Phase I - II trial of the combination of cyclophosphamide, RT, and Avelumab in relapsed/metastatic HNSCC (R/M-HNC). Patients pretreated with at least one line therapy containing platinum, fluorouracil, and Cetuximab. Treatment consists of metronomic cyclophosphamide 50 mg daily without drug free break, avelumab 10 mg/kg d1 and 15 q 29, and radiotherapy in one or three daily fractions up to 8 Gy maximum dose, starting at day 8. The aim of the study is to reverse tumor immune-escape by: 1. Provide a self-vaccination with radiotherapy 2. Inhibit the immunosuppressive CD4+ CD25+ FoxP3+ Treg cells with metronomic cyclophosphamide 3. Reactivate the effector T cell by the inhibition of PD-1 - PD-L1 axis with avelumab. Due to the supposed biological effects of the present trial, an ancillary translational study is needed and will be extended to all the patients' population enrolled.
Rational of the trial A phase I - II trial in RM-HNC based on pharmacologic and physic interventions related to each other facing immunology as a system rather than a single pathway, theoretically able to restore immune competence toward the tumor. The immune suppressive mechanisms that could be affected by this study and how the experimental approach could inhibit them, are listed below: * PD-1 - PD-L1 axis is widespread among immune cell family including CTL, Treg, NK, NKT, APC and others showing, for example, opposite effect in CD8+ CTL (inhibitory signal) or in CD4+ CD25+ Foxp3+ (activating signal). * Depletion of Treg results in tumor regression, in experimental models. The effect seems to be dependent on the extent of Treg suppression. * Avelumab is a fully human anti-PD-L1 IgG1 monoclonal antibody. It enables the activation of T-cells and the adaptive immune system by inhibiting PD-1 - PD-L1 axis, induces antibody-dependent cell-mediated cytotoxicity (ADCC) and engages the innate immune system. * Low dose cyclophosphamide (metronomic cyclophosphamide), selectively reduce Treg population both in experimental models and in humans, but it does not affect effector T cells * PD-1 - PD-L1 axis enhances and sustains Foxp3 expression and the suppressive function of inducible Tregs (iTrge)7. The blockade of the PD1 - PDL1 axis by Avelumab may have an opposite effect. * The contemporary use of two, independent, mechanisms of Treg control (Avelumab inhibiting Treg clonal expansion and functions, and cyclophosphamide reducing Treg population) may result in a profound inhibition of Treg population. * If the suppressive mechanisms of the immune system are weakened, the release of high quantity of tumor specific antigens or stress related antigens (epcam, HSPs, HMBG-1, Calreticulin, ATP), obtained by the induction of immunogenic cell death may induce a sort of "self vaccination" resulting into an effective immune response. * Radiation may induce immunogenic cell death even in heavily pretreated patients in whom the use of cytotoxic chemotherapy may not, due to the previous exposure to drugs and the development of resistance mechanisms. More precisely, this effect is considered the basis of the Abscopal effect, i.e. the regression of tumor deposits outside the irradiated field. This effect is more frequently observed with low-dose, non ablative, hypofractionated radiation therapy (described at point 2.3.2) and represent a proof of concept that in particular situations, radiotherapy act as an inducer of "self vaccination". * IgG1 mAbs, such as Avelumab, triggers ADCC; PD-L1 is widely express in many tumors and so ADCC may represent an additional mechanism of tumor control.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
71
AO Santa Croce e Carle di Cuneo
Cuneo, Italia/cuneo, Italy
NOT_YET_RECRUITINGAzienda Ospedaliera S. Croce E Carle Di Cuneo - Cuneo (Cn) Oncologia Medica
Cuneo, Italy
RECRUITINGAdverse Events (AEs)
Assessment of the safety profile of the association of avelumab and metronomic cyclophosphamide will be graded using the common toxicity criteria and adverse events (NCI CTC-AE v 4.0).Grade refers to the severity of the AE. Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated. Grade 2 Moderate; minimal, local or noninvasive intervention indicated; Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; Grade 4 Life-threatening consequences; urgent intervention indicated. Grade 5 Death related to AE. Each adverse event will be reported as the maximum level observed in each patient.
Time frame: 4 months
Objective response rate
Objective response is defined as complete response or partial response as defined as per RECIST evaluation criteria v1.1 (RECIST 1.1).
Time frame: 2-4 months
Toxicity of the combination
Assessment of the safety profile of the association of avelumab and metronomic cyclophosphamide will be graded using the common toxicity criteria and adverse events (NCI CTC-AE v 4.0).Grade refers to the severity of the AE. Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated. Grade 2 Moderate; minimal, local or noninvasive intervention indicated; Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; Grade 4 Life-threatening consequences; urgent intervention indicated. Grade 5 Death related to AE. Each adverse event will be reported as the maximum level observed in each patient.
Time frame: 1 month
Progression Free Survival (PFS)
Progression free survival is defined as the time from study treatment initiation to the first occurrence of disease progression or death of any cause, whichever occurs first.
Time frame: 54 months
Quality of Life (QoL)
Quality of Life will be assessed using the EORTC QLQ -30. Grade 1 to 4. Grade 1: not at all, Grade 4: Very much
Time frame: 2 months
H&N specific Quality of Life (QoL)
Quality of Life will be assessed using the EORTC QLQ - H\&N35. Grade 1 to 4. Grade 1: not at all, Grade 4: Very much
Time frame: 2 months
Overall Survival (OS)
Overall survival is defined as the time from treatment initiation to death for any cause.
Time frame: 54 months
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