Background: More than 130 primary tumors of the central nervous system (CNS) have been identified. Most affect less than 1,000 people in the United States each year. Because these tumors are so rare, there are few proven therapies. This study will test whether the immunotherapy drug nivolumab is an effective treatment for people with rare CNS tumors. Objectives: To learn if stimulating the immune system using the drug nivolumab can shrink tumors in people with rare CNS (brain or spine) tumors or increase the time it takes for these tumors to grow or spread. Eligibility: Adults whose rare CNS tumor has returned. Design: Individuals will be screened: * Heart and blood tests * Physical and neurological exam * Hepatitis tests * Pregnancy test * Magnetic resonance imaging (MRI). They will lay in a machine that takes pictures. * Tumor tissue sample. This can be from a previous procedure. At the start of the study, participants will have blood tests. They will answer questions about their symptoms and their quality of life. Individuals will get nivolumab in a vein every 2 weeks for up to 64 weeks. Individuals will have monthly blood tests. Every other month they will have an MRI and a neurologic function test. They will also answer questions about their quality of life. Genetic tests will be done on individuals' tumor tissue. Individuals will be contacted if any clinically important results are found. After treatment ends, individuals will be monitored for up to 5 years. They will have a series of MRIs and neurological function tests. They will be asked to report any symptoms they experience....
Background: * There are more than 130 identified primary tumors of the central nervous system (CNS). Most have an annual incidence of less than 1000 in the United States. * Given the rarity of each of the tumors listed above, there is a paucity of proven therapies. Most of these neoplasms are treated with maximum surgical resection followed by treatment with external beam radiotherapy. With few exceptions (medulloblastoma, adult ependymoma), there are no effective systemic regimens and even in chemotherapy sensitive disease, most patients with recurrence eventually have no remaining salvage treatments available. * In the setting of this unmet need, we propose to create a basket protocol that will evaluate the efficacy of the programmed cell death protein 1 (PD-1) inhibitor, nivolumab, in patients with refractory rare central nervous system neoplasms. * This study seeks to establish effective therapies at recurrence in patients with rare CNS tumors. We hypothesize that this therapy will improve progression free survival and/or objective responses. * It will be important to determine whether any determined survival benefit is associated with improvements in symptoms or does a worsening of symptoms offset the increase in survival. Precedence exists for measuring non-therapeutic endpoints in oncology research, and specifically in studies evaluating therapeutic benefit in patients with CNS tumors. There have been efforts in neuro-oncology to evaluate secondary endpoints using validated instruments as an additional indicator of benefit. The M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) and Spine Tumor Module (MDASI-SP) allow for the self-reporting of symptom severity and interference with daily activities for patients with either brain or spinal cord tumors. The availability of validated instruments provides an opportunity to prospectively assess the impact of treatment, both positive and negative on patients. Objective: Determine the efficacy of nivolumab in a variety of recurrent, refractory primary central nervous system tumors as measured by disease control rate (confirmed complete response (CR)/partial response (PR) or durable stable disease (SD) for at least 6 months). Eligibility: * Documented recurrent or progressive disease that corresponds to one of the tumors eligible for testing. * Age \>= 18 years of age. * Karnofsky Performance \>= 70%. * Tumor tissue available for central review to confirm morphologic diagnosis * Tumor tissue or slides must be available for central molecular and immune profiling. Design: * This is an open label phase II clinical trial. Patients will be treated with the immune checkpoint inhibitor, nivolumab, at a standard dose of 240 mg intravenously every 2 weeks (+/- 3 days) for cycles 1 through 2, then doses of 480 mg every 4 weeks (+/- 3 days) for a total of 14 additional doses (cycles). A maximum of 18 treatments will be given (64 weeks). * A cycle will be defined as 4 weeks and patients will undergo efficacy assessments using MR imaging (and/or other imaging tests if applicable) every 2 cycles. Toxicity assessments will occur before the initiation of each cycle and patient outcomes measures (PROs) will be completed at the time of each imaging study (every 2 cycles) but prior to the patient being informed of the imaging results. * After completion of the planned treatment course or if treatment was stopped because of toxicity, patients will undergo imaging evaluations and PRO measurements every 8 weeks (or 2 months) for one year, then every 3 months for the next year, then every 4 months for the next year and then every 6 months while the patient remains on the protocol. Patients off treatment because of disease progression will not undergo future imaging or PRO assessments on this protocol. * Bayesian Optimal Phase 2 design (BOP2), will be used to conduct this phase II trial in patients with a variety of recurrent, refractory primary central nervous system tumors. * The study will be comprised of 2 disease cohorts: heavily pretreated (defined as having received 3 or more prior therapies) and non-heavily pretreated (defined as having received up to 2 prior therapies). Each cohort will be evaluated independently for efficacy.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
136
Individuals will receive nivolumab at standard dose of 240 mg intravenous (IV) every 2 weeks for cycles 1 through 2, then doses of 480 mg every 4 weeks for a total of 14 additional doses.
Screening/baseline.
Screening/baseline.
Screening/baseline.
Screening/baseline. During active treatment and post therapy follow up.
Screening/baseline. During active treatment and post therapy follow up.
Northwestern University
Chicago, Illinois, United States
National Institutes of Health Clinical Center
Bethesda, Maryland, United States
UT MD Anderson Cancer Center
Houston, Texas, United States
Disease Control Rate (Complete Response (CR) + Partial Response (PR) or Durable Stable Disease (SD) for 6 Months Measured in a Variety of Recurrent Refractory Primary Central Nervous System Tumors Reported With Standard Deviation
Disease control rate (DCR) measured in a variety of recurrent refractory primary central nervous system tumors. DCR is defined as a confirmed CR/PR or durable stable disease (SD) for 6 months assessed by the Immunotherapy Response Assessment Neuro-Oncology (iRANO) criteria. Complete Response is complete disappearance of all enhancing measurable and non-measurable disease sustained for at least 4 weeks. Partial Response is ≥ 50% decrease compared to baseline in the sum of products of perpendicular diameters of all measurable enhancing lesions sustained for at least 4 weeks. Durable stable disease does not qualify for CR, PR or progression (\>25% increase in the sum of the products of perpendicular diameters of enhancing lesions (over best response \[smallest tumor size\] or baseline if no decrease) on stable or increasing doses of corticosteroids. A single value was calculated (e.g. summed or averaged) by
Time frame: From cycle one Day 1 of the treatment through the end of treatment, up to 64 weeks
Disease Control Rate (Complete Response (CR) + Partial Response (PR) or Durable Stable Disease (SD) for 6 Months Measured in a Variety of Recurrent Refractory Primary Central Nervous System Tumors Reported With a 95% Confidence Interval
Disease control rate (DCR) measured in a variety of recurrent refractory primary central nervous system tumors. DCR is defined as a confirmed CR/PR or durable stable disease (SD) for 6 months assessed by the Immunotherapy Response Assessment Neuro-Oncology (iRANO) criteria. Complete Response is complete disappearance of all enhancing measurable and non-measurable disease sustained for at least 4 weeks. Partial Response is ≥ 50% decrease compared to baseline in the sum of products of perpendicular diameters of all measurable enhancing lesions sustained for at least 4 weeks. Durable stable disease does not qualify for CR, PR or progression (i.e., \>25% increase in the sum of the products of perpendicular diameters of enhancing lesions (over best response \[smallest tumor size\] or baseline if no decrease) on stable or increasing doses of corticosteroids. A single value was calculated (e.g. summed or averaged) by
Time frame: From cycle one Day 1 of the treatment through the end of the treatment, up to 64 weeks
Progression Free Survival (PFS)
PFS is defined as the date of on-study to the date of disease progression or death, estimated with the Kaplan-Meier method and reported with a 95% confidence interval. Response was assessed by the Immunotherapy Response Assessment Neuro-Oncology (iRANO) criteria and estimated using the Kaplan-Meier method. Progressive Disease is \>25% increase in sum of the products of perpendicular diameters of enhancing lesions (over best response \[smallest tumor size\] or baseline if no decrease) on stable or increasing doses of corticosteroids.
Time frame: From cycle one Day 1 of the treatment through the end of the treatment, up to 64 weeks
Progression Free Survival at 6 Months With 95% Confidence Interval
PFS-6 is the rate of durable Stable Disease lasting at least 6 months defined from the day of study entry until imaging is confirmed to show disease progression reported with a 95% confidence interval based on the Brookmeyer-Crowley method. Response was assessed by the Immunotherapy Response Assessment Neuro-Oncology (iRANO) criteria and estimated using the Kaplan-Meier method. Progressive Disease is \>25% increase in sum of the products of perpendicular diameters of enhancing lesions (over best response \[smallest tumor size\] or baseline if no decrease) on stable or increasing doses of corticosteroids.
Time frame: 6 months after the initiation of treatment, up to 24 weeks
Overall Survival (OS)
OS is defined as the date of on-study to the date of death from any cause or last follow up, estimated with the Kaplan-Meier method and reported with a 95% confidence interval based on the Brookmeyer-Crowley method.
Time frame: Time from the study entry and after initiation of nivolumab to participants death, up to 5 years
Mean Symptom Burden Severity and Interference Using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP) Module Reported With a 95% Confidence Interval, at Each Time Point
Symptom burden is composed of severity and interference as measured by the MD Anderson Symptom Inventory-Brain tumor (MDASI-BT) or MD Anderson Symptom Inventory-Spine Tumor. The MDASI-BT questionnaire contains 23 symptoms and 6 interference items. The MDASI-SP questionnaire contains 19 symptoms and 6 interference items. Symptom severity is the Mean of the 23 or 19 symptoms and ranges from 0 to 10. Symptom interference is the Mean of the 6 interference items and ranges from 0 to 10. Higher scores indicate worse symptoms or worse interference.
Time frame: Baseline (Up to 14 days prior to treatment), and at time of imaging - cycle 2, 4, 6, 8, 10, and 12 (one cycle = 4 weeks)
Mean Symptom Burden Severity & Interference Using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) & MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP) Module Reported With Standard Deviation(SD) at Each Time Point
Symptom burden is composed of severity and interference as measured by the MD Anderson Symptom Inventory-Brain tumor (MDASI-BT) or MD Anderson Symptom Inventory-Spine Tumor. The MDASI-BT questionnaire contains 23 symptoms and 6 interference items. The MDASI-SP questionnaire contains 19 symptoms and 6 interference items. Symptom severity is the Mean of the 23 or 19 symptoms and ranges from 0 to 10. Symptom interference is the Mean of the 6 interference items and ranges from 0 to 10. Higher scores indicate worse symptoms or worse interference.
Time frame: Baseline (up to 14 days prior to treatment), and at time of imaging - cycle 2, 4, 6, 8, 10, or 12 (one cycle = 4 weeks)
Mean Symptom Burden Severity and Interference Using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP) Between Responders and Non-responders Reported With 95% Confidence Interval
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Symptom burden is composed of severity and interference as measured by the MD Anderson Symptom Inventory-Brain tumor (MDASI-BT) or MD Anderson Symptom Inventory-Spine Tumor. The MDASI-BT questionnaire contains 23 symptoms and 6 interference items. The MDASI-SP questionnaire contains 19 symptoms and 6 interference items. Symptom severity is the Mean of the 23 or 19 symptoms and ranges from 0 to 10. Higher scores indicate. Symptom interference is the Mean of the 6 interference items and ranges from 0 to 10. Higher scores indicate worse symptoms or worse interference. Response status was determined by whether disease progression occurred prior to or at cycle 6 or not. Participants who had disease progression prior to or at cycle 6 were non-responders and participants who did not have disease progression by cycle 6 were responders. Relevant MDASI-BT \& MDASI-SP data are those that correspond to the cycle where response status was determined. It is a unique cycle for each participant.
Time frame: Two possible timepoints dependent on response status. Non-responders: determined by whether disease progression occurred prior to or at cycle 6 or not. Responders: cycle 6. One cycle= 4 weeks/participants who did not have disease progression by cycle 6.
Mean Symptom Burden Severity and Interference Using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP) Between Responders and Non-responders Reported With Standard Deviation
Symptom burden is composed of severity and interference as measured by the MD Anderson Symptom Inventory-Brain tumor (MDASI-BT) or MD Anderson Symptom Inventory-Spine Tumor. The MDASI-BT questionnaire contains 23 symptoms and 6 interference items. The MDASI-SP questionnaire contains 19 symptoms and 6 interference items. Symptom severity is the Mean of the 23 or 19 symptoms and ranges from 0 to 10. Higher scores indicate. Symptom interference is the Mean of the 6 interference items and ranges from 0 to 10. Higher scores indicate worse symptoms or worse interference. Response status was determined by whether disease progression occurred prior to or at cycle 6 or not. Participants who had disease progression prior to or at cycle 6 were non-responders and participants who did not have disease progression by cycle 6 were responders. Relevant MDASI-BT \& MDASI-SP data are those that correspond to the cycle where response status was determined. It is a unique cycle for each participant.
Time frame: Two possible timepoints dependent on response status. Non-responders: determined by whether disease progression occurred prior to or at cycle 6 or not. Responders: cycle 6. One cycle= 4 weeks/participants who did not have disease progression by cycle 6.
Mean Change Scores in Symptom Burden Severity and Interference Using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP) Module Between Baseline and Even-numbered Cycle
Symptom burden is composed of severity and interference as measured by the MD Anderson Symptom Inventory-Brain tumor (MDASI-BT) or MD Anderson Symptom Inventory-Spine Tumor. The MDASI-BT questionnaire contains 23 symptoms and 6 interference items. The MDASI-SP questionnaire contains 19 symptoms and 6 interference items. Symptom severity is the Mean of the 23 or 19 symptoms and ranges from 0 to 10. Symptom interference is the Mean of the 6 interference items and ranges from 0 to 10. Higher scores indicate worse symptoms or worse interference. Mean change score is even-numbered cycle minus baseline. Hence, negative change scores indicate improvement.
Time frame: Between Baseline (up to 14 days prior to treatment) and at time of imaging - cycle 2, 4, 6, 8, 10, and 12 (one cycle = 4 weeks)
Number of Grades 1, 2, 3, 4, and/or 5 Treatment Related Serious and/or Non-serious Adverse Events and Type
Here is the number of Grade 1, 2, 3, 4, and/or 5 serious and/or non-serious adverse events and type assessed by the Common Terminology Criteria for Adverse Events (CTCAE v5.0). A non-serious adverse event is any untoward medical occurrence. A serious adverse event is an adverse event or suspected adverse reaction that results in death, a life-threatening adverse drug experience, hospitalization, disruption of the ability to conduct normal life functions, congenital anomaly/birth defect or important medical events that jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the previous outcomes mentioned. Grade 1 is mild. Grade 2 is moderate. Grade 3 is severe. Grade 4 is life-threatening. Grade 5 is death related to adverse event.
Time frame: Adverse Events were monitored/assessed from the first study intervention, Study Day 1 through 100 days after the study agent was last administered, up to 5 years