M7824 in 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 typically require repeated interventional procedures for disease control.
• A recently completed phase II clinical trial investigating avelumab in subjects with aggressive RRP demonstrated an acceptable safety profile from Avelumab and a high rate of partial responses.
• RRP is characterized by frequent expression of PD-L1 and transforming growth factor beta (TGF)-beta in the tumor microenvironment.
• This clinical trial will evaluate the activity of M7824, a novel bifunctional fusion protein composed of a fully human Immunoglobulin G1 (IgG1) monoclonal antibody against human PD-L1 (avelumab) fused, via a flexible glycine-serine linker, to the soluble extracellular domain of human TGF- B receptor II (Transforming growth factor, beta receptor II (TGF-BRII), which functions as a TGF-B trap. 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 M7824 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

• This is a phase II clinical trial with two cohorts that will enroll simultaneously.
• Cohort 1 will consist of subjects who have not been treated previously with an immune checkpoint inhibitor. Cohort 2 will consist of subjects whose disease has been treated previously with andrefractory to an immune checkpoint inhibitor. Each cohort will have a Simon optimal two-stage design with initial enrollment of 12 patients and expands 21 patients if one or more complete response(s) is/are observed in the initial patients. With amendment D, dated 7/24/2019, cohort 2 will be closed to further enrollment.

• 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 and evaluated by Response Evaluation Criteria in Solid Tumors (RECIST) Criteria.
• 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 at least 3 half-lives of the prior drug(s).
• Screening laboratory values must meet the following criteria and should be obtained within 14 days prior to first dose:

• White Blood Count (WBC) > 2000/ microliter
• Neutrophils > 1000/ microliter
• Platelets > 75 x10(3)/ microliter
• Hemoglobin > 9.0 g/dL
• Serum Creatinine < 1.5 x upper limits of normal (ULN) OR estimated glomerular filtration rate (eGFR) > 30 mL/min (measured or calculated using the Modification of Diet in Renal Disease (MDRD) equation).
• Aspartate aminotransferase (AST)/Alanine aminotransferase (ALT) less than or equal to 2.5 x ULN
• Total Bilirubin: 1.5 x ULN
• Prothrombin time (PT)/International Normalized Ratio (INR) and partial thromboplastin time (PTT) less than or equal to ULN
• Sexually active subjects (men and women) of reproductive potential must agree to use two methods of contraception: one highly effective and one other effective method throughout M7824 treatment and for at least 120 days after M7824 treatment. Highly Effective Methods are defined as: Intrauterine device (IUD), hormonal (birth control pills, injections, implants), tubal ligation and partner s vasectomy; Other 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) Quant, hepatitis B virus (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 Ribonucleic acid (RNA) Quant, hepatitis C virus (HCV) Viral Load and be HCV 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 disease, lung disease (with the exception of what is specified in inclusion criteria) , 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.
• 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 for Adverse Events (CTCAE) v 5.0), 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 5.0; 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 M7824 and 4 weeks after the last dose of M7824 are prohibited.
• Human papillomavirus (HPV) vaccination within one year of the first dose of M7824
• With amendment D, patients that received prior Programmed cell death protein 1 (PD-1) based immunotherapy will be excluded.