Nivolumab and Intrapleural T-VEC in Treating Patients with Malignant Pleural Effusion

Inclusion Criteria

• Signed a written Institutional Review Board (IRB)-approved informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization for the trial.
• Eastern Cooperative Oncology Group (ECOG) performance status =< 2.
• Histologically or cytologically confirmed stage IV metastatic cancer.
• Confirmation of malignant pleural effusion via imaging (chest x-ray [CXR], computed tomography [CT] scan, ultrasound, magnetic resonance imaging [MRI], or positron emission tomography [PET]/CT) and cytology for which pleurX catheter placement is standard of care. * Dose level 1: either no systemic therapy available per standard of care, or delay in administration of systemic therapy considered clinically acceptable. * Dose level 2/phase II: nivolumab alone would be an acceptable standard treatment OR have a tumor type with prior data for PD1 efficacy OR non-pleural disease is not considered a significant risk to the patient OR refractory to standard therapies.
• Absolute neutrophil count (ANC) >= 1000 /uL performed within 14 days of treatment initiation.
• Platelets >= 50,000/uL performed within 14 days of treatment initiation.
• Hemoglobin >= 10 g/dL (acceptable to reach this through transfusion) performed within 14 days of treatment initiation.
• Calculated creatinine clearance (Cockcroft-Gault) >= 45 mL/min performed within 14 days of treatment initiation.
• International normalized ratio (INR) or prothrombin time (PT) =< 1.5 x upper limit of normal (ULN) unless the subject is receiving anticoagulant therapy, in which case PT and partial thromboplastin time (PTT)/activated partial thromboplastin time (aPTT) must be within therapeutic range of intended use of anticoagulants performed within 14 days of treatment initiation.
• Serum total bilirubin =< 1.5 X ULN OR direct bilirubin =< ULN for subjects with total bilirubin levels > 1.5 ULN performed within 14 days of treatment initiation.
• Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 X ULN OR =< 5 X ULN for subjects with liver metastases performed within 14 days of treatment initiation.
• Albumin > 2.5 mg/dL performed within 14 days of treatment initiation.
• Pulse oximetry at least 90% on room air (OR 95% on oxygen) performed within 14 days of treatment initiation.
• Electrocardiography (EKG) no clinically relevant cardiac dysfunction performed within 14 days of treatment initiation.
• Troponin < 0.3 performed within 14 days of treatment initiation.
• Recovered from all reversible toxicities related to their previous treatment (other than alopecia) to =< grade 1 or baseline; exceptions to this criterion may be allowed following review by the principal investigator for toxicities that are not expected to be exacerbated by nivolumab or talimogene laherparepvec. Grade 2 peripheral neuropathy will not result in exclusion as neither study agent would be expected to exacerbate it.
• No history of untreated brain metastasis. Treated brain metastases must not be known to be progressive, symptomatic, or currently requiring > 10 mg of prednisone or prednisone equivalents within two weeks prior to study drug administration.
• Females of childbearing potential must have a negative serum pregnancy test within 72 hours prior to receiving the first dose of study medication. Females of childbearing potential must agree to use 2 methods of effective contraception or abstain from heterosexual sex throughout the treatment period and for 5 months after the last dose of study treatment. Females of childbearing potential are women who have not been surgically sterilized (have undergone a hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or have not been free of menses for > 1 year.
• Male patients with female partners must have had a prior vasectomy or agree to use an adequate method of contraception (i.e. double barrier method: condom plus spermicidal agent) starting with the first dose of study therapy through 7 months after the last dose of study treatment.
• As determined by the enrolling physician or protocol designee, ability or willingness of the patient to understand and comply with study procedures.

Exclusion Criteria

• Receiving any investigational agent, or using an investigational device, currently or within 28 days or 5 half-lives of day 1 of treatment on this study, whichever is longer.
• Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior to study day 1.
• Has had a prior monoclonal antibody within 4 weeks prior to study day 1, or who has not recovered to =< grade 1 toxicity at baselines from adverse events due to agents administered more than 4 weeks earlier. Exceptions to these criteria may be allowed at the discretion of the investigator for toxicities that are not expected to be exacerbated by nivolumab or talimogene laherparepvec (e.g., alopecia, peripheral neuropathy, etc.).
• Any concurrent chemotherapy, investigational product (IP), biologic or hormonal therapy for cancer treatment. Concurrent use of hormonal therapy for non-cancer-related conditions (e.g., hormone replacement therapy) is acceptable.
• Major surgery within 28 days prior to day 1 of study treatment from which the patient has not completely recovered.
• 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.
• Has a known secondary 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.
• Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires systemic steroids or immunosuppressive agents; subjects with resolved childhood asthma/atopy would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement or Sjogren’s syndrome will not be excluded from the study. 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. Subjects with vitiligo, Grave’s disease, or psoriasis not requiring systemic treatment (within the past 2 years) are not excluded.
• Has a history of non-infectious pneumonitis that required steroids; currently active non-infectious pneumonitis; or evidence of interstitial lung disease.
• Has an active infection requiring systemic therapy or history of uncontrolled infection.
• 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. This includes known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial. This also includes unstable angina, serious uncontrolled cardiac arrhythmia, uncontrolled infection, or myocardial infarction =< 6 months prior to study entry.
• Has inadequate home environment or social support to safely complete the trial procedures.
• Is pregnant or breastfeeding.
• Known human immunodeficiency virus (HIV), hepatitis C virus (HCV) or evidence of active hepatitis B virus (HBV).
• Has a multi-loculated pleural effusion that would not lead to relief of dyspnea from drainage of a single loculation.
• Current active hepatic or biliary disease (with exception of patients with Gilbert's syndrome, asymptomatic gallstones, or stable chronic liver disease per investigator assessment).
• Active herpetic skin lesions or prior complications of herpetic infection or requires intermittent or chronic systemic (intravenous or oral) treatment with an antiherpetic drug (e.g., acyclovir), other than intermittent topical use.