1. To determine safety of each of the following study agents, anti-GITR, IDO1 inhibitor, and
ipilimumab, in combination with nivolumab (BMS-936558) flat dose in patients with first
recurrence of GBM.
1. To estimate toxicity
2. To estimate progression-free survival
3. To estimate overall survival
4. To evaluate pain for patients undergoing the treatment of anti-GITR, IDO1 inhibitor, and
ipilimumab, in combination with nivolumab.
1. To characterize the immune response during and after treatment as measured by
immunohistochemistry, and other T cells etc. in peripheral blood
2. To characterize the pharmacodynamic and genomic activity in tumor tissue as target
3. To characterize radiographic response
4. Genetic characterization of correlative samples
- Patients must have histologically proven glioblastoma or gliosarcoma which is
progressive or recurrent following radiation therapy with or without temozolomide.
- Patients must be in first recurrence of glioblastoma following radiation therapy with
or without temozolomide. Patients with previously grade 3 astrocytoma who after first
recurrence after radiotherapy with or without temozolomide are found to have GBM are
eligible. Patients who have received Gliadel wafers during their initial surgery are
- Patients must be undergoing repeat surgery that is clinically indicated as determined
by their care providers, where a significant debulking or a gross total surgical
resection of the contrast-enhancing area is intended.
- Patients must consent to our acquiring tumor tissue removed before, during, or after
the study, if it becomes available.
- Patients must be able to undergo MRI of the brain with gadolinium.
- Patients receiving corticosteroid to treat cerebral edema or hypothalamic-pituitary
insufficiency are eligible.
- Patients must have recovered from severe toxicity of prior therapy. An interval of at
least 12 weeks must have elapsed since the completion of radiation therapy or
placement of Gliadel wafers, and at least 6 weeks must have elapsed from the last dose
of temozolomide (TMZ). No prior therapies are allowed other than radiation,
temozolomide, and Gliadel wafers (placed during the first surgery at diagnosis of high
grade glioma (HGG)).
- Patients must be 18 years of age or older.
- Patients must have a Karnofsky Performance Status (KPS) ≥ 60% (i.e. the patient must
be able to care for himself/herself with occasional help from others).
- Patients must have the following organ and marrow function:
- Absolute lymphocyte count ≥ 750/mcl
- Absolute neutrophil count ≥ 1,500/mcl
- Platelets ≥ 100,000/mcl
- Hemoglobin ≥ 9 g/dl
- Total bilirubin ≤ institutional upper limit of normal (except for patients with
Gilberts' syndrome who must have normal direct bilirubin)
- Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase
[SGOT])/alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) ≤
3 × institutional upper limit of normal
- Creatinine ≤ institutional upper limit of normal OR Creatinine clearance ≥ 60
ml/min/1.73m2 for patients with creatinine levels above institutional normal
- activated partial thromboplastin time (APTT) or partial thromboplastin time (PTT) ≤
1.5 x institutional upper limit of normal
- Patients must be able to provide written informed consent.
- Women of childbearing potential (WOCBP) must agree to have a negative serum pregnancy
test within -7 days prior to treatment start. Women of childbearing potential must
agree to use non-hormonal (due to induction of Cyp3a4) (barrier method of birth
control; abstinence) prior to study entry, for the duration of study treatment, and
through at least 5 months after the last dose of study drug. Should a woman become
pregnant or suspect she is pregnant while participating in this study, she should
inform her treating physician immediately. Males who are sexually active with WOCBP
must agree to use a condom during penile vaginal intercourse for the duration of
treatment with study treatment plus 7 months after the last dose of the study
treatment (i.e., 90 days [duration of sperm turnover] plus the time required for
nivolumab to undergo approximately 5 half-lives). This criteria applies to azoospermic
males as well.
- Patients must have no concurrent malignancy except curatively treated basal or
squamous cell carcinoma of the skin or carcinoma in situ of the cervix, breast, or
bladder. Patients with prior malignancies must be disease-free for ≥ five years.
- Patients receiving any other investigational agents are ineligible.
- Patients with a history of allergic reactions attributed to compounds of similar
chemical or biologic composition to IO agents used in this study are ineligible. The
Investigator Brochures can be referenced for more information.
- Patients with active or a known history of known or suspected autoimmune disease are
ineligible. Subjects with Type 1 diabetes mellitus, hypothyroidism only requiring
hormone replacement, and skin disorders (vitiligo, psoriasis, or alopecia) not
requiring systemic treatment, are permitted to enroll.
- Patients with a condition requiring systemic treatment with either corticosteroids
(other than for cerebral edema or hypothalamic-pituitary dysfunction) or other
immunosuppressive medications within 14 days of study entry are ineligible.
- Patients must not have evidence of significant mass effect.
- Patients must have no evidence of significant hematologic, renal, or hepatic
dysfunction. Patients with underlying hepatocellular disease should be given careful
risk/benefit consideration prior to enrollment. Patients with a known history of any
chronic hepatitis as evidenced by the following are ineligible:
- Positive test for hepatitis B surface antigen (HBsAg)
- Positive test for qualitative hepatitis C viral load (by PCR) (Note: Subjects
with positive hepatitis C antibody and negative quantitative hepatitis C by PCR
are eligible. History of resolved hepatitis A virus infection is not an exclusion
- History of alcoholic or non-alcoholic steatohepatitis (NASH), auto-immune
hepatitis, or previous grade 3-4 drug-related hepatitis, or any form of chronic
- Patients with a confirmed history of encephalitis or meningitis in the year prior to
signing informed consent are ineligible.
- Patients with uncontrolled or significant cardiovascular disease including, but not
limited to, any of the following are ineligible:
- Myocardial infarction or stroke/transient ischemic attack (TIA) within the 6
months prior to consent
- Uncontrolled angina within the 3 months prior to consent
- Any history of clinically significant arrhythmias (such as ventricular
tachycardia, ventricular fibrillation, or torsades de pointes)
- QTc prolongation > 480 msec
- History of other clinically significant cardiovascular disease (i.e.,
cardiomyopathy, myocarditis, congestive heart failure with New York Heart
Association (NYHA) functional classification III-IV, pericarditis, significant
pericardial effusion, significant coronary stent occlusion, deep venous
- Cardiovascular disease-related requirement for daily supplemental oxygen Patients
with other uncontrolled intercurrent illness including, but not limited to,
ongoing or active infection that requires systemic antibacterial, antiviral or
antifungal therapy < 7 days prior to the first dose of study drug, or psychiatric
illness/social situations that would limit compliance with study requirements,
- Pregnant women are excluded from this study because the study agents have potential
for teratogenic or abortifacients effects. Because there is an unknown but potential
risk for adverse events in nursing infants secondary to treatment of the mother with
IO agents used in this study, breastfeeding should be discontinued if the mother is
treated with these agents.
- Patients with a known history of testing positive for human immunodeficiency virus
(HIV) or known acquired immunodeficiency syndrome (AIDS), hepatitis C (HCV) negative
(by qPCR) and HBcAb negative (no prior Hepatitis B infection)) are ineligible.
- Participants with a personal or family (i.e., in a first-degree relative) history of
cytochrome b5 reductase deficiency (previously called methemoglobin reductase
deficiency) or other diseases that put them at risk of methemoglobinemia. All
participants will be screened for methemoglobin levels prior to randomization.
- Participants with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency or
other congenital or autoimmune hemolytic disorders. All participants will be screened
for G6PD levels prior to arm assignment.
- Patients with prior organ or tissue allograft are ineligible.
- Patients with a history of life-threatening toxicity related to prior immune therapy
- Quantitative or qualitative G6PD assay results suggesting underlying G6PD deficiency.
- Blood methemoglobin > upper limit of normal (ULN), assessed in an arterial or venous
blood sample or by co-oximetry.
- History or presence of hypersensitivity or idiosyncratic reaction to methylene blue.
- Prior history of serotonin syndrome
- Participants with active interstitial lung disease (ILD) or pneumonitis or with recent
history of ILD or pneumonitis requiring steroids (excluding radiation pneumonitis)
- Participants with conditions known to interfere significantly with the absorption of
oral medication, as per investigator judgement.