Lenvatinib and Pembrolizumab in Differentiated Thyroid Cancers (DTC)
Condition: Columnar Cell Variant Thyroid Gland Papillary Carcinoma; Follicular Variant Thyroid Gland Papillary Carcinoma; Metastatic Thyroid Gland Follicular Carcinoma; Metastatic Thyroid Gland Papillary Carcinoma; Poorly Differentiated Thyroid Gland Carcinoma; Recurrent Differentiated Thyroid Gland Carcinoma; Recurrent Thyroid Gland Follicular Carcinoma; Recurrent Thyroid Gland Papillary Carcinoma; Stage III Differentiated Thyroid Gland Carcinoma AJCC v7; Stage III Thyroid Gland Follicular Carcinoma AJCC v7; Stage III Thyroid Gland Papillary Carcinoma AJCC v7; Stage IV Thyroid Gland Follicular Carcinoma AJCC v7; Stage IV Thyroid Gland Papillary Carcinoma AJCC v7; Stage IVA Differentiated Thyroid Gland Carcinoma AJCC v7; Stage IVA Thyroid Gland Follicular Carcinoma AJCC v7; Stage IVA Thyroid Gland Papillary Carcinoma AJCC v7; Stage IVB Differentiated Thyroid Gland Carcinoma AJCC v7; Stage IVB Thyroid Gland Follicular Carcinoma AJCC v7; Stage IVB Thyroid Gland Papillary Carcinoma AJCC v7; Stage IVC Differentiated Thyroid Gland Carcinoma AJCC v7; Stage IVC Thyroid Gland Follicular Carcinoma AJCC v7; Stage IVC Thyroid Gland Papillary Carcinoma AJCC v7; Tall Cell Variant Thyroid Gland Papillary Carcinoma; Thyroid Gland Hurthle Cell Carcinoma; Unresectable Differentiated Thyroid Gland Carcinoma; Unresectable Thyroid Gland Carcinoma
MeSH terms: Carcinoma; Thyroid Neoplasms; Carcinoma, Papillary; Thyroid Cancer, Papillary; Adenocarcinoma, Follicular; Thyroid Diseases; Recurrence
Intervention: Laboratory Biomarker Analysis; Lenvatinib; Lenvatinib Mesylate; Pembrolizumab
Intervention description: Correlative studies; Given PO; Given PO; Given IV
Intervention MeSH terms: Pembrolizumab; Lenvatinib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 57.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No

Summary:

      This phase II trial studies how well pembrolizumab and lenvatinib work in treating patients
      with differentiated thyroid cancer that has spread to other places in the body or has come
      back and cannot be removed by surgery. Immunotherapy with monoclonal antibodies, such as
      pembrolizumab, may help the body's immune system attack the cancer, and may interfere with
      the ability of tumor cells to grow and spread.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Locally recurrent and unresectable and/or distant metastatic differentiated thyroid
             cancer (DTC), histologically or cytologically confirmed; the diagnosis of DTC includes
             the following subtypes: papillary thyroid cancer (PTC) (including but not limited to
             variants such as follicular variant, tall cell, columnar cell, Hurthle cell variant of
             papillary carcinoma, and poorly differentiated), follicular thyroid cancer (FTC),
             including insular variant, Hurthle cell carcinoma and poorly differentiated thyroid
             cancer

          -  Measurable disease meeting the following criteria:

               -  At least 1 lesion of >= 1.0 cm in the longest diameter for a non-lymph node or >=
                  1.5 cm in the short-axis diameter for a lymph node which is serially measurable
                  according to RECIST 1.1 using computerized tomography/magnetic resonance imaging
                  (CT/MRI); if there is only one target lesion and it is a non-lymph node, it
                  should have a longest diameter of >= 1.5 cm

               -  Lesions that have had external beam radiotherapy (EBRT) or loco-regional
                  therapies such as radiofrequency (RF) ablation must show evidence of progressive
                  disease based on RECIST 1.1 to be deemed a target lesion

          -  For cohort 1 only: evidence of disease progression =< 14 months prior to registration
             according to RECIST 1.1, as confirmed by the site study principal investigator (PI)

          -  For cohort 2 only: progressive disease (PD) on lenvatinib per RECIST 1.1 =< 60 days
             prior to registration, as confirmed by the site study PI; patients need to have
             documented imaging and measurement of RECIST target lesions within 30 days of starting
             pembrolizumab

          -  Radioiodine (RAI)-resistant disease as defined by one or more of the following
             criteria:

               -  One or more measurable lesions that do not demonstrate RAI uptake

               -  One or more measurable lesions progressive by RECIST 1.1 =< 14 months of prior
                  RAI therapy

               -  One or more measurable lesions present after cumulative RAI dose of >= 600 mCi

               -  One or more measurable lesions that are fludeoxyglucose F-18 (FDG)-avid (> 5
                  standardized uptake value [SUV]), if positron emission tomography (PET)/CT scan
                  performed; these lesions may also be RAI-avid

          -  Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1

          -  Absolute neutrophil count (ANC) >= 1,500 /mcL (obtained =< 30 days prior to
             registration)

          -  Platelets >= 100,000 / mcL (obtained =< 30 days prior to registration)

          -  Hemoglobin >= 9 g/dL or >= 5.6 mmol/L without transfusion or erythropoietin dependency
             (=< 7 days prior to registration) (obtained =< 30 days prior to registration)

          -  Serum creatinine =< 1.5 X upper limit of normal (ULN) OR measured or calculated
             creatinine clearance (glomerular filtration rate [GFR] can also be used in place of
             creatinine or creatinine clearance [CrCl]) >= 60 mL/min for subject with creatinine
             levels > 1.5 X institutional ULN (obtained =< 30 days prior to registration)

          -  Serum total bilirubin =< 1.5 X ULN OR direct bilirubin =< ULN for subjects with total
             bilirubin levels > 1.5 ULN (obtained =< 30 days prior to registration)

          -  Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) and
             alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 X
             ULN OR =< 5 X ULN for subjects with liver metastases (obtained =< 30 days prior to
             registration)

          -  Albumin >= 2.5 mg/dL (obtained =< 30 days prior to registration)

          -  International normalized ratio (INR) or prothrombin time (PT) =< 1.5 X ULN unless
             subject is receiving anticoagulant therapy as long as PT or partial thromboplastin
             time (PTT) is within therapeutic range of intended use of anticoagulants (obtained =<
             30 days prior to registration)

          -  Activated partial thromboplastin time (aPTT) =< 1.5 X ULN unless subject is receiving
             anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use
             of anticoagulants (obtained =< 30 days prior to registration)

          -  Adequately controlled blood pressure with or without antihypertensive medications
             defined as blood pressure (BP) < 150/90 mmHg at screening

          -  Negative pregnancy test done =< 7 days prior to registration, for women of
             childbearing potential only

          -  Ability to complete patient medication and blood pressure diaries by themselves or
             with assistance

          -  Willing and able to provide informed written consent

          -  Willing to return to enrolling institution for follow-up (during the active monitoring
             phase of the study)

               -  Note: during the active monitoring phase of a study (i.e., active treatment and
                  observation), participants must be willing to return to the consenting
                  institution for follow-up

          -  Willing to provide tissue and blood samples for correlative research purposes

        Exclusion Criteria:

          -  Cohort 1 only: prior treatment with previous VEGFR active multikinase inhibitor

          -  Cohort 2 only: discontinued lenvatinib due to toxicity

          -  Pregnant or breastfeeding, or expecting to conceive or father children within the
             projected duration of the trial, starting with the pre-screening or screening visit
             through 120 days after the last dose of trial treatment

          -  Female subjects of childbearing potential: unwilling or unable to use 2 methods of
             birth control or be surgically sterile, or abstain from heterosexual activity for the
             course of the study through 120 days after the last dose of study medication; NOTE:
             subjects of childbearing potential are those who have not been surgically sterilized
             or have not been free from menses for > 1 year

          -  Male subjects: unwilling or unable to use an adequate method of contraception starting
             with the first dose of study therapy through 120 days after the last dose of study
             therapy

          -  Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment
             of the investigator, would make the patient inappropriate for entry into this study or
             interfere significantly with the proper assessment of safety and toxicity of the
             prescribed regimens

          -  Immunocompromised patients and patients known to be human immunodeficiency virus (HIV)
             positive (HIV 1/2 antibodies) and currently receiving antiretroviral therapy

          -  Currently participating and receiving study therapy (except lenvatinib for patients in
             cohort 2) or has participated in a study of an investigational agent and received
             study therapy within 4 weeks prior to registration

          -  Diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other
             form of immunosuppressive therapy =< 7 days prior to the first dose of trial treatment

          -  Known history of active TB (Bacillus tuberculosis)

          -  Hypersensitivity to pembrolizumab or any of its excipients

          -  Prior anti-cancer monoclonal antibody (mAb) =< 4 weeks prior to registration or who
             has not recovered (i.e., =< grade 1 or at baseline) from adverse events due to agents
             administered >= 4 weeks prior to registration

          -  Prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2
             weeks prior to study day 1 (except lenvatinib for patients in cohort 2) or who has not
             recovered (i.e., =< grade 1 or at baseline) from adverse events due to a previously
             administered agent

               -  NOTE:

                    -  Subjects with =< grade 2 neuropathy are an exception to this criterion and
                       may qualify for the study

                    -  If subject received major surgery, they must have recovered adequately from
                       the toxicity and/or complications from the intervention prior to
                       registration, as deemed by treating investigator or site PI

          -  Known additional malignancy that is progressing or requires active treatment;
             exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
             skin that has undergone potentially curative therapy or in situ cervical cancer

          -  Known active central nervous system (CNS) metastases and/or carcinomatous meningitis;
             NOTE: subjects with previously treated brain metastases may participate provided they
             are stable (without evidence of progression by imaging for at least four weeks prior
             to the first dose of trial treatment and any neurologic symptoms have returned to
             baseline), have no evidence of new or enlarging brain metastases, and are not using
             steroids for >= 7 days prior to trial treatment; this exception does not include
             carcinomatous meningitis which is excluded regardless of clinical stability

          -  Active autoimmune disease that has required systemic treatment in the past 2 years
             (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive
             drugs); NOTE: replacement therapy (e.g., thyroxine, insulin, or physiologic
             corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is
             not considered a form of systemic treatment

          -  Known history of, or any evidence of active, non-infectious pneumonitis that required
             steroids

          -  Active infection requiring systemic therapy

          -  History or current evidence of any condition, therapy, or laboratory abnormality that
             might confound the results of the trial, interfere with the subject's participation
             for the full duration of the trial, or is not in the best interest of the subject to
             participate, in the opinion of the treating investigator

          -  Known psychiatric or substance abuse disorders that would interfere with cooperation
             with the requirements of the trial

          -  Received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent

          -  Known active hepatitis B (e.g., hepatitis B surface antigen [HBsAg] reactive) or
             hepatitis C (e.g., hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] is
             detected)

          -  Received a live vaccine =< 30 days of planned start of study therapy; NOTE: seasonal
             influenza vaccines for injection are generally inactivated flu vaccines and are
             allowed; however intranasal influenza vaccines (e.g., Flu-Mist) are live attenuated
             vaccines, and are not allowed

          -  Proteinuria > 1+ on dipstick urinalysis; patients with > 1+ proteinuria on dipstick
             urinalysis will undergo 24-hour urine collection for quantitative assessment; NOTE:
             patients with > 1 g/24 hours will be ineligible

          -  Clinically significant gastrointestinal malabsorption syndrome

          -  New York Heart Association congestive heart failure of grade II or above, unstable
             angina, myocardial infarction within the past 6 months, or serious cardiac arrhythmia
             associated with significant cardiovascular impairment within the past 6 months;
             ejection fraction (EF) by multi-gated acquisition (MUGA) or echo should not be less
             than the institutional lower limit of normal

          -  Corrected QT (QTc) prolongation > 480 msec, as calculated by either the Bazett or
             Fridericia formula, as per institutional standard

          -  Active hemoptysis (bright red blood > 1 teaspoon on more than one occasion) =< 3 weeks
             prior to registration

          -  Cohort 2 only: more than one prior treatment with VEGFR active multikinase inhibitor
             prior to original start of lenvatinib