Nivolumab with or without Relatlimab before Chemoradiotherapy in Treating Patients with Operable Stage II-III Esophageal or Gastroesophageal Junction Cancer
This phase Ib trial studies the side effects of nivolumab with or without relatlimab before chemoradiotherapy in treating patients with stage II-III esophageal or gastroesophageal junction cancer that can be removed by surgery (operable). Immunotherapy with monoclonal antibodies, such as nivolumab and relatlimab, may help the body’s immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Drugs used in chemotherapy, such as carboplatin and paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. It is not yet known whether giving nivolumab with or without relatlimab prior to current chemoradiotherapy works better in treating patients with esophageal or gastroesophageal junction cancer.
Inclusion Criteria
- Histologically proven (squamous cell or adenocarcinoma) esophageal or gastro- esophageal junction cancer (core biopsy required)
- Stage II/III disease as per American Joint Committee on Cancer (AJCC) staging 7.0 * Baseline imaging with standard of care fludeoxyglucose F-18 (FDG)-positron emission tomography (PET) scan and endoscopic ultrasound within 28 days prior to registration
- Eastern Cooperative Oncology Group (ECOG) performance status 0-1
- Adequate oral intake/nutritional status without the need for enteral or parenteral feeding during chemoradiation or preoperative period
- Leukocytes >= 2,000/mm^3
- Absolute neutrophil count (ANC) >= 1000/mm^3
- Platelet count >= 100,000/mm^3
- Hemoglobin >= 9 g/dL
- Creatinine =< 2.0 mg/dL
- Bilirubin (total) within normal institutional limits (except subjects with Gilbert syndrome who must have total bilirubin < 3.0 mg/dL)
- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]), alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 times the upper limit of normal
- Alkaline phosphatase =< 2.5 times the upper limit of normal
- Prothrombin time (PT) such that international normalized ratio (INR) is =< 1.5 (or an in-range INR, usually between 2 and 3, if a patient is on a stable dose of therapeutic warfarin and a partial thromboplastin time (PTT) =< upper limit of normal
- No evidence of PR prolongation or atrioventricular (AV) block on baseline electrocardiogram (ECG)
- Radiation oncology consultation within 28 days to confirm that disease can be encompassed in the radiotherapy field and that normal tissue constraints can be met
- Subjects must have adequate lung function to permit surgical resection determined by pre-enrollment pulmonary function tests to include diffusion capacity of the lung for carbon monoxide (DLCO) as follows: * DLCO >= 70% predicted OR DLCO < 70% but >= 55% with an oxygen consumption (VO2) max >= 10 L/min/kg (assessed by cardiopulmonary exercise testing) or 6 minute walk test >= 500 meters * Subjects with a DLCO < 55% are excluded from this study * Subjects must have a baseline oxygen (O2) saturation by pulse oximetry that is >= 92% both at rest and while walking, off supplemental oxygen
- Esophagogastrectomies will be performed via a laparotomy and a right thoracotomy with en-bloc removal of perigastric, celiac, periesophageal and subcarinal lymph nodes; esophagogastric reconstruction will be performed above the level of the azygo-caval junction using an end-to-end (EEA) stapling device
- Either a formalin fixed paraffin block or a minimum of ten 5-micron tissue section’s (slides) of tumor biopsy sample must be available for biomarker evaluation from baseline and repeat esophagogastroduodenoscopy (EGD)
- The effects of nivolumab or nivolumab/relatlimab, on the developing human fetus are unknown. For this reason, women of child-bearing potential (WOCBP) and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation and for 5 months after the last dose of nivolumab +/- relatlimab; should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately; sexually active fertile men must use effective barrier birth control if their partners are WOCBP for 7 months after the last dose of nivolumab +/- relatlimab; WOCBP must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin [HCG]) within two weeks of registration
- Patient understands the study regimen, its requirements, risks and discomforts and is able and willing to sign the informed consent form; voluntary signed and dated Institutional Review Board (IRB)/Independent Ethics Committee (IEC) approved written informed consent form in accordance with regulatory and institutional guidelines must be obtained before the performance of any protocol related procedures that are not part of normal patient care; subjects must be competent to report adverse events (AEs), understand the drug dosing schedule and use of medications to control AEs
- (Relatlimab arm only): LVEF (left ventricular ejection fraction) assessment with documented LVEF >= 50% by either transthoracic echocardiography (TTE) or multigated acquisition scan (MUGA) (TTE preferred test) within 6 months from first study drug administration
Exclusion Criteria
- Patient has active, known or suspected autoimmune disease; subjects with vitiligo, type I diabetes mellitus, residual hypothyroidism due to autoimmune thyroiditis only requiring hormone replacement, or conditions not expected to recur in the absence of an external trigger are permitted to enroll
- Esophageal tumors that are located in the mid esophagus or higher i.e. not involving distal esophagus or gastroesophageal (GE) junction
- Tumors whose proximal end are higher that the level of the carina
- Biopsy proven involvement of supraclavicular lymph nodes
- Tumors extend 5 cm or more into the stomach
- Patient has a condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalent) or other immunosuppressive medications within 14 days of first dose; inhaled or topical steroids and adrenal replacement steroid doses are permitted in the absence of active autoimmune disease
- Subjects with previous malignancies (except non-melanoma skin cancers, in situ bladder, gastric, breast, colon or cervical cancers/dysplasia) are excluded unless a complete remission was achieved at least 1 years prior to study entry and no additional therapy (other than adjuvant hormonal therapy for breast cancer) is required or anticipated to be required during the study period
- Subjects with known brain metastasis are excluded from this study; patients with suspected brain metastasis must have brain imaging (either magnetic resonance imaging [MRI] brain or computed tomography [CT] brain with contrast) prior to enrollment
- Subjects with a history of interstitial lung disease
- Active systemic infection requiring therapy, positive tests for hepatitis B surface antigen or hepatitis C ribonucleic acid (RNA)
- Known positive history or positive test for human immunodeficiency virus or acquired immunodeficiency syndrome (AIDS)
- History of allergy to study drug components
- Women who are pregnant or nursing
- WOCBP and men with female partners (WOCBP) that are not willing to use contraception
- Prior therapy with an anti-PD-1, anti-PD-L1, anti-PDL-2, or anti-LAG-3 antibody (or any other antibody targeting T cell co-regulatory pathways)
- Underlying medical conditions that, in the investigator’s opinion, will make the administration of study drug hazardous or obscure the interpretation of toxicity or adverse events
- Prisoners or subjects who are involuntarily incarcerated or compulsorily detained for treatment of either a psychiatric or physical (e.g. infectious disease) illness
- (Relatlimab arm only): Troponin T (TnT) or I (TnI) > 2 X institutional ULN. Subjects with TnT or TnI levels between > 1 to 2 X ULN will be permitted if repeat levels within 24 hours are =< 1 X ULN. If TnT or TnI levels are > 1 to 2 X ULN within 24 hours, the subject may undergo a cardiac evaluation and be considered for treatment, following a discussion with the Bristol-Myers Squibb (BMS) medical monitor or designee. When repeat levels within 24 hours are not available, a repeat test should be conducted as soon as possible. If TnT or TnI repeat levels beyond 24 hours are < 2 X ULN, the subject may undergo a cardiac evaluation and be considered for treatment, following a discussion with the BMS medical monitor or designee
- (Relatlimab arm only): Participants must not have a history of myocarditis
- (Relatlimab arm only): Uncontrolled or significant cardiovascular disease including, but not limited to, any of the following: * Myocardial infarction (MI) or stroke/transient ischemic attack (TIA) within the 6 months prior to consent * Uncontrolled angina within the 3 months prior to consent * Any history of clinically significant arrhythmias (such as ventricular tachycardia, poorly controlled atrial fibrillation, ventricular fibrillation, or torsades de pointes) * Corrected QT (QTc) prolongation > 480 msec * History of other clinically significant cardiovascular disease (i.e., cardiomyopathy, congestive heart failure with New York Heart Association [NYHA] functional classification III-IV, pericarditis, significant pericardial effusion, significant coronary stent occlusion, , poorly controlled venous thrombosis etc.) * Cardiovascular disease-related requirement for daily supplemental oxygen * History of two or more MIs OR two or more coronary revascularization procedures
Additional locations may be listed on ClinicalTrials.gov for NCT03044613.
See trial information on ClinicalTrials.gov for a list of participating sites.
PRIMARY OBJECTIVE:
I. To investigate the safety of induction nivolumab or nivolumab/relatlimab administration prior to concurrent chemo-radiation in subjects with resectable stage II/III esophageal/gastroesophageal junction cancer.
SECONDARY OBJECTIVES:
I. To investigate the feasibility of induction nivolumab or nivolumab/relatlimab prior to concurrent chemo-radiation administration in subjects with stage II/III esophageal and gastro-esophageal junction cancer.
II. To determine the pathological complete response rate in patients treated with induction checkpoint inhibition followed by chemo-radiation prior to surgical resection.
III. To explore the association between nivolumab +/- relatlimab exposure and selected pharmacodynamics markers in the peripheral blood and in the tumor microenvironment, including measurement of PD-1 receptor occupancy on tumor infiltrating lymphocytes.
IV. To measure changes in expression of selected immune markers including changes in the quality and quantity of tumor infiltrating lymphocytes and the T effector to regulatory T-cells (T-Reg) ratio compared to baseline, in the blood, primary tumor tissue and draining lymph nodes.
V. To assess recurrence-free survival in patients receiving neoadjuvant checkpoint inhibitors.
VI. To assess overall survival in patients receiving neoadjuvant checkpoint inhibitors.
OUTLINE: Patients are assigned to 1 of 2 arms.
ARM I: Patients receive nivolumab intravenously (IV) over 30 minutes on day 1. Treatment repeats every 14 days for up to 2 cycles in the absence of disease progression or unacceptable toxicity. Patients then receive standard of care carboplatin and paclitaxel weekly for 5 weeks.
ARM II: Patients receive nivolumab IV over 30 minutes and relatlimab IV over 60 minutes on day 1. Treatment repeats every 14 days for up to 2 cycles in the absence of disease progression or unacceptable toxicity. Patients then receive standard of care carboplatin and paclitaxel weekly for 5 weeks.
After completion of study treatment, patients are followed up at 1 month, every 2 weeks for 3 visits, every 12 weeks for 1 year, every 16 weeks for 1 year, and then every 24 weeks for 3 years.
Trial PhasePhase I
Trial Typetreatment
Lead OrganizationJohns Hopkins University/Sidney Kimmel Cancer Center
Principal InvestigatorVincent K. Lam
- Primary IDJ1714
- Secondary IDsNCI-2017-01509, CRMS-65831, IRB00122689
- ClinicalTrials.gov IDNCT03044613