Metastatic Melanoma, Metastasis to Brain
Conditions
Brief summary
The purpose of this pilot study is to determine the safety and feasibility of giving a single dose of Nivolumab with Ipilimumab or Relatlimab in participants with brain metastases from melanoma who can undergo surgery for removal of their brain metastases 7- 10 days after receiving the study drug.
Interventions
DRUGNivolumab
Nivolumab is a monoclonal antibody o PD-1 protein, which is normally express on the surface of activated T cells. The interaction of PD-1 with its ligand (PD-L1) on T cells decreases their cytotoxic activity, helping protect normal cells in the setting of chronic inflammation. Tumor cells can utilize mechanisms to evade T cell mediated cytotoxicity by expressing PD-L1 on their surface or on the surface of T cells. Nivo, by blocking the interaction between PD-1 and its ligands, PD-L1 and PD-L2, allows T cells to remain active.
DRUGIpilimumab
Ipilimumab is a recombinant, human antibody to CTLA-4.\[18-20\] CTLA-4 regulates T cell activation by binding with CD80 or CD86 with higher affinity than CD28, resulting in blockage of the co-stimulation signal and preventing further T cell activation. Blockade of CTLA-4 results in further T cell activation.
Opdualag (Nivolumab and Relatlimab-rmbw) is a human monoclonal antibody to LAG-3, currently under investigation.\[6\] Relatlimab is an antibody (IgG4 isotype) that has a stabilizing hinge mutation for attenuated Fc receptor binding to decrease or get rid of the possibility of antibody-mediated and/or complement-mediated target cell killing. Rela binds to an epitope on LAG-3 with high affinity and specificity, with subsequent blockade of LAG-3 and its interaction with its ligand, MHC class II. This antibody displays compelling in vitro functional activity in reversing LAG-3 that facilitates inhibition of an antigen-specific murine T cell hybridoma overexpressing human LAG-3 . Relatlimab was also shown to improve the activation of human T cells in superantigen stimulation assays when added either alone or in combination with Nivolumab.
PROCEDUREStandard of Care Craniotomy
Participants will undergo craniotomy for surgical resection of melanoma brain metastases.
Sponsors
Bristol-Myers Squibb
H. Lee Moffitt Cancer Center and Research Institute
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age 18 years old or older on day of signing the informed consent. * Histological confirmation of systemic cancer from melanoma. * Surgery for metastatic brain lesions (i.e., MBM) is needed but not imminent. Imminent defined as requiring emergent intervention. A multidisciplinary team will determine the appropriateness for resection via craniotomy and level of urgency for surgery of the MBM. * Resectable metastatic brain lesions (i.e., MBM) in whom surgical resection is a reasonable therapeutic option. A resectable metastatic brain lesion is defined as a lesion that is ≥10 mm in size of longest diameter and in a location outside of the brainstem. (Other target lesions, i.e. those that are not resected but are followed for response, can be ≥5 mm). A multidisciplinary team will determine the appropriateness for resection via craniotomy and level of urgency for surgery of the MBM. * Patient is on ≤4 mg/day dexamethasone or equivalent/day over pre-op period. * Patients treated with prior monotherapy with PD-1/PD-L1 are permitted. * Treatment with BRAF MEK inhibitors (BRAF MEKi) (for example, dabrafenib / trametinib) is permitted as long as has been at least five half-lives or one week prior to study treatment, whichever is shorter. * MRI with enhancing metastatic brain lesions (i.e., MBM) amenable to resection of contrast-enhancing tumor (determined by neurosurgeon). A multidisciplinary team will determine the appropriateness for resection via craniotomy and level of urgency for surgery of the MBM. * Patient willing to undergo craniotomy and resection. * Patient eligible for surgery in the 7-10 days after initial treatment. * Patients who had prior surgical resection of MBM are eligible to enroll. * Usual acceptable lab parameters, demonstrating adequate organ function as defined in protocol. All screening labs should be performed within 21 days of treatment initiation. * Resting baseline O2 saturation by pulse oximetry of 92% or higher at rest. * Be willing and able to provide written informed consent for the trial. * Willing to provide tissue and blood samples for correlative research purposes. * Has ECOG Performance Status (PS) of 0, 1 or 2. * Prior whole Brain radiation therapy (WBRT), single fraction radiation therapy (e.g., SRS), or multiple fraction radiation therapy (e.g., fSRT) to the brain is permitted. * A negative serum pregnancy test must be documented at the screening visit. Additionally, female patients must exhibit a negative urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) within 72 hours prior to the start of study drug, therefore the screening pregnancy test may need to be repeated prior to the start of study drug dosing. A urine pregnancy test can be used for this. A pre-dosing urine pregnancy test must be performed prior to each dose during study phase. A urine pregnancy test will also be conducted at End of Treatment Visit. * Female patients of childbearing potential must be willing to use an adequate method of contraception as outlined in Section 13.1.2 Contraception Guidance for Female Participants of Child Bearing Potential. Contraception, for the duration of treatment and an additional 5 months after the last dose of the study drug. Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the patient. * Male patients of childbearing potential who are sexually active with Women of Child Bearing Potential do not require contraception.
Exclusion criteria
* Has a metastatic brain lesion (or all brain lesions) that is (are) unresectable. Unresectable defined as located in the brainstem or measuring \<10 mm in longest diameter. Note, patients with multiple metastatic brain lesions that include non-targetable lesions of \<10 mm are allowed to enroll in the study as long as they have at least 1 lesion that is ≥10 mm in size of longest diameter. * Has clear evidence of leptomeningeal disease. * Is currently participating and receiving study therapy or has participated in a study of an investigational agent and received study therapy or used an investigational device within 4 weeks of the first dose of treatment or five half-lives, whichever is shorter, or has not recovered (i.e., ≤ Grade 1 or at baseline) from AEs due to a previously administered agent. * Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment. Physiologic doses of steroid therapy (≤ 3 mg/day dexamethasone equivalents) by the time of first dose of treatment are allowed. * Has a known history of active Bacillus Tuberculosis. * Hypersensitivity to either Nivolumab, Ipilimumab, or Relatlimab or any of its excipients. * Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from AEs due to a previously administered agent. Note: Patients with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study. Note: If patient received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy. * 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 the 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. Patients with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Patients that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Patients with hypothyroidism stable on hormone replacement or Sjogren's syndrome will not be excluded from the study. * Has a prior history of life-threatening toxicity related to prior immune therapy (i.e., anti-CTLA-4 or anti- PD-1/PD-L1 treatment or any other antibody or drug specifically targeting T-cell co-stimulation or immune checkpoint pathways) except those that are unlikely to re-occur with standard countermeasures (i.e., hormone replacement after adrenal crisis). * Has prior treatment with Relatlimab or any other LAG-3 targeted agent or CTLA-4 targeted agent within 3 months prior to day 1 of treatment. * Other than the medications explicitly stated in the
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Feasibility: Ability to recruit per treatment arm | At 30 months | Feasibility is defined as being able to recruit 8 patients per treatment arm (16 total) within 30 months. |
| Comparison of immune cell population per treatment arm | Up to 15 months | Investigators will compare immune cell population between treatment arms (Nivolumab + Ipilimumab vs Nivolumab +Relatlimab). The expression of PD-1 and PD-L1 in all samples collected will be evaluated, as well as the expression of cytokines and inflammatory cells including CD4+ T cells, CD8+ T cells, NK cells, T regulatory cells, B cells, plasma cells, IL-2, IFN-γ, TNF-β, GM-CSF, IL-3, IL-4, IL-5, IL-10, IL-13, myeloid-derived suppressor cells(MDSCs), dendritic cells (DCs), and macrophages. Size of immune cell population will be summarized in the following two ways. One is normalized per 100 cells so that the numbers are comparable between samples. The other estimation is the proportion of cells for each cell population. Other characterizations will be performed. |
Countries
United States
Outcome results
None listed