Patient case: 64-year-old female with melanoma; genetic feature: BRAF (E586K)

Clinical trial: Radiation Therapy Plus Temozolomide and Pembrolizumab With and Without HSPPC-96 in Newly Diagnosed Glioblastoma (GBM)

Summary: Background:
  GBM refers to a specific kind of brain cancer called glioblastoma. The standard treatment for GBM is radiation plus temozolomide, an oral chemotherapy drug. Pembrolizumab is an immune therapy that is now used to treat other cancers. The addition of pembrolizumab to the standard treatment of radiation and temozolomide has been shown to be well tolerated. Researchers want to see if adding a vaccine made from the person s own tumor will improve the effect of the pembrolizumab. The vaccine which is developed from fresh tumor taken at the time of surgery is called HSPPC-96.
  Objectives:
  To see if the adding pembrolizumab and HSPPC-96 improves the standard treatment for glioblastoma multiforme.
  Eligibility:
  Adults at least 18 years old with glioblastoma.
  Design:
  Participants will be screened with typical cancer tests:
  Brain scan
  Medical history
  Blood and urine tests
  Questions about quality of life and symptoms
  These tests will be repeated throughout the study.
  Participants will have surgery to remove their tumor. A tissue sample from the tumor will be sent to a lab. A vaccine will be made from it.
  Some participants will get pembrolizumab and vaccine. Some will get pembrolizumab and placebo. Participants will not know which they get.
  Participants will get radiation for 6 weeks.
  Participants will take temozolomide by mouth before each treatment.
  Participants will get pembrolizumab by IV for 30 minutes 3 times over the radiation cycle.
  Participants will keep taking the 2 drugs every few weeks for about a year. Some may take pembrolizumab for an additional year.
  Most participants will get the vaccine or placebo after radiation. They will get it 5 times over 6 weeks. Some participants will continue to get the vaccine every few weeks for 1 or 2 years.
  Participants will repeat the screening tests when they stop study treatment. They will also have follow-up phone calls.

Detailed description: Background:
  -  Malignant gliomas are unfortunately, in most cases, a uniformly fatal tumor. Despite aggressive surgery, radiation treatment (RT) and chemotherapy at initial diagnosis these tumors almost always recur.
  -  Many clinical trials in glioblastoma (GBM) have evaluated the addition of agent(s) to standard therapy which consists of concurrent radiation with temozolomide chemotherapy after maximal surgical resection in patients with newly diagnosed disease and salvage chemotherapy with either rechallenge with temozolomide or an alternative alkylating agent such as CCNU or cisplatin. To date, none of the combination strategies have demonstrated clinical benefit. Furthermore, in subjects with an unmethylated MGMT (O6-methylguanine-DNA methyltransferase) promoter temozolomide has only modest benefit and salvage therapies have not demonstrated a significant impact in this subject group underscoring the need for more research.
  -  Immunotherapy offers the promise of improving outcomes for patients with GBM by evoking specific immune responses that may produce a more sustained and less toxic effect than conventional therapy. Heat-shock proteins (HSPs), which function as intracellular chaperones, can be used to deliver a variety of tumor antigens to antigen presenting cells for immune stimulation.
  -  Heat Shock Protein-Peptide Complex-96 (HSPPC-96) consists of the heat shock protein glycoprotein-96 (HSP gp-96) and a wide array of chaperoned proteins, including autologous antigenic peptides (aka vaccine ). Heat shock proteins (HSP) are molecules that respond to cellular stress and counteract abnormal protein folding. They are known to modulate immune responses, especially the HSP gp-96. In a stressful environment, such as a tumor, HSPs are upregulated and highly expressed on tumor cells. This protects the tumor and leads to resistance to therapy. HSP expression is associated with cellular proliferation, apoptosis evasion, tissue invasion, metastasis, and angiogenesis.
  -  Pembrolizumab is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. Additionally, pembrolizumab is thought to also have activity in the peripherally circulating T-effector cells by reversing lymphocyte exhaustion. It is currently FDA approved for use in patients with unresectable or metastatic melanoma and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor and NSCLC with elevated PDL1 in the tumor. recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy. It is also FDA approved for with advanced (metastatic) non-small cell lung cancer (NSCLC) whose disease has progressed after other treatments and with tumors that express a protein called PD-L1 and for the treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinum-containing chemotherapy
  -  This study will be the first to evaluate this combination of vaccine (HSPPC-96) and PD- 1 inhibition (pembrolizumab) in newly diagnosed GBM patients whose tumors are MGMT promoter unmethylated and are isocytrate dehydrogenase (IDH) wildtype; and will provide important data on immune-modulatory effect of this combination. This may be of particular value in patients with high peripheral PD-L1 expression, but also the value of PD-1 added to standard GBM therapy. As vaccine needs to be generated from the patient s tumor, patients will need to be identified prior to surgery.
  Eligibility:
  -  MRI findings consistent with a suspected GBM or histologically confirmed newly diagnosed GBM that has not been treated and would benefit from further surgical resection.
  -  Tumor must be supratentorial.
  -  GBM diagnosis must be made by surgical excision (stereotactic biopsy will not be allowed unless there is plan for second surgery to remove greater than or equal to 80 % of the tumor) and patients tumors must not have MGMT promoter methylation and must be IDH wildtype.
  -  No prior treatment with radiation or chemotherapy for their GBM.
  -  Age greater than or equal to 18 years on day of signing informed consent
  Objective:
  - The primary endpoint is to determine whether the one year overall survival (OS) rate is improved in newly diagnosed GBM patients whose tumors have an unmethylated MGMT promoter and are IDH wildtype treated with RT + TMZ + Pembrolizumab followed by TMZ + Pembrolizumab + HSPPC-96 vaccine or Placebo vaccine x 6 cycles (1 cycle is 9 weeks).
  Design:
  -  This will be a randomized, double blind phase II trial of surgery, RT + TMZ + Pembrolizumab followed by TMZ + Pembrolizumab +/- HSPPC-96 in newly diagnosed GBM patients whose tumors have an unmethylated MGMT promotor and are IDH wildtype.
  -  Subjects will be assigned to intervention based on tumor resection and ability to generate vaccine as follows:
  -  If < 80 % of tumor removed, <7 g of tumor is resected or HSPPC-96 cannot be generated, subjects will be treated on the ancillary cohort of RT+TMZ +Pembrolizumab followed by TMZ+ Pembrolizumab.
  -  If greater than or equal to 80% of contrasting enhanced tumor removed (based on T1 Post contrast MRI using cross sectional measurement), greater than or equal to 7 g of tumor is resected and sufficient HSPPC-96 is generated, subjects will be included in the main cohort and will be randomized on a 1:1 basis to receive:
  1. RT+TMZ +Pembrolizumab followed by TMZ+Pembrolizumab + Placebo
  OR
  2. RT+TMZ +Pembrolizumab followed by TMZ+Pembrolizumab+HSPPC-96
  -  Approximately 8 potentially eligible patients are seen per month, and it is anticipated that at least 1-2 per month will be accrued per site.

Eligibility: -  INCLUSION CRITERIA:
  Pre Surgery (Step 1)
  -  MRI findings consistent with a suspected GBM or a histologically confirmed newly diagnosed GBM that has not been treated and would benefit from further surgical resection. As vaccine needs to be generated from the patient s tumor, patients will need to be identified prior to definitive surgery.
  -  Age greater than or equal to 18 years on day of signing informed consent.
  -  Karnofsky performance status greater than or equal to 70%.
  -  Tumor must be supratentorial only.
  -  Stereotactic biopsy will not be allowed unless there is plans for second surgery to remove greater than or equal to 80 % of the tumor.
  -  No prior treatment with radiation or chemotherapy for their GBM.
  -  No prior treatment with carmustine wafers.
  Post-Surgery for vaccine or placebo (Step 2):
  -  Pathology must be a GBM, MGMT promoter region determined to be unmethylated and IDH wild type. Greater than or equal to 80 % resection of contrast enhanced tumor on post operative MRI is required for randomization, otherwise treatment will occur on the ancillary arm.
  -  Treatment must be initiated greater than or equal to 14 days and < 6 weeks from surgery.
  -  Craniotomy site must be adequately healed and free of drainage or cellulitis, and the underlying cranioplasty must appear intact at the time of radiation. Radiation must start within 6 weeks of surgery.
  -  Dexamethasone dose should be less than or equal to 4 mg/day or steroid equivalent prior to starting treatment. If higher doses are needed, consult with Study Chair.
  -  Female subjects of childbearing potential should have a negative urine or serum pregnancy within 7 days prior to receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a negative serum pregnancy test will be required.
  -  Patients must have adequate organ and bone marrow function within 14 days prior to step 2 registration, as defined below:
  -  Absolute neutrophil count (ANC) > 1.5 (SqrRoot) 10(9)/L; platelet count > 100 (SqrRoot) 10(9)/L; and hemoglobin (Hb) >9.0 g/dL within 7 days prior to step 2 registration. Note: The use of transfusion or other intervention to achieve Hb greater than or equal to 9.0 g/dL is acceptable.
  -  Total bilirubin < 1.5 (SqrRoot) ULN (except in patients diagnosed with Gilbert s disease)
  -  AST (SGOT), ALT (SGPT), and alkaline phosphatase (ALP) < 2.5 (SqrRoot) ULN
  -  Serum creatinine < 1.5 (SqrRoot) ULN
  -  International normalized ratio (INR), prothrombin time (PT), or activated partial thromboplastin time (APTT) as follows: In the absence of therapeutic intent to anticoagulate the patient: INR < 1.5 or PT < 1.5(SqrRoot) ULN or aPTT < 1.5(SqrRoot) ULN. In the presence of therapeutic intent to anticoagulate the patient: INR or PT and aPTT within therapeutic limits (according to the medical standard in the institution) and the patient has been on a stable dose of anticoagulants for at least 2 weeks before registration.
  -  Females of child-bearing potential (FOCBP) and males must agree to use two adequate contraception methods (give examples, e.g. hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for 120 days following completion of therapy. Should a female patient become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. Male patients who father a child should notify the treating physician.
  NOTE: A FOCBP is any woman (regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by choice) who meets the following criteria:
  1. Has not undergone a hysterectomy or bilateral oophorectomy
  2. Has had menses at any time in the preceding 12 consecutive months (and therefore has not been naturally postmenopausal for > 12 months)
  -  Patients must have the ability to understand and the willingness to sign a written informed consent prior to registration on study.
  -  Diagnosis must be made by surgical excision.
  -  Patients should not be on antibiotics for any infection but post operative antibiotics are allowed if used prophylactically but should be completed prior to starting RT.
  EXCLUSION CRITERIA:
  -  Patients who are receiving any other investigational agents.
  -  Known history of immunodeficiency (HIV). This medical entity can be exacerbated by PD-1 blockade.
  -  Any form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment excluding steroids. Attempts should be made to have patient on lowest possible dose of steroids. These medical entities can be exacerbated by PD-1 blockade.
  -  History of another malignancy in the previous 3 years, with a disease-free interval of < 3 years. Exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy. Patients who have undergone a bne marrow or stem-cell transplant for any malignancy are excluded.
  -  Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires chronic systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections will not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement or Sjorgen s syndrome will not be excluded from the study.
  -  Has a history of interstitial lung disease, non-infectious pneumonitis or pneumonitis.
  -  Has an active infection requiring systemic antibiotics within 10 days of surgery.
  -  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.
  Examples include:
  -  Hypertension (defined as 160/95) that is not controlled on medication
  -  Ongoing or active infection requiring systemic treatment
  -  Symptomatic congestive heart failure
  -  Unstable angina pectoris
  -  Cardiac arrhythmia
  -  Psychiatric illness/social situations or substance abuse disorders that would limit compliance with study requirements
  -  Any other illness or condition that the treating investigator feels would interfere with study compliance or would compromise the patient s safety or study endpoints.
  -  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.
  -  The effects of pembrolizumab and HSPPC-96 on the developing human fetus are unknown. For this reason and because checkpoint inhibitors and immunotherapeutic vaccines as well as other therapeutic agents used in this trial are known to be teratogenic, 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.
  -  Has 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).
  -  On treatment for Hepatitis B or Hepatitis C or history of TB.
  -  Has received a live vaccine within 30 days prior to the first dose of trial treatment
  -  Patients who have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to Pembrolizumab are not eligible. Known hypersensitivity to any excipients of Pembrolizumab.

Relevance to patient case: not relevant