Gestational trophoblastic neoplasias (GTN) are characterized by the persistence of elevated hCG titers after complete uterine evacuation of a partial hydatidiform mole (PHM) or a complete hydatidiform mole. GTN patients are commonly treated with single agent treatment (methotrexate or actinomycine-D) or polychemotherapy (first line treatment EMA-CO) according to the predicted risk of resistance to single agent treatment by FIGO score. GTN patients with resistance to these treatments are treated with another single agent drug or polychemotherapy regimens. Chemotherapy standard regimens are old and toxic for these young lady patients, with potential long term effects detrimental for further maternity and quality of life. There is a need for modern targeted agents with better benefit/toxicity profiles. There is a strong rational for investigating the anti-PDL1 monoclonal antibody avelumab in chemoresistant GTN patients. Several elements suggest that the normal pregnancy immune tolerance is "hijacked" by GTN cell for proliferating : * Spontaneous regressions of metastasic GTN are regularly observed, thereby the role of immune system for rejecting GTN cells. * Strong and constant overexpression of PDL1 and NK cells has been found in all subtypes and settings of GTN tumors from French reference gestational trophoblastic center. * The case of complete and durable response to pembrolizumab was reported in a patient with multi chemo-resistant GTN.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
24
Avelumab administration at 10 mg/kg as a 1 hour IV infusion once every 14 days during 6 months (maximum).
Institut Bergonie
Bordeaux, France
Centre Francois Baclesse
Caen, France
Institut Paoli-Calmettes
Marseille, France
Aphp Hopital Tenon
Paris, France
Hospices Civils de Lyon - CHLS
Pierre-Bénite, France
Institut Universitaire Du Cancer de Toulouse - Oncopole
Toulouse, France
The rate of patients with successful normalization of hCG assays
Clinical efficacy of avelumab administration will be evaluated by the rate of patients with successful normalization of hCG assays allowing for treatment discontinuation (hCG normalization). Patients will continue on treatment until the hCG assays, measured weekly, reach the institutional normal threshold and then for 3 additional cycles.
Time frame: up to 6 months
Resistance free survival
Number of patients alive free resistance (defined as a rise ≥ 20% rise over between two assays in three consecutive weekly hCG assays or plateau ≤ 10% decrease between two assays in four consecutive weekly hCG)
Time frame: up to 6 months
Progression free survival
Number of patients alive progression free survival (defined as a rise ≥ 20% rise over between two assays in three consecutive weekly hCG assays or plateau ≤ 10% decrease between two assays in four consecutive weekly hCG)
Time frame: up to 6 months
Overall survival
Number of patients alive 1 months after the end of treatment.
Time frame: up to 6 months
Overall response rate according to RECIST
Radiological response to avelumab assessed by the overall response rate according to RECIST version 1.1 criteria and immune-related RECIST criteria assessed by imaging (TAP CT scanner and / or MRI if contraindication) after cycle 4, 8 and 12
Time frame: up to 6 months
NCI CTCAE version 4.0
The safety of avelumab administration will be evaluated throughout the duration of treatment (6 months max) and until the end of patient follow up (1 month after treatment discontinuation) according to NCI CTCAE version 4.0
Time frame: up to 7 months
Kinetics of hCG
Modeled hCGres parameter calculated with weekly values of hCG measured during treatment days after start of Avelumab treatment.
Time frame: up to 7 months
PD-L1 expression in tumor samples
To predict the efficacy of anti-PD-L1 immunotherapy, we will quantify and characterize the intra and peritumoral immune infiltrate of GTN
Time frame: up to 7 months
Phenotype of the intratumoral immune cell infiltrate
Immunohistochemistry with anti PD-L1, anti CD3, anti CD8, anti CD4, anti CD56 (uterine NK cells), anti FoxP3 primary antibodies will be performed on serial cuts of formalin fixed and paraffin embedded specimens from patients treated with avelumab.
Time frame: up to 7 months
Phenotype of the peritumoral immune cell infiltrate
Immunohistochemistry with anti PD-L1, anti CD3, anti CD8, anti CD4, anti CD56 (uterine NK cells), anti FoxP3 primary antibodies will be performed on serial cuts of formalin fixed and paraffin embedded specimens from patients treated with avelumab.
Time frame: up to 7 months
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