Inclusion Criteria:
- Male or female subjects aged ≥18 years.
- Histopathological evidence of glioblastoma or gliosarcoma, WHO grade IV.
- Tumor MGMT promoter DNA not methylated (i.e., unmethylated) by central testing.
- Maximal tumor diameter (including residual tumor and resection cavity if subjects had
tumor resection rather than only stereotactic biopsy) of 6.6 cm or less. Maximal tumor
size allowed is derived from an estimated maximal radiotherapy planning target volume
(PTV) of 150 cm3.
- Subjects must not have received any prior standard or investigational anti-tumor
therapy other than surgery and must not intend to receive any standard or
investigational anti-tumor therapy other than the study regimen.
- Karnofsky performance status (Appendix 2) of ≥60.
- Availability of a paraffin-embedded or frozen tumor-tissue block with a minimum of 1
cm2 of tumor surface area, or 20 unstained slides from the glioblastoma tissue
specimen if a tumor block cannot be submitted.
- Subjects must start study agent within 6 weeks from the first diagnostic surgery for
glioblastoma.
- An interval of at least 2 weeks for surgical resection and 1 week for stereotactic
biopsy from the start of study treatment.
- A contrast-enhanced MRI must be obtained within 7 days of the first dose of study
treatment.
- Adequate hematologic, hepatic, and renal function defined by
- White blood cell count ≥ 2.0 x 109/L
- Absolute neutrophil count ≥ 1.5 x 109/L
- Platelet count ≥ 100 x 109/L
- Hemoglobin > 9 g/dL
- Serum creatinine ≤1.5 x upper limit of normal (ULN) or creatinine clearance
(CrCl) ≥ 40 mL/min according to the Cockcroft-Gault formula or local
institutional standard method
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 3 x ULN
- Total bilirubin ≤ 1.5 x ULN (except subjects with Gilbert Syndrome, who can have
total bilirubin < 3.0 mg/dL)
- Women of child-bearing potential (WOCBP) and men able to father a child must agree to
use highly effective contraception (any contraceptive method with a failure rate of
less than 1% per year) while on study drug and for 23 weeks (for women) or 31 weeks
(for men) after the last dose of study drug.
1. WOCBP must have a negative serum or urine pregnancy test within 24 hours of
initiation of study drug.
2. WOCBP is defined as any female who has experienced menarche and who has not
undergone surgical sterilization (hysterectomy or bilateral oophorectomy) or who
is not postmenopausal. Menopause is defined clinically as 12 months of amenorrhea
in a woman over 45 in the absence of other biological or physiological causes. In
addition, women under the age of 55 must have a documented serum follicle
stimulating hormone (FSH) level less than 40 mIU/mL to be defined as
post-menopausal.
3. WOCBP receiving nivolumab will be instructed to adhere to contraception for a
period of 23 weeks after the last dose of investigational product. 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 investigational
product. These durations have been calculated using the upper limit of the
half-life for nivolumab (25 days) and are based on the protocol requirement that
WOCBP use contraception for 5 half-lives plus 30 days and men who are sexually
active with WOCBP use contraception for 5 half-lives plus 90 days.
4. Highly effective contraceptive measures include: stable use of oral
contraceptives such as combined estrogen and progestogen and progestogen only
hormonal contraception or other prescription pharmaceutical contraceptives for 2
or more menstrual cycles prior to screening; intrauterine device [IUD];
intrauterine hormone-releasing system (IUS); bilateral tubal ligation; vasectomy
and sexual abstinence.
5. Contraception is not required for men with documented vasectomy.
6. Pregnancy testing and contraception are not required for women with documented
hysterectomy or tubal ligation.
7. Women must not be breastfeeding.
- Willing to and capable of providing written informed consent prior to any study
related procedures.
- Ability and willingness to comply with all study requirements, including scheduled
visits, treatment plans, laboratory tests, and other study-related procedures.
Exclusion Criteria:
- Prior use of any standard or investigational anti-tumor therapy other than surgery
- Planned participation in another study of an investigational agent or investigational
device or planned use of any other agent or therapeutic device intended for therapy of
glioma.
- Prior systemic treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CTLA-4
antibody, or any other antibody or drug specifically targeting T-cell costimulation or
immune checkpoint pathways.
- Primary brainstem or spinal cord tumor.
- Diffuse leptomeningeal gliomatosis.
- Known mutation of the IDH1 or IDH2 genes in the tumor, since glioblastomas with these
mutations have different biology and are associated with improved prognosis.
- Systemic treatment with either immunosuppressive doses of corticosteroids (> 10 mg
daily prednisone equivalents) or other immunosuppressive medications within 14 days of
study drug administration.
1. Subjects on a standard high-dose steroid taper after craniotomy or stereotactic
biopsy may have received a higher dose of corticosteroids within 14 days of
registration, however must be at a dose < 10 mg daily prednisone or bioequivalent
per day within 5 days prior to initiation of study drug.
2. Administration of steroids through a route known to result in a minimal systemic
exposure [i.e., intranasal, intraocular, inhaled, topical, or local injection
(e.g., intra-articular injection) corticosteroids (<5% of body surface area)] are
permitted in the absence of active autoimmune disease.
3. Subjects requiring adrenal replacement with corticosteroids are eligible if the
steroids are at doses ≤ 10 mg prednisone or bioequivalent per day in the absence
of active autoimmune disease.
4. Steroids as premedication for hypersensitivity reactions (e.g., CT scan
premedication) are allowed.
- Active autoimmune disease that might deteriorate when receiving an immuno-stimulatory
agent. The following conditions are not exclusions (subjects with the following
conditions are permitted):
a.Patients with diabetes type I, vitiligo, residual hypo- or hyperthyroidism due to
autoimmune condition only requiring hormone replacement, or psoriasis not requiring
systemic immunosuppressive treatment, or autoimmune conditions not expected to recur
in the absence of an external trigger.
- Prior organ transplantation, including allogeneic stem cell transplantation.
- Known history of, or any evidence of active, non-infectious pneumonitis within the
last 5 years.
- Known severe (NCI-CTCAE v4.03 Grade 3 or 4) infusion-related allergy or acute
hypersensitivity reaction attributed to any monoclonal antibody, any history of
anaphylaxis, or uncontrolled asthma (that is, 3 or more features of partially
controlled asthma).
- Unable tolerate an MRI, or have a contraindication to MRI.
- Active infection requiring systemic therapy.
- Known history of testing positive for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome.
- Positive test for hepatitis B virus surface antigen (HBV sAg) or hepatitis C virus
(HCV antibody) indicating acute or chronic infection.
- Vaccination within 4 weeks of the first dose of study drug and while on trials is
prohibited except for administration of inactivated vaccines. 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.
- Clinically significant (i.e., active) cardiovascular disease: cerebral vascular
accident/stroke (< 6 months prior to enrollment), myocardial infarction (< 6 months
prior to enrollment), unstable angina, congestive heart failure (≥ New York Heart
Association Classification Class II), or serious cardiac arrhythmia requiring
medication.
- Patients with another active cancer [excluding basal cell carcinoma, cervical
carcinoma in situ or melanoma in situ]. Prior history of other cancer is allowed, as
long as there was no active disease within the prior 2 years.
- All other unstable, severe, or chronic medical or psychiatric conditions including
colitis, inflammatory bowel disease, pneumonitis, pulmonary fibrosis, recent (within
the past year) or active suicidal ideation or behavior, known alcohol or drug abuse,
or laboratory abnormalities that may increase the risk associated with study
participation or study treatment administration or may interfere with the
interpretation of study results and, in the judgment of the investigator, would make
the patient inappropriate for entry into this study.
