Vanderbilt Clinical Trials

Conditions

• Bladder Adenocarcinoma
• Bladder Clear Cell Adenocarcinoma
• Bladder Mixed Adenocarcinoma
• Bladder Neuroendocrine Carcinoma
• Bladder Small Cell Neuroendocrine Carcinoma
• Bladder Squamous Cell Carcinoma
• Chromophobe Renal Cell Carcinoma
• Collecting Duct Carcinoma
• Invasive Bladder Giant Cell Urothelial Carcinoma
• Invasive Bladder Lymphoepithelioma-Like Carcinoma
• Invasive Bladder Nested Urothelial Carcinoma
• Invasive Bladder Plasmacytoid Urothelial Carcinoma
• Invasive Bladder Sarcomatoid Urothelial Carcinoma
• Invasive Bladder Urothelial Carcinoma
• Kidney Medullary Carcinoma
• Large Cell Neuroendocrine Carcinoma
• Malignant Testicular Leydig Cell Tumor
• Malignant Testicular Sertoli Cell Tumor
• Metastatic Bladder Carcinoma
• Metastatic Bladder Clear Cell (Glycogen-Rich) Urothelial Carcinoma
• Metastatic Bladder Giant Cell Urothelial Carcinoma
• Metastatic Bladder Large Cell Neuroendocrine Carcinoma
• Metastatic Bladder Lipid-Rich Urothelial Carcinoma
• Metastatic Bladder Micropapillary Urothelial Carcinoma
• Metastatic Bladder Plasmacytoid Urothelial Carcinoma
• Metastatic Bladder Sarcomatoid Urothelial Carcinoma
• Metastatic Bladder Small Cell Neuroendocrine Carcinoma
• Metastatic Bladder Squamous Cell Carcinoma
• Metastatic Chromophobe Renal Cell Carcinoma
• Metastatic Kidney Medullary Carcinoma
• Metastatic Malignant Genitourinary System Neoplasm
• Metastatic Papillary Renal Cell Carcinoma
• Metastatic Penile Carcinoma
• Metastatic Prostate Small Cell Neuroendocrine Carcinoma
• Metastatic Sarcomatoid Renal Cell Carcinoma
• Metastatic Urethral Carcinoma
• Papillary Renal Cell Carcinoma
• Sarcomatoid Renal Cell Carcinoma
• Stage IV Bladder Cancer AJCC v8
• Stage IV Penile Cancer AJCC v8
• Stage IV Renal Cell Cancer AJCC v8
• Stage IV Urethral Cancer AJCC v8
• Stage IVB Prostate Cancer AJCC v8
• Urachal Adenocarcinoma
• Urethral Clear Cell Adenocarcinoma

Eligibility

Eligible Ages

Over 18 Years

Eligible Genders

All

Accepts Healthy Volunteers

No

Criteria

Inclusion Criteria:

- Metastatic disease defined as new or progressive lesions on cross-sectional imaging
or bone scan. Patients must have at least:

- One measurable site of disease as per Response Evaluation Criteria in Solid
Tumors (RECIST) version (v) 1.1

- One bone lesion on bone scan (tec99 or sodium fluoride [NaF] PET/CT, CT or MRI)
for the bone-only cohort.

- Histologically confirmed diagnosis of one of the following metastatic cohorts:

- Small cell/ neuroendocrine carcinoma of the bladder (Cohort A)- All
urothelial carcinomas with any amount of neuroendocrine differentiation
(including small cell differentiation) will be included. If the tumor is
purely neuroendocrine, metastasis from another site of origin should be
clinically excluded

- Adenocarcinoma of the bladder, or urachal adenocarcinoma, or
bladder/urethra clear cell adenocarcinoma (Cohort B) - must be pure (per
World Health Organization [WHO] definition), (i.e. urothelial carcinoma
with glandular differentiation is not considered a pure adenocarcinoma

- Squamous cell carcinoma of the bladder (Cohort C) - must be pure (i.e.
urothelial carcinoma with squamous differentiation is not considered a
pure squamous cell carcinoma)

- Plasmacytoid urothelial carcinoma (Cohort D) - Tumor should show
predominantly > or equal ~ 50% plasmacytoid histology (including all types
of discohesive growth, such as tumors with signet-ring and/or rhabdoid
features as well)

- Any penile cancer (Cohort E)

- Sarcomatoid renal cell carcinoma (Cohort F) - Tumor should be
predominantly sarcomatoid ~ 50% (including rhabdoid differentiation) is
also unclassified renal cell carcinomas (RCCs): all (assuming they are
high grade with metastasis) malignant angiomyolipomas are allowed

- Other miscellaneous histologic variants of the urothelial carcinoma, such
as, but not limited to (Cohort G) : Micropapillary (Tumor should show
predominantly > or equal 50% micropapillary architecture), giant cell,
lipid-rich, clear cell and nested variants (Tumor should predominantly >
or equal 50% show these features), large cell neuroendocrine carcinoma,
lymphoepithelioma-like carcinoma and mixed patterns will be considered, as
well as small cell neuroendocrine prostate cancer (Only treatment-naïve
primary small cell of prostate with any amount of small cell component
allowed. Post-treatment small cell prostatic carcinomas are not allowed),
Malignant testicular Sertoli or Leydig cell tumors, and papillary and
chromophobe RCC

- Note: Translocation positive renal cell carcinoma patients are
eligible. However, AREN1721 should be considered before this trial

- Sarcomatoid urothelial carcinoma (Cohort H) - Tumor should show
predominantly ~ 50% sarcomatoid differentiation

- Renal medullary carcinoma (Cohort I) - Per World Health Organization (WHO)
definition, ideally confirmed with immunostains

- Bone-only metastatic GU tumors (non-prostate) (Cohort J) - All
genitourinary histologies, except prostate are eligible

- Renal Collecting Duct Carcinoma (Cohort K) - Per WHO definition (medullary
involvement, predominant tubular morphology, desmoplastic stromal
reaction, high grade cytology, infiltrative growth pattern, and absence of
other renal cell carcinoma subtype or urothelial carcinoma)

- Urethra carcinoma (Cohort L) - May be of any histology but if urothelial
carcinoma then must be isolated to the urethra and not have metachronous
or synchronous urothelial carcinoma of the bladder

- H&E slides from diagnostic tumor tissue for retrospective central pathology
review

- Patients may have received up to 2 systemic anti-cancer treatments or be treatment
naive. Patients with small cell carcinoma should have received a platinum-based
combination regimen either as neoadjuvant, adjuvant or first-line treatment).
Patients in the bone-only cohort may be urothelial carcinoma histology but must
receive standard cisplatin-based chemotherapy (if cisplatin-eligible)

- Age >= 18 years

- Patients must be able to swallow oral formulation of the tablets

- Karnofsky performance status >= 80%

- Absolute neutrophil count (ANC) >= 1,000/mcL

- Platelet count >= 75,000/mcL

- Total bilirubin =< 1.5 x upper limit of normal (ULN). For subjects with known
Gilbert's disease or similar syndrome with slow conjugation of bilirubin, total
bilirubin =< 3.0 mg/dL

- Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 3.0 x
institutional upper limit of normal (ULN) (or =< 5 x ULN for patients with liver
metastases or Gilbert's disease)

- Creatinine =< 1.5 x upper limit of normal (ULN) OR creatinine clearance >= 40
mL/min/1.73 m^2 (calculated using the Chronic Kidney Disease Epidemiology [CKD-EPI]
equation or Cockcroft-Gault formula) for patients with creatinine levels above
institutional normal

- Hemoglobin >= 9 g/dL (transfusion of packed red blood cells [PRBCs] allowed)

- Serum albumin >= 3.2 g/dL

- Lipase and amylase =< 2.0 x ULN and no radiologic (on baseline anatomical imaging)
or clinical evidence of pancreatitis

- Prior treatment with MET or VEGFR inhibitors is allowed. However, prior cabozantinib
will not be allowed. Also, patients that have received both prior MET or VEGF and
prior PD-1/PD-L1/CTLA-4 (sequentially or in combination) are also not allowed

- No prior treatment with any therapy on the PD-1/PD-L1 axis or anti- CTLA-4/CTLA-4
inhibitors with the exception of patients with "urothelial carcinoma" histology
(cohorts D, H, J, L)

- Human immunodeficiency virus (HIV)-positive patients are eligible if on stable dose
of highly active antiretroviral therapy (HAART), no clinically significant drug-drug
interactions are anticipated with the current HAART regimen, CD4 counts are greater
than 350 and viral load is undetectable

- Patients with rheumatoid arthritis and other rheumatologic arthropathies, Sjogren's
syndrome and psoriasis controlled with topical medication only and patients with
positive serology, such as antinuclear antibodies (ANA), anti-thyroid antibodies
etc. are eligible but should be considered for rheumatologic evaluation for the
presence of target organ involvement and potential need for systemic treatment

- Patients with vitiligo, endocrine deficiencies including thyroiditis managed with
replacement hormones or medications (e.g. thyroiditis managed with propylthiouracil
[PTU] or methimazole) including physiologic oral corticosteroids are eligible

- Patients who have evidence of active or acute diverticulitis, intra-abdominal
abscess, and gastrointestinal (GI) obstruction, within 12 months are not eligible

- Women of childbearing potential must have a negative pregnancy test =< 7 days prior
to registration

- Women of childbearing potential include women who have experienced menarche and
who have not undergone successful surgical sterilization (hysterectomy,
bilateral tubal ligation, or bilateral oophorectomy) or are not postmenopausal.
Post menopause is defined as amenorrhea >= 12 consecutive months. Note: women
who have been amenorrheic for 12 or more months are still considered to be of
childbearing potential if the amenorrhea is possibly due to prior chemotherapy,
antiestrogens, ovarian suppression or any other reversible reason

- Pregnant women may not participate in this study because with cabozantinib,
nivolumab, and ipilimumab have 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 cabozantinib, nivolumab, and ipilimumab,
breastfeeding should be discontinued if the mother is treated with these agents

- The patient has received no cytotoxic chemotherapy (including investigational
cytotoxic chemotherapy) or biologic agents (e.g., cytokines or antibodies) within 2
weeks before the first dose of study treatment

- The patient has received no radiation therapy:

- To the lungs and mediastinum or abdomen within 4 weeks before the first dose of
study treatment, or has ongoing complications, or is healing from prior
radiation therapy

- To brain metastasis within 3 weeks for whole-brain radiotherapy (WBXRT), and 2
weeks for stereotactic body radiation therapy (SBRT) before the first dose of
study treatment

- To the abdomen within 4 weeks before the first dose of study treatment, or has
ongoing complications, or is healing from prior radiation therapy

- To any other site(s) within 2 weeks before the first dose of study treatment

- The patient has received no radionuclide treatment within 6 weeks of the first dose
of study treatment

- The patient has received no prior treatment with a small molecule kinase inhibitor
within 14 days or five half-lives of the compound or active metabolites, whichever
is longer, before the first dose of study treatment

- The patient has received no prior treatment with hormonal therapy within 14 days or
five half-lives of the compound or active metabolites, whichever is longer, before
the first dose of study treatment. Subjects receiving gonadotropin-releasing hormone
(GnRH) agonists and antagonists are allowed to participate

- The patient has not received any other type of investigational agent within 14 days
before the first dose of study treatment

- The patient must have recovered to baseline or Common Terminology Criteria for
Adverse Events (CTCAE) =< grade 1 from toxicity due to all prior therapies except
alopecia, neuropathy and other non-clinically significant adverse events (AEs)
defined as lab elevation with no associated symptoms or sequelae

- The patient may not have active brain metastases or epidural disease. Patients with
brain metastases previously treated with whole brain radiation or radiosurgery who
are asymptomatic and do not require steroid treatment for at least 2 weeks before
starting study treatment are eligible. Neurosurgical resection of brain metastases
or brain biopsy is permitted if completed at least 3 months before starting study
treatment. Baseline brain imaging with contrast-enhanced CT or MRI scans for
subjects with known brain metastases is required to confirm eligibility

- No concomitant treatment with warfarin. Aspirin (up to 325 mg/day), thrombin or
factor Xa inhibitors, low-dose warfarin (=< 1 mg/day), prophylactic and therapeutic
low molecular weight heparin (LMWH) are permitted

- No chronic concomitant treatment with strong CYP3A4 inducers (e.g., dexamethasone,
phenytoin, carbamazepine, rifampin, rifabutin, rifapentine, phenobarbital, and St.
John's wort) or strong CYP3A4 inhibitors

- Because the lists of these agents are constantly changing, it is important to
regularly consult medical reference texts such as the Physicians' Desk
Reference may also provide this information. As part of the enrollment/informed
consent procedures, the patient will be counseled on the risk of interactions
with other agents, and what to do if new medications need to be prescribed or
if the patient is considering a new over-the-counter medicine or herbal product

- The patient has not experienced any of the following:

- Clinically-significant gastrointestinal bleeding within 6 months before the
first dose of study treatment

- Hemoptysis of >= 0.5 teaspoon (2.5 mL) of red blood per day within 1 months
before the first dose of study treatment

- Any other signs indicative of pulmonary hemorrhage within 3 months before the
first dose of study treatment

- The patient has no tumor invading any major blood vessels

- The patient has no evidence of tumor invading the GI tract (esophagus, stomach,
small or large bowel, rectum or anus), or any evidence of endotracheal or
endobronchial tumor within 28 days before the first dose of cabozantinib. Patients
with rectal tumor masses are not eligible

- The patient has no uncontrolled, significant intercurrent or recent illness
including, but not limited to, the following conditions:

- Cardiovascular disorders including:

- Congestive heart failure (CHF): New York Heart Association (NYHA) class
III (moderate) or class IV (severe) at the time of screening.

- Concurrent uncontrolled hypertension defined as sustained blood pressure
(BP) > 150 mm Hg systolic, or > 90 mm Hg diastolic despite optimal
antihypertensive treatment within 7 days of the first dose of study
treatment

- The subject has a corrected QT interval calculated by the Fridericia
formula (QTcF) > 500 ms within 28 days before randomization. Note: if
initial QTcF is found to be > 500 ms, two additional electrocardiograms
(EKGs) separated by at least 3 minutes should be performed. If the average
of these three consecutive results for QTcF is =< 500 ms, the subject
meets eligibility in this regard

- Any history of congenital long QT syndrome

- Any of the following within 6 months before registration of study
treatment:

- Unstable angina pectoris

- Clinically-significant cardiac arrhythmias (patients with atrial
fibrillation are eligible)

- Stroke (including transient ischemic attack [TIA], or other ischemic
event)

- Myocardial infarction

- Cardiomyopathy

- No significant gastrointestinal disorders particularly those associated with a
high risk of perforation or fistula formation including:

- Any of the following that have not resolved within 28 days before the
first dose of study treatment:

- Active peptic ulcer disease

- Acute diverticulitis, cholecystitis, symptomatic cholangitis or
appendicitis, or malabsorption syndrome

- None of the following within 2 years before the first dose of study
treatment:

- Abdominal fistula or genitourinary fistula

- Gastrointestinal perforation

- Bowel obstruction or gastric outlet obstruction

- Intra-abdominal abscess. Note: Complete resolution of an
intra-abdominal abscess must be confirmed prior to initiating
treatment with cabozantinib even if the abscess occurred more than 2
years before the first dose of study treatment

- Disorders associated with a high risk of fistula formation including
percutaneous endoscopic gastrostomy (PEG) tube placement are not eligible

- No other clinically significant disorders such as:

- Severe active infection requiring IV systemic treatment within 14 days
before the first dose of study treatment

- Serious non-healing wound/ulcer/bone fracture within 28 days before the
first dose of study treatment

- History of organ or allogeneic stem cell transplant

- Concurrent uncompensated hypothyroidism or thyroid dysfunction within 7
days before the first dose of study treatment (for asymptomatic patients
with an elevated thyroid-stimulating hormone [TSH], thyroid replacement
may be initiated if clinically indicated without delaying the start of
study treatment)

- No history of major surgery as follows:

- Major surgery within 3 months of the first dose of cabozantinib; however,
if there were no wound healing complications, patients with rapidly
growing aggressive cancers, may start as soon as 6 weeks if wound has
completely healed post-surgery

- Minor surgery within 1 month of the first dose of cabozantinib if there
were no wound healing complications or within 3 months of the first dose
of cabozantinib if there were wound complications excluding core biopsies
and mediport placement

- Complete wound healing from prior surgery must be confirmed before the
first dose of cabozantinib irrespective of the time from surgery

- No history of severe hypersensitivity reaction to any monoclonal antibody

- No evidence of active malignancy, requiring systemic treatment within 2 years of
registration

- No history of allergic reactions attributed to compounds of similar chemical or
biologic composition to cabozantinib, nivolumab, ipilimumab or other agents used in
study

- No positive test for hepatitis B virus surface antigen (HBV sAg) or hepatitis C
virus ribonucleic acid (HCV antibody) indicating acute or chronic infection. If HBV
sAG is positive, subsequent ribonucleic acid (RNA) polymerase chain reaction (PCR)
must be negative

- No patients with active autoimmune disease or history of autoimmune disease that
might recur, which may affect vital organ function or require immune suppressive
treatment including systemic corticosteroids. These include, but are not limited to
patients with a history of immune related neurologic disease, multiple sclerosis,
autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome, myasthenia gravis;
systemic autoimmune disease such as systemic lupus erythematosus (SLE), connective
tissue diseases, scleroderma, inflammatory bowel disease (IBD), Crohn's, ulcerative
colitis, hepatitis; and patients with a history of toxic epidermal necrolysis (TEN),
Stevens-Johnson syndrome, or phospholipid syndrome should be excluded because of the
risk of recurrence or exacerbation of disease

Recruiting Locations

Study Contact

Detailed Description

PRIMARY OBJECTIVE: I. To evaluate the efficacy of cabozantinib s-malate (cabozantinib) combined with nivolumab and ipilimumab in the first or second-line (and beyond) setting for patients within each of the rare genitourinary (GU) variant histology group of interest, as measured by objective response rate (ORR). SECONDARY OBJECTIVES: I. To estimate the progression-free survival (PFS) for patients treated with cabozantinib combined with nivolumab and ipilimumab within each rare variant histology. II. To estimate the overall survival (OS) for patients treated with cabozantinib combined with nivolumab and ipilimumab within each rare variant histology. III. To estimate the clinical benefit rate (defined as complete response [CR] or partial response [PR] or stable disease [SD]) for patients treated with cabozantinib combined with nivolumab and ipilimumab within each rare variant histology. IV. To assess the safety of treating patients with rare variant histologies with cabozantinib combined with nivolumab and ipilimumab. V. To support tissue banking and collection of clinical follow-up data for GU tract rare histological variants. EXPLORATORY OBJECTIVE: I. To assess effects of treatment in patients with bone-only disease by bone scan. OUTLINE: Patients receive cabozantinib orally (PO) once daily (QD) on days 1-21 of cycles 1-4 and on days 1-28 of subsequent cycles. Patients also receive nivolumab intravenously (IV) over 30 minutes on day 1 and ipilimumab IV over 90 minutes on day 1 of cycles 1-4. Patients then receive nivolumab IV over 30 minutes on day 1 of subsequent cycles. Treatment repeats every 21 days for cycles 1-4 and every 28 days for subsequent cycles for 2 years in the absence of disease progression or unacceptable toxicity. Patients may undergo echocardiography during screening and undergo computed tomography (CT) or magnetic resonance imaging (MRI), bone scan and blood and urine sample collection throughout the trial and may undergo positron emission tomography (PET)/CT throughout the trial. After completion of study treatment, patients are followed up every 2 months for up to 5 years.