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Lenvatinib and Pembrolizumab for the Treatment of Recurrent or Metastatic Adenoid Cystic Carcinoma or Other Salivary Gland Cancers

Trial Status: Active

This phase II trial studies how well lenvatinib and pembrolizumab work in treating patients with adenoid cystic carcinoma or other salivary gland cancers that have come back (recurrent) or have spread to other places in the body (metastatic). Lenvatinib works by blocking receptor tyrosine kinases, proteins that help cells grow and develop blood vessels. Blocking these proteins may slow the growth of cancer cells and cut off the blood supply that feeds them. Pembrolizumab blocks a protein, PD-1, that acts as a “brake” on the immune system. Blocking this protein is like releasing the brakes; it frees the immune system to target and kill cancer cells. Giving lenvatinib and pembrolizumab may work better in slowing and stopping the growth of adenoid cystic carcinoma or other salivary gland cancers compared to lenvatinib or pembrolizumab alone.

Inclusion Criteria

  • ACC COHORT (COHORT 1) ONLY: Patients must have pathologically or cytologically confirmed adenoid cystic carcinoma. Cancers arising from non-salivary gland primary sites are allowed
  • NON-ACC COHORT (COHORT 2) ONLY: Patients must have pathologically or cytologically confirmed salivary gland cancer of any histology (except for adenoid cystic carcinoma that is enrolled into cohort 1)
  • Patients must have recurrent and/or metastatic disease not amenable to other curative intent therapy
  • At least 4 weeks must have elapsed since the end of prior systemic treatment and/or since completion of radiotherapy with resolution of all treatment related toxicity to National Cancer Institute (NCI) CTCAE version 5.0 grade =< 1 (or tolerable grade 2) or back to baseline (except for alopecia, lymphopenia, or hypothyroidism) prior to starting study drug treatment
  • Patients must have RECIST v1.1 measurable disease, defined as at least one non-nodal lesion measuring >= 20 mm with conventional techniques or as >= 10 mm with computed tomography (CT) scan, magnetic resonance imaging (MRI), or calipers by clinical exam in the longest dimension AND/OR a nodal lesion measuring >= 15 mm in the shortest dimension. Tumors in previously irradiated fields may be considered measurable if there is evidence of tumor progression after radiation treatment
  • COHORT 1 AND ACINIC CELL CARCINOMA PATIENTS IN COHORT 2 ONLY: Patients must have documentation of a new or progressive lesion on radiologic imaging study performed within 6 months prior to study enrollment (progression of disease over any interval is allowed) and/or new/worsening disease related symptoms within 6 months prior to study enrollment. Note: This assessment will be performed by the treating investigator and evidence of progression by RECIST criteria is not required
  • Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (or Karnofsky >= 70%)
  • Patients must have tissue from the primary tumor or metastases available for correlative studies. Either a paraffin block or at least 20 unstained slides are acceptable (paraffin block or at 30 unstained slides would be ideal). Patients without available tissue for submission may still be eligible if approved by the principal investigator
  • Neutrophils >= 1500/uL
  • Platelets >= 100 x 10^3/uL
  • Hemoglobin > 9.0 g/dL (without packed red blood cell [pRBC] transfusion within the last 2 weeks)
  • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN (if liver metastases are present, AST and ALT =< 5 x ULN)
  • Total bilirubin =< 1.5 x ULN OR direct bilirubin =< ULN for participants with total bilirubin levels > 1.5 x ULN (except participants with Gilbert syndrome, who can have a total bilirubin < 3.0 mg/dL)
  • Serum creatinine =< 1.5 x ULN OR creatinine clearance (CrCl) >= 40 mL/min per the Cockcroft-Gault formula if creatinine is > 1.5 x ULN
  • International normalized ratio (INR) =< 1.5, unless participant is receiving anticoagulant therapy as long as PT or activated partial thromboplastin time (aPTT) is within therapeutic range of intended use of anticoagulants
  • Participants must be willing to sign the written informed consent form. A signed informed consent form must be appropriately obtained prior to the conduct of any trial specific procedure
  • Male participants must agree to use adequate contraception, not be planning/expecting to father children, and refrain from donating sperm from the time of the screening visit through 120 days after the last dose of trial treatment
  • A female participant is eligible to participate if she is not pregnant (for women of child-bearing potential, a pregnancy test must be negative within 72 hours prior to initiation; if a urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required), not breast feeding, not planning/expecting to conceive children from the time of the screening visit through 120 days after the last dose of trial treatment, and at least one of the following conditions applies: * Not a woman of child bearing potential including: ** Pre-menopausal with one of the following: documented hysterectomy, documented bilateral salpingectomy, documented bilateral oophorectomy ** Postmenopausal females defined as no menses for 12 months without an alternative medical cause (a high follicle stimulating hormone level in the postmenopausal range may be used to confirm a post-menopausal state in women not using hormonal contraception or hormonal replacement therapy [HRT]). However, in the absence of 12 months of amenorrhea, confirmation with two follicle-stimulating hormone (FSH) measurements in the postmenopausal range is required * A woman of child bearing potential who agrees to highly effective contraception from the start of therapy through 120 days after the last dose of study medication
  • Participants must be able to swallow and retain oral medication or have a functioning gastrostomy (G)-tube in place

Exclusion Criteria

  • Untreated metastatic brain (subjects with treated brain metastases will be eligible, provided that they are radiographically stable, i.e. without evidence of progression for at least 4 weeks by repeat imaging (note that the repeat imaging should be performed during study screening), clinically stable and without requirement of steroid treatment for at least 14 days prior to the first dose of study treatment)
  • Concurrent anti-cancer therapy (chemotherapy, definitive radiation therapy, surgery, immunotherapy, biologic therapy or tumor embolization) other than study treatment. Concurrent therapy with bisphosphonates or denosumab for bone metastases is allowed, provided they are started prior to study entry. Palliative radiation to non-target lesions is also allowed
  • Prior malignancy if diagnosed and treated within 2 years of trial drug initiation (with the exception of non-melanomatous skin cancers). Patients may be included if they have completed therapy for a prior malignancy > 2 years prior to drug initiation and are currently no evidence of disease (NED). Participants with basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or carcinoma in situ (breast ductal carcinoma in situ [DCIS], or cervical carcinoma in situ [CIS]) that have undergone potentially curative therapy at any time are not excluded from trial participation
  • History of allergy or intolerance to study drug components (or any of their excipients), or severe (>= grade 3) hypersensitivity reaction to any excipients of pembrolizumab or any monoclonal antibody
  • Prior use of lenvatinib or any PD-1/PD-L1 or anti-PD-L2 targeted therapies or with an agent directed at another stimulatory or co-inhibitory T-cell receptor (CTLA-4, OX-40, CD137)
  • Uncontrolled hypertension (systolic pressure > 140 mm Hg or diastolic pressure > 90 mm Hg) despite optimal medical management
  • Prior systemic anti-cancer therapy including use of another investigational drug or device (i.e., outside study treatment) during, or within 4 weeks of trial entry (time of initiation of experimental drug)
  • Clinically significant proteinuria: * Subjects having > 1+ proteinuria on urinalysis will undergo 24-hour urine collection for quantitative assessment of proteinuria. Subjects with proteinuria >= 1 gm/24-hour will be ineligible
  • Gastrointestinal malabsorption, gastrointestinal anastomosis, or any other condition that might affect the absorption of lenvatinib
  • New York Heart Association congestive heart failure of grade II or above, unstable angina, myocardial infarction within the past 6 months, or serious cardiac arrhythmia associated with significant cardiovascular impairment within the past 6 months (baseline echocardiogram is not required unless clinically indicated)
  • Subjects with thrombotic, embolic, venous or arterial events, such as cerebrovascular accidents (including transient ischemic attacks), deep venous thrombosis or pulmonary embolism within 6 months of study treatment start
  • Prolongation of corrected QT (QTc) interval to > 480 msec
  • Any hemorrhage or bleeding event >= NCI CTCAE v5.0 grade >= 3 within 4 weeks prior to start of study medication
  • Active infection (any infection requiring systemic treatment)
  • Subject is known to be positive for human immunodeficiency virus (HIV) or active hepatitis C virus (HCV) or active hepatitis B (HBV) infection (positive viral load). Testing for HIV, HCV, or HBV prior to initiation of the study drug is not required. If patients have a known history of treated HCV, then a viral load is required to confirm clearance of infection
  • Serious non-healing wound, ulcer or bone fracture, that is not tumor related
  • History of organ allograft (including corneal transplant)
  • Biologic response modifiers (e.g., granulocyte colony-stimulating factor) within 4 weeks before study entry. Chronic erythropoietin therapy is permitted provided that no dose adjustments were made within 2 months before first dose of study treatment
  • Has a history or current evidence of any medical or other condition, therapy or laboratory abnormality which, in the opinion of the investigator, might confound the results of the study, or preclude participation in a clinical study
  • Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of study treatment. The use of physiologic doses of corticosteroids (up to 10 mg/d of prednisone or equivalent) may be approved after consultation with the primary investigator
  • Active autoimmune disease that has required systemic treatment in the past 2 years (i.e., with the use of disease modifying agents, corticosteroids or immunosuppressive drugs), with the exception of autoimmune thyroid disease, vitiligo, type 1 diabetes mellitus, or psoriasis. Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
  • Has a history of (non-infectious) pneumonitis that required steroids, or current pneumonitis
  • Renal failure requiring active hemo- or peritoneal dialysis
  • Has received a live-virus vaccination within 30 days of planned treatment start. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus Calmette-Guerin (BCG), and typhoid vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however, intranasal influenza vaccines (e.g., FluMist) are live attenuated vaccines and are not allowed
  • Has known psychiatric or substance abuse disorders that would interfere with the cooperation with the requirements of the trial

Florida

Miami
Miami Cancer Institute
Status: ACTIVE
Contact: Guilherme Rabinowits
Phone: 786-596-2000

New Jersey

Basking Ridge
Memorial Sloan Kettering Basking Ridge
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org
Middletown
Memorial Sloan Kettering Monmouth
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org
Montvale
Memorial Sloan Kettering Bergen
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org

New York

Commack
Memorial Sloan Kettering Commack
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org
New York
Memorial Sloan Kettering Cancer Center
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org
Uniondale
Memorial Sloan Kettering Nassau
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org
West Harrison
Memorial Sloan Kettering Westchester
Status: ACTIVE
Contact: Alan Loh Ho
Phone: 646-888-4235
Email: hoa@mskcc.org

PRIMARY OBJECTIVE:

I. To evaluate the best overall response rate (ORR = complete response [CR] + partial response [PR]) by Response Evaluation Criteria in Solid Tumors (RECIST) version (v) 1.1 of lenvatinib mesylate (lenvatinib) plus pembrolizumab in patients with progressive recurrent/metastatic (R/M) adenoid cystic carcinoma (ACC) and non-ACC salivary gland cancer (SGC) patients.

SECONDARY OBJECTIVES:

I. To evaluate the median progression-free survival (PFS) of patients with progressive R/M ACC and non-ACC SGC patients treated with lenvatinib plus pembrolizumab.

II. To evaluate the safety and tolerability of lenvatinib plus pembrolizumab in R/M ACC and non-ACC SGC patients by Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

EXPLORATORY OBJECTIVES:

I. To assess changes in quality of life during treatment with lenvatinib plus pembrolizumab using the Functional Assessment of Cancer Therapy - General 7-item (FACT-G7) survey.

II. To evaluate baseline tumor characteristics, changes in peripheral serologic markers, and changes in peripheral immune cell populations that may correlate with response to lenvatinib plus pembrolizumab.

III. To explore the efficacy of re-treatment with lenvatinib and/or pembrolizumab for progression that occurs after treatment had been discontinued after achieving complete response or completion of 2 years of therapy.

OUTLINE:

INITIAL TREATMENT PHASE: Patients receive lenvatinib mesylate orally (PO) once daily (QD) on days 1-21 and pembrolizumab intravenously (IV) over 30 minutes on day 1. Treatment repeats every 3 weeks for up to 35 cycles (2 years) in the absence of disease progression or unacceptable toxicity.

SECOND COURSE PHASE: Patients who stop treatment with stable disease or better and progress after the initial treatment phase may receive an additional 17 cycles (1 year) of treatment.

After completion of study treatment, patients are followed up periodically.

Trial Phase Phase II

Trial Type Treatment

Lead Organization
Memorial Sloan Kettering Cancer Center

Principal Investigator
Alan Loh Ho

  • Primary ID 19-310
  • Secondary IDs NCI-2020-04133
  • Clinicaltrials.gov ID NCT04209660