PRIMARY OBJECTIVES:
I. To compare event-free survival (EFS) between patients with upper tract urothelial cancer (UTUC) randomized to neoadjuvant accelerated methotrexate, vinblastine, adriamycin, cisplatin (aMVAC) alone or in combination with durvalumab. (Cisplatin eligible patients \[Arms A and B\]) II. Evaluation of pathologic complete response at radical nephroureterectomy (RNU) (pathologic complete response \[pCR\], pT0N0/ Nx). (Cisplatin ineligible patients \[Arm C\]).
SECONDARY OBJECTIVES:
I. To assess pathologic complete response (pCR) at surgery. (Cisplatin eligible cohort) II. Event-free survival (EFS) will be evaluated for the cisplatin ineligible cohort as a secondary endpoint. (Cisplatin ineligible cohort) III. Overall survival in all, and by post chemotherapy response (ypCR, yp =\< T1N0, yp \>= T2Nany). (All patients) IV. To evaluate disease-free survival (DFS) in each arm of the trial separately. (All patients) V. To evaluate cancer-specific survival of patients in each arm of the trial separately. (All patients) VI. To evaluate renal function outcomes following systemic treatment and following surgery (\[RNU) in each arm of the trial separately. (All patients) VII. To evaluate safety and tolerability of neoadjuvant aMVAC alone or in combination with durvalumab prior to RNU. (All patients)
OUTLINE: Patients eligible for cisplatin are randomized to Arms A or B. Patients ineligible for cisplatin are assigned to Arm C.
ARM A: Patients receive durvalumab intravenously (IV) over 60 minutes on day 1 of chemotherapy cycles 1 and 3. Patients also receive methotrexate IV over 2-3 minutes, vinblastine sulfate IV, doxorubicin IV, cisplatin IV over at least 2 hours on day 1. Treatments repeat every 14 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Within 21- 60 days after completion of systemic treatment, patients with continued lack of radiographic presence of metastatic or unresectable disease undergo surgery.
ARM B: Patients also receive methotrexate IV over 2-3 minutes, vinblastine sulfate IV, doxorubicin IV, cisplatin IV over at least 2 hours on day 1. Treatments repeat every 14 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Within 21- 60 days after completion of systemic treatment, patients with continued lack of radiographic presence of metastatic or unresectable disease undergo surgery.
ARM C: Patients receive durvalumab IV over 60 minutes on day 1 and gemcitabine hydrochloride IV over 30 minutes on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Within 21- 60 days after completion of systemic treatment patients with continued lack of radiographic presence of metastatic or unresectable disease undergo surgery.
Patients also undergo tissue biopsy and blood sample collection on study, and computed tomography (CT) or magnetic resonance imaging (MRI) throughout the trial.
After completion of study treatment, patients are followed up within 30 days and then every 3-6 months for up to 5 years from study entry.
Inclusion Criteria:
- STEP 1 REGISTRATION AND RANDOMIZATION
- Patients must be >= 18 years of age
- Patient must have the ability to understand and the willingness to sign a written
informed consent document. Patients with impaired decision-making capacity (IDMC) who
have a legally authorized representative (LAR) or caregiver and/or family member
available will also be considered eligible
- Patient must have a diagnosis of high grade upper tract urothelial carcinoma proven by
biopsy within 12 weeks (84 days) prior to registration/randomization with one of the
following:
- Upper urinary tract mass on cross-sectional imaging or
- Tumor directly visualized during upper urinary tract endoscopy before referral to
medical oncology
- NOTE: Biopsy is standard of care (SOC) and required for enrollment to study.
This is vital for best practice
- Leukocytes >= 3,000/mcL (obtained =< 14 days prior to registration/randomization)
- Platelets >= 100,000/mcL (obtained =< 14 days prior to registration/randomization)
- Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) (or =< 2.5 x ULN
for patients with Gilbert's disease) (obtained =< 14 days prior to
registration/randomization)
- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase
[SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT])
=< 2.5 x institutional ULN (obtained =< 14 days prior to registration/randomization)
- Hemoglobin (Hgb) >= 9 g/dL (obtained =< 14 days prior to registration/randomization)
- NOTE: Packed red blood transfusion is allowed to achieve this parameter as per
treating investigator
- Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral
therapy with undetectable viral load within 6 months prior to
registration/randomization are eligible for this trial
- NOTE: These patients must be stable on their anti-retroviral regimen with
evidence of at least two undetectable viral loads within the past 6 months on the
same regimen; the most recent undetectable viral load must be within the past 12
weeks. They must have a CD4 count of greater than 250 cells/mcL over the past 6
months on this same anti-retroviral regimen and must not have had a CD4 count <
200 cells/mcL over the past 2 years, unless it was deemed related to the cancer
and/or chemotherapy induced bone marrow suppression. They must not be currently
receiving prophylactic therapy for an opportunistic infection and must not have
had an opportunistic infection within the past 6 months
- NOTE: For patients who have received chemotherapy in the past 6 months, a CD4
count < 250 cells/mcL during chemotherapy is permitted as long as viral loads
were undetectable during this same chemotherapy. They must have an undetectable
viral load and a CD4 count >= 250 cells/mcL within 7 days of
registration/randomization
- For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral
load must be undetectable on suppressive therapy, if indicated
- NOTE: Testing for HIV, hepatitis B or hepatitis C is not required unless
clinically indicated
- Patients with a history of hepatitis C virus (HCV) infection must have been treated
and have undetectable viral load. For patients with HCV infection who are currently on
treatment, they are eligible if they have an undetectable HCV viral load
- Patients with known history or current symptoms of cardiac disease, or history of
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac
function using the New York Heart Association Functional Classification. To be
eligible for this trial, patients should be class 2B or better
- Patient must have a body weight of > 30 kg
- Patient must have life expectancy of >= 12 weeks
- Patient must have creatinine clearance > 15 ml/min as by Crockroft-Gault formula or
24-hour creatinine clearance within 28 days prior to registration/randomization
- NOTE: Patients will be assigned to cisplatin-ineligible and cisplatin-eligible
cohorts based on their creatinine clearance, Eastern Cooperative Oncology Group
(ECOG) performance status, and grade (if any) of peripheral neuropathy and/or
hearing loss in keeping with SOC cisplatin contraindications. Patients that are
cisplatin-eligible will be randomized to either Arm A or Arm B
- Patients that meet any of the following criteria will be registered and
assigned to the cisplatin-ineligible Arm C if they meet other eligibility
criteria:
- Creatinine clearance > 15 ml/min and =< 50 ml/min or hearing loss grade
>= 3, or neuropathy >= 2, or ECOG PS 2
- Patient must have an absolute neutrophil count (ANC) >= 1,000/mcL
obtained =< 14 days prior to registration
- Patient must have ECOG performance status 0-2
- Patients that meet the following criteria will be randomized to the
cisplatin-eligible Arm A or Arm B:
- Patient must have creatinine clearance of > 50ml/min, PS ECOG 0-1,
absence of hearing loss grade >= 3, and/or neuropathy >= 2
- Patient must have an absolute neutrophil count (ANC) >= 1,500/mcL
obtained =< 14 days prior to randomization
- Patient must have left ventricular ejection fraction (LVEF) >= 50% by
(either multigated acquisition scan [MUGA] or 2-D echocardiogram)
obtained within obtained within 28 days prior to randomization
Exclusion Criteria:
- Patients must not have any component of small cell/neuroendocrine carcinoma. Other
variant histologic types are permitted provided the predominant (>= 50%) subtype is
urothelial carcinoma
- Patients must not be pregnant or breast-feeding due to the potential harm to an unborn
fetus and possible risk for adverse events in nursing infants with the treatment
regimens being used. All patients of childbearing potential must have a blood test or
urine study within 14 days prior to registration to rule out pregnancy. A patient of
childbearing potential is defined as any patient, regardless of sexual orientation or
whether they have undergone tubal ligation, who meets the following criteria: 1) has
achieved menarche at some point, 2) has not undergone a hysterectomy or bilateral
oophorectomy; or 3) has not been naturally postmenopausal (amenorrhea following cancer
therapy does not rule out childbearing potential) for at least 24 consecutive months
(i.e., has had menses at any time in the preceding 24 consecutive months)
- Patients of childbearing potential and sexually active patients must not expect to
conceive or father children, either by using accepted and effective method(s) of
contraception or by abstaining from sexual intercourse from the time of registration,
while on study treatment and for at least 6 months after the last dose of protocol
treatment
- Patients must have no evidence of metastatic disease or clinically enlarged regional
lymph nodes (>= 1.5 cm short axis) on imaging required within 28 days prior to
registration (Non-regional findings >=1.5 cm short axis that in the opinion of the
investigator are not concerning for involvement based on radiographic characteristics,
chronicity, avidity on positron emission tomography (PET) or other imaging or other
criteria can be eligible based on investigator discretion).
- NOTE: Patients with elevated alkaline phosphatase, calcium or suspicious bone
pain/tenderness can also undergo baseline bone scans to evaluate for bone
metastasis at the discretion of local provider.
- Patient must meet below criteria for prior/current malignancy history:
- Non-urothelial cancer malignancy history:
- Patient must not have another active (or within two years) second malignancy
other than resected non-melanoma skin cancers, resected in situ breast,
cervical or other in situ carcinoma, and either clinically insignificant per
the investigator (e.g. =< Gleason 3+4) on active surveillance (or watchful
waiting) or previously treated prostate cancer with no rising prostate
specific antigen (PSA) and no plan to treat
- NOTE: Patients with a prior or concurrent malignancy whose natural
history or treatment does not have the potential to interfere with the
safety or efficacy assessment of the investigational regimen are
eligible for this trial. Patients in whom concomitant or prior
bladder/urethra predominant (>= 50%) urothelial carcinoma have been
surgically resected and demonstrated to be only non-invasive cancer (<
cT1N0) are eligible regardless of time elapsed
- Urothelial cancer malignancy history:
- Patient may have a history of resectable urothelial cancer as long as
patients meet one of the following:
- T0, Ta or Tis at any time
- T1-4a N0 and no evidence of disease (NED) for more than 2 years from
the latest therapy [e.g., radical surgery, transurethral resection of
bladder tumor (TURBT), radiation, chemotherapy (neoadjuvant or
adjuvant, or with radiation)]. Prior immune checkpoint inhibitor is not
allowed.
- Patient with history of >= pT4b, N+, and/or M1 is not eligible.
- NOTE: Patients in whom concomitant or prior bladder/urethra predominant
(>= 50%) urothelial carcinoma have been surgically resected and
demonstrated to be only Ta or carcinoma in situ (CIS) (< cT1 N0) are
eligible regardless of time elapsed
- Patient must not have any uncontrolled illness including, but not limited to, ongoing
or active infection including tuberculosis (clinical evaluation that includes clinical
history, physical examination and radiographic findings, and tuberculosis [TB] testing
in line with local practice), symptomatic congestive heart failure (CHF), myocardial
infarction (MI) in last three months, or unstable angina pectoris, significant
uncontrolled cardiac arrhythmia, clinically relevant liver cirrhosis, interstitial
lung disease, or psychiatric illness/social situations that would limit compliance
with study requirements
- Patient must not have received prior radiation therapy to >= 25% of the bone marrow
for other diseases
- Patient must not have received prior systemic anthracycline therapy
- NOTE: Patients who have received prior intravesical chemotherapy at any time for
non-muscle invasive urothelial carcinoma of the bladder are eligible
- Patient must not have either history of or active autoimmune disease requiring
immunosuppressive therapy within 2 years prior to registration/randomization or any
history of inflammatory bowel disease (inflammatory bowel disease [IBD], colitis, or
Crohn's disease), neuromuscular autoimmune condition, immune-related pneumonitis or
interstitial lung disease. Patients with well-controlled hyper/hypothyroidism, celiac
controlled by diet alone, diabetes mellitus type I, vitiligo, alopecia, psoriasis,
eczema, lichen planus, or similar skin/mucosa condition are eligible
- Patient must not be on or have used immunosuppressive medication within 14 days prior
to the first dose of durvalumab. The following are exceptions to this criterion:
- Intranasal, inhaled, intra-auricular, topical steroids, or local steroid
injections (e.g. intra-articular injection
- Systemic corticosteroids at physiologic doses not to exceed 10 mg/day of
prednisone or its equivalent at the time of enrollment
- Steroids as premedications for hypersensitivity reactions (e.g. computed
tomography [CT] scan premedication)
- Patient must not have received live attenuated vaccine within 30 days prior to the
first dose of durvalumab, while on protocol treatment and within 30 days after the
last dose of durvalumab
- Patient must not have had a major surgical procedure within 28 days prior to
registration/randomization
- NOTE: Cystoscopy/ureteroscopy, stent placement or nephrostomy tube is not
considered major surgery
- Patient must not have history of allogenic organ transplantation