Clinical Trials /

Pembrolizumab in Combination With Decitabine and Hypofractionated Index Lesion Radiation in Pediatrics and Young Adults

NCT03445858

Description:

This pilot study is designed to assess the safety, tolerability, and preliminary anti-tumor activity of the combination of pembrolizumab, decitabine and fixed-dose hypofractionated index site radiotherapy in pediatric and young adult patients with relapsed, refractory or progressive non-primary CNS solid tumors and lymphomas. Primary Objectives - To determine the feasibility of administering pembrolizumab in combination with decitabine and hypofractionated index lesion radiation - To identify the treatment related toxicity and tolerability of the combination of decitabine and pembrolizumab with hypofractionated index lesion radiation Secondary Objective To preliminarily define the anti-tumor efficacy of the combination of pembrolizumab, decitabine and hypofractionated index lesion radiation in patients with relapsed, refractory, or progressive non-CNS solid tumors and lymphomas using overall response rate (CR + PR) by irRECIST after 2 cycles of therapy. Exploratory Objectives To profile the kinetics of the immune response and to correlate with promotor methylation changes, nuclear imaging, stool microbiota diversity, and tumor associated antigen immune responses.

Related Conditions:
  • Lymphoma
  • Malignant Solid Tumor
Recruiting Status:

Recruiting

Phase:

Early Phase 1

Trial Eligibility

Document

Title

  • Brief Title: Pembrolizumab in Combination With Decitabine and Hypofractionated Index Lesion Radiation in Pediatrics and Young Adults
  • Official Title: A Pilot Study of Pembrolizumab in Combination With Decitabine and Hypofractionated Index Lesion Radiation in Pediatric and Young Adult Patients With Relapsed and Refractory Solid Tumors or Lymphoma

Clinical Trial IDs

  • ORG STUDY ID: Pembro_BT_1603
  • NCT ID: NCT03445858

Conditions

  • Childhood Solid Tumor
  • Childhood Lymphoma
  • Relapsed Cancer
  • Refractory Cancer
  • Adult Solid Tumor
  • Adult Lymphoma

Interventions

DrugSynonymsArms
PembrolizumabKeytrudaPembrolizumab, Decitabine, Radiation
DecitabineDacogenPembrolizumab, Decitabine, Radiation

Purpose

This pilot study is designed to assess the safety, tolerability, and preliminary anti-tumor activity of the combination of pembrolizumab, decitabine and fixed-dose hypofractionated index site radiotherapy in pediatric and young adult patients with relapsed, refractory or progressive non-primary CNS solid tumors and lymphomas. Primary Objectives - To determine the feasibility of administering pembrolizumab in combination with decitabine and hypofractionated index lesion radiation - To identify the treatment related toxicity and tolerability of the combination of decitabine and pembrolizumab with hypofractionated index lesion radiation Secondary Objective To preliminarily define the anti-tumor efficacy of the combination of pembrolizumab, decitabine and hypofractionated index lesion radiation in patients with relapsed, refractory, or progressive non-CNS solid tumors and lymphomas using overall response rate (CR + PR) by irRECIST after 2 cycles of therapy. Exploratory Objectives To profile the kinetics of the immune response and to correlate with promotor methylation changes, nuclear imaging, stool microbiota diversity, and tumor associated antigen immune responses.

Detailed Description

      Patients will receive pembrolizumab and decitabine every 28 days, and a single 3 day course
      of fixed-dose hypofractionated index site radiotherapy to one or more index lesions.

      One cycle lasts 28 days. Radiation is given in Cycle 1 only. Cycles may repeat for a total of
      26 cycles if patient meets criteria to continue protocol therapy.
    

Trial Arms

NameTypeDescriptionInterventions
Pembrolizumab, Decitabine, RadiationExperimentalPatients will receive pembrolizumab and decitabine every 28 days, and a single 3 day course of fixed-dose hypofractionated radiotherapy to one or more index lesions.
  • Pembrolizumab
  • Decitabine

Eligibility Criteria

        Criteria: Inclusion Criteria:

          -  Age: greater than or equal to 12 months and less than or equal to 40 years.

          -  Diagnosis: Patients must have had histologic verification of malignancy at original
             diagnosis or relapse. Eligible diagnoses include:

               -  Relapsed or refractory solid tumors (excluding primary CNS tumors)

               -  Lymphoma in second or greater relapse or with refractory disease

          -  Disease Evaluation: Patients must have evaluable or measurable disease (patients with
             evaluable disease must have at least one lesion that is amenable to radiation as
             below).

          -  Patients with stable non-brainstem CNS metastases may be eligible.

          -  Therapeutic Options: Patient's current disease state must be one for which there is no
             known curative therapy or therapy proven to prolong survival with an acceptable
             quality of life.

          -  Performance Level: Lansky/Karnofsky greater than or equal to 50.

          -  Prior Therapy: Patients who have previously received inhibitors of PD-1, PD-L1, CTLA4
             or other immune checkpoint inhibitors, regardless of response, are eligible as long as
             they had not experienced a medically significant immune related adverse event that
             required treatment with supraphysiologic steroids or other immunomodulatory drug.

          -  Patients must have recovered from the acute toxic effects of all prior anti-cancer
             chemotherapy and meet the following:

               -  Myelosuppressive chemotherapy: At least 21 days after the last dose of
                  myelosuppressive chemotherapy (42 days if prior nitrosourea).

               -  Hematopoietic growth factors: At least 21 days after the last dose of a
                  long-acting growth factor (e.g. Neulasta) or 7 days for short-acting growth
                  factor.

               -  Biologic (anti-neoplastic agent): At least 7 days after the last dose of a
                  biologic agent.

               -  Immunotherapy: At least 42 days after the completion of any type of
                  immunotherapy, e.g. tumor vaccines.

               -  Monoclonal antibodies: At least 4 weeks after the last dose of a monoclonal
                  antibody.

               -  XRT: At least 14 days after local palliative XRT (limited field); At least 150
                  days must have elapsed if prior TBI, craniospinal XRT or radiation treatment
                  resulting in greater than or equal to 50% of the pelvis receiving greater than or
                  equal to 10 Gy.

               -  Stem Cell Infusion without TBI: At least 84 days must have elapsed after
                  autologous stem cell transplant or stem cell infusion. Patients having received
                  allogeneic stem cells within the past 5 years are not eligible.

          -  Adequate Bone Marrow Function Defined as:

               -  Peripheral absolute neutrophil count (ANC) greater than or equal to 750/mm3

               -  Platelet count greater than or equal to 75,000/mm3 (transfusion independent,
                  defined as not receiving platelet transfusions for at least 7 days prior to
                  enrollment)

               -  Hemoglobin greater than or equal to 8 (transfusions allowed)

               -  Patients with known bone marrow involvement will be eligible for the study
                  provided that they have a platelet count of greater than or equal to 50,000/mm3
                  (transfusion independent, defined as not receiving platelet transfusion for at
                  least 7 days prior to enrollment).

          -  Adequate Renal Function Defined as:

             o Creatinine clearance, cystatin C based GFR, or radioisotope GFR greater than or
             equal to 70ml/min/1.73 m2 or a serum creatinine based on protocol requirements.

          -  Adequate Liver Function Defined as:

               -  Direct bilirubin less than or equal to 1.5 x upper limit of normal (ULN) for age

               -  SGPT (ALT) less than or equal to 3.0 x upper limit of normal (ULN). For patients
                  with known liver metastases or primary tumor, SGPT (ALT) less than or equal to 5
                  x upper limit of normal (ULN) may be accepted. For the purposes of this study,
                  the ULN of SGPT is 45 U/L.

          -  Adequate Cardiac Function Defined as:

               -  Ejection fraction of greater than or equal to 50% by echocardiogram (3D if
                  available) or cardiac MRI.

               -  QTC less than or equal to 480 msec.

          -  Adequate Pulmonary Function Defined as:

             o Pulse oximetry greater than 94% on room air and no dyspnea at rest.

          -  Radiation Considerations:

               -  Patients must have at least one non-CNS lesion amenable to radiation as defined
                  in the protocol and at the discretion of the Study Chair.

               -  Patients with previously irradiated sites of disease may be considered eligible
                  if potential index lesions meet the following: There has been documented
                  progression at that site (by RECIST or for neuroblastoma patients enrolled with
                  evaluable disease, persistent MIBG avidity), and Re-irradiation would not expose
                  the patient to a substantial increase in toxicity (as determined by consultation
                  with co-principal investigator or designee and treating oncologist).

        Exclusion Criteria:

          -  Patients with primary CNS tumors, brainstem metastases, and/or carcinomatous
             meningitis are not eligible.

          -  Pregnant or breast-feeding women will not be entered on this study.

          -  Corticosteroids and other immunosuppressive therapy: Patients requiring systemic
             corticosteroids or other immunosuppressive medication within 7 days prior to
             enrollment are not eligible with the exception of physiologic replacement doses of
             corticosteroids.

          -  Patients who are currently receiving another investigational drug are not eligible.

          -  Patients who are currently receiving other anti-cancer agents are not eligible.

          -  Patients with a history of a non-thyroiditis autoimmune disorder are not eligible.
             Asymptomatic laboratory abnormalities (e.g. ANA, rheumatoid factor) will not render a
             patient ineligible in the absence of a diagnosis of an autoimmune disorder. Autoimmune
             thyroiditis will not render a patient ineligible.

          -  Patients with known hepatitis B (HBsAg reactive) or C (HCV RNA -qualitative is
             detected) are excluded.

          -  Patients with HIV are excluded if they have detectable viral loads or CD4 count is
             below 400 or they are not compliant with antiretroviral agents.

          -  Patients who have an uncontrolled infection are not eligible.

          -  Patients with immunodeficiency syndromes are not eligible.

          -  Patients with a history of clinically significant cardiac disease are not eligible.

          -  Patients with ongoing interstitial lung disease or pneumonitis are not eligible.

          -  Patients with any clinically significant unrelated systemic illness (serious
             infections or significant cardiac, pulmonary, hepatic or other organ dysfunction).

          -  Patients who have received a live vaccine less than or equal to 30 days prior to
             enrollment are ineligible.

          -  Patients who have received a prior solid organ transplant at any time, or allogeneic
             bone marrow transplantation within the past 5 years (or have signs or symptoms of
             GVHD) are not eligible.

        Patients who in the opinion of the investigator may not be able to comply with the safety
        monitoring requirements of the study are not eligible.
      
Maximum Eligible Age:40 Years
Minimum Eligible Age:12 Months
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Feasibility of administering Pembrolizumab in combination with Decitabine and hypofractionated index radiation
Time Frame:Days 1 thru 57
Safety Issue:
Description:Incidence of number of patients who experience a DLT

Secondary Outcome Measures

Measure:Identification of treatment related toxicities and tolerability
Time Frame:Days 1 thru 57
Safety Issue:
Description:Incidence of adverse events (toxicities) according to NCI CTCAE version 5.0
Measure:Define anti-tumor efficacy of treatment combination of pembrolizumab, decitabine, and hypofractionated index radiation (per irRECIST criteria)
Time Frame:2 cycles (56 days)
Safety Issue:
Description:Incidence of patients who experience an overall complete response or partial response to study treatment

Details

Phase:Early Phase 1
Primary Purpose:Interventional
Overall Status:Recruiting
Lead Sponsor:Children's Hospital Medical Center, Cincinnati

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