Pre-operative treatment for Stage II-IIIa urothelial cancer using nivolumab with or without relatlimab

A Phase 2 Trial in Stage II-IIIa Urothelial Cancer Randomizing Pre-operative Nivolumab With or Without Relatlimab

This study is testing if giving a combination of two immunotherapy drugs before surgery can help people with muscle-invasive bladder cancer have no remaining cancer when they go in for their operation.

Quick facts

• Phase: Phase 2
• Study type: Interventional
• Enrollment: 90 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: The Netherlands Cancer Institute (Academic / other)
• Drugs / interventions: chemotherapy, immunotherapy, prednisone, nivolumab, relatlimab
• Locations: 9 sites (Arnhem, Gelderland and 8 other locations)
• Trial ID: NCT06237920 on ClinicalTrials.gov

What this trial studies

This phase 2 trial involves ninety adult patients with muscle-invasive urothelial bladder cancer who will receive two cycles of either nivolumab alone or nivolumab combined with relatlimab before surgery. The study aims to evaluate the effectiveness of this dual immunotherapy in achieving a pathological complete response, which is defined as no residual cancer at the time of cystectomy. Patients will be monitored through various assessments, including cystoscopy and imaging, to determine treatment response and safety. Follow-up will occur at 6, 12, and 24 months post-treatment to assess long-term outcomes and quality of life.

Who should consider this trial

Good fit: Ideal candidates are adults aged 18 and older with resectable muscle-invasive urothelial bladder cancer who are either ineligible for or choose not to undergo cisplatin-based chemotherapy.

Not a fit: Patients with non-urothelial cancer histologies or those who are not eligible for surgical resection may not benefit from this study.

Why it matters

Potential benefit: If successful, this treatment approach could improve bladder preservation and overall survival for patients with advanced urothelial cancer.

How similar studies have performed: Other studies have shown promising results with immunotherapy approaches in urothelial cancer, suggesting potential for success in this novel combination.

Eligibility criteria

Inclusion Criteria:

* Willing and able to provide informed consent
* Age ≥ 18 years
* Resectable muscle-invasive UC of the bladder, defined as cT2-4aN0M0 OR cT1-4aN1M0. In cT1N1 patients, lymph node positivity would need to be cytologically or histologically confirmed.
* Surgical resection (cystectomy) is the advised locoregional treatment and is accepted by the subject after consultation with the urologist.
* Patients are either cisplatin ineligible or elect to not undergo cisplatin based neoadjuvant chemotherapy after a balanced discussion of risks and benefits with the treating physician. Cisplatin eligibility is determined based on the Galsky criteria
* World Health Organization (WHO) performance Status 0 or 1.
* Urothelial cancer is the dominant histology (\>50%). Any component of small cell or adenocarcinoma is not allowed.
* Formalin-fixed paraffin-embedded (FFPE) tumor specimens in paraffin blocks from diagnostic TUR available.
* Screening laboratory values must meet the following criteria: WBC ≥ 2.0x109/L, Platelets ≥100 x109/L, Hemoglobin ≥5.5 mmol/L, GFR\>30 ml/min, AST ≤ 1.5 x ULN, ALT ≤1.5 x ULN, Bilirubin ≤1.5 X ULN
* Negative pregnancy test (βHCG in blood or urine) within 2 weeks of Day 1 Cycle 1 for female patients of childbearing potential.
* Highly effective contraception for female subjects if the risk of conception exists. Female patients of childbearing potential must comply with contraception methods as requested by the study protocol (→ 8.2.1 Pregnancy, contraception and breastfeeding)

Exclusion Criteria:

* Subjects with active autoimmune disease in the past 2 years. Patients with diabetes mellitus, properly controlled hypothyroidism or hyperthyroidism, vitiligo, psoriasis or other mild skin disease can still be included.
* Documented history of severe autoimmune disease (e.g. inflammatory bowel disease, myasthenia gravis).
* Previous intravenous systemic therapy or radiotherapy for UC.
* Upper urinary tract disease, unless all disease is planned to be resected in the same surgery as for UBC. This includes non-muscle-invasive disease.
* Prior CTLA-4, LAG3 or PD-1/PD-L1-targeting immunotherapy.
* Known active Human Immunodeficiency Virus infection, or tuberculosis, or other active infection:
* HIV-positive patients are eligible if the following applies:
* No AIDS defining opportunistic infection within the last year and a current CD4 count \>350 cells/uL.
* Received antiretroviral therapy (ART) for at least 4 weeks prior to treatment and continued while enrolled on study
* CD4 counts and viral load are monitored per standard of care by a local health care provider
* In patients with a known history of hepatitis B or hepatitis C infection, Hepatitis B surface antigen or Hepatitis C ribonucleic acid (RNA) should be negative
* Underlying medical conditions that, in the investigator's opinion, will make the administration of study drug hazardous or obscure the interpretation of adverse events. Examples may include severe pulmonary disease with extensive radiological abnormalities or intestinal disease causing severe diarrhea, not covered by other eligibility criteria, that may obscure colitis.
* Medical condition requiring the use of immunosuppressive medications, with the exceptions of intranasal and inhaled corticosteroids or systemic corticosteroids at physiological doses, which are not to exceed 10 mg/day of prednisone, or an equivalent corticosteroid. Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication) will be allowed.
* Use of other investigational drugs before study drug administration.
* Malignancy, other than urothelial cancer, in the previous 2 years, with a high chance of recurrence (estimated \>10%). Patients with low-risk prostate cancer (defined as Stage T1/T2a, Gleason score ≤ 6, and PSA ≤ 10 ng/mL) who are treatment-naive and undergoing active surveillance are eligible.
* Pregnant and lactating female patients.
* Major surgical procedure within 4 weeks prior to enrolment or anticipation of need for a major surgical procedure during the course of the study other than for diagnosis.
* Severe infections within 2 weeks prior to enrolment in the study including but not limited to hospitalization for complications of infection, bacteremia, or severe pneumonia.
* Significant cardiovascular disease, such as New York Heart Association cardiac disease (Class II or greater), myocardial infarction within 3 months prior to enrolment, unstable arrhythmias and unstable angina.

Where this trial is running

Arnhem, Gelderland and 8 other locations

• Rijnstate — Arnhem, Gelderland, Netherlands (Not_yet_recruiting)
• Radboud University Medical Center — Nijmegen, Gelderland, Netherlands (Recruiting)
• Nki-Avl — Amsterdam, North Holland, Netherlands (Recruiting)
• Amsterdam UMC (AUMC) — Amsterdam, North Holland, Netherlands (Recruiting)
• Spaarne Gasthuis — Hoofddorp, North Holland, Netherlands (Recruiting)
• Isala — Zwolle, Overijssel, Netherlands (Not_yet_recruiting)
• Leiden University Medical Center (LUMC) — Leiden, South Holland, Netherlands (Recruiting)
• Erasmus Medical Center — Rotterdam, Zuid_Holland, Netherlands (Recruiting)
• University Medical Center Utrecht — Utrecht, Netherlands (Recruiting)

Study contacts

• Principal investigator: Michiel Van der Heijden, PhD — The Netherlands Cancer Institute
• Study coordinator: Michiel Van der Heijden, PhD

Conditions Urologic Neoplasms; Urogenital Neoplasms; Neoplasms by Site; Neoplasms; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Urinary Bladder Diseases