Inclusion Criteria.
- - Cohorts A and B: Histologically or cytologically confirmed advanced RCC with any
clear cell or non-clear cell component.
100% sarcomatoid is permissible.
- - Cohorts A and B: Patient may have had any number of prior therapies for Cohort A,
but for Cohort B patients must not have received any systemic therapy in the
metastatic setting.
- - Patients who have received prior (neo)adjuvant immunotherapy with pembrolizumab or
similar are eligible for Cohort B IF they completed the adjuvant therapy > 12
months from start of trial therapy.
- - Treatment naïve patients may be treated in Cohort A if deemed not candidates for
nivolumab or if felt single agent cabozantinib most appropriate by the treating
clinician.
- - Cohort C: Well differentiated NET, grades 1-3 (any primary site) who have progressed
on or are not eligible for somatostatin analogs per treating physician discretion.
- - Cohort C: Disease progression within prior 12 months.
- - Cohort C: Prior or concurrent treatment with somatostatin analogue allowed but no
limit on lines of therapy (stable dose of somatostatin for 2 months)
All Cohorts:
- At least one measurable lesion as defined by RECIST version 1.1.
- - No evidence of pre-existing uncontrolled hypertension as assessed by investigator.
Patients may undergo adjustments or additions to their antihypertensive regimen
before or during screening to achieve optimal BP control.
- - ECOG performance status 0 - 2.
- - Patients must have normal organ and marrow function as defined below.
- - Leukocytes, > 2,000/mcL.
- - Absolute neutrophil count, > 1,500/mcL.
- - Platelets, > 100,000/mcL.
- - Hgb, > 9 g/dL (>90 g/L)
- Total bilirubin, ≤ 1.5 x ULN (with the exception of of individuals with
Gilberts syndrome who may have a bilirubin <3.0 mg/dL)
- AST/ALT (SGOT/SGPT)/ALP, < 3 x ULN ALP ≤ 5x ULN with documented bone
metastases.
- - Creatinine clearance, > 30 Ml/min/1.73 m2 for patients with creatinine
levels above institutional normal.
- - PT/INR or PTT, < 1.3 x the laboratory ULN.
- - Ability to understand and willingness to sign a written informed consent and HIPAA
consent document.
- - Sexually active fertile subjects and their partners must agree to use medically
accepted methods of contraception (e.g., barrier methods, including male condom,
female condom, or diaphragm with spermicidal gel) during the course of the study and
for 4 months after the last dose of study treatment.
Exclusion Criteria.
- - Patients who have had systemic anti-cancer therapy or radiotherapy within 14 days or
five half-lives, whichever is shorter, prior to entering the study.
- - Radiation therapy for bone metastases within 2 weeks, any other radiation therapy
within 4 weeks, or systemic treatment with radionuclides within 6 weeks before first
dose of study treatment.
Ongoing clinically relevant complications from prior
radiation therapy would preclude eligibility.
- - Patients with prior therapy with cabozantinib.
- - Prior systemic therapy directed at advanced RCC is not allowed for patients enrolled
to Cohort B (treatment-naïve group).
- - Cohort B only: Active, known or suspected autoimmune disease.
Subjects are permitted
to enroll if they have vitiligo, type I diabetes mellitus, residual hypothyroidism
due to autoimmune condition only requiring hormone replacement, psoriasis not
requiring systemic treatment, or conditions not expected to recur in the absence of
an external trigger.
- - Cohort B only: Patients have a condition requiring systemic treatment with either
corticosteroids (> 10 mg daily prednisone or equivalent) or other
immunosuppressive medications within 14 days of study drug administration.
Inhaled
or topical steroids and adrenal replacement doses > 10 mg daily prednisone
equivalents are permitted in the absence of active autoimmune disease.
- - Patients may not be receiving any other investigational agents.
- - History of allergic reactions or hypersensitivity attributed to compound of similar
chemical or biologic composition to the agent(s) used in this study.
- - Current use or anticipated need for treatment with drugs or foods that are known
strong CYP3A4 inhibitors and inducers.
Refer to Section 5.3.2 for detailed
information. The topical use of these medications (if applicable), such as 2%
ketoconazole cream, is allowed.
- - Concomitant anticoagulation with coumarin agents (e.g., warfarin), direct thrombin
inhibitors (e.g., dabigatran), direct factor Xa inhibitor betrixaban, or platelet
inhibitors (e.g., clopidogrel).
Allowed anticoagulants are the following:
- - Prophylactic use of low-dose aspirin for cardio-protection (per local applicable
guidelines) and low-dose low molecular weight heparins (LMWH).
- - Therapeutic doses of LMWH or anticoagulation with direct factor Xa inhibitors
rivaroxaban, edoxaban, or apixaban in subjects without known brain metastases who
are on a stable dose of the anticoagulant for at least 1 week before first dose of
study treatment without clinically significant hemorrhagic complications from the
anticoagulation regimen or the tumor.
- - Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance
with study requirements.
- - Cardiovascular disorders:
- Congestive heart failure New York Heart Association Class 3 or 4, unstable angina
pectoris, serious cardiac arrhythmias.
- - QTcF > 500 msec within 28 days before first dose of study treatment.
- - Uncontrolled hypertension defined as sustained blood pressure (BP) > 160 mm Hg
systolic or > 100 mm Hg diastolic despite optimal antihypertensive treatment.
- - Stroke (including transient ischemic attack [TIA]), myocardial infarction (MI), or
other ischemic event, or thromboembolic event (e.g., deep venous thrombosis,
pulmonary embolism) within 6 months before first dose of study treatment.
- - Subjects with a diagnosis of incidental, sub-segmental PE or DVT within 6 months are
allowed if stable, asymptomatic, and treated with a stable dose of permitted
anticoagulation (see exclusion criterion #6) for at least 1 week before first dose
of study treatment.
- - Gastrointestinal (GI) disorders including those associated with a high risk of
perforation or fistula formation:
- The subject has evidence of tumor invading the GI tract, active peptic ulcer
disease, inflammatory bowel disease (e.g., Crohn's disease), diverticulitis,
cholecystitis, symptomatic cholangitis or appendicitis, acute pancreatitis, acute
obstruction of the pancreatic duct or common bile duct, or gastric outlet
obstruction.
- - Abdominal fistula, GI perforation, bowel obstruction, or intra-abdominal abscess
within 6 months before first dose of study treatment.
Note: Complete healing of an intra-abdominal abscess must be confirmed before first dose
of study treatment.
- - Cavitating pulmonary lesion(s) or known endotracheal or endobronchial disease
manifestation.
- - Lesions invading or encasing any major blood vessels.
Subjects with lesions invading
the intrahepatic vasculature, including portal vein, hepatic vein, and hepatic
artery, are eligible.
