Birinapant and Carboplatin in Treating Patients With Recurrent High Grade Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

PRIMARY OBJECTIVES:

I. To assess whether addition of birinapant to carboplatin therapy can reduce the percentage
of platinum resistant tumor initiating cells by 50% compared to pre-therapy biopsies in
participants with recurrent high grade serous ovarian carcinomas (HGSOC) whose tumors score
positive in the in vitro organoid bioassay test.

II. Assess target engagement by comparing levels of cellular inhibitor of apoptosis protein
(cIAP) and percentage of apoptotic cells in pre-versus post therapy tumor biopsies (obtained
after three cycles of treatment).

SECONDARY OBJECTIVES:

I. To see if there is an increase in progression free survival of participants treated with
co-therapy (birinapant/carboplatin) compared with historic controls.

TERTIARY OBJECTIVES:

I. Develop a companion diagnostic test by correlating clinical response seen in participants
with two biomarker assays developed in our laboratory.

1. Measuring levels of cIAP protein by western blot in tumor biopsies obtained from
participants prior to start of therapy.

2. Measuring percentage of cIAP positive cells by immunohistochemistry in tumor biopsies
obtained from participants prior to start of therapy.

OUTLINE:

Patients receive birinapant intravenously (IV) over 30 minutes on days 1 and 8, and
carboplatin IV over 30 minutes to 1 hour on day 1. Treatment repeats every 21 days for up to
6 courses in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for up to 2
years from Course 1, Day 1.

Inclusion Criteria:

- All patients must have measurable disease by imaging defined as tumor that can be
measured >= 10 mm with multiparametric magnetic resonance imaging (MRI) (primary
modality of imaging) or computed tomography (CT) (as an alternative) or >= 10 mm by
caliper on physical examination

- Participant is capable of understanding and complying with parameters as outlined in
the protocol and able to sign and date the informed consent, approved by an
Independent Ethics Committee (IEC)/Institutional Review Board (IRB), prior to
initiation of any screening or study-specific procedures

- The participant must have a histologic diagnosis of recurrent high grade serous
ovarian cancer (ovarian, tubal, peritoneal), to be treated with chemotherapy

- Participants must have an image guided biopsy performed to yield fresh tissue for the
in vitro organoid bio-assay and two biomarker testing (western blot and
immunohistochemistry)

- Only patients with tumors that score positive in the in vitro organoid bio-assay will
be enrolled in the clinical trial; patients with tumors that score negative in this
bio-assay will be considered screening failures and will not be enrolled in the
clinical trial

- Participant must have either no neuropathy (sensory and motor) or neuropathy less than
or equal to grade 1

- The participant must have an Eastern Cooperative Oncology Group (ECOG) score between 0
- 2 at screening

- The participant must have a life expectancy of greater than 12 weeks

- Absolute neutrophil count >= 1,500/mm^3

- Platelets >= 100,000/ mm^3

- Hemoglobin >= 9 g/dL or equivalent

- Total bilirubin =< 1.5 ? institutional upper limit of normal (ULN), unless known
Gilbert?s syndrome has been diagnosed

- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase
[SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT])
=< 2.5 ? institutional ULN (=< 5 ? ULN if liver metastasis)

- Serum creatinine =< 1.5 ? ULN or creatinine clearance >= 50 mL/min/1.73 m^2

- Amylase < ULN

- Lipase < ULN

- Female participants of childbearing potential must have a negative serum pregnancy
test at screening and negative (serum or urine) pregnancy test within 72 hours before
the first study-drug dose; if the urine test is positive or cannot be confirmed as
negative, a serum pregnancy test will be required; the serum pregnancy test must be
negative for the participant to be eligible

- Female participants of childbearing potential should ensure use of a highly effective
method of birth control as defined by the investigator, for example, those which
result in a low failure rate (i.e., less than 1% per year) when used consistently and
correctly such as implants, injectable, combined oral contraceptives, some
intrauterine devices (IUDs), sexual abstinence or vasectomized partner during the
study and for a period of at least 4 months following the last dose of any drug
administered during the study

Exclusion Criteria:

- Patients with tumors that score negative in the in vitro organoid bio-assay will be
excluded

- Patients with non-measurable disease < 10 mm on multiparametric MRI or CT scan will be
excluded

- Participants with a secondary malignancy that is progressing or requires active
treatment; participants with basal cell carcinoma of the skin, squamous cell carcinoma
of the skin or in situ cervical cancer that has undergone potentially curative
treatment are not excluded

- Participants who have a history of allergic reactions attributed to compounds of
similar chemical or biologic composition to birinapant or its constituents

- Participants requiring the use of anti-tumor necrosis factor (anti-TNF) therapies,
such as infliximab, or has received treatment with anti-TNF therapies within 5
half-lives of the drug

- Participants with an uncontrolled inter-current illness including, but not limited to,
symptomatic congestive heart failure, hypertension, unstable angina pectoris, cardiac
arrhythmia, autoimmune disease or inflammatory diseases, or psychiatric illness/social
situations that would limit compliance with study requirements

- Pregnant women or women who expect to conceive a child are excluded from the study;
breastfeeding should be discontinued if the mother is treated on this study

- Participants who have a known active infection requiring systemic therapy, including
human immunodeficiency virus (HIV), hepatitis B, and hepatitis C

- Participants with a history of cranial nerve palsy

- Participant is or has an immediate family member (e.g., spouse, parent/legal guardian,
sibling or child) who is an investigational site or sponsor-investigator staff
directly involved with this trial, unless prospective IRB approval (by chair or
designee) is granted allowing exception to this criterion for a specific subject

- In the opinion of the investigator, the participant is an unsuitable candidate for
this study

- Patients who are taking or anticipate taking any maintenance therapy while actively
being treated on protocol or while being followed on protocol will be excluded; an
example of this would be maintenance therapy with a Poly (adenosine diphosphate
[ADP]-ribose) polymerase (PARP) inhibitor such as olaparib