Mesothelioma, Malignant
Conditions
Brief summary
This study will evaluate the combination of Nivolumab and Ramucirumab in patients with previously-treated mesothelioma.
Detailed description
The programmed death ligand 1 (PD-L1) \[16\] and VEGFR2 \[34\] are highly-expressed on mesothelioma cells, and are therefore attractive options for this cancer. We chose to study the combination of ramucirumab with nivolumab because of the potential efficacy of these two agents in mesothelioma and because of the potential synergistic activity between them \[30\]. As previously discussed, immunotherapies such as anti-PD-1 inhibitors must contend with a hostile, immunosuppressive tumor microenvironment due to angiogenesis that results in hypoxia. This hypoxia decreases the ability of antibodies to infiltrate the tumor. We hypothesize that the normalization of tumor vasculature (by reducing the area of the tumor that is hypoxic) with an anti-VEGF strategy (i.e., ramucirumab) used in synergy with a PD-1 inhibitor will facilitate the infiltration of T-lymphocytes into tumor parenchyma. We will conduct a phase II study based on this premise using nivolumab and ramucirumab as second-line therapy in patients with malignant mesothelioma who have failed standard doublet platinum and anti-folate therapy.
Interventions
DRUGNivolumab
Nivolumab 240mg, IV over 30 minutes.
DRUGRamucirumab
8mg/kg, IV over 60 minutes.
Sponsors
HealthPartners Institute Regions Cancer Care Center
Eli Lilly and Company
Bristol-Myers Squibb
Arkadiusz Z. Dudek, MD
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
* Male or female ≥ 18 years of age at time of consent. * Histologically-confirmed malignant mesothelioma not amenable to curative surgery and who have received at least one pemetrexed-containing chemotherapy regimen. * Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. * total bilirubin \< 1.5 mg/dL (25.65 μmol/L) OR direct bilirubin ≤ ULN for subjects with total bilirubin levels \> 1.5 mg/dL (except subject with Gilbert's Syndrome, who can have total bilirubin \< 3.0 mg/dl) * aspartate aminotransferase (AST) ≤ 3 × ULN or ≤ 5 × ULN for subjects with known hepatic metastases * alanine aminotransferase (ALT) ≤ 3 × ULN or ≤ 5 × ULN for subjects with known hepatic metastases * hemoglobin ≥ 8 g/dL, subjects requiring transfusion will not be eligible to start study * absolute neutrophil count (ANC) ≥ 1.5 × 109/L * platelet count ≥ 100 × 109/L * serum creatinine ≤1.5 times the ULN, or creatinine clearance (measured via 24-hour urine collection) ≥40 mL/minute (that is, if serum creatinine is \>1.5 times the ULN, a 24-hour urine collection to calculate creatinine clearance must be performed) * subject's urinary protein is ≤1+ on dipstick or routine urinalysis (UA; if urine dipstick or routine analysis is ≥2+, a 24-hour urine collection for protein must demonstrate \<1000 mg of protein in 24 hours to allow participation in this protocol) * INR \< 1.5, and a partial thromboplastin time (PTT) (PTT/aPTT) \< 1.5 x ULN (unless receiving anticoagulant therapy) * Subjects on full-dose anticoagulation must be on a stable dose (minimum duration 14 days) of oral anticoagulant or low molecular weight heparin (LMWH). Patients receiving warfarin must be switched to low molecular weight heparin and have achieved stable coagulation profile prior to first dose of protocol therapy. For heparin and LMWH there should be no active bleeding (that is, no bleeding within 14 days prior to first dose of protocol therapy) or pathological condition present that carries a high risk of bleeding (for example, tumor involving major vessels or known varices). * Subjects must be willing to undergo a CT-guided biopsy (i.e., image-guided percutaneous lung biopsy) to obtain tumor tissue within 28 days before initiation of treatment and after 4 cycles (8 weeks) of treatment. * Women of childbearing potential (WOCP) must be willing to use birth control as outlined in the protocol. * Men who are not surgically or medically sterile must agree to use contraception as outlined in the protocol. * Measurable disease, defined as at least 1 tumor that fulfills the criteria for a target lesion according to modified RECIST 1.1 criteria, and obtained by imaging within 28 days prior to study registration. * Prior intracavity cytotoxic or sclerosing agents (including bleomycin) is acceptable. * Radiation therapy must be completed \> 28 days before study registration, and the measurable disease must be outside of the radiation port. * Pemetrexed-containing chemotherapy must be completed \> 28 days before study registration. * Must provide written informed consent and HIPAA authorization approved by an Institutional Review Board (IRB). NOTE: HIPAA authorization may be included in the informed consent or obtained separately. * All previous toxicity resolved to Grade 1 or less.
Exclusion criteria
* Any Grade 3-4 GI bleeding within 3 months prior to study registration. * History of deep vein thrombosis, pulmonary embolism, or any other significant thromboembolism (venous port or catheter thrombosis or superficial venous thrombosis are not considered significant) during the 3 months prior to study registration. * Any arterial thromboembolic events, including but not limited to myocardial infarction, transient ischemic attack, cerebrovascular accident, or unstable angina, within 6 months prior to study registration. * Cirrhosis at a level of Child-Pugh B (or worse), or cirrhosis (any degree) with 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. * Uncontrolled or poorly-controlled hypertension (\>160 mmHg systolic or \> 100 mmHg diastolic for \>4 weeks) despite standard medical management. * Prior history of GI perforation/fistula (within 6 months of study registration) or risk factors for perforation. * Serious or nonhealing wound, ulcer, or bone fracture within 28 days prior to study registration. * Active brain metastases or carcinomatous meningitis. Subjects with neurological symptoms must undergo a head CT scan or brain MRI to exclude brain metastasis. Subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to the first dose of study drugs 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 14 days prior to study registration. This exception does not include carcinomatous meningitis, which is excluded regardless of clinical stability. * Major surgery within 28 days prior to study registration * Subcutaneous venous access device placement within 7 days prior to study registration. * Elective or planned major surgery to be performed during the course of the clinical trial. * Is receiving chronic antiplatelet therapy, including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs, including ibuprofen, naproxen, and others), dipyridamole or clopidogrel, or similar agents. Once-daily aspirin use (maximum dose 325 mg/day) is permitted. * Known history of testing positive for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS). NOTE: HIV testing is not required. * Known history of testing positive for hepatitis B virus surface antigen (HBV sAg) or hepatitis C virus ribonucleic acid (HCV antibody), indicating acute or chronic infection. NOTE: Hepatitis B and Hepatitis C testing is not required. * 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. * 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). 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. o NOTE: 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. * Received a live vaccine within 30 days prior to the first dose of trial treatment. Examples of live vaccines include, but are not limited to: measles, mumps, rubella, chicken pox, yellow fever, rabies, BCG, and typhoid (oral) vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however, intranasal influenza vaccines (e.g. Flu-Mist®) are live attenuated vaccines and are not allowed. * History of interstitial lung disease or active, non-infectious pneumonitis. * Female subject is pregnant or breast-feeding. * NOTE: Women of childbearing potential (WOCP) must have a negative pregnancy test (either serum β-HCG with a sensitivity of 50 mIU/ml or urine dipstick within 24 hours of study registration). * NOTE: Women are not considered to be of childbearing potential if they meet at least one of the following: 1) surgically sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has not had menses for greater than 1 year), or 3) not heterosexually active for the duration of the study. See section 5.6.2. * Major blood vessel invasion or significant intratumor cavitation. * If they experience hemoptysis (defined as bright red blood or ≥ ½ 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. * Any condition that, in the opinion of the investigator, might jeopardize the safety of the subject or interfere with protocol compliance. * Any mental or medical condition that prevents the subject from giving informed consent or participating in the trial. * Any pathological condition that carries a high risk of bleeding (for example, tumor involving major vessels or known varices.) * Known hypersensitivity to nivolumab or ramucirumab or any of their components. * Known history of active tuberculosis. * Received prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) antibody (including ipilimumab or any other antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways). * No prior malignancy is allowed except for adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, localized Gleason ≤ grade 7 prostate cancers. Subjects with other solid tumors treated curatively and without evidence of recurrence for at least 3 years prior to enrollment may be eligible for study after discussion with the sponsor-investigator * Treatment with any investigational agent within 28 days prior to study registration. The subject must have recovered from the acute toxic effects of the regimen.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Response Rate | Up to a maximum of 23 months | Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST): Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD) \>= 20% increase in tumor burden relative to nadir or the appearance of one or more new lesions; Stable Disease (SD), not meet criteria for CR/PR/PD. Response rate will be defined as the proportion of all subjects with confirmed PR or CR according to RECIST 1.1. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Adverse Event Assessment | AE had been recorded from time of consent until 100 days after discontinuation of study drug or until a new anti-cancer treatment starts, whichever occurs first; up to a maximum of 28 months. | The frequency and severity of all grade ≥ 2 treatment related adverse events are reported by CTCAE v4 term. |
| Progression-free Survival (PFS) | Time of treatment start until the criteria for disease progression or death, up to a maximum of 23 months. | Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST): Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD) \>= 20% increase in tumor burden relative to nadir or the appearance of one or more new lesions; Stable Disease (SD), not meet criteria for CR/PR/PD. PFS is defined as time from treatment start until disease progression met by RECIST 1.1 or death from any cause. |
| Overall Survival | Time of treatment start until death or date of last contact, up to a maximum of 32 months. | Overall survival (OS) is defined as time of treatment start until death or date of last contact. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Nivolumab + Ramucirumab Nivolumab 240mg IV + Ramucirumab 8mg/kg IV
Nivolumab: Nivolumab 240mg, IV over 30 minutes.
Ramucirumab: 8mg/kg, IV over 60 minutes. | 34 |
| Total | 34 |
Baseline characteristics
| Characteristic | Nivolumab + Ramucirumab |
|---|---|
| Age, Continuous | 72 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 2 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 31 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 1 Participants |
| Histology Peritoneal | 4 Participants |
| Histology Pleural | 30 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 1 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 | 31 Participants |
| Region of Enrollment United States | 34 Participants |
| Sex: Female, Male Female | 4 Participants |
| Sex: Female, Male Male | 30 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 22 / 34 |
| other Total, other adverse events | 34 / 34 |
| serious Total, serious adverse events | 9 / 34 |
Outcome results
Primary
Response Rate
Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST): Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD) \>= 20% increase in tumor burden relative to nadir or the appearance of one or more new lesions; Stable Disease (SD), not meet criteria for CR/PR/PD. Response rate will be defined as the proportion of all subjects with confirmed PR or CR according to RECIST 1.1.
Time frame: Up to a maximum of 23 months
Population: Out of 34 patients, one patient was not evaluable for response after he withdrew from study because of generalized weakness one day after first infusion of ramucirumab and nivolumab.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Nivolumab + Ramucirumab | Response Rate | 22.6 Percentage of participants |
Secondary
Adverse Event Assessment
The frequency and severity of all grade ≥ 2 treatment related adverse events are reported by CTCAE v4 term.
Time frame: AE had been recorded from time of consent until 100 days after discontinuation of study drug or until a new anti-cancer treatment starts, whichever occurs first; up to a maximum of 28 months.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Nivolumab + Ramucirumab | Adverse Event Assessment | Hypertension | 3 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Dyspnea | 5 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Proteinuria | 9 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Arial fibrillation | 2 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Abdominal Pain | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Anorexia | 2 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Dehydration | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Diarrhea | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Dysphagia | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Esophageal Obstruction | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Fatigue | 7 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Hyperkalemia | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Hyponatremia | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Muscle Weakness | 3 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Non-Cardiac Chest Pain | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Pancreatitis | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Thromboembolic Event | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Pain | 3 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Sinusitis | 3 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Depression | 2 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Hypothyroidism | 2 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Dizziness | 2 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Chest Wall Pain | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Cough | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Creatinine Increased | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Heart Failure | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Hypoxia | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Lower Gastrointestinal Bleed | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Mucositis Oral | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Periodontal Disease | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Pneumonitis | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Presyncope | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Weight loss | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Atopic Dermatitis | 1 Participants |
| Nivolumab + Ramucirumab | Adverse Event Assessment | Upper Respiratory Tract Infection | 1 Participants |
Secondary
Overall Survival
Overall survival (OS) is defined as time of treatment start until death or date of last contact.
Time frame: Time of treatment start until death or date of last contact, up to a maximum of 32 months.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Nivolumab + Ramucirumab | Overall Survival | 12.5 Months |
Secondary
Progression-free Survival (PFS)
Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST): Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD) \>= 20% increase in tumor burden relative to nadir or the appearance of one or more new lesions; Stable Disease (SD), not meet criteria for CR/PR/PD. PFS is defined as time from treatment start until disease progression met by RECIST 1.1 or death from any cause.
Time frame: Time of treatment start until the criteria for disease progression or death, up to a maximum of 23 months.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Nivolumab + Ramucirumab | Progression-free Survival (PFS) | 4.2 Months |