Phase I/II trial of PD-1 antibody nivolumab with peptide vaccine in patients naive to or that failed ipilimumab

9011

Background: Nivolumab, an IgG4 fully human monoclonal antibody against checkpoint protein PD-1, is active in metastatic melanoma, renal cell and non-small cell lung cancer. It was administered with a multi-peptide vaccine to patients (pts) with unresectable melanoma who failed at least one regimen for metastatic disease and were ipilimumab naïve, or failed ipilimumab, to assess the toxicity and tolerability of the combination and perform correlative immune assays. Methods: Three cohorts of 10 HLA A0201 positive ipilimumab-naïve pts received nivolumab at 1, 3 or 10 mg/kg, then three additional cohorts of pts who had failed prior ipilimumab received nivolumab at 3 mg/kg: two cohorts of 10 pts each who were A0201 positive and had either grade 2 or less ipilimumab toxicity, or grade 3 dose limiting ipilimumab toxicity; finally 40 pts were treated with antibody who had grade 2 or less ipilimumab toxicity and were not HLA restricted. Pre-treatment archived tumor tissue as well as pre- and post-treatment peripheral blood cells were collected. Results: Median age for all pts was 59;76% were M1c. Response rates by RECIST were 28% in 34 pts naïve to, and 32% for 46 pts who failed prior ipilimumab. Nivolumab did not induce the same irAEs in pts with prior ipilimumab induced toxicity. No cohort had more than one dose limiting toxicity. 2 pts had grade 3 pneumonitis. Three of ten pts who failed nivolumb had stable disease or a partial response to subsequent ipilimumab. Biomarker studies showed that elevated NY-ESO 1 and MART-1 specific CD8 T cells pre-treatment were associated with non-response (p<0.005 and <0.001), and that CTLA-4 positive CD4 T cells and T regulatory cells were elevated after treatment in non-responders (p<0.01). Immunohistochemical analysis of pre-treatment tumors indicated that PD-L1 staining was associated with response, but responses were also observed in pts whose tumors did not stain. Conclusions: Objective responses to nivolumab were observed after failing ipilimumab, and to ipilimumab after failing nivolumab. Elevation of CTLA-4 after nivolumab in non-responders suggest that sequential therapy with the combination should be tested. Tumor PD-L1 was associated with but not predictive of response. Clinical trial information: NCT01176461.

Safety and efficacy of adjuvant anti-PD1 therapy (nivolumab) in combination with vaccine in resected high-risk metastatic melanoma

9056^

Background: Nivolumab (BMS-936558), a fully human monoclonal antibody targeting the programmed death-1 (PD-1) receptor, has demonstrated clinical activity in advanced metastatic melanoma patients (pts). In this phase I study, the safety and activity of nivolumab plus a multipeptide vaccine was investigated as adjuvant therapy in resected stage IIIC and IV melanoma pts. Methods: HLA-A*0201 positive pts with HMB-45, NY-ESO-1, and/or MART-1 positive tumors received nivolumab (1mg/kg, 3mg/kg, or 10mg/kg IV) with a multipeptide vaccine (gp100, MART-1, NY-ESO-1, Montanide ISA 51 VG) every 2 weeks for 12 doses followed by nivolumab maintenance every 3 months (8 doses) or until disease recurrence. The primary objective was safety and determination of maximum tolerated dose (MTD). Secondary objectives were immunologic response and relapse free survival. Results: 33 pts were enrolled: 12 pts at 1mg/kg, 10 pts at 3mg/kg, and 11 pts at 10mg/kg nivolumab. Median age was 47 yrs; 55% male and 52% M1c disease (2 IIIc, 7 M1a, 7 M1b, and 17 M1c pts). As of January 16, 2012, median follow up time was 14 months and median number of doses was 12 (20 pts still receiving therapy). A MTD was not reached. Grade 2-3 related adverse events (AEs) occurred in 27 pts with the most common AEs being fatigue, rash/pruritis, and endocrinopathies. 4 pts experienced grade 3 AEs: (colitis/diarrhea (3), rash (1)). No drug related grade 4 or higher AEs occurred. 7/33 pts have relapsed to date. One pt with biopsy-proven relapse on trial had spontaneous disease regression. Non-relapsing pts had higher pre-treatment PD-1 expression on Treg and TCD4+ cells (p=0.053) and a greater increase in Treg cells after 12 weeks on treatment (p=0.027). Among all pts, treatment led to a rise in Treg cells (p=0.015) and decreased PD-1 expression on TCD4+ and TCD8+cells (p=0.014 and p<0.001, respectively). Conclusions: Nivolumab is well tolerated in combination with vaccine and preliminary data demonstrates immunologic and clinical activity as adjuvant therapy, justifying a randomized phase III study in resected high risk melanoma pts. Clinical trial information: NCT01176474.

Effect of prophylactic fluconazole on oral mucositis and candidiasis during radiation therapy for head-and-neck cancer

PURPOSE

Radiation therapy (RT) or chemoradiation therapy (CRT) for carcinoma of the head and neck can result in high rates of candidiasis and mucositis. Prophylactic fluconazole (FCZ) has been shown to reduce the incidence of candidiasis. We report our outcomes of patients with head-and-neck cancer undergoing CRT treated prophylactically with FCZ.

METHODS AND MATERIALS

An institutional review board-approved database of head-and-neck cancer patients treated with RT or CRT was reviewed to identify patients treated between 2004 and 2009 who received at least 50 Gy to approximately two-thirds of the oral cavity or oropharynx mucosa. Eligible patients were divided into 2 groups: the usual care group and the prophylaxis group. The primary endpoints were the incidence of mucositis and candidiasis.

RESULTS

A total of 181 patients were eligible for analysis: 72 patients in the prophylactic group and 109 patients in the usual care group. Patient characteristics and radiation dose were comparable between groups. RT alone was given in 28 patients (16%). Mucositis data were available in 161 (89%) patients. Grade 2 or higher mucositis was seen in 131 (81%) patients. Prophylactic FCZ had significantly decreased grade 2 or higher mucositis. In the usual care group and prophylaxis group patients, 83 of 93 patients (89.3%) and 48 of 68 patients (70.6%), respectively, developed grade 2 or higher mucositis (P = .003).

CONCLUSIONS

Prophylactic administration of FCZ twice weekly during CRT for head-and-neck cancer reduces incidence of mucositis and thrush.

Long-term cure after complete resection and adjuvant immunotherapy for distant melanoma metastases

8534

Background: In phase II trials, postoperative therapy with Canvaxin allogeneic melanoma cell vaccine plus Bacillus Calmette-Guerin (BCG) improved the survival of patients with stage IV melanoma. A multicenter, phase III placebo-controlled study was undertaken to investigate the vaccine’s efficacy. Methods: After complete resection of melanoma involving up to 5 distant sites, patients were randomized to treatment with BCG plus Canvaxin (BCG-Canvaxin) or BCG plus placebo (BCG-placebo). The primary endpoint was overall survival (OS); secondary endpoints were disease-free survival (DFS) and skin test responsiveness to the study agent. Results: Between May 1998 and April 2005, 496 patients were randomized. In April 2005, entry to the study was terminated due to low probability of demonstrating treatment differences. However, 256 patients from sites enrolled in a follow-up study were monitored until March 2010. Median OS and 5-year and 10-year rates of OS were 39.1 months, 43.3% and 33.3%, respectively, in the BCG-placebo group, versus 34.9 months, 42.5% and 36.4%, respectively, in the BCG-Canvaxin group (hazard ratio, 1.053; 95% confidence interval, 0.81 to 1.36; p=0.6964). Median DFS, 5-year DFS, and 10-year DFS were 7.6 months, 23.8% and 21.7%, respectively, for the BCG-placebo group, versus 8.5 months, 30.0%, and 30.0%, respectively, for the BCG-Canvaxin group (hazard ratio, 0.882; 95% confidence interval, 0.708 to 1.097; p=0.2595). Positive skin test results correlated with improved survival. Conclusions: BCG-Canvaxin was not superior to BCG-placebo, but the highly favorable long-term survival for combined groups indicates that complete metastasectomy should be considered as initial therapy for patients with resectable stage IV melanoma (ClinicalTrials.gov identifier: NCT00052156).

Should age affect our treatment decisions for head and neck cancer?

5564

Background: Current opinion suggests elderly patients (pts) with head and neck cancer, those 65 or older, do not tolerate surgery, chemotherapy, or radiation as well as their younger counterparts. If this holds true, elderly pts may not be offered standard treatments to prevent assumed complications. Methods: A retrospective cohort study at our comprehensive cancer center was conducted of newly diagnosed pts with head and neck squamous cell carcinoma to explore differences in treatment-related complications between older and younger groups. We included data from the first 199 eligible pts (99 younger than 65 year old and 100 older than 65) evaluated between April 2009 and June 2010. Results: 79% of pts receiving treatment were male with a mean age of 54.9 and 71.6 years for the younger and older groups respectively. The older group had significantly more comorbidities (p < 0.001). The majority of older pts presented with oral cavity tumors (46%) while the oropharynx was the predominant site in the younger group (45%). 55% of younger and 49% of older pts presented with stage 4 disease across all sites. A total of 51 pts were p16 positive with no statistical differences between the groups. Surgery was the initial treatment for 57% of older pts (p < 0.008) while 46% of younger pts received concurrent chemotherapy and radiation as the primary treatment (p < 0.008). There was no statistically significant difference in surgical or radiation complications between the groups. Although most pts receiving chemotherapy experienced complications, older pts had slightly more (93% vs. 78%; p<0.031). The mean survival was 24.8 months with no statistical difference between groups. Significantly more pts in the older group, at last follow-up, were disease free (p < 0.012). Conclusions: The treatment of elderly pts with head and neck squamous cell carcinoma in our experience was congruent with that of younger pts. Elderly pts did not suffer more complications with surgery or radiation, however chemotherapy produced somewhat more complications in the elderly pts. Elderly pts did display less evidence of disease on follow-up. Age is always a consideration when treating individuals, but should not preclude the curative standard.