PRIMARY OBJECTIVES:
I. To determine the objective response rate (ORR) of patients with locally advanced or
metastatic renal medullary carcinoma (RMC) treated with combination of nivolumab plus
ipilimumab.
SECONDARY OBJECTIVES:
I. To determine the efficacy and safety of the combination of nivolumab plus ipilimumab in
patients with RMC.
II. To evaluate potential biomarkers for patient stratification and treatment response, as
well as tumor antigen-specific immune responses, such as antibody and T cell responses, as
surrogates for anti-tumor activity.
OUTLINE:
Patients receive nivolumab intravenously (IV) over 60 minutes and ipilimumab IV over 90
minutes on day 1. Treatment repeats every 21 days for up to 4 courses in the absence of
disease progression or unacceptable toxicity. Patients then receive nivolumab IV over 60
minutes on day 1. Courses repeat every 28 days for up to 2 years in the absence of disease
progression or unacceptable toxicity.
After completion of study treatment, patients are followed up every 3 months.
Inclusion Criteria:
- Patients must give written informed consent prior to initiation of therapy, in keeping
with the policies of the institution. Patients with a history of major psychiatric
illness must be judged able to fully understand the investigational nature of the
study and the risks associated with the therapy.
- Patients with locally advanced or metastatic RMC histologically confirmed by expert
pathology review and loss of SMARCB1 staining by immunohistochemistry. Patients with
advanced or metastatic unclassified renal cell carcinoma with medullary phenotype (a
rare SMARCB1 negative RMC variant occurring in individuals without sickle
hemoglobinopathies) are also eligible. The principal investigator (PI) is the final
arbiter in questions related to eligibility.
- Patients will be eligible regardless of whether they have had prior nephrectomy or
still have their primary tumor in-situ.
- Patients must have at least one measurable site of disease, defined as a lesion that
can be accurately measured in at least one dimension (longest diameter to be recorded)
and measures >= 15 mm with conventional techniques or >= 10 mm with more sensitive
techniques such as magnetic resonance imaging (MRI) or spiral computerized tomography
(CT) scan. If the patient has had previous radiation to the marker lesion(s), there
must be evidence of progression since the radiation.
- Patients should be willing to provide a newly obtained fresh core biopsy of a tumor
lesion. Not required if there is a recently obtained fresh specimen on an
Institutional Review Board (IRB) approved correlated trial up to 6 weeks (42 days)
prior to initiation of treatment on day 1.
- Patients can be either naive for any previous systemic treatment or have had any
number of prior systemic therapies. However, patients must not have received prior
anticancer therapy with anti-PD1, anti-PD-L1, or anti-CTLA-4 immune checkpoint
inhibitors.
- There must be evidence of progression on or after last treatment regimen received.
NOTE: If subject is unable to walk due to paralysis, but is mobile in a wheelchair,
subject is considered to be ambulatory for the purpose of assessing their performance
status.
- Eastern Cooperative Oncology Group (ECOG) performance status 0-2.
- Consent to MD Anderson companion laboratory protocol 2014-0938.
- Hemoglobin >= 9 g/dl (treatment allowed) (within 14 days of the first dose of the
study drugs).
- Absolute neutrophil count >= 1000/mcL (within 14 days of the first dose of the study
drugs).
- Platelets >= 75,000/L (within 14 days of the first dose of the study drugs).
- Total bilirubin =< 1.5 mg/dl (within 14 days of the first dose of the study drugs).
- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) or
alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 X
institutional upper limit of normal (ULN), except in known hepatic metastasis, wherein
may be =< 5 x ULN (within 14 days of the first dose of the study drugs).
- Serum creatinine =< 1.5 x ULN by gender (as long as patient does not require dialysis)
(within 14 days of the first dose of the study drugs); May receive transfusion;
Without growth factor support (filgrastim or pegfilgrastim) for at least 14 days; If
creatinine is not < 1.5 x ULN, then calculate by Cockcroft-Gault methods or local
institutional standard and creatinine clearance (CrCl) must be > 30 mL/kg/1.73 m^2.
- International normalized ratio (INR) and partial thromboplastin time (PTT) =< 1.5 x
ULN prior to study entry. Therapeutic anticoagulation with warfarin is allowed if
target INR =< 3 on a stable dose of warfarin or on a stable dose of low molecular
weight (LMW) heparin for > 2 weeks (14 days) at the time of enrollment.
- Patients with controlled brain metastases are allowed on protocol if they had solitary
brain metastases that was surgically resected or treated with radiosurgery or Gamma
knife, without recurrence or edema for 1 month (4 weeks).
- Women of childbearing potential (WOCBP) must have a negative serum or urine pregnancy
test (minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin
[HCG]) within 24 hours prior to the start of the study drug.
- Women must not be breastfeeding.
- WOCBP must agree to follow instructions for method(s) of contraception from the time
of enrollment for the duration of treatment with study drug (s) plus 5 half-lives of
study drug (s) plus 30 days (duration of ovulatory cycle) for a total of 5 months post
treatment completion.
- Men who are sexually active with WOCBP must agree to follow instructions for method(s)
of contraception for the duration of treatment with study drug (s) plus 5 half-lives
of study drug (s) plus 90 days duration of sperm turnover for a total of 5 months
post-treatment completion.
- Azoospermic males and WOCBP who are continuously not heterosexually active are exempt
from contraceptive requirements. However WOCBP must still undergo pregnancy testing as
described in these sections.
Exclusion Criteria:
- Patients must not have any other malignancies within the past 2 years except for in
situ carcinoma of any site, or adequately treated (without recurrence post-resection
or post-radiotherapy) carcinoma of the cervix or basal or squamous cell carcinomas of
the skin.
- Patients currently receiving anticancer therapies or who have received anticancer
therapies (including chemotherapy and targeted therapy) within 2 weeks (14 days) prior
to study day are excluded. Patients who have completed palliative radiation therapy
more than 14 days prior to the first dose of the combination ipilimumab plus nivolumab
are eligible.
- Patients, who have had a major surgery or significant traumatic injury (injury
requiring > 4 weeks [28 days] to heal) within 4 weeks (28 days) of start of study
drug, patients who have not recovered from the side effects of any major surgery
(defined as requiring general anesthesia) or patients that are expected to require
major surgery, other than cytoreductive nephrectomy +/- retroperitoneal lymph node
dissection, during the course of the study.
- Patients who have organ allografts.
- Known or suspected autoimmune disease. Patients with a history of inflammatory bowel
disease (including Crohn's disease and ulcerative colitis) and autoimmune disorders
such as rheumatoid arthritis, systemic progressive sclerosis (scleroderma), systemic
lupus erythematosus or autoimmune vasculitis (e.g., Wegener's granulomatosis) are
excluded from this study. Patients with a history of Hashimoto's thyroiditis only
requiring hormone replacement, type I diabetes, or psoriasis not requiring systemic
treatment, or conditions not expected to recur in the absence of an external trigger
are allowed to participate.
- Known history of testing positive for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome (AIDS).
- Positive test for hepatitis B virus (HBV) using HBV surface antigen (HBVsAg) test or
positive test for hepatitis C virus (HCV) using HCV ribonucleic acid (RNA) or HCV
antibody test indicating acute or chronic infection. If hepatitis C antibody test is
positive then active infection has to be confirmed by hepatitis C RNA testing for the
patient to be excluded.
- Any underlying medical condition, which in the opinion of the investigator, will make
the administration of study drug hazardous or obscure the interpretation of adverse
events, such as a condition associated with frequent diarrhea, uncontrolled nausea or
vomiting.
- Patients must not have received prior anticancer therapy with anti-PD1, anti-PD-L1, or
anti- CTLA-4 immune checkpoint inhibitors.
- Patients receiving any concomitant systemic therapy for renal cell cancer are
excluded.
- Patients must not be scheduled to receive another experimental drug while on this
study.
- Patients who are on high dose steroid (e.g., > 10 mg prednisone daily or equivalent)
or other more potent immune suppression medications (e.g., infliximab). Topical,
inhaled, intraarticular, ocular, or intranasal corticosteroids (with minimal systemic
absorption) are allowed. A brief course (< 48 hours) of systemic corticosteroids for
prophylaxis (e.g., from contrast dye allergy) is permitted. Physiological
corticosteroid replacement therapy for adrenal insufficiency is also permitted.
- Patients who have any severe and/or uncontrolled medical conditions or other
conditions that could affect their participation in the study such as: a) Symptomatic
congestive heart failure of New York heart Association class III or IV; b) Unstable
angina pectoris, symptomatic congestive heart failure, myocardial infarction within 6
months of start of study drug, serious uncontrolled cardiac arrhythmia or any other
clinically significant cardiac disease; c) Severely impaired lung function as defined
as oxygen (O2) saturation that is 92% or less at rest on room air; d) Uncontrolled
diabetes as defined by fasting serum glucose > 1.5 x ULN; e) Systemic fungal,
bacterial, viral, or other infection that is not controlled (defined as exhibiting
ongoing signs/symptoms related to the infection and without improvement) despite
appropriate antibiotics or other treatment; f) Known active or symptomatic viral
hepatitis or chronic liver disease. Uncontrolled adrenal insufficiency.
- Patients must not have history of other diseases, metabolic dysfunction, physical
examination finding, or clinical laboratory finding giving reasonable suspicion of a
disease or condition that contraindicates the use of ipilimumab or nivolumab or that
might affect the interpretation of the results of the study or render the subject at
high risk from treatment complications.
- Patients should not receive immunization with attenuated live vaccines within one week
(7 days) of study entry or during study period; Note: Seasonal influenza vaccines for
injection are generally inactivated flu vaccines and are allowed; however intranasal
influenza vaccines (e.g., Flu-Mist) are live attenuated vaccines, and are not allowed.
- Uncontrolled brain or leptomeningeal metastases, including patients who continue to
require glucocorticoids for brain or leptomeningeal metastases.
- Female patients who are pregnant or breast feeding, or adults of reproductive
potential who are not using effective birth control methods as defined above. If
barrier contraceptives are being used, these must be continued throughout the trial by
both sexes. Hormonal contraceptives are not acceptable as a sole method of
contraception.
- Any patients who cannot be compliant with the appointments required in this protocol
must not be enrolled in this study.
