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Irreversible Electroporation (IRE) Followed by Nivolumab in Patients With Metastatic Pancreatic Cancer.

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ClinicalTrials.gov Identifier: NCT04212026
Recruitment Status : Recruiting
First Posted : December 26, 2019
Last Update Posted : November 2, 2020
Sponsor:
Information provided by (Responsible Party):
Swiss Group for Clinical Cancer Research

Brief Summary:
This proof of concept trial aims to assess whether the combination of IRE with Nivolumab is safe and effective to treat metastatic pancreatic cancer, based on the available preliminary evidence that IRE is able to cause a systemic anti-tumor immune response (i.e. abscopal effect), which may enhance the effect of subsequent Nivolumab treatment. In addition, the trial aims to clarify the systemic effects of IRE over time and thereby to provide more insight in the mechanism of work of the technique.

Condition or disease Intervention/treatment Phase
Metastatic Pancreatic Cancer Drug: Nivolumab Phase 2

Detailed Description:

The prognosis of patients newly diagnosed with pancreatic ductal adenocarcinoma (PDAC) is extremely poor with a 5-year overall survival rate of less than 5%. To improve this dismal outcome, new treatment approaches are urgently needed. So far, immune-checkpoint therapy was not successful in patients with PDAC. Given the poor response to conventional chemotherapy, there is an imperative need to make PDACs amenable to immune-checkpoint therapy. Irreversible electroporation (IRE) is a relatively novel and safe ablation technique that destroys tumors by using apoptosis-inducing electrical currents inducing local and systemic pro-inflammatory cytokine expression and enhances the presence of cytotoxic CD8+ T-cells, while the apoptotic cell material preserves neo-antigen properties detectable by dendritic cells. This effect might be further enhanced by immune-checkpoint therapy.

The rationale of our study is to convert immunologically cold PDACs into hot PDACs by triggering an enhanced local and systemic immune response. We hypothesize that among patients with metastatic PDAC, the IRE of one liver metastasis followed by the administration of an immune-checkpoint inhibitor leads to a measurable radiological response in a selected non-treated liver metastasis. Furthermore, we hypothesize that the immune response is both local in the form of tumor infiltrating lymphocytes (TILS) and an immunologically activated tumor microenvironment in the IRE-treated metastasis, as well as systemic as evidenced by an abscopal response in the IRE-untreated metastatic and primary site.

The objective of the trial is to examine whether for patients with metastatic PDAC the combination of IRE of one liver metastasis followed by the administration of five doses of nivolumab leads to a measurable radiological response in a selected non-treated liver metastasis.

To demonstrate that the trial treatment leads to a measurable immune response, multiple translational research projects will assess the effect of IRE and nivolumab on the development of the local and peripheral tumor immune response over time.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 15 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Intervention Model Description: This is a pilot, multicenter, single-arm phase II trial.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Irreversible Electroporation (IRE) Followed by Nivolumab in Patients With Metastatic Pancreatic Cancer: a Multicenter Single-arm Phase II Trial
Actual Study Start Date : June 28, 2020
Estimated Primary Completion Date : December 2021
Estimated Study Completion Date : September 2023

Resource links provided by the National Library of Medicine

Drug Information available for: Nivolumab

Arm Intervention/treatment
Experimental: Nivolumab
Nivolumab treatment will be given every 2 weeks at a standard flat dose of 240 mg for a total of 5 doses, and the IRE procedure will be performed using the standard setting to ablate tumors at the level of the liver that is well tolerated by the patients. Two weeks after the last dose of nivolumab ("Week 8"), radiological restaging will be performed (="Week 10").
Drug: Nivolumab
The patients start treatment with nivolumab on day 1 after IRE and will be given nivolumab at a flat dose of 240 mg every 2 weeks (q2wk) for 5 cycles until Week 8.




Primary Outcome Measures :
  1. The objective response rate (ORR) after the 5th dose of nivolumab of the reference liver metastasis that was not biopsied. [ Time Frame: At 2-4 weeks after the 5th dose of nivolumab ]
    The objective response rate (ORR) according to RECIST v1.1 after the 5th dose of nivolumab of the reference liver metastasis that was not biopsied, assessed 2-4 weeks after the 5th dose of nivolumab, defined as proportion of patients achieving Complete Response (CR) or Partial Response (PR). The assessment will be based on re-staging the patients with a CT-scan 2-4 weeks after the 5th dose of nivolumab. Patients without tumor assessment 2-4 weeks after the 5th dose of nivolumab will be counted as non-responders.


Secondary Outcome Measures :
  1. Objective Response Rate (ORR) after the 5th dose of nivolumab of the primary tumor site (pancreas). [ Time Frame: At 2-4 weeks after the 5th dose of nivolumab ]
    The ORR according to RECIST v1.1 after the 5th dose of nivolumab of the primary tumor site (pancreas), assessed 2-4 weeks after the 5th dose of nivolumab, defined as percentage of patients achieving Complete Response (CR) or Partial Response (PR). Patients without tumor assessment 2-4 weeks after the 5th dose of nivolumab will be counted as non-responders.

  2. ORR after the 5th dose of nivolumab of the IRE-treated liver metastasis [ Time Frame: At 2-4 weeks after the 5th dose of nivolumab ]
    The ORR according to RECIST v1.1 after the 5th dose of nivolumab of IRE-treated liver metastasis, assessed 2-4 weeks after the 5th dose of nivolumab, defined as percentage of patients achieving CR or PR. Patients without tumor assessment 2-4 weeks after the 5th dose of nivolumab will be counted as non-responders.

  3. ORR based on best overall response [ Time Frame: From the date of registration until the date of progressive disease according to RECIST v1.1 or death, whichever occurs first, assessed up to 4 years after registration ]
    The ORR based on best overall response according to RECIST v1.1, assessed at any time between registration and disease progression by RECIST v1.1, death, or subsequent anticancer therapy, whichever occurs first, defined as percentage of patients achieving CR or PR.

  4. Immune ORR (iORR) based on best overall immune response [ Time Frame: From the date of registration until the date of progressive disease according to RECIST v1.1 or death, whichever occurs first, assessed up to 4 years after registration ]
    The immune ORR (iORR) based on best overall immune response according to iRECIST, assessed at any time between registration and disease progression by iRECIST, death, or subsequent anticancer therapy, whichever occurs first, defined as percentage of patients achieving CR, PR, iCR or iPR.

  5. Progression free survival (PFS) [ Time Frame: From the date of registration until the date of progressive disease according to RECIST v1.1 or death, whichever occurs first, assessed up to 4 years after registration ]
    Progression-free survival (PFS), defined as the time from registration until progression according to RECIST v1.1 or death from any cause, whichever occurs first.

  6. Immune PFS (iPFS) [ Time Frame: From the date of registration until the date of progressive disease according to RECIST v1.1 or death, whichever occurs first, assessed up to 4 years after registration ]

    Immune PFS (iPFS), defined as the time from registration until progression according to iRECIST (first iUPD without documented iSD, iPR or iCR thereafter) or death from any cause, whichever occurs first.

    Patients without event at the time of analysis and patients starting a new anticancer therapy in the absence of an event will be censored at the date of the last tumor assessment showing non-progression (before the start of the new therapy, if any).


  7. Overall survival (OS) [ Time Frame: From the date of registration until the date of death, assessed up to 4 years after registration ]
    Overall survival (OS), defined as time form registration to death due to any cause. Any patient not known to have died at the time of analysis will be censored based on the last recorded date on which the patient was known alive.

  8. Adverse events [ Time Frame: From the date of registration to 100 days after last trial treatment ]
    Adverse events, assessed according to NCI CTCAE v5.0 and Clavien-Dindo Classification for procedural complications



Information from the National Library of Medicine

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

Inclusion Criteria:

  • Written informed consent according to Swiss law and ICH GCP E6(R2) regulations before registration and prior to any trial specific procedures.
  • Pathologically proven PDAC with liver metastases either by histology or cytology.
  • At least three liver metastases, measurable per RECIST v 1.1, of which at least two are percutaneously accessible lesions for repeat biopsy, while one of the biopsied lesions will be treated with IRE. The lesion amenable to IRE treatment must have a diameter of 1-4 cm;
  • At least stable disease after the completion of 10-18 weeks of first line standard chemotherapy (either (m)FOLFIRINOX or Gemcitabine/Abraxane) as confirmed by tumor assessment within 21 days prior to registration.
  • Patients with a prior malignancy and treated with curative intention are eligible if all treatment of that malignancy was completed at least 2 years before registration and the patient has no evidence of that disease at registration. Note: Less than 2 years is acceptable for malignancies with low risk of recurrence and/or no late recurrence.
  • Measurable disease per RECIST v1.1
  • Patients must be willing to participate in the translational research part of the trial and to undergo a tumor biopsy of the primary tumor and of the two metastatic sites in the liver before trial treatment and after five cycles of nivolumab treatment.
  • Patients must be willing to travel to the hospital where IRE and biopsy will be performed.
  • Age ≥ 18 years
  • WHO performance status 0-1
  • Life expectancy ≥4 months
  • Adequate bone marrow function: neutrophil count ≥ 1.0 x 109/L, platelet count ≥ 100 x 109/L, hemoglobin ≥ 80 g/L
  • Adequate hepatic function: total bilirubin ≤ 1.5 x ULN (except for patients with Gilbert's disease ≤ 3.0 x ULN), AST and ALT ≤ 3 x ULN.
  • Adequate renal function: estimated glomerular filtration rate (eGFR) ≥ 50 mL/min/1.73 m2 (according to CKD-EPI formula).
  • Adequate coagulation function: INR ≤ 1.5 x ULN (the ULN for INR is defined with the value 1.2 for all sites, in case no ULN is documented in the lab certificates/sheets). In case patient is under anti-vitamin K treatment, INR >1.5 x ULN is allowed; however, the patient has to be switched to LMWH treatment prior to any trial intervention.
  • Women of childbearing potential must use effective contraception, are not pregnant or lactating and agree not to become pregnant during trial treatment and until 5 months after the last dose of nivolumab. A negative pregnancy test before inclusion into the trial is required for all women of childbearing potential (for nivolumab product information).
  • Men agree not to donate sperm or to father a child during trial treatment and until 7 months after the last dose of nivolumab (for nivolumab product information).

Exclusion criteria:

  • Clinically significant ascites that is not controllable.
  • Prior surgery or radiotherapy to any PDAC disease site.
  • Prior treatment with any immune checkpoint inhibitor.
  • Concomitant or recent (within 100 days of registration) treatment with any other experimental drug (enrollment in another clinical trial).
  • Concomitant use of other anti-cancer drugs or radiotherapy.
  • Severe or uncontrolled concurrent illness, such as cardiovascular disease (congestive heart failure NYHA III or IV; unstable angina pectoris, history of myocardial infarction within the last six months, serious arrhythmias requiring medication (with exception of atrial fibrillation or paroxysmal supraventricular tachycardia), significant QT-prolongation, uncontrolled hypertension.
  • Known history of human immunodeficiency virus (HIV) or active chronic Hepatitis C or Hepatitis B Virus infection or any uncontrolled active systemic infection requiring intravenous (i.v.) antimicrobial treatment.
  • Known history of tuberculosis, known history of primary immunodeficiency, known history of allogeneic organ transplant, receipt of live attenuated vaccine within 30 days prior to registration.
  • Concomitant or prior use of immunosuppressive medication within 30 days of registration, with the exceptions of intranasal and inhaled corticosteroids, or systemic corticosteroids which must not exceed 10 mg/day of prednisone (or a dose equivalent corticosteroid), and the premedication for chemotherapy
  • Concomitant need for full anticoagulation treatment that cannot be stopped or bridged for the performance of the biopsy/IRE procedures Note: Aspirin or other acetylsalicylic acid containing drugs (up to 300 mg/day) are allowed
  • Any concomitant drugs contraindicated for use with the trial treatment according to the approved product information
  • Known hypersensitivity to nivolumab or to any component of nivolumab, to stainless steel or to contrast agents.
  • Any other serious underlying medical (in particular coagulation deficiencies), psychiatric, psychological, familial or geographical condition, which in the judgment of the investigator may interfere with the planned staging, treatment and follow-up, affect patient compliance or place the patient at high risk from treatment-related complications.

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): NCT04212026


Contacts
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Contact: Daniela Bärtschi +41 31 389 91 91 trials@sakk.ch

Locations
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Switzerland
St. Claraspital Recruiting
Basel, Switzerland, 4058
Contact: Martin Bolli, MD    +41 61 777 75 75    martin.bolli@clarunis.ch   
Principal Investigator: Martin Bolli, MD         
Inselspital Bern Recruiting
Bern, Switzerland, 3010
Contact: Martin D. Berger, MD    +41 31 632 41 14    martin.berger@insel.ch   
Principal Investigator: Martin D. Berger, MD         
CHUV - Swiss Cancer Center Lausanne Recruiting
Lausanne, Switzerland, 1011
Contact: Antonia Digklia, MD    +41 21 314 79 28    Antonia.Digklia@chuv.ch   
Principal Investigator: Antonia Digklia, MD         
UniversitätsSpital Zürich Recruiting
Zürich, Switzerland, 8091
Contact: Ralph Fritsch, MD    +41 44 255 22 14    dispo_onk@usz.ch   
Principal Investigator: Ralph Fritsch, MD         
Sponsors and Collaborators
Swiss Group for Clinical Cancer Research
Investigators
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Study Chair: Mathias Worni, MD Clarunis - St. Clara Hospital and University Hospital Basel
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Responsible Party: Swiss Group for Clinical Cancer Research
ClinicalTrials.gov Identifier: NCT04212026    
Other Study ID Numbers: SAKK 44/19
First Posted: December 26, 2019    Key Record Dates
Last Update Posted: November 2, 2020
Last Verified: October 2020

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by Swiss Group for Clinical Cancer Research:
metastatic Pancreatic Cancer
Irreversible electroporation (IRE)
nivolumab
Phase II trial
Additional relevant MeSH terms:
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Pancreatic Neoplasms
Digestive System Neoplasms
Neoplasms by Site
Neoplasms
Endocrine Gland Neoplasms
Digestive System Diseases
Pancreatic Diseases
Endocrine System Diseases
Nivolumab
Antineoplastic Agents, Immunological
Antineoplastic Agents