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Testing A New Combination of Anti-cancer Immune Therapies, Atezolizumab and CDX-1127 (Varlilumab) With or Without the Addition of A Third Anti-cancer Drug, Cobimetinib, for Advanced-Stage Biliary Tract Cancer

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ClinicalTrials.gov Identifier: NCT04941287
Recruitment Status : Not yet recruiting
First Posted : June 28, 2021
Last Update Posted : September 14, 2021
Sponsor:
Information provided by (Responsible Party):
National Cancer Institute (NCI)

Brief Summary:
This phase II trial investigates the effect of combining two immune therapies, atezolizumab and CDX-1127 (varlilumab), with or without cobimetinib, in treating patients with biliary tract cancer that cannot be removed by surgery (unresectable). Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Varlilumab is a monoclonal antibody specific for a molecule called CD27 and may lead to growth inhibition of CD27-expressing tumor cells upon administration. Cobimetinib is in a class of medications called kinase inhibitors. It works by blocking the action of an abnormal protein that signals cancer cells to multiply. This helps slow or stop the spread of cancer cells. Giving atezolizumab in combination withvarlilumab and cobimetinib may work better than atezolizumab and varlilumab alone in treating patients with unresectable biliary tract cancer.

Condition or disease Intervention/treatment Phase
Unresectable Liver and Intrahepatic Bile Duct Carcinoma Biological: Atezolizumab Drug: Cobimetinib Drug: Varlilumab Phase 2

Detailed Description:

PRIMARY OBJECTIVES:

I. To assess the response rate (ORR) of patients with unresectable, pre-treated biliary cancers treated with the combination of atezolizumab and CDX-1127 (varlilumab) with or without cobimetinib.

II. To assess the progression free survival (PFS) of patients with unresectable, pre-treated biliary cancers treated with the combination of atezolizumab and CDX-1127 (varlilumab) with or without cobimetinib.

SECONDARY OBJECTIVES:

I. To assess the safety and tolerability of combination of atezolizumab and CDX-1127 (varlilumab) with or without cobimetinib in patients with unresectable, pre-treated biliary cancers.

II. To assess overall survival (OS) of patients with unresectable, pre-treated biliary cancers treated with the combination of atezolizumab and CDX-1127 (varlilumab) with or without cobimetinib.

III. To determine the effect of combination atezolizumab and CDX-1127 (varlilumab) +/-cobimetinib on T cell subpopulations systemically and intratumorally.

CORRELATIVE OBJECTIVES:

I. To explore the effect of atezolizumab and CDX-1127 (varlilumab) +/- cobimetinib on local and systemic immune activation pathways, immune suppressive pathways, and cytokine/chemokine signaling in peripheral blood and within the tumor microenvironment.

II. To assess whether atezolizumab and CDX-1127 (varlilumab) clearance at baseline and over time correlate with clinical outcomes (ORR, PFS and OS) and the presence of cachexia.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM A: Patients receive cobimetinib orally (PO) once daily (QD) on days 1-21, atezolizumab intravenously (IV) over 30-60 minutes on days 1 and 15, and varlilumab IV over 90 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive atezolizumab IV over 30-60 minutes on days 1 and 15 and varlilumab IV over 90 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months until death, withdrawal of consent, or study closure.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 64 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Randomized Phase 2 Study of Combination Atezolizumab and CDX-1127 (Varlilumab) With or Without Addition of Cobimetinib in Previously Treated Unresectable Biliary Tract Cancers
Estimated Study Start Date : November 19, 2021
Estimated Primary Completion Date : September 1, 2022
Estimated Study Completion Date : September 1, 2022


Arm Intervention/treatment
Experimental: Arm A (cobimetinib, atezolizumab, varlilumab)
Patients receive cobimetinib PO QD on days 1-21, atezolizumab IV over 30-60 minutes on days 1 and 15, and varlilumab IV over 90 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
Biological: Atezolizumab
Given IV
Other Names:
  • MPDL 3280A
  • MPDL 328OA
  • MPDL-3280A
  • MPDL3280A
  • MPDL328OA
  • RG7446
  • RO5541267
  • Tecentriq

Drug: Cobimetinib
Given PO
Other Names:
  • Cotellic
  • GDC-0973
  • MEK Inhibitor GDC-0973
  • XL518

Drug: Varlilumab
Given IV
Other Names:
  • CDX 1127
  • CDX-1127
  • Immunoglobulin G1, Anti-(Human CD Antigen CD27) (Human Monoclonal CDX-1127 Clone 1f5 Heavy Chain), Disulfide with Human Monoclonal CDX-1127 Clone 1f5 Kappa-chain, Dimer

Experimental: Arm B (atezolizumab, varlilumab)
Patients receive atezolizumab IV over 30-60 minutes on days 1 and 15 and varlilumab IV over 90 minutes on days 1 and 15. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
Biological: Atezolizumab
Given IV
Other Names:
  • MPDL 3280A
  • MPDL 328OA
  • MPDL-3280A
  • MPDL3280A
  • MPDL328OA
  • RG7446
  • RO5541267
  • Tecentriq

Drug: Varlilumab
Given IV
Other Names:
  • CDX 1127
  • CDX-1127
  • Immunoglobulin G1, Anti-(Human CD Antigen CD27) (Human Monoclonal CDX-1127 Clone 1f5 Heavy Chain), Disulfide with Human Monoclonal CDX-1127 Clone 1f5 Kappa-chain, Dimer




Primary Outcome Measures :
  1. Overall response rate [ Time Frame: Up to 1 year ]
    Will be defined as the proportion of response evaluable subjects who have a complete response (CR) or partial response (PR) using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria at any time during the study.

  2. Progression free survival [ Time Frame: Time from date of randomization to time of progression or death, assessed up to 1 year ]
    Will be summarized descriptively using Kaplan-Meier plots, and compared between arms using log-rank tests.


Secondary Outcome Measures :
  1. Overall survival [ Time Frame: Time from start of study treatment to time of death, assessed up to 1 year ]
    Will be summarized descriptively using the Kaplan-Meier method. Median overall survival will be reported and the associated 95% confidence interval will be estimated.

  2. Change in T-Cell populations [ Time Frame: Baseline up to 1 year ]
    The density of CD8+ T cells in each treatment group, at baseline and after treatment, will be visualized using boxplots, and described using summary statistics including means and standard deviation presented with 95% confidence intervals. A student t-test or nonparametric Wilcoxon rank-sum test will be used to determine whether the increase in CD8+ T cells is greater in treatment arm B (combination atezolizumab and CDX-1127 (varlilumab) plus cobimetinib) than in treatment arm A (atezolizumab and CDX-1127 [varlilumab]).

  3. Pharmacokinetic analysis [ Time Frame: Up to 1 year ]
  4. Pharmacodynamic analysis [ Time Frame: Up to 1 year ]

Other Outcome Measures:
  1. Tumor microenvironment modulation and immunologic response [ Time Frame: Up to 1 year ]
    Immunological variables will be examined in plots and summary statistics, to characterize distributions, identify outliers and other potential problems in the data. Joint exploratory analysis will identify associations and potential interactions. Variables may be transformed on the basis of these investigations, to reduce skewness, minimize the influence of outliers and/or to regularize relationships between predictors and response for better model fit. Exploratory analysis of the molecular markers, including visualizations and statistical summaries such as hierarchical cluster analysis, heat maps, multidimensional scaling, and principle component analysis will offer important views of the structural characteristics of the expression data.



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:

  • Pathologically confirmed biliary tract cancer, having received at least 1 prior line of systemic therapy, and received no more than 2 prior lines of therapy in the metastatic setting (disease recurrence < 6 months from the last dose of adjuvant therapy in resected patients will be considered the first line of therapy)

    • Includes intrahepatic cholangiocarcinoma (IHC), extrahepatic cholangiocarcinoma (EHC), and gallbladder carcinoma (GBC), but not Ampulla of Vater cancers
  • Patients must have measurable disease by Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1
  • Age >= 18 years. Because no dosing or adverse event data are currently available on the use of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) in patients < 18 years of age, children are excluded from this study
  • Eastern Cooperative Oncology Group (ECOG) performance status =< 1 (Karnofsky >= 80%)
  • Absolute neutrophil count >= 1,500/mcL
  • Hemoglobin >= 9.0 g/dl
  • Platelets >= 100,000/mcL
  • Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) (Patients with known Gilbert disease who have serum bilirubin level =< 3 x ULN may be enrolled)
  • Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) =< 2.5 x institutional ULN
  • Serum creatinine =< 1.5 x institutional ULN OR
  • Creatinine clearance >= 40 mL/min/1.73 m^2 (using Chronic Kidney Disease Epidemiology Collaboration equation [CKD-EPI]) for patients with creatinine levels above institutional normal
  • Albumin =< 3.0 g/dL
  • Prothrombin time (PT)/activated partial thromboplastin time (aPTT) =< 1.5 x ULN (This applies only to patients who do not receive therapeutic anticoagulation; patients receiving therapeutic anticoagulation, such as low-molecular-weight heparin or warfarin, should be on a stable dose)
  • Oxygen saturation >= 92% on room air
  • Left ventricular ejection fraction > 50%
  • Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial
  • For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
  • Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
  • Patients must be willing to undergo 2 sets of core needle biopsies. If possible, biopsied sites should be different than those used for measurable disease/RECIST measurements, but this is not mandatory
  • Patients must have an estimated life expectancy of greater than 3 months
  • Patients must be able to swallow pills
  • Patients should not have evidence of retinal pathology on ophthalmologic examination; or neurosensory retinal detachment, retinal vein occlusion (RVO), or neovascular macular degeneration
  • The effects of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) on the developing human fetus are unknown. For this reason, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 5 months (150 days) after completion of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) administration
  • Ability to understand and the willingness to sign a written informed consent document

Exclusion Criteria:

  • Patients with prior allogeneic bone marrow transplantation within the past 5 years or prior solid organ transplantation at any point
  • Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events (other than alopecia or neuropathy) due to agents administered more than 4 weeks earlier. However, the following therapies are allowed:

    • Hormone-replacement therapy or oral contraceptives
    • Herbal therapy > 1 week prior to randomization (herbal therapy intended as anticancer therapy must be discontinued at least 1 week prior to randomization)
    • Palliative radiotherapy for bone metastases > 2 weeks prior to randomization
  • Prior treatment with anti-CTLA-4, anti-PD-1, or anti-PD-L1or other immune checkpoint inhibitor therapeutic antibodies or pathway-targeting agents
  • Prior treatment with MEK or ERK inhibitors
  • Treatment with any other investigational agent within 4 weeks prior to randomization
  • Treatment with systemic immunostimulatory agents (including, but not limited to, interferon [IFN]-alpha or interleukin [IL]-2) within 6 weeks prior to randomization
  • Treatment with systemic immunosuppressive medications (including, but not limited to, prednisone (> 10 mg), cyclophosphamide, tacrolimus, sirolimus, azathioprine, methotrexate, thalidomide, and anti-tumor necrosis factor [anti-TNF] agents) within 2 weeks prior to Randomization.

    • Patients who have received acute, low dose, systemic immunosuppressant medications (e.g., a one-time dose of dexamethasone for nausea) may be enrolled.
    • The use of physiologic doses of systemic corticosteroids and mineralocorticoids (e.g., fludrocortisone) for patients with orthostatic hypotension or adrenocortical insufficiency is allowed.
    • The use of topical and inhaled corticosteroids are allowed due to low systemic absorption
  • Patients taking bisphosphonate therapy for symptomatic hypercalcemia. Use of bisphosphonate therapy for other reasons (e.g., bone metastasis or osteoporosis) is allowed
  • Presence of therapeutically actionable mutation with approved targeted therapy (e.g. FGFR fusion patients are eligible for study therapy in the 3rd line setting)
  • Clinically significant ascites (palpable on exam, paracentesis in last 3 months, and/or symptomatic)
  • Patients with known primary central nervous system (CNS) malignancy or symptomatic CNS metastases are excluded, with the following exceptions:

    • Patients with asymptomatic treated CNS metastases may be enrolled, provided all the criteria listed above are met as well as the following:

      • Radiographic demonstration of improvement upon the completion of CNS directed therapy and no evidence of interim progression between the completion of CNS directed therapy and the screening radiographic study
      • No stereotactic radiation or whole-brain radiation within 28 days prior to Randomization
      • Screening CNS radiographic study >= 4 weeks from completion of radiotherapy and =< 2 weeks from discontinuation of corticosteroids
      • Follow-up brain imaging 3 months after central nervous system (CNS)-directed therapy shows no evidence of progression
  • History of malignant bowel obstruction
  • History of severe allergic, anaphylactic, or other hypersensitivity reactions to Chinese hamster ovary cell products, chimeric, humanized, or other recombinant human antibodies or fusion proteins
  • History of allergic reactions attributed to compounds of similar chemical or biologic composition to atezolizumab, cobimetinib, or CDX-1127 (varlilumab)
  • Patients receiving any medications or substances that are considered moderate to strong inhibitors or inducers of CYP3A and are not able to switch to an alternative that minimizes interaction potential will ineligible. Coadministration of cobimetinib with a strong CYP3A4 inhibitor can increased cobimetinib systemic exposure significantly (e.g. itraconazole increased serum systemic cobimetinib exposure by 6.7 fold). On the other end, coadministration of cobimetinib with a strong CYP3A inducer may decrease cobimetinib systemic exposure by more than 80% thus reducing its efficacy. Because the lists of these agents are constantly changing, it is important to regularly consult a frequently-updated list such as http://medicine.iupui.edu/clinpharm/ddis/; medical reference texts such as the Physicians' Desk Reference may also provide this information. As part of the enrollment/informed consent procedures, the patient will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the patient is considering a new over-the-counter medicine or herbal product

    • Patients on mild inhibitors or inducers of CYP3A are allowed
  • Patients with a known clinically significant liver disease, including active viral, alcoholic, or other hepatitis; cirrhosis; fatty liver; and inherited liver disease.

    • Patients with past or resolved hepatitis B infection (defined as having a negative hepatitis B surface antigen [HBsAg] test and a positive anti-HBc [antibody to hepatitis B core antigen] antibody test) are eligible.
    • Patients positive for hepatitis C virus (HCV) antibody are eligible only if polymerase chain reaction (PCR) is negative for HCV ribonucleic acid (RNA)
  • Patients who have received immunosuppressive treatment for systemic autoimmune disease, including, but not limited to, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis, Sjögren's syndrome, multiple sclerosis, vasculitis, or glomerulonephritis within the last 2 years.

    • Patients with a history autoimmune endocrine disorders on stable doses of physiologic hormone replacement may be eligible.
    • Patients with controlled type 1 diabetes mellitus on a stable insulin regimen may be eligible.
    • Patients with eczema, psoriasis, lichen simplex chronicus of vitiligo with dermatologic manifestations only (e.g., patients with psoriatic arthritis would be excluded) are permitted provided that they meet the following conditions:

      • Patients with psoriasis must have a baseline ophthalmologic exam to rule out ocular manifestations
      • Rash must cover less than 10% of body surface area (BSA)
      • Disease is well controlled at baseline and only requiring low potency topical steroids (e.g., hydrocortisone 2.5%, hydrocortisone butyrate 0.1%, flucinolone 0.01%, desonide 0.05%, aclometasone dipropionate 0.05%)
      • No acute exacerbations of underlying condition within the last 12 months (not requiring psoralen plus ultraviolet A radiation [PUVA], methotrexate, retinoids, biologic agents, oral calcineurin inhibitors; high potency or oral steroids)
    • Patients with history Guillain-Barre syndrome or myasthenia gravis at any point will not be eligible
  • History of idiopathic pulmonary fibrosis, pneumonitis (including drug induced), organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing pneumonia, etc.), or evidence of active pneumonitis on screening chest computed tomography (CT) scan. History of radiation pneumonitis in the radiation field (fibrosis) is permitted
  • Patients with active tuberculosis (TB) are excluded
  • Severe infections within 4 weeks prior to randomization, including, but not limited to, hospitalization for complications of infection, bacteremia, or severe pneumonia
  • Signs or symptoms of infection within 2 weeks prior to randomization
  • Received oral or intravenous (IV) antibiotics within 2 weeks prior to randomization
  • Patients receiving prophylactic/suppressive antibiotics will not be eligible
  • Major surgical procedure within 28 days prior to randomization or anticipation of need for a major surgical procedure during the course of the study
  • Administration of a live, attenuated vaccine within 4 weeks before randomization or anticipation that such a live, attenuated vaccine will be required during the study and up to 5 months after the last dose of atezolizumab.

    • Influenza vaccination should be given during influenza season only (approximately October to March). Patients must not receive live, attenuated influenza vaccine within 4 weeks prior to Randomization or at any time during the study.
    • COVID-19 vaccination is not exclusionary but should be administered at least 7 days before study start
  • Patients with psychiatric illness/social situations that would limit compliance with study requirements
  • Pregnant women are excluded from this study because one or more study agents have the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with atezolizumab, cobimetinib, and CDX-1127 (varlilumab), breastfeeding should be discontinued if the mother is treated with atezolizumab, cobimetinib, and CDX-1127 (varlilumab)
  • Patients with a history of clinically significant cardiac dysfunction, including the following:

    • Left ventricular ejection fraction (LVEF) below institutional lower limit of normal (LLN) or below 50%, whichever is lower
    • Current unstable angina
    • Current symptomatic congestive heart failure (CHF) of New York Heart Association class 2 or higher
    • Uncontrolled hypertension >= grade 2 (patients with a history hypertension controlled with anti-hypertensives to =< grade 1 are eligible).
    • Uncontrolled arrhythmias
    • Myocardial infarction, severe/unstable angina, symptomatic chronic heart failure (CHF), cerebrovascular accident or transient ischemic attack within the previous 6 months
    • History of treatment with cardiotoxic agents

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): NCT04941287


Sponsors and Collaborators
National Cancer Institute (NCI)
Investigators
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Principal Investigator: Nilofer S Azad JHU Sidney Kimmel Comprehensive Cancer Center LAO
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Responsible Party: National Cancer Institute (NCI)
ClinicalTrials.gov Identifier: NCT04941287    
Other Study ID Numbers: NCI-2021-06445
NCI-2021-06445 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) )
ETCTN10476
10476 ( Other Identifier: JHU Sidney Kimmel Comprehensive Cancer Center LAO )
10476 ( Other Identifier: CTEP )
UM1CA186691 ( U.S. NIH Grant/Contract )
First Posted: June 28, 2021    Key Record Dates
Last Update Posted: September 14, 2021
Last Verified: September 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: NCI is committed to sharing data in accordance with NIH policy. For more details on how clinical trial data is shared, access the link to the NIH data sharing policy page.
URL: https://grants.nih.gov/policy/sharing.htm

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Biliary Tract Neoplasms
Digestive System Neoplasms
Neoplasms by Site
Neoplasms
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Neoplasms, Ductal, Lobular, and Medullary
Carcinoma, Ductal
Biliary Tract Diseases
Digestive System Diseases
Adenocarcinoma
Carcinoma
Atezolizumab
Immunoglobulins
Antibodies, Monoclonal
Immunoglobulin G
Antineoplastic Agents
Immunologic Factors
Physiological Effects of Drugs