Romidepsin and Erlotinib Hydrochloride in Treating Patients With Stage III or Stage IV Non-Small Cell Lung Cancer

A Phase I/II Study of Erlotinib and Romidepsin in Advanced Non-Small Cell Lung Cancer

RATIONALE: Romidepsin and erlotinib hydrochloride may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

PURPOSE: This phase I/II trial is studying the side effects and best dose of romidepsin when given together with erlotinib hydrochloride and to see how well they work in treating patients with stage III or stage IV non-small cell lung cancer.

OBJECTIVES:

Primary

• To characterize the toxicity and determine the maximum-tolerated dose (MTD) of erlotinib hydrochloride plus romidepsin. (Phase I)
• To obtain preliminary data regarding efficacy, including response rate and progression-free survival. (Phase II)

Secondary

• To characterize the pharmacokinetic profile of romidepsin in combination with erlotinib hydrochloride.
• To evaluate the impact of erlotinib hydrochloride on the biologic activity of romidepsin by analyzing peripheral blood mononuclear cell (PBMC) histone acetylation status and histone acetylase activity. (Exploratory)
• To evaluate the effect of romidepsin and erlotinib hydrochloride on components of the EGFR (epidermal growth factor receptor)-signaling pathway in skin biopsies, particularly downstream mediators such as MAPK (mitogen-activated protein kinase). (Exploratory)

OUTLINE: This is a dose-escalation study of romidepsin followed by a phase II study.

Patients receive romidepsin IV on days 1, 8, and 15 and erlotinib hydrochloride orally (PO) once daily beginning on day 3 of course 1 and on days 1-28 of all subsequent courses. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

Patients undergo blood sample collection at baseline and periodically during study for pharmacokinetic studies. Additional samples of peripheral blood mononuclear cells and skin biopsies may be also collected for correlative studies.

After completion of study therapy, patients are followed up for 30 days.

PROJECTED ACCRUAL: A total of 39 patients (15 patients for phase I and 24 patients for phase II) will be accrued for this study.

To be eligible for study participation, patients must fulfill all of the following criteria:

• Histologically confirmed locally advanced or metastatic (stage IIIB pleural effusion or stage IV) NSCLC;
• Age ≥ 18 years;
• Written informed consent;
• Measurable disease as defined by Response Evaluation Criteria in Solid Tumors (RECIST);
• ECOG (Eastern Cooperative Oncology Group ) performance status 0 to 1;
• Serum potassium and magnesium greater than or equal to the lower limit of institutional normal range (electrolyte abnormalities may be corrected with supplementation to meet inclusion criteria);
• Negative urine or serum pregnancy test on females of childbearing potential;
• All women of childbearing potential must use an effective barrier method of contraception (an intrauterine contraceptive device [IUCD] or double barrier method using condoms or a diaphragm plus spermicide) during the treatment period and for at least 1 month thereafter. Male patients should use a barrier method of contraception during the treatment period and for at least 1 month thereafter. Hormonal methods of contraception such as the contraceptive pill or patch (particularly those containing ethinyl-estradiol) should be avoided due to a potential drug interaction (see Appendix D).
• Adequate bone marrow, liver, and renal function as evidenced by
• Hemoglobin ≥10 g/dL (transfusions and/or erythropoietin-stimulating agents are permitted)
• Absolute neutrophil count (ANC) ≥1.5 x 109 cells/L • Platelet count ≥100 x 109 cells/L
• Total bilirubin <1.5 x upper limit of normal (ULN)
• (Aspartate amino transferase) AST/SGOT(serum glutamic-oxaloacetic transaminase) and (amino alanine transferase) ALT/SGPT (serum glutamic-pyruvic transaminase) <2.0 x upper limit of normal (ULN) or <3.0 x ULN in the presence of demonstrable liver metastases
• Serum creatinine <2.0 x ULN
• Clinically stable brain metastases are permitted

Phase I study:

• Prior erlotinib therapy is permitted (with a 3-week washout period)
• Patients may have received prior anti-cancer therapy (with a 3-week washout period) or, at the discretion of the investigator, may be treatment-naïve

Phase II study:

• Patients must have received at least one and no more than two prior chemotherapy regimens for their advanced NSCLC
• Patients may not have received prior erlotinib

Patients are ineligible for entry if any of the following criteria are met:

• Chemotherapy for NSCLC within 3 weeks prior to study entry;

• Concomitant use of any other anti-cancer therapy;

• Concomitant use of any investigational agent;

• Use of any investigational agent within 4 weeks prior to study entry;

• Any known cardiac abnormalities such as:

  • Congenital long QT syndrome;
  • QTc interval (corrected QT interval) Myocardial infarction within 12 months prior to study entry;
  • Other significant ECG abnormalities including type II second-degree atrio ventricular (AV) block, third-degree AV block, or bradycardia (ventricular rate < 50 beats/min); o A history of coronary artery disease (CAD); eg, angina Canadian Class II-IV. In any patient in whom there is doubt, the patient should have a stress imaging study and, if abnormal, angiography to define whether or not CAD is present;
  • An ECG recorded at screening showing significant ST depression (ST depression of ≥2 mm, measured from isoelectric line to the ST segment at a point 60 msec from the end of the QRS complex). If there is any doubt, the patient should have a stress imaging study and, if abnormal, angiography to define whether or not CAD is present;
  • Congestive heart failure (CHF) that meets New York Heart Association (NYHA) Class II to IV definitions and/or ejection fraction < 40% by MUGA ( multiple gated acquisition) scan or <50% by echocardiogram and/or MRI;
  • A known history of sustained ventricular tachycardia (VT), ventricular fibrillation (VF), Torsades de Pointes, or cardiac arrest unless currently addressed with an automatic implantable cardiac defibrillator (AICD);
  • Hypertrophic cardiomyopathy or restrictive cardiomyopathy from prior treatment or other causes (if there is any doubt, see ejection fraction criteria above);
  • Uncontrolled hypertension (defined as blood pressure [BP] ≥160/95; or
  • Any cardiac arrhythmia requiring anti-arrhythmic medication;

• Serum potassium or serum magnesium below lower limit of institutional normal range (electrolyte abnormalities may be corrected with supplementation to meet inclusion criteria)

• Concomitant use of drugs that may cause a prolongation of the QTc interval .

• Concomitant use of CYP3A4 inhibitors

• Concomitant use of warfarin (due to a potential drug interaction);

• Clinically significant active infection (including known infection with human immunodeficiency virus [HIV], hepatitis B, or hepatitis C); l >480 milliseconds (msec);

• Major surgery or radiation within 2 weeks prior to study entry;

• Patients who are pregnant or breast-feeding;

• Any significant medical or psychiatric condition that might prevent the patient from complying with all study procedures;

• Prior exposure to romidepsin