Leptomeningeal Carcinomatosis
Conditions
Keywords
Leptomeningeal Metastases
Brief summary
This research study is studying a combination of two drugs as a possible treatment for Leptomeningeal Metastases. The names of the study interventions involved in this study are: * Ipilimumab * Nivolumab
Detailed description
This research study is a Phase II clinical trial. Researchers hope to study the effects of the combination of Nivolumab and Ipilimumab. Many cancers use specific pathways, such as programmed death-1 (PD-1), programmed death-ligand-1 (PD-L1), and cytotoxic T lymphocyte antigen-4 (CTLA-4), to evade the body's immune system. Nivolumab and ipilimumab work by blocking the PD-1/PD-L1 and CTLA-4 pathways and thus releasing the brakes on the immune system so it can stop or slow cancer. The FDA (the U.S. Food and Drug Administration) has approved Nivolumab and Ipilimumab as a treatment option for melanoma, but has not approved them for use when cancer cells spread to the cerebrospinal fluid
Interventions
DRUGNivolumab
* Melanoma: \- Combination therapy with Nivolumab 1 mg/kg for 4 doses followed by monotherapy Nivolumab 480 mg per cycle. * Non-small Cell Lung Cancer / Head and Neck Cancer: \- Combination therapy with Nivolumab 3 mg/kg * Small Cell Lung Cancer / Breast Cancer / Bladder Cancer: \- Combination therapy with Nivolumab 1 mg/kg for 4 doses followed by monotherapy Nivolumab 240 mg per cycle. * Renal Cell Carcinoma / Other Solid Tumors (not listed above): * Combination therapy with Nivolumab 3 mg/kg for 4 doses followed by monotherapy Nivolumab 480 mg per cycle.
DRUGIpilimumab
* Non-small Cell Lung Cancer / Head and Neck Cancer: \- Combination therapy with Ipilimumab 1 mg/kg * Small Cell Lung Cancer / Breast Cancer / Bladder Cancer: \- Combination therapy with Ipilimumab 3 mg/kg for 4 doses * Renal Cell Carcinoma / Other Solid Tumors (not listed above): * Combination therapy with Ipilimumab 3 mg/kg for 4 doses
Sponsors
Bristol-Myers Squibb
Massachusetts General Hospital
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Participants must have histologically or cytologically confirmed disease from any solid tumor * Age ≥18 years. * Eastern Cooperative Oncology Group (ECOG) performance status ≤2 (Karnofsky ≥60%) * Life expectancy of greater than 3 weeks * Participants must have normal organ and marrow function as defined below, all screening labs should be performed within 10 days of treatment initiation. Adequate Organ Function Laboratory Values: Unit key: mcL = microliter, ULN = upper limit normal * Hematological * Absolute neutrophil count (ANC) ≥1500 /mcL * Platelets ≥100,000 / mcL * Hemoglobin ≥9 g/dL or ≥5.6 mmol/L without transfusion or Erythropoietin (EPO) dependency (within 7 days of assessment) * Renal * Serum creatinine OR Measured or calculated creatinine clearance (GFR can also be used in place of creatinine or CrCl) ≤ Serum creatinine ≤ 1.5 x ULN or creatinine clearance (CrCl) ≥ 40 mL/min (if using the Cockcroft-Gault formula below): * Female CrCl = (140 - age in years) x weight in kg x 0.85 72 x serum creatinine in mg/dL * Male CrCl = (140 - age in years) x weight in kg x 1.00 72 x serum creatinine in mg/dL * Hepatic * Serum total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with total bilirubin levels \> 1.5 ULN * Aspartate transaminase (AST) and Alanine transaminase (ALT) ≤ 3 ULN OR ≤ 5 X ULN for subjects with liver metastases * Albumin ≥ 2.5 mg/dL * Coagulation * International Normalized Ratio (INR) or Prothrombin Time (PT) ≤1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants * Activated Partial Thromboplastin Time (aPTT) ≤1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants * Creatinine clearance should be calculated per institutional standard. * Women of childbearing potential (WOCBP) must use appropriate method(s) of contraception. WOCBP should use an adequate method to avoid pregnancy for 23 weeks (30 days plus the time required for Nivolumab to undergo five half-lives) after the last dose of investigational drug. * Women of childbearing potential must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) within 24 hours prior to the start of Nivolumab * Women must not be breastfeeding * Men who are sexually active with WOCBP must use any contraceptive method with a failure rate of less than 1% per year. Men receiving nivolumab and who are sexually active with WOCBP will be instructed to adhere to contraception for a period of 31 weeks after the last dose of investigational product. Women who are not of childbearing potential, ie, who are postmenopausal or surgically sterile as well as azoospermic men do not require contraception * Ability to understand and the willingness to sign a written informed consent document. * Stable dose of dexamethasone 2 mg or less for 7 days prior to initiation of treatment * Carcinomatous meningitis, as defined by positive cytology
Exclusion criteria
* Participants who have had chemotherapy, targeted small molecule therapy or study therapy within 14 days of protocol treatment, or those who have not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents administered more than 2 weeks earlier. Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study. If subject received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy. * Participants who are receiving any other investigational agents. * Patients should be excluded if they have an active, known or suspected autoimmune disease. Subjects are permitted to enroll if they have vitiligo, type I diabetes mellitus, residual hypothyroidism due to autoimmune condition only requiring hormone replacement, psoriasis not requiring systemic treatment, or conditions not expected to recur in the absence of an external trigger * Patients should be excluded if they have a condition requiring systemic treatment with either corticosteroids (\> 10 mg daily prednisone equivalents) or other immunosuppressive medications within 14 days of study drug administration. Inhaled or topical steroids and adrenal replacement doses \> 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease. Subjects are permitted to use topical, ocular, intra-articular, intranasal, and inhalational corticosteroids (with minimal systemic absorption). Physiologic replacement doses of systemic corticosteroids are permitted, even if \> 10 mg/day prednisone equivalents. A brief course of corticosteroids for prophylaxis (eg, contrast dye allergy) or for treatment of non-autoimmune conditions (eg, delayed-type hypersensitivity reaction caused by contact allergen) is permitted. * As there is potential for hepatic toxicity with nivolumab or nivolumab/ipilimumab combinations, drugs with a predisposition to hepatoxicity should be used with caution in patients treated with nivolumab-containing regimen. * Patients should be excluded if they have had prior systemic treatment with an anti-CTLA4 antibody * Has a known history of active TB (Bacillus Tuberculosis) * Patients should be excluded if they are positive test for hepatitis B virus surface antigen (HBV sAg) or hepatitis C virus ribonucleic acid (HCV antibody) indicating acute or chronic infection * Patients should be excluded if they have known history of testing positive for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS). These participants are at increased risk of lethal infections when treated with marrow-suppressive therapy. Appropriate studies will be undertaken in participants receiving combination antiretroviral therapy when indicated. * Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. * Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial. * 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 a known additional malignancy that is progressing or requires active treatment. Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer. * Has known history of, or any evidence of active, non-infectious pneumonitis. * Has an active infection requiring systemic therapy. * Has received a live vaccine within 30 days of planned start of study therapy. Note: Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated vaccines, and are not allowed. * History of allergy to study drug components * History of severe hypersensitivity reaction to any monoclonal antibody
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of Participants With Overall Survival | 3 months | Overall Survival (OS) is defined as the time from registration to death due to any cause, or censored at date last known alive. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Cumulative Incidence of Progressive Disease at 3 Months for Intracranial Sites | 3 months post-treatment | Cumulative incidence describes the average probability of developing progressive disease (PD) by immunotherapy response assessment for neuro-oncology (iRANO) criteria. PD is defined as any of the following: (1) \>/= 25% increase in 2-dimensional contrast lesions; (2) significant worsened changes on T2-weighted MRI scans; (3) new lesion; or (4) significant clinical decline. Confirmation of progressive disease is based on follow-up imaging for participants without significant clinical decline. |
| Cumulative Incidence of Progressive Disease at 3 Months for Extracranial Sites | 3 months post-treatment | Cumulative incidence describes the average probability of developing progressive disease (PD) by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 criteria. PD is defined as any of the following: (1) \>/= 25% increase in 2-dimensional contrast lesions; (2) significant worsened changes on T2-weighted MRI scans; (3) new lesion; or (4) significant clinical decline. Confirmation of progressive disease is based on follow-up imaging for participants without significant clinical decline. |
| Percentage of Participants With Treatment-related Adverse Events | 2 years | Grade 3 or 4 treatment-related adverse events occurring in at least 15% of participants, based on CTCAE v4.0 criteria. |
| Extracranial Progression-Free Survival | 2 years | Extracranial Progression-Free Survival (EPFS) is defined as the time from first dose of study drug to documented extracranial disease progression or death, whichever occurs first. Extracranial disease progression is assessed with CT scans of the chest, abdomen, and pelvis, by Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 criteria and immune-related response criteria (irRC) criteria. Progression is defined using RECIST v1.0 as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. The follow-up of participants who have neither died nor progressed at the time of analysis will be censored at the date of last adequate disease assessment. |
| Intracranial Progression-Free Survival | 2 years | Intracranial Progression-Free Survival (IPFS) is defined as the time from first dose of study drug to documented intracranial disease progression or death, whichever occurs first. Intracranial disease progression is assessed with CT or MRI scans of the brain, using the Response assessment in neuro-oncology (RANO) criteria, which defines progression as: * ≥ 25% increase in in the sum of products of all measurable lesions over smallest sum observed (over baseline if no decrease) using the same techniques as baseline; or * Presence of new lesions; or * Worsening of clinical/neurologic status (unless clearly unrelated to the cancer); or * Worsening of non-measurable disease. The follow-up of participants who have neither died nor progressed at the time of analysis will be censored at the date of last adequate disease assessment. |
| Number of Participants With Leptomeningeal Disease (LMD) Response Post-Treatment | 6-9 weeks after treatment initiation | Cerebrospinal fluid (CSF) collection and cytology is done 6-9 weeks after treatment initiation to assess for LMD response, especially complete response or partial response. Complete Response is defined as: * Reversion to negative CSF cytology (or NA) * Disappearance of all disease related symptoms present prior to therapy (or NA) * Complete disappearance of all detectable radiographic evidence of disease (or NA). Partial Response is defined as: * \> 50% decrease in malignant CSF cytology * Improvement in neurologic symptoms or no worsening of symptoms * Improvement in radiographic evidence of disease. No new sites of measurable or assessable central nervous system (CNS) disease. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Combination Of Nivolumab With Ipilimumab All patients will be treated with the combination regimen of Nivolumab at pre-determine dose with Ipilimumab at a pre-determine dose.This will be followed by Nivolumab Monotherapy.
Each treatment Cycle will last 6 weeks
Nivolumab
Ipilimumab | 18 |
| Total | 18 |
Baseline characteristics
| Characteristic | Combination Of Nivolumab With Ipilimumab |
|---|---|
| Age, Continuous | 54 years |
| Brain metastases at the time of leptomeningeal disease (LMD) diagnosis No | 5 Participants |
| Brain metastases at the time of leptomeningeal disease (LMD) diagnosis Yes | 13 Participants |
| Eastern Cooperative Oncology Group (ECOG) performance status 0 = Fully active; no performance restrictions | 4 Participants |
| Eastern Cooperative Oncology Group (ECOG) performance status 1 = Strenuous physical activity restricted; fully ambulatory and able to carry out light work | 10 Participants |
| Eastern Cooperative Oncology Group (ECOG) performance status 2 = Capable of all self-care but unable to carry out work activities.Up and about >50% of waking hrs | 4 Participants |
| Extracranial disease at the time of leptomeningeal disease (LMD) diagnosis No | 5 Participants |
| Extracranial disease at the time of leptomeningeal disease (LMD) diagnosis Unknown | 2 Participants |
| Extracranial disease at the time of leptomeningeal disease (LMD) diagnosis Yes | 11 Participants |
| Primary tumor diagnosis Anaplastic astrocytoma | 1 Participants |
| Primary tumor diagnosis Breast Cancer | 8 Participants |
| Primary tumor diagnosis Ependymoma | 1 Participants |
| Primary tumor diagnosis Esophageal adenocarcinoma | 1 Participants |
| Primary tumor diagnosis Gastroesophageal (GE) junction adenocarcinoma | 1 Participants |
| Primary tumor diagnosis Glioblastoma | 1 Participants |
| Primary tumor diagnosis Lung adenocarcinoma | 1 Participants |
| Primary tumor diagnosis Melanoma | 2 Participants |
| Primary tumor diagnosis Ovarian | 1 Participants |
| Primary tumor diagnosis Small cell lung carcinoma | 1 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 2 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 2 Participants |
| Race (NIH/OMB) White | 14 Participants |
| Sex: Female, Male Female | 11 Participants |
| Sex: Female, Male Male | 7 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 13 / 18 |
| other Total, other adverse events | 17 / 18 |
| serious Total, serious adverse events | 10 / 18 |
Outcome results
Primary
Percentage of Participants With Overall Survival
Overall Survival (OS) is defined as the time from registration to death due to any cause, or censored at date last known alive.
Time frame: 3 months
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Percentage of Participants With Overall Survival | 44 percentage of participants |
Secondary
Cumulative Incidence of Progressive Disease at 3 Months for Extracranial Sites
Cumulative incidence describes the average probability of developing progressive disease (PD) by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 criteria. PD is defined as any of the following: (1) \>/= 25% increase in 2-dimensional contrast lesions; (2) significant worsened changes on T2-weighted MRI scans; (3) new lesion; or (4) significant clinical decline. Confirmation of progressive disease is based on follow-up imaging for participants without significant clinical decline.
Time frame: 3 months post-treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Cumulative Incidence of Progressive Disease at 3 Months for Extracranial Sites | 33 percentage of participants |
Secondary
Cumulative Incidence of Progressive Disease at 3 Months for Intracranial Sites
Cumulative incidence describes the average probability of developing progressive disease (PD) by immunotherapy response assessment for neuro-oncology (iRANO) criteria. PD is defined as any of the following: (1) \>/= 25% increase in 2-dimensional contrast lesions; (2) significant worsened changes on T2-weighted MRI scans; (3) new lesion; or (4) significant clinical decline. Confirmation of progressive disease is based on follow-up imaging for participants without significant clinical decline.
Time frame: 3 months post-treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Cumulative Incidence of Progressive Disease at 3 Months for Intracranial Sites | 45 percentage of participants |
Secondary
Extracranial Progression-Free Survival
Extracranial Progression-Free Survival (EPFS) is defined as the time from first dose of study drug to documented extracranial disease progression or death, whichever occurs first. Extracranial disease progression is assessed with CT scans of the chest, abdomen, and pelvis, by Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 criteria and immune-related response criteria (irRC) criteria. Progression is defined using RECIST v1.0 as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. The follow-up of participants who have neither died nor progressed at the time of analysis will be censored at the date of last adequate disease assessment.
Time frame: 2 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Extracranial Progression-Free Survival | 1.94 months |
Secondary
Intracranial Progression-Free Survival
Intracranial Progression-Free Survival (IPFS) is defined as the time from first dose of study drug to documented intracranial disease progression or death, whichever occurs first. Intracranial disease progression is assessed with CT or MRI scans of the brain, using the Response assessment in neuro-oncology (RANO) criteria, which defines progression as: * ≥ 25% increase in in the sum of products of all measurable lesions over smallest sum observed (over baseline if no decrease) using the same techniques as baseline; or * Presence of new lesions; or * Worsening of clinical/neurologic status (unless clearly unrelated to the cancer); or * Worsening of non-measurable disease. The follow-up of participants who have neither died nor progressed at the time of analysis will be censored at the date of last adequate disease assessment.
Time frame: 2 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Intracranial Progression-Free Survival | 1.93 months |
Secondary
Number of Participants With Leptomeningeal Disease (LMD) Response Post-Treatment
Cerebrospinal fluid (CSF) collection and cytology is done 6-9 weeks after treatment initiation to assess for LMD response, especially complete response or partial response. Complete Response is defined as: * Reversion to negative CSF cytology (or NA) * Disappearance of all disease related symptoms present prior to therapy (or NA) * Complete disappearance of all detectable radiographic evidence of disease (or NA). Partial Response is defined as: * \> 50% decrease in malignant CSF cytology * Improvement in neurologic symptoms or no worsening of symptoms * Improvement in radiographic evidence of disease. No new sites of measurable or assessable central nervous system (CNS) disease.
Time frame: 6-9 weeks after treatment initiation
Population: Due to the clinical nature of LMD with rapidly progressive disease, the majority participants did not undergo post-treatment lumbar punctures before going off study or passing away. CSF cytology 6-9 weeks after treatment initiation was only obtained on 4 participants, which does not provide statistically meaningful interpretation of data. Individual results are reported below.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Number of Participants With Leptomeningeal Disease (LMD) Response Post-Treatment | Complete Response | 0 participants |
| Combination Of Nivolumab with Ipilimumab | Number of Participants With Leptomeningeal Disease (LMD) Response Post-Treatment | Partial Response | 1 participants |
Secondary
Percentage of Participants With Treatment-related Adverse Events
Grade 3 or 4 treatment-related adverse events occurring in at least 15% of participants, based on CTCAE v4.0 criteria.
Time frame: 2 years
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Combination Of Nivolumab with Ipilimumab | Percentage of Participants With Treatment-related Adverse Events | 33 percentage of participants |