A Phase II Study Evaluating The Efficacy And Tolerability Of Everolimus (RAD001) In Combination With Trastuzumab And Vinorelbine In The Treatment Of Progressive HER2-Positive Breast Cancer Brain Metastases
- Histologically-confirmed HER2-positive (IHC 3+ or fluorescence in situ hybridization
[FISH] amplified; by clinical assay on either primary or metastatic tumor)
adenocarcinoma of the breast with at least one progressive and/or new metastatic
brain lesion (>/=5 mm on radiographic imaging) after receipt of intracranial
radiation therapy (whole brain radiation therapy, stereotactic radiosurgery, gamma
knife, or equivalent).
- ECOG performance status of 0-2.
- Life expectancy >12 weeks.
- At least 21 years of age.
- No limit to prior therapies with exception of mTOR inhibitors or Navelbine with last
anti-cancer treatment (including any investigational drug) ≥2 weeks from initiation
of protocol-based therapy, provided all AEs (other than alopecia) have resolved to
≤grade 1 at baseline.
- Prior navelbine allowed provided navelbine therapy discontinued >/= 12 months from
Day 1 of treatment under this protocol.
- No active serious infection or other comorbid illness which would impair ability to
participate in the trial.
- Left ventricular ejection fraction assessment (echocardiogram or MUGA scan) performed
within 4 weeks prior to study initiation, showing a LVEF value ≥ lower limit of
- If patient is on dexamethasone, must be on stable or decreasing dose of dexamethasone
for ≥7 days. If patient is on different glucocorticoid e.g., prednisone, must be
converted to dexamethasone prior to enrollment. Refer to dose modification of
everolimus for patients taking dexamethasone.
- Interval ≥4 weeks between open brain biopsy and initiation of protocol-based therapy.
- INR ≤2.0. Anticoagulation is allowed if target INR ≤2.0 on a stable dose of warfarin
or if patient on a stable dose of LMW heparin for >1 weeks at time of enrollment.
- Fasting serum cholesterol ≤300 mg/dL OR ≤7.75 mmol/L AND fasting triglycerides ≤2.5 x
ULN. NOTE: In case one or both of these thresholds are exceeded, the patient can
only be included after initiation of appropriate lipid lowering medication.
- Patients must have adequate organ function as evidenced by:
- Absolute neutrophil count ≥1.5/µL
- Platelet count ≥100,000/µL
- Hg ≥9 g/dL
- Bilirubin ≤1.5 x upper limit of normal (ULN)
- AST or ALT ≤2.5 x ULN (≤5 x ULN if liver metastases are present)
- Serum creatinine ≤1.5 x ULN
- Archived, paraffin-embedded tissue block (primary or metastatic) available for
genomic studies is required.
- Signed, IRB-approved written informed consent.
- Patients who have received prior treatment with an mTOR inhibitor (e.g., sirolimus,
temsirolimus, everolimus) or vinca alkaloids.
- Patients with a known hypersensitivity to everolimus or other rapamycins (e.g.,
sirolimus, temsirolimus); patients who have received prior treatment with navelbine
within prior 12 months.
- patients with a known hypersensitivity to everolimus or other rapamycins (e.g.
sirolimus, temsirolimus) or to its excipients.
- Patients requiring treatment with any other systemic glucocorticoid. NOTE: This
restriction regarding choice of glucocorticoid does not apply should patient need <2
week course of glucocorticoid for treatment of non-infectious pneumonitis during
study (see section 4.5.2).
- Patients with a known hypersensitivity to vinorelbine or to its excipients.
- Prior allergic reaction to trastuzumab for the treatment of metastatic breast cancer.
- Concurrent or planned radiation, hormonal, chemotherapeutic, experimental or targeted
- Peripheral neuropathy ≥grade 3.
- Evidence of frank hemorrhage or impending herniation on baseline brain imaging.NOTE:
asymptomatic micro-hemorrhage is allowed.
- Evidence of diffuse leptomeningeal disease on brain MRI or by previously documented
CSF cytology. NOTE: discrete dural metastases are permitted.
- Active cardiac disease including any of the following:
- Angina pectoris that requires the use of anti-anginal medication;
- Ventricular arrhythmias except for benign premature ventricular contractions;
- Supraventricular and nodal arrhythmias requiring a pacemaker or not controlled
- Conduction abnormality requiring a pacemaker;
- Valvular disease with documented compromise in cardiac function;
- Symptomatic pericarditis
- History of cardiac dysfunction including any one of the following:
- Myocardial infarction documented by elevated cardiac enzymes or persistent
regional wall abnormalities on assessment of LV function;
- History of documented congestive heart failure (New York Heart Association
functional classification III-IV);
- Documented cardiomyopathy
- Patients who have had a major surgery or significant traumatic injury within 4 weeks
of start of study drug, patients who have not recovered from the side effects of any
major surgery (defined as requiring general anesthesia), or patients that may require
major surgery during the course of the study.
- Patients should not receive immunization with attenuated live vaccines within 1 week
of study entry or during study period. Close contact with those who have received
attenuated live vaccines should be avoided during treatment with everolimus.
Examples of live vaccines include intranasal influenza, measles, mumps, rubella, oral
polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines.
- Other malignancies within the past 3 years except for adequately treated carcinoma of
the cervix or basal or squamous cell carcinomas of the skin.
- Patients who have any severe and/or uncontrolled medical conditions or other
conditions that could affect their participation in the study such as:
- severely impaired lung function, defined as spirometry and diffusion lung
capacity for carbon monoxide (DLCO) that is 50% of the normal predicted value
and/or 02 saturation that is ≤88% at rest on room air
- uncontrolled diabetes, defined as fasting serum glucose >1.5 x ULN (Note:
Optimal glycemic control should be achieved before starting trial therapy)
- active (acute or chronic) or uncontrolled severe infections
- liver disease such as cirrhosis or severe hepatic impairment (Child-Pugh class
Note: A detailed assessment of Hepatitis B/C medical history and risk factors must be done
at screening for all patients. HBV DNA and HCV RNA PCR testing are required at screening
for all patients with a positive medical history based on risk factors and/or confirmation
of prior HBV/HCV infection.
- A known history of HIV seropositivity.
- Impairment of gastrointestinal function or gastrointestinal disease that may
significantly alter the absorption of everolimus (e.g., ulcerative disease,
uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome, or small bowel
- Patients with an active, bleeding diathesis or on oral anti-vitamin K medication
(except low-dose warfarin and aspirin or equivalent, as long as the INR ≤2.0).
- Unable or unwilling to discontinue use of prohibited fruit (or its juices) and
prohibited medications listed in Appendices II and III for at least 14 days or 5
half-lives of a drug (whichever is longer) prior to the first dose of study drug and
for the duration of the study.
- Female patients who are pregnant or breastfeeding, or adults of reproductive
potential who are not using effective birth control methods. Adequate contraception
must be used throughout the trial and for 8 weeks after the last dose of study drug,
by both sexes. Women of childbearing potential (WOCBP) must have a negative urine or
serum pregnancy test within 7 days prior to everolimus initiation.
- Male patients whose sexual partner(s) are WOCBP who are not willing to use adequate
contraception, during the study and for 8 weeks after the end of treatment
- Contraindication to gadolinium-enhanced MRI imaging.
- Inability to comply with study and/or follow-up procedures.
- History of noncompliance to medical regimens.