendment 
will be submitted that details the rationale and specific details for which technique(s) is (are) selected. 
3.
PARTICIPANT SELECTION
Any labs drawn on Cycle 1, Day 1 will not be used to reconfirm eligibility. Eligibility is confirmed at 
screening; it is not required to be reassessed on Cycle 1, Day 1.
3.1
Eligibility Criteria 


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35
3.1.1
For Dose-Escalation Phase: Patients must have histologically confirmed, BRAF-mutant 
(V600E/K) malignancy (molecularly confirmed using Cobas assay or a comparable FDA-
approved assay (for exceptions, see below*) that is metastatic or unresectable, have received and 
tolerated prior BRAF or BRAF and MEK inhibitor (BRAF targeted) therapy or not previously 
received BRAF targeted therapy, and for which standard curative or palliative 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 to the Overall Principal Investigator (PI) for approval.  (FDA approved tests 
for BRAF V600 mutations in melanoma include:  THxID BRAF Detection Kit and Cobas 4800 
BRAF V600 Mutation Test).
3.1.2
For Dose-Expansion Phase: Patients must have histologically confirmed, BRAF-mutant 
(V600E/K) melanoma (molecularly confirmed using Cobas assay or a comparable FDA-approved 
assay (for exceptions, see below*) 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.
*If test at CLIA-certified lab used a non-FDA approved method, information about the assay 
must be provided to the Overall Principal Investigator (PI) for approval.  (FDA approved tests 
for BRAF V600 mutations in melanoma include:  THxID BRAF Detection Kit and Cobas 4800 
BRAF V600 Mutation Test).
3.1.3
Patients must have measurable disease by RECIST, 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.
3.1.4
Patients may have received any number of prior lines of therapy. All prior systemic anti-cancer 
treatment-related toxicities must be less than or equal to Grade 1 according to the Common 
Terminology Criteria for Adverse Events version 4 (CTCAE version 4.0; NCI, 2009) at the time 
of enrollment. This does not include alopecia and Grade 1 or less peripheral neuropathy.
 
3.1.5
Age ≥18 years.  Because no dosing or adverse event data are currently available on the use of 
INCB039110 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 in the opinion of the investigator.
3.1.8
Patients must have acceptable organ and marrow function as defined below:

Leukocytes (WBCs)
≥3,000/uL 

absolute neutrophil count
≥1,500/uL 

hemoglobin
> 9 g/dl (patients may be transfused to this level)

platelets
≥ 100,000/uL 

total bilirubin
< 1.5 x institutional upper limit of normal
OR


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
36
> 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 ULN1

Serum creatinine
≤1.5 mg/dL
OR
creatinine clearance ≥50 mL/min/1.73 m2 

Potassium
>3 and <5.5mmol/L 

Magnesium
>1.2 and <2.5 mg/dL 
1Therapeutic levels of anti-coagulation are permitted if clinically indicated, as per section 3.2.15. 
Thus PT/INR may be >1.3 if therapeutically anti-coagulated.
3.1.9
The effects of INCB039110, 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 registration 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 registration, 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. 
Men with a female partner of childbearing potential must have either had a prior vasectomy or 
agree to use effective contraception. Additionally, male subjects (including those who are 
vasectomized) whose partners are pregnant or might be pregnant must agree to use condoms for 
the duration of the study and for 4 months following completion of therapy.
3.1.10 Ability to understand and the willingness to sign a written informed consent document.
3.1.11 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 radiotherapy, 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 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 JAK1 inhibitor therapy. 


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37
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 registration. 
3.2.4
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. 
3.2.5
Patients must have no clinical evidence of leptomeningeal or brain metastasis causing spinal cord 
compression that are symptomatic, untreated, not stable for ≥ 4 weeks prior to Day 1 of Cycle 1  
(must be documented by imaging), or requiring corticosteroids to manage metastasis-related 
symptoms. Subjects who have been off of corticosteroids for at least 2 weeks prior to Day 1 of 
Cycle 1 or are on a stable dose of ≤10 mg per day of a prednisone equivalent for >1 month prior 
to Day 1 of Cycle 1 can be enrolled.  Subjects must also be off of enzyme-inducing 
anticonvulsants for >4 weeks prior to Day 1 of Cycle 1. 
3.2.6
History of known immediate or delayed hypersensitivity reactions attributed to compounds of 
similar chemical or biologic composition to INCB039110, 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 INCB039110, 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
History of interstitial lung disease or pneumonitis.
3.2.10 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.
3.2.11 History of another malignancy other than the study indication under this trial within 5 years of 
study enrollment, with the exception of the following:  

Subjects who underwent successful definitive 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.

Subjects who have had a localized (i.e. no history of regional or metastatic spread) solid 
tumor malignancy ≥ 3 years within study enrollment and, in the opinion of the investigator, has a 
very low probability of recurrence.  
3.2.12 History or current evidence/risk of retinal vein occlusion (RVO) or retinal pigment epithelial 
detachment (RPED):


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38

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:

A QT interval corrected for heart rate using the Bazett’s formula QTcB ≥460 msec on the 
pre-study baseline single 12 lead EKG.

History or evidence of current clinically significant uncontrolled arrhythmias (exception:  
patients with controlled atrial fibrillation for >30 days prior to registration are eligible).

History of acute coronary syndromes (including myocardial infarction and unstable angina), 
coronary angioplasty, or stenting within 6 months prior to registration.

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. In patients 
with no history of hypertension and a pre-study baseline blood pressure of systolic >140 
mmHg and/or diastolic >90 mmHg, a second reading must be taken at least 1 minute later, 
with the two readings averaged to obtain a final BP measurement.  

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 For patients requiring anti-coagulation with vitamin K antagonists, 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.  If clinically indicated, prophylactic low dose warfarin may be given to 
maintain central catheter patency.
3.2.16 Current use of a prohibited medication.  The following medications or non-drug therapies are 
prohibited 

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.


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-
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). 
-
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, 
fluconazole
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.  
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.
4.
REGISTRATION PROCEDURES


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4.1
General Guidelines for DF/HCC 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. 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 Institutions
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol Registration 
(SOP #: REGIST-101) must be followed.  
5.
TREATMENT PLAN
Treatment will be administered on an outpatient basis.  A cycle of treatment will be 28 days in length. 
Patients are asked to maintain a medication diary for recording each dose of Dabrafenib, Trametinib and 
INCB039110.
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 C) 
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. Dose 
escalation to the next dose level will occur when the preceding cohort reaches the end of Cycle 1. Patients 
who do not complete treatment in cycle 1 for reasons other than dabrafenib, trametinib or INCB039110 
toxicity will be replaced. Intra-patient 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 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)
IRB approval of an amendment to the protocol that clearly describes the rationale for and the 
logistics of the intermediate dose level.  


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Table 5.1 Dose Escalation Levels for Phase I Study
Dose Level
Dabrafenib 
[BID/PO]
Trametinib 
[QD/PO]
INCB039110 (mg QD)
-2
75 mg
1 mg
100 mg
-1
150 mg
2 mg
100 mg
1
150 mg
2 mg
200 mg
2
150 mg
2 mg
300 mg
3
150 mg
2 mg
400 mg
5.1
Pre-Treatment Criteria
5.1.1
Screening Visit: Patients must meet criteria at screening as outlined in Section 3.1. 

Of note, screening eligibility labs do not need to be repeated on cycle 1 day 1.  If labs are 
drawn on Cycle 1, Day 1 will not be used to reconfirm eligibility. Eligibility is confirmed 
at screening; it is not required to be reassessed on Cycle 1, Day 1. Please see section 5.1.2 
and the study calendar (Section 10) for information on laboratory studies and treatment 
parameters.
5.1.2
Hematologic Parameters for treatment:
Absolute Neutrophil Count

Cycle 1, Day 1: ≥ 1,500/uL 

Cycle 2 and Beyond, Day 1: Per Table in Section 6.2.1.1
White Blood Cell Count

Cycle 1, Day 1: ≥ 3,000/uL 

Cycle 2 and Beyond, Day 1: Per Table in Section 6.2.1.1
Hemoglobin

Cycle 1, Day 1: ≥ 9g d/gl (patients may be transfused to this level)

Cycle 2 and Beyond, Day 1: Per Table in Section 6.2.1.1
Platelets

Cycle 1, Day 1: ≥ 100,000/uL 

Cycle 2 and Beyond, Day 1: Per Table in Section 6.2.1.1
5.1.3
Liver Function Parameters for treatment:
Transaminases (AST/ALT):

Cycle 1, Day 1: ≤ 2.5 x institutional upper limit of normal

Cycle 2 and Beyond, Day 1: Per Table in Section 6.1.16
Bilirubin

Cycle 1, Day 1: < 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

Cycle 2 and Beyond, Day 1: Per Table in Section 6.1.16
5.1.4
Renal Function Parameters for treatment:
Creatinine:

Cycle 1, Day 1: ≤1.5 mg/mL OR creatinine clearance ≥50 mL/min/1.73 m2

Cycle 2 and Beyond, Day 1: Per Table in Section 6.1.9


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5.1.5
All Cycles, Day 1: Patients must have all the following:

Adequate blood pressure control as detailed in Section 6.1.11.  

ECOG performance status of 0 or 1.  

No evidence of life-threatening medical problems.  
5.2
Agent Administration
5.2.1
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 more than 6 hours have lapsed from the scheduled/planned dose time (i.e. no more than 30 
hours from the previous dose). Vomited doses of trametinib should not be made up.
In the event that dabrafenib, INCB039110, 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.
5.2.2
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, INCB039110, 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.
5.2.3
INCB039110
INCB039110 is administered orally and provided in 100 mg tablets. 
A positive food-effect was observed for all INCB039110 formulations studied at the 300 mg (3 × 100 mg) 
dose level. The SR3 formulation delivered a mean relative bioavailability of 48% and is likely to be 
associated with a moderate food-effect. The current recommendation is to administer INCB039110 on an 
empty stomach, either 1 hour before or 2 hours after a meal; the recommendation to administer 
INCB039110 fasting may change based on emerging data.  Missed doses of INCB039110 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). Vomited doses of INCB039110 should not be made up.
In the event that trametinib, dabrafenib, or both agents need to be discontinued due to toxicity reasons, 
treatment with INCB039110 may continue at the discretion of the investigator until time of disease 
progression.
5.2.4
Concomitant Administration
Dabrafenib, INCB039910 and Trametinib may be taken together.


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5.3
Definition of Dose Limiting Toxicity
Dose-limiting toxicity (DLT) is based on the CTEP Active Version 4 of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE). DLT refers to INCB039110, Dabrafenib, or Trametinib treatment-
related toxicities experienced during the first cycle of treatment between days 1-28. A DLT will be defined 
as follows:

Any grade 4 toxicity

Grade 3 non-hematologic toxicity

Grade ≥ 3 neutropenia with fever > 38.5°C

Grade 3 thrombocytopenia with clinically significant bleeding

Toxicity resulting in patients missing more than 20% of the doses
In general, all Grade 3, non-hematological toxicities related to INCB039110, Dabrafenib, or Trametinib 
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 in less than 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.
Patients that have missed more than 20% of the doses for non-toxicity related reasons will not be 
considered evaluable for DLTs. 
Dose escalation will proceed within each cohort according to the following scheme.  Dose-limiting 
toxicity (DLT) is defined above.
Table 5.2. Dose escalation table
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
Proceed to the next dose level.


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5.4
General Concomitant Medication and Supportive Care Guidelines
5.4.1
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.  After discussion with the Principal 
Investigator, agents known to affect or with the potential to affect selected CYP450 isoenzymes may be 
permitted, if clinically indicated.  
5.4.2
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 B 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.  
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.
5.4.3
INCB039110
INCB039110 does not induce or 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 
≥ 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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form. In vitro studies indicate that CYP3A4 is the major isozyme responsible for the metabolism of 
INCB039110 in human liver microsomes. INCB039110 did not significantly inhibit the activity of 
CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4, suggesting that the potential 
for INCB039110 to cause clinical drug-drug interactions through CYP inhibition is low.
Supportive treatment should be given as per the institution standards and at the Investigator’s discretion. 
Antiemetics, anti-diarrheal agents, etc. may be given to treat or prevent gastrointestinal toxicities. 
5.5
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.
Participants will be removed from the protocol therapy when any of these criteria apply.  The reason for 
removal from protocol therapy, and the date the participant was removed, must be documented in the case 
report form (CRF). Alternative care options will be discussed with the participant.
In the event of unusual or life-threatening complications, treating investigators must immediately (within 
24 hours of awareness of the event) notify the Overall PI, David Miller, M.D., P.h.D at 617-724-4000, 
pager 36066. 
5.6
Duration of Follow Up
Participants will be followed for 2 years after removal from study treatment or until death, whichever 
occurs first. Participants removed from study treatment for unacceptable adverse events will be followed 
until resolution or stabilization of the adverse event. All patients will have a follow-up encounter 30 days 
(+ 3 days) after last study treatment for assessment of adverse effects. This encounter can be carried out in 
clinic or over the telephone. 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. Dermatologic skin assessments should be completed every 3 months for 6 months 
after discontinuation of dabrafenib or initiation of another anti-neoplastic therapy.  Participants’ vital 
status will be followed every 6 months (telephone contact is adequate) following removal from the study 
treatment. Date and cause of death should be provided for participants who become deceased within the 
2-year interval following removal from the study treatment. 
5.7
Criteria for Removal from Study


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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.
The research team updates the relevant Off Treatment/Off Study information in OnCore. 
6.
DOSING DELAYS/DOSE MODIFICATIONS
The criteria for dose modification of dabrafenib, trametinib, and INCB039110 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 according to the specified dose modifications for 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
150 mg BID

100 mg BID
100 mg BID

75 mg BID
75 mg BID

50 mg BID
50 mg BID

Discontinue dabrafenib
Current Dose Trametinib
If Dose Reduction Required
Reduce To
2 mg QD

1.5 mg QD
1.5 mg QD

1.0 mg QD
1.0 mg 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 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 INCB039110. Conversely, if trametinib is permanently discontinued for trametinib-related 
toxicities, patients will be allowed to continue dabrafenib and INCB039110.
In the event that INCB039110 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 INCB039110 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 INCB039110 need to be discontinued due to toxicity reasons, treatment 
with dabrafenib may continue at the discretion of the investigator until time of disease progression.


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6.1.1
Dabrafenib or Dabrafenib + Trametinib Dose Modification for Treatment Related Toxicities Not 
Specified in Subsequent Sections
Table 6-1:  Dabrafenib or Dabrafenib + Trametinib Dose Modification for Treatment 
Related Toxicities Not 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.
If dabrafenib must be reduced to <50 mg BID, permanently 
discontinue dabrafenib 
If trametinib must be reduced to < 1.0 mg QD, permanently 
discontinue trametinib 
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 dabrafenib must be reduced to <50 mg BID, permanently 
discontinue dabrafenib 
If trametinib must be reduced to < 1.0 mg QD, permanently 
discontinue trametinib 
*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. 
6.1.2
Dabrafenib or Dabrafenib + Trametinib Dose Modification for Pyrexia Suspected to be 
Treatment-Related

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 


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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 
Requirements for Pyrexia Suspected to be Related to Treatment
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 (must 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 Event:
Clinical evaluation for infection 
and hypersensitivity
Laboratory work-up
Hydration as required
Administer anti-pyretic treatment 
if clinically indicated and 
continue prophylactic treatment
Interrupt dabrafenib.
Continue trametinib.
Once pyrexia resolves to baseline, if fever 
was associated with rigors, dehydration, 
hypotension, or renal insufficiency, reduce 
dabrafenib by one dose level. If it was not, 
restart dabrafenib at the same 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, if fever 
was associated with rigors, dehydration, 
hypotension, or renal insufficiency, reduce 
dabrafenib by one dose level. If it was not, 
restart dabrafenib at the same dose level. 


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Table 6-2:  Dabrafenib or Dabrafenib + Trametinib dose Modification and Management 
Requirements for Pyrexia Suspected to be Related to Treatment
Event
Management Guideline
Dose Modification
Subsequent 
Events: 
Clinical evaluation for infection 
and hypersensitivity
Laboratory work-up
Hydration as required
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.a
If dabrafenib must be reduced to <50 mg 
BID, permanently discontinue dabrafenib.
a  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 Suspected to be Related to 
Treatmenta
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).


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Table 6-3:  Dabrafenib or Dabrafenib + Trametinib Supportive care and Dose Modification for 
Rash Suspected to be Related to Treatment
CTCAE 
Grade
Adverse Event Management
Action and Dose Modification
The following Rash prophylaxis is recommended for the first 6 weeks of study treatment: 
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.
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 dermatologist or surgeon
Infected lesions:  appropriate bacterial/fungal culture-driven systemic or topical antibiotics.
* Subjects who develop rash/skin toxicities should be seen by a qualified physician and should 
receive evaluation for symptomatic/supportive care management
Grade 1
If not yet started, initiate 
prophylactic and symptomatic 
treatment measures.1
Use moderate strength topical 
steroid.2
Reassess within 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)
If not yet started, initiate 
prophylactic and symptomatic 
treatment measures.1
Use moderate strength topical 
steroid.2
Reassess within 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.
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
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:  Triamcinolone 0.1% cream or ointment or Fluticasone 
propionate 0.05% cream or 0.005% ointment. 
3. 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 section 1.2 for dose modification.
6.1.5
Dabrafenib or Dabrafenib + Trametinib Dose Modification for New Primary/ Recurrent 
Malignancies:

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.  Skin exams should continue every 2-3 months 
for 6 months after discontinuation of dabrafenib or initiation of another anti-neoplastic therapy.  
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.  
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 require treatment modification 
other than excision. 

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.  


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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.
        
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. Upon confirmed diagnosis of pancreatitis, dabrafenib should 
be interrupted until completely resolved.  Patients should be closely monitored when re-starting 
dabrafenib after an episode of pancreatitis.
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.
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.


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Table 6-5: Dabrafenib or Dabrafenib + Trametinib Dose Modification for Renal Insufficiency
Serum Creatinine Level
Management Guideline
Action and Dose 
Modification
Serum creatinine increase
>0.5 mg/dL (44 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.


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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 
dabrafenib plus trametinib.  
Table 6-6:  Dabrafenib + Trametinib Treatment Modification and Management Requirements 
for LVEF Decrease
Clinic
LVEF-drop (%) or
CTCAE grade
Dose Modification
Symptomatica
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 with cardiologist.
Repeat ECHO after 2, 4, 8, 12, and 16 weeks 
or until resolution.
a If ECHO does not show LVEF recovery within 2 weeks, repeat ECHO 2 weeks later (prior to 
reaching end of 4 weeks).
b Symptoms may include:  dyspnea, orthopnea, 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.  
Requirements for BP monitoring and management are provided below.

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.

Symptomatic hypertension is 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


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Table 6-7:  Dabrafenib or Dabrafenib + Trametinib Treatment Modification and Management 
Requirements 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
clinically 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
(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.  
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


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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 mseca
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.
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 
Recommendations for Diarrhea Suspected to be Related to Treatment
CTCAE Grade
Management Recommendations
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.


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6.1.14 Dabrafenib or Dabrafenib  + Trametinib Dose Modification for Vision Changes Suspected to be 
Related to Treatment 
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 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 
Considered to be Related to Study Treatment 
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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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 until resolution.
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 Suspected to be Related to 
Treatment
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 Suspected to be 
Related to Treatment 
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 trametinib reduced 
by one dose level.
Escalation to previous dose level 
after 4 weeks 
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
If no recovery to grade ≤1 
within 4 weeks, permanently 
discontinue trametinib.


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CTCAE Grade
Adverse Event Management
Action and Dose Modification
Grade 4
Same as grade 2
Permanently discontinue 
trametinib.
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 Total Bilirubin <2x 
ULN, without symptoms 
considered related to liver 
injury or hypersensitivity and 
who can be monitored 
weekly for 4 weeks
May continue study treatment.
If liver chemistry stopping criteria are met any time, proceed as 
described below.
MONITORING:
Repeat ALT, AST, ALK, and total bilirubin until they return to 
normal/baseline or stabilise 
Criteria for discontinuing 
study drug:  When any of the 
liver stopping criteria below is 
met, discontinue trametinib 
and dabrafenib
1. ALT ≥3xULN and Total 
bilirubin ≥2x ULN  or >35% 
direct bilirubin1, 2
2. ALT  3xULN and INR 
>1.5, if INR measured and if 
subject is not on 
anticoagulation2  
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 
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). 
MONITORING:
In patients stopping for criteria 1-2 (with abnormal TB and INR, 
indicating potentially more significant liver toxicities):
Repeat ALT, AST, ALK, and total bilirubin) and perform liver 
assessment and workup 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.


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Event
Treatment modifications and assessment/monitoring
CBC with differential to assess eosinophilia.
Record clinical symptoms of liver injury, or hypersensitivity on 
AE CRF.
Record concomitant medications (including acetaminophen, 
herbal 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.
Footnotes
1. Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin 
fractionation testing is unavailable, record presence of detectable urinary bilirubin on dipstick, which 
indicates direct bilirubin elevations and suggesting liver injury. 
2. All events of ALT ≥3xULN and bilirubin ≥2xULN (>35% direct bilirubin) or ALT 3x ULN and 
INR >1.5 (if INR measured) may indicate severe liver injury (possible “Hy’s Law”). INR 
measurement is not required, and the threshold value stated will not apply to subjects receiving 
anticoagulants. 
3. New or worsening symptoms believed to be related to liver injury (such as fatigue, nausea, 
vomiting, right upper quadrant pain or tenderness, or jaundice) or believed to be related to 
hypersensitivity (such as fever, rash or eosinophilia) 
4. Includes: Hepatitis A IgM antibody; Hepatitis B surface antigen and Hepatitis B Core Antibody 
(IgM); Hepatitis C RNA; Cytomegalovirus IgM antibody; Epstein-Barr viral capsid antigen IgM 
antibody (or if unavailable, obtain heterophile antibody or monospot testing); Hepatitis E IgM 
antibody 
5. PK sample is desired if feasible. Record the date/time of the PK blood sample draw and the 
date/time of the last dose of study treatment prior to blood sample draw on the CRF. If the date or 
time of the last dose is unclear, provide the subject’s best approximation. If the date/time of the last 
dose cannot be approximated OR a PK sample cannot be collected in the time period indicated above, 
do not obtain a PK sample. Not required for single-dose studies. 
6. If hepatitis delta antibody assay cannot be performed, it can be replaced with a PCR of hepatitis D 
RNA virus (where needed) (Le Gal et al., 2005). 
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 


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lower dose level.
• If not improved, permanently discontinue.
Life Threatening PE
Permanently discontinue 
dabrafenib
Permanently discontinue trametinib.
6.2
INCB039110 Dose modifications
INCB039110 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
400 mg

300 mg
300 mg

200 mg
200 mg

100 mg
100 mg

discontinue
In the event that dabrafenib, trametinib, or both agents need to be discontinued due to toxicity reasons, 
treatment with INCB039110 may continue at the discretion of the investigator until time of disease 
progression.  
6.2.1
Management of INCB039110 toxicity
The only consistently observed effects of INCB039110 in healthy volunteers, patients with inflammatory 
diseases and cancer are decreases in neutrophils, hemoglobin and platelet count. For occurrences of grade 
3 or 4 events by CTCAE in any of these three categories, the dose reduction table below will be followed.  
Patients may receive transfusions or growth factor support as indicated in cases of severe toxicity. 
Dabrafenib and trametinib rarely cause severe effects on blood counts. Therefore, in INCB039110 will be 
modified in the case of severe decreases in blood counts, assuming that these events are considered 
treatment related.
6.2.1.1
Dose Reduction and Interruption


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Table 6-15:  INCB039110 Dose Modification for Toxicities
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 permanently discontinue study 
treatment 
7.
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The expected  
adverse events listed in the Investigator Drug Brochure and/or Package Insert and the characteristics of an 
observed AE (Section 7.1) will determine whether the event requires expedited reporting in addition to 
routine reporting.
The following definitions of terms apply to this section: 
Adverse event means any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug related. 
Life-threatening adverse event or life-threatening suspected adverse reaction. An adverse event or 
suspected adverse reaction is considered "life-threatening" if, in the view of either the investigator or 
sponsor, its occurrence places the patient or subject at immediate risk of death. It does not include an 
adverse event or suspected adverse reaction that, had it occurred in a more severe form, might have 
caused death.
 


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65
Serious adverse event: An adverse event or suspected adverse reaction is considered "serious" if, in the 
view of either the investigator or sponsor, it results in any of the following outcomes: 

Death, 

a life-threatening adverse event, 

inpatient hospitalization or prolongation of existing hospitalization, 

a persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions, or a congenital anomaly/birth defect. 

Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate 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. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias 
or convulsions that do not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse. 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility that the 
drug caused the adverse event. For the purposes of IND safety reporting, "reasonable possibility" means 
there is evidence to suggest a causal relationship between the drug and the adverse event. Suspected 
adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which means 
any adverse event caused by a drug. 
Unexpected adverse event or unexpected suspected adverse reaction. An adverse event or suspected 
adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at 
the specificity or severity that has been observed.
7.1
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 4.0 will be 
utilized for AE reporting.  All appropriate treatment areas should have access to a copy of the 
CTCAE version 4.0.  A copy of the CTCAE version 4.0 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(s) that are listed in the Investigator Drug Brochure or package insert should 
be reported only if the adverse event varies in nature, intensity or frequency from the 
expected toxicity information which is provided.

Attribution of the AE:
-
Definite – The AE is clearly related to the study treatment.
-
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.
7.2
Expedited Adverse Event Reporting 


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66
Investigators must report to the Overall PI any serious adverse event (SAE) that occurs after the 
initial dose of study treatment, during treatment, or within 30 days of the last dose of treatment on 
the local institutional SAE form. 
7.3
DF/HCC Expedited Reporting Guidelines
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for Human 
Research Studies (OHRS) per the DFCI IRB reporting policy. 
7.4
Expedited Reporting to the Food and Drug Administration (FDA)
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA.
7.5
Expedited Reporting to the company Supplying Drug (Incyte)
Incyte needs to be notified within 24 hrs of learning of an event. Inctye also needs to be provided 
a completed SAE form via email. SAE reporting for each subject begins the day the informed 
consent is signed by the patient and within 30 days after subject has completed or discontinued 
from the study or has taken last dose of the study drug, or as described in the IST protocol.
SAEs, occurring using Incyte Study drug, are reported in accordance with the effective protocol.  
SAEs occurring with any another commercial drug are reported to manufacturer of that drug in 
accordance with regulations and protocol. 
Initial Serious Adverse events (SAEs) and/or subsequent follow-up reports should be reported via 
email to: IncytePhVOpsIST@incyte.com.  SAE reports should be for a single subject with any 
additional documents (i.e. discharge summary, relevant test results) included for the same subject 
as individual attachments to the email. One email can have multiple attachments as long as each 
attachment contains relevant information for the same subject.
Please email your SAE form with a cover sheet and any additional attachments to the IST email 
address: IncytePhVOpsIST@incyte.com.
Telerx C3i is the PhV Clinical Research Organization (CRO) for Incyte.  They will be contacting 
you for SAE follow-up requests and data clarifications by sending you a data clarification form 
(DCF).  See follow-up section for details on this process.  The following is general contact 
information for Telerx C3i.
TELERX C3I (Incyte PhV CRO)
US SAE fax number 1-866-726-9234 
Telerx C3i tracks any critical outstanding follow-up items and questions and contacts the 
investigational site via a faxed DCF for the additional requested information until all outstanding 
queries are resolved.  This includes requests for hospital discharge summaries, autopsy reports, 
and death certificates (if applicable), results of relevant laboratory, and diagnostic tests.  The 


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67
investigational site faxes the additional information to Telerx C3i, using the Telerx C3i SAE fax 
number.  The site personnel will update all relevant data on the appropriate SAE Report Form or 
equivalent to include any new or changed information.  The Incyte Safety Representative (IC SR) 
will monitor outstanding queries and take appropriate action needed for resolution.
Any serious SAE upgraded to death or life-threatening requires that the follow up report be 
emailed to: IncytePhVOpsIST@incyte.com email address within 24 hours of learning of the 
change.
If the SAE is not previously documented in the Investigator’s Brochure for INCB039110 and is 
thought to be related to the study drug, a manufacturer’s associate may urgently require further 
information from the Investigator or Sponsor for reporting to Health Authorities. Incyte will be 
notified within 24hrs of any IND safety event and will receive a copy of the initial and follow up 
IND Adverse Event reports within 48hrs of submission to regulatory authorities. This will be 
submitted to the following email address: IncytePhVOpsIST@incyte.com
Reporting of Pregnancy
An “Initial Pregnancy Report” or equivalent must be completed in full and emailed to 
IncytePhVOpsIST@incyte.com within 24 hrs of discovery of a pregnancy of a subject who has 
taken the Incyte product or the pregnancy of a partner for a subject who has taken the Incyte 
product.  The “Follow-up Pregnancy Report Form” or equivalent must be completed and emailed 
to IncytePhVOpsIST@incyte.com within 30 days after delivery, so that Incyte is provided with 
information regarding the outcome of the pregnancy.  If the pregnancy results in any events 
which meet the serious criteria (i.e., miscarriage or termination), the SAE reporting process needs 
to be followed and the timelines associated with an SAE should be followed.
7.6
Expedited Reporting to Hospital Risk Management
Participating investigators will report to their local Risk Management office any participant safety 
reports or sentinel events that require reporting according to institutional policy. 
7.7
Routine Adverse Event Reporting
All Adverse Events must be reported in routine study data submissions to the Overall PI on the 
toxicity case report forms.  AEs reported through expedited processes (e.g., reported to the 
IRB, FDA, etc.) must also be reported in routine study data submissions.
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
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)


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68
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 commercially supplied in 
bottles of #120 capsules as 50 mg and 75 mg capsules for oral administration. 

50 mg capsules: Dark red capsule imprinted with ‘GS TEW’ and ‘50 mg’. Each 
bottle contains a silica gel desiccant.

75 mg capsules: Dark pink capsule imprinted with ‘GS LHF’ and ‘75 mg’. Each 
bottle contains a silica gel desiccant.
 
Storage:  Store between 15°C to 30°C (59°F to 86°F).
Stability:  Shelf-life studies of dabrafenib mesylate (GSK2118436B) are ongoing.
Route of Administration:  Oral administration.  Take dabrafenib mesylate (GSK2118436B ) 1 
hour prior or 2 hours after a meal. Pill cannot be crushed, chewed or dissolved in water.
Potential Drug Interactions:  Dabrafenib mesylate (GSK2118436B) induces CYP3A4, 2C9, and 
possibly 2B6, 2C8, and 2C19 enzymes.  Use caution in patients who are taking substrates that are 
metabolized in these enzyme pathways, such as warfarin.
Dabrafenib mesylate (GSK2118436B) metabolism appears to be mediated by CYP3A4 and 
CYP2C8.  Use caution if strong inducers or inhibitors of CYP2C8 or 3A4 are co-administered 
with dabrafenib.
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. Commercial drug will used in this study.


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8.2
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 (<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:  Trametinib is commercially supplied in bottles of #30 tablets, and is supplied as 
0.5 mg and 2 mg (as free base) tablets.

0.5 mg tablets: Yellow, modified oval, biconvex, film-coated tablets with ‘GS’ 
debossed on one face and ‘TFC’ on the opposing face. 

2 mg tablets: Pink, round, biconvex, film-coated tablets with ‘GS’ debossed on one 
face and ‘HMJ’ on the opposing face. 
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.  
Stability:  Shelf life studies of trametinib dimethyl sulfoxide are ongoing.
Route of Administration:  Oral. Take by mouth on an empty stomach, either 1 hour before or 2 
hours after a meal. Pill cannot be crushed, chewed or dissolved in water.
Potential Drug Interactions
In vitro studies suggest that trametinib dimethyl sulfoxide is not a substrate of CYP enzymes or of 
human Pgp, BCRP, OATP1B1 or OATP1B3 transporters. 
Trametinib dimethyl sulfoxide is a weak CYP2C8 inhibitor and weak CYP3A4 inducer. Drug-
drug interactions with sensitive substrates of 2C8 and 3A4 are not anticipated. 


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Availability
Trametinib dimethyl sulfoxide (GSK1120212B) is FDA-approved for the treatment of 
unresectable or metastatic BRAF-mutant melanoma.  Commercial drug will used in this study.
8.3
INCB039110
Chemical Name:  2-(3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-1-(1-(3-fluoro-2-
(trifluoromethyl)isonicotinoyl)piperidin-4-yl)azetidin-3-yl)acetonitrile adipate
Other Names:  None
Classification:  JAK inhibitor
CAS Registry Number:  
Molecular Formula:  C32H33F4N9O5
M.W.:  699.66 
Mode of Action:  INCB039110 is a potent and selective inhibitor of JAK1
How Supplied:  INCB039110 will be provided as 100 mg (free-base equivalent) SR tablets. 
These tablets contain the active ingredient, hypromellose, microcrystalline cellulose, lactose 
monohydrate, and magnesium stearate. The higher strength tablet formulations (200 mg and 300 
mg) also contain pregelatinized starch. 
Storage:  All INCB039110 drug product should be stored at ambient conditions (15°C to 30°C, 
or 59°F to 86°F).
Route of Administration:  Oral administration.  Pill cannot be crushed, chewed or dissolved in 
water.
Potential Drug Interactions:  None identified
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 due to high binding to 
plasma proteins. 
Availability: INCB039110 is an investigational agent and will be supplied by Incyte 
Pharmaceuticals.
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
9.1
Biomarker Studies
9.1.1
Blood BRAF Assay


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71
Collection of Specimens
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

Cycle 1, day 15 

Day 1 of every cycle of therapy

At the time of progression
Handling of Specimens
Specimens will either be processed on site using the collection and processing SOP 
(Appendix H) or shipped to the Flaherty Laboratory overnight for processing and storage.  
Following processing, samples will be stored in a -80 degree freezer until batch analysis is 
performed.
Shipping of Specimens
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:
Flaherty Laboratory
c/o Dennie Frederick
55 Fruit Street; Jackson 9th Floor
Boston, MA 02114
Sites Performing Correlative Study  
All DF/HCC study sites are expected to participate in this correlative study.
9.2
Pharmacokinetics
Little is known about the potential for drug-drug interactions (DDI) of the triple combination of 
dabrafenib, trametinib, and INCB039110. However, the available evidence regarding effect of each 
agent on cytochrome P450 isoenzymes and clearance of concomitantly administered drugs does not 
indicate a likely interaction. 
Limited PK sampling will be performed in this protocol to enable analysis of trough levels of each 
agent pre-dose at the beginning of cycles 2, 4 and 6 in the case that the rate of combined toxicity is 
greater than expected.  
Handling of Specimens
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.
INCB039110 PK Samples
1.
At each time point, collect 4 mL whole blood PK sample into a properly labeled 4 mL 


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72
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 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
Tissue analysis of pharmacodynamic effects
Collection of Specimens
Optional tumor biopsies will be performed pretreatment, one week (+/- 3 days) after 
commencing therapy with the combination as part of the phase I dose escalation and dose 
expansion cohorts, and post-treatment following completion of all study therapy. Biopsies 
may be also taken at any time, including at the time of clinically meaningful events such as 
response, disease progression or adverse events of interest. 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 analysis.
Handling of Specimens
As described above, four cores will be obtained and fixed.  The SOP for collection, handling, 
and processing is attached (Appendix H). Samples will either be stored at the individual 
DF/HCC sites and sent in batch at the time of planned correlative study analysis or sent to 
and stored at the Flaherty Laboratory at MGH. FFPE samples will be stored at room 
temperature.  Frozen samples will be stored in a -80 degree freezer.
Shipping of Specimens
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. Flaherty’s laboratory and 
the remainder of samples sent to Dr. Flaherty’s laboratory.  
The addresses of the laboratories are:
Massachusetts General Hospital


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
73
Jackson 9
55 Fruit Street
Boston, MA 02114
Site Performing Correlative Study: Being conducted only at Massachusetts General Hospital
10. STUDY CALENDAR
Baseline evaluations are to be conducted within 2-week prior to start of protocol therapy with the 
exception of scans and x-rays.  Scans and x-rays must be done <4 weeks prior to the start of therapy.
Assessments must be performed prior to administration of any study agent. Study assessments and agents 
should be administered within + 3 days of the protocol-specified date, unless otherwise noted.
Pre-
Study
Cycle 1
Cycles 2+
Procedure
Baseline 1
Day 
12,b
Day
 84
Day 
155
Day 12
End of 
Txt 
Visit
30 Day F-U 
Encounter3
2-6 
Month 
F-U
Dabrafenib and 
Trametinib A
DT --------------------------- DT
INCB039110 B
I-----------------------------I
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) 
X c
X c
Physical Examination 
X
X
X
X
X
Vital Signs (BP d, HR, 
body temperature)
Xd
Xd
Xd
Xd
Xd
Xd
ECOG Performance 
Status
X
X
X
X
X
X
Dermatology 
Examination e
X
X
Xe
Height
X
Weight
X
X
X
X
Ophthalmology 
Examination f
X
X
12 Lead EKG
X
X
X
Hematology/Clinical 
Chemistry g
X
X
X
X
Xh
X
Coagulation i
X
Tumor Measurements j
Xj
Xj
  
PK Analysis k
X k
Optional Tumor 
Biopsies l
X l
X l
X l
Blood BRAF testing m
X
X
X
X
Rash Prophylaxis n
Xn
Xn
X n
AE assessment o
X
X
X
X
X
X
X
Long term Follow up p
Xp


Protocol Version / Version Date: Amendment 3, Date June 10, 2020
74
Color Photography q
X q
X q
Loperamider
X r
A.
Dabrafenib and Trametinib: doses as assigned; Dabrafenib BID and Trametinib QD.
B.
INCB039110: dosing as assigned per dose level.
1.
All Pre-study assessments must be completed within 14 days prior to first dose, except for Scans that must be 
done within 28 days prior to first dose.
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. 
Assessment for each visit can be done within 3 days of the projected visit date.
3.
Follow up encounter, which can be carried out over the phone, should be 30 days from last dose of study drugs 
(± 3 days).
4.
Medical History, Concurrent Medications, Vital Signs, ECOG Status, Hematology and Blood Chemistry panels 
will be completed prior to Day 8 treatment.  
5.
Physical Exam, Medical History, Concurrent Medications, Vital Signs, ECOG Status, Hematology and Blood 
Chemistry panels will be completed prior to Day 15 treatment.  
a.
Informed Consent can be obtained within 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) if done within 72 hours of first dose does not 
need to be repeated on Day 1 of the first dose.
d.
In patients with blood pressure of systolic >140 mmHg and/or diastolic >90 mmHg, a second reading should be 
taken at least 1 minute later, with the two readings averaged to obtain a final BP measurement.  
e.
Dermatological Examination done at screening and then every 8 weeks (2 cycles). For patients enrolling in the 
expansion cohort who may have been on DT prior to enrolling and have had a recent skin exam, skin exams 
within 28 days of C1D1 will suffice for eligibility. Skin exams should continue every 2-3 months for 6 months 
after discontinuation of dabrafenib or initiation of another anti-neoplastic therapy.  
f.
Ophthalmological examination is done at screening, week 4, and annually. For patients enrolling in the 
expansion cohort who may have been on DT prior to enrolling and have had a recent ophthalmological exam 
that includes all requirements listed in Section 6.1.14, eye exams within 28 days of C1D1 will suffice for 
eligibility. Additional ophthalmic exams will be performed only as symptomatically warranted. For further 
details on requirements of exam see Section 6.1.14.
g.
Clinical chemistries include 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. Hematology samples will be collected before study 
treatment administration and at all applicable study visits 
h.
During Cycle 2, patients will have day 15 (+/- 3 days) clinical chemistries collected as outlined in footnote g 
above. After cycle 2, clinical chemistries are collected on Day 15 at the investigator’s discretion. 
i.
Includes PT, PT-INR, PTT, repeated as indicated. These chemistries may be collected at a remote facility and 
the results can be faxed to the research team.
j.
Tumor measurements and radiological exam done every 8 weeks 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 samples will be collected pre-dose on Day 1 of Cycles 2, 4 and 6. Also, per Section 6.1.14, 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. Also, see section 6.1.16 for PK collection in the setting of Liver Chemistry Changes.
l.
Optional tumor biopsies will be performed pretreatment. Pre-treatment tissue obtained by biopsy or resection 
performed according to standard of care may be utilized, provided tissue was obtained within 8 weeks of study 
entry, and subsequent to the last systemic anticancer therapy received. Optional tumor biopsies will also be 
performed one week (+/- 3 days) after commencing therapy with the combination as part of the phase I dose 
escalation and dose expansion cohorts; however, biopsies may be taken at any time, including at the time of 
clinically meaningful events such as response, disease progression or adverse events of interest. Post-treatment 
biopsies (following completion of all study therapy) will be optional.


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75
m. Blood BRAF analysis performed pretreatment C1D1, C1D15, at the beginning of each subsequent cycle and at 
disease progression (Section 9.1.1).
n.
See table 6.3 for detailed prophylaxis recommended for the first 6 weeks of treatment. 
o.
AE assessment starting from the day 1 of dosing throughout the study
p.
After 30 day follow up visit, patient is followed for survival for 2 years. See section 5.6 for full details. 
q.
In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the 
lesion, is recommended. See section 11.1.3 for full details. 
r.
Loperamide should be made available prior to start of study treatment so loperamide administration can begin at 
the first signs of diarrhea. See table 6-9 for full details. 
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 (with a window of minus 1 week prior to day 1 of the cycle).  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 (with a window 
of minus 1 week prior to day 1 of the cycle).
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 INCB039110.
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 


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with CT scan, MRI, or calipers by clinical exam.  All tumor measurements must be recorded in 
millimeters (or decimal fractions of centimeters).
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. 
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 


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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 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.


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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 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.


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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 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
CR
Not evaluated
No
PR
PR
Non-CR/Non-
PD/not evaluated
No
PR
>4 wks. Confirmation**
SD
Non-CR/Non-
PD/not evaluated
No
SD
Documented at least once >4 wks. 
from baseline**
PD
Any
Yes or No
PD
Any
PD***
Yes or No
PD
no prior SD, PR or CR


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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.
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).


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12.1
Data Reporting
12.1.1 Method
The ODQ will collect, manage, and perform quality checks on the data for this study.
12.1.2 Responsibility for Data Submission
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or data 
forms to ODQ according to the schedule set by the ODQ.
12.2
Data Safety Monitoring
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity and 
accrual data from this study. The committee is composed of clinical specialists with experience in 
oncology and who have no direct relationship with the study. Information that raises any questions about 
participant safety will be addressed with the Overall PI and study team.
The DSMC will review each protocol up to four times a year or more often if required to review toxicity 
and accrual data. Information to be provided to the committee may include: up-to-date participant accrual; 
current dose level information; DLT information; all grade 2 or higher unexpected adverse events that 
have been reported; summary of all deaths occurring with 30 days of intervention for Phase I or II 
protocols; for gene therapy protocols, summary of all deaths while being treated and during active follow-
up; any response information; audit results, and a summary provided by the study team. Other 
information (e.g. scans, laboratory values) will be provided upon request. 
13. STATISTICAL CONSIDERATIONS
13.1
Study Design/Endpoints
This is a phase I trial of the combination of dabrafenib, trametinib, and INCB039110 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, up to an additional 20 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.


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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, up to 20 patients will be enrolled in an expansion cohort of patients 
with melanoma 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.  
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 20
0.01
0.18
0.03
0.46
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
Proceed 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.
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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True Incidence of Unexpected or Severe 
Toxicity
Probability of Observing One or More 
Patients with Toxicity among 20
0.05
0.64
0.08
0.81
0.09
0.85
0.10
0.88
0.15
0.96
Secondary endpoints that will be assessed for the 20 patients treated at the MTD in the dose-expansion 
cohort 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 38 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 38 patients reflects four complete dose escalation cohorts of 
6 patients each and the expansion cohort of 20 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.
13.3.1 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.   


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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. 

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 – pembrolizumab, nivolumab, ipilimumab, atezolizumab, or high-dose IL-2 – 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 the RNF125-JAK1-AXL/EGFR axis
In order to characterize the changes on the tumor and its microenvironment during and following inhibition 
of the RNF125-JAK1-AXL/EGFR axis, we will use single-cell resolving technologies developed by our 
collaborators at the Dana-Farber/Harvard Cancer Center and apply them to pre-, on- and post-treatment 
biopsy specimens. Our collaborators in the Garraway and Regev labs at DF/HCC have developed a platform 
for processing single-cell isolates from patient specimens to generate single-cell transcriptome profiles (sc-
RNAseq). (Tirosh et al., 2016) Through a process of disaggregation into single cells, fluorescence-activated 
flow sorting, RNA isolation and massively paralleled sequencing of complementary DNA libraries, this 
technology permits the deconvolution of intra-tumoral heterogeneity and enhanced granularity of the tumor 
ecosystem compared to bulk RNA sequencing. With assistance from our collaborator Dr. Benjamin Izar of 
the Garraway/Regev labs, we will perform single-cell RNA sequencing on pre-, on- and post-treatment 
patient specimens to evaluate for gene expression profiles that correlate with drug-resistance or predict 
treatment response. Cell states will be analyzed via: 1) unbiased assessment of the intercellular 
transcriptional hetereogeneity using principal component analysis (PCA) followed by downstream 
enrichment analysis of emerging principal components (PCs); and 2) Gene Set Enrichment Analysis (GSEA) 
to specifically assess the activity and variability of hundreds of pathways across cells within the same tumor. 
We will also utilize highly multiplexed imaging via a high-throughput cyclic immunofluorescence 
(CycIF) method developed by the Sorger lab at DF/HCC to perform deep-profiling at the protein level of 
single-cells from patient specimens. (Lin et al., 2015) Our collaborator Dr. Izar of DF/HCC has optimized 
this technique - which can permit up to 30 protein markers per slide - for formalin-fixed paraffin embedded 
patient-tumor specimens (personal communication of unpublished data). We will leverage this approach to 
validate that proof of mechanism and target engagement of INCB039110 by evaluating RNF125-JAK1-
AXL/EGFR axis proteins implicated in therapeutic escape including BRAF, CRAF, AKT, JAK1, phospho-
AKT, phospho-ERK, phospho-STAT3, EGFR and AXL. We will also use CycIF to immunophenotype 
tumor-infiltrated lymphocytes and tumor-associated macrophages to characterize the effects of triple 
JAK1i/BRAFi/MEKi targeting on the immune cell microenvironment. Multi-spectral CycIF images are 
segmented using freely available tools (ImageJ, CellProfiler) to generate a coordinate map against which 
fluorescence intensities for all channels can be aligned. Data from 105-107 cells can then be visualized as 
images and/or studied using dimensionality reduction methods such as principal component analysis or t-
Distributed Stochastic Neighbor Embedding. 
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 


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analysis of INCB039110 effect on relevant RNF125-JAK1-AXL/EGFR axis 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 specimens embedded in OCT will be evaluated for tumor 
and necrotic content.
Skyline version 1.3 will be 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 (%). 
13.3.2 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) 
version 4.0), 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 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). 
14. PUBLICATION PLAN
The results will be made public within 24 months of reaching the end of the study. The end of the study is 
the time point at which the last data items are to be reported, or after the outcome data are sufficiently 
mature for analysis, as defined in the section on Sample Size, Accrual Rate and Study Duration. A full 
report of the outcomes will be made public no later than three (3) years after the end of the study. 


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melanoma treated with immunotherapy prior to or after targeted therapy. Cancer. 2014 – In 
Press.
American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016 
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APPENDIX A
PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
100
Normal, no complaints, no evidence of 
disease.
0
Normal activity.  Fully active, able to 
carry on all pre-disease performance 
without restriction.
90
Able to carry on normal activity; minor 
signs or symptoms of disease.
80
Normal activity with effort; some 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).
70
Cares for self, unable to carry on 
normal activity or to do active work.
60
Requires occasional assistance, but is 
able to care for most of his/her needs.
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.
50
Requires considerable assistance and 
frequent medical care.
40
Disabled, requires special care and 
assistance.
3
In bed >50% of the time.  Capable of 
only limited self-care, confined to bed 
or chair more than 50% of waking 
hours.
30
Severely disabled, hospitalization 
indicated.  Death not imminent.
20
Very sick, hospitalization indicated. 
Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or chair.
10
Moribund, fatal processes progressing 
rapidly.
5
Dead.
0
Dead.


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APPENDIX B
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 
INCB039110, Dabrafenib mesylate and trametinib dimethyl sulfoxide. This form is addressed to the 
patient, but includes important information for others who care for this patient. 
INCB039110, 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 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 


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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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INFORMATION ON POSSIBLE DRUG INTERACTIONS 
You are enrolled on a clinical trial using the experimental agents 
INCB039110, 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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APPENDIX C
 
Participant Name: __________________________
Your Doctor_____________________ Phone___________________
Your Nurse______________________ Phone___________________
Dosing Instructions for Study Drug:
Your dose of Trametinib is ______ mg made up of ______ - ______ mg tablets. 
Your dose of INCB039110 is ______ mg made up of ______ - ______ mg tablets. 
Your dose of Dabrafenib is ______ mg made up of ______ - ______ mg capsules. 

You will take trametinib once per day in the morning. You will take INCB039110 once per day in the 
morning. You will take dabrafenib twice per day, once in the morning and then twelve hours later. 

Pills need to be taken without food on an empty stomach, at least 1 hour prior to a meal and 2 hours after a 
meal. Pills can be taken with water.  

Pill cannot be crushed, chewed or dissolved in water.

Dabrafenib, INCB039910 and Trametinib may be taken together.

Vomited doses should not be made up.

Missed doses should not be made up if more than 6 hours have lapsed from the scheduled/planned dose time. 

Each of the study drugs should be kept in the original contained they are distributed in. 

Please remember to bring any unused drug, all empty containers, and your drug diary to your clinic visits. 

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

Dabrafenib and INCB039110 should be stored at room temperature. Trametinib should be refrigerated. 
Study Participant Self-Administration Drug Diary
DFCI Study Number: 


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
Wash your hands with soap and water after taking your dose
Page 1 of 3
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 
Trametinib  
Dose
# Tablets
Time of 
INCB039110 
Dose
# Tablets
Time of 
Morning 
Dabrafenib 
Dose
# Capsules
Time of 
Evening 
Dabrafenib 
Dose
# Capsules
Comments
If dose was vomited, 
missed or skipped, 
indicate reason below.
1
□ am 
□ pm
□ am 
□ pm
□ am 
□ pm
□ am 
□ pm
2
□ am 
□ pm
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3
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4
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5
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6
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7
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8
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Day 
Date
Time of 
Trametinib  
Dose
# Tablets
Time of 
INCB039110 
Dose
# Tablets
Time of 
Morning 
Dabrafenib 
Dose
# Capsules
Time of 
Evening 
Dabrafenib 
Dose
# Capsules
Comments
If dose was vomited, 
missed or skipped, 
indicate reason below.
13
□ am 
□ pm
□ am 
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Participant Signature or Initials
Date


Page 98
APPENDIX D
PREGNANCY REPORT FORM
SAE FAX NO:  (301) 230-0159
Alternate Phone FAX NO:  (301) 897-7404
    ALTERNATE
Ticket Number:_______________


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APPENDIX E
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 registration 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. The list may be modified based on emerging data. Refer to 
the SPM for the most current list. 


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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 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 
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 


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exposure to dabrafenib, these medicinal products that increase gastric pH should be used with 
caution when administered with dabrafenib 
Table 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.


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APPENDIX F
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 G
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 H
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 
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.


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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
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.


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
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 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 


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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.

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 


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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.
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


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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 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). 


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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.
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 


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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 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 


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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 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-


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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 I
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. 
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. 


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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.