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Trial of Radiation and Gene Therapy Before Nivolumab for Metastatic Non-Small Cell Lung Carcinoma and Uveal Melanoma (ENSIGN)

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ClinicalTrials.gov Identifier: NCT02831933
Recruitment Status : Recruiting
First Posted : July 13, 2016
Last Update Posted : March 15, 2018
Sponsor:
Information provided by (Responsible Party):
Eric Bernicker, MD, The Methodist Hospital System

Brief Summary:
This is a Phase II trial to determine the efficacy and safety of in situ gene therapy and stereotactic body radiation therapy (SBRT) used as a window of opportunity treatment before nivolumab in patients with metastatic squamous or non-squamous non-small cell lung carcinoma (NSCLC) and metastatic uveal melanoma. In situ gene therapy will consist of adenovirus-mediated expression of herpes simplex virus thymidine kinase (ADV/HSV-tk) plus Valacyclovir therapy.

Condition or disease Intervention/treatment Phase
Lung Squamous Cell Carcinoma Stage IV Nonsquamous Nonsmall Cell Neoplasm of Lung Metastatic Uveal Melanoma Biological: ADV/HSV-tk Drug: Valacyclovir Radiation: SBRT Drug: nivolumab Phase 2

Detailed Description:
This is a Phase II trial to determine the efficacy and safety of in situ gene therapy and stereotactic body radiation therapy (SBRT) used as a window of opportunity treatment before nivolumab in patients with metastatic squamous or non-squamous non-small cell lung carcinoma (NSCLC) and metastatic uveal melanoma. In situ gene therapy will consist of adenovirus-mediated expression of herpes simplex virus thymidine kinase (ADV/HSV-tk) plus Valacyclovir therapy. Male or female patients aged ≥18 years with histologically or cytologically confirmed metastatic squamous or non-squamous NSCLC whose disease has progressed after a platinum-based chemotherapy and a single-agent immunotherapy OR histologically or cytologically confirmed metastatic uveal melanoma that is immunotherapy naive are eligible to participate in the study. NSCLC patients with EGFR or ALK genomic tumor aberrations are eligible only if they have had disease progression on FDA-approved therapy for these aberrations. ADV/HSV-tk (5 x 1011 viral particles) in a 2-mL total volume will be injected intratumorally on day 0 of the study. Valacyclovir will be orally administered at a dose of 2 g three times daily for 14 days. Valacyclovir treatment will be administered 24 hours after the gene vector injection from day 1 to day 15 of the study. SBRT of 30 gray (Gy; 6 Gy X 5 fractions) will be administered over 2 weeks from day 2 to day 16 of the study. Nivolumab (480 mg) will be administered intravenously over 30 minutes every 4 weeks starting on day 17 of the study and continuing until disease progression, unacceptable toxicity, or up to 12 months in patients without disease progression. The primary endpoint will be the objective response rate (ORR) of ADV/HSV-tk + Valacyclovir therapy in combination with SBRT used as a window of opportunity treatment before nivolumab in patients with metastatic squamous or non-squamous NSCLC. Both RECIST 1.1 and modified immune-related response criteria (irRC; derived from RECIST 1.1) will be used to assess treatment response. Secondary endpoints will include a) clinical benefit rate (CBR); b) duration of response (DoR); c) overall survival (OS) and progression-free survival (PFS) rates; d) safety and toxicity (toxicity will be defined as any treatment-related death or any ≥ grade 3 toxicity excluding alopecia and constitutional symptoms as assessed by the NCI CTCAE v4.03); and e) immune-mediated antitumor activity (assessed by RECIST 1.1 and modified irRC) of ADV/HSV-tk plus Valacyclovir therapy in combination with SBRT used as a window of opportunity treatment before nivolumab.

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 25 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: ENSIGN: Phase II Window of Opportunity Trial of Stereotactic Body Radiation Therapy and In Situ Gene Therapy Followed by Nivolumab in Metastatic Squamous or Non-Squamous Non-Small Cell Lung Carcinoma and Metastatic Uveal Melanoma
Actual Study Start Date : February 15, 2017
Estimated Primary Completion Date : December 2021
Estimated Study Completion Date : June 2022


Arm Intervention/treatment
Experimental: Experimental

ADV/HSV-tk (5 x 1011 viral particles) in a 2-mL total volume will be injected intratumorally on day 0 of the study.

Valacyclovir will be orally administered at a dose of 2 g three times daily for 14 days. Valacyclovir treatment will be administered 24 hours after the gene vector injection from day 1 to day 15 of the study.

SBRT of 30 gray (Gy; 6 Gy X 5 fractions) will be administered over 2 weeks from day 2 to day 16 of the study.

Nivolumab (480 mg) will be administered intravenously over 30 minutes every 4 weeks starting on day 17 of the study and continuing until disease progression, unacceptable toxicity, or up to 12 months in patients without disease progression.

Biological: ADV/HSV-tk
Replication-defective recombinant adenovirus vector

Drug: Valacyclovir
Prodrug of the antiviral drug acyclovir
Other Name: valacyclovir hydrochloride

Radiation: SBRT
Low-dose SBRT

Drug: nivolumab
Fully human immunoglobulin (Ig) G4 anti-PD-1 monoclonal antibody
Other Name: Opdivo




Primary Outcome Measures :
  1. ORR [ Time Frame: 30 days after the last dose of nivolumab ]
    Determine the ORR of ADV/HSV-tk plus Valacyclovir therapy in combination with SBRT used as a window of opportunity treatment before nivolumab


Secondary Outcome Measures :
  1. DoR [ Time Frame: 30 days after the last dose of nivolumab ]
    Determine the DoR

  2. OS rate [ Time Frame: 30 days after the last dose of nivolumab ]
    Determine the OS rate

  3. PFS rate [ Time Frame: 30 days after the last dose of nivolumab ]
    Determine the PFS rate

  4. Number of participants with treatment-related adverse events as assessed by the NCI CTCAE v4.03 [ Time Frame: 30 days after the last dose of nivolumab ]
    Number of participants with treatment-related adverse events as assessed by the NCI CTCAE v4.03

  5. Antitumor activity [ Time Frame: 30 days after the last dose of nivolumab ]
    Document the antitumor activity as assessed by RECIST 1.1 and modified immune-related criteria

  6. CBR [ Time Frame: 30 days after the last dose of nivolumab ]
    Estimate the CBR as assessed by RECIST 1.1 and modified immune-related criteria


Other Outcome Measures:
  1. Abscopal effect of ADV/HSV-tk plus Valacyclovir therapy in combination with SBRT [ Time Frame: Baseline and Day 17 ]
    Determine the abscopal effect of ADV/HSV-tk plus Valacyclovir therapy in combination with SBRT

  2. Immune response to nivolumab [ Time Frame: 30 days after the last dose of nivolumab ]
    Measure the immune response to nivolumab

  3. T-helper1 (cellular-based) response [ Time Frame: Baseline and Day 17 ]
    Assess the T-helper1 (cellular-based) response

  4. Tumor-infiltrating lymphocytes before and after ADV/HSV-tk plus Valacyclovir therapy [ Time Frame: Baseline and Day 17 ]
    Measure tumor-infiltrating lymphocytes before and after ADV/HSV-tk plus Valacyclovir therapy



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Male or female ≥18 years of age.
  • Histologically or cytologically confirmed stage IV, metastatic squamous or non-squamous NSCLC that has progressed after a platinum-based chemotherapy and after a single-agent immunotherapy OR histologically or cytologically confirmed metastatic uveal melanoma that is immunotherapy naive
  • Evaluable or measurable disease as per RECIST 1:1, a target lesion of suitable diameter (at least 1 cm) for SBRT, and a non-target lesion of at least 1 cm in diameter for abscopal effect evaluation.
  • ≥ 4 weeks since any major surgery, completion of radiation therapy, or completion of all prior systemic anticancer therapy (adequately recovered from the acute toxicities of any prior therapy).
  • Life expectancy greater than or equal to 6 months.
  • Eastern Cooperative Oncology Group performance status of 0-1.
  • Adequate bone marrow function:

    • Absolute neutrophil count ≥ 1.5 x 10^9/L (without granulocyte colony stimulating factor support within 2 weeks of laboratory test used to determine eligibility)
    • Platelets ≥ 100 x 10^9/L (without transfusion within 2 weeks of laboratory test used to determine eligibility)
    • Hemoglobin ≥ 9 g/dL (without blood transfusion)
    • White blood cell count > 2,500/uL and < 15,000/uL
    • Lymphocyte count ≥ 500/uL
  • Adequate liver function:

    • Serum bilirubin less than or equal to 1.0 X upper limit of normal (ULN; patients with known Gilbert's disease who have serum bilirubin level less than or equal to 3 X ULN may be enrolled)
    • Serum transaminases (aspartate transaminase [AST] or alanine transaminase [ALT]) activity less than or equal to 2.5 X ULN with normal alkaline phosphatase (patients with liver metastases less than or equal to 5 x ULN) OR AST and ALT less than or equal to 1.5 X ULN with an alkaline phosphatase greater than 2.5 X ULN
  • International normalized ratio and activated partial thromboplastin time (aPTT) less than or equal to 1.5 X ULN (unless patient is receiving anticoagulant therapy as long as PT or aPTT is within therapeutic range of intended use of anticoagulants)
  • Adequate renal function: serum creatinine less than or equal to 1.5 X ULN.
  • Women of childbearing potential (WOCBP) must have a negative serum pregnancy test within 7 days prior to the administration of the first study treatment. Women must not be lactating.
  • WOCBP and men must practice an effective method of birth control
  • Signed informed consent to participate in the study must be obtained from patients after they have been fully informed of the nature and potential risks of the study by the investigator (or his/her designee) with the aid of written information.
  • Willing to provide biopsies as required by the study.

Exclusion Criteria:

  • Prior treatment with gene therapy.
  • Any cytotoxic chemotherapy, RT, or any investigational drug within 3 weeks of study treatment start.
  • Any immunotherapy within 3 weeks of study treatment start (NSCLC cohort only)
  • Prior treatment with immunotherapy (uveal melanoma cohort only)
  • Patients with EGFR or ALK genomic tumor aberrations that have not received any FDA-approved therapy for these aberrations (NSCLC cohort only).
  • Oxygen-dependent chronic obstructive pulmonary disease (NSCLC cohort only).
  • Patients requiring oral prednisone for emphysema management (NSCLC cohort only).
  • History of liver disease, such as cirrhosis or active/chronic hepatitis B or C.
  • History of or current alcohol misuse/abuse within the past 12 months.
  • Known gallbladder or bile duct disease (i.e., infection or cholecystitis) or acute or chronic pancreatitis.
  • Major surgery within 4 weeks prior to study enrollment.
  • Uncontrolled brain or leptomeningeal metastases or brain or leptomeningeal metastases requiring continued glucocorticoid treatment. Patients who have been treated at least 4 weeks prior to enrollment and have a CT or magnetic resonance imaging scan of the brain showing no evidence of disease progression within 4 weeks of enrollment are eligible.
  • Congestive heart failure: New York Heart Association class III or IV heart failure or unstable angina.
  • History of syncope or family history of idiopathic sudden death.
  • Sustained or clinically significant cardiac arrhythmias including sustained ventricular tachycardia, ventricular fibrillation, clinically significant bradycardia, advanced heart block (Mobitz II or higher atrioventricular nodal block), prolonged heart rate-corrected QT interval (longer than 470 milliseconds), or history of acute myocardial infarction. (The QT interval is the time between the start of the Q wave and the end of the T wave in the cardiac electrical cycle)
  • Concomitant disease(s) that could prolong QT such as autonomic neuropathy (caused by diabetes or Parkinson's disease), human immunodeficiency virus (HIV), cirrhosis, uncontrolled hypothyroidism, or cardiac failure.
  • Presence of active or suspected acute or chronic uncontrolled infection or history of immunocompromise, including a positive HIV test result.
  • Any severe and/or uncontrolled medical conditions or other conditions that could affect patient participation in the study such as severely impaired lung function, any active (acute or chronic) or uncontrolled infection/disorders, and nonmalignant medical illnesses that are uncontrolled or whose control may be jeopardized by the study therapy.
  • Known or suspected allergy or hypersensitivity to any component of nivolumab or its analogues or any component of the proposed regimen (gene vector/Valacyclovir).
  • Inability to swallow food or any condition of the upper gastrointestinal tract that precludes administration of oral medications (Valacyclovir).
  • Any active malignancy except for non-melanoma skin cancer or in situ cervical cancer or treated cancer from which the patient has been continuously disease free for more than 5 years.
  • Pregnant or breastfeeding women or women/men able to conceive and unwilling to practice an effective method of birth control.
  • Unwilling or unable to comply with the study protocol.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02831933


Contacts
Contact: Houston Methodist Cancer Center 713-441-0629 ccresearch@houstonmethodit.org

Locations
United States, Texas
Houston Methodist Hospital Recruiting
Houston, Texas, United States, 77030
Contact: Houston Methodist Cancer Center    713-441-0629    ccresearch@houstomethodist.org   
Sponsors and Collaborators
Eric Bernicker, MD
Investigators
Principal Investigator: Eric Bernicker, M.D. Houston Methodist Cancer Center

Responsible Party: Eric Bernicker, MD, Sponsor-Investigator/Principal Investigator, The Methodist Hospital System
ClinicalTrials.gov Identifier: NCT02831933     History of Changes
Other Study ID Numbers: Pro00014976
First Posted: July 13, 2016    Key Record Dates
Last Update Posted: March 15, 2018
Last Verified: March 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: Data and materials on human subjects will be shared with other eligible investigators through appropriate means in accordance with the NIH policy on Sharing Research Data (NIH Guide, February 26, 2003). Data will be also shared with the funding agency and regulatory agencies as required. Data will be shared with other investigators within the limits of HIPAA and other patient confidentiality requirements. This will generally require removal of all patient identifiers for all source documents and the use of arbitrarily assigned one-way identifiers. In some cases, requestors will be asked to sign a formal data sharing agreement that will provide for a commitment to use data only for research purposes and not to identify individuals, keep the data secure, and destroy or return data after analyses are complete. Prior approval will be obtained from collaborating investigators, research sponsors, and/or other stake-holders before sharing if proprietary information or products are involved.

Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Eric Bernicker, MD, The Methodist Hospital System:
lung cancer
metastatic
gene therapy
immunotherapy
melanoma
uveal

Additional relevant MeSH terms:
Carcinoma
Melanoma
Carcinoma, Squamous Cell
Lung Neoplasms
Carcinoma, Non-Small-Cell Lung
Uveal Neoplasms
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Neoplasms
Neuroendocrine Tumors
Neuroectodermal Tumors
Neoplasms, Germ Cell and Embryonal
Neoplasms, Nerve Tissue
Nevi and Melanomas
Neoplasms, Squamous Cell
Respiratory Tract Neoplasms
Thoracic Neoplasms
Neoplasms by Site
Lung Diseases
Respiratory Tract Diseases
Carcinoma, Bronchogenic
Bronchial Neoplasms
Eye Neoplasms
Eye Diseases
Uveal Diseases
Nivolumab
Antibodies, Monoclonal
Valacyclovir
Acyclovir
Antineoplastic Agents