Biomarker Development for Response Prediction by DNA Mutational Analysis

• Biopsy (Procedure), also known as Histological biopsy: Histological biopsy of the "index lesion" (a radiological measurable lesion on which biopsy is performed) at baseline, as well as when showing progressive disease. Histological biopsies will be subjected to DNA sequencing to assess the mutational profile, as well as to analysis of carboxylesterase activity.
• Blood samples (Procedure), also known as Blood sampling: Blood samples will be taken at baseline to determine patient's genetic background variation (germline DNA).
• Pharmacokinetics (Procedure), also known as PK, Pharmacokinetic analysis, Pharmacokinetic analyses: Blood samples will be taken for pharmacokinetic analysis of the active irinotecan metabolite (SN-38).
• Midazolam clearance test (Procedure), also known as MCT: Patients who are being treated in Rotterdam will be subjected to blood draws for validation of the earlier developed midazolam phenotyping test (midazolam clearance test), which may be an indicator for pharmacokinetics of irinotecan.

Primary outcomes

• Exploration of the correlation between the mutational profile and the percentage change in volumetric measurement of the index lesion after the first two cycles of chemotherapy. [Change in radiological volume of the index lesion after the first 2 cycles of irinotecan. Radiological response (according to RECIST 1.1) after the first 2 cycles of irinotecan (i.e. after 2 x 3 weeks = 6 weeks)]

Secondary outcomes

• Exploration of the correlation between the mutational profile and radiological response according to RECIST-criteria after the first two cycles of chemotherapy. [Analysis 6 weeks after initiation of treatment]
• Exploration of the correlation between the mutational profile and progression free survival and overall survival. [Overall survival approximately after 2 years of first cycle of irinotecan. Progression free survival approximately 3 months after first irinotecan]
• Exploration of the correlation between the mutational profile of the index lesion and patient's germline DNA background variation. [Analysis after progressive disease, on average after 3 months.]
• Differences in mutational profile of metastasis prior to and after exposure to treatment. [Analysis after progressive disease and subsequent post-treatment biopsy, on average after 3 months of treatment]
• Determine reliable and valid strategies for statistical analysis for biomarker discovery [2 years]
• Correlate response to pharmacokinetics of SN-38 [After progressive disease and subsequent post-treatment biopsy, in general after 3 months of treatment]
• Determine carboxylesterase activity in metastatic tumor material (pre- and posttreatment) and correlate intra-tumoral carboxylesterase activity to systemic SN-38 pharmacokinetics and to irinotecan response [After progressive disease and subsequent post-treatment biopsy, in general after 3 months of treatment]
• Determine clinical applicability of the midazolam phenotyping probe [After first cycle of irinotecan, at three weeks]
• Number and nature of all (serious) adverse events of study related procedures [14 days after baseline biopsy and 14 days after post-treatment biopsy (approximately after 3 months of treatment)]

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. Patients with a metastatic solid tumor who have failed at least one line of palliative chemotherapy and are irinotecan naïve.
2. Patients who are, as per local protocol, eligible for palliative treatment with (standard of care) irinotecan.
3. Measurable metastatic lesion(s), according to RECIST 1.1 criteria.
4. Radiological measurable metastatic lesion(s) of which a histological biopsy can safely be obtained:

   1. Patients with safely accessible metastases.
   2. Patients not known with bleeding disorders (such as hemophilia) or bleeding complications from biopsies, dental procedures or surgeries.
   3. Patients not using any anti-coagulant medication at the time of biopsy: all aspirin derivatives, NSAID's, coumarines, platelet function inhibitors, heparins (including LMWHs) and oral factor Xa inhibitors are not allowed, unless medication can either be safely stopped or counteracted.
   4. Adequate coagulation status on the day of biopsy as measured by:

      * PTT < 1.5 x ULN
      * APTT < 1.5 x ULN
      * Platelet count 100 x 10*9 / L or higher
      * PT-INR < 1.6
      * HB > 6
   5. Biopsies should be performed at least four weeks after last bevacizumab administration.
5. Patients age 18 years or up, willing and able to comply with the protocol as judged by the investigator with a signed informed consent.

Exclusion Criteria:

Patients not meeting all of the above inclusion criteria.

• Marlies Langenberg, MD/PhD, Principal investigator, UMC Utrecht
• Neeltje Steeghs, MD/PhD, Principal investigator, Netherlands Cancer Institute - Antoni van Leeuwenhoek hospital, Amsterdam
• Ron Mathijssen, MD/PhD, Principal investigator, Erasmus Medical Center - Daniël den Hoed clinic, Rotterdam