This phase II trial investigates the effect of combining two immune therapies, atezolizumab and CDX-1127 (varlilumab), with or without cobimetinib, in treating patients with biliary tract cancer that cannot be removed by surgery (unresectable).
Principal Investigator
Sukeshi Arora
Frances Crawford
(210) 450-5037
crawfordf1@uthscsa.edu
Sonia Creighton
(210) 450-1366
creighton@uthscsa.edu
Myrna Montenegro
(210) 450-5954
montenegro@uthscsa.edu
Jennifer Moseley
(210) 450-1799
moseleyj@uthscsa.edu
Courtney Nichols
(210) 450-1794
nicholsc2@uthscsa.edu
Mailbox Ctrc Regulatory Affairs
regaffapp@uthscsa.edu
Kathleen Rodriguez
(210) 450-1365
rodriguezk3@uthscsa.edu
Benjamin Schleif
(210) 450-1366
schleifb@uthscsa.edu
Morgan Seekatz
(210) 450-1133
seekatz@uthscsa.edu
Pathologically confirmed biliary tract cancer, having received at least 1 prior line of systemic therapy, and received no more than 2 prior lines of therapy in the metastatic setting (disease recurrence < 6 months from the last dose of adjuvant therapy in resected patients will be considered the first line of therapy)
Patients must have measurable disease by RECIST v1.1
Age ≥18 years. Because no dosing or adverse event data are currently available on the
use of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) in patients <18 years of age, children are excluded from this study.
ECOG performance status ≤1 (Karnofsky ≥80%, see Appendix A).
Patients must have adequate organ and marrow function as defined below:
OR
Gault method) for patients with creatinine levels above institutional normal
(This applies only to patients who do not receive therapeutic anticoagulation; patients receiving therapeutic anticoagulation, such as low-molecular-weight heparin or warfarin, should be on a stable dose)
HIV-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial.
For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated.
Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load.
Patients must be willing to undergo 2 sets of core needle biopsies. If possible, biopsied sites should be different than those used for measurable disease/RECIST measurements, but this is not mandatory.
Patients must have an estimated life expectancy of greater than 3 months.
Patients must be able to swallow pills
Patients should not have evidence of retinal pathology on ophthalmologic examination; or neurosensory retinal detachment, RVO, or neovascular macular degeneration.
The effects of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) on the developing human fetus are unknown. For this reason, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 5 months (150 days) after completion of atezolizumab, cobimetinib, and CDX-1127 (varlilumab) administration.
Ability to understand and the willingness to sign a written informed consent document.
Patients with prior allogeneic bone marrow transplantation within the past 5 years or prior solid organ transplantation at any point.
Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events (other than alopecia or neuropathy) due to agents administered more than 4 weeks earlier. However, the following therapies are allowed:
Prior treatment with anti-CTLA-4, anti-PD-1, or anti-PD-L1or other immune checkpoint inhibitor therapeutic antibodies or pathway-targeting agents. Patients who have only received previous durvalumab (anti-PD-1) as part of first line in combination with gemcitabine and cisplatin (TOPAZ-1 regiman [NCT03875235]) are eligible.
Prior treatment with MEK or ERK inhibitors
Treatment with any other investigational agent within 4 weeks prior to Randomization.
Treatment with systemic immunostimulatory agents (including, but not limited to, interferon [IFN]-a or interleukin [IL]-2) within 6 weeks prior to Randomization.
Treatment with systemic immunosuppressive medications (including, but not limited to, prednisone (>10mg), cyclophosphamide, tacrolimus, sirolimus, azathioprine,
methotrexate, thalidomide, and anti-tumor necrosis factor [anti-TNF] agents) within 2 weeks prior to Randomization.
Patients taking bisphosphonate therapy for symptomatic hypercalcemia. Use of bisphosphonate therapy for other reasons (e.g., bone metastasis or osteoporosis) is allowed.
Presence of therapeutically actionable mutation with approved targeted therapy (e.g.
FGFR fusion patients are eligible for study therapy in the 3rd line setting). Patient must have received somatic mutation testing (tissue or liquid) prior to enrollment.
Clinically significant ascites (palpable on exam, paracentesis in last 3 months, and/or
symptomatic).
Patients with known primary central nervous system (CNS) malignancy or symptomatic CNS metastases are excluded, with the following exceptions:
History of malignant bowel obstruction.
History of severe allergic, anaphylactic, or other hypersensitivity reactions to Chinese hamster ovary cell products, chimeric, humanized, or other recombinant human antibodies or fusion proteins
History of allergic reactions attributed to compounds of similar chemical or biologic composition to atezolizumab, cobimetinib, or CDX-1127 (varlilumab).
Patients receiving any medications or substances that are considered moderate to strong inhibitors or inducers of CYP3A and are not able to switch to an alternative that
minimizes interaction potential will ineligible. Coadministration of cobimetinib with a strong CYP3A4 inhibitor can increase cobimetinib systemic exposure significantly (e.g. itraconazole increased serum systemic cobimetinib exposure by 6.7 fold). On the other end, coadministration of cobimetinib with a strong CYP3A inducer may decrease cobimetinib systemic exposure by more than 80% thus reducing its efficacy. Because the lists of these agents are constantly changing, it is important to regularly consult a frequently-updated list such as http://medicine.iupui.edu/clinpharm/ddis/; medical reference texts such as the Physicians’ Desk Reference may also provide this information. 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. Appendix C should be presented to patient.
Patients with a known clinically significant liver disease, including active viral, alcoholic, or other hepatitis; cirrhosis; fatty liver; and inherited liver disease.
Patients who have received immunosuppressive treatment for systemic autoimmune
disease, including, but not limited to, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener’s granulomatosis, Sjögren’s syndrome, multiple sclerosis, vasculitis, or glomerulonephritis within the last 2 years.
History of idiopathic pulmonary fibrosis, pneumonitis (including drug induced), organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing pneumonia, etc.), or evidence of active pneumonitis on screening chest computed tomography (CT) scan. History of radiation pneumonitis in the radiation field (fibrosis) is permitted.
Patients with active tuberculosis (TB) are excluded.
Severe infections within 4 weeks prior to Randomization, including, but not limited to, hospitalization for complications of infection, bacteremia, or severe pneumonia.
Signs or symptoms of infection within 2 weeks prior to Randomization.
Received oral or intravenous (IV) antibiotics within 2 weeks prior to Randomization.
Patients receiving prophylactic/suppressive antibiotics will not be eligible.
Major surgical procedure within 28 days prior to Randomization or anticipation of need for a major surgical procedure during the course of the study.
Administration of a live, attenuated vaccine within 4 weeks before Randomization or anticipation that such a live, attenuated vaccine will be required during the study and up to 5 months after the last dose of atezolizumab.
Patients with psychiatric illness/social situations that would limit compliance with study requirements.
Pregnant women are excluded from this study because one or more study agents have the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with atezolizumab, cobimetinib, and CDX-1127 (varlilumab), breastfeeding should be discontinued if the mother is treated with atezolizumab, cobimetinib, and CDX-1127 (varlilumab).
Patients who are using ethinyl estradiol containing oral contraceptives when administered concomitantly with cobimetinib, are excluded due to increased risk of venous thromboembolism.
Patients with a history of clinically significant cardiac dysfunction, including the following: