This research study is a Phase II clinical trial. Phase II clinical trials test the safety
and effectiveness of an investigational drug to learn whether the drug works in treating a
specific disease. "Investigational" means that the drug is being studied.
The U.S. Food and Drug Administration (FDA) has not approved all-trans retinoic acid (ATRA)
for this specific disease but it has been approved for other uses.
The main purpose of this study is to see how effective all-trans retinoic acid (ATRA) is in
treating tumor. Other reasons for conducting the study are:
- To determine for how long all-trans retinoic acid (ATRA) may reduce the size or slow
down the growth of tumor
- To evaluate levels of circulating tumor DNA (ctDNA) released in the bloodstream as an
indication of the disease activity
- To better understand mechanisms of tumor resistance to ATRA
- Participants must have histologically confirmed adenoid cystic carcinoma with evidence
of recurrent, metastatic or advanced, unresectable disease that is not amenable to
curative surgery with or without radiotherapy.
- Participants must have at least one RECIST v1.1 measurable non-CNS based lesion, as
defined as at least one lesion that can be accurately measured in at least one
dimension (longest diameter to be recorded for non-nodal lesions and short axis for
nodal lesions) equal to or greater than 1 cm with CT scans or MR imaging.
- Participants must be willing to undergo fresh tissue core needle biopsy prior to study
registration and repeat tumor biopsy while on study for correlatives. Willingness to
provide blood samples for research throughout the study is also required.
- Prior systemic therapy: At least 2 weeks must have elapsed since the end of prior
chemotherapy, biological agents (4 weeks for anti-cancer monoclonal antibody
containing regimens) or any investigational drug product, with adequate recovery of
treatment-related toxicity to NCI CTCAE Version 5.0 grade ≤ 1 (or tolerable grade 2)
or back to baseline (except for alopecia or neuropathy). Any number of prior therapies
for recurrent/metastatic ACC are permitted.
- Be ≥ 18 years of age on day of signing informed consent.
- Have a performance status of 0 or 1 on the ECOG Performance Scale (see Appendix A).
- Participants must have documentation of a new or progressive lesion on a radiologic
imaging study performed within 12 months prior to study registration (progression of
disease over any interval is allowed) and/or new or worsening disease-related symptoms
within 12 months prior to study registration. This assessment is performed by the
treating investigator. Evidence of progression by RECIST v1.1 criteria is not
- Participants must have normal organ and marrow function as defined below (within 14
days prior to study registration):
- leukocytes ≥ 3,000/mcL
- absolute neutrophil count ≥ 1,500/mcL
- hemoglobin ≥ 9 g/dL without transfusion within 7 days of treatment
- platelets ≥ 100,000/mcL
- total bilirubin ≤ 2x upper limit of normal (ULN)
- AST(SGOT)/ALT(SGPT) ≤ 2.5x institutional ULN or ≤ 5x ULN for those with liver
- serum creatinine ≤ 1.5x ULN OR
- creatinine clearance ≥ 60 mL/min/1.73 m2 for participants with creatinine levels
above 1.5x ULN
- coagulation profile INR ≤ 1.5x ULN unless the participant is receiving an
- triglyceride level < 500 mg/dL or < 5.7 mmol/L
- cholesterol level < 400 mg/dL or < 10.34 mmol/L
- Baseline tumor measurements must be documented from imaging within 28 days prior to
study registration. Other non-laboratory tests must be performed within 28 days prior
to study registration.
- Female subjects of childbearing potential should have a negative urine or serum
pregnancy test within 14 days of study registration. Female subjects of childbearing
potential should have a negative urine or serum pregnancy test repeated within 72
hours prior to receiving the first dose of study medication. If the urine test is
positive or cannot be confirmed as negative, a serum pregnancy test will be required.
- Female and male subjects of childbearing potential must agree to use an adequate
method of contraception (hormonal or barrier method of birth control; abstinence)
prior to study entry, for the duration of study participation, and 4 months after
completion of tretinoin administration. Contraception is required before starting the
first dose of study medication through 120 days after the last dose of study
medication. Note: Abstinence is acceptable if this is the usual lifestyle and
preferred contraception for the subject. There is a significant risk of fetal
malformation if pregnancy occurs while on tretinoin at any dose level, even if for
short exposure periods.
- Be willing and able to provide written informed consent for the trial.
- Metastatic disease impinging on the spinal cord or threatening spinal cord
compression. Patients that have had previous treatment of disease with impinging on
the cord with either surgery or radiotherapy with clinical or radiographic evidence of
response or stability are eligible.
- Participant has known active central nervous system (CNS) metastases and/or
carcinomatous meningitis. Subjects with previously treated brain metastases may
participate provided they are stable (without evidence of progression by imaging for
at least four weeks prior to the first dose of trial treatment), and have no evidence
of new or enlarging brain metastases. This exception does not include carcinomatous
meningitis which is excluded regardless of clinical stability, because of their poor
prognosis and because they often develop progressive neurologic dysfunction that would
confound the evaluation of neurologic and other adverse events.
- Concurrent administration of other cancer specific therapy or investigational agents
during the course of this study is not allowed.
- Uncontrolled intercurrent illness including but not limited to ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, or cardiac
- Has a known additional malignancy that is progressing or requires active treatment.
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
skin that has undergone potentially curative therapy or in situ cervical cancer.
- Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject's
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator.
- Subjects who are pregnant, or breastfeeding, or expecting to conceive or father
children within the projected duration of the trial, starting with the pre-screening
or screening visit through 120 days after the last dose of trial treatment. Pregnant
women are excluded from this study because tretinoin has the potential for teratogenic
or abortifacient effects. Breastfeeding should be discontinued if the mother is
treated on this protocol. Women who could potentially become pregnant while undergoing
treatment on this protocol must be willing to use 2 methods of contraception.