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Nivolumab (Anti-PD1), Tadalafil and Oral Vancomycin in People With Refractory Primary Hepatocellular Carcinoma or Liver Dominant Metastatic Cancer From Colorectal or Pancreatic Cancers

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ClinicalTrials.gov Identifier: NCT03785210
Recruitment Status : Active, not recruiting
First Posted : December 24, 2018
Last Update Posted : December 27, 2022
Information provided by (Responsible Party):
National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) )

Brief Summary:


A most common liver cancer in adults is hepatocellular carcinoma. Other kinds of liver cancer happen when colorectal or pancreatic cancer spreads to the liver. Researchers want to study if a combination of drugs helps people with these cancers. The drugs are nivolumab, tadalafil, and vancomycin.


To investigate if nivolumab given with tadalafil and vancomycin causes liver cancer to shrink.


Adults ages 18 years and older with hepatocellular carcinoma or metastases to the liver from colorectal or pancreatic cancer for which standard treatment has not worked


Participants will be screened with:

Medical and cancer history

Review of symptoms and ability to perform normal activities

Physical exam

Heart test. Some participants may meet with a cardiologist and/or have another heart test.

Scan of the chest, abdomen, and pelvis

Blood and urine tests

Tumor sample review. This can be from a previous procedure.

Participants will receive the study drugs in 4-week cycles. In each cycle participants will:

Get nivolumab through a small plastic tube in the arm on Day 1.

Take tadalafil by mouth 1 time every day.

Take vancomycin by mouth 4 times a day. They will take it every day for weeks 1 3, then not take it for week 4.

Complete a medicine diary of dates, times, missed doses and symptoms.

Throughout the study, participants will repeat screening tests and will give stool samples or rectal swabs.

After their last cycle, participants will have 3 follow-up visits over 3 months. Then they will be contacted every 6 months by phone or email and asked about their general well-being.

Condition or disease Intervention/treatment Phase
Hepatocellular Carcinoma Hepatocellular Cancer Metastatic Pancreatic Cancer Metastatic Colorectal Cancer Liver Metastasis Drug: nivolumab Drug: tadalafil Drug: oral vancomycin Phase 2

Detailed Description:


  • Current treatment options for patients with liver cancers, including hepatocellular carcinoma(HCC) and advanced liver cancers are limited and take no account of the known biological and genetic heterogeneity in these diseases. Median survival for advanced disease remains poor at approximately 1 year.
  • Nivolumab is a fully human monoclonal immunoglobulin G4 (IgG4) antibody that is specific for human programmed death-1 (PD-1, cluster of differentiation 279 [CD279]) cell surface membrane receptor. Nivolumab has been approved by FDA for the treatment of HCC and other solid tumors.
  • Tadalafil is a phosphodiesterase type 5 (PDE5) inhibitor which have been approved by the FDA for the treatment of pulmonary arterial hypertension, benign prostatic hyperplasia and erectile dysfunction, with a relative safe clinical profile. PDE5 inhibitors have been examined in multiple malignancies and cancer cell lines for their direct anticancer activities, for their

efficacy as chemo-sensitizers and for cancer chemoprevention.

  • Oral vancomycin is antibiotic that has effect on altering gut commensal bacteria subsequently inducing a liver-selective anti-tumor effect.
  • The aim of the study is to evaluate whether the immunomodulatory effect induced by PDE5 inhibitor and oral vancomycin can be enhanced by immune checkpoint inhibition in advanced liver cancer.


-To determine the Best Overall Response (BOR) according to Response Evaluation Criteria (RECIST 1.1) to combined treatment of nivolumab, oral vancomycin and tadalafil in patients with refractory primary HCC or liver dominant metastatic cancer from colorectal cancer (CRC) or pancreatic adenocarcinoma (PDAC).


  • Histologically confirmed, hepatocellular carcinoma (HCC) Or
  • Histologically confirmed carcinoma highly suggestive of a diagnosis of HCC Or
  • Histologically confirmed advanced colorectal or pancreatic malignancy with liver involvement as dominant site of metastasis
  • Measurable lesion, accessible for biopsy.
  • Age greater than or equal to 18 years
  • ECOG less than or equal to 1
  • Acceptable renal, bone marrow and liver function.
  • Willingness to undergo two mandatory tumor biopsies.


  • The proposed study is a phase II study of combined nivolumab, oral vancomycin and tadalafil treatment in patients with HCC or liver dominant metastatic cancer from colorectal or pancreatic cancers.
  • Treatment will be delivered in cycles consisting of 4 weeks (+/- 3 days) until progression or unacceptable toxicity.
  • Patients will be seen in Clinical Center on monthly basis with disease status evaluation every

    8 (+/-1) weeks after start of study therapy.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 22 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Phase II Study of Nivolumab (Anti-PD1), Tadalafil and Oral Vancomycin in Patients With Refractory Primary Hepatocellular Carcinoma or Liver Dominant Metastatic Cancer From Colorectal or Pancreatic Cancers
Actual Study Start Date : June 5, 2019
Estimated Primary Completion Date : December 31, 2022
Estimated Study Completion Date : December 31, 2023

Arm Intervention/treatment
Experimental: 1/Arm 1
Nivolumab, tadalafil and oral vancomycin
Drug: nivolumab
480 mg IV every 4 weeks

Drug: tadalafil
10 mg PO daily

Drug: oral vancomycin
125 mg every 6-hour (500 mg total daily dose) PO from week 1 to week 3, week 4 off.

Primary Outcome Measures :
  1. Best Overall Response (BOR) [ Time Frame: every 2 months ]
    Changes in tumor size and occurrence of metastases

Secondary Outcome Measures :
  1. To assess the safety and tolerability of nivolumab in combination with oral vancomycin and tadalafil in patients with refractory primary HCC or liver dominant metastatic cancer from CRC or PDAC [ Time Frame: 90 days after treatment ]
    toxicities will be reported by type and grade.

  2. To assess overall survival (OS) of nivolumab combined with oral vancomycin and tadalafil in patients with refractory HCC or liver dominant metastatic cancer from CRC or PDAC [ Time Frame: death ]
    calculated from the on-study date using the Kaplan-Meier method

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
  • Patients must have

    • histopathological confirmation of HCC (Cohort 1) OR
    • histopathological confirmation of carcinoma by in the setting of clinical and radiological characteristics which, together with the pathology, are highly suggestive of a diagnosis of HCC (Cohort 1) OR
    • histopathological confirmation of advanced colorectal or pancreatic malignancy with liver involvement as dominant site of metastasis (Per multidiscipline tumor board review and approval) (Cohort 2).
  • Patients must have disease that is not amenable to potentially curative resection, transplantation or ablation.
  • Patients must have progressed on, been intolerant to, or refused prior sorafenib/lenvatinib and/or atezolizumab/bevacizumab therapy (Cohort 1 only).
  • Subjects must have progressed on or after standard systemic chemotherapy (at least one line of chemotherapy for patients with liver metastasis from PDAC, at least two lines of chemotherapy for patients with liver metastasis from CRC) (Cohort 2 only).
  • Patients must have evaluable or measurable disease per RECIST 1.1
  • Patients must have lesion accessible for biopsy and be willing to undergo pre- and posttreatment biopsies.
  • ECOG performance status of 0 to 1
  • If liver cirrhosis is present, patient must have a Child-Pugh score less than or equal to 7
  • Active chronic HBV infected subjects must be on antivirals and have HBV DNA <100IU/mL. HCV infected subjects can be enrolled with close HCV RNA level monitoring.
  • Age greater than or equal to 18 years. Because no dosing or adverse event data are currently available on the use of nivolumab in combination with tadalafil and vancomycin in patients less than 18 years of age, children are excluded from this study, but will be eligible for future pediatric trials
  • Adequate hematological function defined by:

    • white blood cell (WBC) count greater than or equal to 3 (SqrRoot) 10^9/L
    • absolute neutrophil count (ANC) greater than or equal to 1.5 (SqrRoot) 10^9/L,
    • lymphocyte count greater than or equal to 0.5 (SqrRoot) 10^9/L,
    • platelet count greater than or equal to 60 (SqrRoot) 10^9/L, and
    • Hgb greater than or equal to 9 g/ dL (more than 48 hours post-completion of blood transfusion)
  • Adequate hepatic function defined by:

    • a total bilirubin level less than or equal to 1.5 (SqrRoot) ULN,
    • an AST level <5(SqrRoot) ULN,
    • an ALT level <5 (SqrRoot) ULN.
  • Adequate renal function defined by:

    • Creatinine clearance (CrCl) greater than or equal to 50 mL/min/1.73 m^2 by 24 hours urine collection or as predicted by the Cockcroft-Gault formula:
    • CrCl = (140 age (y)) x (weight in kg) x (0.85, if female) x1.73 m^2/72 x Serum Creatinine (mg/dL) x pt. s BSA (m^2) Or
  • The effects of nivolumab on the developing human fetus are unknown. For this reason, women of child-bearing potential 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 up to 5 months (women) and 7 months (men) after the last dose of the drug. 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.
  • Patients with a history of cardiovascular disease may be enrolled per cardiology consultation and approval with echocardiogram and troponin level in normal range at the time of enrollment.
  • Patient must be able to understand and willing to sign a written informed consent document.


  • Patients who have had standard-of-care anti-cancer therapy or therapy with investigational agents (e.g. chemotherapy, immunotherapy, endocrine therapy, targeted therapy, biologic therapy, tumor embolization, monoclonal antibodies or other investigation agents), large field radiotherapy, or major surgery within 4 weeks prior to enrollment.
  • Therapy with antibiotics within 30 days prior to enrollment.
  • Therapy with nitrates, alpha-blockers, or cytochrome P450 (CYP3A4) inhibitors within 7- days prior to enrollment and for whom stopping is unsafe and/or a safe substitute is not medically recommended. Use of PDE5 inhibitors such as vardenafil (Levitra ), tadalafil (Cialis ), and sildenafil citrate (Viagra ) less than or equal to 15-days prior to enrollment.
  • The patient must not be currently on a corticosteroid dose greater than physiologic replacement dosing defined as 10 mg of cortisone per day or its equivalent.
  • For PDAC patients with liver metastases, primary PDAC has not been resected (unless the primary is in the tail of the pancreas).
  • Patients with known brain metastases will be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events.
  • Have signs of liver failure, e.g. clinical significant ascites, encephalopathy, or variceal bleeding within 6 months prior to enrollment.
  • Prior major liver resection: remnant liver <50% of the initial liver volume. Patients with a biliary stent can be included.
  • Patients with active autoimmune disease or history of autoimmune disease that might recur, which may affect vital organ function or require immune suppressive treatment including systemic corticosteroids. These include but are not limited to patients with a history of immune related neurologic disease, multiple sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome or CIDP, myasthenia gravis; systemic autoimmune disease such as SLE, connective tissue diseases, scleroderma, inflammatory bowel disease (IBD), Crohn s, ulcerative colitis, hepatitis; and patients with a history of toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome, or phospholipid syndrome. Such diseases should be excluded because of the risk of recurrence or exacerbation of disease.

Of note, patients with vitiligo, endocrine deficiencies including thyroiditis managed with replacement hormones including physiologic corticosteroids are eligible. Patients with rheumatoid arthritis and other arthropathies, Sjogren s syndrome and psoriasis controlled with topical medication and patients with positive serology, such as antinuclear antibodies (ANA), anti-thyroid antibodies should be evaluated for the presence of target organ involvement and potential need for systemic treatment but should otherwise be eligible.

  • Have history of idiopathic pulmonary fibrosis (including bronchiolitis obliterans with organizing pneumonia) or evidence of active pneumonitis on screening chest CT scan.
  • Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
  • Patients with myocardial infarction or myocarditis within 12 months prior to enrollment.
  • History of severe or unstable cerebrovascular disease.
  • Sustained hypotension (<90/50 mmHg) or uncontrolled hypertension (>160/100 mmHg)
  • Stroke within 6 months prior to enrollment.
  • HIV-positive patients are excluded because HIV causes complicated immune deficiency and study treatment can possess more risks for these patients.
  • Have had prior transplant of any kind.
  • Have ascites.
  • History of allergic reactions attributed to compounds of similar chemical or biologic composition to nivolumab, tadalafil or vancomycin.
  • History of severe hypersensitivity reaction to any monoclonal antibody.
  • Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free for a minimum of 3 years prior to enrollment.
  • Pregnant women are excluded from this study because nivolumab s potential for teratogenic or abortifacient effects is unknown. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with nivolumab, breastfeeding should be discontinued if the mother is treated with nivolumab

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03785210

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United States, Maryland
National Institutes of Health Clinical Center
Bethesda, Maryland, United States, 20892
Sponsors and Collaborators
National Cancer Institute (NCI)
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Principal Investigator: Tim F Greten, M.D. National Cancer Institute (NCI)
Additional Information:
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Responsible Party: National Cancer Institute (NCI)
ClinicalTrials.gov Identifier: NCT03785210    
Other Study ID Numbers: 190033
First Posted: December 24, 2018    Key Record Dates
Last Update Posted: December 27, 2022
Last Verified: October 3, 2022
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: .All IPD recorded in the medical record will be shared with intramural investigators upon request.@@@@@@In addition, all large scale genomic sequencing data will be shared with subscribers to dbGaP
Supporting Materials: Study Protocol
Statistical Analysis Plan (SAP)
Informed Consent Form (ICF)
Time Frame: Clinical data available during the study and indefinitely.@@@@@@Genomic data are available once genomic data are uploaded per protocol GDS plan for as long as database is active.
Access Criteria: Clinical data will be made available via subscription to BTRIS and with the permission of the study PI.@@@@@@Genomic data are made available via dbGaP through requests to the data custodians.

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) ):
Anticancer Activities
Altering Gut Commensal Bacteria
Immunomdulatory Effect
Checkpoint Inhibition
Additional relevant MeSH terms:
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Neoplasm Metastasis
Pancreatic Neoplasms
Carcinoma, Hepatocellular
Liver Neoplasms
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Digestive System Neoplasms
Neoplasms by Site
Digestive System Diseases
Neoplastic Processes
Pathologic Processes
Endocrine Gland Neoplasms
Pancreatic Diseases
Endocrine System Diseases
Liver Diseases
Antineoplastic Agents, Immunological
Antineoplastic Agents
Immune Checkpoint Inhibitors
Molecular Mechanisms of Pharmacological Action
Anti-Bacterial Agents
Anti-Infective Agents
Vasodilator Agents
Phosphodiesterase 5 Inhibitors
Phosphodiesterase Inhibitors