PHP and Immunotherapy in Metastasized UM

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  • participants needed
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  • sponsor
    Leiden University Medical Center
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Updated on 19 February 2024
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Summary

Melanoma of the eye (ocular/uveal melanoma) is an uncommon type of cancer that is associated with a high mortality. It usually disseminates rapidly throughout the body, most commonly to the liver and lungs. In this study a combination therapy with immunotherapy (ipilimumab with nivolumab) and chemotherapy (melphalan) will be assessed for the treatment of disseminated uveal melanoma. Melphalan will be administered selectively to the liver via percutaneous hepatic perfusion, limiting the systemic effect of chemotherapy. With this treatment combination we aim to find a treatment for disseminated uveal melanoma, both in the liver as in the other organs.

Description

Uveal melanoma (UM) is an uncommon malignancy (0.6-0.7 cases/100.000/year) that, in the case of metastatic stage, has a poor prognosis for response to treatment and survival. It is remarkable for its purely hematogenous pattern of dissemination, most commonly to the liver (60%) and lungs (25%). Current approaches using percutaneous hepatic perfusion (PHP) with melphalan resulted in response rates of up to 40% in the liver (1, 2) (for results of our own phase II study see paragraph 6.3.2). However, a main part of the patients developed extrahepatic disease in the follow-up, whereas the liver metastases were mainly stable.

Checkpoint inhibitors have been shown to improve overall survival in metastasized cutaneous melanoma in phase III studies (3-6), but seem to have limited activity as monotherapies in metastasized uveal melanoma (7-9). The combination of ipilimumab and nivolumab has achieved 2 out of 6 patients PR in a retrospective analysis (10). Interestingly, both patients had a liver-directed therapy (SIRT and chemoembolization) before the immunotherapy.

Combination of radio-frequency ablation (RFA) and anti-CTLA-4 enhanced antigen-loading of dendritic cells, and induced long-lasting anti-tumor immune responses in a murine melanoma model without induction of any severe side effects (11, 12). A phase Ib/II trial by Blank et al. (13) showed unconfirmed responses in some patients when RFA was combined with ipilimumab in uveal melanoma, but long-term disease stabilization was not achieved. Most of the responses were seen in extrahepatic metastases. Combining percutaneous hepatic perfusion (PHP) with checkpoint inhibitors could together lead to control of hepatic and extrahepatic disease. Therefore, we propose the current trial: Phase1b/2 Study Combining Hepatic Percutaneous Perfusion with Ipilimumab plus Nivolumab in advanced Uveal Melanoma (CHOPIN).

Details
Condition Uveal Melanoma, Metastatic
Age 18-75 years
Treatment Ipilimumab and nivolumab, Melphalan chemosaturation via percutaneous hepatic perfusion
Clinical Study IdentifierNCT04283890
SponsorLeiden University Medical Center
Last Modified on19 February 2024

Eligibility

 Yes No Not Sure

Inclusion Criteria

Age between 18-75 yrs
World Health Organization (WHO) Performance Status 0 or I
50% or less histologically or cytologically confirmed unresectable metastatic uveal melanoma in the parenchyma of the liver
Hepatic metastases, confined to or predominantly in the liver
No prior systemic treatment (including chemotherapy, vaccine therapy, monoclonal Ab treatment, IL-2)
Local pre-treatment of uveal melanoma metastases is allowed (resection and/or thermal ablation), except for chemotherapy containing procedures (e.g. chemoembolization) and radio-embolization, and as long as patients have progressed with measurable disease according to RECIST 1.1
No concurrent immunosuppressive medications (including dexamethasone, prednisolone, azathioprine)
Screening laboratory values must meet the following criteria: WBC 2.0x109/L, Neutrophils 1.0x109/L, Platelets 100 x109/L, Hemoglobin 6.5 mmol/L, Creatinine 2x ULN, AST 2.5 x ULN, ALT 2.5 x ULN, Total bilirubin 1.5 X ULN, INR and PTT in normal range, LDH < 2xULN
Women of child bearing potential (WOCBP) must agree to use a reliable form of contraceptive as described in paragraph 5.4
Men must agree to the use of male contraception as described in paragraph 5.4
Absence of additional severe and/or uncontrolled concurrent disease
No prior, or ongoing other malignancy, except adequately treated basal cell or squamous cell skin cancer, cervical cancer in situ or adequately treated other cancer with eradicative intent for which the patient has been continuously disease-free for > 2 years
No aberrant vascular anatomy of the liver that precludes PHP

Exclusion Criteria

Cerebral or meningeal metastasized uveal melanoma
Subjects with any active autoimmune disease or a documented history of autoimmune disease, or history of syndrome that required systemic steroids or immunosuppressive medications, except for subjects with vitiligo or resolved childhood asthma/atopy
Prior immunotherapy (tumor vaccine, cytokine, or growth factor)
Known history of infection with Human Immunodeficiency Virus
Active infection requiring therapy, positive serology for Hepatitis B surface antigen or Hepatitis C ribonucleic acid (RNA)
History of congestive heart failure, active cardiac conditions, including unstable coronary syndromes (unstable or severe angina, recent myocardial infarction), significant arrhythmias and severe valvular disease must be evaluated for risks of undergoing general anesthesia
History or evidence of clinically significant pulmonary disease e.g. severe COPD that precludes the use of general anesthesia
Underlying medical conditions that, in the Investigator's opinion, will make the administration of study treatment hazardous or obscure the interpretation of toxicity determination or adverse events
Latex allergy, and known hypersensitivity/allergy to ipilimumab, nivolumab, melphalan or heparin
Prior Whipple's Surgery
Concurrent medical condition requiring the use of immunosuppressive medications, or immunosuppressive doses of systemic or absorbable topical corticosteroids
History of or current immunodeficiency disease, splenectomy or splenic irradiation; prior allogeneic stem cell transplantation
Patients who are unable to be temporarily removed from chronic anti-coagulation therapy
Patients with active bacterial infections with systemic manifestations (malaise, fever, leucocytosis) are not eligible until completion of appropriate therapy
Use of other investigational drugs before study drug administration for systemic malignancy
Pregnancy or nursing
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