Last updated on July 2019

Immune Checkpoint Inhibitor Nivolumab in People With Select Rare CNS Cancers


Brief description of study

Background

More than 130 primary tumors of the central nervous system (CNS) have been identified. Most affect less than 1,000 people in the United States each year. Because these tumors are so rare, there are few proven therapies. This study will test whether the immunotherapy drug nivolumab is an effective treatment for people with rare CNS tumors.

Objectives

To learn if stimulating the immune system using the drug nivolumab can shrink tumors in people with rare CNS (brain or spine) tumors or increase the time it takes for these tumors to grow or spread.

Eligibility

Adults whose rare CNS tumor has returned.

Design

Participants will be screened:

  • Heart and blood tests
  • Physical and neurological exam
  • Hepatitis tests
  • Pregnancy test
  • MRI. They will lay in a machine that takes pictures.
  • Tumor tissue sample. This can be from a previous procedure.

At the start of the study, participants will have blood tests. They will answer questions about their symptoms and their quality of life.

Participants will get nivolumab in a vein every 2 weeks for up to 64 weeks.

Participants will have monthly blood tests. Every other month they will have an MRI and a neurologic function test. They will also answer questions about their quality of life.

Genetic tests will be done on participants tumor tissue. Participants will be contacted if any clinically important results are found.

After treatment ends, participants will be monitored for up to 5 years. They will have a series of MRIs and neurological function tests. They will be asked to report any symptoms they experience....

Detailed Study Description

Background
  • There are more than 130 identified primary tumors of the central nervous system (CNS). Most have an annual incidence of less than 1000 in the United States.
  • Given the rarity of each of the tumors listed above, there is a paucity of proven therapies. Most of these neoplasms are treated with maximum surgical resection followed by treatment with external beam radiotherapy. With few exceptions (medulloblastoma, adult ependymoma), there are no effective systemic regimens and even in chemotherapy sensitive disease, most patients with recurrence eventually have no remaining salvage treatments available.
  • In the setting of this unmet need, we propose to create a basket protocol that will evaluate the efficacy of the PD-1 inhibitor, nivolumab, in patients with refractory rare central nervous system neoplasms.
  • This study seeks to establish effective therapies at recurrence in patients with rare CNS tumors. We hypothesize that this therapy will improve progression free survival and/or objective responses.
  • It will be important to determine whether any determined survival benefit is associated with improvements in symptoms or does a worsening of symptoms offset the increase in survival. Precedence exists for measuring non-therapeutic endpoints in oncology research, and specifically in studies evaluating therapeutic benefit in patients with CNS tumors. There have been efforts in neuro-oncology to evaluate secondary endpoints using validated instruments as an additional indicator of benefit. The M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) and Spine Tumor Module (MDASI-SP) allow for the self-reporting of symptom severity and interference with daily activities for patients with either brain or spinal cord tumors. The availability of validated instruments provides an opportunity to prospectively assess the impact of treatment, both positive and negative, on patients.
    Objective

Determine the efficacy of nivolumab in a variety of recurrent, refractory primary central nervous system tumors as measured by either objective imaging response or 6-month progression free survival rate.

Eligibility
  • Documented recurrent or progressive disease that corresponds to one of the tumors eligible for testing.
  • Age greater than or equal to 18 years of age.
  • Karnofsky Performance greater than or equal to 70%.
  • Tumor tissue available for review to confirm morphologic diagnosis
  • Tumor tissue or slides available for molecular and immune profiling
Design
  • This is an open label phase II clinical trial. Patients will be treated with the immune checkpoint inhibitor, nivolumab, at a standard dose of 240 mg intravenously every 2 weeks (+/- 3 days) for cycles 1 through 4, then doses of 480 mg every 4 weeks for a total of 12 additional doses (cycles). A maximum of 20 treatments will be given (64 weeks).
  • A cycle will be defined as 4 weeks and patients will undergo efficacy assessments using MR imaging every 2 cycles. Toxicity assessments will occur before the initiation of each cycle and patient outcomes measures (PROs) will be completed at the time of each imaging study (every 2 cycles) but prior to the patient being informed of the imaging results.
  • After completion of the planned treatment course or if treatment was stopped because of toxicity, patients will undergo imaging evaluations and PRO measurements every 8 weeks (or 2 months) for one year, then every 3 months for the next year, then every 4 months for the next year and then every 6 months while the patient remains on the protocol. Patients off treatment because of disease progression will not undergo future imaging or PRO assessments on this protocol.
  • Bayesian multi-stage, multi-cohort design will be used to conduct this phase II trial in patients with Ependymoma, Medulloblastoma, Pineoblastoma/Pineocytoma, Choroid Plexus Carcinoma or Papilloma, Chordoma, Gliomatosis Cerebri, Brainstem Glioma, Midline Glioma, Atypical Teratoid Rhabdoid Tumor (ATRT), Malignant or Atypical Meningioma or Gliosarcoma or Primary Brain Sarcoma.
  • Due the low prevalence of some diseases, the study will be comprised of 3 single disease cohorts (ependymoma, malignant or atypical meningioma, chordoma) for which accrual is likely to be robust and a fourth cohort for the remaining 8 diseases which are very rare and this trial will look for a preliminary signal. Each cohort will be evaluated independently for efficacy.

Clinical Study Identifier: NCT03173950

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Recruitment Status: Open


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