Bevacizumab (Avastin) combined with erlotinib (Tarceva) showed activity in patients with hereditary leiomyomatosis and renal cell cancer (HLRCC)-associated or sporadic papillary renal cell carcinoma (RCC), a phase II trial suggested.

Among 43 patients with HLRCC-associated papillary RCC, a confirmed response was achieved in 72%, while median progression-free survival (PFS) was 21.1 months and median overall survival (OS) was 44.6 months, reported Ramaprasad Srinivasan, MD, PhD, of the National Cancer Institute, and colleagues.

The combination was about half as effective among the 40 patients with sporadic papillary RCC, with a confirmed response in 35%. Median PFS was 8.9 months and median OS was 18.2 months.

While the management of advanced clear-cell RCC has been significantly improved in the past 15 years, “few effective options exist for other variants of renal-cell carcinoma, which is exemplified by HLRCC-associated papillary renal-cell carcinoma,” wrote Srinivasan and colleagues in the New England Journal of Medicine.

“This variant is typically associated with an aggressive clinical course; most patients die from progressive disease, with a median overall survival of 16 to 21 months in most retrospective series,” they added. “This study showed that the combination of bevacizumab and erlotinib was effective in these patients, and durable responses were seen in a subset of patients with sporadic papillary renal-cell carcinoma.”

HLRCC is an autosomal dominant inherited disorder that leaves patients predisposed to developing an aggressive form of papillary RCC. Srinivasan and colleagues explained that 12% to 43% of patients with HLRCC will go on to have kidney cancer during their lifetime, and there is currently no effective therapy for these patients.

This open-label trial evaluated bevacizumab (10 mg/kg of body weight every 2 weeks) and erlotinib (150 mg once daily) in 83 patients from May 2010 to May 2019. Median age was 43 years among patients with HLRCC-associated papillary RCC, 70% were men, and 77% were white. For those with sporadic papillary RCC, median age was 55.5 years, 65% were men, and 88% were white.

At the time of data cutoff, 28 patients with HLRCC-associated papillary RCC had died, while two patients remained in the study, one of whom continued to receive therapy. Of the patients with sporadic papillary RCC, 36 had died, and one patient remained in the study and continued to receive therapy.

In a post-hoc subgroup analysis, OS was worse among patients with any previous treatment (HR 5.6, 95% CI 2.3-13.5) or previous use of VEGF pathway inhibitors (HR 5.0, 95% CI 2.0-12.2). In a multivariable analysis, previous treatment was associated with worse OS (HR 5.2, 95% CI 2.1-13.1).

Srinivasan and colleagues reported that the combination’s safety profile was similar to that seen in previous studies.

A dose reduction in erlotinib was needed in 24 patients, with one patient permanently discontinuing the agent due to grade 3 cutaneous toxic effects.

Dose reductions in bevacizumab were not allowed, and three patients permanently discontinued the drug (two had a myocardial infarction and one had a bronchopulmonary hemorrhage).

Every patient in the study had at least one treatment-related adverse event (TRAE) of any grade, and about half had a TRAE of grade ≥3.

The most common TRAEs of any grade were acneiform rash (93%), diarrhea (89%), proteinuria (78%), and dry skin (64%). Hypertension (34%) was the most common TRAE of grade 3 or higher, followed by proteinuria (17%), diarrhea (5%), and acneiform rash (5%).

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