Trial of mFOLFOX6 + Trastuzumab + Avelumab in Gastric and Esophageal Adenocarcinomas
Condition: Gastric Adenocarcinoma; Esophageal Adenocarcinoma; Metastasis; HER-2 Gene Amplification
MeSH terms: Adenocarcinoma; Esophageal Neoplasms
Intervention: Oxaliplatin; Leucovorin; 5 fluorouracil; Trastuzumab; Avelumab
Intervention description: Oxaliplatin 85 mg/m2; Leucovorin 400 mg/m2; 5 fluorouracil 400 mg/m2 bolus and 2400 mg/m2 continuous infusion; Trastuzumab 6 mg/kg loading dose C1D1 then 4 mg/kg Day 1; Avelumab 800 mg
Intervention MeSH terms: Leucovorin; Fluorouracil; Oxaliplatin; Trastuzumab; Avelumab
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 18.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No

Summary:

      The initial intent of the study was to be a multi-center single-arm open-label Simon's
      two-stage Phase II clinical trial of first-line mFOLFOX6 + trastuzumab + avelumab in
      metastatic HER2-amplified gastric and esophageal adenocarcinomas.

      Accrual will halt after completion of Stage I (enrollment of 18 patients). This decision is
      not due to safety issues. Subjects currently on treatment will continue until criteria as
      defined in the protocol is met.
    

Eligibility criteria:

        Inclusion Criteria:

          1. Written informed consent and HIPAA authorization for release of personal health
             information prior to registration.

          2. Age ≥ 18 years at the time of consent.

          3. ECOG Performance Status of 0 or 1.

          4. Histologically confirmed esophageal, gastroesophageal junction, or gastric
             adenocarcinoma, with unresectable or metastatic disease documented on diagnostic
             imaging studies.

          5. HER2 amplification confirmed by standard of care testing of tumor specimen (3+ by
             immunohistochemistry, or 2+ on IHC with ISH with HER2/CEP17 ratio ≥2).

          6. Radiographically measurable disease according to RECIST 1.1 within 28 days prior to
             registration.

          7. Adequate organ function as defined in the table below. All screening labs to be
             obtained within 28 days prior to registration.

               -  Absolute Neutrophil Count ≥ 1.5 x 10^9/L

               -  Hemoglobin (Hgb) ≥ 9 g/dL (may have been transfused)

               -  Platelets ≥ 100 x 10^9/L OR ≥ 75 x 10^9/L for patients who received Cycle 1 of
                  mFOLFOX6 +/- trastuzumab prior to registration

               -  Calculated creatinine clearance1 ≥ 30 mL/min OR creatinine ≤ 1.5 × upper limit of
                  normal (ULN)

               -  Bilirubin ≤ 1.5 × upper limit of normal (ULN) (Subjects with Gilbert's syndrome
                  may be enrolled despite a total bilirubin level >1.5 mg/dL, if their conjugated
                  bilirubin is < 1.5× ULN)

               -  Aspartate aminotransferase (AST) ≤ 2.5 × ULN OR ≤ 5x ULN in patients with known
                  liver metastases

               -  Alanine aminotransferase (ALT) ≤ 2.5 × ULN OR ≤ 5x ULN in patients with known
                  liver metastases

          8. Left ventricular ejection fraction (LVEF) ≥ 50% or above the lower limit of the
             institutional normal range, whichever is lower.

          9. Females of childbearing potential must have a negative serum pregnancy test at
             screening. NOTE: Females are considered of child bearing potential unless they are
             surgically sterile (have undergone a hysterectomy, bilateral tubal ligation, or
             bilateral oophorectomy) or they are naturally postmenopausal for at least 12
             consecutive months.

         10. Females of childbearing potential and males must be willing to abstain from
             heterosexual activity or to use 2 forms of effective methods of contraception from the
             time of informed consent until 210 days after treatment discontinuation. The two
             contraception methods can be comprised of two barrier methods, or a barrier method
             plus a hormonal method.

         11. As determined by the enrolling physician or protocol designee, ability of the subject
             to understand and comply with study procedures for the entire length of the study.

        Exclusion Criteria:

          1. Previous systemic therapy for stage IV disease - EXCEPT that patient may have received
             one cycle of mFOLFOX6 +/- trastuzumab within the 4 weeks prior to registration.

          2. Active infection requiring intravenous systemic therapy.

          3. Pregnant or breastfeeding (NOTE: breast milk cannot be stored for future use while the
             mother is being treated on study).

          4. Treatment with any investigational drug within 28 days prior to registration.

          5. Prior immune checkpoint inhibitor therapy (i.e. anti-CTLA-4, anti-PD-L1, anti-PD-1),
             or HER2-directed therapy (including trastuzumab)

          6. Evidence of interstitial lung disease or active, non-infectious pneumonitis

          7. Untreated brain metastasis or brain metastasis treated within 4 weeks prior to
             enrollment.

          8. Known additional malignancy that is active and/or progressive requiring treatment;
             exceptions include basal cell or squamous cell skin cancer, in situ cervical or
             bladder cancer, or other cancer for which the subject has been disease-free for at
             least five years.

          9. Serious cardiovascular event within 6 months prior to study entry, including
             myocardial infarction, malignant hypertension, severe/unstable angina, symptomatic
             congestive heart failure (≥ New York Heart Association Classification Class II),
             cerebral vascular accident, transient ischemic attack, or serious cardiac arrhythmia
             requiring medication.

         10. History of organ allograft or allogeneic stem cell transplantation

         11. Active autoimmune disease requiring systemic treatment in the past 3 months (for
             example with disease modifying agents, corticosteroids, or immunosuppressive drugs).

             Exceptions Include:

               -  Subjects with endocrine diseases stable on replacement therapy (e.g., thyroxine,
                  insulin, or physiologic corticosteroid replacement therapy for adrenal or
                  pituitary insufficiency, etc.) or hormone suppression.

               -  Subjects that require intermittent use of bronchodilators, local steroid
                  injections, or inhaled or topical steroids

               -  Subjects with vitiligo, psoriasis, Sjogren's syndrome, or resolved childhood
                  asthma/atopy

         12. Current use of immunosuppressive medication, EXCEPT for the following: a. intranasal,
             inhaled, topical steroids, or local steroid injection (e.g., intra-articular
             injection); b. Systemic corticosteroids at physiologic doses ≤ 10 mg/day of prednisone
             or equivalent; c. Steroids as premedication for hypersensitivity reactions (e.g., CT
             scan premedication).

         13. Known history of testing positive for HIV or known acquired immunodeficiency syndrome.

         14. Known history of Hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.
             Subjects with laboratory evidence of cleared HBV and HCV infection will be permitted.

         15. Vaccination within 4 weeks of the first dose of avelumab and while on trials is
             prohibited except for administration of inactivated vaccines.

         16. Known prior severe hypersensitivity to investigational product or any component in its
             formulations, including known severe hypersensitivity reactions to monoclonal
             antibodies (NCI CTCAE v5 Grade ≥ 3).

         17. Persisting toxicity related to prior therapy (NCI CTCAE v5 Grade > 1); however,
             alopecia, sensory neuropathy Grade ≤ 2, or other Grade ≤ 2 not constituting a safety
             risk based on investigator's judgment are acceptable.

         18. Other severe acute or chronic medical conditions including immune colitis,
             inflammatory bowel disease, immune pneumonitis, pulmonary fibrosis or psychiatric
             conditions including recent (within the past year) or active suicidal ideation or
             behavior; or laboratory abnormalities that may increase the risk associated with study
             participation or study treatment administration or may interfere with informed
             consent, the interpretation of study results and, in the judgment of the investigator,
             would make the patient inappropriate for entry into this study.