A Longitudinal Assessment of Tumor Evolution in Patients With Brain Cancer

Study Overview
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Brief Summary
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The purpose of this study is to test the safety and tolerability of the research study drugs nivolumab, ipilimumab, lomustine, bevacizumab, and temozolomide when used following surgery and before standard therapy with radiation and temozolomide in patients with newly diagnosed high grade glioma. Additional aims of the study are to: Find out side effects (good and bad) of study drug combinations. Evaluate any preliminary evidence of anticancer activity of study drug combinations . Evaluate tumor characteristics by collecting brain tumor tissue samples. Measure the amount of nivolumab and ipilimumab in biospecimens. Look at biomarkers in biospecimens.

Detailed Description
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Patients having a clinically planned surgical procedure (biopsy or cytoreduction) for a suspected diagnosis of high grade glioma will be approached for participation in this study. Tumor tissue obtained from surgery will be used for histological diagnosis and clinical molecular profiling, and excess tumor tissue will be collected for potential correlative studies. A small sample of blood and CSF for research will also be collected. Once a diagnosis of high grade glioma is confirmed, the patient will be allocated to one of the study arms. Treatment will be started approximately 7-42 days following surgery once the patient has recovered from surgery. Routine clinical evaluations will be performed prior to treatment initiation and throughout treatment as clinically indicated. Radiographic brain imaging will be performed approximately 21-42 after treatment initiation and then routinely for medical management. Tumor response will be assessed according to immunotherapy Response Assessment in Neuro-Oncology (iRANO) Working Group criteria. Treatment may continue until the patient experiences unacceptable toxicity or clear disease progression. The determination of whether to stop treatment due to disease progression will be based on the investigator's evaluation of the patient's clinical and radiographic condition, taking into consideration the interpretation of localized inflammatory responses that can mimic radiographic features of tumor progress. Patients discontinuing treatment will have further medical management as directed by their treating physician. As part of follow-up, if the patient undergoes a surgery, results of clinical molecular profiling will be collected, and excess resected tumor tissue will be collected if available along with blood and CSF for correlative studies. A record of any additional anti-cancer treatments and survival status will be made every three to six months.

Official Title
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A Longitudinal Assessment of Tumor Evolution in Patients With Brain Cancer

Conditions
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Newly Diagnosed High Grade Glioma

Intervention / Treatment
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* Drug: Temozolomide
* Radiation: conformal brain radiation therapy
* Drug: Nivolumab
* Drug: Ipilimumab
* Drug: Bevacizumab
* Drug: 5-day Temozolomide
* Drug: 5-day Temozolomide
* Drug: Lomustine
* Drug: Nivolumab monotherapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Participant has the ability to understand and the willingness to provide a signed and dated informed consent form. Participant has the willingness to comply with all study procedures and availability for the duration of the study. Participant is being evaluated for a potential, or known, diagnosis of high grade glioma. Participant is a candidate for brain surgery or has undergone prior surgery and has not received any additional treatment for high grade glioma. Participant is male or female, ≥ 18 years of age. Participant has a Karnofsky Performance Status (KPS) ≥ 60%: Exclusion Criteria: Participant has received prior anti-cancer treatment for high grade glioma. Participant has a diagnosis of immunodeficiency or active autoimmune disease. Participant is receiving chronic systemic steroid therapy in dosing exceeding 8 mg daily of dexamethasone equivalent or any other form of immunosuppressive therapy within 7 days prior to the first dose of study drug. Note: This is assessed after surgery, prior to starting drug treatment. Participant has received a live vaccine within 28 days prior to the first dose of study agent. Examples of live vaccines include, but are not limited to measles, mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus Calmette-Guérin (BCG), typhoid vaccine, and intranasal influenza vaccines (e.g., FluMist®). Participant has a severe or uncontrolled medical disorder that would, in the investigator's opinion, impair ability to receive study intervention (i.e., uncontrolled diabetes, chronic renal disease, chronic pulmonary disease or active, uncontrolled infection, psychiatric illness/social situations that would limit compliance with study requirements). Participant is a female of childbearing potential who is pregnant or nursing. Participant has a history of thrombotic or hemorrhagic stroke or myocardial infarction within 6 months. Participant has a history of intestinal perforations, fistula, hemorrhages, and/or hemoptysis ≤ 6 months prior to first study treatment. Participant has active gastrointestinal bleeding. Participant has uncontrolled hypertension (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg).

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: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: 1 SOC (closed to enrollment)<br>Standard conformal brain radiation therapy with concurrent and adjuvant temozolomide | Drug: Temozolomide<br>* concomitant and 5-day adjuvant temozolomide<br>* Other names: temodar;Radiation: conformal brain radiation therapy<br>* standard radiation therapy for newly diagnosed glioblastoma<br>|
| Experimental: 2 Nivo<br>Nivolumab | Drug: Nivolumab monotherapy<br>* nivolumab 300 mg IV every 2 weeks for the first 28-day cycle, then option to modify to 480 mg IV every 4 weeks<br>* Other names: opdivo;|
| Experimental: 3 Nivo-Ipi (closed to enrollment)<br>Nivolumab plus Ipilimumab | Drug: Nivolumab<br>* nivolumab 240 mg IV every 2 weeks for the first 28-day cycle, then option to modify to 480 mg IV every 4 weeks<br>* Other names: opdivo;Drug: Ipilimumab<br>* ipilimumab 1 mg/kg IV every 6 weeks (or every 8 weeks when nivolumab is administered every 4 weeks) for a maximum of 4 doses<br>* Other names: yervoy;|
| Experimental: 4 Nivo-Ipi-CCNU-TMZ<br>Nivolumab plus Ipilimumab plus Lomustine (CCNU) plus 5-day Temozolomide | Drug: Nivolumab<br>* nivolumab 240 mg IV every 2 weeks for the first 28-day cycle, then option to modify to 480 mg IV every 4 weeks<br>* Other names: opdivo;Drug: Ipilimumab<br>* ipilimumab 1 mg/kg IV every 6 weeks (or every 8 weeks when nivolumab is administered every 4 weeks) for a maximum of 4 doses<br>* Other names: yervoy;Drug: 5-day Temozolomide<br>* 100 mg/m^2 oral, once daily on Days 2-6 of each 6 week course (stepwise titration every cycle up to 200 mg/m^2 permitted)<br>* Other names: temodar;Drug: Lomustine<br>* 100 mg/m^2 oral, on Day 1 of each 6 week course<br>* Other names: CCNU;|
| Experimental: 5 Nivo-Ipi-TMZ<br>Nivolumab plus Ipilimumab plus 5-day Temozolomide | Drug: Nivolumab<br>* nivolumab 240 mg IV every 2 weeks for the first 28-day cycle, then option to modify to 480 mg IV every 4 weeks<br>* Other names: opdivo;Drug: Ipilimumab<br>* ipilimumab 1 mg/kg IV every 6 weeks (or every 8 weeks when nivolumab is administered every 4 weeks) for a maximum of 4 doses<br>* Other names: yervoy;Drug: 5-day Temozolomide<br>* 150 mg/m^2 oral, once daily on Days 1-5 of each 28-day cycle (stepwise titration every cycle up to 200 mg/m^2 permitted)<br>* Other names: temodar;|
| Experimental: 6 Nivo-Ipi-Bev-TMZ<br>Nivolumab plus Ipilimumab plus Bevacizumab plus 5-day Temozolomide | Drug: Nivolumab<br>* nivolumab 240 mg IV every 2 weeks for the first 28-day cycle, then option to modify to 480 mg IV every 4 weeks<br>* Other names: opdivo;Drug: Ipilimumab<br>* ipilimumab 1 mg/kg IV every 6 weeks (or every 8 weeks when nivolumab is administered every 4 weeks) for a maximum of 4 doses<br>* Other names: yervoy;Drug: Bevacizumab<br>* bevacizumab 5 mg/kg IV every 2 weeks (up to 10 mg/kg at treating physician's discretion)<br>* Other names: avastin;Drug: 5-day Temozolomide<br>* 150 mg/m^2 oral, once daily on Days 1-5 of each 28-day cycle (stepwise titration every cycle up to 200 mg/m^2 permitted)<br>* Other names: temodar;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of dose limiting toxicities | treatment-related adverse events that impact administration of treatment | first 28 days of treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment-related adverse events | Toxicity will be assessed according to the NCI Common Toxicity Criteria for Adverse Events (CTCAE), version 4.03. | approximately 7 months | 
| Tumor response rates | Evidence of anti-tumor activity as measured according to immunotherapy Response Assessment in Neuro-Oncology (iRANO) criteria. | up to 5 years | 
| Progression free survival (PFS) | The duration of time from start of treatment until objective tumor response. | up to 5 years | 
| Overall survival (OS) | The duration of time from start of treatment to death. | up to 5 years | 
| Levels of immunotherapeutic agents in specimens | Immunotherapeutic drug levels in specimens. | approximately 4 months | 
| Change in clinical molecular profile of tumor tissue after treatment | Comparison of tumor tissue molecular profile generated from before and after study treatment. | approximately 6 months to 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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immunotherapy, nivolumab, ipilimumab, bevcizumab, temozolomide