Adjuvant Nivolumab Treatment in Stage II (IIA, IIB, IIC) High-risk Melanoma

Study Overview
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Brief Summary
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Stage II patients with primary surgical treatment of cuMM are often at risk for recurrence of their disease. This risk may be reduced by adjuvant systemic treatment. Due to toxicities of adjuvant therapies the aim is to identify patients at high risk for relapse and to administer adjuvant treatment only to these patients. Thus an optimal balance between insufficient treatment vs. overtreatment has to be found. To define these patients a prognostic biomarker test will be used in addition to conventional AJCC staging. AJCC staging takes into account several prognostic factors. However, to subdivide stage II melanoma patients into having a low or high risk for relapse further methods are needed. This clinical trial will evaluate whether adjuvant nivolumab treatment will improve relapse-free survival (RFS) in patients with stage II high-risk melanoma as compared to observation only. The randomized approach of this trial offers the most objective method with the least influence of bias. Since patients with stage II melanoma are usually not receiving adjuvant treatment, no patient will be undertreated in case of randomization into observational arm.

Detailed Description
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The NivoMela trial is a randomized, controlled, prospective, multi-center national phase III trial with biomarker-based risk stratification. Stage II melanoma patients having undergone surgery of the malignant melanoma will be screened using the MelaGenix GEP score to identify patients at high risk for relapse. It is expected, that 61% of screened patients will belong to this group. Patients with a risk score of > 0.0 (HR 1.48, 1.11-1.98) corresponding to high risk of relapse will be randomized at a ratio of 2:1 to receive either nivolumab as adjuvant treatment (arm A) or observation only (arm B). Stratification factors for randomization are: Tumor stage: IIA versus IIB versus IIC Gender: Female versus Male Site of primary tumor: extremities versus trunk versus head &neck All screened patients with a risk score of ≤ 0.0 who are not eligible for randomization will be followed for RFS, DMFS and OS for at least 5 years according to German Follow-up guidelines (Arm C). Various factors that could potentially predict clinical response and incidence of AEs to treatment with nivolumab will be investigated in peripheral blood and tumor specimen taken at baseline. Data from these investigations will be evaluated for associations with clinical efficacy (eg, ORR, PFS, OS) and safety/toxicity (AE). The samples may also be used for exploratory analyses to assess biomarkers associated with melanoma and/or with immunotherapy treatment.

Official Title
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Adjuvant Nivolumab Treatment in Stage II High-risk Melanoma - A Randomized, Controlled, Phase III Trial With Biomarker-based Risk Stratification

Conditions
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Malignant Melanoma Stage II

Intervention / Treatment
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* Drug: Nivolumab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically confirmed diagnosis of stage II (AJCCv8) melanoma arising from a primary cutaneous site after surgery therapy Sentinel node biopsy (SNB) without detection of melanoma deposits Randomization not later than 12 weeks after SNB procedure Tumor tissue from primary tumor must be provided for biomarker analyses. In order to be randomized, a subject must be classified by MelaGenix risk analysis. Men and women at the age of 18 to 80 years Signed written, informed consent Patients must be willing and able to comply with scheduled visits, treatment schedule, laboratory testing, and other requirements of the study Minimum life expectancy of five years excluding their melanoma diagnosis ECOG performance status of 0-1 Screening laboratory values must meet the following criteria and should be obtained within 14 days prior to randomization: White blood cells (WBC) ≥ 2000/μL Neutrophils ≥ 1500/μL Platelets ≥ 100 x103/μL Hemoglobin ≥ 9.0 g/dL Serum creatinine ≤ 1.5xUL Creatinine clearance (CrCl) ≥ 40mL/min (using the Cockcroft-Gault formula) AST / ALT ≤ 3 x ULN Total Bilirubin ≤ 1.5 x ULN (except subjects with Gilbert Syndrome, who may have total bilirubin < 3.0 mg/dL) Negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) for women of childbearing potential (WOCBP) within 72 hours prior to registration. Women will be considered to be of childbearing potential unless surgically sterilized (hysterectomy, bilateral tubal ligation, or bilateral oophorectomy), or being post-menopausal for at least 24 months or being amenorrheic for > 12 months and follicle-stimulating hormone (FSH) levels ≥ 40 IU/L. WOCBP and male patients with partners of childbearing potential must agree to always use a highly effective form of contraception according to CTFG during the course of this study and for at least 5 months after last dose of study medication (in Arm A only). Exclusion Criteria: History of primary uveal or mucosal melanoma No access to sufficient tumor tissue of primary tumor SNB procedure > 12 weeks before randomization Prior active malignancy within the previous 3 years except for locally curable cancers that have been apparently cured, such as: basal or squamous cell skin cancer, superficial bladder cancer or carcinoma in situ of the prostate, cervix, or breast. Exception: Participants with a history of non-ulcerated cutaneous/acral primary melanoma <1 mm in depth with no nodal involvement are allowed in this trial. Prior or planned therapy with Interferon alpha, CTLA4 or PD-1 / PD L1 antibodies Use of any investigational or non-registered product (drug or vaccine) other than the study treatment Administration of live vaccines within 4 weeks before start of study therapy Any immunosuppressive therapy given within the past 30 days Active psychiatric or addictive disorders that may compromise his/her ability to give informed consent or to comply with the trial procedures Active immune deficiencies or significant autoimmune disease Serious cardiac, gastrointestinal, hepatic or pulmonary disease which would reduce life expectancy to less than five years Serious intercurrent illness, requiring hospitalization Other serious illnesses, e.g., serious infections requiring antibiotics or bleeding disorders The patient is known to be positive for Human Immunodeficiency Virus (HIV) or other active chronic infections (HBV, HCV) or has another confirmed or suspected immunosuppressive or immunodeficient condition Any serious or uncontrolled medical disorder that, in the opinion of the investigator, may increase the risk associated with study participation or study drug administration, impair the ability of the subject to receive protocol therapy, or interfere with the interpretation of study results. Hypersensitivity to the active substance or to any of the excipients Participation in another clinical study within the 30 days before registration For female patients: Pregnancy or breast-feeding For WOCBP and male patients with partners of childbearing potential: Refusal or inability to use effective means of contraception Lack of availability for clinical follow-up assessments Legal incapacity or limited legal capacity

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 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
Interventional Model Description: Patients with a risk score of > 0.0 (HR 1.48, 1.11-1.98) corresponding to high risk of relapse will be randomized at a ratio of 2:1 to receive either nivolumab as adjuvant treatment (arm A) or observation only (arm B). All screened patients with a risk score of ≤ 0.0 who are not eligible for randomization will be followed for RFS, DMFS and OS for at least 5 years according to German Follow-up guidelines (Arm C).
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Nivolumab (Arm A)<br>Patients with a risk score of > 0.0 corresponding to high risk of relapse (randomized): Nivolumab will be applied at a flat dose of 480 mg given as 60-minute iv infusion every 4 weeks for 12 doses over 1 year. Afterwards these patients will receive intense clinical follow up according German Follow up guidelines. | Drug: Nivolumab<br>* 480 mg nivolumab fixed dose given as 60-minute iv infusion every 4 weeks for 12 doses over 1 year<br>* Other names: Opdivo;|
| No Intervention: Observation, High Risk (Arm B)<br>Patients with a risk score of > 0.0 corresponding to high risk of relapse (randomized): Control group (observation only). These patients will receive intense clinical follow up but no further specific therapy according German Follow up guidelines. | |
| No Intervention: Observation, Low Risk (Arm C)<br>Patients with a risk score of ≤ 0.0 corresponding to low risk of relapse who are not eligible for randomization: These patients will receive intense clinical follow up but no further specific therapy according German Follow up guidelines. Documentation of clinical outcome of these patients. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Relapse-Free Survival (RFS) rates | Determination of efficacy of nivolumab in a biomarker-selected high-risk-enriched stage II melanoma patient population in comparison to control receiving observation only in a 2 (Arm A=nivolumab) : 1 (Arm B=observation) randomization, as measured by Relapse-Free Survival (RFS) rates at 36 and 60 months. RFS is defined as the time from date of registration until documented tumor progression date or date of death of any cause, whichever occurs first in all patients tested with the MelaGenix gene expression profiling (GEP). | 5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Distant metastasis-free survival (DMFS) rates | DMFS rates at 36 and 60 months | 5 years | 
| Melanoma-specific survival (MSS) rates | MSS rates at 36 and 60 months | 5 years | 
| Overall survival (OS) rates | OS rates at 36 and 60 months | 5 years | 
| Adverse events ≥ Grade 3 according to CTCAE Version 5.0 criteria (Safety / Toxicity) | All adverse events ≥ Grade 3 according to CTCAE Version 5.0 criteria, that are definitely, probably, or possibly related to the administration of the investigational agent | Arm A: Until 100 days after discontinuation of dosing of the investigational product; Arm B: Until 1 year after patient´s written consent | 
| Clinical utility/decision impact of the MelaGenix Gene Expression Profiling (GEP) Score in stratifying patients for adjuvant therapy | Patients with a risk score of > 0.0 (HR 1.48, 1.11-1.98) will be classified as high risk for relapse. It is expected, that 61% of screened patients will belong to this group. Patients with a risk score of score of ≤ 0.0 will be classified as low risk for relapse. | 5 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stage II malignant melanoma, patients having undergone surgery, IIA melanoma, IIB melanoma, IIC melanoma