Patients with metastatic Neuroblastoma RAS (NRAS) melanoma are currently treated with first line immune checkpoint inhibitors (nivolumab, pembrolizumab). Thus far, no targeted therapy has been approved in NRAS mutated melanoma as a second line treatment, because although the use of a MEK inhibitor (binimetinib) alone was superior to the gold standard chemotherapy (dacarbazine) in a phase 3 trial, the progression free survival gain was very modest. In vitro and in vivo work from the study team's lab (McMAHON, Huntsman Cancer Institute (HCI), Salt Lake City), as well as, Ravi Amaravardi and Jean Mulchey-Levy suggests that the activation of autophagy is a mechanism of resistance to BRAF and MEK inhibitors in RAS and RAF mutated cancers, such as melanoma, pediatric brain tumors and pancreatic adenocarcinoma. The study team has shown in vivo, in four different NRAS mutated melanoma Patient Derived Xenograft (PDX) models that the combination of the MEK inhibitor trametinib and the autophagy inhibitor chloroquine results in a more dramatic tumor regression and inhibition than trametinib or chloroquine used as single agents (Nat Med. 2019 Apr;25(4):620-627. doi: 10.1038/s41591-019-0367-9. Epub 2019 Mar 4). In two of the PDX models, the combination resulted in almost complete tumor regression (quasi disappearance) that was not observed in the single agent treatment arms. Trametinib (MEKINISTR) is an orally available MEK inhibitor that is currently approved in combination with the BRAF inhibitor dabrafenib (TAFINLARR) to treat BRAF mutated metastatic melanoma at the standard dosing of 2 milligrams (mg) once a day. Hydroxychloroquine (PLAQUENILR) is an orally available autophagy inhibitor that has been used for many years to treat autoimmune diseases like lupus, sarcoidosis and rheumatoid arthritis at the standard dosing of 400-600mg/day. For this study, the investigating team would like to evaluate the safety and tolerability of the combination of hydroxychloroquine and trametinib in a phase I trial in patients with NRAS mutated metastatic melanoma.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
29
Standard dosing of trametinib at 2 milligrams (mg) by mouth once a day, with an escalation of hydroxychloroquine. The escalation of hydroxychloroquine will be decided by a 3+3 design with the goal of estimating the Maximum Tolerated Dose (MTD) of trametinib plus hydroxychloroquine. A cycle of treatment will last 28 days. Patients will be evaluated weekly during the first cycle of treatment. • Level -1 = Hydroxychloroquine 400 mg by mouth once a day
Standard dosing of trametinib at 2 milligrams (mg) by mouth once a day, with an escalation of hydroxychloroquine. The escalation of hydroxychloroquine will be decided by a 3+3 design with the goal of estimating the Maximum Tolerated Dose (MTD) of trametinib plus hydroxychloroquine. A cycle of treatment will last 28 days. Patients will be evaluated weekly during the first cycle of treatment. • Level 1 (starting dose) = Hydroxychloroquine 800 mg by mouth once a day
Standard dosing of trametinib at 2 milligrams (mg) by mouth once a day, with an escalation of hydroxychloroquine. The escalation of hydroxychloroquine will be decided by a 3+3 design with the goal of estimating the Maximum Tolerated Dose (MTD) of trametinib plus hydroxychloroquine. A cycle of treatment will last 28 days. Patients will be evaluated weekly during the first cycle of treatment. • Level 2 = Hydroxychloroquine 600 mg by mouth two times a day
CHU Estaing
Clermont-Ferrand, Clermont Ferrand, France
CHU Grenoble Alpes
La Tronche, La Tronche, France
AP-HP_HOPITAL Saint Louis
Paris, Paris, France
Centre Hospitalier Lyon Sud
Lyon, Pierre-Bénite, France
INSTITUT Claudius Rigaud
Toulouse, Toulouse, France
Incidence of Dose-Limiting Toxicities (DLTs)
DLTs will be determined weekly during the first cycle of treatment (28 days) in order to choose the optimal dose for the phase II
Time frame: 28 days
Percentage of patients with a partial or complete response to treatment
Percentage of patients with a partial or complete response to treatment according to the Response Evaluation Criteria In Solid Tumors (RECIST) guidelines version 1.1 which allows the Evaluation of the Overall Response Rate (ORR) based on 3 main criteria: patients' tumor improves ("responds"), stays the same ("stabilizes"), or worsens ("progresses") during treatment. The comparison of target lesions will be based on a Computed Tomography (CT) scan performed after two cycles of treatment (56 days) to those present on the base line CT prior to treatment initiation.
Time frame: 56 days
Change in Median progression Free survival
Median progression Free survival will be determined in the cohort treated by the recommended phase 2 dose (RP2D). Subjects who discontinue treatment for reasons other than disease progression will have Computed Tomography (CT) scans at the end of therapy (EOT) visit (unless their previous restaging was performed within 6 weeks).
Time frame: at the end of 2 cycles of treatment (each cycle is 28 days), at the end of the 3rd cycle of treatment and every 12 weeks thereafter up to 12 months
Change in Overall Survival
Overall Survival will be determined in the cohort treated by the recommended phase 2 dose (RP2D); Subjects who discontinue treatment for reasons other than progression will have Computed Tomography (CT) scans at the end of therapy (EOT) visit (unless their previous restaging was performed within 6 weeks).
Time frame: at the end of 2 cycles of treatment (each cycle is 28 days), at the end of the 3rd cycle of treatment and every 12 weeks thereafter up to 12 months
Safety of the drug combination Trametinib and Hydroxychloroquine
Adverse events (AEs) and Serious Adverse Events (SAEs) according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be reported
Time frame: 1 year
Quantification of the autophagic substrate p62
p62 will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients without cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Quantification of Microtubule-associated protein Light Chain 3 (LC3)
LC3 will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients without cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Quantification of p-ERK
p-ERK will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients without cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Quantification of the autophagic substrate p62 (cutaneous metastasis)
p62 will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients with cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Quantification of Microtubule-associated protein Light Chain 3 (LC3) (cutaneous metastasis)
LC3 will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients with cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Quantification of p-ERK (cutaneous metastasis)
p-ERK will be quantified by immunohistochemistry (IHC) using a skin punch biopsy of normal tissue in patients with cutaneous metastasis.
Time frame: At Day 1 (before treatment) and Day 15 (after treatment)
Serum trametinib and hydroxychloroquine concentrations (AUC)
Serum trametinib and hydroxychloroquine concentrations (AUC) will be evaluated and compared to predicted published concentrations
Time frame: Day 28
Changes in treatment induced immune modifications in patient blood serum
The evaluation of treatment induced immune modifications in the blood serum will be based on patient peripheral blood mononuclear cell (PBMC) collection
Time frame: At Day 1 (before treatment), at Day 15 (after treatment), at 2 months (after treatment), and at 30 days after last treatment
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