Nivolumab or Expectant Observation Following Ipilimumab, Nivolumab, and Surgery in Treating Patients With High Risk Localized, Locoregionally Advanced, or Recurrent Mucosal Melanoma
Cervical Carcinoma, Esophageal Carcinoma, Mucosal Melanoma
About this trial
This is an interventional treatment trial for Cervical Carcinoma
Eligibility Criteria
Inclusion Criteria:
- STEP 1 ELIGIBILITY CRITERIA
Documentation of disease:
- Histologic documentation: histologically proven mucosal melanoma by local pathology
- Tumor tissue: tumor tissue from the primary site of disease must be available for PD-L1 testing (stratification factor)
Disease status
- Tumors must have NOT been completely resected, or must be locoregionally recurrent if previously resected; tumor must be deemed potentially resectable by local surgeon
- MM arising from the head/neck, genitourinary, or gastrointestinal tract
Disease meets any 1 of 4 characteristics:
- Regional lymph node (LN) involvement; OR
- Multifocal/satellite primary disease; OR
Single localized, primary disease meeting one of the following site-specific requirements:
- Head/neck - any primary lesion if sinonasal; pT4a or above for nasal or oral cavity
- Anorectal - any primary lesion
- Conjunctiva - any primary lesion T2 or T3 stage by American Joint Committee on Cancer (AJCC)
- Vaginal/cervical - any primary
- Vulvar (hair bearing surface, labia majora) - AJCC cutaneous stage IIB or higher
- Esophageal - any primary
- Locoregionally recurrent following prior resection
- No evidence of metastatic disease at the time of registration
- No prior medical therapy (chemotherapy, immunotherapy, biologic or targeted therapy) or radiation therapy for MM, unless locoregionally recurrent; if recurrent, no prior medical or radiation therapy is allowed for the latest recurrence
No history of the following:
- Active known or suspected autoimmune disease
- Human immunodeficiency virus (HIV) with CD4+ count < 300 or detectable viral load; patients with HIV, undetectable viral load, and CD4+ count >= 300 are eligible
Known active hepatitis B or C
Hepatitis B can be defined as:
- Hepatitis B virus surface antigen (HBsAg) > 6 months
- Serum hepatitis B virus (HBV) deoxyribonucleic acid (DNA) 20,000 IU/ml (105 copies/ml), lower values 2,000-20,000 IU/ml (104-105 copies/ml) are often seen in hepatitis B virus e antigen (HBeAg)-negative chronic hepatitis B
- Persistent or intermittent elevation in alanine aminotransferase (ALT)/aspartate aminotransferase (AST) levels
- Liver biopsy showing chronic hepatitis with moderate or severe necroinflammation
Hepatitis C can be defined as:
- Hepatitis C antibody (AB) positive
- Presence of hepatitis C virus (HCV) RNA
- Known active pulmonary disease with hypoxia defined as oxygen saturation < 85% on room air
Not pregnant and not nursing
- For women of childbearing potential only, a negative pregnancy test done =< 14 days prior to registration is required
- Eastern Cooperative Oncology Group (ECOG) performance status =< 2
- Absolute neutrophil count (ANC) >= 1,500/mm^3
- Platelet count >= 100,000/mm^3
- Creatinine clearance >= 30 mL/min by Modified Diet in Renal Disease (MDRD) equation or Cockcroft-Gault
Total bilirubin =< 1.5 x upper limit of normal (ULN)
- Except in case of Gilbert disease
- AST/ALT =< 2.5 x upper limit of normal (ULN)
Thyroid-stimulating hormone (TSH) within normal limits (WNL)
- Supplementation is acceptable to achieve a TSH WNL; in patients with abnormal TSH if free T4 is normal and patient is clinically euthyroid, patient is eligible
Concomitant medications
- No systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications within 7 days of registration (inhaled steroids for patients with underlying chronic pulmonary disease is acceptable as long as they meet other eligibility as listed above)
- No other planned concurrent investigational agents or other tumor directed therapy (chemotherapy, radiation) while on study
- STEP 2 ELIGIBILITY CRITERIA
Surgical resection of all gross disease
- This assessment will be made by the local investigator based on review of the operative report, pathology results, and/or radiology reports; microscopically positive margins (e.g. R1 resection) are permitted
Completion of PD-L1 testing
- Patients will be stratified as PD-L1 >= 5% versus (vs) < 5% OR inevaluable; baseline tumor will be utilized; if this returns inevaluable, efforts should be made to utilize the resected specimen
Randomization within 112 days of completion of surgical
- The primary region must be included on cross-sectional imaging (e.g. sinus/neck if arising from sinonasal primary; pelvis if genitourinary); radiographic changes considered nonspecific or possibly due to surgery or radiation are not considered evidence of disease
No significant immune-related adverse event due to the nivolumab plus ipilimumab dose received in the neoadjuvant setting, as follows:
- Any grade myocarditis, including an asymptomatic troponin elevation felt to be related to nivolumab plus ipilimumab
- Any grade neurologic complication (e.g. meningitis, encephalitis, neuropathy); study chair should be contacted if there is any question whether an adverse event (AE) was neurologic in nature
- Grade 2 or higher pneumonitis
- Grade 2 colitis
- Grade 2 or higher anemia (due to drug; unrelated anemia is not exclusionary)
- Thyroid/adrenal AEs regardless of grade that have stabilized or are clinically asymptomatic are eligible
- Fatigue, regardless of grade, is not a contraindication to randomization
- Grade 4 AST or ALT elevation
- Asymptomatic elevated amylase and lipase, regardless of grade, are not contraindications to randomization
Grade 4 rash; grade 3 rash is not a contraindication to randomization; any oropharyngeal lesions or bullous skin lesions that are suggestive of toxic epidermal necrolysis or Stevens-Johnson syndrome are contraindications to randomization regardless of the grade of rash
- If not specified above, other Common Terminology Criteria for Adverse Events (CTCAE) grade 3 or higher AEs deemed possibly related to the nivolumab plus ipilimumab are exclusions to randomization; AEs that were attributable to surgery or adjuvant RT would not be contraindications to randomization
Sites / Locations
- Alliance for Clinical Trials in Oncology
Arms of the Study
Arm 1
Arm 2
Active Comparator
Experimental
Arm I (nivolumab, ipilimumab, surgery, active surveillance)
Arm II (nivolumab, ipilimumab, surgery, nivolumab)
PART I: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Within 3-6 weeks after receiving nivolumab and ipilimumab, patients undergo surgery per standard of care. Within 84 days of last surgical resection, patients may also undergo adjuvant RT, if clinically appropriate. PART II: Patients undergo active surveillance for 1 year.
PART I: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Within 3-6 weeks after receiving nivolumab and ipilimumab, patients undergo surgery per standard of care. Within 84 days of last surgical resection, patients may also undergo adjuvant RT, if clinically appropriate. PART II: Patients receive nivolumab IV over 30 minutes once every 2 weeks for 4 doses. Patients then continue to receive nivolumab IV over 30 minutes once every 4 weeks for up to 11 doses in the absence of disease progression or unacceptable toxicity.