Modified Immune Cells (Autologous Dendritic Cells) and a Vaccine (Prevnar) After High-Dose External Beam Radiation Therapy in Treating Patients With Unresectable Liver Cancer

Study Overview
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Brief Summary
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This Phase I-II trial studies the safety and efficacy of autologous dendritic cells and a vaccine called Prevnar in treating patients with liver cancer that cannot be removed by surgery after undergoing standard high-dose external beam radiotherapy. Autologous dendritic cells are immune cells generated from the patients' own white blood cells that are grown in a special lab and trained to stimulate the immune system to destroy tumor cells. A pneumonia vaccine called Prevnar may also help stimulate the immune system. Giving autologous dendritic cells and Prevnar to patients with liver cancer after radiotherapy may help doctors determine if it is possible to stimulate the body's own immune system to fight against the tumor, and to see if this immune stimulation can be done safely (Phase I) and can be combined with immune checkpoint inhibitors (Phase II). The Phase I cohort will only include patients with unresectable intrahepatic cholangiocarcinoma, while the Phase II cohort will only include patients with unresectable hepatocellular carcinoma..

Detailed Description
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PRIMARY OBJECTIVES: I. Evaluation of safety and tolerability of an autologous dendritic cell (DC) vaccine delivered by intra-tumoral injection in patients with unresectable intrahepatic cholangiocarcinoma treated with high-dose conformal external beam radiotherapy (EBRT). (Phase I) II. Assess the safety and clinical efficacy of an autologous dendritic cell (DC) vaccine delivered by intra-tumoral injection, in combination with intravenous atezolizumab and bevacizumab, in patients with unresectable hepatocellular carcinoma treated with high-dose conformal external beam radiotherapy (EBRT). (Phase II) SECONDARY OBJECTIVES: I. To assess feasibility in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. II. To assess overall response rate in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. III. To assess progression free survival in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. IV. To assess clinical benefit rate in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. V. To assess time to response in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. VI. To assess duration of response in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. VII. To assess overall survival in patients with liver cancer treated with high-dose conformal EBRT followed by autologous DC vaccine injection. RADIOLOGIC STUDY OBJECTIVE: I. To assess the radiologic response over time of primary liver tumors treated with high-dose conformal EBRT followed by autologous DC vaccine injection. CORRELATIVE RESEARCH OBJECTIVES: I. To monitor patients' immune response after vaccine therapy. II. To assess the immune response to pneumococcal 13-valent conjugate vaccine (Prevnar). OUTLINE: PILOT STUDY (GROUP I): Patients with unresectable intrahepatic cholangiocarcinoma (CCA) undergo apheresis for dendric cell manufacturing and standard of care high-dose EBRT for 5 or 15 fractions over 1-3 weeks (cycle 1). Patients then receive autologous dendritic cells intratumorally (IT) on day 1 of cycles 2-8 and pneumococcal 13-valent conjugate vaccine intramuscularly (IM) on day 1 of cycles 2-4 only. Treatment repeats every 28 days for up to 7 cycles in the absence of disease progression or unacceptable toxicity. PHASE II STUDY (GROUP II): Patients with unresectable hepatocellular carcinoma (HCC) undergo apheresis for dendric cell manufacturing and standard of care high-dose EBRT for 5 or 15 fractions over 1-3 weeks (cycle 1). Patients then receive autologous dendritic cells IT on day 1 of cycles 2-8 and pneumococcal 13-valent conjugate vaccine IM on day 1 of cycles 2-4 only. Patients also receive standard of care atezolizumab intravenously (IV) and bevacizumab IV starting on day 2 of cycles 2-8. Treatment repeats every 21 days for up to 7 cycles in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up at 2 weeks and then every 3 months for 1 year (beginning at week 36 or 12 weeks after last autologous dendritic cell dose whichever is earlier). Patients are then followed every 3 months until disease progression, and then every 6 months until 5 years after registration.

Official Title
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Study of Intratumoral Injection of Dendritic Cells After High-Dose Conformal External Beam Radiotherapy in Patients With Unresectable Liver Cancer

Conditions
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Stage III Hepatocellular Carcinoma AJCC v8, Stage III Intrahepatic Cholangiocarcinoma AJCC v8, Stage IV Hepatocellular Carcinoma AJCC v8, Unresectable Hepatocellular Carcinoma, Stage IV Intrahepatic Cholangiocarcinoma AJCC v8, Unresectable Intrahepatic Cholangiocarcinoma

Intervention / Treatment
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* Biological: Atezolizumab
* Biological: Bevacizumab
* Radiation: External Beam Radiation Therapy
* Procedure: Pheresis
* Biological: Pneumococcal 13-valent Conjugate Vaccine
* Biological: Therapeutic Autologous Dendritic Cells


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >= 18 years Pilot study (group 1): Histologic confirmation of intrahepatic CCA Phase II study (group 2): Histological and/or radiologic confirmation of hepatocellular carcinoma (HCC) The following tumor characteristics must be met Unresectable HCC (group 2) or intrahepatic CCA (group 1) Measurable or evaluable disease All lesions should be treatable by EBRT while meeting normal tissue constraints Tumor lesions should be accessible using an ultrasound (US) guided approach for intratumoral DC injection Patients are required to have no evidence of extrahepatic tumor (excluding tumor thrombus) by computed tomography (CT) or magnetic resonance imaging (MRI) scan NOTE: Patients who are not candidates for surgical treatment or for ablation with curative intent are allowed Good candidate for standard of care high-dose conformal EBRT in the view of the investigator Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1 Absolute neutrophil count (ANC) >= 1000/mm^3 (obtained =< 14 days prior to registration) Absolute lymphocyte count (ALC) >= 500/mm^3 (obtained =< 14 days prior to registration) Absolute monocyte count (AMC) >= 300/mm^3 (obtained =< 14 days prior to registration) Platelet count >= 50,000/mm^3 (obtained =< 14 days prior to registration) Hemoglobin >= 9.0 g/dL (obtained =< 14 days prior to registration) Total bilirubin < 1.5 mg/dL (obtained =< 14 days prior to registration) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 5 x upper limit of normal (ULN) (obtained =< 14 days prior to registration) Creatinine =< 2 mg/dL (obtained =< 14 days prior to registration) Prothrombin time/international normalized ratio (PT/ INR) =< 1.5 x ULN (obtained =< 14 days prior to registration) Group 2 ONLY: Absence of proteinuria at screening as demonstrated by one of the following: Urine protein/creatinine (UPC) ratio < 1.0 at screening OR Urine dipstick for proteinuria < 2+ (patients discovered to have >= 2+ proteinuria on dipstick urinalysis at baseline should undergo a 24-hour urine collection and must demonstrate =<1g of protein in 24 hours to be eligible) Negative pregnancy test done =< 7 days prior to registration, for persons of childbearing potential only Ability to provide written consent Willingness to return to enrolling institution for follow-up (during the active monitoring phase of the study) Willingness to provide blood and tissue samples for correlative research purposes Exclusion Criteria: Any of the following because this study involves an investigational agent whose genotoxic, mutagenic and teratogenic effects on the developing fetus and newborn are unknown: Pregnant persons Nursing persons Persons of childbearing potential who are unwilling to employ adequate contraception Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment of the investigator, would make the patient inappropriate for entry into this study or interfere significantly with the proper assessment of safety and toxicity of the prescribed regimens Immunocompromised patients and patients known to be human immunodeficiency virus (HIV) positive and currently receiving antiretroviral therapy NOTE: Patients known to be HIV positive, but without clinical evidence of an immunocompromised state, are eligible for this trial Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements Receiving any other investigational agent that would be considered a treatment for the primary neoplasm Other active malignancy =< 3 years prior to registration. EXCEPTIONS: Non-melanotic skin cancer or carcinoma-in-situ of the cervix NOTE: If there is a history of prior malignancy, they must not be receiving other specific treatment for their cancer Major surgery =< 4 weeks prior to enrollment (other than diagnostic surgery or surgical spacer placement in preparation for radiation treatment) History of hypersensitivity or anaphylactoid reactions to pneumococcal vaccine or any component of the formulation, including diphtheria toxoid Active autoimmune disease such as autoimmune hepatitis, Crohn's disease, rheumatoid arthritis, Sjogren's disease, systemic lupus erythematosus, or similar conditions Requires coagulopathy treatment (INR > 1.5) or use of anti-platelet agents that cannot be discontinued for the intratumoral injection procedure NOTE: Heparin for line patency without detectable lab abnormalities in coagulation will be allowed Corticosteroids =< 2 weeks prior to registration, including oral, intravenous (IV), subcutaneous, or inhaled routes of administration NOTE: Patients on chronic corticosteroids for adrenal insufficiency or other reasons may enroll if they receive less than 10 mg/day of prednisone (or equivalent) History of myocardial infarction =< 6 months, or congestive heart failure requiring use of ongoing maintenance therapy for life-threatening ventricular arrhythmias Child Pugh class B or C cirrhosis of the liver Previously received immune modulating therapies including but not limited to immune checkpoint inhibitors targeting PD-1 PDL-1 CTLA4, etc; or prior dendritic cell therapy Prior liver radiation, including radioembolization Barcelona Clinic Liver Cancer (BCLC) stage D disease History of untreated high-risk gastroesophageal varices.

Ages Eligible for Study
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Minimum Age: 18 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: Non-Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Phase II(pheresis, EBRT, dendritic cells, Prevnar, atezo, bev)<br>Patients with unresectable HCC undergo apheresis for dendric cell manufacturing and standard of care high-dose EBRT for 5 or 15 fractions over 1-3 weeks (cycle 1). Patients then receive autologous dendritic cells IT on day 1 of cycles 2-8 and pneumococcal 13-valent conjugate vaccine IM on day 1 of cycles 2-4 only. Patients also receive standard of care atezolizumab IV and bevacizumab IV starting on day 2 of cycles 2-8. Treatment repeats every 21 days for up to 7 cycles in the absence of disease progression or unacceptable toxicity. | Biological: Atezolizumab<br>* Given IV<br>* Other names: Tecentriq;Biological: Bevacizumab<br>* Given IV<br>* Other names: Zirabev;Radiation: External Beam Radiation Therapy<br>* Undergo high-dose EBRT<br>* Other names: Teletherapy Radiation;Procedure: Pheresis<br>* Undergo apheresis<br>* Other names: Hemapheresis;Biological: Pneumococcal 13-valent Conjugate Vaccine<br>* Given IM<br>* Other names: Prevnar 13;Biological: Therapeutic Autologous Dendritic Cells<br>* Given IT<br>|
| Experimental: Pilot study (pheresis, EBRT, dendritic cells, Prevnar)<br>Patients with unresectable intrahepatic CCA undergo apheresis for dendric cell manufacturing and standard of care high-dose EBRT for 5 or 15 fractions over 1-3 weeks (cycle 1). Patients then receive autologous dendritic cells IT on day 1 of cycles 2-8 and pneumococcal 13-valent conjugate vaccine IM on day 1 of cycles 2-4 only. Treatment repeats every 28 days for up to 7 cycles in the absence of disease progression or unacceptable toxicity. | Radiation: External Beam Radiation Therapy<br>* Undergo high-dose EBRT<br>* Other names: Teletherapy Radiation;Procedure: Pheresis<br>* Undergo apheresis<br>* Other names: Hemapheresis;Biological: Pneumococcal 13-valent Conjugate Vaccine<br>* Given IM<br>* Other names: Prevnar 13;Biological: Therapeutic Autologous Dendritic Cells<br>* Given IT<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of significant toxicity (Pilot study) | A significant toxicity is defined as a dose limiting toxicity that is possibly, probably, or definitely related to dendritic cell (DC) treatment. Toxicities will be assessed using the Cancer Therapy Evaluation Program active version of the Common Terminology Criteria for Adverse Events. | Up to completion of cycle 2 (each cycle is 28 days) | 
| Progression-free survival rate at 2 years (Phase II) |  | At 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall response rate | The overall response rate will be estimated by the number of patients with an objective status of complete response (CR) or partial response (PR) divided by the total number of evaluable patients. Exact binomial 95% confidence intervals for the true overall response rate will be calculated. | Up to 1 year post treatment | 
| Number of patients who received at least one dose of intratumoral DC injection | The feasibility of the regimen will be estimated by the number of patients who received at least one dose of intratumoral DC injection divided by the total number of patients who received apheresis. | Up to 1 year post treatment | 
| Clinical benefit rate | The clinical benefit rate will be estimated by the number of patients with an objective status of stable disease or CR or PR at any time divided by the total number of evaluable patients. Exact binomial 95% confidence intervals for the true clinical benefit rate will be calculate | Up to 1 year post treatment | 
| Time to response | Time to response is defined for all evaluable patients who have achieved an objective response as the date of initiation of vaccination treatment to the date at which the patient's objective status is first noted to be either a CR or PR. Time to response will be summarized descriptively using Kaplan-Meier methodology. | Up to 1 year post treatment | 
| Duration of response | Duration of response is defined for all evaluable patients who have achieved an objective response as the date at which the patient's objective status is first noted to be either a CR or PR to the earliest date progression is documented. Duration of response will be summarized descriptively using Kaplan-Meier methodology. | Up to 1 year post treatment | 
| Overall survival | Kaplan-Meier methodology will be used to estimate the survival over time. | From registration to death from any cause, assessed up to 5 years after registration | 
| Progression-free survival | Kaplan-Meier methodology will be used to estimate the progression-free survival over time. | From registration to the first of either disease progression or death from any cause, assessed up to 5 years after registration |