This study is for people who have high-risk Ewing sarcoma (ES), or a related Ewing's family tumor, desmoplastic small round cell tumor (DSRCT). The purpose of this study is to see if a new EWSR1 immunotherapy (a lipid nanoparticle coated with EWSR1 mRNA) which is given as a shot is safe and whether it can help the body's immune system better recognize and fight cancer. This EWSR1 immunotherapy is designed to target a specific genetic change (EWSR1 fusion gene) that is found in cancer cells but not in normal, healthy cells. Because the EWSR1 gene is broken in cancer cells and the small protein it makes are only in the ES or DSRCT cancer cells, the goal of EWSR1 immunotherapy is to help the immune system identify and attack the cancer without harming normal cells. It is not yet approved by the Food and Drug Administration (FDA). EWSR1 immunotherapy will be given as a shot into the muscle of the arm, leg, or buttock. If participants also receive pembrolizumab (an infusion every 2 weeks), it is given intravenously (IV) by a needle in the arm over 30 minutes. Participants in this study will receive treatment for about 6 months or until their cancer gets worse. Participants will remain in the study for follow-up for an additional year, for a total time of about 1.5 years in the study.
Ewing sarcoma (ES) is an aggressive type of cancer that has a high risk of spreading to other parts of the body. Even though it often responds well to chemotherapy and radiation at first, it still carries the risk of coming back and/or spreading. Children and young adults whose cancer is limited to one area generally have a better outlook with overall survival at about 75%. However, outcomes are much worse for adults and for people whose cancer has already spread, returned after treatment, or relapsed. In these groups, overall survival is only about 15-25%. People with relapsed or metastatic ES, who make up nearly half of all cases, still need better treatments than the current standard of care. More effective therapies are needed to achieve longer-lasting results. Desmoplastic small round cell tumor (DSRCT) is a rare cancer that belongs to the Ewing family of tumors. It often spreads widely throughout the abdomen. Like Ewing sarcoma, DSRCT often responds to chemotherapy and radiation at first. However, even with standard of care treatment, long-term outcomes remain poor. Overall survival is only about 10-15%, and the cancer frequently returns in additional, outside areas. Because current treatments have had limited success, there is an urgent need to develop new targeted therapies that can more effectively treat these cancers. Both ES and DSRCT are driven by recurrent, highly conserved gene fusion events that create neoantigens. Conventional therapies are often unable to target these gene events, and thus are unable to effectively treat the cause of the cancer. However, because these fusion events create proteins that are required for tumor survival and generate unique tumor-specific neoantigens that are absent from normal tissues, they represent highly attractive targets for immunotherapeutic approaches. Recent advances in immuno-oncology have highlighted the promise of tumor-specific neoantigens, particularly those arising from gene fusions, as targets for precision immunotherapy. Our group has been at the forefront of defining the importance of tumor mutations and neoantigens in cancer therapy. The overall goal of this study in using EWSR1 immunotherapy without or with anti-PD1 is to develop cancer-specific long-lasting immunity against EWSR1 neoantigens. Adding anti-PD1 will be done because of concern that monotherapy may not overcome tumor inhibitory microenvironment (TIME) and T-cell exhaustion. Therefore, it is hypothesized that this combination will be safe because of the known safety profiles of other immunotherapy interventions with anti-PD1.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
24
Participants will receive EWSR1 immunotherapy at 50 micrograms (mcg) (or 25 mcg for children 12 years and younger) through an intramuscular injection on Weeks 0, 4, 12 and 24.
Participants will receive Pembrolizumab (anti-PD1) at 3 milligram per kilogram (mg/kg) intravenously (through an IV) on Week 0 and Week 4.
Case Comprehensive Cancer Center, Cleveland Clinic Foundation Taussig Cancer Institute
Cleveland, Ohio, United States
Safety of EWSR1 immunotherapy, measured by number of participants with grade 4 immunotherapy-related adverse events
Safety will be achieved in the EWSR1 immunotherapy monotherapy cohort if no participant has grade 4 EWSR1 immunotherapy-related toxicity
Time frame: Up to 6 months
Safety of combination therapy (EWSR1 immunotherapy + pembrolizumab), measured by number of participants with grade 3 drug related adverse events lasting greater than 1 week
In the combination therapy cohort (EWSR1 immunotherapy + pembrolizumab) cohort, safety will be achieved if participants without progression at 6 months have no grade 3 drug related AE lasting \> 1 week
Time frame: Up to 6 months
Feasibility of EWSR1 immunotherapy monotherapy, measured by proportion of participants who receive doses
Feasibility will be achieved in the EWSR1 immunotherapy monotherapy cohort if participants receive at least 3 of 4 proposed doses.
Time frame: Up to 6 months
Feasibility of combination therapy (EWSR1 immunotherapy + pembrolizumab), measured by number of participants who receive at least 3 months of therapy
In the combination therapy cohort (EWSR1 immunotherapy + pembrolizumab) cohort, feasibility will be achieved if 12 participants receive at least 3 months of combination therapy.
Time frame: Up to 6 months
Progression free survival (PFS)
PFS will be assessed using iRECIST (Immunologic Response Evaluation Criteria in Solid Tumors) criteria and is defined as the duration of time from start of treatment to time of progression or death, whichever occurs first.
Time frame: Up to 1.5 years
Overall survival (OS)
OS is defined as the time from start of treatment until death from any cause.
Time frame: Up to 1.5 years
Tumor response, as measured by change in tumor volume
Tumor responses will be determined comparing chest CT (Computed Tomography) and PET-CT (Positron Emission Tomography - Computed Tomography) scans. Trends of lesion size will be depicted using waterfall and "spaghetti" plots showing and tumor volume differences over time.
Time frame: Baseline, month 6
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