Domvanalimab plus zimberelimab immunotherapy for advanced rare cancers

IMMUNORARE5: A National Platform of 5 Academic Phase II Trials Coordinated by Lyon University Hospital to Assess the Safety and the Efficacy of the IMMUNOtherapy With Domvanalimab + Zimberelimab Combination in Patients With Advanced RARE Cancers

This trial will try domvanalimab with zimberelimab (with or without FOLFOX-4) in adults whose advanced rare cancers have progressed after at least one standard treatment to see if the combination controls disease or shrinks tumors.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 154 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: Hospices Civils de Lyon (other)
• Drugs / interventions: sunitinib, chemotherapy, immunotherapy, Domvanalimab, Zimberelimab
• Locations: 15 sites (Angers and 14 other locations)
• Trial ID: NCT06790706 on ClinicalTrials.gov

What this trial studies

IMMUNORARE5 is a national phase II platform of five parallel cohorts coordinated by Lyon University Hospital testing domvanalimab plus zimberelimab, with an option to add FOLFOX-4 in selected patients, for five types of advanced rare cancers after failure of at least one standard line. Each cohort enrolls adults with measurable or assessable disease and ECOG performance status 0–1, and requires archival tumor tissue or a fresh biopsy when feasible. Treatments are given systemically and tumor response will be measured by RECIST, mRECIST, or disease-specific biomarkers (for example serum hCG for trophoblastic tumors), with safety and efficacy compared to historical outcomes. For the peritoneal mesothelioma cohort, debulking surgery may be considered after six months of response to study treatment.

Who should consider this trial

Good fit: Adults (≥18) with one of the specified advanced rare cancers that progressed after at least one standard systemic treatment, ECOG 0–1, measurable or assessable disease, and willing to provide tumor tissue or undergo biopsy are ideal candidates.

Not a fit: Patients with cancers not included in the five cohorts, ECOG performance status >1, active autoimmune disease or contraindications to immunotherapy, or those with effective standard curative options are unlikely to benefit.

Why it matters

Potential benefit: If successful, the combination could offer a new, better-tolerated systemic option that controls disease and improves outcomes for several advanced rare cancers that currently lack validated later-line treatments.

How similar studies have performed: Case reports and early-phase studies have shown that immune checkpoint inhibitors can help some rare cancers, but this particular domvanalimab plus zimberelimab combination is relatively novel and not yet proven.

Eligibility criteria

Inclusion Criteria:

General inclusion criteria for all cohorts

* Histologically proven advanced solid tumors that progressed/resisted after minimum one line of standard systemic treatment, or resisted during the first-line of treatment
* No indication of curative surgery for this disease at inclusion (For cohort 1 only (peritoneal mesothelioma), debulking surgery could be considered after minimum 6 months of study treatment in the case of important tumor response)
* Evaluable lesions (target or non-target lesions) for radiological response according to RECIST 1.1 (cohorts 3, 4, 5), or mRECIST (cohort 1), or assessable for biological response with serum hCG (cohort 2)
* Patients older than 18 years
* Patients with Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1
* Patients must be willing to provide an archival tumor tissue block or slides, or undergo procedure to obtain a new biopsy in absence of medical contraindication (If either a fresh biopsy or archival material is not available, patient inclusion has to be discussed and validated with the coordinators of the cohort)
* Patients with adequate bone marrow function measured within 28 days prior to administration of study treatment:

  * Absolute Neutrophil count \> 1.5 x 109/L
  * Platelets count ≥ 100 X 109/L
  * Hemoglobin ≥ 9.0 g/dL
* Patients with adequate renal function: Calculated creatinine clearance ≥ 30 ml/min according to the local institutional standard method (MDRD preferred)
* Serum bilirubin ≤ 1.5 x UNL (Upper Normal Limit) (\< 3 x UNL for patients with known Gilbert's syndrome), AST/ALT ≤ 2.5 X UNL (≤ 5 X UNL for patients with liver metastases)
* Life expectancy ≥ 16 weeks
* Highly effective contraception for men and childbearing age women.
* Signed informed consent prior to participating in any study related procedures.
* Patients affiliated to the French social security system or equivalent
* Patient able to comply with the protocol, including follow-up visits and examinations

Specific inclusion criteria for each cohort:

* Cohort 1 (Peritoneal mesothelioma)

  * Histologically-confirmed malignant peritoneal mesotheliomas (epithelioid, sarcomatoid, or biphasic)
  * Evidence of progression or recurrence after at least one line of platinum + pemetrexed based-chemotherapy regimen (Previous treatment with pressurized intra-peritoneal aerosol chemotherapy (PIPAC) is authorized)
* Cohort 2 (Gestational trophoblastic tumors)

  * Gestational trophoblastic tumors (including placenta site trophoblastic tumors and epithelioid carcinomas) histologically or cytologically-confirmed by a referent pathologist of the French National Center for Gestational Trophoblastic Diseases (In exceptional cases, the patients with typical clinical presentation of gestational trophoblastic tumors with elevated hCG, and experiencing resistance to polychemotherapy, can be included even if the gestational trophoblastic tumor was not histologically or cytologically-confirmed, provided that the French gestational trophoblastic center has validated the case and the inclusion of the patient)
  * Evidence of resistance or relapse after at least one line of polychemotherapy (e.g. EP low dose, BEP regimen, EMA-CO regimen …)
* Cohort 3 (B3 thymomas and thymic carcinomas)

  * B3 thymomas and thymic carcinoma, histologically confirmed by a referent pathologist of the RYTHMIC network
  * Evidence of progression or relapse after at least one line of platinum-based chemotherapy
* Cohort 4 (Anaplastic thyroid carcinomas)

  * Anaplastic thyroid carcinoma with non-mutated or mutated B-RAF, histologically or cytologically-confirmed by a referent pathologist of the Tuthyref network
  * In B-RAF non-mutated anaplastic thyroid carcinomas: Persistent disease at the first evaluation after chemoradiation or disease progression/relapse after the end of chemoradiation
  * In B-RAF mutated anaplastic thyroid carcinoma: evidence of progression after a standard B-RAF inhibitor
* Cohort 5 (GEP-NET and carcinoid tumors)

  * Histologically or cytologically-confirmed well-differentiated neuroendocrine tumor (WHO classification as NET G1, G2 or G3), or typical/atypical carcinoid tumor (according to WHO classification for thoracic NETs), from gastroenteropancreatic, thoracic (thymus or lung) or unknown primary origin
  * Indication of oxaliplatin-based regimen treatment
  * Evidence of progression or relapse after at least 1 line of systemic treatment, such as somatostatine analog, or targeted agents such as everolimus or sunitinib, or chemotherapy without oxaliplatin, or peptide receptor radionuclide therapy.

Exclusion Criteria:

General exclusion criteria for all cohorts:

* Previous treatment with immune checkpoint inhibitors (including anti-TIGIT, anti-PD1, anti-PD-L1, anti-CTLA4), or other types of immunotherapy.
* Active or prior documented autoimmune or immune-related disorders (Stevens-Johnson syndrome, immune-related myocarditis, immune-related pneumonitis, immune-related colitis, immune-related hepatitis, immune mediated dermatologic adverse reactions, immune-mediated nephritis). (The following are exceptions to this criterion: Patients with vitiligo or alopecia; Patients with hypothyroidism (e.g., following Hashimoto syndrome) stable on hormone replacement; Any chronic skin condition that does not require systemic therapy; Patients without active disease and no treatment for the last 5 years may be included but only after consultation with the coordinator of the cohort)
* Medical condition that requires chronic systemic steroid therapy, or any other forms of immunosuppressive medication. (For example, patients with autoimmune disease that requires systemic steroids or immunosuppression agents should not to be included. Replacement therapy (eg., thyroxine, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment.)
* Uncontrolled intercurrent illness, including but not limited to, congestive heart failure; respiratory distress; liver failure; allergy; psychiatric illness/social situations that would limit compliance with study requirement according to the investigator, or that substantially increase risk of incurring AEs or compromise the ability of the patient to give written informed consent.
* Patients with a second primary cancer, except for: adequately treated non-melanoma skin cancer, curatively treated in-situ cancer of the cervix, or other hematological or solid cancers curatively treated with no evidence of disease for ≥ 3 years.
* All subjects with meningeal involvement.
* Untreated or symptomatic Central nervous system (CNS) metastases. (Patients are eligible if the following criteria are met:

  * CNS lesions are asymptomatic and previously treated.
  * Patient does not require ongoing steroid treatment
  * Imaging demonstrates stability of disease 28 days from last treatment for CNS metastases.)
* Patients receiving any systemic chemotherapy, radiotherapy (except for palliative reasons), within 6 weeks from the last dose prior to study treatment (or at least 5 half-lives depending on the defined characteristics of the agents used). The patient can receive a stable dose of bisphosphonates for bone metastases, before and during the study as long as these were started at least 4 weeks prior to treatment with study drug.
* Treatment with other investigational agents prone to interact with outcomes of the trial upon to investigator opinion.
* Bowel occlusive syndrome, inflammatory bowel disease, immune colitis, or other gastro-intestinal disorders that do not allow oral medication such as malabsorption.
* Active HIV, HBV or HCV infection.
* Prior organ transplantation, including allogeneic stem cell transplantation (excluding autologous bone marrow transplant).
* Ongoing participation in any other clinical trial who may interfere with the present study in the judgment of the investigator
* Patients under tutorship or guardianship.

Specific exclusion criteria by cohort:

* Cohort 1 (Peritoneal mesothelioma)

  * Planned cytoreductive surgery or PIPAC within 6 months of study treatment in order to be able to assess the primary endpoint
* Cohort 3 (B3 thymomas and thymic carcinomas)

  * Neuroendocrine tumors
  * Any mixed histology with A/AB/B2 component
  * Any paraneoplastic syndrome
  * Positivity to anti RACh antibodies
* Cohort 5 (GEP-NET and carcinoid tumors)

  * Poorly differentiated neuroendocrine carcinomas
  * Mixed tumors
  * Contraindication to FOLFOX-4 (DPD deficiency, i.e. uracilemia levels ≥ 16 ng/mL)
  * Previous administration of oxaliplatin

Where this trial is running

Angers and 14 other locations

• Institut de Cancerologie de l'Ouest , medical oncology department — Angers, France (NOT_YET_RECRUITING)
• Institut Bergonié, medical oncology department — Bordeaux, France (NOT_YET_RECRUITING)
• Hospices Civils de Lyon, Thoracic Oncology Department, Louis Pradel Hospital — Bron, France (RECRUITING)
• Centre Hospitalier Universitaire de Lille, medical oncology department — Lille, France (NOT_YET_RECRUITING)
• Hospices Civils de Lyon, Medical Oncology Department, Edouard Herriot Hospital — Lyon, France (RECRUITING)
• AP-HM, TIMONE Hospital, medical oncology department — Marseille, France (NOT_YET_RECRUITING)
• Institut Paoli-Calmettes Marseille, medical oncology department — Marseille, France (NOT_YET_RECRUITING)
• Institut Régional du Cancer de Montpellier, medical oncology department — Montpellier, France (NOT_YET_RECRUITING)
• Institut Curie, thoracic oncology department — Paris, France (NOT_YET_RECRUITING)
• AP-HP, Tenon Hospital, medical oncology department — Paris, France (NOT_YET_RECRUITING)
• Hospices Civils de Lyon, Medical Oncology Department, Lyon SUD Hospital — Pierre-Bénite, France (RECRUITING)
• Centre Eugène Marquis, medical oncology department — Rennes, France (NOT_YET_RECRUITING)
• Insitut de Cancérologie Strasbourg Europe, medical oncology department — Strasbourg, France (NOT_YET_RECRUITING)
• ONCOPOLE Claudius Regaud, IUCT-Oncopole, medical oncology department — Toulouse, France (NOT_YET_RECRUITING)
• Institut Gustave Roussy, medical oncology department — Villejuif, France (NOT_YET_RECRUITING)

Study contacts

• Study coordinator: Benoit YOU, Prof; MD/PhD

Conditions: Peritoneal Mesothelioma, Gestational Trophoblastic Tumor, Thymoma and Thymic Carcinoma, Anaplastic Thyroid Carcinomas, Gastroenteropancreatic Neuroendocrine Tumor, Carcinoid Tumor, Rare cancers, Immunotherapy