Avelumab for People With Recurrent Respiratory Papillomatosis

Background

• Recurrent respiratory papillomatosis (RRP) is a rare papillomatous disease of the aerodigestive tract that is caused by the Human Papilloma Virus (HPV).
• RRP can progress to cause airway compromise, fatal pulmonary lesions, and invasive cancers.
• There is no effective systemic therapy for RRP. Patients require repeated interventional procedures for disease control.
• Study of a small number of RRP samples has shown programmed death-ligand 1 (PD-L1) expression by inflammatory mononuclear cells and by papilloma epithelial cells.
• This clinical trial will evaluate the activity of a PD-L1-targeted drug, avelumab, in the treatment of RRP. This drug was selected for its demonstrated activity in a variety of cancers and for its acceptable safety profile.

Objective

-Determine the complete response rate for avelumab in the treatment of patients with RRP.

Eligibility

• Histologically confirmed diagnosis of RRP.
• One of the following:

• A Derkay anatomic score of 10 or greater and a history of two or more endoscopic interventions in the last 12 months for control of RRP.
• Pulmonary RRP with pulmonary disease that is measurable by computed tomography scan.
• Tracheal involvement with RRP that has required either two or more endoscopic interventions in the last 12 months or a tracheostomy.
• Age 18 years or greater.
• Eastern Oncology Cooperative Group Performance Score of 0 or 1.

Design

• Phase II clinical trial
• Simon optimal two-stage design with initial enrollment of 12 patients and expansion to 37 patients if one or more complete response(s) is/are observed in the initial patients.

• INCLUSION CRITERIA:

Recurrent Respiratory Papillomatosis (RRP) CRITERIA:

• Histological diagnosis of RRP confirmed by pathology report from a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory.

-One of the following:

• A Derkay anatomic score of 10 or greater and a history of two or more endoscopic interventions in the last 12 months for control of RRP.
• Pulmonary RRP with pulmonary disease that is measurable by computed tomography scan.
• Tracheal involvement with RRP that has required either two or more endoscopic interventions in the last 12 months or a tracheostomy.

• Greater than or equal to 18 years of age.
• Able to understand and sign the Informed Consent Document.
• Clinical performance status of Eastern Cooperative Oncology Group (ECOG) 0 or 1.
• Willing to undergo endoscopic evaluation with biopsies in compliance with this protocol.
• No systemic therapy for RRP for four weeks prior to treatment.
• Screening laboratory values must meet the following criteria and should be obtained within 14 days prior to first dose:
• White blood cells (WBC) > 2000/microL
• Neutrophils > 1500/microL
• Platelets > 100 times10(3)/microL
• Hemoglobin > 9.0 g/dL
• Serum creatinine < 1.5 times upper limit of normal (ULN) or creatinine clearance (CrCl) > 30 mL/min (measured or calculated using the Cockcroft-Gault formula below):

• Female CrCl: (140 - age in years) times weight in kg x 0.85/72 times serum creatinine in mg/dL
• Male CrCl: (140 - age in years) times weight in kg x 1.00/72 times serum creatinine in mg/Dl
• Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) less than or equal to 2.5 times ULN; for subjects with documented metastatic disease to theliver, AST and ALT levels less than or equal to 5 times ULN
• Total Bilirubin less than or equal to 1.5 times ULN

• Sexually active subjects (men and women) and all subjects of reproductive potential must agree to use two methods of contraception: one highly effective and one other effective method for at least 28 days prior, throughout the avelumab treatment and for at least 60 days after avelumab treatment. Highly Effective Methods are defined as: Intrauterine device (IUD), hormonal (birth control pills, injections, implants), tubal ligation and partners vasectomy; Other Effective Methods are defined as: latex condom, diaphragm and cervical cap.
• Seronegative for human immunodeficiency virus (HIV) antibody. The experimental treatment being evaluated in this protocol depends on an intact immune system. Patients who are HIV seropositive can have decreased immune function and thus are likely less responsive to the experimental treatment.
• Seronegative for hepatitis B antigen, positive hepatitis B tests can be further evaluated by confirmatory tests (Hep B deoxyribonucleic acid (DNA) Quantification (Quant), HBV Viral Load), and if confirmatory tests are negative, the patient can be enrolled.
• Seronegative for hepatitis C antibody unless antigen negative. If hepatitis C antibody test is positive, then patients must be tested for the presence of antigen by Hep C RNA Quant, Hepatitis C Virus (HCV) Viral Load and be HCV ribonucleic acid (RNA) negative.

Exclusion criteria

• Any severe acute or chronic medical or psychiatric conditions including recent (within the past year) or active suicidal ideation or behavior; liver, lung disease (with the exception of what is specified in inclusion criteria above), or laboratory abnormalities that, in the opinion of the investigators, may increase the risk associated with study participation or study drug administration, impair the ability of the subject to receive protocol therapy, or interfere with the interpretation of study results and in the judgment of the investigator, would make the patient inappropriate for entry into this study. Patients with mild to moderate asthma or chronic obstructive pulmonary disease (COPD) well controlled with oral or inhaled medications are permitted to enroll.
• Subjects with active, known or suspected autoimmune disease. Subjects with vitiligo, residual hypothyroidism due to autoimmune condition only requiring hormone replacement, or psoriasis not requiring systemic treatment, are permitted to enroll.
• Subjects with a condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications within 14 days of study drug administration. Inhaled, topical intranasal or intro-ocular steroids, and adrenal replacement doses <10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease.
• Prior organ transplantation, including allogeneic stem cell transplantation.
• Prior treatment with an anti-programmed death-ligand 1 (PD-1), anti-PD-L1, anti-programmed death-ligand 2 (PD-L2), anti-cytotoxic T-lymphocyte associated protein 4 (CTLA-4) antibody, or any other antibody or drug specifically targeting T-cell co-stimulation or immune checkpoint pathways.
• Patients who are receiving any other investigational agents
• Pregnant or breast feeding. Women of childbearing potential must have a negative pregnancy test at screening. Women of childbearing potential include women who have experienced menarche and who have not undergone successful surgical sterilization (hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or are not postmenopausal. Post-menopause is defined as amenorrhea greater than or equal to 12 consecutive months. Note: women who have been amenorrheic for 12 or more months are still considered to be of childbearing potential if the amenorrhea is possibly due to prior chemotherapy, anti-estrogens, ovarian suppression or any other reversible reason.
• History of allergy to study drug components.

History of severe hypersensitivity reaction to any monoclonal antibody (Grade greater than or equal to 3 National Cancer Institute (NCI)-Common Terminology Criteria in Adverse Events (CTCAE) v 4.03), any history of anaphylaxis, or uncontrolled asthma (that is, 3 or more features of partially controlled asthma).

• Clinically significant (i.e., active) cardiovascular disease: cerebral vascular accident/stroke (< 6 months prior to enrollment), myocardial infarction (< 6 months prior to enrollment), unstable angina, congestive heart failure (greater than or equal to New York Heart Association Classification Class II), or serious cardiac arrhythmia requiring medication.
• Persisting toxicity related to prior therapy of Grade >1 NCI-CTCAE v 4.03; however, alopecia, sensory neuropathy Grade less than or equal to 2 or other Grade less than or equal to 2 adverse events (AEs) not constituting a safety risk based on investigator's judgment are acceptable.
• Known alcohol or drug abuse.
• Vaccination within 4 weeks of the first dose of avelumab and while on trial is prohibited except for administration of inactivated vaccines.