LDR Brachytherapy + Immunotherapy for Melanoma

Overseen By Jay Ciezki, MD

Age: 18+

Sex: Any

Trial Phase: Phase 1

Sponsor: Case Comprehensive Cancer Center

Must not be taking: Systemic corticosteroids

Disqualifiers: Uveal melanoma, Uncontrolled illness, Others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Breakthrough Therapy This drug has been fast-tracked for approval by the FDA given its high promise

Approved in 4 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 15

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests a new approach for treating advanced skin, kidney, and bladder cancers. It combines low dose rate brachytherapy (a type of internal radiation therapy) with standard immunotherapy to assess the combination's effectiveness. Participants will first receive a single brachytherapy treatment, followed by regular doses of the immunotherapy drug nivolumab (also known as Opdivo). The trial seeks patients with stage III or IV melanoma, stage IV renal cell cancer, or stage IV urothelial cancer who haven't had recent treatment and meet certain health criteria. As a Phase 1 trial, the research focuses on understanding how the treatment works in people, offering participants the opportunity to be among the first to receive this innovative combination therapy.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop taking your current medications, but you cannot have had prior anti-cancer therapy for melanoma, renal cell cancer, or urothelial cancer less than 14 days before starting the study treatment. Also, you cannot be on high doses of systemic corticosteroids.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research has shown that low dose rate brachytherapy, a type of internal radiation treatment, is generally safe. It effectively targets tumors and reduces the chance of recurrence. However, side effects can occur, especially if the tumor is near sensitive areas like the eye, where 20% of patients experienced issues.

Nivolumab, an immunotherapy drug approved for treating melanoma, has been shown in long-term studies to be well-tolerated. Patients using nivolumab alone or with another drug, ipilimumab, have demonstrated good survival rates over many years. While nivolumab is generally safe, side effects can range from mild to serious.

In summary, both treatments, low dose rate brachytherapy and nivolumab, have shown promising safety in previous research. However, discussing individual risks and benefits with a healthcare provider is important. ^{1 2 3 4 5}

Why are researchers excited about this trial's treatments?

Researchers are excited about the combination of LDR brachytherapy and immunotherapy with nivolumab for melanoma because it offers a unique approach compared to current treatments like surgery, chemotherapy, and radiation. This treatment uses a two-step process, starting with brachytherapy to trigger the release of cancer antigens, which can enhance the immune system's ability to recognize and attack melanoma cells. Following this, nivolumab, an immune checkpoint inhibitor, is administered to boost the body's natural defenses against cancer. This combined approach aims to not only target the visible tumor but also help prevent the spread and recurrence of melanoma by stimulating a stronger immune response.

What evidence suggests that LDR brachytherapy combined with immunotherapy could be effective for melanoma?

Research has shown that low dose rate (LDR) brachytherapy effectively treats certain types of melanoma, particularly in the eye. For instance, one study found that 93% of patients with uveal melanoma achieved local cancer control using LDR brachytherapy.

In this trial, participants will receive LDR brachytherapy followed by standard of care (SOC) immunotherapy, which includes Nivolumab. Nivolumab, a common immunotherapy drug, has shown promising results for advanced melanoma. In clinical trials, 44% of patients treated with Nivolumab alone survived for five years. When combined with another drug, Yervoy, the five-year survival rate increased to 52%. These findings suggest that LDR brachytherapy followed by Nivolumab could effectively treat melanoma and possibly other cancers. ^{6 7 8 9 10}

Who Is on the Research Team?

Jay Ciezki

Principal Investigator

Cleveland Clinic, Case Comprehensive Cancer Center

Are You a Good Fit for This Trial?

This trial is for adults with certain advanced cancers (stage III/IV melanoma, stage IV kidney or urothelial cancer) who are in fair to good health and not pregnant. They must have measurable disease, meet specific lab value criteria, and agree to use contraception if applicable. It's not for those with other active metastatic cancers needing treatment, recent anti-cancer therapy, high-dose steroid use, uncontrolled HIV/hepatitis, certain types of melanoma or brain radiation history.

Inclusion Criteria

Your blood test results need to be within certain ranges.

My cancer is advanced and cannot be removed by surgery.

I am a woman who is either postmenopausal, surgically sterile, or using contraception.

Exclusion Criteria

Unwilling or unable to follow protocol requirements

Any condition which in the Investigator's opinion deems the participant an unsuitable candidate to receive study treatment

I do not have active cancer needing treatment, except for skin, kidney, or bladder cancer.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Brachytherapy

Participants receive one treatment of low-dose-rate brachytherapy on treatment day 1

1 day

1 visit (in-person)

Immunotherapy

Participants begin standard of care immunotherapy after brachytherapy, administered on day 1 of each cycle

Up to 12 months

Every 14, 21, 28, or 42 days (in-person)

Follow-up

Participants are monitored for tumor response and overall survival

12 months after brachytherapy

What Are the Treatments Tested in This Trial?

Interventions

• Low Dose Rate Brachytherapy (LDR)
• Nivolumab

Trial Overview The study tests adding low dose rate brachytherapy (LDR), a type of internal radiation therapy, to the standard immune checkpoint inhibitors used in treating advanced skin cancer (melanoma), kidney cancer (renal cell carcinoma), and bladder cancer (urothelial). The goal is to see how well they work together.

How Is the Trial Designed?

Group I: LDR + SOC Immunotherapy Experimental Treatment 2 Interventions

Participants will receive one treatment of brachytherapy on treatment day 1 (LDRD1). After a minimum of 7 days but no more than 30 days to allow antigenic release, participants will then begin immunotherapy treatment with SOC immunotherapy at the standard FDA-approved dose. Standard immunotherapy will be administered on D1 of every standard of care cycle (either 14, 21, 28, or 42 day cycle) at the standard dose. Participants can receive up to 1 year of SOC immunotherapy.

Nivolumab is already approved in United States, European Union, Canada, Switzerland for the following indications:

Approved in United States as Opdivo for:

• Advanced or metastatic gastric cancer
• Gastroesophageal junction cancer
• Esophageal adenocarcinoma
• Melanoma
• Non-small cell lung cancer
• Renal cell carcinoma
• Hodgkin lymphoma
• Head and neck squamous cell carcinoma
• Urothelial carcinoma
• Colorectal cancer
• Hepatocellular carcinoma
• Esophageal squamous cell carcinoma

Approved in European Union as Opdivo for:

• Melanoma
• Non-small cell lung cancer
• Renal cell carcinoma
• Hodgkin lymphoma
• Head and neck squamous cell carcinoma
• Urothelial carcinoma
• Colorectal cancer
• Gastric cancer
• Gastroesophageal junction cancer
• Esophageal adenocarcinoma

Approved in Canada as Opdivo for:

• Melanoma
• Non-small cell lung cancer
• Renal cell carcinoma
• Hodgkin lymphoma
• Head and neck squamous cell carcinoma
• Urothelial carcinoma
• Colorectal cancer
• Gastric cancer
• Gastroesophageal junction cancer
• Esophageal adenocarcinoma

Approved in Switzerland as Opdivo for:

• Melanoma
• Non-small cell lung cancer
• Renal cell carcinoma
• Hodgkin lymphoma
• Head and neck squamous cell carcinoma
• Urothelial carcinoma
• Colorectal cancer
• Gastric cancer
• Gastroesophageal junction cancer
• Esophageal adenocarcinoma

Who Is Running the Clinical Trial?

Case Comprehensive Cancer Center

Lead Sponsor

Trials

472

Recruited

33,400+

Published Research Related to This Trial

In a phase 3 trial involving 405 patients with advanced melanoma, nivolumab resulted in a significantly higher objective response rate (31.7%) compared to investigator's choice of chemotherapy (10.6%), indicating its superior efficacy as a treatment option.

Nivolumab was associated with fewer severe adverse effects compared to chemotherapy, with only 5% of patients experiencing serious drug-related side effects, suggesting it is a safer alternative for patients who have progressed after previous treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nivolumab versus chemotherapy in patients with advanced melanoma who progressed after anti-CTLA-4 treatment (CheckMate 037): a randomised, controlled, open-label, phase 3 trial. Weber, JS., D'Angelo, SP., Minor, D., et al.[2022]

The combination of nivolumab and relatlimab shows a manageable safety profile for patients with advanced melanoma who have already undergone treatment.

This combination therapy may offer a new option for patients with pretreated melanoma, suggesting potential efficacy in this challenging patient population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nivolumab Plus Relatlimab Is Safe and Efficacious in Pretreated Melanoma. [2023]

In a real-world study of 709 patients with advanced melanoma treated with ipilimumab plus nivolumab, 50.7% experienced severe treatment-related adverse events, highlighting the need for careful monitoring during therapy.

Despite the high rate of adverse events, the combination therapy showed promising long-term survival outcomes, with a median overall survival of 28.7 months and a 4-year overall survival rate of 50% for patients similar to those in the CheckMate-067 trial.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Real-world Outcomes of Ipilimumab Plus Nivolumab Combination Therapy in a Nation-wide Cohort of Advanced Melanoma Patients in the Netherlands. van Zeijl, MCT., van Breeschoten, J., de Wreede, LC., et al.[2023]

Nivolumab, an immune checkpoint inhibitor, shows strong antitumor activity but is associated with immune-related adverse events that can affect patient safety and treatment continuation, necessitating careful monitoring.

Long-term safety data, including a 5-year follow-up, suggests that nivolumab can be safely administered to various challenging patient subgroups, but identifying biomarkers for severe toxicity could improve patient selection for this therapy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An update on the safety of nivolumab for the treatment of advanced melanoma. Czarnecka, AM., Rutkowski, P.[2021]

Nivolumab significantly improved overall survival and progression-free survival in patients with unresectable or metastatic melanoma compared to dacarbazine, with hazard ratios of 0.42 and 0.43 respectively, based on a trial involving 418 patients.

The most common side effects of nivolumab included fatigue, diarrhea, and rash, but it was still considered to have a favorable benefit-risk profile compared to dacarbazine.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

FDA Approval of Nivolumab for the First-Line Treatment of Patients with BRAFV600 Wild-Type Unresectable or Metastatic Melanoma. Beaver, JA., Theoret, MR., Mushti, S., et al.[2018]

In the phase III CheckMate 238 trial, 67.7% of patients receiving nivolumab experienced treatment-related adverse events (TRAEs), with the most common being pruritus and diarrhea, primarily occurring within the first 3 months of treatment.

Despite the high incidence of TRAEs, there was no significant association found between these adverse events and recurrence-free survival (RFS), indicating that the safety profile of nivolumab remains consistent and does not negatively impact long-term outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adjuvant nivolumab for stage III/IV melanoma: evaluation of safety outcomes and association with recurrence-free survival. Mandala, M., Larkin, J., Ascierto, PA., et al.[2022]

Combining nivolumab with ipilimumab results in higher response rates in cancer treatment compared to using nivolumab alone, indicating a potentially more effective therapeutic strategy.

This combination therapy may enhance the immune response against cancer, but specific details on the number of subjects or study duration are not provided in the abstract.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nivolumab plus Ipilimumab Achieves Responses in dMMR/MSI-H Tumors. [2019]

In a randomized trial comparing FDA-approved immune checkpoint inhibitors for advanced melanoma, pembrolizumab showed significantly better treatment outcomes than ipilimumab.

This study is notable as it is the first to directly compare these two therapies as first-line treatments, highlighting pembrolizumab's potential as a more effective option for patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pembrolizumab superior to ipilimumab in melanoma. [2017]

Nivolumab is shown to be the most cost-effective treatment option for advanced melanoma patients in England, with incremental cost-effectiveness ratios of £24,483 for BRAF mutation-negative and £17,362 for mutation-positive patients.

The analysis utilized a Markov state-transition model based on patient-level data from clinical trials, indicating that nivolumab provides long-term survival benefits while being economically favorable compared to other treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The cost-effectiveness of nivolumab monotherapy for the treatment of advanced melanoma patients in England. Meng, Y., Hertel, N., Ellis, J., et al.[2020]

In a study of 37 patients with stage IV metastatic melanoma, high levels of soluble CD73 (sCD73) enzyme activity in the serum were linked to significantly poorer overall survival and progression-free survival when treated with nivolumab.

Patients with high sCD73 activity had a median progression-free survival of only 2.6 months compared to 14.2 months for those with lower activity, suggesting that measuring sCD73 could help predict how well patients will respond to nivolumab therapy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Soluble CD73 as biomarker in patients with metastatic melanoma patients treated with nivolumab. Morello, S., Capone, M., Sorrentino, C., et al.[2018]

In mouse models of BRAF- and NRAS-mutant melanoma, the sequence of immunotherapy (IT) followed by targeted therapy (TT) significantly improved antitumor responses compared to either treatment alone.

The IT→TT sequence enhanced the immune environment by increasing T cell and natural killer cell infiltration while reducing suppressive immune cells, leading to durable responses that depended on T-cell activity.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Targeted Therapy Given after Anti-PD-1 Leads to Prolonged Responses in Mouse Melanoma Models through Sustained Antitumor Immunity. Phadke, MS., Chen, Z., Li, J., et al.[2022]

Nivolumab, a monoclonal antibody targeting the programmed death receptor-1, has shown promising efficacy in treating advanced malignant melanoma, with nearly 25% of patients achieving a partial tumor response in a phase II trial involving previously treated stage III/IV patients.

The treatment demonstrated a durable clinical benefit, with a median progression-free survival of 172 days and an acceptable safety profile, as less than 18% of patients experienced severe adverse events.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nivolumab: a review of its use in patients with malignant melanoma. Deeks, ED.[2021]

Citations

1. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/35644778/

Ocular malignancies treated with iodine-125 low dose rate ... The aim of our study is to document our cases of choroidal melanoma treated with low dose rate (LDR) brachytherapy and to correlate the ...

2. ophthalmologyretina.org ophthalmologyretina.org/article/S2468-6530(25)00362-8/abstract

Efficacy of Low-Dose-Rate Iodine-125 Plaque ... We performed a single-center, retrospective chart review of all patients diagnosed with uveal melanoma from 1984 to 2022 in accordance with the ...

3. sciencedirect.com sciencedirect.com/science/article/abs/pii/S0958394722000462

Ocular malignancies treated with iodine-125 low dose rate ... The aim of our study is to document our cases of choroidal melanoma treated with low dose rate (LDR) brachytherapy and to correlate the dosimetry and ...

4. thegreenjournal.com thegreenjournal.com/article/S0167-8140(25)00070-2/fulltext

Dose response relation for optic nerve atrophy at low ... Brachytherapy is one of the most effective methods treating small and medium sized uveal melanoma [31,39,43]. The primary goals are to preserve the organ and ...

5. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/40789531/

Efficacy of Low-Dose-Rate Iodine-125 Plaque ... Results: Of 1807 patients, 1674 (93%) achieved local control, 762 (42%) developed radiation retinopathy, and 332 (18%) developed radiation optic ...

6. ro-journal.biomedcentral.com ro-journal.biomedcentral.com/articles/10.1186/s13014-024-02580-w

Efficacy and safety of proton radiotherapy in treating choroidal ... The 1-, 3-, 5-, and 10-year local control rates of choroidal melanoma patients treated using PBT were 98%, 92%, 94%, and 88%, respectively. This ...

7. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11919603/

Clinical outcomes and risk factors for local failure and visual ... Local control 5 years after Ru-106 brachytherapy for uveal melanoma was high: 92 %. However, local failure is common in juxtapapillary tumours: 20%.

8. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10513906/

The oncologic and safety outcomes of low-dose-rate ... The 7-year biochemical progression-free survival of LDR brachytherapy was significantly higher than that of DE-EBRT both in intermediate- and high-risk patients ...

9. nature.com nature.com/articles/s41598-020-68232-7

Forty-year prognosis after plaque brachytherapy of uveal ... 172 of 209 (82%) uveal melanoma-related deaths occurred within the first decade after brachytherapy. Relative survival rates were 74% at 5 years ...

10. thegreenjournal.com thegreenjournal.com/article/S0167-8140(21)08799-5/fulltext

Local tumor control and treatment related toxicity after ... We present a systematic review of the literature from the last sixteen years on EPB treatment of UM. Ru-106 EPB provided high local control outcomes.