Cyclin D kinase 4 (CDK4) is a key regulator of the G1-S transition in the cell cycle. Alterations in CDK4-cyclin D-retinoblastoma (Rb) pathway may lead to carcinogenesis in many cancers. Several mechanisms have been described: (i) Amplification or overexpression of cyclin D1, (ii) Amplification of CDK4, (iii) Activating mutation of CDK4, and (iv) Loss of the CDK4 inhibitor, p16 (CDKN2A). Human Papilloma Virus (HPV) plays a major role in squamous cell carcinoma of head and neck (SCCHN) carcinogenesis. It induces many alterations in the CDK4-Cyclin D-Rb and apoptotic pathways such as up-regulation of p16, loss of Rb and p53 functions. A novel therapy for HPV-negative SCCHN is clearly an unmet medical need. Palbociclib (PD 0332991) is an orally active, highly selective inhibitor of the CDK4/6 with ability to block Rb phosphorylation in the low nanomolar range. The most advanced development is in a treatment of metastatic breast cancer. In addition, palbociclib showed a radiosensitization property. Since combination of cetuximab and radiation improved PFS and overall survival (OS) in locally advanced SCCHN when compared with radiation alone, these provide a strong rationale to evaluate a combination of palbociclib, cetuximab, and radiation for locally advanced SCCHN. Because many genetic alterations in SCCHN significantly involve in the CDK4-cyclin D-Rb pathway, predictive biomarker(s) of palbociclib in this combination will be explored. Thus, the investigators propose a non-randomized, dose escalation, phase I study designed to determine the maximum tolerated dose (MTD) and toxicity of palbociclib, cetuximab, and IMRT for locally advanced SCCHN.
The enrollment of an initial patient cohort of 3 or 6 patients will follow the traditional "3 + 3" dose escalation scheme (see table below). The patients will be treated with palbociclib, cetuximab, and IMRT at starting at Dose Level (DL) 1. Subsequent patient cohort(s) will be enrolled depending on the safety and tolerability of the initial cohort. If \<33% patients treated at Dose Level 1 experience DLT (see definition below) by the end of treatment (56 days), then next cohort of 3 patients will be enrolled and treated at Dose Level 2. If 2 treatment-related DLTs are observed at Dose Level 1, patients will be accrued to Dose Level -1. The MTD is defined as the maximum dose level at which ≤1/6 patients have DLTs. At the MTD or RP2D, we will accrue up to 15 locally advanced unresectable p16-negative SCCHN patients to allow for definitive evaluation of tolerability, correlative endpoints and preliminary efficacy. CT/PET scan will be performed at 3 months after the last dose of radiation to evaluate residual disease. Patients with residual disease will be considered for salvage surgery following standard of care. * IMRT will be administered 5 days on/2 days off with a total dose of 70 Gy for 33-35 fractions. * Cetuximab will be administered 400 mg/m2 IV at 7 days before (day -7) starting radiation and then 250 mg/m2 IV weekly for 7 weeks. * Palbociclib will be administered orally daily 3 week-on and 1-week of during IMRT (Day 1-21 and Day 29-49).
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
27
Dose Level -1: 100 mg oral every other day 3 week-on and 1-week of during IMRT (Day 1-21 and Day 29-49).
Dose Level 1: 75 mg per oral daily 3 week-on and 1-week of during IMRT (Day 1-21 and Day 29-49).
Dose Level 2: 100 mg per oral daily 3 week-on and 1-week of during IMRT (Day 1-21 and Day 29-49).
Dose Level 3: 125 mg per oral daily 3 week-on and 1-week of during IMRT (Day 1-21 and Day 29-49).
All dose levels: 400 mg/m2 IV at 7 days before (day -7) starting radiation and then 250 mg/m2 IV weekly for 7 weeks.
5 days on/2 days off with a total dose of 70 Gy for 33-35 fractions.
Faculty of Medicine, Ramathibodi Hospital
Bangkok, Thailand
Determination of dose-limiting toxicities (DLTs) and recommended phase II dose (RP2D)
To describe the dose-limiting toxicities and identify the recommended phase I dose (RP2D) of the combination of palbociclib, cetuximab, and IMRT for locally advanced SCCHN. Recommended Phase II Dose (RP2D) is a maximum tolerated dose (MTD) or the highest dose level when MTD is not reached. Toxicity will be assessed using the NCI Common Toxicity Criteria for Adverse Events (CTCAE), version 4.0. A DLT is defined by the occurrence of any of the following toxicities related to palbociclib and the combination within 8 weeks of treatment duration.
Time frame: From baseline to the completion of radiotherapy (up to 8 weeks)
Evaluate preliminary efficacy of the combination
Objective response rate (ORR) by the RECIST criteria version 1.1 and PET/CT scan response at 3 months after completion of treatment will be used to evaluate preliminary efficacy of this combination.
Time frame: From baseline to 3 months after completion of radiotherapy (up to 5 months)
Evaluate safety profile of the combination of palbociclib, cetuximab and IMRT
All toxicities, including acute and chronic toxicities will be evaluated by the CTCAE V.4.
Time frame: From baseline to 1 year after completion of radiotherapy (up to 14 months)
Evaluate anti-tumor activity of the combination depending on Rb status
Objective response rate (ORR) by the RECIST criteria version 1.1 and PET/CT scan response at 3 months after completion of treatment will be used to evaluate preliminary efficacy of this combination. Rb status will be correlated with the ORR.
Time frame: From baseline to 3 months after completion of radiotherapy (up to 5 months)
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