Window of Opportunity Study of Pembrolizumab Alone and in Combinations in Bladder Cancer

Study Overview
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Brief Summary
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This is an open-label, window of opportunity platform study for subjects with muscle-invasive bladder cancer (MIBC) who are deemed ineligible or refuse cisplatin-based neoadjuvant chemotherapy and are scheduled to undergo definitive surgery (radical cystectomy), or are planning to undergo trimodality therapy (maximal transurethral resection of the bladder tumor followed by concurrent chemoradiation). The primary objective of this study is to assess changes to immunogenomic markers after treatment with pembrolizumab alone and in combination with the selective class I histone deacetylase (HDAC) inhibitor (entinostat).

Detailed Description
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The study will enroll 20 subjects with a confirmed diagnosis of MIBC (cT2-T4aN0M0) who are planned for definitive therapy with either radical cystectomy without cisplatin-based neoadjuvant chemotherapy or trimodality therapy. Subjects who are planned to undergo radical cystectomy must be deemed ineligible for (based on consensus criteria) [1] or refuse neoadjuvant cisplatin-based chemotherapy. Prior to study entry, subjects must consent to having tissue collected for research purposes during the scheduled cystectomy or maximal TURBT. After screening and enrollment, baseline blood and archived transurethral resection of the bladder tumor (TURBT) tumor tissue will be collected from each subject for baseline analyses. Subjects will then start on clinical trial treatment followed by either radical cystectomy or maximal TURBT followed by chemoradiation. Blood and tumor will be collected from each subject at the time of cystectomy or maximal TURBT. The investigators do not anticipate delays in surgery due to the planned schedule of the preoperative treatment administration for the purposes of this study and based on the phase II ENCORE 601 trial (pembrolizumab and entinostat in melanoma) which reported an acceptable safety profile. Phase I data identified grade 1/2 fatigue as the most common entinostat-related toxicity, with neutropenia and anemia only occurring at doses exceeding those proposed for this study. Safety stopping rules for drug-related toxicity will dictate whether the trial should be halted if subjects are experiencing drug-related toxicity that delays or interferes with standard of care procedures.

Official Title
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Window of Opportunity Platform Study to Define Immunogenomic Changes With Pembrolizumab Alone and in Rational Combinations in Muscle-Invasive Bladder Cancer

Conditions
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Bladder Cancer

Intervention / Treatment
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* Drug: Pembrolizumab
* Drug: Entinostat


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Written informed consent obtained to participate in the study and HIPAA authorization for release of personal health information. Subjects must agree to donate tumor tissue from their transurethral resection of the bladder tumor (TURBT) and from their cystectomy, as well as agree to donate whole blood prior to initiating therapy, and at cystectomy. Age ≥18 years at the time of consent. Eastern Cooperative Oncology Group performance status of ≤ 2. Histological confirmation of urothelial carcinoma of the bladder; those with mixed histology, including a component of urothelial carcinoma, are eligible. Pure small cell carcinoma, pure adenocarcinoma, and pure squamous cell carcinoma are excluded. Subject has clinical stage T2-T4a N0/X M0 urothelial carcinoma. Clinical T stage is based on the pre-study standard of care transurethral resection of the bladder tumor (TURBT) sample and imaging studies (abdominal/pelvic CT or MRI scan and CT scan of the chest performed within 4 weeks prior to treatment initiation). Available formalin-fixed paraffin-embedded (FFPE) archival tumor specimen that contains sufficient tissue to generate at least 15 (preferably 20) unstained slides, each with tissue sections that are 5 - 10 microns thick. Subject is planned to undergo definitive surgery (radical cystectomy). Subject demonstrates adequate organ function as defined by the protocol; all screening laboratory assessments should be performed within 10 days of treatment initiation. Subject refuses to receive or is ineligible to receive cisplatin-based neoadjuvant chemotherapy. Determination of ineligibility for cisplatin is based on at least one of the following criteria: Eastern Cooperative Oncology Group performance status of 2 Glomerular filtration rate (GFR) per Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation ≤ 60 mL/min NCI CTCAE v5.0 Grade ≥ 2 hearing loss NCI CTCAE v5.0 Grade ≥ 2 neuropathy Female subjects of childbearing potential should have a negative serum pregnancy within 72 hours prior to receiving the first dose of the study treatment. Female subjects of childbearing potential must be willing to use an adequate method of contraception as outlined in the protocol, 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 as outlined in the protocol, 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. Subject is able to tolerate and retain oral medication. Life expectancy greater than 3 months. Exclusion Criteria: Subject is currently participating in or has participated in a study of an investigational agent or using an investigational device within 4 weeks of the first dose of pembrolizumab. Subject 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. Inhaled and topical steroids are allowed. Subject has a known history of active tuberculosis. Subject has known hypersensitivity to pembrolizumab or any of its excipients. For subjects in arm 2 only, to benzamide or inactive ingredients of entinostat. Subject has a known additional malignancy that is progressing or requires active treatment. 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. Subject 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. Subject has a history of (non-infectious) pneumonitis that required steroids or a current pneumonitis. Subject has an active infection requiring systemic therapy. Subject 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. Please note that subjects with Grade ≥2 peripheral neuropathy, are allowed on this study. Subject has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial. Subject 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. Subject 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). Subject has had prior systemic cytotoxic chemotherapy for urothelial carcinoma (prior intravesicular chemotherapies are permitted). Subject is receiving histone deacetylase inhibitors, including valproic acid, DNA methyltransferase inhibitors. For subjects in arm 2 only, subject is receiving drugs that are known to inhibit or induce P-gp. For subjects in arm 2 only, subject has gastrointestinal impairment that may significantly affect absorption of entinostat, such as ulcerative disease, malabsorption syndrome, and a history of small bowel resection. Subject has received prior radiation therapy to the bladder for the purpose of treating urothelial carcinoma. Subject has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). Subject has known history of Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA [qualitative] has been detected). Subject has received a live vaccine within 30 days prior to the first dose of study drug. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus Calmette-Guérin (BCG), and typhoid vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however, intranasal influenza vaccines (e.g., FluMist®) are live attenuated vaccines and are not allowed. For subjects in arm 2 only, subject uses drugs or herbal supplements that are known sensitive cytochromes P450 (CYP) substrates of CYP1A2, CYP2C8, CYP3A with narrow therapeutic range

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 99 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: A: Pembrolizumab alone<br>Subjects will be administered pembrolizumab alone 200 mg IV on day 1 and day 22 | Drug: Pembrolizumab<br>* 200 mg IV on day 1 and day 22<br>* Other names: Keytruda;|
| Experimental: B: Pembrolizumab plus Entinostat<br>Subjects will be administered pembrolizumab on day 1 and day 22 and entinostat 5 mg given orally on day 1, day 8 and day 15 | Drug: Pembrolizumab<br>* 200 mg IV on day 1 and day 22<br>* Other names: Keytruda;Drug: Entinostat<br>* 5 mg given orally on day 1, day 8 and day 15<br>* Other names: MS-275;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline in Z-score of T cell CD8 immune 37-gene signature | The primary objective will be assessed by the change in the T cell immune gene signature in patients treated with pembrolizumab compared to those treated with pembrolizumab plus entinostat. Gene expression for each gene included in the T cell CD8 immune 37-gene signature (Bindea et al, Immunity 2013) will be quantified based on messenger RNA sequencing (mRNAseq). For each patient in each treatment group, the change in Z-score of the T cell immune gene signature will be calculated from the post-treatment tumor biopsy (cystectomy) compared with the pre-treatment biopsy and changes in Z-scores in the two groups will be compared. | Less than 10 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline in number and character of neoantigens | Neoantigens will be predicted based on whole exome sequencing data using mRNAseq-based filtering. The number of predicted neoantigens will be calculated in the pre-treatment biopsy specimen and the post-treatment cystectomy specimen for each patient. The change from baseline in number and character of neoantigens will be described and compared for each treatment group. Similarly, the T cell receptor (TCR) repertoire will be sequenced and clonality in blood and tumor will be compared between pre- and post-treatment samples for each patient, and change in clonality will be compared between treatment groups. | Less than 10 weeks | 
| Change from baseline in Signal transducer and activator of transcription factors (STAT) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) gene signatures and histone acetylation (H3K9Ac, H3K27Ac, and others) levels | Compare changes in STAT and NF-κB gene signatures and histone acetylation (H3K9Ac, H3K27Ac, and others) levels after combination treatment with pembrolizumab and entinostat as compared to pembrolizumab alone (subset of subjects with frozen pre- and post-treatment tumor tissue available) Gene expression for each gene in representative STAT, NF-κB, and histone acetylation gene signatures (from MSigDB) will be quantified based on mRNA sequencing. Change in Z-score of these gene signatures will be calculated from pre- and post-treatment tissue samples for patients in both cohorts (pembrolizumab alone or pembrolizumab plus entinostat), and then changes in Z-scores will be compared between cohorts. | 10 weeks | 
| Frequency and Severity by grade of Adverse Events as Assessed by CTCAE v5.0 | The analysis of the toxicity and safety will be based on the frequency of adverse events and their severity, occurred day 1 of the study treatment until 30 days after completion of the study treatment. Worst toxicity grades per subject will be tabulated for adverse events and laboratory measurements by using the National Cancer Institute- Common Terminology Criteria for Adverse Events (NCI-CTCAE version 5.0) and will be reported in the form of frequency tables. | 10 weeks | 
| Proportion of patients who have no cancer in tissue samples at surgery (pathologic Complete Response, or only non-invasive cancer (pathologic Partial Response) | The proportion of patients who have a pathologic response to less than stage 2 (<pT2) will be reported along with a 95% confidence interval. Similarly, the proportion of patients who have a complete response (pT0) will be reported. | 10 weeks | 
| Event Free Survival (EFS) | EFS is defined as day 1 of neoadjuvant/protocol treatment to date of first documentation of disease progression (or until recurrence after surgery or radiation) or death due to any cause. Recurrence includes the development of second primary muscle-invasive urothelial malignancies. | Up to 3 years | 
| Overall Survival (OS) | OS is defined as day 1 of neoadjuvant/protocol treatment to date of death due to any cause. Patients will be censored at date of last follow-up. | Up to 3 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Muscle Invasive Bladder Cancer, MIBC, pembrolizumab, entinostat