Inclusion Criteria:
- Written informed consent and HIPAA authorization for release of personal health
information prior to registration. NOTE: HIPAA authorization may be included in the
informed consent or obtained separately.
- Age ≥ 18 years at the time of consent.
- ECOG Performance Status (PS) of 0-1within 28 days prior to registration. NOTE: Within
0-3 days prior to the anticipated C1D1, ECOG PS must be 0-1.
- Archived tumor tissue must be available and identified during screening and shipped
after subject registration. If archived tissue is not available and the subject is not
undergoing a standard of care biopsy, the subject is not eligible for trial
participation.
- PD-L1 results are required, if available. If PD-L1 testing has not been done, it
should be ordered as standard of care prior to C1D1. PD-L1 testing must be performed
by a CLIA certified lab using the Dako 22C3 antibody.
- Histologically or cytologically proven adenocarcinoma of the stomach or GEJ.
- Metastatic, recurrent, or locally advanced unresectable disease.
- Intolerant of or progressed on at least one prior line of therapy for metastatic
disease. NOTE: Neoadjuvant or adjuvant therapy administered < 12 months prior to
diagnosis of recurrent disease counts as one line of therapy.
- Measurable disease per RECIST v1.1
- Candidate for pembrolizumab, ramucirumab, and paclitaxel
- Demonstrate adequate organ function as defined in the table below. All screening labs
to be obtained within 28 days prior to registration. NOTE: Labs must also be obtained
within 10 days prior to C1D1 treatment.
- Absolute Neutrophil Count (ANC) ≥ 1,100/mm3
- Hemoglobin (Hgb) ≥ 8.5 g/dL without transfusion or EPO dependency
- Platelets ≥ 100,000 / mcL
- Creatinine OR Calculated creatinine clearance1 ≤ 1.5 x upper limit of normal
(ULN) OR ≥ 60 mL/min for subject with creatinine levels > 1.5 x institutional ULN
- Total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with total
bilirubin levels > 1.5 ULN OR total bilirubin ≤ 2 x ULN if liver metastases are
present (patients with Gilbert's syndrome are allowed)
- Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) ≤ 2.5 X ULN
OR ≤ 5 x ULN for subjects with liver metastases
- Albumin > 2.5 g/dL
- Willingness to provide tissue and blood samples for correlative research purposes.
NOTE: Enrollment in parallel biopsy protocol, if open for enrollment, is required.
Parallel biopsy protocol entitled: "Exploration of tumor biology in patients with
metastatic esophageal and gastric cancer (biorepository protocol for prospective
tissue collection)".
- Females of childbearing potential must have a negative pregnancy test within 72 hours
prior to registration. If the urine test is positive or cannot be confirmed as
negative, a serum pregnancy test will be required. NOTE: Females are considered of
child bearing potential unless they are surgically sterile (have undergone a
hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or they are
naturally postmenopausal for at least 12 consecutive months
- Females of childbearing potential and males must be willing to abstain from
heterosexual intercourse or to use 2 forms of effective methods of contraception from
the time of informed consent (females)/prior to C1D1 (males) until 120 days after
treatment discontinuation. See the protocol for contraception options.
- Willingness to return to the enrolling institution for follow up
Exclusion Criteria:
- Past medical history of interstitial lung disease (ILD), drug-induced ILD, radiation
pneumonitis which required steroid treatment, or any evidence of clinically active
interstitial lung disease (relevant for ramucirumab).
- Any of the following cardiac criteria (relevant for ramucirumab):
- Mean resting corrected QT interval (QTc using Fridericia's formula) > 470 msec.
- Any clinically important abnormalities in rhythm, conduction or morphology of
resting ECG e.g., complete left bundle branch block, third degree heart block,
second degree heart block, PR interval >250msec.
- Symptomatic heart failure, uncontrolled hypokalemia despite repletion, congenital
long QT syndrome, family history of long QT syndrome or unexplained sudden death
under 40 years of age in first degree relatives. NOTE: Factors that increase risk
of QTc prolongation or risk of arrhythmia, such as concomitant medications, may
require increased monitoring during Combination Therapy (See Section 7).
- The patient has experienced any arterial thromboembolic events, including but not
limited to myocardial infarction, transient ischemic attack, cerebrovascular
accident, or unstable angina, within 6 months prior to first dose of protocol
therapy.
- The patient has uncontrolled or poorly-controlled hypertension (>160 mmHg
systolic or > 100 mmHg diastolic for >4 weeks) despite standard medical
management.
- The patient has experienced any Grade 3-4 GI bleeding within 3 months prior to first
dose of protocol therapy (relevant for ramucirumab).
- Cirrhosis at a level of Child-Pugh B (or worse) or cirrhosis (any degree) and a
history of hepatic encephalopathy or clinically meaningful ascites resulting from
cirrhosis. Clinically meaningful ascites is defined as ascites from cirrhosis
requiring diuretics or paracentesis (relevant for ramucirumab).
- Any hemoptysis (defined as bright red blood or ≥ 1/2 teaspoon) within 2 months prior
to first dose of protocol therapy or with radiographic evidence of intratumor
cavitation or has radiologically documented evidence of major blood vessel invasion or
encasement by cancer (relevant for ramucirumab).
- The patient has a prior history of GI perforation/fistula (within 6 months of first
dose of protocol therapy) or risk factors for perforation (relevant for ramucirumab).
- The patient has a serious or nonhealing wound, ulcer, or bone fracture within 28 days
prior to first dose of protocol therapy (relevant for ramucirumab).
- The patient has undergone major surgery within 28 days prior to first dose of protocol
therapy prior to the first dose of protocol therapy. The patient has elective or
planned major surgery to be performed during the course of the clinical trial
(relevant for ramucirumab).
- Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment
of the investigator, would make the patient inappropriate for entry into this study or
interfere significantly with the proper assessment of safety and toxicity of the
prescribed regimens.
- Has 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 (eg., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment. NOTE: Inhaled steroids or steroid injections for joint
disease are allowed.
- Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy or used an investigational
device within 4 weeks of the first dose of treatment.
- Disease progression according to RECIST v1.1 or irRECIST, or treatment intolerance,
during prior therapy with an anti-PD-1, anti-PD-L1, or anti- PD-L2 agent. NOTE: Stable
or responsive disease on anti-PD-1/L1-L2 therapy (without concurrent cytotoxic
therapy) is allowed.
- Weight loss ≥5% during prior anti-PD-1, anti-PD-L1, or anti- PD-L2-containing therapy
(from time of initiation of such therapy to most recent dose).
- Prior therapy combining anti-angiogenesis agent with cytotoxic agent(s). NOTE: Prior
single-agent anti-angiogenesis therapy (eg, ramucirumab monotherapy) is allowed.
- Patients known to be HIV positive.
- Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
[qualitative] is detected).
- Prior severe allergic reactions to a monoclonal antibody or hypersensitivity to
pembrolizumab or any of its excipients.
- Has had a prior anti-cancer monoclonal antibody (mAb) within 3 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 3 weeks earlier.
- Other active malignancy which requires current treatment and which in the opinion of
the site investigator is likely to interfere with evaluation of disease assessment.
NOTE: Continuation of hormonal therapies is allowed.
- Patients with known active central nervous system (CNS) metastases may participate
provided they are stable (without evidence of progression by imaging for at least four
weeks prior to the first dose of trial treatment and any neurologic symptoms have
returned to baseline), 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.
- Uncontrolled intercurrent illness which in the opinion of the investigator poses
unacceptably high risk when combined with study treatment, including but not limited
to the following:
- Symptomatic congestive heart failure
- Unstable angina pectoris
- Severely impaired lung function
- Known history of active TB (Bacillus Tuberculosis)
- Uncontrolled diabetes as defined by fasting serum glucose >1.5 x ULN (NOTE:
Optimal glycemic control should be achieved before starting trial therapy.)
- Significant underlying liver disease such as severe cirrhosis or hepatic
impairment
- Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.
- Has an active infection requiring systemic therapy prior to therapy initiation.
- Has a 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.
- Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the pre-screening or screening visit
through 120 days after the last dose of trial treatment.
- Has known history of or any evidence of active, non-infectious pneumonitis.
- Currently uncontrolled hyper/hypothyroidism or hyper/hypocortism if in the opinion of
the investigator they pose unacceptably high risk when combined with study treatment.
- Received live vaccine or live attenuated vaccine within 30 days prior to registration.
NOTE: Administration of killed vaccines is allowed.
- Prior pancreatitis that was symptomatic or required medical intervention ≤ 6 months
prior to registration (known toxicity of pembrolizumab).
- Prior enteritis that was symptomatic or required medical intervention ≤ 6 months prior
to registration (known toxicity of pembrolizumab).
- Pre-existing motor or sensory neurotoxicity grade 3 or higher.
- For patients who received palliative RT, there must be no evidence of disease
progression on clinical or imaging exams for at least two weeks prior to first dose of
treatment.
- Parenteral or oral corticosteroids in the last two weeks prior to starting study
treatment.
- Prior solid organ or allogeneic transplant.