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Neoadjuvant Pembrolizumab and Axitinib in Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus (NEOPAX)

Primary Purpose

Renal Cancer, Kidney Cancer, Renal Cell Carcinoma

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Axitinib
Pembrolizumab
Sponsored by
University of Colorado, Denver
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Renal Cancer

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Provision to sign and date the consent form. Stated willingness to comply with all study procedures and be available for the duration of the study. Participant self-identified gender ages >/= 18 years old is acceptable and appropriate if they meet other inclusion criteria. Histologically proven clear cell component RCC. An upfront candidate for definitive surgery per treating Urologist. Suitable for and willing to undergo nephrectomy (either cytoreductive or with curative intent) per treating urologist. T Stage of any of the following: cT3b, cT3c, cT4 N stage of any of the following: cN0 or cN1 M stage of any of the following: cM0 or cM1 ECOG performance status 0 - 2. Urinalysis <2+ protein. If dipstick is ≥2+ then a 24-hour urine collection should be performed, and the patient may enter the trial if urinary protein is <2g per 24 hours. All participants who have reproductive potential must have a negative serum or urine pregnancy test within a maximum of 14 days prior to starting trial treatment. Reproductive potential is defined as the following: Women will be considered post-menopausal if they have been amenorrheic for 12 months without an alternative medical cause. The following age-specific requirements apply: Women <50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of exogenous hormonal treatments and if they have luteinizing hormone and follicle-stimulating hormone levels in the post-menopausal range for the institution or underwent surgical sterilization (bilateral oophorectomy or hysterectomy) Women ≥50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments, had radiation-induced menopause with last menses >1 year ago, had chemotherapy-induced menopause with last menses >1 year ago, or underwent surgical sterilization (bilateral oophorectomy, bilateral salpingectomy or hysterectomy For males with reproductive potential, use effective birth control during treatment with Axitinib and Pembrolizumab is recommended. Exclusion Criteria: Is currently participating in or has participated in a study of an investigational agent or has used an investigational device within 4 weeks prior to enrollment. Has had major surgery within 4 weeks or received radiation therapy within 1 week prior to enrollment to the study. Has had prior treatment with any anti-programmed cell death (anti-PD-1) or programmed cell death ligand 1 (PD-L1), or an antibody targeting any other immune-regulatory receptors or mechanisms. Has received prior systemic anti-cancer therapy for RCC with vascular endothelial growth factor (VEGF)/VEGF receptors (VEGFR). Has a history of severe hypersensitivity reaction (e.g., generalized rash/erythema, hypotension, bronchospasm, angioedema, or anaphylaxis) to Axitinib. Has a diagnosis of immunodeficiency OR is receiving a systemic steroid therapy greater than Prednisone 10 mg daily or a steroid equivalent, or any other form of immunosuppressive therapy within 7 days prior to enrollment to the study except in the case of central nervous system (CNS) metastases. Has an active autoimmune disease requiring systemic treatment within the past 2 years OR a documented history of clinically severe autoimmune disease. Note: Participants with vitiligo, Sjogren's syndrome, Type 1 diabetes, resolved childhood asthma/atopy, hypothyroidism or adrenal or pituitary insufficiency who are stable on hormone replacement are not excluded. Has a known additional malignancy that has progressed or has required active treatment in the last 3 years. Note: Basal cell carcinoma of the skin, squamous cell carcinoma of the skin, superficial bladder cancer, or carcinoma in situ such as breast cancer in situ, thyroid cancer (papillary, hurthle cell or follicular), or localized prostate cancer are acceptable if they have undergone potentially curative therapy. Has known active CNS metastases and/or carcinomatous meningitis. Has a history of (non-infectious) pneumonitis that required steroids or current pneumonitis. ALT or AST above 3 times the upper limit of normal Has received a live virus vaccine within 30 days of enrollment to the study. Active GI bleeding, as evidenced by hematemesis, hematochezia, or melena in the past 3 months without evidence of resolution documented by endoscopy or colonoscopy. Intraluminal metastatic lesion with suspected bleeding, inflammatory bowel disease, ulcerative colitis or other GI condition associated with increased risk of perforation. Has QT interval corrected for heart rate (QTc) ≥480 msec. Has a history of any of the following cardiovascular conditions within 12 months of enrollment to the study: Myocardial infarction Unstable angina pectoris Cardiac angioplasty or stenting Coronary/peripheral artery bypass graft Class III or IV congestive heart failure per New York Heart Association Cerebrovascular accident or transient ischemic attack Has poorly controlled hypertension defined as systolic blood pressure (SBP) ≥150 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg on 3 or more dose optimized anti- hypertensive medication. Has evidence of inadequate wound healing per treating physician discretion. Has active bleeding disorder or other history of significant bleeding episodes within 30 days of enrollment to the study. Has current use (within 7 days of enrollment) or anticipated need for treatment with drugs or foods that are known to be strong cytochrome P450 (CYP3A4/5) inhibitors. Has current use (within 7 days of enrollment) or anticipated need for treatment with drugs that are known strong CYP3A4/5 inducers, including but not limited to carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, and St. John's wort; or drugs that are known with proarrhythmic potential. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the study by subject self-report. Has had a prior solid organ transplant. Is pregnant or breastfeeding or expecting to conceive or father children within the projected duration of the study, starting with the screening visit through 120 days after the last dose of study drug.

Sites / Locations

  • University of Colorado Cancer CenterRecruiting

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Combination Pembrolizumab and Axitinib

Arm Description

Neoadjuvant therapy with the combination of Pembrolizumab and Axitinib will be given for eligible RCC patients with an IVC TT for a total of 12 weeks. Patients will then undergo imaging with a contrast enhanced, diffusion weighted imaging MRI of the abdomen to evaluate the IVC TT response. A CT chest will also be done to ensure there is no progression of disease. Patients can undergo definitive surgery per treating Urologist within 2 weeks (+/- 7 days) after end of treatment scan.

Outcomes

Primary Outcome Measures

Evaluate Change in IVC Tumor Thrombus Extent Based on the Mayo Classification
Patients will get baseline imaging with an MRI of the abdomen to evaluate the level of the IVC TT based on the Mayo Classification. Patients will get an end of treatment MRI at 12 weeks to evaluate the efficacy of neoadjuvant therapy with Pembrolizumab and Axitinib. The Mayo classification is described as below: Level 0: thrombus limited to the renal vein Level 1: into IVC <2cm from renal vein ostium level Level 2: IVC extension >2cm from renal vein ostium and below hepatic vein Level 3: thrombus at the level of or above the hepatic veins but below the diaphragm Level 4: thrombus extending above the diaphragm
Evaluate a change in IVC TT Size from Baseline
o Evaluation of IVC TT anteroposterior and transverse diameter will also be measured at baseline and the end of treatment at 12 weeks. The baseline largest diameter will be subtracted to the largest diameter as the end of treatment divided by the baseline largest diameter will be computed to evaluate the percentage change in the IVC TT size.

Secondary Outcome Measures

Evaluate Surgical Complications after the Neoadjuvant Combination of Pembrolizumab and Axitinib Among Patients with RCC with IVC TT
Surgical morbidity will be graded based on the Clavien- Dindo Classification. This will be graded as below: Grade I: Any deviation from the normal post-operative course not requiring surgical, endoscopic, or radiological intervention (inc. certain drugs, physiotherapy and wound infections that are opened at the bedside) Grade II: Complications requiring drug treatments other than those allowed for Grade I complications (inc. blood transfusion and total parenteral nutrition (TPN)) Grade III: Complications requiring surgical, endoscopic, or radiological intervention (IIIa=not under general anesthetic/IIIb=under general anesthetic) Grade IV: Life-threatening complications (inc. CNS complications requiring intensive care, but excludes transient ischemic attacks (TIAs)) (IVa=single-organ dysfunction (inc. dialysis)/IVb=multi-organ dysfunction) Grade V: Death of the patient
Safety profile of the combination of Axitinib and Pembrolizumab
Catalogue o Any grade adverse event o Grade 3 or higher adverse event possibly, probably, or definitely related to study therapy All treatment related adverse events will be assessed using the Common Terminology Criteria for Adverse Events v5.0
1 year Progression Free Survival
Progression-free survival is defined as any clinical or radiographic progression or death from any cause one year after enrollment in the study
1 year Overall Survival
One year- Overall survival. Overall survival is defined as death from any cause one year after enrollment in the study

Full Information

First Posted
July 24, 2023
Last Updated
September 25, 2023
Sponsor
University of Colorado, Denver
Collaborators
Cancer League of Colorado
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1. Study Identification

Unique Protocol Identification Number
NCT05969496
Brief Title
Neoadjuvant Pembrolizumab and Axitinib in Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus
Acronym
NEOPAX
Official Title
Neoadjuvant Pembrolizumab and Axitinib in Renal Cell Carcinoma With Associated Inferior Vena Cava Tumor Thrombus (NEOPAX)
Study Type
Interventional

2. Study Status

Record Verification Date
September 2023
Overall Recruitment Status
Recruiting
Study Start Date
October 14, 2023 (Anticipated)
Primary Completion Date
November 1, 2026 (Anticipated)
Study Completion Date
November 2029 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Colorado, Denver
Collaborators
Cancer League of Colorado

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
The primary objective of this study is to evaluate whether the combination of Pembrolizumab and Axitinib given in the neoadjuvant setting can change the Inferior Vena Cava Tumor Thrombus burden. A decrease in the size of the tumor thrombus can potentially lead to decrease in surgical complications, improve patient related health outcomes, and improve long term outcomes such as progression free survival and overall survival.
Detailed Description
Patients will receive the combination of Axitinib 5 mg orally twice daily (can be increased to 7 mg twice daily after 2 weeks, and further to 10 mg twice daily as tolerated) and Pembrolizumab 200 mg IV every 21 days. This combination will be given for a total of 12 weeks (4 cycles). A radiographic assessment will be done up to 12 weeks (4 cycles of therapy) to evaluate the primary endpoint of IVC TT response. Patients will undergo a definitive surgery per treating urologist within 2 weeks (+/- 7 days) after the end of treatment scan. During the course of the trial, patient-related health outcomes using Kidney Cancer validated questionnaires with FKSI-DRS and FKSI-19 will also be obtained. These are validated paper questionnaires that will be given to each patient on study visits while receiving neoadjuvant therapy.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Renal Cancer, Kidney Cancer, Renal Cell Carcinoma, Inferior Vena Cava Thrombosis

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
17 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Combination Pembrolizumab and Axitinib
Arm Type
Experimental
Arm Description
Neoadjuvant therapy with the combination of Pembrolizumab and Axitinib will be given for eligible RCC patients with an IVC TT for a total of 12 weeks. Patients will then undergo imaging with a contrast enhanced, diffusion weighted imaging MRI of the abdomen to evaluate the IVC TT response. A CT chest will also be done to ensure there is no progression of disease. Patients can undergo definitive surgery per treating Urologist within 2 weeks (+/- 7 days) after end of treatment scan.
Intervention Type
Drug
Intervention Name(s)
Axitinib
Other Intervention Name(s)
Inlyta
Intervention Description
Axitinib is a potent oral, vascular endothelial growth factor, c-kit and platelet derived growth factor inhibitor.
Intervention Type
Drug
Intervention Name(s)
Pembrolizumab
Other Intervention Name(s)
Keytruda
Intervention Description
Pembrolizumab is a type of immunotherapy. It stimulates the body's immune system to fight cancer cells. Pembrolizumab targets and blocks a protein called PD-1 on the surface of certain immune cells called T-cells. Blocking PD-1 triggers the T-cells to find and kill cancer cells.
Primary Outcome Measure Information:
Title
Evaluate Change in IVC Tumor Thrombus Extent Based on the Mayo Classification
Description
Patients will get baseline imaging with an MRI of the abdomen to evaluate the level of the IVC TT based on the Mayo Classification. Patients will get an end of treatment MRI at 12 weeks to evaluate the efficacy of neoadjuvant therapy with Pembrolizumab and Axitinib. The Mayo classification is described as below: Level 0: thrombus limited to the renal vein Level 1: into IVC <2cm from renal vein ostium level Level 2: IVC extension >2cm from renal vein ostium and below hepatic vein Level 3: thrombus at the level of or above the hepatic veins but below the diaphragm Level 4: thrombus extending above the diaphragm
Time Frame
baseline and 12 weeks
Title
Evaluate a change in IVC TT Size from Baseline
Description
o Evaluation of IVC TT anteroposterior and transverse diameter will also be measured at baseline and the end of treatment at 12 weeks. The baseline largest diameter will be subtracted to the largest diameter as the end of treatment divided by the baseline largest diameter will be computed to evaluate the percentage change in the IVC TT size.
Time Frame
baseline and 12 weeks
Secondary Outcome Measure Information:
Title
Evaluate Surgical Complications after the Neoadjuvant Combination of Pembrolizumab and Axitinib Among Patients with RCC with IVC TT
Description
Surgical morbidity will be graded based on the Clavien- Dindo Classification. This will be graded as below: Grade I: Any deviation from the normal post-operative course not requiring surgical, endoscopic, or radiological intervention (inc. certain drugs, physiotherapy and wound infections that are opened at the bedside) Grade II: Complications requiring drug treatments other than those allowed for Grade I complications (inc. blood transfusion and total parenteral nutrition (TPN)) Grade III: Complications requiring surgical, endoscopic, or radiological intervention (IIIa=not under general anesthetic/IIIb=under general anesthetic) Grade IV: Life-threatening complications (inc. CNS complications requiring intensive care, but excludes transient ischemic attacks (TIAs)) (IVa=single-organ dysfunction (inc. dialysis)/IVb=multi-organ dysfunction) Grade V: Death of the patient
Time Frame
Date of surgery up to 30 days post operative or date of hospital discharge whichever occurs first
Title
Safety profile of the combination of Axitinib and Pembrolizumab
Description
Catalogue o Any grade adverse event o Grade 3 or higher adverse event possibly, probably, or definitely related to study therapy All treatment related adverse events will be assessed using the Common Terminology Criteria for Adverse Events v5.0
Time Frame
baseline to 30 days post operative
Title
1 year Progression Free Survival
Description
Progression-free survival is defined as any clinical or radiographic progression or death from any cause one year after enrollment in the study
Time Frame
baseline, 3 months, 6 months, 9 months, 12 months from study enrollment
Title
1 year Overall Survival
Description
One year- Overall survival. Overall survival is defined as death from any cause one year after enrollment in the study
Time Frame
12 months from study enrollment

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Provision to sign and date the consent form. Stated willingness to comply with all study procedures and be available for the duration of the study. Participant self-identified gender ages >/= 18 years old is acceptable and appropriate if they meet other inclusion criteria. Histologically proven clear cell component RCC. An upfront candidate for definitive surgery per treating Urologist. Suitable for and willing to undergo nephrectomy (either cytoreductive or with curative intent) per treating urologist. T Stage of any of the following: cT3b, cT3c, cT4 N stage of any of the following: cN0 or cN1 M stage of any of the following: cM0 or cM1 ECOG performance status 0 - 2. Urinalysis <2+ protein. If dipstick is ≥2+ then a 24-hour urine collection should be performed, and the patient may enter the trial if urinary protein is <2g per 24 hours. All participants who have reproductive potential must have a negative serum or urine pregnancy test within a maximum of 14 days prior to starting trial treatment. Reproductive potential is defined as the following: Women will be considered post-menopausal if they have been amenorrheic for 12 months without an alternative medical cause. The following age-specific requirements apply: Women <50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of exogenous hormonal treatments and if they have luteinizing hormone and follicle-stimulating hormone levels in the post-menopausal range for the institution or underwent surgical sterilization (bilateral oophorectomy or hysterectomy) Women ≥50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments, had radiation-induced menopause with last menses >1 year ago, had chemotherapy-induced menopause with last menses >1 year ago, or underwent surgical sterilization (bilateral oophorectomy, bilateral salpingectomy or hysterectomy For males with reproductive potential, use effective birth control during treatment with Axitinib and Pembrolizumab is recommended. Exclusion Criteria: Is currently participating in or has participated in a study of an investigational agent or has used an investigational device within 4 weeks prior to enrollment. Has had major surgery within 4 weeks or received radiation therapy within 1 week prior to enrollment to the study. Has had prior treatment with any anti-programmed cell death (anti-PD-1) or programmed cell death ligand 1 (PD-L1), or an antibody targeting any other immune-regulatory receptors or mechanisms. Has received prior systemic anti-cancer therapy for RCC with vascular endothelial growth factor (VEGF)/VEGF receptors (VEGFR). Has a history of severe hypersensitivity reaction (e.g., generalized rash/erythema, hypotension, bronchospasm, angioedema, or anaphylaxis) to Axitinib. Has a diagnosis of immunodeficiency OR is receiving a systemic steroid therapy greater than Prednisone 10 mg daily or a steroid equivalent, or any other form of immunosuppressive therapy within 7 days prior to enrollment to the study except in the case of central nervous system (CNS) metastases. Has an active autoimmune disease requiring systemic treatment within the past 2 years OR a documented history of clinically severe autoimmune disease. Note: Participants with vitiligo, Sjogren's syndrome, Type 1 diabetes, resolved childhood asthma/atopy, hypothyroidism or adrenal or pituitary insufficiency who are stable on hormone replacement are not excluded. Has a known additional malignancy that has progressed or has required active treatment in the last 3 years. Note: Basal cell carcinoma of the skin, squamous cell carcinoma of the skin, superficial bladder cancer, or carcinoma in situ such as breast cancer in situ, thyroid cancer (papillary, hurthle cell or follicular), or localized prostate cancer are acceptable if they have undergone potentially curative therapy. Has known active CNS metastases and/or carcinomatous meningitis. Has a history of (non-infectious) pneumonitis that required steroids or current pneumonitis. ALT or AST above 3 times the upper limit of normal Has received a live virus vaccine within 30 days of enrollment to the study. Active GI bleeding, as evidenced by hematemesis, hematochezia, or melena in the past 3 months without evidence of resolution documented by endoscopy or colonoscopy. Intraluminal metastatic lesion with suspected bleeding, inflammatory bowel disease, ulcerative colitis or other GI condition associated with increased risk of perforation. Has QT interval corrected for heart rate (QTc) ≥480 msec. Has a history of any of the following cardiovascular conditions within 12 months of enrollment to the study: Myocardial infarction Unstable angina pectoris Cardiac angioplasty or stenting Coronary/peripheral artery bypass graft Class III or IV congestive heart failure per New York Heart Association Cerebrovascular accident or transient ischemic attack Has poorly controlled hypertension defined as systolic blood pressure (SBP) ≥150 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg on 3 or more dose optimized anti- hypertensive medication. Has evidence of inadequate wound healing per treating physician discretion. Has active bleeding disorder or other history of significant bleeding episodes within 30 days of enrollment to the study. Has current use (within 7 days of enrollment) or anticipated need for treatment with drugs or foods that are known to be strong cytochrome P450 (CYP3A4/5) inhibitors. Has current use (within 7 days of enrollment) or anticipated need for treatment with drugs that are known strong CYP3A4/5 inducers, including but not limited to carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, and St. John's wort; or drugs that are known with proarrhythmic potential. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the study by subject self-report. Has had a prior solid organ transplant. Is pregnant or breastfeeding or expecting to conceive or father children within the projected duration of the study, starting with the screening visit through 120 days after the last dose of study drug.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Matthew Lee
Phone
720-848-0630
Email
matthew.lee@cuanscutz.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Elizabeth E Kessler, MD
Organizational Affiliation
University of Colorado, Denver
Official's Role
Principal Investigator
Facility Information:
Facility Name
University of Colorado Cancer Center
City
Aurora
State/Province
Colorado
ZIP/Postal Code
80045
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Elizabeth Kessler
Phone
720-848-0170
Email
elizabeth.kessler@cuanschutz.edu

12. IPD Sharing Statement

Plan to Share IPD
No

Learn more about this trial

Neoadjuvant Pembrolizumab and Axitinib in Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

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