Clinical Trials /

Combining Radiosurgery and Nivolumab in the Treatment of Brain Metastases

NCT02978404

Description:

Stereotactic radiosurgery (SRS) is increasingly administered as the sole treatment of brain metastases, in order to spare acute and long term side effects associated with whole brain radiotherapy. Local control of SRS treated lesions is good, but patients tend to develop additional brain metastases subsequently. Nivolumab is a modulator of the immune system. Treatment with Nivolumab is associated with an increase in local control and survival in patients with non-small cell lung cancer and clear cell renal cell carcinoma. In the presence of Nivolumab, treatment of brain metastases with SRS may trigger an immune reaction against cancer. Therefore, the combination of SRS with Nivolumab may reduce the development of new brain metastases and improve patient survival. The purpose of this study is to assess the effect of combining Nivolumab and SRS in controlling cancer progression. SRS will be administered to patients while they are receiving Nivolumab.

Related Conditions:
  • Clear Cell Renal Cell Carcinoma
  • Melanoma
  • Non-Small Cell Lung Carcinoma
  • Small Cell Lung Carcinoma
Recruiting Status:

Active, not recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: Combining Radiosurgery and Nivolumab in the Treatment of Brain Metastases
  • Official Title: A Phase II, Multi-centre Study, of Combining Radiosurgery and Nivolumab in the Treatment of Brain Metastases From Non-small Cell Lung Cancer and Renal Cell Cancer

Clinical Trial IDs

  • ORG STUDY ID: 16.206
  • SECONDARY ID: OZM-080
  • NCT ID: NCT02978404

Conditions

  • Clear-Cell Metastatic Renal Cell Carcinoma
  • Non Small Cell Lung Cancer Metastatic
  • Brain Metastases, Adult
  • Small Cell Lung Cancer
  • Melanoma

Interventions

DrugSynonymsArms
NivolumabRadiosurgery and Nivolumab

Purpose

Stereotactic radiosurgery (SRS) is increasingly administered as the sole treatment of brain metastases, in order to spare acute and long term side effects associated with whole brain radiotherapy. Local control of SRS treated lesions is good, but patients tend to develop additional brain metastases subsequently. Nivolumab is a modulator of the immune system. Treatment with Nivolumab is associated with an increase in local control and survival in patients with non-small cell lung cancer and clear cell renal cell carcinoma. In the presence of Nivolumab, treatment of brain metastases with SRS may trigger an immune reaction against cancer. Therefore, the combination of SRS with Nivolumab may reduce the development of new brain metastases and improve patient survival. The purpose of this study is to assess the effect of combining Nivolumab and SRS in controlling cancer progression. SRS will be administered to patients while they are receiving Nivolumab.

Trial Arms

NameTypeDescriptionInterventions
Radiosurgery and NivolumabExperimentalInterventions: Nivolumab (240mg IV q2week or 480mg IV q4week) and Radiosurgery (15-20 Gray (Gy) in 1 fraction) Upon entering this trial, patients with metastatic brain disease(s) will receive Nivolumab. One to 2 week after receiving the first dose of Nivolumab, radiosurgery will be delivered at doses ranging from 15 to 20 Gy in 1 fraction to the brain metastases to a maximum volume of 10 cubic centimeter.
  • Nivolumab

Eligibility Criteria

        Inclusion Criteria:

          1. Men and women, ≥ 18 years of age

          2. Willing and able to give written informed consent

          3. Eastern Cooperative Oncology Group (ECOG) Performance Status of 0-1 within 28 days
             prior to registration

          4. Radiation Therapy Oncology Group (RTOG) neurological function score of 0-1 within 28
             days prior to registration

          5. Histologic diagnosis of NSCLC, SCLC, Melanoma OR ccRCC

          6. Stage IV cancer with brain metastases (Patients may have untreated primary disease)

          7. Presenting with previously un-irradiated brain metastasis (10 cc maximum volume of
             brain disease based on the diagnostic screening MRI done within 28 days of
             registration))

          8. Measurable/evaluable brain disease

          9. Having received less than 4 lines of prior systemic treatments

         10. Ability to be treated with either gamma knife or a linear accelerator based
             radiosurgery system

         11. Ability to complete neurocognitive exams without assistance

         12. Ability to complete QOL questionnaires with or without assistance

         13. Screening laboratory values must meet the following criteria and should be obtained
             within 28 days prior to registration:

               -  White Blood Cell (WBC) ≥ 2000/uL

               -  Absolute Neutrophil Count (ANC) ≥ 1.5 x 109/L

               -  Platelets≥ 100 x 109/L

               -  Hemoglobin ≥ 90 g/L (may be transfused)

               -  Serum creatinine ≤ 1.5 x Upper Limit of Normal (ULN) or Creatinine Clearance ≥ 50
                  ml/min (calculated -cockcroft-Gault)

               -  Aspartate aminotransferase/alanine aminotransferase (AST/ALT) ≤3 x ULN without
                  liver metastasis,≤ 5 x ULN with liver metastases

               -  Total Bilirubin ≤ 1.5 x ULN (except subjects with Gilbert Syndrome, who can have
                  total bilirubin < 3.0 mg/dL)

         14. Women of childbearing potential (WOCBP) must use appropriate method(s) of
             contraception. WOCBP should use an adequate method to avoid pregnancy for 23 weeks (28
             days plus the time required for Nivolumab to undergo five half-lives) after the last
             dose of investigational drug

         15. Women of childbearing potential must have a negative serum or urine pregnancy test
             (minimum sensitivity 25 IU/L or equivalent units of HCG) within 24 hours prior to the
             start of Nivolumab

         16. Women must not be breastfeeding

         17. Men who are sexually active with WOCBP must use any contraceptive method with a
             failure rate of less than 1% per year. Men receiving Nivolumab and who are sexually
             active with WOCBP will be instructed to adhere to contraception for a period of 31
             weeks after the last dose of Nivolumab product. Women who are not of childbearing
             potential (ie, who are postmenopausal or surgically sterile as well as azoospermic men
             do not require contraception).

        Exclusion Criteria:

          1. Brain metastasis in the brainstem

          2. Patients who experienced prior seizures are eligible, however patients should not have
             had a seizure within 7 days of registration without the use of corticosteroids.

          3. All other cancer histology other than NSCLC or ccRCC

          4. Patients who cannot undergo MRI

          5. Active, known or suspected autoimmune disease. Subjects are permitted to enroll if
             they have vitiligo, type I diabetes mellitus, residual hypothyroidism due to
             autoimmune condition only requiring hormone replacement, psoriasis not requiring
             systemic treatment, or conditions not expected to recur in the absence of an external
             trigger

          6. Patients with a condition requiring systemic treatment with either corticosteroids
             including steroids used for treating peritumoral edema (> 50 mg daily prednisone
             equivalents) or other immunosuppressive medications within 14 days of study drug
             administration. Inhaled or topical steroids and adrenal replacement doses > 10 mg
             daily prednisone equivalents are permitted in the absence of active autoimmune
             disease.

          7. Drugs with a predisposition to hepatoxicity should be used with caution in patients
             treated with Nivolumab-containing regimen

          8. Any underlying medical or psychiatric condition, which in the opinion of the
             investigator will make the administration of Nivolumab hazardous or obscure the
             interpretation of AEs, such as a condition associated with frequent diarrhea.

          9. History of prior treatment with a CTLA-4, PD-1 or PD-L1 inhibitor, CD137 agonist, or
             anti-PD-L2.

         10. Concomitant therapy with any of the following: IL-2, interferon, or other non-study
             immunotherapy regimens; immunosuppressive agents; other investigation therapies

         11. Prisoners or subjects who are compulsorily detained (involuntarily incarcerated) for
             treatment of either a psychiatric or physical (eg, infectious) illness.

         12. Known history of hepatitis B virus surface antigen (HBV sAg) or hepatitis C virus
             ribonucleic acid (HCV antibody) indicating acute or chronic infection

         13. History of allergy to study drug components.

         14. Known history of testing positive for human immunodeficiency virus (HIV) or known
             acquired immunodeficiency syndrome (AIDS).
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Intracranial progression-free survival
Time Frame:1 year
Safety Issue:
Description:To evaluate whether the combination SRS with Nivolumab will improve the intracranial progression-free survival of patients. Response will be assessed as per RECIST version 1.1.

Secondary Outcome Measures

Measure:Treated brain lesions control rate
Time Frame:1 year
Safety Issue:
Description:Treated brain lesions control will be assessed as per RECIST version 1.1.
Measure:Overall survival after receiving Nivolumab.
Time Frame:2 years
Safety Issue:
Description:Overall Survival is assessed at the end of the study at 2 years. A subject will be classified as either alive or dead due to any cause. The time to event will be calculated as the time from Day 1 until date of death. Day 1 is the date of 1st treatment consisting of an infusion of Nivolumab.
Measure:Maximum response rate of distant non-irradiated disease
Time Frame:1 year
Safety Issue:
Description:Response will be assessed as per RECIST version 1.1.
Measure:Progression-free survival
Time Frame:1 year
Safety Issue:
Description:Response will be assessed as per RECIST version 1.1.
Measure:Correlation between tumor PD-L1 expression and clinical outcomes
Time Frame:1 year
Safety Issue:
Description:Tumor PD-L1 expression level will be correlated with patient overall response rate, loco-regional recurrence free survival and overall survival.
Measure:Patient quality of life
Time Frame:1 year
Safety Issue:
Description:Quality of life will be assessed using the the Functional Assessment of Cancer Therapy - General (FACT-G) and the Brain Subscale (FACT-BR) questionnaires. A composite score will be obtained from the score of each subscale. Quality of life decline is the time to the first minimal important difference in the composite score from baseline.
Measure:Neurocognitive function, as measured by the HVLT-R
Time Frame:1 Year
Safety Issue:
Description:Neurocognitive function will be assessed using the Hopkins Verbal Learning Test - Revised (HVLT-R). Neurocognitive failure is the time to the first failure on the assessments using the Reliable Change Index. Baseline neurocognitive function will be compared to the test results at 1 year using either a t-test or Wilcoxon-Mann-Whitney test, depending on the normality of the data.
Measure:Neurocognitive function, as measured by TMT
Time Frame:1 year
Safety Issue:
Description:Neurocognitive function will be assessed using the Trail Making Test (TMT). Neurocognitive failure is the time to the first failure on the assessments using the Reliable Change Index. Baseline neurocognitive function will be compared to the test results at 1 year using either a t-test or Wilcoxon-Mann-Whitney test, depending on the normality of the data.
Measure:Neurocognitive function, as measured by COWA
Time Frame:1 Year
Safety Issue:
Description:Neurocognitive function will be assessed using the Controlled Oral Word Association (COWA). Neurocognitive failure is the time to the first failure on the assessments using the Reliable Change Index. Baseline neurocognitive function will be compared to the test results at 1 year using either a t-test or Wilcoxon-Mann-Whitney test, depending on the normality of the data.
Measure:Acute and late toxicity of SRS + Nivolumab
Time Frame:1 year
Safety Issue:
Description:Adverse events will be coded according to MedDRA. The results will be tabulated to examine their frequency, organ systems affected, severity, and relationship to study treatment. Terminology Criteria for Adverse Events (CTCAE) V4.03 will be used for grading of AEs. Investigators will provide their assessment of causality as 1) unrelated, 2) unlikely, 3) possibly related, 4) probably, or 5) definitely related.
Measure:Imaging indicators of response
Time Frame:1 year
Safety Issue:
Description:Patient response to the treatment will be analysed using the Immune-related Response Evaluation Criteria In Solid Tumors (irRECIST) criteria.

Details

Phase:Phase 2
Primary Purpose:Interventional
Overall Status:Active, not recruiting
Lead Sponsor:Centre hospitalier de l'Université de Montréal (CHUM)

Trial Keywords

  • radiosurgery
  • PD-1
  • Nivolumab

Last Updated

August 4, 2021