Description:
This phase II trial studies how well pembrolizumab and palliative radiation therapy works in
treating patients with esophagus, stomach, or gastroesophageal junction cancer that has
spread to other parts of the body. Monoclonal antibodies, such as pembrolizumab, may
interfere with the ability of tumor cells to grow and spread. Palliative radiation therapy,
such as external beam radiation therapy, uses high energy beams to treat symptoms that are
caused by tumors. Giving pembrolizumab together with palliative radiation therapy may work
better in treating patients with esophagus, stomach, or gastroesophageal junction cancer that
has spread to other parts of the body.
Title
- Brief Title: Pembrolizumab and Palliative Radiation Therapy in Treating Patients With Metastatic Esophagus, Stomach, or Gastroesophageal Junction Cancer
- Official Title: Combining Pembrolizumab and Palliative Radiotherapy in Gastroesophageal Cancer to Enhance Anti-Tumor T Cell Response and Augment the Abscopal Effect
Clinical Trial IDs
- ORG STUDY ID:
16099
- SECONDARY ID:
NCI-2016-00686
- SECONDARY ID:
16099
- NCT ID:
NCT02830594
Conditions
- Gastric Adenocarcinoma
- Gastric Squamous Cell Carcinoma
- Gastroesophageal Junction Adenocarcinoma
- Metastatic Malignant Neoplasm in the Stomach
- Stage IV Esophageal Adenocarcinoma AJCC v7
- Stage IV Esophageal Squamous Cell Carcinoma AJCC v7
Interventions
Drug | Synonyms | Arms |
---|
Pembrolizumab | Keytruda, Lambrolizumab, MK-3475, SCH 900475 | Treatment (pembrolizumab, RT) |
Purpose
This phase II trial studies how well pembrolizumab and palliative radiation therapy works in
treating patients with esophagus, stomach, or gastroesophageal junction cancer that has
spread to other parts of the body. Monoclonal antibodies, such as pembrolizumab, may
interfere with the ability of tumor cells to grow and spread. Palliative radiation therapy,
such as external beam radiation therapy, uses high energy beams to treat symptoms that are
caused by tumors. Giving pembrolizumab together with palliative radiation therapy may work
better in treating patients with esophagus, stomach, or gastroesophageal junction cancer that
has spread to other parts of the body.
Detailed Description
PRIMARY OBJECTIVE:
I. To establish that the combination of pembrolizumab and traditional external beam
multifractionated radiation therapy (RT) to the primary tumor or a single target metastatic
site of patients with metastatic gastric, esophageal, and/or gastroesophageal junction (GEJ)
cancers will lead to an increase in tumor infiltrating cytotoxic T-cells and circulating
cytotoxic T cells and a reduction in immunosuppressive regulatory T cells (Tregs) and
myeloid-derived suppressor cells (MDSCs) in metastatic sites.
SECONDARY OBJECTIVES:
I. To establish that the combination of pembrolizumab and RT is feasible in the patient
population and evaluate toxicities per National Cancer Institute (NCI) Common Toxicity
Criteria for Adverse Events (CTCAE) version (ver.) 4.03.
II. To evaluate overall response rate (ORR) per Response Evaluation Criteria in Solid Tumors
(RECIST) 1.1 and immune related (ir)RECIST in this treatment population and correlate with
tumor T-cell response.
III. To evaluate progression-free (PFS) and overall survival (OS) in this treatment
population.
EXPLORATORY OBJECTIVES:
I. To measure changes in whole genome serum micro ribonucleic acid (miRNA) signature before
and after protocol therapy and correlate with tumor/immune/stromal cell miRNA expression
profiling determined by deep sequencing.
II. To measures changes in fecal and oral microbiomic diversity and correlative with ORR,
PFS, and OS.
III. To assess germline mutations in a panel of miRNA regulatory genes using the MiraDx assay
as predictors of response and toxicity to pembrolizumab and RT.
OUTLINE:
INITIAL TREATMENT: Patients undergo palliative external beam RT daily. On day 1, patients
undergo the first RT fraction and then receive pembrolizumab intravenously (IV) over 30
minutes. Cycles repeat every 3 weeks for up to 35 cycles in the absence of disease
progression or unacceptable toxicity.
SECOND PHASE: Patients who achieve a complete response, stop study treatment, and then
experience radiographic disease progression may be eligible for the second phase at the
discretion of the investigator if no cancer treatment was administered since the last dose of
pembrolizumab and trial eligibility safety parameters are met. Patients receive pembrolizumab
IV over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 17 cycles in the absence
of disease progression or unacceptable toxicity.
After completion of treatment, patients are followed up at 30 days, every 6 weeks for 1 year,
and then every 9 and 12 weeks for up to 2 years.
Trial Arms
Name | Type | Description | Interventions |
---|
Treatment (pembrolizumab, RT) | Experimental | INITIAL TREATMENT: Patients undergo palliative external beam RT daily. On day 1, patients undergo the first RT fraction and then receive pembrolizumab intravenously (IV) over 30 minutes. Cycles repeat every 3 weeks for up to 35 cycles in the absence of disease progression or unacceptable toxicity.
SECOND PHASE: Patients who achieve a complete response, stop study treatment, and then experience radiographic disease progression may be eligible for the second phase at the discretion of the investigator if no cancer treatment was administered since the last dose of pembrolizumab and trial eligibility safety parameters are met. Patients receive pembrolizumab IV over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 17 cycles in the absence of disease progression or unacceptable toxicity. | |
Eligibility Criteria
Inclusion Criteria:
- Documented informed consent of the participant
- Willing to provide tumor tissue amenable to ultrasound or computed tomography
(CT)-guided biopsy for biomarker analyses
- Patients with malignant ascites are permitted to participate and provide ascites
samples for biomarker analyses
- Patents receiving radiation to a single metastatic site in which only the primary
tumor is accessible for biopsy by endoscopy will also be eligible
- Eastern Cooperative Oncology Group (ECOG) performance status of =< 1
- Life expectancy of >= 3 months
- Diagnosis of metastatic squamous cell carcinoma and/or adenocarcinoma of the
esophagus, gastroesophageal junction, or stomach in need of palliative radiotherapy to
the primary tumor or a single metastatic site for symptoms such as pain, dysphagia,
and/or gastrointestinal bleeding
- Patients with adenocarcinoma histology and known human epidermal growth factor
receptor 2 (HER2) overexpressing disease are permitted to participate if the
progressed or are intolerant of prior trastuzumab-containing therapy
- Measurable metastatic sites of disease outside of the target lesion undergoing
palliative radiation based on RECIST 1.1 as assessed by the investigator
- Have no limits on prior lines of therapy or may be treatment-naive if in need of
palliative RT provided the patient has not received prior anti-programmed cell death
protein 1(PD-1), anti-programmed cell death 1 ligand 1 (PD-L1), or anti-programmed
cell death 1 ligand 2 (PD-L2) therapy
- Absolute neutrophil count (ANC) >= 1,500/mm^3
- Platelets >= 100,000/mm^3
- Hemoglobin >= 9 g/dL
- May receive transfusion to meet this goal
- Total serum bilirubin =< 1.5 x upper limit of normal (ULN) OR direct bilirubin =< ULN
if total bilirubin levels > 1.5 x ULN
- Albumin >= 2.5 mg/dL
- Aspartate aminotransaminase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN OR
=< 5.0 x ULN if liver metastases present
- Serum creatinine =< 1.5 x ULN OR creatinine clearance (if measured or calculated per
institutional standard) >= 60 mL/min if creatinine levels > 1.5 x ULN
- Glomerular filtration rate (GFR) can also be used in place of creatinine or
creatinine clearance (CrCl)
- If not receiving anticoagulants: international normalized ratio (INR) OR prothrombin
(PT) =< 1.5 x ULN; if on anticoagulant therapy: PT must be within therapeutic range of
intended use of anticoagulants
- If not receiving anticoagulants: activated partial thromboplastin time (aPTT) =< 1.5 x
ULN; if on anticoagulant therapy: aPTT must be within therapeutic range of intended
use of anticoagulants
- Negative urine or serum pregnancy test (female of childbearing potential only)
- If the urine test is positive or cannot be confirmed as negative, a serum
pregnancy test will be required
- Female of childbearing potential: willing 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
- Childbearing potential defined as not being surgically sterilized or have not
been free from menses for > 1 year
- Male: use an adequate method of contraception starting with the first dose of study
therapy through 120 days after the last dose of study therapy
Exclusion Criteria:
- Anti-PD-1, anti-PD-L1, or anti-PD-L2 agents
- Prior radiation therapy within the field of the target lesion that in the opinion of
the treating radiation oncologist would preclude further palliative radiation to a
dose of 30 gray (Gy)
- Anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study day 1 or who has
not recovered (i.e., =< grade 1 or at baseline) from adverse events due to agents
administered more than 4 weeks earlier
- Chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks
prior to study day 1 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
- Note: If subject received major surgery, they must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting therapy
- Live vaccine within 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
- Immunosuppressive therapy within 7 days prior to the first dose of trial treatment
- Investigational device within 4 weeks of the first dose of treatment
- Currently receiving an investigational agent
- About to undergo palliative radiation for a symptomatic central nervous system (CNS)
metastasis
- Systemic steroid therapy
- Hypersensitivity to pembrolizumab or any of its excipients
- Diagnosis of immunodeficiency
- 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)
- 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
- Current active infection requiring systemic therapy
- Known history of active tuberculosis (TB), human immunodeficiency virus (HIV) 1/2,
hepatitis B or hepatitis C
- 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
- Subjects with previously treated brain metastases may participate provided they
are stable, have no evidence of new or enlarging brain metastases, and are not
using steroids for at least 7 days prior to trial treatment; this exception does
not include carcinomatous meningitis which is excluded regardless of clinical
stability
- 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
- Pregnant or breastfeeding (female only)
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Changes in tumor infiltrating cytotoxic T-cells and circulating cytotoxic T-cells assessed by immunohistochemistry and flow cytometry |
Time Frame: | Baseline to 105 weeks |
Safety Issue: | |
Description: | Each patient will serve as their own control, and levels of tumor cytotoxic T cell infiltration and immunosuppressive regulatory T cells (Tregs) will be compared pre- and post-treatment. A sample size of 14 patients will have 80% power to detect an effect size of 0.71 using a paired t-test with a 0.05 one-sided significance level. The effect size is the man difference divided by the standard deviation of the difference. |
Secondary Outcome Measures
Measure: | Incidence of adverse events of pembrolizumab and RT graded per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (ver).4.03 |
Time Frame: | Up to 36 months |
Safety Issue: | |
Description: | |
Measure: | Overall response rate (ORR) assessed by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and immune related (ir)RECIST |
Time Frame: | Up to 36 months |
Safety Issue: | |
Description: | |
Measure: | Progression free survival (PFS) |
Time Frame: | Up to 36 months |
Safety Issue: | |
Description: | Will be determined using the Kaplan-Meier method. |
Measure: | Overall survival (OS) |
Time Frame: | Up to 36 months |
Safety Issue: | |
Description: | Will be determined using the Kaplan-Meier method. |
Details
Phase: | Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Active, not recruiting |
Lead Sponsor: | City of Hope Medical Center |
Last Updated
February 11, 2021