Intravenous and Intraperitoneal Paclitaxel and Oral Nilotinib for Peritoneal Carcinomatosis

Background:

• Peritoneal carcinomatosis is uniformly fatal if untreated; despite advances in systemic chemotherapy, cytoreductive surgery, and intraperitoneal chemotherapy, survival remains poor for the majority of patients
• The combination of oral nilotinib and intravenous paclitaxel has demonstrated pre-clinical and clinical synergism in the treatment of solid tumors, with an ongoing Phase I trial at the National Institutes of Health (NIH)
• The synergy of oral nilotinib with intraperitoneal paclitaxel remains to be characterized
• This study involves the combination of intravenous and intraperitoneal paclitaxel and oral nilotinib for unresectable peritoneal carcinomatosis from colorectal, appendiceal, small bowel, gastric, cholangiocarcinoma, breast, ovarian, or other gynecologic primary histologies.

Objective:

-To evaluate efficacy of bidirectional chemotherapy using intraperitoneal and intravenous paclitaxel and oral nilotinib by calculating the rate of downstaging of peritoneal disease burden to become resectable, based on Peritoneal Carcinomatosis Index (PCI)

Eligibility:

• Participants >= 18 years of age with histologically confirmed peritoneal carcinomatosis of colorectal, appendiceal, small bowel, gastric, cholangiocarcinoma, breast, ovarian, or other gynecologic primary histology
• Demonstrated resistance or lack of response to at least one line of already approved and available systemic chemotherapy
• No history of allergic reactions attributed to compounds of similar chemical or biologic composition to study drugs
• No intraperitoneal chemotherapy within the last six months
• Deemed unable to undergo complete cytoreduction

Design:

• Phase II open-label, non-randomized study
• After confirmation of eligibility, at the time of diagnostic laparoscopy, biopsies will be taken, and an intraperitoneal catheter will be placed for subsequent chemotherapy administration
• Up to 6 cycles will be planned, with restaging laparoscopy and biopsies after Cycles 3 and 6

• INCLUSION CRITERIA:

In order to be eligible to participate in this study, an individual must meet all of the following criteria.

• Histological confirmation of peritoneal carcinomatosis from colorectal, appendiceal, small bowel, gastric, cholangiocarcinoma, breast, ovarian, or other gynecologic (i.e., endometrial, fallopian tube, primary peritoneal, cervical) primary by the Laboratory of Pathology, national Cancer Institute (NCI).
• Participants must have been treated with at least one line of approved systemic chemotherapy, with demonstrated resistance or lack of response
• Measurable or evaluable disease as defined by the Response Evaluation Criteria in Solid Tumors (RECIST) v1.1. criteria and/or by Peritoneal Carcinomatosis Index (PCI)
• Participants must be assessed to not be candidates for cytoreductive surgery, with laparoscopically assessed Peritoneal Cancer Index (PCI) score thresholds as indicated below:

--Primary Histology PCI Cutoff for Eligibility

• Gastric Total Score >= 10 (out of 39 possible points)
• Others Total Score >= 20 (out of 39 possible points)
• Any Jejunoileal Score >= 4 (out of 12 possible points)
• Age >= 18 years
• Eastern Cooperative Oncology Group (ECOG) performance status <= 2 (Karnofsky >= 60%).
• Participants must have adequate organ and marrow function as defined below:

• Absolute neutrophil count >= 1,000/mcL
• Platelets >= 100,000/mcL
• Total bilirubin within <= 1.5x institutional upper limit of normal (ULN)
• Aspartate aminotransferase (AST) serum glutamic oxaloacetic transaminase (SGOT)/Alanine aminotransferase (ALT) serum glutamic pyruvic transaminase (SGPT) <= 3x institutional ULN, or <= 5.0x ULN in participants with liver metastases (only)
• Serum potassium and magnesium greater than institutional lower limit of normal
• Creatinine <= 1.5 mg/dL or creatinine clearance >= 60 mL/min/1.73 m^2 for participants with creatinine levels above institutional normal calculated using estimated glomerular filtration rate (eGFR)
• Nursing (including breastfeeding) participant must agree to discontinue nursing.
• Individuals of child-bearing potential (IOCBP) must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and for 90 days after last study treatment. Should an individual of child-bearing potential suspect to be pregnant while participating in this study, the individual should inform the treating physician immediately.
• Ability of participant to understand and the willingness to sign a written informed consent document.
• Participants must agree to co-enrollment on the tissue collection protocol 13C0176, Tumor, Normal Tissue and Specimens from Patients Undergoing Evaluation or Surgical Resection of Solid Tumors

Exclusion criteria

An individual who meets any of the following criteria will be excluded from participation in this study.

• Participants who are receiving any other investigational agents or who have received an investigational agent within 30 days prior to the start of study treatment.
• Participants with a history of allergic reactions attributed to compounds of similar chemical or biologic composition to study drugs.
• Participants who have received systemic (i.e., oral or intravenous) chemotherapy or other anti-cancer therapy (i.e., immunotherapy) within either 5 half-lives or within 30 days of the last dose of individual agent(s) administered prior to the start of study treatment, whichever is shorter.
• Participants who have undergone major abdominal surgery within the last 12 weeks prior to the start of study treatment.

Note: Exclusion of participants who have undergone major abdominal surgery within the last 12 weeks prior to start of study treatment is to allow for scar tissue formation from that surgery to stabilize. Participant ECOG performance status will be checked to account for prolonged or difficult recoveries from other types of major surgery that would appropriately influence eligibility assessment.

• Participants who have received previous intraperitoneal chemotherapy within the last 6 months prior to the start of study treatment
• Participants requiring the use of drugs known to prolong the QT interval or known to strongly inhibit cytochrome P450 3A4 (CYP3A4), cytochrome P450 CYP (2C8). Participants on such agents at the time of screening are permitted on study if an alternative that does not have the same pharmacokinetic interactions can be found.
• 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. Note: No subject will be excluded based on a social situation prior to consultation with the Department of Social Work.
• Pregnant individuals are excluded from this study.
• Participants with human immunodeficiency virus (HIV) who have detectable viral load, or whose Antiretroviral therapy (ART) contains corrected QT interval (QTc) Prolonging Medications or CYP3A4 Inhibitors regardless of viral load. (NOTE: Participants with HIV who have an undetectable viral load and have been on stable doses of ART that does not prolong the QT interval or is a strong CYP3A4, 2C8 inhibitor are eligible).
• QT corrected for heart rate by Fridericia's cube root formula (QTcF) interval of >= 450 msec at study entry, or congenital long QT syndrome.
• More than 3 liters of ascites present at initial laparoscopy, or history of more than two therapeutic paracentesis procedures, each yielding at least 1.5 liters of fluid, in the 30 days prior to initial laparoscopy, or confirmation of predominantly mucinous ascites at the time of screening laparoscopy.
• Advanced hepatic failure, as indicated by Child-Pugh Class C cirrhosis.
• Sensory/motor neuropathy >= Grade 2