| Eligibility |
Inclusion Criteria:
- Male or female
- Age >= 18 years
- Eastern Cooperative Oncology Group (ECOG) performance status =< 2 ,Karnofsky >= 50%.
- Metastatic disease or unresectable locally advanced disease.
- Histologically documented adrenal cortical carcinoma.
- Untreated or having received any number of lines of prior therapy.
- Measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) version
(v)1.1
- Life expectancy >= 12 weeks
- Tumor tissue samples must be available for submission prior to initiation of study
treatment. If not, agree to undergo biopsy.
- Recovery to baseline or =< grade 1 Common Terminology Criteria for Adverse Events
(CTCAE) version 5 from toxicities related to any prior treatments, unless adverse
event (AE)(s) are clinically nonsignificant and/or stable on supportive therapy.
- Absolute neutrophil count (ANC) >= 1500/uL without granulocyte colony-stimulating
factor support within 28 days before first dose of study treatment.
- Lymphocyte count 0.5 x 10^9/L (500/mL) within 28 days before first dose of study
treatment.
- White blood cell count >= 2500/uL within 28 days before first dose of study treatment.
- Platelets >= 100,000/uL without transfusion within 28 days before first dose of study
treatment.
- Hemoglobin >= 9 g/dL (>= 90 g/L). Patients may be transfused to meet this criterion
within 28 days before first dose of study treatment.
- Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline
phosphatase (ALP) =< 3 x upper limit of normal (ULN). ALP =< 5 x ULN with documented
bone metastases within 28 days before first dose of study treatment.
- Total bilirubin =< 1.5 x ULN for subjects with Gilbert's disease =< 3 x ULN within 28
days before first dose of study treatment.
- Serum albumin >= 2.8 g/dl within 28 days before first dose of study treatment.
- Prothrombin time (PT) / international normalized ratio (INR) or partial thromboplastin
time (PTT) test < 1.3 x the laboratory ULN within 28 days before first dose of study
treatment.
- Serum creatinine =< 1.5 x ULN or calculated creatinine clearance >= 40mL/min (>=
0.675mL/sec) using the Cockcroft-Gault equation within 28 days before first dose of
study treatment.
- Urine protein/creatinine ratio (UPCR) =< 1 mg/mg (=< 113.2 mg/mmol), or 24-h urine
protein =< 1 g within 28 days before first dose of study treatment.
- Negative human immunodeficiency virus (HIV) test at screening, with the following
exception: patients with a positive HIV test at screening are eligible provided they
are stable on anti-retroviral therapy, have a CD4 count >= 200/uL, and have an
undetectable viral load.
- Negative hepatitis B surface antigen (HBsAg) test at screening.
- Negative hepatitis C virus (HCV) antibody test at screening, or positive HCV antibody
test followed by a negative hepatitis C virus (HCV) ribonucleic acid (RNA) test at
screening.
- The hepatitis C virus (HCV) ribonucleic acid (RNA) test must be performed for
patients who have a positive HCV antibody test
- The effects of study drugs on the developing human fetus are unknown. For this reason,
female of child-bearing potential (FCBP) must have a negative serum or urine pregnancy
test prior to starting therapy
- Female of child-bearing potential (FCBP) and men treated or enrolled on this protocol
must agree to use adequate contraception with a failure rate < 1% prior to study
entry, for the duration of study participation, and 5 months after completion of study
drug administration.
- Examples of contraceptive methods with a failure rate of < 1% per year include
bilateral tubal ligation, male sterilization, hormonal contraceptives that
inhibit ovulation, hormone-releasing intrauterine devices, and copper
intrauterine devices
- The reliability of sexual abstinence should be evaluated in relation to the
duration of the clinical trial and the preferred and usual lifestyle of the
patient. Periodic abstinence e.g., calendar, ovulation, symptothermal, or
postovulation methods and withdrawal are not adequate methods of contraception
- Should a woman become pregnant or suspect she is pregnant while she or her
partner is participating in this study, she should inform her treating physician
immediately
- Female subjects of childbearing potential must not be pregnant at screening. Female
subjects are considered to be of childbearing potential unless one of the following
criteria is met: documented permanent sterilization (hysterectomy, bilateral
salpingectomy, or bilateral oophorectomy) or documented postmenopausal status (defined
as 12 months of amenorrhea in a woman > 45 years-of-age in the absence of other
biological or physiological causes. In addition, females < 55 years-of-age must have a
serum follicle stimulating [FSH] level > 40 mIU/mL to confirm menopause). Note:
Documentation may include review of medical records, medical examinations, or medical
history interview by study site
- Willingness and ability of the subject to comply with scheduled visits, drug
administration plan, protocol-specified laboratory tests, other study procedures, and
study restrictions
- Evidence of a personally signed informed consent indicating that the subject is aware
of the neoplastic nature of the disease and has been informed of the procedures to be
followed, the experimental nature of the therapy, alternatives, potential risks and
discomforts, potential benefits, and other pertinent aspects of study participation
Exclusion Criteria:
- Receipt of any type of small molecule kinase inhibitor including investigational
kinase inhibitor within 2 weeks before first dose of study treatment
- Prior treatment with CD137 agonists or immune checkpoint blockade therapies, including
anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic antibodies
- Receipt of any type of cytotoxic, biologic or other systemic anticancer therapy
(including immunostimulatory agents or investigational agents) within 4 weeks or 5
half-lives of the drug (whichever is longer) before first dose of study treatment
- Radiation therapy for bone metastasis within 2 weeks or any other radiation therapy
within 4 weeks before first dose of study treatment. Systemic treatment with
radionuclides within 6 weeks before first dose of study treatment. Subjects with
clinically relevant ongoing complications from prior radiation therapy are not
eligible
- Known brain metastases or cranial epidural disease unless adequately treated with
radiotherapy 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 with known brain metastases or cranial epidural disease should
also have no history of intracranial hemorrhage or spinal hemorrhage. Subjects must
have complete wound healing from major surgery or minor surgery before first dose of
study treatment. Eligible subjects must be neurologically asymptomatic and without
corticosteroid treatment at the time of first dose of study treatment. If subject is
receiving anti-convulsant therapy, the dose is considered stable
- 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
- Administration of a live, attenuated vaccine within 30 days before first dose of study
treatment or anticipation of need for such a vaccine during atezolizumab treatment or
within 5 months after the final dose of atezolizumab
- Concomitant mitotane use
- Mitotane must have been discontinued 28 days prior to first dose of study
treatment, with mitotane serum level < 2 mg/L if mitotane administered within
last 6 months
- The subject has uncontrolled, significant intercurrent or recent illness including,
but not limited to, the following conditions:
- Cardiovascular disorders:
- Congestive heart failure New York Heart Association class 3 or 4, unstable
angina pectoris, serious cardiac arrhythmias
- Uncontrolled hypertension defined as sustained blood pressure (BP) > 140 mm
Hg systolic or > 90 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, subsegmental pulmonary
embolism (PE) or deep vein thrombosis (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
- Uncontrolled tumor-related pain:
- Patients requiring pain medication must be on a stable regimen at study
entry
- Symptomatic lesions e.g., bone metastases or metastases causing nerve
impingement amenable to palliative radiotherapy should be treated prior to
enrollment. Patients should be recovered from the effects of radiation (see
exclusion criteria #4 for minimal required duration prior to trial
enrollment)
- Asymptomatic metastatic lesions that would likely cause functional deficits
or intractable pain with further growth (e.g., epidural metastasis that is
not currently associated with spinal cord compression) should be considered
for loco-regional therapy if appropriate prior to enrollment
- Uncontrolled pleural effusion, pericardial effusion, or ascites requiring
recurrent drainage procedures (once monthly or more frequently)
- Patients with indwelling catheters (e.g., PleurX) are allowed
- Uncontrolled or symptomatic hypercalcemia (ionized calcium > 1.5 mmol/L, calcium
> 12 mg/dL or corrected serum calcium > ULN)
- History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g.,
bronchiolitis obliterans), drug-induced pneumonitis, or idiopathic pneumonitis,
or evidence of active pneumonitis on screening chest computed tomography (CT)
scan
- History of radiation pneumonitis in the radiation field (fibrosis) is
permitted
- 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
- Cavitating pulmonary lesion(s) or known endotracheal or endobronchial disease
manifestation
- Lesions invading or encasing any major blood vessels
- Other clinically significant disorders that would preclude safe study participation.
- Active or history of autoimmune disease or immune deficiency, including, but not
limited to, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus
erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid
antibody syndrome, Wegener granulomatosis, Sjogren syndrome, Guillain-Barré
syndrome, or multiple sclerosis with the following exceptions:
- Type 1 diabetes mellitus on an insulin regimen
- Hypothyroidism only requiring hormone replacement
- Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with
dermatologic manifestations only (e.g., patients with psoriatic arthritis
are excluded) are eligible for the study provided all of following
conditions are met:
- Rash must cover < 10% of body surface area
- Disease is well controlled at baseline and requires only low-potency
topical corticosteroids
- No occurrence of acute exacerbations of the underlying condition
requiring psoralen plus ultraviolet A radiation, methotrexate,
retinoids, biologic agents, oral calcineurin inhibitors, or
high-potency or oral corticosteroids within the previous 12 months
- Treatment with systemic immunosuppressive medication (including, but not limited
to, corticosteroids, cyclophosphamide, azathioprine, methotrexate, thalidomide,
and anti-tumor necrosis factor [TNF]-alpha agents) within 2 weeks prior to
initiation of study treatment, or anticipation of need for systemic
immunosuppressive medication during study treatment, with the following
exceptions:
- Patients who received acute, low-dose systemic immunosuppressant medication
or a one-time pulse dose of systemic immunosuppressant medication (e.g., 48
hours of corticosteroids for a contrast allergy) are eligible for the study
after principal investigator confirmation has been obtained
- Patients who received mineralocorticoids (e.g., fludrocortisone),
corticosteroids for chronic obstructive pulmonary disease (COPD) or asthma
or mitotane-associated adrenal insufficiency, or low-dose corticosteroids
for orthostatic hypotension or other causes of adrenal insufficiency are
eligible for the study
- Inhaled, intranasal, intra-articular, or topical steroids are permitted
- Active infection requiring systemic treatment. Acute or chronic hepatitis B or C
infection, known human immunodeficiency virus (HIV) or acquired immunodeficiency
syndrome (AIDS)-related illness, or known positive test for tuberculosis
infection where there is clinical or radiographic evidence of active
mycobacterial infection
- Treatment with therapeutic oral or IV antibiotics within 2 weeks prior to
initiation of study treatment
- Patients receiving prophylactic antibiotics (e.g., to prevent a urinary tract
infection or chronic obstructive pulmonary disease exacerbation) are eligible for
the study
- History of idiopathic pulmonary fibrosis, organizing pneumonia, drug-induced
pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on
screening chest CT scan
- History of radiation pneumonitis in the radiation field (fibrosis) is
permitted
- Serious non-healing wound/ulcer/bone fracture
- Malabsorption syndrome
- Uncompensated/symptomatic hypothyroidism
- Moderate to severe hepatic impairment (Child-Pugh B or C)
- Requirement for hemodialysis or peritoneal dialysis
- History of solid organ or allogenic stem cell transplant
- Known history of COVID-19 unless the subject has clinically recovered from the
disease at least 30 days prior to first dose of study treatment
- Severe infection within 4 weeks prior to initiation of study treatment,
including, but not limited to, hospitalization for complications of infection,
bacteremia, or severe pneumonia, or any active infection that could impact
patient safety
- Major surgery (e.g., laparoscopic nephrectomy, GI surgery, removal or biopsy of brain
metastasis) within 2 weeks before first dose of study treatment. Minor surgeries
within 10 days before first dose of study treatment. Subjects must have complete wound
healing from major surgery or minor surgery before first dose of study treatment.
Subjects with clinically relevant ongoing complications from prior surgery are not
eligible
- Corrected QT interval calculated by the Fridericia formula (QTcF) > 500 ms per
electrocardiogram (ECG) within 14 days before first dose of study treatment.
Furthermore, subjects with a history of additional risk factors for torsades de
pointes (e.g., long QT syndrome) are also excluded. Note: If a single ECG shows a QTcF
with an absolute value > 500 ms, two additional ECGs at intervals of approximately 3
min must be performed within 30 min after the initial ECG, and the average of these
three consecutive results for QTcF will be used to determine eligibility
- Pregnant or lactating females
- Inability to swallow tablets or unwillingness or inability to receive IV
administration
- Previously identified allergy or hypersensitivity to components of the study treatment
formulations or history of severe infusion-related reactions to monoclonal antibodies.
Subjects with rare hereditary problems of galactose intolerance, the Lapp lactase
deficiency or glucose-galactose malabsorption are also excluded
- Any other active malignancy at time of first dose of study treatment or diagnosis of
another malignancy within 3 years prior to first dose of study treatment that requires
active treatment, except for locally curable cancers that have been apparently cured,
such as basal or squamous cell skin cancer, superficial bladder cancer, or carcinoma
in situ of the prostate, cervix, or breast
- Current treatment with anti-viral therapy for hepatitis B virus (HBV).
- History of leptomeningeal disease
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