|E.1 Medical condition or disease under investigation
|Medical condition(s) being investigated
|This trial investigates a novel combination treatment regimen using immune checkpoint inhibition and epigenetic therapy in children with relapsed/refractory/progressive high-risk solid tumors or CNS tumors. Thus, this trial focuses on the pediatric population in 4 biomarker-defined cohorts, for which there is no standard of care treatment available.
|Medical condition in easily understood language
|Children and adolescents with refractory/relapsed/progressive high-risk solid tumors or CNS tumors with no standard of care treatment available
|Kinder und Jugendliche mit behandlungsresistenten Hochrisikoerkrankungen
|Diseases [C] - Cancer [C04]
|Condition being studied is a rare disease
|E.2 Objective of the trial
|Main objective of the trial
To determine the recommended phase II dose (RP2D) of the combination treatment with nivolumab and entinostat administered to adolescents 12-21 years with progressive, relapsed, refractory high-risk solid tumors and CNS tumors
To determine the recommended phase II dose (RP2D) of the combination treatment with nivolumab and entinostat administered to children 6-11 years with progressive, relapsed, refractory high-risk solid tumors and CNS tumors
To evaluate activity of the combination treatment with nivolumab and entinostat in children and adolescents with refractory/relapsed/progressive high-risk solid tumors and CNS tumors with:
Group A: a high mutational load (> 100 somatic SNVs/exome)
Group B: high PD-L1 mRNA expression (RPKM by RNA-Seq > 3)
Group C: Focal MYC(N) amplification
Group D: Patients with biomarker low tumors according to the definitions of group A-C.
|Secondary objectives of the trial
|• Comparison of patient outcomes in group D (biomarker low) with all biomarker positive groups A, B and C (pooled and separately)
• Comparison of patient outcomes in group A-D with matching groups of the INFORM registry (pooled and separately)
• Evaluation of somatic SNV count as a predictive biomarker: relation of patient outcomes to the level of somatic SNVs
• Evaluation of PD-L1 mRNA expression as a predictive biomarker: relation of patient outcomes to the level of PD-L1 mRNA expression
• Evaluation of the level of MYC(N) amplification as a predictive biomarker: relation to patient outcomes
• Evaluate activity using immune related response evaluation methods
• Entinostat plasma PK (CSF if appropriate)
|Trial contains a sub-study
|Principal inclusion criteria
|- Children and adolescents with refractory/relapsed/progressive high-risk
-CNS tumors: medulloblastoma, ependymoma, ATRT, ETMR, pediatric high grade glioma (including DIPG) or other pediatric embryonal CNS tumors
-solid tumors: neuroblastoma, nephroblastoma, rhabdoid tumor, embryonal or alveolar rhabdomyosarcoma or other embryonal small round blue cell tumors including pediatric type (bone) sarcoma, or other pediatric type solid tumors
Children and adolescents with newly diagnosed high grade glioma (HGG) in the context of a constitutional mismatch repair deficiency syndrome after maximum safe surgical resection with no established standard of care treatment option with curative intention available.
- No standard of care treatment available
- Age at registration ≥ 6 to ≤ 21 years.
- Molecular analysis for biomarker identification (SNV load, PDL1 mRNA expression, MYC/N amplification) in laboratories complying with DIN EN ISO/IEC 17025 or similar via INFORM molecular diagnostic platform or equivalently valid molecular pipeline.
- Biomarker determined using whole exome sequencing (SNV load), RNA-sequencing (PDL1 mRNA expression) and whole genome or whole exome sequencing (MYC/N amplification).
- In case molecular analysis was not performed via INFORM Registry molecular pipeline: transfer of molecular data (whole exome and RNA sequencing)
- Time between biopsy/puncture/resection of the current refractory/relapsed/progressive tumor and registration ≤ 24 weeks. In patients receiving therapy not impacting biomarker stratification, time between biopsy/puncture/resection of the current refractory/relapsed/progressive tumor and registration of ≤ 36 weeks is allowed.
- Disease that is measurable as defined by RANO criteria or RECIST v1.1 (as appropriate).
- Life expectancy > 3 months, sufficient general condition score (Lansky ≥ 70 or Karnofsky ≥ 70). Transient states like infections can be accepted, and also stable disabilities resulting from disease/surgery (hemiparesis, amputations etc.) can be accepted and will not be considered for Lansky/Karnofsky assessments.
- Laboratory requirements:
- Hematology: absolute granulocytes ≥ 1.0 × 109/l (unsupported)
platelets ≥ 100 × 109/l&stable
hemoglobin ≥ 8 g/dl or ≥ 4,96 nmol/L
- Biochemistry: Total bilirubin ≤ 1.5 x upper limit of normal (ULN)
AST(SGOT) ≤ 3.0 x ULN
ALT(SGPT) ≤ 3.0 x ULN
serum creatinine ≤ 1.5 x ULN for age
- ECG: normal QTc interval ≤ 480 msec
- Patient is able to swallow oral study medication
- Ability of patient and/or legal representative(s) to understand the character and individual consequences of clinical trial
- Females of childbearing potential must have a negative serum or urine pregnancy test within 7 days prior to initiation of treatment. Sexually active women of childbearing potential must agree to use acceptable and appropriate contraception during the study and for at least 6 months after the last study treatment administration. Sexually active male patients must agree to use a condom during the study and for at least 7 months after the last study treatment administration.
- Absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial
- Before patient screening and registration, written informed consent, also concerning data and blood transfer, must be given according to ICH/GCP, and national/local regulations.
- No prior therapy with the combination of immune checkpoint inhibitors and HDACi
- BSA ≥ 0.9m2
- Phase I: molecular analysis performed and biomarker status known (mutational load, PD-L1 mRNA expression AND MYC(N) amplification status).
- Phase II: molecular analysis performed, biomarker status known (mutational load, PD-L1 mRNA expression AND MYC(N) amplification status) and stratification according to the following criteria:
- Group A: high mutational load (defined as > 100 somatic SNVs/exome) based on whole exome sequencing
- Group B: high PD-L1 mRNA expression (defined as reads per million total reads per kilobase of exon model (RPKM) > 3) based on RNA sequencing
- Group C: Focal MYC(N) amplification based on whole genome sequencing or whole exome sequencing
- Group D: Patients with biomarker low tumors according to the definitions of group A-C.
|Principal exclusion criteria
|- Patients with CNS tumors or metastases who are neurologically unstable despite adequate treatment (e.g. convulsions).
- Patients with low-grade gliomas or tumors of unknown malignant potential are not eligible
- Evidence of > Grade 1 recent CNS hemorrhage on the baseline MRI scan.
- Participants with bulky CNS tumor on imaging are ineligible; bulky tumor is defined as:
- Tumor with any evidence of uncal herniation or severe midline shift
- Tumor with diameter of > 6 cm in one dimension on contrast-enhanced MRI
- Tumor that in the opinion of the investigator, shows significant mass effect
- Previous allogeneic bone marrow, stem cell or organ transplantation
- Diagnosis of immunodeficiency
- Diagnosis of prior or active autoimmune disease
- Evidence of interstitial lung disease
- Any contraindication to oral agents or significant nausea and vomiting, malabsorption, or significant small bowel resection that, in the opinion of the investigator, would preclude adequate absorption.
- Known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies). Known active hepatitis B (e.g., hepatitis B surface antigen-reactive) or hepatitis C (e.g., hepatitis C virus ribonucleic acid [qualitative]). Patients with past hepatitis B virus (HBV) infection or resolved HBV infection (defined as the presence of hepatitis B core antibody [HBc Ab] and absence of HBsAg) are eligible. HBV DNA test must be performed in these patients prior to study treatment. Patients positive for hepatitis C virus (HCV) antibody are eligible only if polymerase chain reaction is negative for HCV RNA.
- Clinically significant, uncontrolled heart disease
- Major surgery within 21 days of the first dose. Gastrostomy, ventriculo-peritoneal shunt, endoscopic ventriculostomy, tumor biopsy and insertion of central venous access devices are not considered major surgery, but for these procedures, a 48 hour interval must be maintained before the first dose of the investigational drug is administered.
- Any anticancer therapy (e.g., chemotherapy, HDACi (including valproic acid), DNA methyltransferase inhibitors, other immunotherapy, targeted therapy, biological response modifiers, endocrine anticancer therapy or radiotherapy) within 2 weeks or at least 5 half-lives (whichever is longer) of study drug administration.
- Radiologically confirmed radiotherapy induced pseudoprogression in CNS tumors
- Traditional herbal medicines; these therapies are not fully studied and their use may result in unanticipated drug-drug interactions that may cause or confound the assessment of toxicity. As part of the enrollment/informed consent procedures, the patient will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the patient is considering a new over-the-counter medicine or herbal product. For information on CYP substrates and P-gp inhibitors or inducers see section 5.8.
- History of hypersensitivity to the investigational medicinal product or to any drug with similar chemical structure or to any excipient present in the pharmaceutical form (including benzamide) of the investigational medicinal product
- Participation in other ongoing clinical trials.
- Pregnant or lactating females.
- Presence of underlying medical condition (e.g. gastrointestinal disorders or electrolyte disturbances) that in the opinion of the Investigator or Sponsor could adversely affect the ability of the subject to comply with or tolerate study procedures and/or study therapy, or confound the ability to interpret the tolerability of combined administration of entinostat and nivolumab in treated subjects
- Patients receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of study treatment. The use of physiologic doses of corticosteroids (up to 5 mg/m2/day prednisone equivalent) may be approved after consultation with the Sponsor.
No patient will be allowed to enroll in this trial more than once.
|E.5 End points
|Primary end point(s)
|Phase I: Dose Limiting Toxicity (DLT) of the combination treatment
Phase II: Best response (CR or PR) will be based on RANO criteria for all primary CNS tumors and RECIST for non-CNS tumors, defined for each patient as the best response under study combination therapy during the first 6 cycles (assessment every 2 cycles) by central review.
|Timepoint(s) of evaluation of this end point
Response: every 2 cycles
|Secondary end point(s)
|• Duration of Response (DOR)
• Disease Control Rate (DCR)
• Stable disease (SD)
• Progression-free survival (PFS)
• Time to Response (TTR)
• Overall Survival (OS)
• Immune related Response Rate (RR) measured by iRECIST criteria and iRANO criteria by central review
• Entinostat plasma PK on 1 day, 1 week and 5 weeks after initiation of therapy
|Timepoint(s) of evaluation of this end point
|Response: every 2 cycles
Pharmakokinetik (Entinostat): on 1 day, 1 week and 5 weeks after initiation of therapy
|E.6 and E.7 Scope of the trial
|Scope of the trial
|Trial type and phase
|Human pharmacology (Phase I)
|First administration to humans
|Other trial type description
|dosefinding of the combination of nivolumab and entinostat in children and adolescents
|Therapeutic exploratory (Phase II)
|Therapeutic confirmatory (Phase III)
|Therapeutic use (Phase IV)
|E.8 Design of the trial
| Comparator of controlled trial
|Other medicinal product(s)
The trial involves single site in the Member State concerned
| The trial involves multiple sites in the Member State concerned
|Number of sites anticipated in Member State concerned
|The trial involves multiple Member States
|Number of sites anticipated in the EEA
|E.8.6 Trial involving sites outside the EEA
|Trial being conducted both within and outside the EEA
|Trial being conducted completely outside of the EEA
|If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned
|Trial has a data monitoring committee
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
|E.8.9 Initial estimate of the duration of the trial
|In the Member State concerned years
|In the Member State concerned months
|In the Member State concerned days
|In all countries concerned by the trial years