Using Avelumab and Methotrexate to Treat Low-risk Gestational Trophoblastic Neoplasias

TROPHAMET, a Phase I/II Trial of Avelumab and METhotrexate in Low-risk Gestational TROPHoblastic Neoplasias as First Line Treatment

This study is testing if combining avelumab with methotrexate can help women with low-risk gestational trophoblastic neoplasias feel better and have fewer side effects than standard chemotherapy.

Quick facts

• Phase: Phase1; Phase2
• Study type: Interventional
• Enrollment: 26 (estimated)
• Ages: 18 Years and up
• Sex: Female
• Sponsor: Hospices Civils de Lyon (Academic / other)
• Drugs / interventions: avelumab, ipilimumab, tremelimumab, chemotherapy, methotrexate, prednisone, pembrolizumab
• Locations: 9 sites (Pierre-Bénite, Pierre Bénite and 8 other locations)
• Trial ID: NCT04396223 on ClinicalTrials.gov

What this trial studies

This clinical trial investigates the use of avelumab, an anti-PDL1 monoclonal antibody, in combination with methotrexate as a first-line treatment for women with low-risk gestational trophoblastic neoplasias (GTN). The study aims to improve treatment outcomes for patients who have elevated hCG levels after the evacuation of hydatidiform moles. By targeting the immune response associated with GTN, the trial seeks to provide a less toxic alternative to traditional chemotherapy regimens. Participants will be monitored for hCG normalization as a measure of treatment success.

Who should consider this trial

Good fit: Ideal candidates for this study are women over 18 years old diagnosed with low-risk gestational trophoblastic neoplasia and suitable for methotrexate treatment.

Not a fit: Patients with high-risk gestational trophoblastic neoplasia or those who do not meet the eligibility criteria may not benefit from this study.

Why it matters

Potential benefit: If successful, this treatment could offer a more effective and less toxic option for women with low-risk GTN, potentially improving their quality of life and future fertility.

How similar studies have performed: While traditional treatments for GTN have shown varying success rates, the use of avelumab in this context is a novel approach that has not been extensively tested in previous studies.

Eligibility criteria

Inclusion Criteria:

* \- Woman older than 18 years
* Low-risk gestational trophoblastic neoplasia according to FIGO score (FIGO score ≤ 6) with indication of methotrexate as first line treatment
* Patients with Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2
* Patients with adequate bone marrow function measured within 28 days prior to administration of study treatment as defined below

  * Absolute granulocyte count ≥ 1.5 x 10 9 /L
  * Platelet count ≥ 100 x 10 9 /L
  * Haemoglobin ≥ 9.0 g/dL (may have been blood transfused)
* Patients with adequate renal function:

  \* Calculated creatinine clearance ≥ 30 ml/min according to the Cockcroft-Gault formula (or local institutional standard method)
* Patients with adequate hepatic function

  \*Serum bilirubin ≤ 1.5 x UNL and AST/ALT ≤ 2.5 X UNL (≤ 5 X UNL for patients with liver metastases)
* Patients must have a life expectancy ≥ 16 weeks
* Confirmation of non-childbearing status for women of childbearing potential.

An evolutive pregnancy can be ruled out in the following cases:

* in case of a previous hysterectomy
* if serum hCG level ≥ 2 000 IU/L and no intra or extra-uterine gestational sac is detected on pelvic ultrasound
* if serum hCG level \< 2 000 IU/L on a first measurement and serum hCG increases \<100% on a second measurement performed 3 days later.

  * Highly effective contraception if the risk of conception exists. (Note: The effects of the trial drug on the developing human fetus are unknown; thus, women of childbearing potential must agree to use 2 highly effective contraceptions, defined as methods with a failure rate of less than 1 % per year. Highly effective contraception is required at least 28 days prior, throughout and for at least 12 months after avelumab treatment.
  * Patients who gave its written informed consent to participate to the study
  * Patients affiliated to a social insurance regime
  * Patient is willing and able to comply with the protocol for the duration of the treatment

Exclusion Criteria:

* Prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti- CTLA 4 antibody (including ipilimumab, tremelimumab or any other antibody or drug specifically targeting T-cell costimulation or immune checkpoint pathways).
* Illness, incompatible with avelumab, such as congestive heart failure; respiratory distress; liver failure; uncontrolled epilepsy; allergy.
* Patients with a known allergic hypersensitivity to methotrexate or any of the other ingredients (sodium chloride, sodium hydroxide, and hydrochloric acid if excipient)
* Patients with second primary cancer, except: adequately treated non-melanoma skin cancer, curatively treated in-situ cancer of the cervix, or other solid tumours curatively treated with no evidence of disease for ≥ 5 years.
* All subjects with brain metastases, except those meeting the following criteria:

  * Brain metastases that have been treated locally and are clinically stable for at least 2 weeks prior to enrolment, No ongoing neurological symptoms that are related to the brain localization of the disease (sequelae that are a consequence of the treatment of the brain metastases are acceptable).
  * Subjects with brain metastases must be either off steroids except a stable or decreasing dose of \<10mg daily prednisone (or equivalent).
* Patients receiving any systemic chemotherapy, radiotherapy (except for palliative reasons), within 2 weeks from the last dose prior to study treatment (or a longer period 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.
* Persistent toxicities (\>=CTCAE grade 2) with the exception of alopecia and sensory neuropathy, caused by previous cancer therapy.
* Treatment with other investigational agents.
* Bowel occlusive syndrome, inflammatory bowel disease, immune colitis, or other gastro-intestinal disorder that does not allow oral medication such as malabsorption.
* Stomatitis, ulcers of the oral cavity and known active gastrointestinal ulcer disease
* Clinically significant (i.e., active) and severe cardiovascular disease according to investigator opinion such as myocardial infarction (\< 6 months prior to enrollment)
* Patients with immune pneumonitis, pulmonary fibrosis
* Known severe hypersensitivity reactions to monoclonal antibodies, any history of anaphylaxis, or uncontrolled asthma (ie, 3 or more features of partially controlled asthma Global Initiative for Asthma 2011).
* Known human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) related illness.
* Active infection requiring systemic therapy.
* Positive test for HBV surface antigen and / or confirmatory HCV RNA (if anti-HCV antibody tested positive)
* Administration of a live vaccine within 30 days prior to study entry.
* Current or prior use of immunosuppressive medication within 7 days prior to start of study treatment.

The following are exceptions to this exclusion criterion:

* Intranasal, inhaled, topical steroids, or local steroid injections (eg, intra-articular injection);
* Systemic corticosteroids at physiologic doses not to exceed 10 mg/day of prednisone or equivalent;
* Steroids as premedication for hypersensitivity reactions (eg, CT scan premedication).

  * Active autoimmune disease that might deteriorate when receiving an immunostimulatory agents.

Patients with diabetes type I, vitiligo, psoriasis, hypo- or hyperthyroid disease not requiring immunosuppressive treatment are eligible.

* Female patients who are pregnant or lactating, or are of childbearing potential and not practicing a medically acceptable method of birth control.
* Treatment with oral anticoagulant such Coumadin.
* Alcoholism (patient interview, investigator judgment)
* Resting ECG with QTc \> 470msec on 2 or more time points within a 24 hour period or family history of long QT syndrome. Torsades de Pointes, arrhythmias (including sustained ventricular tachyarrhythmia and ventricular fibrillation, bradycardia defined as \<50 bpm), right bundle branch block and left anterior hemiblock (bifascicular block), unstable angina, coronary/peripheral artery bypass graft, symptomatic congestive heart failure (CHF New York Heart Association Class III or IV), cerebrovascular accident, transient ischemic attack or symptomatic pulmonary embolism.
* Prior organ transplantation, including allogeneic stem cell transplantation (excluding autologous bone marrow transplant)
* Patients under guardianship.

Where this trial is running

Pierre-Bénite, Pierre Bénite and 8 other locations

• Centre Hospitalier Lyon Sud — Pierre-Bénite, Pierre Bénite, France (Recruiting)
• Institut Bergonié — Bordeaux, France (Recruiting)
• Centre François Baclesse — Caen, France (Not_yet_recruiting)
• Centre Oscar Lambret — Lille, France (Not_yet_recruiting)
• Institut Paoli-Calmettes — Marseille, France (Not_yet_recruiting)
• Centre Antoine Lacassagne — Nice, France (Recruiting)
• Assistance Publique Hôpitaux de Paris — Paris, France (Recruiting)
• Centre Eugène Marquis — Rennes, France (Recruiting)
• Institut Universitaire du Cancer de Toulouse - Oncopole — Toulouse, France (Recruiting)

Study contacts

• Study coordinator: Benoit YOU, MD

Conditions Gestational Trophoblastic Neoplasias; avelumab; methotrexate; PDL1; gestational trophoblastic neoplasias, GTN; hydatiform mole; hCG,