Inclusion Criteria:
- Have histologically confirmed WHO grade II or III meningioma that is progressive or
recurrent. Metastatic meningiomas are allowed. Participants must have failed maximal
safe resection and radiation therapy.
- Prior therapy:
- There is no limit on the number of prior surgeries, radiation therapy, radiosurgery
treatments or systemically administered therapeutic agents.
- Patients may have been treated with standard external beam radiation or
radiosurgery in any combination, however, an interval of ≥ 12 weeks (84 days)
must have elapsed from the completion of the radiation therapy to start of study
therapy unless there is histopathologic confirmation of recurrent tumor or there
is new enhancing tumor outside the radiation field (beyond the high dose region
or the 80% isodose line).
- In addition, there must be subsequent evidence of tumor progression after
completion of radiation therapy;
- An interval of ≥ 28 days and full recovery (no ongoing safety issues) from
surgical resection
- An interval of ≥ 7 days from stereotactic biopsy;
- For prior systemic agents, participants must be at least 4 weeks (or 5 half-lives,
whichever is shorter) from other prior cytotoxic chemotherapy (6 weeks from
nitrosoureas) or biologic therapies.
- Participants must have recovered to grade ≤ 1 or pretreatment baseline from clinically
significant adverse events related to prior therapy (exclusions include but are not
limited to alopecia, laboratory values listed per inclusion criteria and lymphopenia);
- Be 18 years of age on day of signing informed consent.
- Have a Karnofsky performance status (KPS) ≥ 70 (Appendix A).
- Participants must demonstrate adequate organ and marrow function as defined below (all
screening labs to be performed within 14 days of treatment initiation):
- White blood cell (WBC) ≥ 2000/mm3
- Absolute neutrophil count (ANC) ≥ 1,000/mm3
- Platelet count ≥ 100,000/mm3
- Hemoglobin ≥ 9 gm/dl
- AST(SGOT)/ALT(SGPT) ≤ 3 x laboratory upper limit of normal (ULN)
- Serum creatinine ≤ 1.5 X ULN OR
- creatinine clearance (meas or calc) ≥ 60 mL/min for participants with creatinine
levels > 1.5 X ULN
- (GFR can be used in place of creatinine or creatinine clearance)
- Total serum bilirubin ≤ 1.5 X ULN
- (except participants with Gilbert's Syndrome, who can have a total bili < 5 X
ULN)
- Resting baseline oxygen saturation ≥ 92% at rest by pulse oximetry
- MRI (or CT if MRI contraindicated) within 14 days prior to start of study drug.
Corticosteroid dose must be stable or decreasing for at least 5 days prior to the
scan. If steroids are added or the steroid dose is increased between the date of the
screening MRI or CT scan and the start of treatment, a new baseline MRI or CT is
required.
- Ability to understand and the willingness to comply with scheduled visits, treatment
schedule, laboratory testing, and other requirements of the study, including disease
assessment by MRI (or CT), as confirmed by signing a written informed consent
document.
- For cohort 2, patients must be a candidate for external beam radiotherapy including
either conventional fractionated conformal dosing or stereotactic radiosurgical boost
dosing (participants may enroll if they are receiving radiotherapy or have completed
it within 8 weeks of starting immunotherapy);
- For cohort 2 patients who are undergoing fractionated conformal re-irradiation to a
tumor site that has been previously irradiated, an interval of at least 6 months must
have passed since they completed their prior irradiation to be eligible unless the
current course of radiation is targeting a new area of tumor growth outside the 80%
isodose line of the original radiation field as determined by the treating
investigator.
- The effects of nivolumab on the developing human fetus are unknown. For this reason:
- Women of childbearing potential (WOCPB; defined in Section 3.4) must have a negative
serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG)
within 24 hours of starting study therapy;
- Women must not be breastfeeding;
- WOCPB must agree to follow instructions for method(s) of contraception from the time
of enrollment for the duration of treatment with study therapy plus 5 months after the
last dose of Nivolumab.
- Should a woman become pregnant or suspect she is pregnant while she or her partner is
participating in this study, she should inform her treating physician immediately.
- Men who are sexually active with WOCBP must agree to follow instructions for method(s)
of contraception for the duration of treatment with study drug plus 7 months after the
last dose of Nivolumab.
- Investigators shall counsel WOCBP and male subjects who are sexually active with WOCBP
on the importance of pregnancy prevention and the implications of an unexpected
pregnancy Investigators shall advise WOCBP and male subjects who are sexually active
with WOCBP on the use of highly effective methods of contraception. Highly effective
methods of contraception have a failure rate of < 1% per year when used consistently
and correctly.
- At a minimum, subjects must agree to the use of two methods of contraception, with one
method being highly effective and the other method being either highly effective or
less effective as listed below:
- HIGHLY EFFECTIVE METHODS OF CONTRACEPTION
- Male condoms with spermicide
- Hormonal methods of contraception including combined oral contraceptive
pills, vaginal ring, injectables, implants, and intrauterine devices (IUDs)
such as Mirena by WOCBP subjects or male subject's WOCBP partner. Female
partners of male subjects participating in the study may use hormone based
contraceptives as one of the acceptable methods of contraception since they
will not be receiving study drug
- Progestogen only hormonal contraception associated with inhibition of
ovulation
- Intrauterine hormone-releasing system (IUS)
- Nonhormonal IUDs, such as ParaGard
- Tubal ligation
- Vasectomy
- Complete Abstinence - Complete abstinence is defined as complete avoidance
of heterosexual intercourse and is an acceptable form of contraception for
all study drugs. Subjects who choose complete abstinence are not required to
use a second method of contraception, but female subjects must continue to
have pregnancy tests. Acceptable alternate methods of highly effective
contraception must be discussed in the event that the subject chooses to
forego complete abstinence.
- LESS EFFECTIVE METHODS OF CONTRACEPTION
- Diaphragm with spermicide
- Cervical cap with spermicide
- Vaginal sponge
- Male Condom without spermicide
- Progestin only pills by WOCBP subjects or male subject's WOCBP partner
- Female Condom - A male and female condom must not be used together
- UNACCEPTABLE METHODS OF CONTRACEPTION
- Periodic abstinence (calendar, symptothermal, post-ovulation methods)
- Withdrawal (coitus interruptus)
- Spermicide only
- Lactation amenorrhea method (LAM)
- NOTE: Azoospermic males and WOCBP who are continuously not heterosexually active are
exempt from contraceptive requirements. However, WOCBP participants must still undergo
pregnancy testing as described.
Exclusion Criteria:
- Current or planned participation in a study of an investigational agent or using an
investigational device.
- Tumors that are primarily localized to the brainstem or spinal cord;
- Evidence of intratumoral or peritumoral hemorrhage on baseline MRI scan other than
those that are grade ≤ 1 and either post-operative or stable on at least 2 consecutive
MRI scans;
- Prior Therapy:
- Prior treatment with systemic immunosuppressive treatments, aside from systemic
dexamethasone therapy for cerebral edema, such as methotrexate, chloroquine,
azathioprine, etc. within 3 months of start of study therapy;
- Prior treatment with interstitial brachytherapy within 6 months of start of study
therapy;
- All patients: Previous treatment with PD-1 or PD-L1 directed therapy;
- Cohort 2 patients: Previous treatment with CTLA-4 directed therapy;
- Surgical procedure (including open biopsy, surgical resection, wound revision, or any
other major surgery involving entry into a body cavity) or significant traumatic
injury within 28 days prior to first study treatment, or anticipation of need for
major surgical procedure during the course of the study;
- Minor surgical procedure (eg, stereotactic biopsy within 7 days of first study
treatment; placement of a vascular access device within 2 days of first study
treatment);
- Other Meds:
- Participants who are receiving any other investigational agents.
- Immunosuppressive medications / steroids:
- Subject must not require high dose systemic corticosteroids defined as
dexamethasone > 4 mg/day or bioequivalent for at least 3 consecutive days within
2 weeks prior to Day 1of study therapy;
- Inhaled or topical steroids and adrenal replacement doses > 10 mg daily
prednisone equivalents are permitted in the absence of active autoimmune disease.
- Subjects are permitted to use topical, ocular, intra-articular, intranasal, and
inhalational corticosteroids (with minimal systemic absorption).
- Physiologic replacement doses of systemic corticosteroids are permitted, even if
> 10 mg/day prednisone equivalents.
- A brief course of corticosteroids for prophylaxis (eg, contrast dye allergy) or
for treatment of non-autoimmune conditions (eg, delayed-type hypersensitivity
reaction caused by contact allergen) is permitted.
- Has received a live vaccine within 30 days prior to the first dose of study drug;
seasonal influenza vaccination is permitted excluding the nasal spray formulation;
- No concurrent treatment on another clinical trial. Supportive care trials or non-
treatment trials, e.g. quality of life, are allowed;
- Concomitant Medical Illnesses: Uncontrolled intercurrent illness, including-but not
limited to:
- Known additional malignancy that is progressing or requires active treatment within 3
years of start of study drug. Exceptions include basal cell carcinoma of the skin,
squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone
potentially curative therapy;
- Has evidence of interstitial lung disease or active, non-infectious pneumonitis;
- Any serious or uncontrolled medical disorder that, in the opinion of the investigator,
may increase the risk associated with study participation or study drug
administration, impair the ability of the subject to receive protocol therapy, or
interfere with the interpretation of study results examples include but are not
limited to symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia or psychiatric illness/social situations that would limit compliance with
study requirements;
- Has an active autoimmune disease requiring systemic treatment within the past 3 months
or a documented history of clinically severe autoimmune disease, or a syndrome that
requires systemic steroids or immunosuppressive agents. Subjects with vitiligo, type 1
diabetes mellitus, residual hypothyroidism due to autoimmune condition requiring
hormone replacement, psoriasis not requiring systemic treatment, conditions not
expected to recur in the absence of an external trigger or resolved childhood
asthma/atopy would be exceptions to this rule. Subjects that require intermittent use
of bronchodilators or local steroid injections would not be excluded from the study.
Subjects with hypothyroidism stable on hormone replacement or Sjorgen's syndrome will
not be excluded from the study;
- Has an active infection requiring intravenous therapy;
- Positive test for hepatitis B virus surface antigen (HBV sAg) or detectable hepatitis
C virus ribonucleic acid (HCV RNA) indicating acute or chronic infection
- Medical History:
- History of intracranial abscess within 6 months prior to start of study therapy;
- Known history of testing positive for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome (AIDS);
- NOTE: HIV-positive participants on combination antiretroviral therapy are ineligible
because of the potential for pharmacokinetic interactions with Nivolumab. Appropriate
studies will be undertaken in participants receiving combination antiretroviral
therapy when indicated.
- History of allergy to study drug components
- History of severe hypersensitivity reaction to any monoclonal antibody;
- Prisoners or participants who are involuntarily incarcerated;
- Pregnant women are excluded from this study because Nivolumab is an agent with the
potential for teratogenic or abortifacient effects. Because there is an unknown but
potential risk for adverse events in nursing infants secondary to treatment of the
mother with Nivolumab, breastfeeding should be discontinued if the mother is treated
Nivolumab.
