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    Clinical Trial Results:
    METIMMOX: COLORECTAL CANCER METASTASIS – SHAPING ANTI-TUMOR IMMUNITY BY OXALIPLATIN

    Summary
    EudraCT number
    		 2017-001845-29
    Trial protocol
    		 NO  
    Global end of trial date
    15 Mar 2024

    Results information
    Results version number
    		 v1(current)
    This version publication date
    09 Feb 2025
    First version publication date
    09 Feb 2025
    Other versions
    Summary report(s)
    		 First-line oxaliplatin-based chemotherapy and nivolumab for metastatic microsatellite-stable colorectal cancer-the randomised METIMMOX trial

    Trial information

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    Trial identification
    Sponsor protocol code
    CA209-9M8
    Additional study identifiers
    ISRCTN number
    		 -
    US NCT number
    		 NCT03388190
    WHO universal trial number (UTN)
    		 -
    Sponsors
    Sponsor organisation name
    Akershus University Hospital
    Sponsor organisation address
    Sykehusveien 25, Lørenskog, Norway, 1478
    Public contact
    Karin Vassbakk, Akershus University Hospital, karin.anne.vassbakk@ahus.no
    Scientific contact
    Karin Vassbakk, Akershus University Hospital, karin.anne.vassbakk@ahus.no
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    15 Mar 2024
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    15 Mar 2024
    Global end of trial reached?
    Yes
    Global end of trial date
    15 Mar 2024
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    Primary objective: To determine progression-free survival, in terms of failure of treatment strategy, of sequential treatment with the Nordic FLOX regimen and nivolumab compared with the standard-of-care Nordic FLOX regimen in previously untreated microsatellite-stable metastatic colorectal cancer.
    Protection of trial subjects
    Subjects will be evaluated for safety and tolerability if they have received any study drug. Toxicity assessments will be continuous during the treatment phase and formally recorded at each new therapy cycle, and every 8 weeks during planned breaks from active study therapy, and should be done in person. Once subjects reach the survival follow-up phase, either in-person or documented telephone calls to assess the subject’s status are acceptable. AE and laboratory values will be graded according to CTCAE v4.0. The start and stop time of the study therapy infusions will be documented. Additional measures, including non-study required laboratory tests, will be performed as clinically indicated or to comply with local regulations. Laboratory toxicities (e.g., suspected drug-induced liver enzyme evaluations) will be monitored during the follow-up phase via local laboratories until all study drug-related toxicities resolve, return to baseline, or are deemed irreversible. Some of the assessments referred to in this section may not be captured as data in the CRF. They are intended to be used as safety monitoring by the treating physician. Additional testing or assessments may be performed as clinically necessary or where required by institutional or local regulations.
    Background therapy
    		 Administration of the FLOX regimen will be according to the schedule that was used in the NORDIC-VII Study [Tveit et al., 2012], which in recent years has also been implemented in clinical practice.
    Evidence for comparator
    		 The concept referred to as immunogenic cell death (ICD) essentially implies cytotoxic damage of tumor cells by either radiation or systemic therapies and the resulting priming of tumor-targeting T lymphocytes via capture and presentation of shed tumor antigens by dendritic cells [Galluzzi et al., 2015]. Preclinical studies have highlighted oxaliplatin as an ICD-inducing agent [Tesniere et al., 2010; Zitvogel et al., 2010]. In mouse models, oxaliplatin has been shown to sensitize CRC and other adenocarcinomas to ICB therapy via enhanced tumor infiltration of cytotoxic T lymphocytes [Gou et al., 2014; Pfirschke et al., 2016]. Increasing clinical evidence also supports the notion that oxaliplatin is able to induce ICD [Pol et al., 2015] and thereby invoke efficacious anti-tumor immunity.
    Actual start date of recruitment
    01 Mar 2018
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    Yes
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Norway: 76
    Worldwide total number of subjects
    76
    EEA total number of subjects
    76
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    38
    From 65 to 84 years
    38
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    		 The 80 patients were enrolled between 29 May 2018 and 22 October 2021 from Akershus University Hospital, Oslo University Hospital and Sørlandet Hospital in the South-Eastern Region of Norway, as well as Haukeland University Hospital in the Western Region of Norway and St. Olavs Hospital in the Central Region of Norway.

    Pre-assignment
    Screening details
    		 Essential study inclusion criteria were age ≥18 years, measurable infradiaphragmatic (liver, peritoneal and/or nodal) metastatic manifestation(s) according to RECIST 1.1, and ECOG performance status 0-1. In addition, CRP <60 mg/L was required at study entry.

    Period 1
    Period 1 title
    Overall trial (overall period)
    Is this the baseline period?
    		 Yes
    Allocation method
    Randomised - controlled
    Blinding used
    		 Not blinded
    Blinding implementation details
    Tumour assessments were based on blinded independent central review according to RECIST 1.1 as the primary method and the consensus guidelines for assessment of response to immune-modulating therapies (iRECIST) as the subsidiary method, by means of CT scans repeated every 8 weeks throughout the study participation.

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    		 Control arm
    Arm description
    		 The control arm patients were assigned to eight cycles of the FLOX regimen Q2W (oxaliplatin 85 mg/m2 day 1 and bolus 5-fluorouracil 500 mg/m2 and folinic acid 100 mg days 1–2)
    Arm type
    		 Active comparator

    Investigational medicinal product name
    Oxaliplatin
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Injection/infusion
    Routes of administration
    Infusion
    Dosage and administration details
    85 mg/m2 (over 30–60 minutes) on day 1; bolus (over <5 minutes)

    Investigational medicinal product name
    5-Fluorouracil
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Injection/infusion
    Routes of administration
    Infusion
    Dosage and administration details
    500 mg/m2 and 30 minutes later bolus (over <10 minutes)

    Arm title
    		 Experimental arm
    Arm description
    		 Experimental arm patients were scheduled for two cycles of FLOX Q2W before two cycles of nivolumab (240 mg flat dose) Q2W in an alternating schedule to a total of eight cycles.
    Arm type
    		 Experimental

    Investigational medicinal product name
    Oxaliplatin
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Injection/infusion
    Routes of administration
    Infusion
    Dosage and administration details
    85 mg/m2 (over 30–60 minutes) on day 1; bolus (over <5 minutes)

    Investigational medicinal product name
    Nivolumab
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Injection/infusion
    Routes of administration
    Infusion
    Dosage and administration details
    240 mg flat dose Q2W

    Investigational medicinal product name
    5-Fluorouracil
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Injection/infusion
    Routes of administration
    Infusion
    Dosage and administration details
    500 mg/m2 and 30 minutes later bolus (over <10 minutes)

    Number of subjects in period 1
    		Control arm Experimental arm
    Started
    38
    38
    Completed
    31
    36
    Not completed
    7
    2
         Consent withdrawn by subject
    1
    -
         Adverse event, non-fatal
    4
    2
         Protocol deviation
    2
    -

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Control arm
    Reporting group description
    		 The control arm patients were assigned to eight cycles of the FLOX regimen Q2W (oxaliplatin 85 mg/m2 day 1 and bolus 5-fluorouracil 500 mg/m2 and folinic acid 100 mg days 1–2)

    Reporting group title
    Experimental arm
    Reporting group description
    		 Experimental arm patients were scheduled for two cycles of FLOX Q2W before two cycles of nivolumab (240 mg flat dose) Q2W in an alternating schedule to a total of eight cycles.

    Reporting group values
    		 Control arm Experimental arm Total
    Number of subjects
    		 38 38 76
    Age categorical
    Units: Subjects
        In utero
    		 0
        Preterm newborn infants (gestational age < 37 wks)
    		 0
        Newborns (0-27 days)
    		 0
        Infants and toddlers (28 days-23 months)
    		 0
        Children (2-11 years)
    		 0
        Adolescents (12-17 years)
    		 0
        Adults (18-64 years)
    		 0
        From 65-84 years
    		 0
        85 years and over
    		 0
    Age continuous
    Units: years
        median (full range (min-max))
    		 65.0 (38 to 79) 60.5 (43 to 80) -
    Gender categorical
    Units: Subjects
        Female
    		 15 20 35
        Male
    		 23 18 41
    Eastern Cooperative Oncology Performance status
    Units: Subjects
        Status 0
    		 21 23 44
        Status 1
    		 17 15 32
    Primary tumor sidedness
    Units: Subjects
        Right
    		 11 11 22
        Left or rectum
    		 27 27 54
    RAS/BRAF status
    Units: Subjects
        Wildtype
    		 9 12 21
        Mutant
    		 29 26 55
    Number of metastatic sites
    Units: Subjects
        1-2
    		 22 24 46
        >2
    		 16 14 30
    Involved liver
    Units: Subjects
        No
    		 6 7 13
        Yes
    		 32 31 63

    End points

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    End points reporting groups
    Reporting group title
    Control arm
    Reporting group description
    		 The control arm patients were assigned to eight cycles of the FLOX regimen Q2W (oxaliplatin 85 mg/m2 day 1 and bolus 5-fluorouracil 500 mg/m2 and folinic acid 100 mg days 1–2)

    Reporting group title
    Experimental arm
    Reporting group description
    		 Experimental arm patients were scheduled for two cycles of FLOX Q2W before two cycles of nivolumab (240 mg flat dose) Q2W in an alternating schedule to a total of eight cycles.

    Primary: Progression-free survival

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    End point title
    		 Progression-free survival
    End point description
    End point type
    Primary
    End point timeframe
    Within 2 years of active treatment and follow-up.
    End point values
    		 Control arm Experimental arm
    Number of subjects analysed
    38
    38
    Units: 76
    median (confidence interval 95%)
        Median PFS
    9.2 (6.3 to 12.7)
    9.2 (4.5 to 15.0)
    Statistical analysis title
    		 Progression-free survival
    Comparison groups
    Control arm v Experimental arm
    Number of subjects included in analysis
    76
    Analysis specification
    Pre-specified
    Analysis type
    		 superiority
    P-value
    		 = 0.52
    Method
    		 Logrank
    Confidence interval

    Secondary: Safety

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    End point title
    		 Safety
    End point description
    End point type
    Secondary
    End point timeframe
    Within the study period, and up to 12 months after treatment termination.
    End point values
    		 Control arm Experimental arm
    Number of subjects analysed
    38
    38
    Units: 76
        Any grade 3 event
    25
    37
        Any grade 4 event
    10
    11
    Statistical analysis title
    		 Safety
    Comparison groups
    Control arm v Experimental arm
    Number of subjects included in analysis
    76
    Analysis specification
    Pre-specified
    Analysis type
    		 equivalence
    P-value
    		 > 0.05
    Method
    		 Chi-squared
    Confidence interval

    Secondary: Overall survival

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    End point title
    		 Overall survival
    End point description
    End point type
    Secondary
    End point timeframe
    Within the study period and up to two years after treatment termination
    End point values
    		 Control arm Experimental arm
    Number of subjects analysed
    36
    36
    Units: 76
    median (confidence interval 95%)
        Overall survival
    14.6 (10.6 to 23.2)
    20.7 (15.9 to 24.9)
    Statistical analysis title
    		 Overall survival
    Comparison groups
    Control arm v Experimental arm
    Number of subjects included in analysis
    72
    Analysis specification
    Pre-specified
    Analysis type
    		 superiority
    P-value
    		 = 0.68
    Method
    		 Logrank
    Confidence interval

    Secondary: Objective response

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    End point title
    		 Objective response
    End point description
    End point type
    Secondary
    End point timeframe
    Within the study period
    End point values
    		 Control arm Experimental arm
    Number of subjects analysed
    31
    36
    Units: 67
        Objective response
    20
    17
    Statistical analysis title
    		 Objective response
    Comparison groups
    Control arm v Experimental arm
    Number of subjects included in analysis
    67
    Analysis specification
    Pre-specified
    Analysis type
    		 superiority
    P-value
    		 = 0.16
    Method
    		 Chi-squared
    Confidence interval

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    Adverse events were recorded for the time of study participation, and up to one year after treatment termination.
    Adverse event reporting additional description
    2 patients died of adverse events before receiving nivolumab.
    Assessment type
    		 Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    		 MedDRA
    Dictionary version
    20.1
    Reporting groups
    Reporting group title
    Control arm
    Reporting group description
    		 The control arm patients were assigned to eight cycles of the FLOX regimen Q2W (oxaliplatin 85 mg/m2 day 1 and bolus 5-fluorouracil 500 mg/m2 and folinic acid 100 mg days 1–2)

    Reporting group title
    Experimental arm
    Reporting group description
    		 Experimental arm patients were scheduled for two cycles of FLOX Q2W before two cycles of nivolumab (240 mg flat dose) Q2W in an alternating schedule to a total of eight cycles.

    Serious adverse events
    		 Control arm Experimental arm
    Total subjects affected by serious adverse events
         subjects affected / exposed
    35 / 38 (92.11%)
    33 / 38 (86.84%)
         number of deaths (all causes)
    33
    34
         number of deaths resulting from adverse events
    0
    2
    Cardiac disorders
    Hypertension
         subjects affected / exposed
    1 / 38 (2.63%)
    0 / 38 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Atrial fibrillation
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cardiac arrest
         subjects affected / exposed
    0 / 38 (0.00%)
    2 / 38 (5.26%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 1
    Dehydration
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Oedema
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Nervous system disorders
    Fatigue
         subjects affected / exposed
    4 / 38 (10.53%)
    3 / 38 (7.89%)
         occurrences causally related to treatment / all
    0 / 4
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pain
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Paraesthesia
         subjects affected / exposed
    1 / 38 (2.63%)
    0 / 38 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Spinal cord compression
         subjects affected / exposed
    1 / 38 (2.63%)
    0 / 38 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Febrile neutropenia
         subjects affected / exposed
    1 / 38 (2.63%)
    7 / 38 (18.42%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 7
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Neutropenia
         subjects affected / exposed
    22 / 38 (57.89%)
    15 / 38 (39.47%)
         occurrences causally related to treatment / all
    22 / 22
    0 / 15
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Thrombocytopenia
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Embolism venous
         subjects affected / exposed
    4 / 38 (10.53%)
    7 / 38 (18.42%)
         occurrences causally related to treatment / all
    0 / 4
    5 / 7
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    General disorders and administration site conditions
    Infusion related reaction
         subjects affected / exposed
    2 / 38 (5.26%)
    0 / 38 (0.00%)
         occurrences causally related to treatment / all
    2 / 2
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Immune system disorders
    Arthritis
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hyperglycaemia
         subjects affected / exposed
    0 / 38 (0.00%)
    4 / 38 (10.53%)
         occurrences causally related to treatment / all
    0 / 0
    4 / 4
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hypophysitis
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pneumonitis
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Rash
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    1 / 38 (2.63%)
    3 / 38 (7.89%)
         occurrences causally related to treatment / all
    1 / 1
    2 / 3
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Ileus
         subjects affected / exposed
    3 / 38 (7.89%)
    4 / 38 (10.53%)
         occurrences causally related to treatment / all
    3 / 3
    0 / 4
         deaths causally related to treatment / all
    0 / 0
    0 / 1
    Nausea
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Respiratory, thoracic and mediastinal disorders
    Dyspnoea
         subjects affected / exposed
    1 / 38 (2.63%)
    0 / 38 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal and urinary disorders
    Renal failure
         subjects affected / exposed
    1 / 38 (2.63%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 1
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Urinary retention
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infections and infestations
    Infection
         subjects affected / exposed
    5 / 38 (13.16%)
    5 / 38 (13.16%)
         occurrences causally related to treatment / all
    5 / 5
    0 / 5
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Fever
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Metabolism and nutrition disorders
    Hypokalaemia
         subjects affected / exposed
    0 / 38 (0.00%)
    1 / 38 (2.63%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 1%
    Non-serious adverse events
    		 Control arm Experimental arm
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    0 / 38 (0.00%)
    2 / 38 (5.26%)
    Hepatobiliary disorders
    Hepatic enzyme increased
         subjects affected / exposed
    0 / 38 (0.00%)
    2 / 38 (5.26%)
         occurrences all number
    0
    2

    More information

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    Substantial protocol amendments (globally)
    Were there any global substantial amendments to the protocol? No

    Interruptions (globally)
    Were there any global interruptions to the trial? No

    Limitations and caveats
    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported

    Online references
    http://www.ncbi.nlm.nih.gov/pubmed/38664577
    http://www.ncbi.nlm.nih.gov/pubmed/36229579
    http://www.ncbi.nlm.nih.gov/pubmed/38952672
    For support, Contact us.
    The status and protocol content of GB trials is no longer updated since 1 January 2021. For the UK, as of 31 January 2021, EU Law applies only to the territory of Northern Ireland (NI) to the extent foreseen in the Protocol on Ireland/NI. Legal notice
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