Tinzaparin in Treating Patients With Metastatic Kidney Cancer That Cannot Be Removed By Surgery

A Phase I/II Trial of Tinzaparin (Innohep), a Low Molecular Weight Heparin (LMWH) for Treatment of Advanced Renal Cell Carcinoma

RATIONALE: Tinzaparin may stop the growth of kidney cancer by blocking blood flow to the tumor.

PURPOSE: This phase I/II trial is studying the side effects of tinzaparin and to see how well it works in treating patients with metastatic kidney cancer that cannot be removed by surgery.

OBJECTIVES:

Primary

• Determine the effect of tinzaparin sodium on fibrin formation (prothrombin fragment F1.2), thrombin generation (thrombin-antithrombin complexes), and fibrinolysis (D-Dimer) from baseline to 2 weeks and at nadir or disease progression in patients with unresectable metastatic renal cell carcinoma (RCC).

Secondary

• Determine the effect of tinzaparin sodium treatment on circulating angiogenesis markers, including vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF).
• Determine the proportion of patients developing venous thromboembolism and hemorrhage.
• Determine the tolerability of tinzaparin sodium treatment for up to 6 months in these patients.
• Establish the feasibility of undertaking a multicenter renal cell carcinoma trial with specialized coagulation test collection, shipping, and processing.
• Obtain more accurate and specific mean, median, and variability in biomarker data in advanced RCC patients treated with tinzaparin sodium for purposes of planning larger future trials.
• Estimate the progression-free survival at 4 months in patients treated with tinzaparin sodium.
• Correlate progression-free survival with changes in markers of coagulation activation or angiogenesis.
• Correlate the anticoagulant activity of tinzaparin sodium (anti-Xa activity) with change in coagulation markers, angiogenesis markers, and progression-free survival.

OUTLINE: This is an open-label, pilot, multicenter study.

Patients receive a treatment dose of tinzaparin sodium subcutaneously (SC) once daily for 14 days followed by a prophylactic dose of tinzaparin sodium SC once daily for up to 6 months in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed periodically.

PROJECTED ACCRUAL: A total of 35 patients will be accrued for this study.

DISEASE CHARACTERISTICS:

• Histologically or cytologically confirmed renal cell carcinoma of clear cell histology

  • Tumors of mixed histology eligible if ≥ 50% of tumor has clear cell histology
  • No nonclear cell histologies, collecting duct tumors, oncocytomas, or transitional cell tumors

• Metastatic and unresectable disease that is clinically extending beyond the regional lymph nodes (histological confirmation not required)

  • Patients who are inoperable for their primary tumor representing the sole site of disease are ineligible

• Measurable disease, defined as ≥ 1 unidimensionally measurable lesion ≥ 2 cm by conventional techniques OR ≥ 1 cm by spiral CT scan

• No known brain metastases

PATIENT CHARACTERISTICS:

• Expected survival > 2 months
• CALGB (ECOG/ZUBROD) performance status (PS) 0-2 OR Karnofsky PS 60-100%
• Hemoglobin ≥ 10 g/dL
• Platelet count ≥ 100,000/mm^3
• Bilirubin ≤ 1.5 times upper limit of normal (ULN)
• AST/ALT ≤ 1.5 times ULN
• Creatinine ≤ 1.5 times ULN
• INR ≤ 1.5 times control value
• PTT < 1.5 times control value
• Negative pregnancy test
• Fertile patients must use effective contraception
• Patients must be able to receive subcutaneous injections at home
• No other primary malignancy in the past 5 years other than basal cell carcinoma or carcinoma in situ of the cervix that has been curatively treated and is associated with a less than 30% risk of relapse in the next 5 years
• No signs or symptoms of bleeding within 4 the past weeks
• No known bleeding diathesis or high risk for bleeding due to any condition, including trauma within the past 4 weeks, active current bleeding, or hemorrhagic stroke or intraocular bleeding within the past 6 months
• No active thromboembolism highly likely to require anticoagulation during the study period
• No known or suspected history of type II heparin-induced thrombocytopenia
• No allergy or hypersensitivity to heparin, tinzaparin sodium, pork products, sulfite, or benzyl alcohol
• No uncontrolled severe intercurrent illness, including 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
• No uncontrolled arterial hypertension, history of gastrointestinal ulceration, and/or bleeding in the past 4 weeks
• No diabetic retinopathy or history of retinal hemorrhage
• Not pregnant or nursing
• HIV-positive patients are allowed

PRIOR CONCURRENT THERAPY:

• No treatment with anticoagulation lasting > 1 month in the past 6 months

• No anticoagulation, including treatment with a low molecular weight heparin, at any time within the past month

• More than 4 weeks since prior surgery, radiation therapy, immunotherapy, or chemotherapy

• Recovered from prior therapy

• No other concurrent investigational agents

• No other concurrent anticoagulation therapy, including oral anticoagulants, thrombolytic agents, or any form of heparin

  • Concurrent antiplatelet agents allowed

• No spinal or epidural puncture, anesthesia, or post-operative indwelling epidural catheters within the past 48 hours

• No other concurrent anticancer agents or therapies

• No concurrent sex hormones except for postmenopausal hormone replacement

• No concurrent chemotherapy or immunotherapy

• No concurrent palliative radiotherapy

• Concurrent urgent use of corticosteroids allowed