547 CERPASS: A randomized, controlled, open-label, phase 2 study of cemiplimab ± RP1 in patients with advanced cutaneous squamous cell carcinoma

Background

The prognosis for advanced and metastatic cutaneous squamous cell carcinoma (CSCC) remains poor for many patients with the disease despite approval of the anti-PD1 antibodies cemiplimab and pembrolizumab.1 2 RP1 is an oncolytic virus (HSV-1) that expresses a fusogenic glycoprotein (GALV-GP R-) and granulocyte macrophage colony stimulating factor (GM-CSF). In preclinical studies, RP1 induced immunogenic tumor cell death and provided potent systemic anti-tumor activity, which is further improved by combining anti-PD-1 therapy.3 Preliminary results from IGNYTE, a phase I/II clinical study of RP1 in combination with nivolumab showed a high rate of deep and durable responses in patients (pts) with CSCC.4 The objective of this trial is to evaluate the safety and efficacy of cemiplimab + RP1 versus cemiplimab alone in advanced CSCC.

Methods

This global, multicenter, randomized phase 2 study is enrolling pts with metastatic or unresectable, locally advanced CSCC who are not candidates for/refuse surgery and/or radiotherapy. Key eligibility criteria include no prior treatment with anti-PD1/PD-L1 antibodies or oncolytic viruses. The clinical trial will enroll approximately 180 pts from centers in the EU, Australia, Canada and USA. Pts will be randomized in a 2:1 ratio favoring the RP1 + cemiplimab arm. Pts will receive 350 mg of cemiplimab intravenously (IV) Q3W for up to 108 weeks. In the RP1 + cemiplimab arm, RP1 will be injected intratumorally at a starting RP1 dose of 1 × 10^6 plaque forming units (PFU)/mL alone, followed by up to 7 doses of RP1 at 1 × 10^7 PFU/mL Q3W together with cemiplimab. Pts in the combination arm may receive up to 8 additional RP1 doses. No crossover will be allowed. Pts will be stratified by disease status and prior systemic therapy. Tumor assessments will be performed every 9 weeks. Primary endpoints are overall response rate and complete response rate by blinded independent review. Secondary endpoints include safety, progression free survival, duration of response and overall survival. Exploratory endpoints include viral shedding and biodistribution, and immune biomarker analyses. This trial is currently enrolling pts.

Trial Registration

NCT04050436

References

Migden MR, Rischin D, Schmults CD, Guminski A, Hauschild A, Lewis KD, Chung CH, Hernandez-Aya L, Lim AM, Chang ALS, Rabinowits G, Thai AA, Dunn LA, Hughes BGM, Khushalani NI, Modi B, Schadendorf D, Gao B, Seebach F, Li S, Li J, Mathias M, Booth J, Mohan K, Stankevich E, Babiker HM, Brana I, Gil-Martin M, Homsi J, Johnson ML, Moreno V, Niu J, Owonikoko TK, Papadopoulos KP, Yancopoulos GD, Lowy I, Fury MG. PD-1 blockade with cemiplimab in advanced cutaneous squamous-cell carcinoma. N Engl J Med 2018;379(4):341–351.

Grob JJ, Gonzalez R, Basset-Seguin N, Vornicova O, Schachter J, Joshi A, Meyer N, Grange F, Piulats JM, Bauman JR, Zhang P, Gumuscu B, Swaby RF, Hughes BGM. Pembrolizumab monotherapy for recurrent or metastatic cutaneous squamous cell carcinoma: a single-arm phase II trial (KEYNOTE-629). J Clin Oncol 2020;38(25):2916–2925.

Thomas S, Kuncheria L, Roulstone V, Kyula JN, Mansfield D, Bommareddy PK, Smith H, Kaufman HL, Harrington KJ, Coffin RS. Development of a new fusion-enhanced oncolytic immunotherapy platform based on herpes simplex virus type 1. J Immunother Cancer 2019;7(1):214.

Middleton M, Aroldi F, Sacco J, Milhem M, Curti B, VanderWalde A, Baum S, Samson A, Pavlick A, Chesney J, Niu J, Rhodes T, Bowles T, Conry R, Olsson-Brown A, Earl Laux D, Kaufman H, Bommareddy P, Deterding A, Samakoglu S, Coffin R, Harrington K. 422 An open-label, multicenter, phase 1/2 clinical trial of RP1, an enhanced potency oncolytic HSV, combined with nivolumab: updated results from the skin cancer cohorts. J Immunother Cancer 2020; 8 (3).

Ethics Approval

The study was approved by institutional review board or the local ethics committee at each site. Informed consent was obtained from patients before participating into the trial.

20 Tumor-informed liquid biopsy monitoring of evolving therapeutic resistance mechanisms in head and neck squamous cell carcinoma patients receiving anti-PD-1 therapy

Background

Typical liquid biopsy panels offer a limited understanding of tumor biology, potentially under-representing the heterogeneity of resistance in late-stage cancers. Here, diminished scope can result in undetected, therapeutically-relevant biomarkers which respond dynamically to treatment, as well as potentially missed resistance mechanisms and pathway-level events. To address the challenges associated with identifying multiple concurrent heterogeneous resistance mechanisms in individual patients, we evaluated longitudinal exome-scale tumor-informed cell-free DNA (cfDNA) data from head and neck squamous cell carcinoma (HNSCC) patients receiving anti-PD1 therapy.

Methods

Pre- and post-intervention matched tumor, normal and plasma samples were retrospectively obtained from 15 stage II-IV HNSCC patients. Following baseline sample collection, all patients received a single dose of nivolumab or pembrolizumab. The primary tumor was then resected approximately one month later when possible, or a second biopsy collected where resection was impractical. Paired tumor and normal samples were then profiled using ImmunoID NeXT Platform®, an augmented exome/transcriptome platform and analysis pipeline. Exome-scale cfDNA profiling of matched plasma samples was performed using the NeXT Liquid BiopsyTM platform to detect somatic variants.

Results

Patient neoantigen presentation score (NEOPSTM) rapidly and significantly contracted following therapy (p=.00098). Novel neoantigens arising post-treatment which were predicted to be presented on lost HLA alleles were significantly higher in patients with longer overall survival (p=.019). Variant detection across same-patient serial cfDNA samples revealed significantly correlated VAFs (R=.62, p<.0001) despite significant contraction of mutational burden in solid tumor (p=.0039), suggesting complex clonal/subclonal dynamics. Investigation of the evolving tumor and cfDNA subclonal architecture revealed significant association between decreasing cellular prevalence and NOTCH signaling (q=.001) and the innate immune system (q=.002), while increasing cellular prevalence was associated with p53 signalling (q=.02) and hypoxia (q=.02). These findings were complimented by transcriptomic data which showed significant enrichment of multiple immune pathways across treatment.

Conclusions

We found that immune checkpoint blockade precipitates rapid evolution of the HNSCC tumor microenvironment. By leveraging comprehensive, tumor-informed liquid biopsy data we were able to identify contracting cellular populations enriched for NOTCH pathway mutations. Longer OS following either intervention was associated with an expansion of novel neoantigens predicted to be presented by lost HLA alleles. Our results suggest that tumor-informed liquid biopsy provides a more robust understanding of therapeutic response and resistance mechanisms than that attainable with typical liquid biopsy panels alone.

Ethics Approval

This study obtained ethics approval from Human Subjects Research at Stanford University. ID number is 40425. All participants gave informed consent prior to enrollment.

Abstract CT158: Phase II study of monalizumab, a first-in-class NKG2A monoclonal antibody, in combination with cetuximab in previously treated recurrent or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN): Preliminary assessment of safety and efficacy

Background Monalizumab is an immune checkpoint inhibitor targeting NKG2A receptors expressed on subsets of tumor-infiltrating cytotoxic CD8 T cells and Natural Killer (NK) cells. NKG2A ligand is HLA-E, a non-classical HLA class I molecule often upregulated in cancer. Preclinical experiments have shown that blocking NKG2A binding to HLA-E may promote NK and T cell anti-tumor responses. NK cell stimulation with a checkpoint inhibitor might also enhance antibody dependent cellular cytotoxicity (ADCC) induced by cetuximab. Although approved in SCCHN after platinum-based therapy, cetuximab has limited activity in that setting (12% response rate).

Methods This is a multicenter non-randomized study (NCT02643550). After previous exploration of 5 dose levels of monalizumab (0.4, 1, 2, 4 or 10 mg/kg every 2 weeks) in combination with fixed doses of cetuximab (400 mg/m² load then 250 weekly) using a 3+3 design, the cohort expansion used monalizumab at the highest dose tested (10 mg/kg) and included a futility analysis after the first 11 patients (pts). The trial was open to pts ≥ 18 years old with SCCHN progressing after platinum-based therapy with no more than 2 previous lines, regardless of HLA-E or human papilloma virus status. The primary endpoint for anti-tumor activity was overall response rate per RECIST, assessed every 8 weeks. Pts were treated until disease progression or unacceptable toxicity.

Results As of 12/19/2017, 26 pts were enrolled in the expansion part, and 16 pts had a minimum of 16 weeks of follow-up to be evaluable for efficacy. The safety profile was as expected, similar to the single agent experience with either agent. The majority of adverse events (AE) were of Grade 1-2 severity, rapidly reversible and easily manageable, with 3 treatment-related grade 3-4 AE and 1 pt stopped monalizumab due to safety. Median age was 62 years (range: 34-77); 56 % were male; PS was 0 or 1; 4 were HPV+. All 16 pts had received prior platinum-based therapy, 8 prior immune therapy, 2 prior cetuximab with radiation. There were 6 pts with partial responses (PR) (4 confirmed; 2 not yet confirmed) of whom 2 were previously treated with immune therapy and 1 had disease deemed resistant to cetuximab. Median treatment duration for confirmed PR is 25+ weeks (16, 23+, 28+, 35+), 9 pts had stable disease (SD). The study was not stopped for futility and is planned to enroll up to 40 pts. Further follow-up is needed to evaluate duration of response, progression-free and overall survival.

Conclusion Preliminary data suggest promising antitumor activity of the combination of monalizumab and cetuximab compared to historical data with single agent cetuximab, with acceptable safety. These encouraging results will need to be confirmed on larger sample size with longer follow up.

Citation Format: Roger Cohen, Jérôme Fayette, Marshall Posner, Gautier Lefebvre, Jessica Bauman, Sébastien Salas, Caroline Even, Tanguy Seiwert, Dimitrios Colevas, Antonio Jimeno, Esma Saada, Barbara Burtness, Pascale André, Carine Paturel, Cécile Bonnafous, Anne-Marie Soulié, Anne Tirouvanziam-Martin, Robert Zerbib, Agnès Boyer-Chammard. Phase II study of monalizumab, a first-in-class NKG2A monoclonal antibody, in combination with cetuximab in previously treated recurrent or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN): Preliminary assessment of safety and efficacy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT158.

Abstract B268: A Phase I Study of CUDC-101, a multitarget inhibitor of HDACs, EGFR, and HER2, in combination with chemoradiation in patients with intermediate/high risk locally advanced squamous cell carcinoma of the head and neck

Purpose: This study sought to establish the maximum tolerated dose (MTD) of CUDC-101 in combination with cisplatin and radiation in patients (pts) with locally advanced untreated squamous cell carcinoma of the head and neck.

Patients and Methods: Pts were enrolled onto two cohorts of IV CUDC-101: 225 mg/m2 and 275 mg/m2. Pts received CUDC-101 alone 3 times a week for 1 week followed by 7 weeks of the same dose plus radiotherapy 70 Gy and cisplatin 100 mg/m2 on days 2, 23 and 44 of radiotherapy. Endpoints included safety/tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of CUDC-101, and clinical activity.

Results: Thirteen pts were enrolled and 12 received treatment: 4 in the 225 mg/m2 and 8 in the 275 mg/m2 cohorts; 2 pts received CUDC-101 monotherapy only.Ten pts were male and 3 were female. Mean age was 63 years. Nine pts had newly diagnosed Stage IV (A or B) disease, 3 had Stage III. Eleven pts had p16 negative disease except 1 pt who was p16 positive but with a past smoking history of &gt;10 packs/year. Four pts had oropharynx as the primary tumor site, 2 larynx, 2 hypopharynx, 2 oral cavity, 1 tongue and 1 tonsil. Dose-limiting toxicities (DLT) included acute renal failure (ARF) in one pt treated at 275 mg/m2 leading to study discontinuation. Grade 3 CUDC-101 related adverse events were decreased appetite, leukopenia, hypertension, ARF (1 pt each). CUDC-101 PK were consistent with prior CUDC-101 single-agent PK.

Tumor, skin and PBMC samples collected for PD analysis showed consistent HDAC inhibition; pEGFR staining was abrogated after therapy in the 2 pts from whom PD data are available. Data at the 12-week post-treatment disease assessment are available in 6 pts: 2 had complete response, 2 had partial response and 2 stable disease. Two pts had a post-treatment biopsy with negative pathology results.

Conclusion: The results of this study showed that CUDC-101 can be combined with chemoradiation at a dose of 275 mg/m2 with ARF being the most prominent DLT. PD results showed effective HDAC target modulation. Preliminary long-term efficacy results are encouraging.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B268.

Citation Format: Antonio Jimeno, Thomas Galloway, Lori Wirth, Jill Gilbert, Nabil Saba, Julie Bauman, Dimitrios Colevas, Ranee Mehra, David Raben, Cheng-Jung Lai, Robert Laliberte, Maurizio Voi, Barbara Burtness. A Phase I Study of CUDC-101, a multitarget inhibitor of HDACs, EGFR, and HER2, in combination with chemoradiation in patients with intermediate/high risk locally advanced squamous cell carcinoma of the head and neck. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B268.

Quantitation of human papillomavirus DNA in plasma of oropharyngeal carcinoma patients

PURPOSE

To determine whether human papillomavirus (HPV) DNA can be detected in the plasma of patients with HPV-positive oropharyngeal carcinoma (OPC) and to monitor its temporal change during radiotherapy.

METHODS AND MATERIALS

We used polymerase chain reaction to detect HPV DNA in the culture media of HPV-positive SCC90 and VU147T cells and the plasma of SCC90 and HeLa tumor-bearing mice, non-tumor-bearing controls, and those with HPV-negative tumors. We used real-time quantitative polymerase chain reaction to quantify the plasma HPV DNA in 40 HPV-positive OPC, 24 HPV-negative head-and-neck cancer patients and 10 non-cancer volunteers. The tumor HPV status was confirmed by p16(INK4a) staining and HPV16/18 polymerase chain reaction or HPV in situ hybridization. A total of 14 patients had serial plasma samples for HPV DNA quantification during radiotherapy.

RESULTS

HPV DNA was detectable in the plasma samples of SCC90- and HeLa-bearing mice but not in the controls. It was detected in 65% of the pretreatment plasma samples from HPV-positive OPC patients using E6/7 quantitative polymerase chain reaction. None of the HPV-negative head-and-neck cancer patients or non-cancer controls had detectable HPV DNA. The pretreatment plasma HPV DNA copy number correlated significantly with the nodal metabolic tumor volume (assessed using (18)F-deoxyglucose positron emission tomography). The serial measurements in 14 patients showed a rapid decline in HPV DNA that had become undetectable at radiotherapy completion. In 3 patients, the HPV DNA level had increased to a discernable level at metastasis.

CONCLUSIONS

Xenograft studies indicated that plasma HPV DNA is released from HPV-positive tumors. Circulating HPV DNA was detectable in most HPV-positive OPC patients. Thus, plasma HPV DNA might be a valuable tool for identifying relapse.

Assessment of the biological and pharmacological effects of the ανβ3 and ανβ5 integrin receptor antagonist, cilengitide (EMD 121974), in patients with advanced solid tumors

BACKGROUND

Cilengitide, an antiangiogenic agent that inhibits the binding of integrins alpha(nu)beta(3) and alpha(nu)beta(5) to the extracellular matrix, was studied at two dose levels in cancer patients to determine the optimal biological dose.

PATIENTS AND METHODS

The doses of cilengitide were 600 or 1200 mg/m(2) as a 1-h infusion twice weekly every 28 days. A novel dose escalation scheme was utilized that relied upon the biological activity rate.

RESULTS

Twenty patients received 50 courses of cilengitide with no dose-limiting toxic effects. The pharmacokinetic (PK) profile revealed a short elimination half-life of 4 h, supporting twice weekly dosing. Of the six soluble angiogenic molecules assessed, only E-selectin increased significantly from baseline. Analysis of tumor microvessel density and gene expression was not informative due to intrapatient tumor heterogeneity. Although several patients with evaluable tumor biopsy pairs did reveal posttreatment increases in tumor and endothelial cell apoptosis, these results did not reach statistical significance due to the aforementioned heterogeneity.

CONCLUSIONS

Cilengitide is a well-tolerated antiangiogenic agent. The biomarkers chosen in this study underscore the difficulty in assessing the biological activity of antiangiogenic agents in the absence of validated biological assays.

University of Chicago Consortium phase II study of ispinesib (SB-715992) in patients (pts) with advanced renal cell carcinoma (RCC)

15573

Background: Ispinesib is a novel kinesin spindle protein inhibitor that has significant antitumor activity in multiple tumor models and has demonstrated preliminary clinical activity in early phase I and II trials. A phase II study of Ispenisib in patients with metastatic RCC who had received at least one prior therapy was thus conducted. Methods: The primary objective was to assess the RECIST based overall response rate (RR) with optimal Simon two-stage design utilizing 10% and 30% RR as the null and alternative hypotheses, respectively. Eighteen pts were to be accrued during the first stage; if 3 or more responses (PR or CR) were seen, an additional 17 pts would be accrued. Further study would be recommended if 7 or more of the 35 total pts had a response. Secondary objectives included toxicity, time to progression, and overall survival. Pts were treated with 7 mg/m2 over one hour on days 1, 8, and 15 every 28 days with radiologic disease re- evaluation every 8 weeks. Results: 19 pts were accrued in 6 months. Baseline characteristics included clear cell histology in 74%, papillary in 11%, and unclassified in 11%; 1 or =2 prior therapies in 37% and 63%; prior immunotherapy in 53%, and prior sunitinib, sorafenib or bevacizumab in 79%; ECOG performance status 0 in 58% and 1 in 42%. 4 patients are too early for radiologic assessment. None of the 15 patients evaluable responded to treatment (95% CI: 0 - 21.8%). Seven patients (47%) experienced stable disease after 8 weeks. One patient experienced grade 3 neutropenia. No other grade 3 or 4 toxicities were attributable to drug. Grade 1 and 2 toxicities included: fatigue (28%), anemia (28%), leukopenia (33%), elevated alkaline phosphatase (18%), anorexia (11%), hyponatremia (11%), dyspnea (11%), headache (11%), and hypoalbuminemia (11%). Conclusions: Treatment with weekly Ispenesib in metastatic RCC is well tolerated but does not lead to objective responses. Under the hypothesis that Ispenesib is a cytotoxic rather than cytostatic agent, further evaluation in patients with metastatic RCC at this dose and schedule is not indicated. Supported by: NCI #N01-CM-62201

No significant financial relationships to disclose.

Peripheral blood mononuclear and tumor cell pharmacodynamics of the novel epothilone B analogue, ixabepilone

BACKGROUND

We previously demonstrated that peak microtubule bundle formation (MBF) in peripheral blood mononuclear cells (PBMCs) occurs at the end of drug infusion and correlates with drug pharmacokinetics (PK). In the current study, a new expanded evaluation of drug target effect was undertaken.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with ixabepilone 40 mg/m2 administered as a 1-h i.v. infusion every 3 weeks. Blood, plasma, and tumor tissue sampling was carried out to characterize pharmacodynamics and PK.

RESULTS

Forty-seven patients were treated with 141 cycles of ixabepilone. In both PBMCs (n=27) and tumor cells (n=9), peak MBF occurred at the end of infusion; however, at 24-72 h after drug infusion, the number of cells with MBF was significantly greater in tumor cells, relative to PBMCs. A Hill model (EC50=109.65 ng/ml; r2=0.94) was fitted, which demonstrated a relationship between percentage of PBMCs with MBF and plasma ixabepilone concentration. The percentage of PBMCs with MBF at the end of infusion also correlated with severity of neutropenia (P=0.050).

CONCLUSIONS

Plasma ixabepilone concentration and severity of neutropenia correlate with the level of MBF in PBMCs. Therefore, this technically straightforward assay should be considered as a complement to the clinical development of novel microtubule-binding agents.

Phase I Clinical Trial of BMS-247550, A Derivative of Epothilone B, Using Accelerated Titration 2B Design

PURPOSE

BMS-247550 is a semisynthetic derivative of epothilone B with mechanism of action analogous to paclitaxel. It has shown impressive antitumor activity in preclinical studies including in taxane-resistant models. We conducted a phase I trial, based on accelerated titration "2B" design, of BMS-247550 given as a 1-hour infusion every 3 weeks.

EXPERIMENTAL DESIGN

Seventeen patients (M:F, 10:7; median age, 54 years; performance status, 0-2) were treated on the trial. Forty-five cycles (1-9 cycles) of BMS-247550 were given at dosages ranging from 7.4 to 56 mg/m2. All patients received prophylaxis for hypersensitivity reactions, related to Cremophor-EL, with steroids and histamine antagonists.

RESULTS

First-course dose-limiting toxicity (DLT) was observed in two of three patients at 56 mg/m2 (neutropenic sepsis, prolonged grade 4 neutropenia) and in one of six patients at 40 mg/m2. Nonhematologic grade 3 to 4 toxicities observed were emesis and fatigue and they occurred only at 56 mg/m2. Grade 1 to 2 peripheral neuropathy was also observed. Other grade 1 to 2 toxicities were myalgias, arthralgias, rash, hand/foot syndrome, and mucositis. AUC and C(max) seemed proportional to the dose and the DLT. Development of neutropenia with BMS-247550 is related to the duration of drug exposure above a threshold.

CONCLUSIONS

The maximum tolerated dose (MTD) of BMS-247550 is 40 mg/m2 given every 3 weeks. Neutropenia is the DLT. The accelerated titration "2B" design may help in determining MTD with fewer patients enrolled and more being treated closer to the MTD. However, the accelerated titration design did not seem to shorten the study duration.

The clinical development of new mitotic inhibitors that stabilize the microtubule

Microtubule-stabilizing agents are increasingly studied for cancer treatment based largely on the prior success of paclitaxel and docetaxel. In this review, we focus on the clinical development of epothilones and discodermolide, and we discuss salient preclinical and clinical highlights of these two novel natural products. These agents are distinguished by their biochemical features making them poor P-glycoprotein substrates and capable of inducing cytotoxicity in cell lines or in vivo tumor models harboring mutations in tubulin. There is now considerable data regarding the efficacy of the epothilones in human beings and discodermolide holds such promise, as well.