Glioblastoma
Conditions
Brief summary
This pilot phase II trial studies how well ferumoxytol magnetic resonance imaging (MRI) works in assessing response to pembrolizumab in patients with glioblastoma. Diagnostic procedures, such as ferumoxytol MRI, may help measure a patient's response to pembrolizumab treatment.
Detailed description
PRIMARY OBJECTIVE: I. Determine the sensitivity and specificity of relative cerebral blood volume (rCBV) measured by steady state MRI with ferumoxytol in identifying true versus (vs) pseudoprogression in patients with newly diagnosed glioblastoma multiforme (GBM) receiving pembrolizumab with standard of care chemo-radiation. SECONDARY OBJECTIVES: I. Determine the safety and toxicity of pembrolizumab when used in combination with standard of care chemo radiation. II. Determine the progression free survival (PFS), overall survival (OS), clinical response and duration of best response. EXPLORATORY OBJECTIVES: I. Compare the immune response as determined by the volume, pattern and intensity of delayed (24 hour \[hr\]) ferumoxytol uptake between subjects who develop true vs pseudoprogression. II. Investigate the serum immunological parameters (serum biomarker) and correlate clinical as well as radiological response with systemic immune response to pembrolizumab as measured by immunological panel. III. Compare the changes in PDL-1 expression in the biopsy tissue before and after therapy at the time of progression and correlate PD-L1 expression with response rates and survival. IV. Investigate the feasibility of measuring vascular volume fraction (VVF), vessel size index (VSI) and vessel density index (VDI) as surrogate for response (true vs pseudoprogression, as determined by Response Evaluation Criteria in Solid Tumors \[RECIST\] 1.1 and immune related response criteria \[irRC\]). OUTLINE: Patients receive pembrolizumab intravenously (IV) over 30 minutes on day 1. Treatment repeats every 3 weeks for up to 2 years or 35 cycles in the absence of disease progression or unacceptable toxicity. Patients also receive ferumoxytol IV and undergo MRI scans at baseline, 4 weeks after the last day of standard of care stereotactic radiosurgery or chemoradiotherapy, every 9 weeks thereafter until suspected radiographic progression, and then within 4 weeks from suspected radiographic progression. After completion of study treatment, patients are followed up at 30 days, every 12 weeks for up to 1 year, and then every 6 months thereafter.
Interventions
DRUGFerumoxytol
Given IV
OTHERLaboratory Biomarker Analysis
Correlative studies
PROCEDUREMagnetic Resonance Imaging
Undergo ferumoxytol MRI
BIOLOGICALPembrolizumab
Given IV
Sponsors
National Cancer Institute (NCI)
Oregon Health and Science University
OHSU Knight Cancer Institute
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
* Be willing and able to provide written informed consent/assent for the trial * Have a life expectancy of at least 6 months * Have a histologically confirmed diagnosis of: * Newly diagnosed glioblastoma (World Health Organization \[WHO\] grade IV) * Have Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 on stable or reducing dose of steroids for symptom management (not more than 8 mg of dexamethasone or equivalent per day) for 5 days prior to enrollment; change in glucocorticoid dose for any purpose other than to modulate symptoms from an adverse event; Note: The use of physiologic doses (e.g., prednisone 10 mg) of corticosteroids may be approved after consultation with Merck & Co; use of prophylactic corticosteroids to avoid allergic reactions (e.g. IV contrast dye) is permitted * At least 14 days from any major surgeries including brain biopsy before the start of study drug pembrolizumab * Absolute neutrophil count (ANC) \>= 1,500/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) * Serum creatinine =\< 1.5 X upper limit of normal (ULN) OR measured or calculated creatinine clearance (glomerular filtration rate \[GFR\] can also be used in place of creatinine or creatinine clearance \[CrCl\]) \>= 60 mL/min for subject with creatinine levels \> 1.5 X institutional ULN * Serum total bilirubin =\< 1.5 X ULN OR direct bilirubin =\< ULN for subjects with total bilirubin levels \> 1.5 ULN * Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase \[SGOT\]) and alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase \[SGPT\]) =\< 2.5 X ULN OR =\< 5 X ULN for subjects with liver metastases * Albumin \>= 2.5 mg/dL * International normalized ratio (INR) or prothrombin time (PT) =\< 1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or partial thromboplastin time (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 * Female subject of childbearing potential should have a negative urine or serum pregnancy within 72 hours prior to receiving the first dose of study medication; if the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required * Female subjects of childbearing potential should be willing to use 2 methods of birth control or be surgically sterile, or abstain from heterosexual activity for the course of the study through 120 days after the last dose of study medication; subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for \> 1 year; male subjects should agree to use an adequate method of contraception, including but not limited to, abstinence from heterosexual activity starting with the first dose of study therapy through 120 days after the last dose of study therapy * Subject is eligible for and agrees to receive standard of care radiation and temozolamide after biopsy or maximum safe surgical resection
Exclusion criteria
* Has a diagnosis of immunodeficiency including human immunodeficiency virus (HIV) (HIV 1/2 antibodies) and is not on continuous daily immunosuppressive therapy within 7 days prior to the first dose of trial treatment; (an exception to this is the use of steroids for brain edema and resulting symptom); subjects may receive a stable or reducing dose of steroids (up to 8 mg dexamethasone or equivalent for at least 5 days prior to signing consent) to prevent or manage cerebral edema; subjects requiring over 8mg of dexamethasone per day on or five days prior to signing consent are excluded) * Has a known history of active TB (Bacillus tuberculosis) * Hypersensitivity to pembrolizumab or ferumoxytol or any of their excipients * Has had a prior anti-cancer monoclonal antibody (mAb) within 4 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 4 weeks earlier * 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 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 * Has known history of, or any evidence of active, non-infectious pneumonitis * Has an active infection requiring systemic therapy * 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 * 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 known active hepatitis B (e.g., hepatitis B surface antigen \[HBsAg\] reactive) or hepatitis C (e.g., hepatitis C virus \[HCV\] ribonucleic acid \[RNA\] \[qualitative\] is detected) * 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 * Subjects with clinically significant signs of uncal herniation, such as acute pupillary enlargement, rapidly developing motor changes (over hours), or rapidly decreasing level of consciousness, are not eligible * Subjects with known allergic or hypersensitivity reactions to parenteral iron, parenteral dextran, parenteral iron-dextran, or parenteral iron-polysaccharide preparations (Ferumoxytol Investigator's Drug Brochure, 2009); subjects with significant drug or other allergies or autoimmune diseases may be enrolled at the investigator's discretion * Subjects who have a contraindication for 3T MRI: metal in their bodies (a cardiac pacemaker or other incompatible device), are severely agitated * Subjects with known iron overload (genetic hemochromatosis); in subjects with a family history of hemochromatosis, hemochromatosis must be ruled out prior to study entry with normal values of the following blood tests: transferrin saturation (TS) test and serum ferritin (SF) test; all associated costs will be paid by the study * Subject who have received ferumoxytol within 3 weeks of study entry * Subjects with three or more drug allergies from separate drug classes
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Specificity of Identifying Pseudoprogression | At suspected progression, up to two years. | Sensitivity and specificity are measures for the diagnostic performance of rCBV (relative cerebral blood volume) to distinguish between pseudoprogression and true progression. Sensitivity measures how well Fe-SS-rCBV identifies those who have true progression, and specificity those who have psuedoprogression. Because rCBV is a continuous variable, the cutoff point for this analysis was 1.75. |
| Sensitivity of Identifying True Progression | At suspected progression, up to two years. | The calculation of sensitivity is based on steady state rCBV (relative cerebral blood volume) at suspected progression. Cutoff point 1.75. Sensitivity and specificity are measures for the diagnostic performance of rCBV (relative cerebral blood volume) to distinguish between pseudoprogression and true progression. Sensitivity measures how well Fe-SS-rCBV identifies those who have true progression, and specificity those who have psuedoprogression. Because rCBV is a continuous variable, the cutoff point for this analysis was 1.75. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Duration of Best Response | Until off study, up to 5 years. | Will be analyzed using the Kaplan-Meier product limit estimates. Response assessment was completed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria. |
| Progression Free Survival | Until off study, up to 5 years. | Will be assessed using the Kaplan-Meier product limit estimates. Response assessment was completed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria. |
| Determine the Safety and Toxicity of Pembrolizumab When Used in Combination With Standard of Care Chemo Radiation. | 30 days after last dose of pembrolizumab, up to 2 years. | Number of participants with adverse events possibly related or related to pembrolizumab in combination with standard of care. Will be analyzed using proportions and exact 95% confidence intervals. |
| Disease Response | Until off study, up to 5 years. | Disease response was assessed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria. |
| Overall Survival | Until off study, up to 5 years. | Will be assessed using the Kaplan-Meier product limit estimates. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) Patients receive pembrolizumab IV over 30 minutes on day 1. Treatment repeats every 3 weeks for up to 2 years or 35 cycles in the absence of disease progression or unacceptable toxicity. Patients also receive ferumoxytol IV and undergo MRI scans at baseline, 4 weeks after the last day of standard of care stereotactic radiosurgery or chemoradiotherapy, every 9 weeks thereafter until suspected radiographic progression, and then within 4 weeks from suspected radiographic progression.
Ferumoxytol: Given IV
Laboratory Biomarker Analysis: Correlative studies
Magnetic Resonance Imaging: Undergo ferumoxytol MRI
Pembrolizumab: Given IV | 52 |
| Total | 52 |
Baseline characteristics
| Characteristic | Diagnostic (Ferumoxytol MRI, Pembrolizumab) |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 15 Participants |
| Age, Categorical Between 18 and 65 years | 37 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 51 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants |
| Race (NIH/OMB) More than one race | 1 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 51 Participants |
| Region of Enrollment United States | 52 participants |
| Sex: Female, Male Female | 19 Participants |
| Sex: Female, Male Male | 33 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 45 / 52 |
| other Total, other adverse events | 51 / 52 |
| serious Total, serious adverse events | 15 / 52 |
Outcome results
Primary
Sensitivity of Identifying True Progression
The calculation of sensitivity is based on steady state rCBV (relative cerebral blood volume) at suspected progression. Cutoff point 1.75. Sensitivity and specificity are measures for the diagnostic performance of rCBV (relative cerebral blood volume) to distinguish between pseudoprogression and true progression. Sensitivity measures how well Fe-SS-rCBV identifies those who have true progression, and specificity those who have psuedoprogression. Because rCBV is a continuous variable, the cutoff point for this analysis was 1.75.
Time frame: At suspected progression, up to two years.
Population: A total of 15 out of 52 participants were evaluable to allow calculation of sensitivity to distinguish true progression from pseudo-progression based on steady state rCBV at suspected progression
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Sensitivity of Identifying True Progression | 46.7 percentage |
Primary
Specificity of Identifying Pseudoprogression
Sensitivity and specificity are measures for the diagnostic performance of rCBV (relative cerebral blood volume) to distinguish between pseudoprogression and true progression. Sensitivity measures how well Fe-SS-rCBV identifies those who have true progression, and specificity those who have psuedoprogression. Because rCBV is a continuous variable, the cutoff point for this analysis was 1.75.
Time frame: At suspected progression, up to two years.
Population: A total of 12 out of 52 participants were evaluable to allow calculation of specificity to distinguish true progression from pseudo-progression based on steady state rCBV at suspected progression
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Specificity of Identifying Pseudoprogression | 58.3 percentage |
Secondary
Determine the Safety and Toxicity of Pembrolizumab When Used in Combination With Standard of Care Chemo Radiation.
Number of participants with adverse events possibly related or related to pembrolizumab in combination with standard of care. Will be analyzed using proportions and exact 95% confidence intervals.
Time frame: 30 days after last dose of pembrolizumab, up to 2 years.
Population: Out of 52 participants, 29 experienced an adverse event greater than or equal to grade 3 that were possibly related or related to pembrolizumab.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Determine the Safety and Toxicity of Pembrolizumab When Used in Combination With Standard of Care Chemo Radiation. | Grade 3 or above possibly related to pembrolizumab | 27 participants |
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Determine the Safety and Toxicity of Pembrolizumab When Used in Combination With Standard of Care Chemo Radiation. | Grade 3 or above related to pembrolizumab | 2 participants |
Secondary
Disease Response
Disease response was assessed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria.
Time frame: Until off study, up to 5 years.
Population: Of the 52 enrolled patients, 43 were evaluable (9 replaced).
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Disease Response | Complete response | 8 Participants |
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Disease Response | Partial response | 18 Participants |
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Disease Response | Stable disease | 9 Participants |
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Disease Response | Disease progression | 8 Participants |
Secondary
Duration of Best Response
Will be analyzed using the Kaplan-Meier product limit estimates. Response assessment was completed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria.
Time frame: Until off study, up to 5 years.
Population: All enrolled subjects
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Duration of Best Response | 6.4 Months |
Secondary
Overall Survival
Will be assessed using the Kaplan-Meier product limit estimates.
Time frame: Until off study, up to 5 years.
Population: All enrolled subjects
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Overall Survival | 15.2 Months |
Secondary
Progression Free Survival
Will be assessed using the Kaplan-Meier product limit estimates. Response assessment was completed based on a modified version of the Response Assessment in Neuro-Oncology (RANO) criteria.
Time frame: Until off study, up to 5 years.
Population: All enrolled subjects
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Diagnostic (Ferumoxytol MRI, Pembrolizumab) | Progression Free Survival | 10.4 Months |