Patient case: 48-year-old female with melanoma; genetic feature: tumor cells with >50% membranous PD-L1 expression

Clinical trial: Pembrolizumab in Recurrent or Metastatic Medullary Thyroid Cancer

Summary: Background:
  Medullary thyroid cancer (MTC) is a tumor of the thyroid gland. Surgery is the only current treatment to cure it. The drug pembrolizumab (MK-3475) is a new type of cancer therapy. It works by allowing the immune system to detect and kill tumor cells.
  Objective:
  To test how pembrolizumab affects people with MTC and if it can offer them clinical benefit.
  Eligibility:
  People ages 18 and older with MTC
  Patients who have recurrent or metastatic MTC, for whom surgery is not a curative option
  Patients with some imaging evidence of MTC
  Patients with minimal symptoms related to MTC
  Design:
  Participants will be screened with:
  -  Medical history
  -  Physical exam
  -  Blood, urine, and heart tests
  -  CT scan or MRI: They lie in a machine that takes pictures of the body.
  -  Bone scan
  Participants will be put in a group based on their treatment history:
  -  Group 1 if they have had an immune stimulating cancer vaccine
  -  Group 2 if they have had no vaccine
  Participants will receive the study drug as a 30-minute IV infusion every 3 weeks. Treatment will continue for up to 2 years as long as they tolerate it and their disease does not get worse.
  Participants will have physical exams and blood tests on the day of each infusion. They will have CT and bone scans every 3 months.
  Participants may save biopsies before treatment and after starting treatment.
  Participants will have a final visit 3-4 weeks after stopping treatment. This will include a physical exam and blood and heart tests.
  After this study, participants will can join a long-term follow-up study.

Detailed description: Background:
  -  Anti PD1/PDL1 therapies have had clinical success in a minority of unselected patients across multiple tumor types
  -  While many questions remain about optimal PD1/PDL1 staining techniques to pre-select responders, less focus is being place on how to optimize responses in a broader cohort of patients
  -  Emerging preclinical and clinical data supports the hypothesis that a strong immunologic response in the tumor microenvironment induces PDL1 expression on the tumor and is associated with better clinical response to anti-PD1/PDL1 therapies
  -  Therapeutic cancer vaccines are one strategy to induce an immunologic response to the tumor, thereby enhancing PDL1 expression and optimizing clinical responses across all patients
  -  Limited clinical data exists about the potential benefit of sequential therapy with a therapeutic cancer vaccine followed by PD1/PDL1 inhibition
  -  This study will explore the role of PD1 inhibition in medullary thyroid cancer and evaluate the potential differences based on previous vaccine therapy
  Objective:
  -The primary objective of this trial is to determine whether administering a PD1 inhibitor to patients with medullary thyroid cancer will permit a modest fraction to be able to experience a 50% or greater decline in calcitonin levels or experience a partial/complete response on imaging
  Key Eligibility:
  -  Patients greater than or equal to 18 years of age with evidence of metastatic medullary thyroid cancer including disease that is evaluable on bone, CT scan or MRI
  -  Must have elevated calcitonin levels greater than 40 pg/mL
  -  Patients with minimal or no disease related-symptoms (minimal symptoms will include those that do not affect activities of daily living or pain that does not require regularly schedule narcotics)
  -  ECOG 0-1
  -  Should have no autoimmune diseases; no evidence of being immunocompromised; no serious inter-current medical illness
  -  No brain metastasis, history of seizures, encephalitis, or multiple sclerosis
  -  Patients with previous history of vandetanib or cabozantinib treatment for more than 28 days of treatment (patients have discontinued treatment for 28 days before enrolling)
  Design:
  -  This is a phase II, open label, single center clinical trial where all patients receive the anti-PD1/PDL1 therapy pembrolizumab
  -  Patients will enroll in one of two cohorts: patients with previous vaccine therapy or patients without previous vaccine therapy
  -  All patients will be TKI -na(SqrRoot) ve, with minimal symptoms (consistent with the eligibility for our current study)
  -  Based on our calcitonin findings with our current study of 30 patients, we have determined that a confirmed calcitonin decline of 50% would be a rare finding, providing compelling preliminary evidence of clinical activity
  -  A total of 30 patients will be enrolled in the proposed study (15 patients in each cohort). Given that we already have 30 patients on a study with vaccine, we would only need to identify and recruit 15 na(SqrRoot) ve patients for the vaccine-naive cohort. This accrual could be done in 18 months based on our current accrual rates
  -  Based on these metrics, we could have >6 months of calcitonin data in 30 patients within 2 years from trial initiation
  -  Additional immune correlative capitalizing on the extensive immune monitoring experience of the LTIB will allow for assessments of antigen specific T-cells and 123 immune subsets. These findings could provide the basis for biomarker development when taken together with biochemical and clinical responses seen in this study

Eligibility: -  INCLUSION CRITERIA:
  -  Diagnosis: Patients must have histologically confirmed medullary thyroid cancer by the Laboratory of Pathology or a pathology report and history consistent with medullary thyroid cancer. It is not uncommon for a secondary, minor pathologic focus of another form of thyroid cancer to be coincidentally found in 15-20% of patients with medullary thyroid cancer. In such cases, eligibility is based on the discretion of the investigator.
  -  Patients must have evidence of metastatic medullary thyroid cancer including disease that is evaluable on bone, CT scan or MRI. (Patients who are surgical candidates and potentially rendered disease free with surgical resection are not eligible.)
  -  Patients must have elevated calcitonin levels greater than 40 pg/mL
  -  Patients must have minimal or no disease related-symptoms (Minimal symptoms will include those that do not affect activities of daily living or pain that does not require regularly scheduled narcotics.)
  -  Patients must have evaluable disease on imaging
  -  No history of seizures, encephalitis, or multiple sclerosis.
  -  Age greater than or equal to 18 years
  -  ECOG performance status of 0-1 at study entry (Karnofsky greater than or equal to 70).
  -  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 must be willing to use an adequate method of contraception, Contraception, for the course of the study through 120 days after the last dose of study medication. Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject
  -  Male subjects of childbearing potential must agree to use an adequate method of contraception. Contraception, starting with the first dose of study therapy through 120 days after the last dose of study therapy. Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject
  -  Willing to travel to the NIH for follow-up visits
  -  Able to understand and sign informed consent.
  -  Demonstrate adequate organ function, all screening labs should be performed within 10 days of treatment initiation.
  -  Patients with previous history of vandetanib or cabozantinib treatment for more than 28 days of treatment (patients have discontinued treatment for 28 days before enrolling).
  -  Adequate Organ Function Laboratory Values
  -  Hematological
  ---Absolute neutrophil count (ANC) greater than or equal to1,000 /mcL
  -  Platelets greater than or equal to 100,000 / mcL
  -  Hemoglobin greater than or equal to 9 g/dL or greater than or equal to 5.6 mmol/L without transfusion or EPO dependency (within 7 days of assessment)
  -  Renal
  -  Serum creatinine less than or equal to1.5 X upper limit of normal (ULN) OR
  -  Measured or calculated* creatinine clearance (GFR can also be used in place of creatinine or CrCl) greater than or equal to 60 mL/min for subject with creatinine levels > 1.5 X institutional ULN
  -  Hepatic
  -  Serum total bilirubin less than or equal to 1.5 X ULN OR Direct bilirubin less than or equal to ULN for subjects with total bilirubin levels > 1.5 ULN
  -  AST (SGOT) and ALT (SGPT) less than or equal to 2.5 X ULN OR less than or equal to 5 X ULN for subjects with liver metastases
  -  Albumin >2.5 mg/dL
  -  Coagulation
  -  International Normalized Ratio (INR) or Prothrombin Time (PT) less than or equal to1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants
  -  Activated Partial Thromboplastin Time (aPTT) less than or equal to1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants
  -  Creatinine clearance should be calculated per Cockcroft-Gault equation
  EXCLUSION CRITERIA:
  -  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.
  -  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.
  -  Has a known history of active TB (Bacillus Tuberculosis)
  -  Hypersensitivity to pembrolizumab or any of its 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., less than or equal to Grade 1 or at baseline) from adverse events due to agents administered more than 4 weeks earlier.
  -  Has had prior targeted small molecule therapy, or radiation therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., less than or equal to Grade 1 or at baseline) from adverse events due to a previously administered agent. Note: Subjects with less than or equal to Grade 2 neuropathy are an exception to this criterion and may qualify for the study. Note: If subject received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy.
  -  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 active central nervous system (CNS) metastases and/or carcinomatous meningitis. Subjects with previously treated brain metastases may participate provided they are stable for 6 months (without evidence of progression by imaging for at least four weeks prior to the first dose of trial treatment 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 7 days prior to trial treatment. This exception does not include carcinomatous meningitis which is excluded regardless of clinical stability.
  -  Has history of (non-infectious) pneumonitis that required steroids, evidence of interstitial lung disease or 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 received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.
  -  Has Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).
  -  Has active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA [qualitative] is detected).
  -  Has received a live vaccine within 30 days of planned start of study therapy
  -  Concurrent use of systemic steroids, except for physiologic doses of systemic steroid replacement or local (topical, nasal, eye drops or inhaled) steroid use. Limited doses of systemic steroids (e.g., in patients with exacerbations of reactive airway disease or to prevent IV contrast allergic reaction or anaphylaxis in patients who have known contrast allergies) are allowed.
  -  Serious inter-current medical illness which would interfere with the ability of the patient to carry out the treatment program.
  -  Patients with second malignancy within 3 years of enrollment; Patients curatively treated non-melanoma skin cancers or carcinoma in situ of the bladder, are not excluded. Patients with MEN2 and a history of pheochromocytoma will also not be excluded. In addition patients with prostate cancer who do not require systemic therapy will not be excluded. (A secondary, minor pathologic focus of another form of thyroid cancer may be coincidentally found in 15-20% of patients with medullary thyroid cancer. In such cases, eligibility is based on the discretion of the investigator.)

Relevance to patient case: not relevant