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

Sponsor

National Cancer Institute (NCI) (NIH)

Overall Status

Active, not recruiting

CT.gov ID

NCT03785210

Collaborator

(none)

Enrollment

Location

Arm

54.9

Anticipated Duration (Months)

0.4

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Background:

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.

Objective:

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

Eligibility:

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

Design:

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

Background:

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.

Objective:

-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).

Eligibility:

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.

Design:

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.

Study Design

Study Type:

Interventional

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 :

Jun 5, 2019

Anticipated Primary Completion Date :

Dec 31, 2022

Anticipated Study Completion Date :

Dec 31, 2023

Arms and Interventions

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.

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.

Outcome Measures

Primary Outcome Measures

Best Overall Response (BOR) [every 2 months]
Changes in tumor size and occurrence of metastases

Secondary Outcome Measures

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 [90 days after treatment]
toxicities will be reported by type and grade.
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 [death]
calculated from the on-study date using the Kaplan-Meier method

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

INCLUSION CRITERIA:
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.

EXCLUSION CRITERIA:

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