Ceritinib in Treating Patients with Activated Gastrointestinal Malignancies That Cannot Be Removed by Surgery

Inclusion Criteria

• Histologically or cytologically confirmed diagnosis of inoperable colorectal adenocarcinoma, pancreatic, hepatocellular, cholangiocarcinoma, small bowel, gastric or esophageal adenocarcinoma that carries an activated ALK or ROS1 pathway
• Patients must have received at least 1 line of cytotoxic chemotherapy
• Patients must have archival tissue sample available, collected either at the time of diagnosis or any time since; if archival tissue is unavailable, patient must be eligible and willing to undergo a fresh tissue biopsy
• Patients must have recovered from all toxicities related to prior anticancer therapies to grade =< 2 (Common Terminology Criteria for Adverse Events [CTCAE] version [v] 4.03) provided that concomitant medication is given prior to initiation of treatment with LDK378 [ceritinib], except for patients with grade 2 nausea/vomiting and/or grade 2 diarrhea despite optimal supportive therapy who will not be allowed to participate in the study; additionally, patients with any grade of alopecia are allowed on treatment
• Patient must have measurable lesions as defined by RECIST version 1.1 criteria
• Eastern Cooperative Oncology Group (ECOG) performance status 0-2
• An absolute neutrophil count (ANC) >= 1,500/mcl
• Platelets >= 75,000/mcl
• Hemoglobin >= 8 g/dl
• Serum creatinine less than or equal to 1.5 x institutional upper limit normal (ULN)
• Calculated or measured creatinine clearance (CrCl) >= 30 mL/min
• Serum total bilirubin < 1.5 x ULN
• Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]), alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3.0 x ULN; if liver involvement, AST and ALT =< 5.0 x ULN
• Alkaline phosphatase =< 3.0 x ULN; if liver involvement, alkaline phosphatase =< 5.0 x ULN
• Serum albumin >= 2.5 g/dl
• Serum amylase =< 2 x ULN
• Serum lipase =< 1 x ULN
• Fasting plasma glucose =< 175 mg/dL (=< 9.8 mmol/L)
• Patient must have the following laboratory values or have the following laboratory values corrected with supplements to be within normal limits at screening: * Potassium >= lower limit of normal (LLN) * Magnesium >= LLN * Phosphorus >= LLN * Total calcium (corrected for serum albumin) >= LLN
• A male subject of fathering potential must use an adequate method of contraception to avoid conception throughout the study (and for up to 12 weeks after the last dose of study drug) to minimize the risk of pregnancy; if the partner is pregnant or breastfeeding, the subject must use a condom; a condom is required to be used also by vasectomized men in order to prevent delivery of the drug via seminal fluid
• Women of childbearing potential (WOCBP) must be using an adequate method of contraception to avoid pregnancy throughout the study and for up to 12 weeks after the last dose of study drug to minimize the risk of pregnancy; WOCBP must have a negative serum or urine pregnancy test within 72 hours before the start of the investigational product; highly effective contraception methods include: * (a) Total abstinence (when this is in line with the preferred and usual lifestyle of the subject; periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception * (b) Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy) or tubal ligation at least six weeks before taking study treatment; in case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment * (c) Male sterilization (at least 6 months prior to screening) with the appropriate post-vasectomy documentation of the absence of sperm in the ejaculate; for female subjects on the study the vasectomized male partner should be the sole partner for that subject * Combination of any two of the following (a+b or a+c or b+c) * Use of oral, injected or implanted hormonal methods of contraception or other forms of hormonal contraception that have comparable efficacy (failure rate < 1%), for example hormone vaginal ring or transdermal hormone contraception * Placement of an intrauterine device (IUD) or intrauterine system (IUS); barrier methods of contraception: condom or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository; in case of use of oral contraception, women should have been stable on the same pill for a minimum of 3 months before taking study treatment; women are considered post-menopausal and not of child bearing potential if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g., age appropriate, history of vasomotor symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy) or tubal ligation at least six weeks prior to screening; in the case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is she considered not of child bearing potential
• Ability to understand and the willingness to sign a written informed consent document

Exclusion Criteria

• Patients who have had chemotherapy or radiotherapy within 3 weeks (4 weeks for radiotherapy to the lung fields and 6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier
• Patients with known hypersensitivity to any of the excipients of ceritinib (microcrystalline cellulose, mannitol, crospovidone, colloidal silicon dioxide and magnesium stearate)
• Prior therapy with ceritinib or other ALK or ROS1 inhibitor agents
• Patients who are currently receiving treatment with warfarin sodium (Coumadin®) or any other coumarin-derivative anti-coagulants
• Patients with symptomatic central nervous system (CNS) metastases who are neurologically unstable or have required increasing doses of steroids within the 1 week prior to study entry to manage CNS symptoms
• Impairment of GI function or GI disease that may significantly alter the absorption of ceritinib
• History of pancreatitis or history of increased amylase or lipase that was due to pancreatic disease
• Patients with known history of extensive disseminated bilateral interstitial fibrosis or interstitial lung disease, including a history of pneumonitis, hypersensitivity pneumonitis, interstitial pneumonia, obliterative bronchiolitis, and clinically significant radiation pneumonitis (i.e. affecting activities of daily living or requiring therapeutic intervention)
• Active coronary artery disease, unstable or newly diagnosed angina or myocardial infarction less than 6 months prior to first study drug administration
• Class II-IV New York Heart Association (NYHA) congestive heart failure
• Cardiac arrhythmias requiring anti-arrhythmic therapy other than beta blockers or digoxin
• Corrected QT (QTc) (Frederica) prolongation > 470 msec
• Subjects with valvular heart disease CTCAE (version 4.0) grade 2
• Known left ventricular ejection fraction (LVEF) < 50%
• Uncontrolled hypertension defined by a systolic blood pressure (SBP) >= 160 mm Hg and/or diastolic blood pressure (DBP) >= 100 mm Hg, with or without anti-hypertensive medication
• Receiving medications that meet one of the following criteria and that cannot be discontinued at least 1 week prior to the start of treatment with LDK378 and for the duration of participation: * Medication with a known risk of prolonging the QT interval or inducing torsades de pointes * Strong inhibitors or strong inducers of cytochrome P450, family 3, subfamily A poly peptide 4/5 (CYP3A4/5) * Medications with a low therapeutic index that are primarily metabolized by CYP3A4/5, and/or cytochrome P450 family 2, subfamily C, polypeptide 9 (CYP2C9) * Therapeutic doses of warfarin sodium (Coumadin) or any other coumarin-derived anti-coagulant; anti-coagulants not derived from warfarin are allowed (e.g., dabigatran, rivaroxaban, apixaban) * Unstable or increasing doses of corticosteroids * Enzyme-inducing anti-convulsive agents * Herbal supplements
• Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris (Canadian Cardiovascular Society grade II-IV despite medical therapy), cardiac arrhythmia, active bleeding diatheses, or psychiatric illness/social situations that would limit compliance with study requirements
• Major surgical procedure, open biopsy, or significant traumatic injury less than 4 weeks or those who receive minor surgical procedures (e.g. core biopsy or fine needle aspiration) within 1 week from first dose of first study drug administration
• Known inability to swallow up to five ceritinib (LDK378) capsules daily
• Pregnant or nursing (lactating) women, where pregnancy is defined as the state of a female after conception and until the termination of gestation, confirmed by a positive human chorionic gonadotropin (hCG) laboratory test