An open label, two-part, phase Ib/II study to investigate the safety, pharmacokinetics, pharmacodynamics, and clinical activity of the MEK inhibitor trametinib and the BCL2-family inhibitor navitoclax (ABT-263) in combination in subjects with KRAS or NRAS mutation-positive advanced solid tumors

This phase Ib/II trial studies the side effects and best dose of trametinib and
navitoclax and how well they work in treating patients with solid tumors that have spread
to other places in the body (advanced or metastatic). Trametinib may stop the growth of
tumor cells by blocking some of the enzymes needed for cell growth. Navitoclax inhibits
members of the BCL2 family of proteins that are believed to play key roles in promoting
the survival of cancer cells. It may stop the growth of cancer cells by blocking Bcl-2,
Bcl-XL, and Bcl-w, proteins needed for cancer cell survival. Giving trametinib and
navitoclax may help stop the growth of tumor cells.

Inclusion Criteria:

- Patients must have histologically- or cytologically-confirmed diagnosis of KRAS or
NRAS mutation-positive malignancy that is metastatic or unresectable and for which
standard curative measures do not exist or are no longer effective; patients must
have activating mutations affecting codons 12, 13, 61, or 146 as determined in a
Clinical Laboratory Improvement Amendments (CLIA)-certified lab to be eligible for
this study

- Patients must have measurable disease by Response Evaluation Criteria in Solid
Tumors (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 by chest x-ray or as >= 10 mm with CT
scan, MRI, or calipers by clinical exam

- Participants must have received at least one line of prior systemic chemotherapy and
must have experienced documented radiographic progression or intolerance on this
therapy

- Paired pre-treatment and post-treatment biopsies are required for all patients on
Part 1 and first 15 patients in Part 2; participants must have available archival
tumor tissue (at least 20 unstained slides); if archival tissue is not available or
is found not to contain tumor tissue, a fresh biopsy is required; if a patient is
having a tumor biopsy, less than 20 unstained slides are acceptable with approval of
the principal investigator (PI); biopsies will only be performed in a given patient
if they are not deemed to involve unacceptable risk based on the sites of disease
and other concurrent medical conditions

- Age >= 18 years

- Because no dosing or adverse event data are currently available on the use of
trametinib in combination with navitoclax in patients < 18 years of age,
children are excluded from this study, but will be eligible for future
pediatric trials

- Eastern Cooperative Oncology Group (ECOG) performance status =< 1

- Life expectancy of greater than 3 months

- Able to swallow and retain orally-administered medication and does not have any
clinically significant gastrointestinal abnormalities that may alter absorption such
as malabsorption syndrome or major resection of the stomach or bowels

- All prior treatment-related toxicities must be Common Terminology Criteria for
Adverse Events version 4 (CTCAE v 4) grade =< 1 (except alopecia) at the time of
enrollment; this requirement to return to =< grade 1 does not apply to immune
checkpoint inhibitor related endocrinopathies (e.g. thyroiditis, hypophysitis, etc.)
that necessitate hormone replacement therapy including, but not limited to
levothyroxine, cortisol, and testosterone; CTCAE v5.0 will be utilized beginning
April 1, 2018

- Leukocytes >= 3,000/mcL

- Absolute neutrophil count (ANC) >= 1,200/mcL (subjects may be treated with
hematopoietic growth factors to achieve or maintain this level)

- Hemoglobin >= 9 g/dL

- Platelets >= 100 x 10^9/L

- Albumin >= 2.5 g/dL

- Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) (patients with
Gilbert's syndrome may have serum bilirubin > 1.5 x ULN)

- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x
institutional ULN

- Serum creatinine =< 1.5 mg/dL OR calculated creatinine clearance (Cockcroft-Gault
formula) >= 50 mL/min OR 24-hour urine creatinine clearance >= 50 mL/min

- Prothrombin time (PT)/international normalized ratio (INR) and partial
thromboplastin time (PTT) =< 1.2 x institutional ULN

- Left ventricular ejection fraction >= institutional lower limit of normal (LLN) by
echocardiogram (ECHO) or multi gated acquisition scan (MUGA)

- The effects of trametinib and navitoclax on the developing human fetus are unknown.
For this reason, women of child-bearing potential and men with a female partner of
child bearing potential must agree to use adequate contraception using one of the
methods listed below prior to study entry, for the duration of study participation,
and up to 4 months following completion of therapy

- Total abstinence from sexual intercourse (minimum one complete menstrual cycle
prior to study drug administration)

- Vasectomized male subject or vasectomized partner of female subjects

- Hormonal contraceptives (oral, parenteral, transdermal or vaginal ring) for at
least 3 months prior to study drug administration; if the subject is currently
using a hormonal contraceptive, she should also use a barrier method during
this study and for 1 month after study completion

- Intrauterine device (IUD)

- Double-barrier method: male condom plus diaphragm or vaginal cap with
spermicide (contraceptive sponge, jellies or creams)

- 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

- Women of childbearing potential must have a negative serum pregnancy test within 7
days prior to initiation of treatment; women will be considered not of childbearing
potential if they are surgically sterile (bilateral oophorectomy or hysterectomy)
and/or post-menopausal (amenorrheic for at least 12 months); should a woman become
pregnant or suspect she is pregnant while she or her partner is participating in
this study, she should inform her treating physician immediately; the potential
hazard to the fetus should be explained to the patient and partner (as applicable)

- Ability to understand and the willingness to sign a written informed consent
document

Exclusion Criteria:

- History of another malignancy; exception: patients who have been disease-free for 3
years, or patients with a history of completely resected non-melanoma skin cancer or
any carcinoma in situ and/or patients with indolent second malignancies, are
eligible; consult the Cancer Therapy Evaluation Program (CTEP) medical monitor if
unsure whether second malignancies meet the requirements specified above

- History of interstitial lung disease or pneumonitis

- Any major surgery, extensive radiotherapy (> 15 days of treatment), chemotherapy
with delayed toxicity, biologic therapy, or immunotherapy within 21 days prior to
first dose of study treatment and/or daily or weekly chemotherapy without the
potential for delayed toxicity within 14 days prior to first dose of study treatment

- Use of other investigational drugs within 28 days (or five half-lives, whichever is
shorter; with a minimum of 14 days from the last dose) preceding the first dose of
study drug(s) and during the study

- Patients with known brain metastases should be excluded from this clinical trial
because of their poor prognosis and because they often develop progressive
neurologic dysfunction that would confound the evaluation of neurologic and other
adverse events; exception: patients with brain metastases will be allowed on study
if they have clinically controlled neurologic symptoms, defined as surgical excision
and/or radiation therapy followed by 21 days of stable neurologic function and no
evidence of central nervous system (CNS) disease progression as determined by CT or
MRI within 21 days prior to the first dose of study drug

- Have a known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs
chemically related to trametinib, or excipients or to dimethyl sulfoxide (DMSO), or
to compounds of similar chemical or biologic composition to navitoclax

- 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

- Because the composition, pharmacokinetics (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)

- Due to the expected dose-limiting toxicity of thrombocytopenia, the following
concomitant medications are not allowed during navitoclax administration:
Warfarin, clopidogrel (plavix), ibuprofen, tirofiban (aggrastat), and other
anticoagulants, drugs, or herbal supplements that affect platelet function are
excluded, with the exception of low-dose anticoagulation medications (such as
heparin) that are used to maintain the patency of a central intravenous
catheter; aspirin will not be allowed within 7 days prior to the first dose of
navitoclax or during navitoclax administration; however, subjects who have
previously received aspirin therapy for thrombosis prevention may resume a low
dose (i.e., maximum 100 mg QD) of aspirin if platelet counts are stable (>=
50,000/mm^3) through 6 weeks of navitoclax administration; all decisions
regarding treatment with aspirin therapy will be determined by the investigator
in conjunction with the medical monitor

- Preclinical studies indicate that navitoclax is metabolized by CYP3A4, is a moderate
inhibitor of CYP2C8, and is a strong inhibitor of CYP2C9; therefore, caution should
be exercised when dosing navitoclax concurrently with CYP2C8 and CYP2C9 substrates;
common CYP2C8 substrates include paclitaxel, statins, and glitazones, whereas CYP2C9
substrates include phenytoin and warfarin; when possible, investigators should
switch to alternative medications or monitor the patients closely (particularly in
the case of medications that have a narrow therapeutic window such as warfarin; use
of warfarin is specifically prohibited while on study); CYP3A inhibitors such as
ketoconazole and clarithromycin are not allowed 7 days prior to the first dose of
navitoclax or during navitoclax administration

- Because the lists of these agents are constantly changing, it is important to
regularly consult a frequently-updated list; 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

- Patient instructions and information of possible drug interactions will be
given to all patients upon enrollment in this study

- History or current evidence/risk of retinal vein occlusion (RVO)

- History or evidence of cardiovascular risk including any of the following:

- Left ventricle ejection fraction (LVEF) < LLN

- A QT interval corrected for heart rate using the Bazett's formula QTcB >= 480
msec

- History or evidence of current clinically significant uncontrolled arrhythmias
(exception: patients with controlled atrial fibrillation for > 30 days prior to
enrollment are eligible)

- History of acute coronary syndromes (including myocardial infarction and
unstable angina), coronary angioplasty, or stenting within 6 months prior to
randomization

- 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

- Known cardiac metastases

- Patients with intra-cardiac defibrillators

- Known hepatitis B virus (HBV), or hepatitis C virus (HCV) infection (patients with
chronic or cleared HBV and HCV infection are eligible); patients with human
immunodeficiency virus (HIV) are not eligible if on anti-retroviral medications

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance
with study requirements

- Subject has an underlying condition predisposing them to bleeding or currently
exhibits signs of clinically significant bleeding

- Subject has a recent history of non-chemotherapy-induced thrombocytopenic-associated
bleeding within 1 year prior to the first dose of study drug

- Subject has a significant history of cardiovascular disease (e.g., myocardial
infarction [MI], thrombotic or thromboembolic event in the last 6 months)

- Pregnant women or nursing mothers; animal reproductive studies have not been
conducted with trametinib or navitoclax; therefore, the study drug must not be
administered to pregnant women or nursing mothers