This is an open-label, window of opportunity platform study for subjects with muscle-invasive bladder cancer (MIBC) who are deemed ineligible or refuse cisplatin-based neoadjuvant chemotherapy and are scheduled to undergo definitive surgery (radical cystectomy), or are planning to undergo trimodality therapy (maximal transurethral resection of the bladder tumor followed by concurrent chemoradiation). The primary objective of this study is to assess changes to immunogenomic markers after treatment with pembrolizumab alone and in combination with the selective class I histone deacetylase (HDAC) inhibitor (entinostat).
The study will enroll 20 subjects with a confirmed diagnosis of MIBC (cT2-T4aN0M0) who are planned for definitive therapy with either radical cystectomy without cisplatin-based neoadjuvant chemotherapy or trimodality therapy. Prior to study entry, subjects must consent to having tissue collected for research purposes during the scheduled cystectomy or maximal TURBT. After screening and enrollment, baseline blood and archived transurethral resection of the bladder tumor (TURBT) tumor tissue will be collected from each subject for baseline analyses. Subjects will then start on clinical trial treatment followed by either radical cystectomy or maximal TURBT followed by chemoradiation. Blood and tumor will be collected from each subject at the time of cystectomy or maximal TURBT. The investigators do not anticipate delays in surgery due to the planned schedule of the preoperative treatment administration for the purposes of this study and based on previous reported results of the trial which includes pembrolizumab and entinostat treatment in melanoma reported an acceptable safety profile. Phase I data identified grade 1/2 fatigue as the most common entinostat-related toxicity, with neutropenia and anemia only occurring at doses exceeding those proposed for this study. Safety stopping rules for drug-related toxicity will dictate whether the trial should be halted if subjects are experiencing drug-related toxicity that delays or interferes with the standard of care procedures.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
20
200 mg IV on day 1 and day 22
5 mg given orally on day 1, day 8 and day 15
A radical cystectomy is a surgical procedure to remove the entire urinary bladder and maximal transurethral resection of bladder tumor (TURBT) is a surgical procedure used to remove as much of the bladder tumor as possible.
Lineberger Comprehensive Cancer Center
Chapel Hill, North Carolina, United States
Fox Chase Cancer Center
Philadelphia, Pennsylvania, United States
Changes in CD8 T Cell Immune Gene Signature in the Pembrolizumab + Entinostat Group and the Pembrolizumab Group
Gene expression levels with the CD8 T cell gene signature were measured using RNA sequencing. The expression level of each gene in the signature were log2 transformed and the mean of the signature genes was calculated in each sample. Then the mean expression of signature in each sample was compared to the average expression and variability across other sample to center the expression values (mean = 0) and scale them by standard deviation and generate a Z-score. Change in z-score was then calculated between pre- and post-treatments for each individual patient and then changes in z-score were compared between treatment arms. An increase in Z-score with treatment denotes an increase in expression of the immune gene signature (IGS).
Time frame: Pre-treatment and at time of definitive treatment within 10 weeks after starting neoadjuvant treatment
Change From Baseline in Number and Character of Neoantigens
Neoantigens will be predicted based on whole exome sequencing data using mRNAseq-based filtering. The number of predicted neoantigens will be calculated in the pre-treatment biopsy specimen and the post-treatment cystectomy specimen for each patient. The change from baseline in number and character of neoantigens will be described and compared for each treatment group. Similarly, the T cell receptor (TCR) repertoire will be sequenced and clonality in blood and tumor will be compared between pre- and post-treatment samples for each patient, and change in clonality will be compared between treatment groups.
Time frame: Less than 10 weeks
Change From Baseline in Signal Transducer and Activator of Transcription Factors (STAT) and Nuclear Factor Kappa-light-chain-enhancer of Activated B Cells (NF-κB) Gene Signatures and Histone Acetylation (H3K9Ac, H3K27Ac, and Others) Levels
Compare changes in STAT and NF-κB gene signatures and histone acetylation (H3K9Ac, H3K27Ac, and others) levels after combination treatment with pembrolizumab and entinostat as compared to pembrolizumab alone (subset of subjects with frozen pre- and post-treatment tumor tissue available) Gene expression for each gene in representative STAT, NF-κB, and histone acetylation gene signatures (from MSigDB) will be quantified based on mRNA sequencing. Change in Z-score of these gene signatures will be calculated from pre- and post-treatment tissue samples for patients in both cohorts (pembrolizumab alone or pembrolizumab plus entinostat), and then changes in Z-scores will be compared between cohorts.
Time frame: 10 weeks
Frequency and Severity of Attributed Adverse Events as Assessed by CTCAE v5.0
The analysis of toxicity and safety will be based on the frequency and severity of adverse events attributed to the study treatment, occurring from Day 1 of treatment through 30 days after its completion. The worst toxicity grades per subject will be tabulated for adverse events and laboratory measurements using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE v5.0) and reported in frequency tables.
Time frame: 10 weeks
Proportion of Patients Who Have no Cancer in Tissue Samples at Surgery (Pathologic Complete Response, or Only Non-invasive Cancer (Pathologic Partial Response)
The proportion of patients who have a pathologic response to less than stage 2 (\<pT2) will be reported along with a 95% confidence interval. Similarly, the proportion of patients who have a complete response (pT0) will be reported.
Time frame: 10 weeks
Event Free Survival (EFS)
EFS is defined as day 1 of neoadjuvant/protocol treatment to date of first documentation of disease progression (or until recurrence after surgery or radiation) or death due to any cause. Recurrence includes the development of second primary muscle-invasive urothelial malignancies.
Time frame: Up to 3 years
Overall Survival (OS)
OS is defined as day 1 of neoadjuvant/protocol treatment to date of death due to any cause. Patients will be censored at date of last follow-up.
Time frame: Up to 3 years
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