A Phase I Trial of Sorafenib and Stereotactic Radiosurgery for Patients With 1-4 Brain Metastases
Inclusion Criteria:
- Histologically confirmed cancer with 1-4 brain metastases (except lymphoma or small
cell histologies)
- ECOG PS 0 or 1
- Patients are candidates for stereotactic radiosurgery as determined by the treating
radiation oncologist. Intra-cranial tumors must measure 4cm or less in greatest
dimension. Patients may have received prior neurosurgical resection(s) of
intra-cranial metastases if their operation(s) was (were) completed at least 6 months
prior to study enrollment. Patients may have had prior whole brain radiation therapy
(WBRT) if it was completed at least 6 months prior to study enrollment.
- Age ≥ 18 years and willing and able to sign a written informed consent; a signed
informed consent must be obtained prior to any study specific procedures
- INR < 1.5 or a PT/PTT within normal limits; patients receiving anti-coagulation
treatment with an agent such as warfarin or heparin may be allowed to participate;
for patients on warfarin, the INR should be measured prior to initiation of sorafenib
and monitored at least weekly (INR must be therapeutic in the range of 2-3)
Subjects must receive 1st dose of sorafenib 5-7 days prior to administration of
Stereotactic Radiosurgery.
Exclusion Criteria:
- Congestive heart failure > class II NYHA; patients must not have unstable angina
(anginal symptoms at rest) or new onset angina (began within the last 3 months) or
myocardial infarction within the past 6 months
- Unable to undergo brain MRI
- CNS metastases from lymphoma or small cell lung cancer
- Cardiac ventricular arrhythmias requiring anti-arrhythmic therapy
- Uncontrolled hypertension defined as systolic blood pressure > 140mm Hg or diastolic
pressure > 90 mm Hg, despite optimal medical management
- Known human immunodeficiency virus (HIV) infection or chronic Hepatitis B or C
- Active clinically serious infection > CTCAE v 4.0 Grade 2
- Thrombolic or embolic events such as a cerebrovascular accident including transient
ischemic attacks within the past 6 months
- Pulmonary hemorrhage/bleeding event >= CTCAE v 3.0 Grade 2 within 4 weeks of first
dose of study drug
- Any other hemorrhage/bleeding event >= CTCAE v 3.0 Grade 3 within 4 weeks of first
dose of study drug
- Serious non-healing wound, ulcer, or bone fracture
- Any drug that results in hepatic enzyme induction such as anti-convulsants (dilantin,
depakote, tegretol, phenobarbital); keppra is allowed
- Evidence or history of bleeding diathesis or coagulopathy
- Any pulmonary hemorrhage CTCAE v 4.0 Grade 2 or higher within 4 weeks of first study
drug
- Any other bleeding or hemorrhage CTCAE v 4.0 Grade 3 or higher within 4 weeks of
first drug
- Major surgery, open biopsy or significant traumatic injury within 4 weeks of first
study drug
- Use of St. John's Wort or rifampin (rifampicin) within the last 8 weeks
- Known or suspected allergy to sorafenib
- Any condition that impairs patient's ability to swallow whole pills
- Concurrent investigational drugs
- Concurrent steroids are allowed if Dexamethasone dose is =< 16mg daily; if feasible,
steroids should be weaned off once sorafenib has been initiated
- Prior therapy with sorafenib or other tyrosine kinase inhibitors within the last 12
months; patients are allowed to have been on prior bevacizumab therapy as long as it
was stopped at least 6-8 weeks prior to enrolling on this trial
- Any malabsorption problem
- Hemoglobin =< 9.0 g/dl
- Absolute neutrophil count (ANC) =< 1,500/mm^3
- Platelet count =< 100,000/mm^3
- Total bilirubin >= 1.5 times upper limit of normal (ULN)
- ALT and AST >= 2.5 times the ULN ( =< 5 x ULN for patients with liver involvement)
- Creatinine >= 1.5 times ULN
- Women of childbearing potential with a positive serum pregnancy test performed within
7 days prior to the start of treatment; women and men of childbearing potential that
do not agree to use adequate contraception (barrier method of birth control) prior to
study entry and for the duration of study participation; men who do not agree to use
adequate birth control for at least three months after the last administration of
sorafenib
- All toxicities from prior therapies must have resolved to CTCAE v3.0 Grade I or
better by the time of study enrollment