Nivolumab and Tocilizumab for Relapsed Hematological Malignancy Post-allogeneic Transplant

This is a phase 1, interventional single arm, open label, treatment study designed to evaluate the safety combination programmed cell death protein 1 (PD-1) and interleukin 6 (IL-6) inhibition in participants with relapsed disease post-allogeneic transplant.

Study disease: Hematologic malignancies including, but not exclusive to,acute/chronic leukemia, lymphoma, and myelodysplastic syndrome that has relapsed after allogeneic transplant.

Study Rationale: Phase 1 Safety/Dose Finding Study: To determine the safety and maximum tolerated dose of Nivolumab in combination with Tocilizumab.

Study Agent Description:

Tocilizumab is a monoclonal antibody and immunosuppressant; specifically, tocilizumab is an IL-6 receptor antagonist.

Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor of T cells blocking its interaction with PD-L1 and PD-L2, thereby enhancing T-cell proliferation and allowing the immune system to attack the tumor.

Number of Subjects: A maximum of 12 participants will be enrolled on this Phase 1 study.

Duration of Follow-up: Participants will be followed for up to one year post-treatment for survival and response.

Study Design: This is a 3 + 3 design. In a "3 + 3 design," three participants are initially enrolled into a given dose cohort. If there is no dose limiting toxicity (DLT) observed in any of these subjects, the trial proceeds to enroll additional subjects into the next higher dose cohort. If one subject develops a DLT at a specific dose, an additional three subjects are enrolled into that same dose cohort. Development of DLTs in more than one of six subjects in a specific dose cohort suggests that the maximum tolerated dose (MTD) has been exceeded, and further dose escalation is not pursued.

Eligibility Criteria:
Inclusion Criteria

1. Age≥18 years with hematological malignancies who have undergone allogeneic transplant for hematological malignancy and are ≥180 days post-transplant.
2. Relapsed disease post-allogeneic transplant defined as follows i. Acute or Chronic Leukemia or myelodysplastic or myeloproliferative disorders or natural killer (NK) cell neoplasms: Bone marrow (BM) with ≥5% disease involvement or peripheral blood evidence of overt relapse ii. Lymphoma: BM evidence of relapsed/persistent disease or PET/CT or CT evidence of persistent/progressive lymphadenopathy consistent with active lymphoma. Active disease defined as nodal lesions ≥ 20 mm in the long axis or extranodal lesions≥10 mm in long and short axis or bone marrow involvement that is biopsy proven
3. Karnofsky performance status ≥70 (See Appendix A for details)
4. Creatinine Clearance≥60 ml/min
5. Adequate hepatic function, defined as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3 x upper limit of normal (ULN). Serum bilirubin and alkaline phosphatase ≤3x x ULN, or considered not clinically significant (e.g. Gilbert's or indirect hyperbilirubinemia) or felt to be due to underlying disease.
6. Without evidence of active acute or chronic graft versus host disease (GVHD)
7. Off all immunosuppression and corticosteroids (other than replacement dose steroids defined as equivalent to a maximum of 10 mg Prednisone daily) for ≥28 days from first treatment.
8. Off all disease targeted treatments for ≥10 days to first treatment day
9. Able to provide written informed consent
10. Women of child-bearing potential and men must agree to use adequate contraception for the duration of study participation and for 120 days after the last treatment with nivolumab.
11. No FDA approved, more appropriate therapies available for disease control as determined by the treating physician

Exclusion Criteria

1. Positive beta-human chorionic gonadotropin (HCG) in female of child-bearing potential
2. Cluster of differentiation 3 (CD3) donor chimerism \<5% within 4 weeks of starting study treatment
3. Prior administration of donor lymphocyte infusion post-allogeneic transplant within the last 6 months of study treatment
4. History of or active autoimmune disease, or other syndrome that requires systemic steroids.
5. History of allergic reactions attributed to compounds of similar chemical or biologic composition to nivolumab.
6. Uncontrolled or active infections on treatment
7. Confirmed active human immunodeficiency virus (HIV), Hepatitis B or C infection.
8. Presence of ≥grade 3 non-hematologic toxicities as per CTCAE version 5 from any previous treatment unless it is felt to be due to underlying disease.
9. Concurrent use of investigational therapeutic agents or enrollment on another therapeutic clinical trial at any institution.

   a. Minimum of 4 weeks from last dose of investigational agent
10. Prior exposure to PD-1 or CTLA4 antibodies in the post-allogeneic transplant setting. Participants who received such agents pre-allogeneic transplant will NOT be excluded.
11. Prior exposure to daratumumab in the post-allogeneic transplant setting within two months of start date of treatment with this investigational protocol. Participants who received this agent pre-allogeneic transplant will NOT be excluded
12. Concurrent therapies targeted at disease relapse. However, previous treatments for relapsed disease are allowed.
13. Concurrent active malignancy (exceptions: treated solid malignancy in \>2 years' remission, treated basal or squamous cell carcinomas of the skin)
14. History of Crohn's disease or ulcerative colitis
15. History of demyelinating disorder
16. Prior intolerance or allergy to tocilizumab