Patient case: 50-year-old male with glioblastoma; genetic feature: IDH1 (R132H)

Clinical trial: Biomarker-Driven Therapy Using Immune Activators With Nivolumab in Patients With First Recurrence of Glioblastoma

Summary: This research is being done to test if it is safe to give nivolumab with targeted immunotherapy drugs for recurrent glioblastoma (GBM), a type of brain tumor. The study doctors believe that giving immunotherapy drugs that match the biomarkers in a tumor will help the immune system fight the tumor. Tumor tissue collected during surgery will be tested for certain biomarkers to determine which immunotherapy might best target the tumor.
  The combination immunotherapy arms include:
  Arm A: Nivolumab + anti-GITR Arm B: Nivolumab + IDO1 inhibitor Arm C: Nivolumab + Ipilimumab

Detailed description: PRIMARY OBJECTIVE
  1. To determine safety of each of the following study agents, anti-GITR, IDO1 inhibitor, and ipilimumab, in combination with nivolumab (BMS-936558) flat dose in patients with first recurrence of GBM.
  SECONDARY OBJECTIVES
  1. To estimate toxicity
  2. To estimate progression-free survival
  3. To estimate overall survival
  4. To evaluate pain for patients undergoing the treatment of anti-GITR, IDO1 inhibitor, and ipilimumab, in combination with nivolumab.
  EXPLORATORY OBJECTIVES
  1. To characterize the immune response during and after treatment as measured by immunohistochemistry, and other T cells etc. in peripheral blood
  2. To characterize the pharmacodynamic and genomic activity in tumor tissue as target inhibition
  3. To characterize radiographic response
  4. Genetic characterization of correlative samples

Eligibility: Inclusion Criteria:
  -  Patients must have histologically proven glioblastoma or gliosarcoma which is progressive or recurrent following radiation therapy with or without temozolomide.
  -  Patients must be in first recurrence of glioblastoma following radiation therapy with or without temozolomide. Patients with previously grade 3 astrocytoma who after first recurrence after radiotherapy with or without temozolomide are found to have GBM are eligible. Patients who have received Gliadel wafers during their initial surgery are eligible.
  -  Patients must be undergoing repeat surgery that is clinically indicated as determined by their care providers, where a significant debulking or a gross total surgical resection of the contrast-enhancing area is intended.
  -  Patients must consent to our acquiring tumor tissue removed before, during, or after the study, if it becomes available.
  -  Patients must be able to undergo MRI of the brain with gadolinium.
  -  Patients receiving corticosteroid to treat cerebral edema or hypothalamic-pituitary insufficiency are eligible.
  -  Patients must have recovered from severe toxicity of prior therapy. An interval of at least 12 weeks must have elapsed since the completion of radiation therapy or placement of Gliadel wafers, and at least 6 weeks must have elapsed from the last dose of temozolomide (TMZ). No prior therapies are allowed other than radiation, temozolomide, and Gliadel wafers (placed during the first surgery at diagnosis of high grade glioma (HGG)).
  -  Patients must be 18 years of age or older.
  -  Patients must have a Karnofsky Performance Status (KPS) ≥ 60% (i.e. the patient must be able to care for himself/herself with occasional help from others).
  -  Patients must have the following organ and marrow function:
  -  Absolute lymphocyte count ≥ 750/mcl
  -  Absolute neutrophil count ≥ 1,500/mcl
  -  Platelets ≥ 100,000/mcl
  -  Hemoglobin ≥ 9 g/dl
  -  Total bilirubin ≤ institutional upper limit of normal (except for patients with Gilberts' syndrome who must have normal direct bilirubin)
  -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) ≤ 3 × institutional upper limit of normal
  -  Creatinine ≤ institutional upper limit of normal OR Creatinine clearance ≥ 60 ml/min/1.73m2 for patients with creatinine levels above institutional normal
  -  activated partial thromboplastin time (APTT) or partial thromboplastin time (PTT) ≤ 1.5 x institutional upper limit of normal
  -  Patients must be able to provide written informed consent.
  -  Women of childbearing potential (WOCBP) must agree to have a negative serum pregnancy test within -7 days prior to treatment start. Women of childbearing potential must agree to use non-hormonal (due to induction of Cyp3a4) (barrier method of birth control; abstinence) prior to study entry, for the duration of study treatment, and through at least 5 months after the last dose of study drug. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. Males who are sexually active with WOCBP must agree to use a condom during penile vaginal intercourse for the duration of treatment with study treatment plus 7 months after the last dose of the study treatment (i.e., 90 days [duration of sperm turnover] plus the time required for nivolumab to undergo approximately 5 half-lives). This criteria applies to azoospermic males as well.
  -  Patients must have no concurrent malignancy except curatively treated basal or squamous cell carcinoma of the skin or carcinoma in situ of the cervix, breast, or bladder. Patients with prior malignancies must be disease-free for ≥ five years.
  Exclusion Criteria:
  -  Patients receiving any other investigational agents are ineligible.
  -  Patients with a history of allergic reactions attributed to compounds of similar chemical or biologic composition to IO agents used in this study are ineligible. The Investigator Brochures can be referenced for more information.
  -  Patients with active or a known history of known or suspected autoimmune disease are ineligible. Subjects with Type 1 diabetes mellitus, hypothyroidism only requiring hormone replacement, and skin disorders (vitiligo, psoriasis, or alopecia) not requiring systemic treatment, are permitted to enroll.
  -  Patients with a condition requiring systemic treatment with either corticosteroids (other than for cerebral edema or hypothalamic-pituitary dysfunction) or other immunosuppressive medications within 14 days of study entry are ineligible.
  -  Patients must not have evidence of significant mass effect.
  -  Patients must have no evidence of significant hematologic, renal, or hepatic dysfunction. Patients with underlying hepatocellular disease should be given careful risk/benefit consideration prior to enrollment. Patients with a known history of any chronic hepatitis as evidenced by the following are ineligible:
  -  Positive test for hepatitis B surface antigen (HBsAg)
  -  Positive test for qualitative hepatitis C viral load (by PCR) (Note: Subjects with positive hepatitis C antibody and negative quantitative hepatitis C by PCR are eligible. History of resolved hepatitis A virus infection is not an exclusion criterion.)
  -  History of alcoholic or non-alcoholic steatohepatitis (NASH), auto-immune hepatitis, or previous grade 3-4 drug-related hepatitis, or any form of chronic liver disease
  -  Patients with a confirmed history of encephalitis or meningitis in the year prior to signing informed consent are ineligible.
  -  Patients with uncontrolled or significant cardiovascular disease including, but not limited to, any of the following are ineligible:
  -  Myocardial infarction or stroke/transient ischemic attack (TIA) within the 6 months prior to consent
  -  Uncontrolled angina within the 3 months prior to consent
  -  Any history of clinically significant arrhythmias (such as ventricular tachycardia, ventricular fibrillation, or torsades de pointes)
  -  QTc prolongation > 480 msec
  -  History of other clinically significant cardiovascular disease (i.e., cardiomyopathy, myocarditis, congestive heart failure with New York Heart Association (NYHA) functional classification III-IV, pericarditis, significant pericardial effusion, significant coronary stent occlusion, deep venous thrombosis, etc.)
  -  Cardiovascular disease-related requirement for daily supplemental oxygen Patients with other uncontrolled intercurrent illness including, but not limited to, ongoing or active infection that requires systemic antibacterial, antiviral or antifungal therapy < 7 days prior to the first dose of study drug, or psychiatric illness/social situations that would limit compliance with study requirements, are ineligible.
  -  Pregnant women are excluded from this study because the study agents have potential for teratogenic or abortifacients effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with IO agents used in this study, breastfeeding should be discontinued if the mother is treated with these agents.
  -  Patients with a known history of testing positive for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS), hepatitis C (HCV) negative (by qPCR) and HBcAb negative (no prior Hepatitis B infection)) are ineligible.
  -  Participants with a personal or family (i.e., in a first-degree relative) history of cytochrome b5 reductase deficiency (previously called methemoglobin reductase deficiency) or other diseases that put them at risk of methemoglobinemia. All participants will be screened for methemoglobin levels prior to randomization.
  -  Participants with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency or other congenital or autoimmune hemolytic disorders. All participants will be screened for G6PD levels prior to arm assignment.
  -  Patients with prior organ or tissue allograft are ineligible.
  -  Patients with a history of life-threatening toxicity related to prior immune therapy are ineligible.
  -  Quantitative or qualitative G6PD assay results suggesting underlying G6PD deficiency.
  -  Blood methemoglobin > upper limit of normal (ULN), assessed in an arterial or venous blood sample or by co-oximetry.
  -  History or presence of hypersensitivity or idiosyncratic reaction to methylene blue.
  -  Prior history of serotonin syndrome
  -  Participants with active interstitial lung disease (ILD) or pneumonitis or with recent history of ILD or pneumonitis requiring steroids (excluding radiation pneumonitis)
  -  Participants with conditions known to interfere significantly with the absorption of oral medication, as per investigator judgement.

Relevance to patient case: not relevant