A Trial of AMG 479, Everolimus (RAD001) and Panitumumab in Patients With Advanced Cancer (RAP)

Inclusion Criteria:

1. Histologically and/or cytologically confirmed malignant solid tumor that is refractory to standard therapies, or for which no standard therapies exist. Disease must be measurable by RECIST criteria.
2. Age >18 years.
3. ECOG performance status 0-2.
4. Life expectancy of at least 3 months.

5. Subjects must have adequate organ and marrow function as defined below:

   • Absolute neutrophil count >/=1,500/μl
   • Platelets >/=100,000/μl
   • Magnesium > 1.8 mg/dL
   • Phosphorus > 2.3 mg/dL
   • Total bilirubin </= 1.5 X upper limit of normal (ULN)
   • AST(SGOT)/ALT(SGPT) </=2.5 X ULN, </=5 X ULN if known hepatic metastases PT/INR; PTT </= 1.3; <1.3 X ULN
   • Creatinine clearance >/=40 mL/min/m2 by Cockroft-Gault or MDRD equation
   • Hemoglobin >9 g/dL
   • Continuation of erythropoietin products is permitted. Hemoglobin must be stable above 9 g/dL for at least 2 weeks without blood transfusion to maintain hemoglobin level.
   • Fasting blood sugar </= 160 mg/dL

   • Patient may be on diabetic medication to achieve glucose control:

     • Documented fasting blood sugars </= 160 mg/dL
     • Diabetic subjects who have recently had their glycemic control regimens adjusted and have documented fasting blood glucose concentrations ≤ 160 mg/dL may be considered regardless of HgbA1c value, if per investigator discretion the subject is considered to have adequate glycemic function
6. Ability to understand and the willingness to sign a written informed consent document.

Exclusion Criteria:

1. Radiation therapy, hormonal therapy, biologic therapy or chemotherapy for cancer within the 28 days prior to day 1 of study drug.
2. Active CNS metastases. MRI (or CT) required within 3 months of starting treatment for all tumor types known to commonly metastasize to the brain (i.e. all tumors except pancreas, colorectal, ovarian) and for all patients with CNS symptoms that may represent CNS metastases. Metastases which have been treated with radiotherapy > 2 months prior to start of protocol therapy and are asymptomatic (off steroid therapy for at least 1 month) may be included. Patients must have had normal or stable (if treated, no new lesions) brain imaging (CT or MRI) within the two months prior to day 1 of study drug.
3. Inadequately controlled hypertension (defined as systolic blood pressure 140 and/or diastolic blood pressure > 90 mmHg). Initiation of antihypertensive is permitted provided adequate control is documented over at least 1 week prior to day 1 of study drug.
4. Evidence of active bleeding diathesis or coagulopathy.
5. No warfarin therapy. Low molecular weight heparin anticoagulation is permitted provided that patients have been clinically stable on anti-coagulation for at least 2 weeks prior to day 1 of study drug and meet platelet inclusion criteria. No history of active GI bleeding or other major bleeding within previous 6 months prior to day 1 of study drug.
6. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to day 1 of study drug (56 days for hepatectomy, open thoracotomy, major neurosurgery) or anticipation of need for major surgical procedure during the course of the study.
7. History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within 6 months prior to day 1 of study drug.
8. Serious, non-healing wound, ulcer, or bone fracture.
9. Any prior history of hypertensive crisis or hypertensive encephalopathy.
10. New York Heart Association (NYHA) Grade II or greater congestive heart failure.
11. History of clinically significant vascular disease, including any of the following within 6 months prior to day 1 of study drug: myocardial infarction or unstable angina, percutaneous coronary intervention, bypass grafting, ventricular arrhythmia requiring medication, stroke or transient ischemic attack, symptomatic peripheral arterial disease and/or involvement of great vessels by tumor with or without vascular grafting.

12. Chronic treatment with systemic steroids or another immunosuppressive agent with the following exceptions:

    Intermittent steroids may be used on an as-needed basis (e.g. treatment for chemotherapy-related nausea.) Patients on physiologic replacement doses of steroids due to adrenal insufficiency for any reason may remain on these medications.

13. A known history of HIV seropositivity, hepatitis C virus, acute or chronic active hepatitis B infection, or other serious chronic infection requiring ongoing treatment.
14. Impairment of gastrointestinal function or gastrointestinal disease that may significantly alter drug absorption (e.g. inflammatory bowel disease, uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome or significant small bowel resection).
15. Patient unwilling to or unable to comply with the protocol.
16. Medical need for the continuous administration of any drugs which affect CYP3A4 though the use of low dose glucocorticoids (e.g. Dexamethasone </= 4 mg daily or equivalent) for anorexia and /or nausea is permitted.
17. History of interstitial lung disease e.g. pneumonitis or pulmonary fibrosis, or any evidence of interstitial lung disease on baseline chest CT scan.
18. Patients who are pregnant and/or lactating are excluded from this study. (The effect of the investigational drugs on the developing human fetus is not known, but these drugs are likely to be embryo- and feto-toxic. Women of child-bearing potential and men must agree to use two forms of adequate contraception (hormonal or barrier method of birth control; abstinence) prior to day 1 of study drug, the duration of study participation and 6 months after the last dose of study drug. Should a woman become pregnant or suspect she is pregnant while she or her partner are participating in this study, she should inform her treating physician and study PI immediately. Oral, implantable, or injectable contraceptives may be affected by cytochrome P450 interactions, and are therefore not considered effective for this study. )

19. Other concurrent severe and/or uncontrolled medical, psychiatric or social conditions that could compromise the safety or compliance of treatment as so judged by treating physician. Examples include but are not limited to:

    History of severely impaired lung function defined as spirometry and DLCO that is </= 50% of the normal predicted value and/or 02 saturation that is </= 88% at rest on room air.

    Uncontrolled diabetes mellitus consistent fasting blood glucose readings > 160 mg/dL or < 50 mg/dL). Use of diabetic medications is permitted.

    Hyperlipidemia (>CTC Grade 2: Total Cholesterol > 300-400; Triglycerides > 2.5 ULN). Use of lipid lowering agents is permitted.

    Other: e.g. severe infection, severe malnutrition, ventricular arrhythmias, known active vasculitis of any cause, tumor invasion of any major blood vessel, severe chronic liver or renal disease, active upper GI tract ulceration.

20. No immunizations with attenuated live vaccines within one week of study entry or during study period.