E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
Advanced (Unresectable or Metastatic) Adrenocortical Carcinoma |
fortgeschrittenes (nicht resektables oder metastasiertes Nebennierenrindenkarzinom |
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E.1.1.1 | Medical condition in easily understood language |
Cancer of the adrenal gland that cannot be removed by surgery or has spread to distant sites |
Nebennierenkarzinom, welches nicht operativ entfernt werden kann oder von dem Absiedelungen (Metastasen) an anderen Stellen im Körper bestehen. |
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E.1.1.2 | Therapeutic area | Diseases [C] - Cancer [C04] |
MedDRA Classification |
E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | HLGT |
E.1.2 | Classification code | 10001353 |
E.1.2 | Term | Adrenal gland disorders |
E.1.2 | System Organ Class | 10014698 - Endocrine disorders |
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E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | HLT |
E.1.2 | Classification code | 10001341 |
E.1.2 | Term | Adrenal cortical hyperfunctions |
E.1.2 | System Organ Class | 10014698 - Endocrine disorders |
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E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | HLT |
E.1.2 | Classification code | 10001376 |
E.1.2 | Term | Adrenal neoplasms |
E.1.2 | System Organ Class | 10014698 - Endocrine disorders |
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E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | HLT |
E.1.2 | Classification code | 10001378 |
E.1.2 | Term | Adrenal neoplasms malignant |
E.1.2 | System Organ Class | 100000004864 |
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E.1.3 | Condition being studied is a rare disease | No |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
To determine the efficacy and safety of cabozantinib as a treatment for advanced adrenocortical carcinoma. |
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E.2.2 | Secondary objectives of the trial |
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E.2.3 | Trial contains a sub-study | No |
E.3 | Principal inclusion criteria |
A subject who meets any of the following criteria is eligible for the study: 1. The subject is ≥ 18 years old on the day of consent 2. Histological confirmation of ACC based on either: i) Weiss Score of ≥ 3 in patients who had earlier surgical resection (Lin-Weiss-Bisceglia system will be used for oncocytic ACC) OR ii) biopsy results compatible with ACC in the context of clinical setting highly sugges-tive of ACC (adrenal mass > 4 cm invading surrounding organs or associated with dis-tant metastases). 3. Locally advanced or metastatic disease not amenable to surgery with curative intent with measurable disease per RECIST 1.1 37 as determined by the investigator based on an assessment of all known disease sites by computerized tomography (CT) scan or magnetic resonance imaging (MRI) of chest/abdomen/pelvis within 28 days before the first dose of cabozantinib 4. Received prior treatment with mitotane and platinum containing chemotherapy. Pa-tients in whom mitotane and/or platinum containing chemotherapy is contraindicated or who refused treatment with mitotane and/or platinum containing chemotherapy are eligible for the study. 5. Documented progressive disease. 6. Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 7. Recovery to baseline or ≤ Grade 1 CTCAE v.5.0 from toxicities related to any prior treatments, unless AE(s) are clinically non-significant and/or stable on supportive ther-apy 8. Life expectancy of at least 3 months 9. Adequate organ and bone marrow function and laboratory values as follows within 14 days prior to the first dose of cabozantinib: a. Absolute neutrophil count (ANC) ≥ 1500/µL without colony stimulating factor support, white blood cell count ≥ 2500/µL. b. Platelets ≥ 100,000/µL without transfusion c. Hemoglobin ≥ 9 g/dL d. Bilirubin ≤ 1.5 × the upper limit of normal (ULN). For subjects with known Gil-bert’s disease, bilirubin ≤ 3.0 mg/dL e. Serum albumin ≥ 2.8 g/dl f. (PT)/INR or partial thromboplastin time (PTT) test < 1.3 x the laboratory ULN g. Serum creatinine ≤ 2.0 × ULN or creatinine clearance (CrCl) ≥ 30 mL/min. For creatinine clearance estimation, the Cockcroft and Gault equation should be used: Male: CrCl (mL/min) = (140 - age) × wt (kg) / (serum creatinine × 72). Female: Multiply above result by 0.85 h. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alka-line phosphatase (ALP) ≤ 3 x upper limit of normal (ULN). In case of liver me-tastases ALT and AST ≤ 5.0 x ULN are acceptable. ALP ≤ 5 x ULN with doc-umented bone metastases. i. Urine protein/creatinine ratio (UPCR) ≤ 1 mg/mg), or 24-h urine protein ≤ 1 g 10. Capable of understanding and complying with the protocol requirements . 11. Women of childbearing potential* must have a negative pregnancy test at screening. Additional pregnancy testing will be performed in WOCBP at monthly intervals. Pa-tients of reproductive potential (men and women) must agree to use highly effective methods of contraception** during the course of the study and for 4 months after the last dose of study drug(s), even if oral contraceptives are also used. 12. Able to give written informed consent |
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E.4 | Principal exclusion criteria |
A subject who meets any of the following criteria is ineligible for the study: 1. Received cytotoxic chemotherapy, or targeted therapy (including investigational cyto-toxic chemotherapy) or biologic agents (e.g., cytokines or antibodies), or other investi-gational agent within 14 days before study treatment. 2. Treatment with mitotane <28 days prior study inclusion OR mitotane serum/plasma concentration documented of ≥2 mg/L at screening. Up to 5 mg/L are acceptable with Sponsor approval. 3. Prior treatment with cabozantinib or other cMET inhibitors 4. Radiation therapy within 4 weeks (2 weeks for radiation for bone metastases) or radi-onuclide treatment (eg, I-131 or Y-90) within 6 weeks before first dose of study treat-ment. Subject is excluded if there are any clinically relevant ongoing complications from prior radiation therapy. 5. Known brain metastases or cranial epidural disease unless adequately treated with ra-diotherapy and/or surgery (including radiosurgery) and stable for at least 4 weeks prior to first dose of study treatment after radiotherapy or at least 4 weeks prior to first dose of study treatment after major surgery (e.g., removal or biopsy of brain metastasis). Subjects must have complete wound healing from major surgery or minor surgery be-fore first dose of study treatment. Eligible subjects must be neurologically asympto-matic and without corticosteroid treatment at the time of first dose of study treatment. Corticosteroid replacement treatment is allowed with dose at the discretion of the in-vestigator. 6. Concomitant anticoagulation with coumarin agents (e.g., warfarin), direct thrombin in-hibitors (e.g., dabigatran), direct factor Xa inhibitor betrixaban, or platelet inhibitors (e.g., clopidogrel). Allowed anticoagulants are the following: a. Prophylactic use of low-dose aspirin for cardio-protection (per local applicable guidelines) and low-dose low molecular weight heparins (LMWH). b. 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. 7. The use of strong CYP3A4 inhibitors (with the exception of ketoconazole). 8. The subject has uncontrolled, significant intercurrent or recent illness including, but not limited to, the following conditions: a. Cardiovascular disorders: i. Congestive heart failure New York Heart Association Class 3 or 4, un-stable angina pectoris, serious cardiac arrhythmias. ii. Uncontrolled hypertension defined as sustained blood pressure (BP) > 140 mm Hg systolic or > 90 mm Hg diastolic despite optimal antihyper-tensive treatment. iii. Stroke (including transient ischemic attack [TIA]), myocardial infarction (MI), or other ischemic event, or thromboembolic event (e.g., deep ve-nous thrombosis, pulmonary embolism) within 6 months before first dose of study treatment. Note: Subjects with a diagnosis of incidental, subsegmental PE or deep vein thrombosis (DVT) or other large vessel thrombosis 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. b. Gastrointestinal (GI) disorders including those associated with a high risk of perforation or fistula formation: i. The subject has evidence of tumor invading the GI tract, active peptic ulcer disease, inflammatory bowel disease (e.g., Crohn’s disease), di-verticulitis, cholecystitis, symptomatic cholangitis or appendicitis, acute pancreatitis, acute obstruction of the pancreatic duct or common bile duct, or gastric outlet obstruction. ii. 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 con-firmed before first dose of study treatment. 9. Clinically significant hematuria, hematemesis, or hemoptysis of > 0.5 teaspoon (2.5 ml) of red blood, or other history of significant bleeding (e.g., pulmonary hemorrhage) within 12 weeks before first dose of study treatment. 10. Cavitating pulmonary lesion(s) or known endotracheal or endobronchial disease mani-festation. 11. Lesions invading or encasing any major blood vessels. In subjects with liver metasta-ses and lesions invading the intrahepatic vasculature, including portal vein, hepatic vein, and hepatic artery, are eligible |
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E.5 End points |
E.5.1 | Primary end point(s) |
Primary Endpoint: To estimate progression free survival at 4 months
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E.5.1.1 | Timepoint(s) of evaluation of this end point |
16 weeks after treatment initiation |
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E.5.2 | Secondary end point(s) |
Secondary Endpoints • overall survival • Best Objective Response Rate (ORR) • duration of response (DR) • progression-free survival • best percentage change in size of target lesions • incidence and severity of adverse events possibly related to cabozantinib graded according to CTC-AE 5.0 • quality of life by EORTC QLQ-C30 Exploratory Endpoints • To explore the relationship between cabozantinib pharmacokinetics and treatment re-sponse and tolerability • To study steroid hormone biomarkers and targeted metabolomics as markers of disease response. • To study the effect of cabozantinib on immune markers by obtaining blood samples collection at baseline, during therapy and at time of progression. • To explore the relation between pharmacogenetic variants and cabozantinib pharmacokinetics. • In archival formalin-fixed paraffin-embedded tumor material: To determine c-MET copy number (FISH), mutations (incl. Delta Exon14), c-MET mRNA expression (RNAscope) and VEGFR2 expression (IHC) as markers of response • In patients in whom fresh tumor material is available: To characterize the major immune cell types (T cells, B cells, NK cells, DC), T cell differentiation status and functionality (IFNgamma, TNFalpha, GB) and expression levels of costimulatory and coinhibitory molecules on T cells and their respective receptors such as PD-L1 on infiltrating myeloid cells and tumor cells and determine tumor neoantigens by exome sequencing |
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
Efficacy analyses will be performed for each of the response criteria as well as for overall and progression free survival using the full analysis set for the primary analysis and, for secondary analyses, the per-protocol set.
A categorical efficacy variable will be computed identifying the patient status at each visit by one of the categories CR, PR, SD or PD. The best response will be defined as a unique categorical variable (categories CR, PR, SD and PD) for each patient. The overall survival (OS) will be handled as time to event variable. Duration of CR, PR and PFS will be also handled as time to event variables and calculated analogously to OS. |
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E.6 and E.7 Scope of the trial |
E.6 | Scope of the trial |
E.6.1 | Diagnosis | No |
E.6.2 | Prophylaxis | No |
E.6.3 | Therapy | Yes |
E.6.4 | Safety | Yes |
E.6.5 | Efficacy | Yes |
E.6.6 | Pharmacokinetic | Yes |
E.6.7 | Pharmacodynamic | No |
E.6.8 | Bioequivalence | No |
E.6.9 | Dose response | No |
E.6.10 | Pharmacogenetic | Yes |
E.6.11 | Pharmacogenomic | No |
E.6.12 | Pharmacoeconomic | No |
E.6.13 | Others | No |
E.7 | Trial type and phase |
E.7.1 | Human pharmacology (Phase I) | No |
E.7.1.1 | First administration to humans | No |
E.7.1.2 | Bioequivalence study | No |
E.7.1.3 | Other | No |
E.7.1.3.1 | Other trial type description | |
E.7.2 | Therapeutic exploratory (Phase II) | Yes |
E.7.3 | Therapeutic confirmatory (Phase III) | No |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | No |
E.8.1.1 | Randomised | No |
E.8.1.2 | Open | Yes |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | No |
E.8.1.5 | Parallel group | No |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | No |
E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | No |
E.8.2.2 | Placebo | No |
E.8.2.3 | Other | No |
E.8.3 |
The trial involves single site in the Member State concerned
| No |
E.8.4 | The trial involves multiple sites in the Member State concerned | Yes |
E.8.4.1 | Number of sites anticipated in Member State concerned | 2 |
E.8.5 | The trial involves multiple Member States | No |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | No |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
E.8.7 | Trial has a data monitoring committee | No |
E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
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E.8.9 Initial estimate of the duration of the trial |
E.8.9.1 | In the Member State concerned years | 5 |
E.8.9.1 | In the Member State concerned months | 6 |
E.8.9.1 | In the Member State concerned days | |