Intervention: Lenvatinib
Trial phase: Phase 2
ATC code: L01EX08 | L01XE29
SMILES: COc1cc2nccc(Oc3ccc(NC(=O)NC4CC4)c(Cl)c3)c2cc1C(N)=O
Sex: All
Age groups: Adult | Older Adult
Healthy volunteers: No
Participants at risk: 3
Group description: Patients receive lenvatinib PO once daily on days 1-28. Courses repeat every 28 days for up to 5 years in the absence of disease progression or unacceptable toxicity. Laboratory Biomarker Analysis: Correlative studies Lenvatinib: Given PO Quality-of-Life Assessment: Ancillary studies
Eligibility criteria:
Inclusion Criteria:

Histologically or cytologically confirmed malignant secretory or non-secretory pheochromocytoma or paraganglioma that is unresectable and deemed inappropriate for alternative local regional therapeutic approaches
Measurable disease
Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, or 2
Life expectancy > 24 weeks
Absolute neutrophil count (ANC) >= 1500/mm^3
White blood cell (WBC) count >= 3,000/mm^3
Platelet count >= 100,000/mm^3
Hemoglobin >= 9.0 g/dL (5.6 mmol/L); NOTE: transfusions are not allowed =< 7 days prior to registration
Total bilirubin =< 1.5 X upper limit of normal (ULN) (or total bilirubin =< 3.0 X ULN with direct bilirubin =< 1.5 X ULN in patients with well-documented Gilbert's Syndrome)
Aspartate transaminase (AST/serum glutamic oxaloacetic transaminase [SGOT]) =< 2.5 X ULN
Creatinine =< 1.5 x ULN
Urine protein/creatinine ratio =< 1 OR 24-hour urine protein < 1.5 gram
Negative pregnancy test done =< 7 days prior to registration, for women of childbearing potential only
Blood pressure (BP) < 150 mmHg (systolic) and < 90 mmHg (diastolic); initiation or adjustment of BP medication is permitted prior to registration provided that the average of three BP readings at a visit prior to registration is < 150/90 mmHg; NOTE: all patients with secretory pheochromocytoma or paraganglioma are REQUIRED to: 1) be evaluated in consultation by a hypertension specialist with specific experience in the management of hypertension in the setting of catecholamine-secreting tumors (usually an endocrinologist, nephrologist, or a cardiologist), and in the setting of hormone-associated hypertension) receive alpha- and beta-adrenergic blockade for at least 7-14 days prior to initiation of lenvatinib; the hypertension specialist of record for each patient should be committed to closely following the patient during the clinical study with evaluation by said specialist required at cycle 1 and 2 and thereafter on an as needed basis
Provide written informed consent
Willing to return to enrolling institution for follow-up (during the active monitoring phase of the study)
Ability to complete questionnaire(s) by themselves or with assistance

Exclusion Criteria:

Any of the following:

Pregnant women
Nursing women
Men or women of childbearing potential who are unwilling to employ adequate contraception
Chemotherapy/systemic therapy, radiotherapy, immunotherapy or surgery =< 21 days prior to registration or kinase inhibitor therapy =< 14 days prior to registration or failure to recover from toxicities (to grade 1 or below) from treatment; NOTE: concurrent therapy with octreotide is allowed providing that tumor progression on this therapy has been demonstrated; concurrent therapy with bisphosphonates (e.g. zoledronic acid) or denosumab is also allowed; NOTE: an unlimited number of prior chemotherapeutic or biologic therapies for malignant pheochromocytoma or paraganglioma is permitted; this includes prior anti-angiogenesis therapies such as tyrosine kinase inhibitors
Active or 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
Receiving any other investigational agent
Current use of warfarin for any reason; NOTE: if patient can be safely transitioned to another anticoagulant, they may be eligible provided other criteria are satisfied

Any of the following:

Correct QT (QTc) prolongation (defined as a QTc interval >= 500 msecs)
Left ventricular ejection fraction (LVEF) < institutional lower limits of normal (LLN)
Frequent ventricular ectopy
Evidence of ongoing myocardial ischemia
Receiving any medications or substances with risk of torsades de pointes; NOTE: medications or substances with known risk of torsades de pointes are prohibited; consult pharmacist for review if needed
Known active and/or untreated brain metastases
Known severe allergic or other prohibitive reactions to other tyrosine kinase inhibitors (TKI)
Prior treatment with lenvatinib

Any of the following conditions:

Active peptic ulcer disease
Inflammatory bowel disease (e.g., ulcerative colitis, Crohn's disease) or other gastrointestinal conditions which increase the risk of perforation
History of new abdominal fistula, gastrointestinal perforation or intra-abdominal abscess =< 84 days prior to registration; NOTE: enrollment of patients with chronic/canalized fistulous tracts (present for > 84 days) is allowed
Serious or non-healing wound, ulcer, or bone fracture
History of familial QTc prolongation syndrome

Any of the following conditions =< 6 months prior to registration:

Cerebrovascular accident (CVA) or transient ischemic attack (TIA)
Serious or unstable cardiac arrhythmia
Admission for unstable angina or myocardial infarction
Cardiac angioplasty or stenting
Coronary artery bypass graft surgery
Pulmonary embolism, untreated deep venous thrombosis (DVT) or DVT which has been treated with therapeutic anticoagulation =< 30 days
Arterial thrombosis
Symptomatic peripheral vascular disease
Other active malignancy =< 2 years prior to registration; EXCEPTIONS: non-melanotic skin cancer or carcinoma-in-situ of the cervix; NOTE: if there is a history of prior malignancy, they must not be receiving other specific treatment for their cancer; NOTE: adjuvant anti-estrogen/hormonal therapy for breast cancer is allowed