Description:
This phase I trial studies the side effects of nivolumab and ipilimumab before and after
surgery in treating children and young adults with high grade glioma that has come back
(recurrent) or is increasing in scope or severity (progressive). Immunotherapy with
monoclonal antibodies, such as nivolumab and ipilimumab, may help the body's immune system
attack the cancer, and may interfere with the ability of tumor cells to grow and spread.
Title
- Brief Title: Immunotherapy (Nivolumab and Ipilimumab) Before and After Surgery for the Treatment of Recurrent or Progressive High Grade Glioma in Children and Young Adults
- Official Title: A Randomized, Double-Blinded, Pilot Trial of Neoadjuvant Checkpoint Inhibition Followed by Combination Adjuvant Checkpoint Inhibition in Children and Young Adults With Recurrent or Progressive High Grade Glioma (HGG)
Clinical Trial IDs
- ORG STUDY ID:
190815
- SECONDARY ID:
NCI-2020-01502
- SECONDARY ID:
PNOC 0019
- NCT ID:
NCT04323046
Conditions
- Glioblastoma
- Malignant Glioma
- Recurrent Glioblastoma
- Recurrent Malignant Glioma
- Recurrent Grade III Glioma
- Grade III Glioma
Interventions
Drug | Synonyms | Arms |
---|
Ipilimumab | Anti-Cytotoxic T-Lymphocyte-Associated Antigen-4 Monoclonal Antibody, BMS-734016, MDX-010, MDX-CTLA4, Yervoy | Group A (neoadjuvant nivolumab and placebo) |
Nivolumab | BMS-936558, MDX-1106, NIVO, ONO-4538, Opdivo | Group A (neoadjuvant nivolumab and placebo) |
Placebo Administration | | Group A (neoadjuvant nivolumab and placebo) |
Purpose
This phase I trial studies the side effects of nivolumab and ipilimumab before and after
surgery in treating children and young adults with high grade glioma that has come back
(recurrent) or is increasing in scope or severity (progressive). Immunotherapy with
monoclonal antibodies, such as nivolumab and ipilimumab, may help the body's immune system
attack the cancer, and may interfere with the ability of tumor cells to grow and spread.
Detailed Description
PRIMARY OBJECTIVES:
I. To measure the relative changes in cell cycle-related genetic signature of the tumor
microenvironment post administration of neoadjuvant nivolumab and placebo, ipilimumab and
placebo, and nivolumab and ipilimumab in children and young adults with recurrent or
progressive high grade glioma (HGG) when compared to a cohort of archived non-treated
recurrent pediatric HGG samples.
II. To characterize the safety and tolerability of neoadjuvant nivolumab and placebo,
neoadjuvant ipilimumab and placebo, and neoadjuvant ipilimumab and nivolumab followed by
adjuvant ipilimumab and nivolumab in children and young adults with recurrent or progressive
HGG.
SECONDARY OBJECTIVES:
I. To determine the 6 month and 12 month overall survival (OS) in children and young adults
with recurrent or progressive HGG treated with neoadjuvant nivolumab and placebo, ipilimumab
and placebo, or nivolumab and ipilimumab followed by adjuvant nivolumab and ipilimumab.
II. To determine the 6 month and 12 month progression-free survival (PFS) in children and
young adults with recurrent or progressive HGG treated with neoadjuvant nivolumab and
placebo, ipilimumab and placebo, or nivolumab and ipilimumab followed by adjuvant nivolumab
and ipilimumab.
EXPLORATORY OBJECTIVES:
I. To measure relative changes in interferon gamma associated genetic signature within the
tumor microenvironment post administration of neoadjuvant nivolumab and placebo, ipilimumab
and placebo, or nivolumab and ipilimumab in children and young adults with recurrent or
progressive HGG compared to archived non-treated recurrent pediatric HGG samples.
II. To explore the correlation of interferon-gamma-associated genetic signature, cell
cycle-related genetic signature and infiltrating T lymphocyte (TIL) density and clonality
with clinical responses for each treatment arm.
III. To measure TIL density post administration of neoadjuvant nivolumab and placebo compared
to neo-adjuvant ipilimumab and placebo, and neoadjuvant nivolumab and ipilimumab in children
and young adults with recurrent or progressive HGG.
IV. To estimate the objective response rate (ORR) in children and young adults with recurrent
or progressive HGG treated with neoadjuvant nivolumab and placebo, neoadjuvant ipilimumab and
placebo, or neoadjuvant ipilimumab and nivolumab followed by adjuvant ipilimumab and
nivolumab.
V. To evaluate the association between advanced magnetic resonance imaging (MRI) parameters
(apparent diffusion coefficient (ADC) on diffusion weighted imaging (DWI), relative cerebral
blood volume (rCBV) on dynamic susceptibility contrast (DSC) perfusion MRI, pre-contrast T1
shortening on T1-weighed images, and/or magnetization transfer ratio with asymmetric analysis
(MTRasym) on pH-weighted amine chemical exchange saturation transfer (CEST)-echo planar
imaging (EPI)) and tumor and peripheral blood immune responses.
VI. To measure relative change in peripheral T-cell response and post administration of
neo-adjuvant nivolumab and placebo, ipilimumab and placebo, or nivolumab and ipilimumab in
children and young adults with recurrent or progressive HGG.
VII. To measure PD-1 and PDL-1 expression by immunohistochemistry for children and young
adults with recurrent or progressive HGG post neoadjuvant nivolumab and placebo, neoadjuvant
ipilimumab and placebo, or neoadjuvant ipilimumab and nivolumab, and evaluate the differences
between the three arms as well as between each group and archived non-treated recurrent
pediatric HGG samples.
VIII. To explore the correlation of tumor mutational load with clinical response for children
and young adults with recurrent or progressive HGG treated with neoadjuvant nivolumab and
placebo, neoadjuvant ipilimumab and placebo, or neoadjuvant ipilimumab and nivolumab followed
by adjuvant ipilimumab and nivolumab.
IX. To assess quality of life (QOL) and cognitive measures in children and young adults with
recurrent or progressive HGG treated with neoadjuvant nivolumab and placebo, neoadjuvant
ipilimumab and placebo, or neoadjuvant ipilimumab and nivolumab followed by adjuvant
ipilimumab and nivolumab.
OUTLINE: Patients are randomized to 1 of 3 groups.
GROUP A:
NEOADJUVANT: Patients receive nivolumab intravenously (IV) over 30 minutes and placebo IV
over 30 minutes 14 days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards),
patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1.
Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or
unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV
over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease
progression or unacceptable toxicity.
GROUP B:
NEOADJUVANT: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes
14 days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards),
patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1.
Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or
unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV
over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease
progression or unacceptable toxicity.
GROUP C:
NEOADJUVANT: Patients receive placebo IV over 30 minutes and ipilimumab IV over 30 minutes 14
days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards),
patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1.
Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or
unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV
over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease
progression or unacceptable toxicity.
After completion of study treatment, patients are followed up at 30 days and then every 2
months for up to 5 years.
Trial Arms
Name | Type | Description | Interventions |
---|
Group A (neoadjuvant nivolumab and placebo) | Experimental | NEOADJUVANT: Patients receive nivolumab IV over 30 minutes and placebo IV over 30 minutes 14 days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards), patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. | - Ipilimumab
- Nivolumab
- Placebo Administration
|
Group B (neoadjuvant nivolumab and ipilimumab) | Experimental | NEOADJUVANT: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes 14 days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards), patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. | |
Group C (neoadjuvant placebo and ipilimumab) | Experimental | NEOADJUVANT: Patients receive placebo IV over 30 minutes and ipilimumab IV over 30 minutes 14 days before undergoing standard of care surgical resection.
ADJUVANT COMBINATION INFUSION: After recovery from surgery (no more than 35 days afterwards), patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity.
ADJUVANT MAINTENANCE: After completion of combination infusion, patients receive nivolumab IV over 30 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. | - Ipilimumab
- Nivolumab
- Placebo Administration
|
Eligibility Criteria
Inclusion Criteria:
1. Participants with recurrent or progressive high-grade gliomas (HGG) (World Health
Organization (WHO) grade III or grade IV) who are candidates for surgical tumor
debulking will be enrolled in this trial
2. All assessments are to occur within 14 days of registration except where otherwise
noted. The participant and their legal parent/guardian must be thoroughly informed
about all aspects of the study, including the study visit schedule and required
evaluations and all regulatory requirements for informed consent. The written informed
consent must be obtained from the participant and legal parent/guardian prior to
enrollment
3. Have a history of previously treated histologically confirmed World Health
Organization grade III or IV HGG. Previous first line therapy with radiation and/or
chemotherapy
4. Have evidence of recurrence or progression of disease by MRI scan
5. Participants must be adequate medical candidates for surgical resection. The intent of
surgical resection is to allow both cytoreduction and tumor debulking as part of
standard of care, and also collect a minimum of 100 mg of tumor tissue for the study
tissue endpoints
6. A primary goal of surgery must be cytoreduction, and not solely on diagnostic biopsy
7. Age: Participants must be > 6 months and < 22 years of age at time of enrollment
8. Karnofsky >= 50 for participants > 16 years of age and Lansky >= 50 for participants
=< 16 years of age. Participants who are unable to walk because of paralysis, but who
are up in a wheelchair, will be considered ambulatory for the purpose of assessing the
performance score
9. Prior Therapy: Participants must have fully recovered from the acute toxic effects of
all prior anti-cancer therapy and must meet the following minimum duration from prior
anti-cancer directed therapy prior to enrollment. If after the required timeframe, the
defined eligibility criteria are met, e.g. blood count criteria, the patient is
considered to have recovered adequately
- Cytotoxic chemotherapy or other anti-cancer agents known to be myelosuppressive.
At least 21 days after the last dose of cytotoxic or myelosuppressive
chemotherapy (42 days if prior nitrosourea)
- An interval of at least 12 weeks from the completion of radiation therapy to
registration unless there is unequivocal histologic confirmation of tumor
progression
- Hematopoietic growth factors: At least 14 days after the last dose of a
long-acting growth factor (e.g. pegfilgrastim) or 7 days for short acting growth
factor. For agents that have known adverse events occurring beyond 7 days after
administration, this period must be extended beyond the time during which adverse
events are known to occur. The duration of this interval must be discussed with
the study chair
- Anti-cancer agents not known to be myelosuppressive (e.g. not associated with
reduced platelet or absolute neutrophil count [ANC] counts): At least 7 days
after the last dose of agent
- Interleukins, interferons and cytokines (other than hematopoietic growth
factors): >= 21 days after the completion of interleukins, interferon or
cytokines (other than hematopoietic growth factors)
- Antibodies: >= 21 days must have elapsed from infusion of last dose of antibody,
and toxicity related to prior antibody therapy must be recovered to grade =< 1
- Participants must not have received prior exposure to PD-1, PD-L1 or CTLA4
inhibitors
- Stem cell infusion (with or without total-body irradiation (TBI)):
- Autologous stem cell infusion including boost infusion: >= 42 days
10. Participants must be willing to forego cytotoxic anti-tumor therapies except
study-defined therapy while being treated on study
11. Organ Function Requirements:
- Peripheral absolute neutrophil count (ANC) >= 1000/mm^3
- Platelet count >= 100,000/mm^3
- Creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70
mL/min/1.73 m^2 OR a serum creatinine based on age/gender as follows:
- Age: Maximum Serum Creatinine (mg/dL)
- 6 months to < 3 years: 0.6 (male and female)
- 3 to < 6 years: 0.8 (male and female)
- 6 to < 10 years: 1 (male and female)
- 10 to < 13 years: 1.2 (male and female)
- 13 to < 16 years: 1.5 (male), 1.4 (female)
- >= 16 years: 1.7 (male), 1.4 (female)
- Bilirubin (sum of conjugated and unconjugated) =< 1.5 x upper limit of normal
(ULN) for age (except participants with Gilbert syndrome who must have a total
bilirubin level of < 3.0
- Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 3.0 x ULN
- Serum albumin >= 2
12. Pregnancy: The effects of nivolumab and ipilimumab on the developing human fetus are
unknown. For this reason women of child-bearing potential must agree to use adequate
contraception (hormonal or barrier method of birth control; abstinence) prior to study
entry, for the duration of study participation and 5 months after completion of
therapy. Should a woman become pregnant or suspect she is pregnant while she or her
partner is participating in this study, she should inform her treating physician
immediately
13. MRI within 28 days prior to registration
Exclusion Criteria:
1. Current or planned participation in a study of an investigational agent or using an
investigational device
2. Has a diagnosis of immunodeficiency
3. Has tumor primarily localized to the brainstem or spinal cord
4. Has presence of diffuse leptomeningeal disease or extracranial disease
5. Has received systemic immunosuppressive treatments (such as methotrexate, chloroquine,
azathioprine, etc.), aside from anti-neoplastic chemotherapy or systemic
corticosteroids within six months of registration
6. Participants with a concurrent condition requiring systemic treatment with either
corticosteroids (> 0.25 mg/kg daily prednisone equivalent) or other immunosuppressive
medications within 14 days of start of study treatment. Inhaled or topical steroids,
and adrenal replacement steroid doses > 0.25 mg/kg daily prednisone equivalent, are
permitted in the absence of active autoimmune disease
7. Unable to taper steroids due to ongoing mass effect; a maximum dexamethasone dose of
0.1 mg/kg/day is allowed, but preferably have been discontinued (inhaled or topical
use of steroids is allowed)
8. Has a known history of active TB (Bacillus tuberculosis)
9. Has a known additional malignancy that is progressing or requires active treatment
within 3 years of registration. Exceptions include basal cell carcinoma of the skin,
squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone
potentially curative therapy
10. 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 (e.g. thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment
11. Has known history of, or any evidence of active non-infectious pneumonitis
12. Has an active infection requiring systemic therapy
13. Has a known hypersensitivity to any of the study therapy products
14. Has a known history of positive test for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome (AIDS)
- NOTE: Testing for HIV must be performed at sites where mandated locally
15. Any prior positive test result for hepatitis B virus or hepatitis C virus indicating
presence of virus, e.g., hepatitis B surface antigen (HBsAg, Australia antigen)
positive, or hepatitis C antibody (anti-HCV) positive (except if HCV-ribonucleic acid
(RNA) negative)
16. Participants who have had prior allogenic hematopoietic stem cell transplant (HSCT)
17. Any serious or uncontrolled medical disorder that, in the opinion of the investigator
may increase the risk associated with study participation or study drug
administration, impair the ability of the participant to receive protocol therapy or
interfere with interpretation of study results
Maximum Eligible Age: | 22 Years |
Minimum Eligible Age: | 6 Months |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Percentage change in cell cycle-related genetic signature |
Time Frame: | From screening to surgery visit (neoadjuvant treatment groups); at time of recurrent high grade glioma (HGG) tissue collection (for archived non-treated samples) |
Safety Issue: | |
Description: | Will assess the percentage change in cell cycle-related genetic signature post administration of neoadjuvant treatments in all 3 treatment groups compared to archived recurrent pediatric HGG group. The number of participants with high cell cycle gene signature (positive median gene set variation analysis (GSVA) score) will be tabulated. Variables involved in the primary analyses will be examined graphically and summarized by descriptive statistics. |
Secondary Outcome Measures
Measure: | Overall survival |
Time Frame: | Up to 12 months |
Safety Issue: | |
Description: | Survival will be assessed at 6 months and 12 months from the time of randomization until the time of death. Kaplan-Meier survival analyses will be performed. Medians together with 2-sided 95% confidence intervals will be computed using a log-log transformation. |
Measure: | Progression-free survival (PFS) |
Time Frame: | Up to 12 months |
Safety Issue: | |
Description: | PFS is defined as the the time of randomization until the time of progressive disease or death. Kaplan-Meier survival analyses will be performed. Medians together with 2-sided 95% confidence intervals will be computed using a log-log transformation. |
Details
Phase: | Phase 1 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | Sabine Mueller, MD, PhD |
Last Updated
June 24, 2021