BBBD Followed By Methotrexate and Carboplatin With or Without Trastuzumab in Treating Women With Breast Cancer That Has Spread to the Brain
BBBD Followed By Methotrexate and Carboplatin With or Without Trastuzumab in Treating Women With Breast Cancer That Has Spread to the Brain
RATIONALE: Osmotic blood-brain barrier disruption uses certain drugs, such as mannitol, to
 open the blood vessels around the brain and allow tumor-killing substances to be carried
 directly to the brain. Drugs used in chemotherapy, such as methotrexate and carboplatin, work
 in different ways to stop the growth of tumor cells, either by killing the cells or by
 stopping them from dividing. Monoclonal antibodies, such as trastuzumab, can block tumor
 growth in different ways. Some block the ability of tumor cells to grow and spread. Others
 find tumor cells and help kill them or carry tumor-killing substances to them. Trastuzumab
 may also help methotrexate and carboplatin work better by making tumor cells more sensitive
 to the drugs. Giving osmotic blood-brain barrier disruption together with methotrexate,
 carboplatin, and trastuzumab may kill more tumor cells.

 PURPOSE: This phase I/II trial is studying the side effects and best dose of carboplatin when
 given together with methotrexate and trastuzumab after mannitol in treating women with breast
 cancer that has spread to the brain.
OBJECTIVES:

 Primary

 -  Determine the safety and toxicity associated with blood-brain barrier disruption
 comprising transfemoral mannitol followed by methotrexate and carboplatin with or
 without trastuzumab (Herceptin®) in women with brain metastasis secondary to breast
 cancer. (Phase I)

 -  Determine if overall survival exceeds 5 months in patients with Human Epidermal growth
 factor Receptor 2(HER2)-positive or HER2-negative disease treated with this regimen.
 (Phase II)

 Secondary

 -  Determine the overall survival of these patients.

 -  Compare the event-free and overall survival, steroid use, response rates, and time to
 best response in patients with HER2-positive vs HER2-negative disease.

 -  Assess the quality of life of patients treated with this regimen.

 -  Assess the neuropsychological effects of this treatment regimen in these patients.

 -  Determine cerebrospinal fluid levels of trastuzumab before and after blood-brain barrier
 disruption.

 OUTLINE: This is a multicenter, phase I, pilot, dose-finding study of carboplatin followed by
 a phase II, open-label study.

 -  Phase I: Patients undergo osmotic blood-brain barrier disruption (BBBD) comprising
 mannitol by transfemoral catheterization followed by methotrexate intra-arterially (IA)
 over 10 minutes and carboplatin IA over 10 minutes on days 1 and 2. Patients also
 receive sodium thiosulfate IV over 15 minutes at 4 and 8 hours after each dose of
 carboplatin; leucovorin calcium IV or orally every 6 hours on days 3-9; and
 pegfilgrastim subcutaneously (SC) on day 4 or filgrastim (G-CSF) SC beginning on day 4
 and continuing until blood counts recover (7-10 days). Patients with HER-2 positive
 disease receive trastuzumab (Herceptin®) IV over 90 minutes within 48 hours prior to
 BBBD and then weekly for 3 weeks (between BBBD therapy sessions). Treatment repeats
 every 4 weeks for up to 12 months in the absence of disease progression or unacceptable
 toxicity.

 Cohorts of 3-6 patients receive decreasing doses of carboplatin and/or methotrexate if the
 proposed dose is not well tolerated. Dose-limiting toxicity is defined as grade IV
 hematologic toxicity with delay in subsequent treatment courses for 4 weeks OR grade III/IV
 nonhematologic toxicity without recovery in 14 days during the course of treatment.

 -  Phase II: Patients undergo BBBD as in phase I and receive carboplatin and methotrexate
 at the doses determined in phase I. Patients also receive sodium thiosulfate, leucovorin
 calcium, and pegfilgrastim or G-CSF as in phase I. Patients with HER2-positive disease
 also receive trastuzumab as in phase I.

 Neuropsychological assessment is performed at baseline, every 6 months during treatment,
 every 6 months for 1 year, and then annually thereafter. Quality of life is assessed at
 baseline, every 3 months during treatment, at the completion of study treatment, every 6
 months for 1 year, and then annually thereafter.

 After completion of study therapy, patients are followed periodically.

 PROJECTED ACCRUAL: A total of 78 patients will be accrued for this study.
DISEASE CHARACTERISTICS:

 -  Histologically or cytologically confirmed breast cancer metastatic to the central
 nervous system (as documented by brain biopsy, cytology [analysis from cerebrospinal
 fluid]) OR radiographic evidence of brain metastasis with a diagnosis of systemic
 breast cancer

 -  Patients must have stable or no systemic disease as determined by a CT scan of the
 chest, abdomen, and pelvis

 -  HER2-positive or -negative disease by fluorescent in situ hybridization (FISH) or
 immunohistochemistry

 -  Patients with HER2-positive disease and signs of intracranial herniation and/or spinal
 block may first undergo intraarterial chemotherapy off study (with carboplatin,
 methotrexate, and trastuzumab [Herceptin®] by the same routes used on study) until
 radiographically shown to be safe to undergo blood brain barrier disruption, at which
 point they may be enrolled in the study

 -  Hormone receptor status not specified

 PATIENT CHARACTERISTICS:

 -  Female

 -  Menopausal status not specified

 -  ECOG performance status (PS) 0-2 OR Karnofsky PS 60-100%

 -  Life expectancy > 6 weeks

 -  Hematocrit ≥ 25%

 -  WBC ≥ 2,500/mm³

 -  Absolute neutrophil count ≥ 1,200/mm³

 -  Platelet count ≥100,000/mm³

 -  Creatinine clearance ≥ 50 mL/min (eligible for full-dose methotrexate) (30-49 mL/min
 allowed for patients receiving reduced-dose methotrexate)

 -  Bilirubin ≤ 2.0 times upper limit of normal

 -  LVEF normal by echocardiogram or MUGA

 -  Adequate pulmonary and cardiac function to tolerate general anesthesia as determined
 by physical examination and history

 -  No New York Heart Association class III-IV heart disease

 -  Not pregnant or nursing

 -  Negative pregnancy test

 -  Fertile patients must use effective contraception

 -  No known allergy to trastuzumab (HER2-positive patients), carboplatin, methotrexate,
 or sodium thiosulfate

 -  No hepatitis B or C positivity

 -  No uncontrolled intercurrent illness including, but not limited to, any of the
 following:

 -  Ongoing or active infection (e.g., HIV)

 -  Symptomatic congestive heart failure

 -  Unstable angina pectoris

 -  Cardiac arrhythmia

 -  Psychiatric illness or social situations that would limit compliance with study
 requirements

 PRIOR CONCURRENT THERAPY:

 -  Prior surgery or biopsy allowed

 -  Prior chemotherapy and radiation therapy for metastatic breast cancer allowed

 -  No radiation or cytotoxic chemotherapy within the past 4 weeks (except trastuzumab or
 hormone therapy that has been part of the patient's ongoing treatment [e.g., aromatase
 inhibitors for estrogen receptor positive patients])

 -  No noncytotoxic regimens (e.g., targeted oral agents) within the past 2 weeks

 -  No investigational agents within the past 4 weeks

 -  No other concurrent anticancer agents or therapies