Background:
LMB-100, and a closely related immunotoxin, SS1P, also targeting mesothelin, given
intravenously, have been studied in Phase 1 clinical studies for mesothelioma and pancreatic
cancer.
LMB-100 given intravenously, results in systemic inflammation in patients, but as a single
agent has limited anti-tumor efficacy.
Almost all patients develop neutralizing anti-LMB-100 antibodies after 2 cycles of therapy.
Intra-tumoral delivery of LMB-100 has been shown to induce immune cell infiltration in
immune-competent mice, bearing murine malignant mesothelioma tumors. Combination with CTLA-4
blockage eradicates murine tumors by promoting anti-cancer immunity.
Ipilimumab is a fully human anti CTLA-4 monoclonal antibody, that is approved for treatment
of melanoma and in combination with nivolumab for many solid tumors.
It is hypothesized that intra-tumoral delivery of anti-mesothelin immunotoxin LMB-100 in
combination with ipilimumab will result in greater anti-tumor efficacy in patients with
mesothelioma.
Objective:
To determine the safety and feasibility of intra-tumoral LMB-100 injection plus ipilimumab
infusion in patients with mesothelioma
To identify the recommended phase 2 dose (RP2D) of intratumorally administered LMB-100 +
ipilimumab in patients with malignant mesothelioma
Eligibility:
Histologically confirmed pleural or peritoneal mesothelioma not amenable to potentially
curative surgical resection.
Have locally accessible disease suitable for intra-tumor injection of LMB-100. This includes
superficial or visceral lesions.
Subjects must have received prior immune checkpoint therapy with anti-PD-1/PD-L1 inhibitors
alone or in combination with anti-CTLA4 blocking antibodies, as well as platinum-based
chemotherapy.
Age >= 18 years.
ECOG performance status of 0 or 1.
Adequate organ and bone marrow function
Subjects with clinically significant pericardial effusion are excluded
Chemotherapy within 3 weeks or radiotherapy within 2 weeks prior to start of study therapy is
prohibited.
Subjects with active CNS metastasis are excluded
Subjects with active autoimmune disease for which they have received systemic
immunosuppressive medications during the previous 2 years (excluding daily
glucocorticoid-replacement therapy for conditions such as adrenal or pituitary insufficiency)
are excluded
Subjects with active interstitial lung disease, or a history of pneumonitis or interstitial
lung disease for which they had received glucocorticoids are excluded
Design:
This is an open-label, single center phase I dose escalation study of intratumorally
administered LMB-concurrently with ipilimumab in subjects with malignant mesothelioma.
Subjects will receive intratumorally administered LMB-100, beginning at dose level 1, in
21-day cycles. LMB-100 will be given on days 1 and 4 and ipilimumab 3 mg/kg given on day 2.
Patients will receive 2 cycles of LMB-100 plus ipilimumab, followed by 2 cycles of ipilimumab
alone
Tumor biopsies will be performed prior to each administration of LMB-100, to evaluate changes
in the tumor immune microenvironment
Up to 12 evaluable subjects will be enrolled.
- INCLUSION CRITERIA:
1. Histologically confirmed malignant pleural or peritoneal mesothelioma not
amenable to potentially curative surgical resection. The diagnosis will be
confirmed by the Laboratory of Pathology, CCR, NCI.
2. Tumor must have epithelioid histology determined by the Laboratory of Pathology
at the NCI. If the patient has biphasic histology, the epithelioid component must
be >50%
3. Have provided archival tumor tissue sample or able to provide newly obtained core
or excisional biopsy of a tumor lesion not previously irradiated. Formalin-fixed,
paraffin embedded (FFPE) tissue blocks are preferred to slides. Newly obtained
biopsies are preferred to archived tissue.
Note: If submitting unstained cut slides, newly cut slides should be submitted to
the testing laboratory within 14 days from the date slides are cut.
4. Have disease locally accessible disease to suitable for intratumoral injection of
LMB- 100.
5. Have measurable disease based on RECIST 1.1. Lesions in a previously irradiated
area are considered measurable if progression has been demonstrated in such
lesions.
6. Subjects must have received prior immune checkpoint therapy with anti-PD-1/PD-L1
inhibitors alone or in combination with anti-CTLA4 blocking antibodies, as well
as platinum based chemotherapy.
7. Age >= 18 years.
8. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
Evaluation of ECOG is to be performed within 28 days prior to initiation of study
therapy.
9. Have adequate organ and marrow function as defined below:
System and Laboratory Value
Hematological<TAB>
hemoglobin >= 9 g/dL(a)
absolute neutrophil count >= 1,500/mcL
platelets >= 100,000/mcL
Hepatic
total bilirubin <= 2.5 X institutional ULN OR direct bilirubin <=ULN for
participants with total bilirubin levels >1.5 X ULN
AST and ALT <= 2.5 X institutional ULN (<= 5 X ULN for participants with liver
metastases)
Renal
Creatinine <=1.5 x ULN OR Measured or calculated(b) creatinine clearance (GFR can
also be used in place of creatinine or CrCl) >= 50 mL/min for participant with
creatinine levels; > 1.5 X institutional ULN
Coagulation
International normalized ratio (INR) OR prothrombin time (PT); Activated partial
thromboplastin time (aPTT): <=1.5 x ULN unless participant is receiving
anticoagulant therapy as long as PT or aPTT is within therapeutic range of
intended use of anticoagulants
ALT (SGPT)=alanine aminotransferase (serum glutamic pyruvic transaminase); AST
(SGOT)=aspartate aminotransferase (serum glutamic oxaloacetic transaminase);
GFR=glomerular filtration rate; ULN=upper limit of normal.
1. Criteria must be met without erythropoietin dependency and without packed
red blood cell (pRBC) transfusion within last 2 weeks.
2. Creatinine clearance (CrCl) should be calculated per institutional standard.
10. Must have left ventricular ejection fraction >50%.
11. The effects of LMB-100 on the developing human fetus are unknown. For this reason
and because ipilimumab is a Category C agent, women of child-bearing potential
and men must agree to use adequate contraception (hormonal or barrier method of
birth control; abstinence) while on study therapy and for four months after the
last dose of study 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.
12. Ability of subject to understand and the willingness to sign a written informed
consent document.
EXCLUSION CRITERIA:
1. Is currently participating in or has participated in a study of an investigational
agent or has used an investigational device within 3 weeks prior to initiation of
study therapy.
Note: Participants who have entered the follow-up phase of an investigational study
may participate as long as it has been 3 weeks after the last dose of the previous
investigational agent. Patients with active devices will be excluded from the study
2. Has known active CNS metastases and/or carcinomatous meningitis. Participants with
previously treated brain metastases may participate provided they are radiologically
stable, i.e. without evidence of progression for at least 4 weeks by repeat imaging
(note that the repeat imaging should be performed during study screening), clinically
stable and without requirement of steroid treatment for at least 14 days prior to
initiation of study therapy.
3. Has active systemic issues as bleeding diathesis or active infections
4. Presence of a clinically significant pericardial effusion
5. Has severe hypersensitivity (>=Grade 3) anti-CTLA4 therapies and/or any of their
excipients.
6. Has received prior radiotherapy to the site of local administration
7. Subjects who have received LMB-100 previously
8. Has received prior systemic anti-cancer therapy including investigational agents
within 3 weeks prior to initiation of study therapy. Patients who have received prior
anti-PD-1/PD- L1 or CTLA4 antibodies are eligible. Any toxicity related to these
agents must have resolved to grade 1 and they must not be on systemic
immunosuppressive therapies (physiologic dose of steroids are permitted).
9. Has received prior radiotherapy to site other than target lesion within 2 weeks prior
to initiation of study therapy. Participants must have recovered from all
radiation-related toxicities, not require corticosteroids, and not have had radiation
pneumonitis. A 1-week washout is permitted for palliative radiation (<=2 weeks of
radiotherapy) to non-CNS disease.
10. Has not recovered from all AEs due to previous therapies to <=Grade 1 or baseline.
Participants with <=Grade 2 neuropathy may be eligible. If participant received major
surgery, they must have recovered adequately from the toxicity and/or complications
from the intervention prior to initiation of study therapy.
11. Has received a live vaccine within 30 days prior to initiation of study therapy.
Examples of live vaccines include, but are not limited to, the following: measles,
mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus
Calmette-Guerin (BCG), and typhoid vaccine. Seasonal influenza vaccines for injection
are generally killed virus vaccines and are allowed; however, intranasal influenza
vaccines (e.g., FluMist(R)) are live attenuated vaccines and are not allowed.
12. Is receiving therapeutic anti-coagulation. Patients receiving prophylactic
anticoagulation may be eligible if in the opinion of the study team, anti-coagulation
may be stopped during the time of LMB-100 administration and tumor biopsies
13. Has a diagnosis of immunodeficiency or is receiving chronic systemic steroid therapy
(in dosing exceeding 10 mg daily of prednisone equivalent) or any other form of
immunosuppressive therapy within 7 days prior to initiation of study therapy.
14. 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.
15. Has a QTcF interval >480 milliseconds
16. Has a history of (non-infectious) pneumonitis/interstitial lung disease(ILD) that
required steroids or has current pneumonitis/ILD
17. Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the study, interfere with the subject s
participation for the full duration of the study, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator.
18. Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.
19. A woman of childbearing potential who has a positive pregnancy test within 72 hours
prior to initiation of study therapy. If the using a urine test and test positive or
cannot be confirmed as negative, a serum pregnancy test will be required. Note: in the
event that 72 hours have elapsed between the screening pregnancy test and the first
dose of study treatment, another pregnancy test (urine or serum) must be performed and
must be negative in order for subject to start receiving study medication.
20. Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the study, starting with the screening visit through 4 months
after the last dose of trial treatment. Pregnant women are excluded from this study
because LMB-100 + ipilimumab are agents with the potential for teratogenic or
abortifacient effects. Because there is an unknown but potential risk for adverse
events in nursing infants secondary to treatment of the mother with LMB-100 +
ipilimumab, breastfeeding should be discontinued if the mother is treated with LMB-100
+ ipilimumab. These potential risks may also apply to other agents used in this study.
21. HIV positive patients will be excluded due to a theoretical concern that the degree of
immune suppression associated with the treatment may result in progression of HIV
infection.
22. Positive for Hepatitis B or C (defined as Hepatitis B surface antigen reactive) or
known active Hepatitis C virus (defined as HCV RNA detected) infection. or active HBV
or HCV infection.
23. Has a known additional malignancy that is progressing or has required active treatment
within the past 2 years. Note: Participants with basal cell carcinoma of the skin,
squamous cell carcinoma of the skin, or carcinoma in situ (e.g. breast carcinoma,
cervical cancer in situ) that have undergone potentially curative therapy are not
excluded.
24. Has an active infection requiring systemic therapy.