Study of Ribociclib and Everolimus in HGG and DIPG

TarGeT-A study strata definitions Stratum A: Patients with localized, intracranial, non-pontine, and non-thalamic HGG (who do not meet criteria for strata C-D) Stratum B: Patients with DIPG Stratum C: Patients with primary thalamic, spinal cord, and/or secondary/radiation-related HGG. Stratum D: Patients with metastatic/disseminated HGG, multifocal HGG, and/or gliomatosis cerebri who received CSI. Inclusion Criteria: Inclusion criteria already met to enroll on TarGeT-SCR (central molecular and histopathologic screening) based on: 1.1) Age: patients must be ≥12 months and ≤30 years of age at the time of enrollment on TarGeT-SCR 1.2) Diagnosis: patients with newly-diagnosed HGG, including DIPG are eligible. All patients must have tumor tissue from diagnostic biopsy or resection, without exceptions. The diagnosis of HGG, including DIPG, must have been confirmed through TarGeT-SCR: For the diagnosis of DIPG, patients must have a tumor with pontine epicenter and diffuse involvement of at least 2/3 of the pons, with histopathology, consistent with diffuse WHO grade 2-4 glioma (e.g., diffuse astrocytoma, anaplastic astrocytoma, glioblastoma, H3K27-altered diffuse midline glioma). For all other tumors, histologic grade must be WHO grade 3-4. 1.3) Disease status: There are no disease status requirements for enrollment Patients without measurable disease are eligible. Patients with metastatic or multifocal disease or gliomatosis cerebri who received upfront CSI are eligible Patients with a primary spinal HGG are eligible Patients with secondary, radiation-related HGG are eligible. Inclusion criteria for assignment to TarGeT-A, for all strata: 2.1) BSA ≥0.45m2 at the time of study entry. 2.2) Presence of at least one relevant actionable somatic alteration, detailed here: Pathogenic alterations presumed to cause activation of cell cycle: Amplification of CDK4 or CDK6 Deletion of CDKN2A, CDKN2B, or CDKN2C Amplification of CCND1 or CCND2 Pathogenic alterations presumed to cause activation of the PI3K/mTOR pathway: Deletion or mutation of PTEN Mutation or amplification of PIK3CA Mutation of PIK3R1 Patients with evidence of homozygous (biallelic) RB1 loss by sequencing are excluded from this treatment protocol (TarGeT-A). Patients whose tumors harbor other alterations suspected to activate the cell cycle and/or PI3K/mTOR pathway could potentially also be eligible, but only following consensus recommendation by the international multidisciplinary molecular screening committee. 2.3) Performance Level: Karnofsky ≥ 50% for patients > 16 years of age and Lansky ≥ 50 for patients ≤ 16 years of ag. Patients who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score. 2.4) Prior Therapy for HGG: Surgery, RT, dexamethasone are permissible. Temozolomide administered concurrently with RT is permissible but discouraged. No other prior anticancer therapy for HGG will be allowed. Patients must have received photon or proton RT. Patients must have started RT within 31 calendar days of initial diagnosis defined as the date of diagnostic biopsy or resection. If a patient underwent 2 upfront surgeries (e.g., biopsy then resection or debulking), this is the date of the second surgery. RT delivered via photon or proton beam, must have been administered to a dose of within 10% of standard dosing (54 Gy for DIPG, 59.4 Gy for other HGG, XX for primary spinal disease, and/or XX Gy craniospinal for patients with spinal or leptomeningeal metastatic disease). Patients must enroll and start treatment No later than 35 calendar days post-completion of RT. The earliest patients can begin protocol treatment is 28 calendar days post-completion of RT. 2.5) Organ Function Requirements 2.5.1) Adequate Bone Marrow Function Defined as: Peripheral absolute neutrophil count (ANC) ≥ 1000/mm3 Platelet count ≥ 100,000/mm3 (transfusion independent, defined as not receiving platelet transfusions for at least 7 days prior to enrollment) Hemoglobin >8 g/dL (may be transfused) 2.5.2) Adequate Renal Function Defined as: Creatinine clearance or radioisotope GFR ≥ 70ml/min/1.73 m2 OR Maximum serum creatinine based on (Schwartz et al. J. Peds, 106:522, 1985) age/gender as follows: 1 to < 2 years=0.6 mg/dL for males and females; 2 to < 6 years=0.8 mg/dL for males and females; 6 to < 10 years= 1.0 mg/dL for males and females; 10 to < 13 years=1.2 mg/dL for males and females. 13 to < 16 years=1.5 mg/dL for males and 1.4 mg/dL for females. 2.5.3) Adequate Liver Function Defined as: Total bilirubin must be ≤ 1.5 times institutional upper limit of normal for age AST(SGOT)/ALT(SGPT) ≤ 3 times institutional upper limit of normal Serum albumin ≥ 2g/dL 2.5.4) Adequate Cardiac Function Defined as: Ejection fraction of ≥ 50% by echocardiogram QTc ≤ 450 msec 2.5.5) Adequate Neurologic Function Defined as: Patients with seizure disorder may be enrolled if well-controlled on anticonvulsants that are not strong inducers or inhibitors of CYP3A4/5. (Patients receiving enzyme inducing anti-epileptic drugs that are known strong inducers or inhibitors of CYP3A4/5 are not eligible) 2.5.6) Adequate Pulmonary Function Defined as: No evidence of dyspnea at rest, and a pulse oximetry >94% on room air if there is clinical indication for determination. 2.6) Informed Consent: All patients and/or their parents or legally authorized representatives must sign a written informed consent. Assent, when appropriate, will be obtained according to institutional guidelines Exclusion Criteria for All Strata: Pregnant or Breast-Feeding women will not be entered on this study due to known potential risks of fetal and teratogenic adverse events as seen in animal/human studies. Pregnancy tests must be obtained in girls who are post-menarchal. Patients of childbearing or child fathering potential must agree to use adequate contraceptive methods (hormonal or barrier method of birth control; abstinence) while being treated on this study and for 3 months after completing therapy. Concomitant Medications Patients receiving corticosteroids are eligible. The use of corticosteroids must be reported. Patients who are currently receiving another investigational drug are not eligible. Patients who are currently receiving other anti-cancer agents are not eligible, with the exception of temozolomide given concurrently with RT only. Patients who are receiving enzyme inducing anticonvulsants that are strong inducers or inhibitors of CYP3A4/5 are not eligible. Patients who are receiving strong inducers or inhibitors of CYP3A4/5 are not eligible and should be avoided from 14 days prior to enrollment to the end of the study. Patients who are receiving medications known to prolong QTc interval are not eligible. Patients who are receiving therapeutic anticoagulation with warfarin or other coumadin-derived anticoagulants are not eligible. Therapy with heparin, low molecular weight heparin (LMWH), or fondaparinux is allowed as long as the patient has adequate coagulation defined as aPTT < 1.5Xs ULN and INR < 1.5. Patients who have an uncontrolled infection are not eligible. Patients who, in the opinion of the investigator, may not be able to comply with the safety monitoring requirements of the study are not eligible. Patients with known clinically significant active malabsorption syndrome or other condition that could affect absorption are not eligible. Patients with prior or ongoing clinically significant medical or psychiatric condition that, in the investigator's opinion, could affect the safety of the subject, or could impair the assessment of study results are not eligible.