A Phase II Study of Bevacizumab and Erlotinib in Subjects With Advanced Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) or Sporadic Papillary Renal Cell Cancer

• ClinicalTrials.gov Identifier: NCT01130519
• Recruitment Status: Active, not recruiting
• First Posted: May 26, 2010
• Last Update Posted: December 27, 2022
• Sponsor: National Cancer Institute (NCI)
• Information provided by (Responsible Party): National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) )

Study Description

Brief Summary:

Background:

• At the present time, there are no drugs that have been proven to work in patients with papillary kidney cancer that has spread (metastasized) beyond the kidneys. Researchers are interested in determining whether the combination of the drugs bevacizumab and erlotinib can be used to treat metastatic papillary kidney cancer.
• Hereditary Leiomyomatosis and Renal Cell Carcinoma (HLRCC) is an inherited type of papillary kidney cancer (it runs in families). Papillary kidney cancer can also occur sporadically, or without a family connection. More research is needed to determine whether treatments for papillary kidney cancer, such as bevacizumab and erlotinib, work in inherited or sporadic types of kidney cancer, and if so, whether there are any differences.

Objectives:

-To determine the effectiveness of the combination of bevacizumab and erlotinib as a treatment for patients with (1) metastatic HLRCC kidney cancer and (2) metastatic kidney cancer not associated with HLRCC (or sporadic papillary RCC).

Eligibility:

• Individuals 18 years of age or older who have been diagnosed with papillary kidney cancer that has spread beyond the kidneys.
• Participants may have either HLRCC or sporadic papillary kidney cancer.

Design:

• Participants will be screened with a full medical history, physical examination, blood and urine tests, and CT and other scans to evaluate tumor size and treatment options.
• Participants will receive 28-day treatment cycles of bevacizumab (given intravenously every 2 weeks) and erlotinib (a tablet taken by mouth daily).
• Every cycle, participants will return for regular blood and urine tests. Every other cycle, participants will have imaging scans to assess tumor size and response to treatment. Female participants who have uterine fibroid tumors related to their kidney cancer may have additional scans to assess tumor size and response to treatment.
• Participants will continue to receive treatment on the study until their tumors grow or spread to new areas (disease progression), intolerable side effects develop, a better treatment option becomes available, the study closes, it is unsafe to continue treatment, or the participant decides not to remain in the study.

Condition or disease	Intervention/treatment	Phase
HLRCC; Sporadic Papillary Renal Cell Cancer	Drug: Bevacizumab; Drug: Erlotinib	Phase 2

Detailed Description:

Background

• Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) is a familial cancer syndrome characterized by a propensity for developing renal cancer, and uterine and cutaneous leiomyomas. The kidney cancer associated with HLRCC is clinically aggressive and is characterized by unique histopathologic features that are sometimes described as type 2 papillary RCC.
• Germline mutations in the fumarate hydratase (FH) gene are the genetic hallmark of HLRCC. Mutational inactivation of FH has been shown to result in VHL-independent upregulation of hypoxia inducible factor (HIF) and its downstream transcriptional targets.
• The recognition that HIF upregulation may play an important role in the formation and propagation of renal cancer associated with HLRCC suggests that interventions directed against components of this pathway, such as VEGF and TGF-Alpha/EGFR, may be of benefit in this patient population.
• We propose to test the hypothesis that dual VEGF/EGFR blockade with bevacizumab/erlotinib is likely to be clinically active in patients with HLRCC associated RCC as well as those with sporadic papillary sporadic RCC.

Objective

Primary Objective

-To determine the overall response rate (RECIST) in patients with 1) metastatic RCC associated with HLRCC and 2) metastatic sporadic/non-HLRCC papillary renal cancer treated with a combination of bevacizumab and erlotinib

Eligibility

• Diagnosis of advanced RCC associated with HLRCC (cohorts 1 and 3) or sporadic/non-HLRCC papillary RCC (cohorts 2 and 4)
• ECOG PS 0-2
• Measurable disease, consistent with RECIST 1.1
• No history of major bleeding, recent or active myocardial ischemia, GI perforation, cerebrovascular accidents or other significant intercurrent illness
• No coagulopathy or bleeding diathesis
• No recent surgery (< 4 weeks or inadequately healed surgical scars)
• Adequate organ function
• Adequate liver function (total bilirubin <= 1.5 mg/dL or < 3 x upper limit of normal (ULN) in subjects with Gilbert s disease, and AST (SGOT) / ALT (SGPT) 2.5 x ULN
• Adequate renal function (creatinine <= 2.0 x ULN or creatinine clearance > 30 mL/min
• Neutrophils >1500/microL and platelets >100,000
• No brain metastases
• No more than 2 prior regimens containing a VEGF-pathway inhibitor; no prior therapy with bevacizumab
• Ability to understand and sign informed consent

Design

• Patients will receive a fixed starting dose of bevacizumab (10mg/kg IV every 2 weeks) and erlotinib (150mg/day po). Dose reductions and drug interruptions for unacceptable toxicity will be allowed.
• Patients will be evaluated for response every 8 weeks using RECIST criteria
• The study is based on an open label Simon two-stage minmax design in two cohorts, 1) cohort 1- patients with HLRCC, and 2) cohort 2- patients with sporadic papillary RCC. In each cohort, 13 patients will be accrued in the first stage and will accrue a maximum of 20 patients. Accrual into and analysis of the two cohorts will be independent.
• Following completion of accrual to cohorts 1 and 2, the study was expanded to include two additional cohorts- Cohort 3 (HLRCC patients and Cohort 4 (patients with sporadic/non HLRCC papillary RCC) to better estimate the overall response rate and to perform additional exploratory biomarker analyses. Up to 20 additional evaluable patients will be included in each of these cohorts.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 83 participants
• Allocation: Non-Randomized
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Phase II Study of Bevacizumab and Erlotinib in Subjects With Advanced Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) or Sporadic Papillary Renal Cell Cancer
• Actual Study Start Date: May 6, 2010
• Actual Primary Completion Date: April 12, 2022
• Estimated Study Completion Date: December 1, 2023

Arms and Interventions

Arm	Intervention/treatment
Experimental: 1; All patient will be receiving fixed starting dose of bevacizumab (10 mg/kg IV every 2 weeks) and erlotinib (150 mg/day PO)	Drug: Bevacizumab; Commercially available. Administered by intravenous infusion.; Drug: Erlotinib; Commercially available. Administered orally.

Outcome Measures

Primary Outcome Measures :

1. Overall response rate. [ Time Frame: 4-5 years ]
   Proportion of patients whose tumors shrunk after therapy

Secondary Outcome Measures :

1. Progression-free survival, duration of response and overall survival [ Time Frame: 4-5 years ]
   Median amount of time subject survives without disease progression after treatment

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

• INCLUSION CRITERIA:

Patients must meet all the following criteria to be eligible for study enrolment:

• Diagnosis of advanced RCC associated with HLRCC (cohorts 1 & 3) or sporadic/non-HLRCC papillary RCC (cohort 2 & 4)
• Measurable disease outlined in RECIST 1.1
• No more than two prior regimens targeting the VEGF pathway; no prior bevacizumab therapy
• Age greater than or equal to 18 years.
• Performance status ECOG 0-2
• Patients must have normal organ and marrow function as defined below: WBC count greater than or equal to 3,000/microL, absolute neutrophil count greater than or equal to 1,500/microL, platelet count greater than or equal to 100,000/microL, serum creatinine greater than or equal to 2 times the upper limit of reference range or creatinine clearance greater than or equal to 30 ml/min, AST and ALT less than 2.5 times the upper limit of reference range, total bilirubin less than 1.5 times the upper limit of reference range ( less than 3 x upper limit of reference range in patients with Gilbert s disease), alkaline phosphatase less than or equal to 2.5 times the upper limit of reference range (or less than than or equal to 5 times the upper limit of reference range if considered to be related to liver or bone metastases by the PI)
• Recovery from acute toxicity of prior treatment for RCC (to less than or equal to grade 1 the active version of CTCAE or to a level permitted under other sections of Inclusion/ Exclusion criteria).
• At least 4 weeks from completion of major surgery and a healed surgical incision
• Negative pregnancy test (within 7 days of enrolment) in women of childbearing potential
• No myocardial infarction, GI perforation/fistula, intraabdominal abscess, cerebrovascular accidents within six months prior to study entry
• No coagulopathy or bleeding diathesis
• Ability to understand and the willingness to sign a written informed consent document.
• Archival tissue block or unstained tumor tissue available for correlative studies

EXCLUSION CRITERIA:

• Prior invasive malignancy of other histology, with the exception of adequately treated basal or squamous cell carcinoma of the skin, or any other malignancy for which the patient does not currently require treatment and/or has no evidence of disease for greater than or equal to 2 years.
• Patients with known brain metastases unless treated with an appropriate modality with no evidence of progression/recurrence for greater than 3 months
• Hypertension not controlled by medical therapy (resting systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90 mmHg on at least two occasions over a 24 hour period despite optimal medical management).
• Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection requiring intravenous antibiotics, symptomatic congestive heart failure (New York Heart Association grade III or greater), unstable angina pectoris, or psychiatric illness/social situations that would limit compliance with study requirements.
• Serious, non-healing wound or ulcer; bone fracture within 3 months prior to study entry
• Patient known to be HIV-positive and requiring antiretroviral therapy (due to the risk of potential drug interactions)
• Concomitant therapy with potent inhibitors of CYP450 3A4 (e.g. ketoconazole, verapamil etc) or with potent CYP450 1A2 inhibitors (fluoroquinolone antibiotics including ciprofloxacin, levofloxacin, and norfloxacin; ticlodipine, cimetidine, amiodarone,etc. see Appendix C)
• Pregnant women are excluded from this study because bevacizumab and erlotinib are anti-cancer agents with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with these agents, breastfeeding should be discontinued if the mother is treated on this study
• All men and women of childbearing potential must be willing to use effective contraception as determined by the principal investigator (including but not limited to abstinence, hormonal contraceptives (birth control pills, injections, or implants), intrauterine device (IUD), tubal ligation, vasectomy) from the time of enrolment to at least six months following the last dose of drug
• Any known hypersensitivity to bevacizumab, erlotinib or other excipients of these drugs
• Documented baseline proteinuria greater than 1000mg/day on 24 hour urine collection. Only patients with 1+ or greater proteinuria on UA and a spot urine protein:creatinine ratio of greater than 0.5 will undergo a 24 hour urine collection for quantitation of proteinuria.
• Left ventricular ejection fraction less than 40% as measured on transthoracic echocardiogram.

INCLUSION OF WOMEN AND MINORITIES:

Both men and women and members of all races and ethnic groups are eligible for this trial.

Contacts and Locations

Locations

United States, Maryland

National Institutes of Health Clinical Center

Bethesda, Maryland, United States, 20892

Sponsors and Collaborators

National Cancer Institute (NCI)

Investigators

• Principal Investigator: Ramaprasad Srinivasan, M.D.; National Cancer Institute (NCI)

More Information

Additional Information:

NIH Clinical Center Detailed Web Page 

Publications:

Wei MH, Toure O, Glenn GM, Pithukpakorn M, Neckers L, Stolle C, Choyke P, Grubb R, Middelton L, Turner ML, Walther MM, Merino MJ, Zbar B, Linehan WM, Toro JR. Novel mutations in FH and expansion of the spectrum of phenotypes expressed in families with hereditary leiomyomatosis and renal cell cancer. J Med Genet. 2006 Jan;43(1):18-27. doi: 10.1136/jmg.2005.033506. Epub 2005 Jun 3.

Lehtonen HJ, Kiuru M, Ylisaukko-Oja SK, Salovaara R, Herva R, Koivisto PA, Vierimaa O, Aittomaki K, Pukkala E, Launonen V, Aaltonen LA. Increased risk of cancer in patients with fumarate hydratase germline mutation. J Med Genet. 2006 Jun;43(6):523-6. doi: 10.1136/jmg.2005.036400. Epub 2005 Sep 9.

Merino MJ, Torres-Cabala C, Pinto P, Linehan WM. The morphologic spectrum of kidney tumors in hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome. Am J Surg Pathol. 2007 Oct;31(10):1578-85. doi: 10.1097/PAS.0b013e31804375b8.

• Responsible Party: National Cancer Institute (NCI)
• ClinicalTrials.gov Identifier: NCT01130519
• Other Study ID Numbers: 100114; 10-C-0114
• First Posted: May 26, 2010
• Last Update Posted: December 27, 2022
• Last Verified: October 3, 2022

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: Yes
• Plan Description: .All IPD recorded in the medical record will be shared with intramural investigators upon request.
• Supporting Materials: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF)
• Time Frame: Clinical data available during the study and indefinitely.
• Access Criteria: Clinical data will be made available via subscription to BTRIS and with the permission of the study PI.

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) ):

Immunotherapy; Biomarker; Kidney Cancer; Renal Cell Cancer; Hereditary Leiomyomatosis and Renal Cell Cancer; HLRCC

Additional relevant MeSH terms:

Carcinoma, Renal Cell; Leiomyomatosis; Neoplastic Syndromes, Hereditary; Skin Neoplasms; Uterine Neoplasms; Adenocarcinoma; Carcinoma; Neoplasms, Glandular and Epithelial; Neoplasms by Histologic Type; Neoplasms; Kidney Neoplasms; Urologic Neoplasms; Urogenital Neoplasms; Neoplasms by Site; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Kidney Diseases; Urologic Diseases; Male Urogenital Diseases; Leiomyoma; Neoplasms, Muscle Tissue; Neoplasms, Connective and Soft Tissue; Genetic Diseases, Inborn; Skin Diseases; Genital Neoplasms, Female; Uterine Diseases; Genital Diseases, Female; Genital Diseases; Bevacizumab