Clinical Trial Details
— Status: Active, not recruiting
Administrative data
| NCT number |
NCT04248582 |
| Other study ID # |
SHAH 008 |
| Secondary ID |
|
| Status |
Active, not recruiting |
| Phase |
Phase 1
|
| First received |
|
| Last updated |
|
| Start date |
February 11, 2020 |
| Est. completion date |
March 1, 2024 |
Study information
| Verified date |
September 2023 |
| Source |
Hunter Holmes Mcguire Veteran Affairs Medical Center |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
Background: In published studies, complete response (CR) to chemoradiation occurs in only
25-30% of patients with locally advanced esophageal cancer. Liquid nitrogen spray cryotherapy
(LNSC) is postulated to stimulate an anti-tumor immune response. In a preliminary study, the
investigators documented CR rate of 56% with a single session of LNSC administered prior to
chemoradiation. Before proceeding with larger trials to corroborate these findings, the
maximally tolerated dose (MTD) of neoadjuvant LNSC must be determined. The aims of this study
are: (1) To determine safety and MTD of LNSC during neoadjuvant chemoradiation in locally
advanced esophageal cancer. (2) To assess whether LNSC results in immunogenic cell death. (3)
To assess changes in tumor micro-environment with LNSC.
Methods: Eligible adult patients with locally advanced esophageal cancer will receive LNSC at
the following dose frequencies: Patient 1, 2, and 3: 2 sessions of LNSC prior to
chemoradiation (chemoXRT); Patients 4, 5, and 6: 2 sessions LNSC prior to chemoXRT, then 1
session during week 4 of chemoXRT; Patients 7, 8, and 9: 2 sessions LNSC prior to chemoXRT,
then 1 session during week 2 and 1 session during week 4 of chemoXRT. If no dose limiting
toxicity (DLT) occurs, the investigators will enroll an additional 3 patients to confirm MTD.
The investigators will contact patients at 48-hours and 1-week post-procedure to evaluate for
adverse events (AEs) and DLTs, and assess for improvements in dysphagia and quality of life
(QOL) using the Mellow-Pinkas and EORTC QLQ-OES18 instruments respectively. The investigators
will obtain peripheral blood for ELISA and biopsies from the tumor to assess
tumor-infiltrating lymphocytes (TILs) and T cell subtypes before the 1st session of LNSC,
before the 2nd session of LNSC, and after chemoradiation is completed.
Expected results: (1) Dose limiting toxicity (DLT) does not occur when patients received 2
session of LNSC prior to chemoXRT, and 2 sessions during chemoXRT (2) LNSC results in
immunogenic cell death, as assessed by increased levels of HMGB1 in serum, and calreticulin
in biopsy specimens (CRT) (3) LNSC is associated with increased T cell infiltration and
activation (increased TILs, CD8+, CD3+ T cells, and granzyme B), and decrease in regulatory T
cells (CD45R0, FOXP3).
Description:
LNSC will be administered as follows: up to three cycles of 20 to 40 seconds each directed at
the bulkiest aspect of the tumor. During each cycle, a surface area of approximately 2 to 3
cm2 is targeted. Up to three sites are treated during each session. Tissue thawing is
verified between cycles by waiting at least 60 seconds before re-treatment, and by observing
a return to baseline color of the tissue and complete disappearance of ice crystals after
reperfusion. After the procedure is completed, patients will be monitored in the recovery
unit for at least 30 minutes. Patients will be discharged after monitoring if they meet the
endoscopy unit's standard discharge criteria.
Cryotherapy dose frequency intervals
1. Two LNSC sessions (patient 1, 2, and 3): 2 sessions of LNSC administered at 2-week
intervals, followed by concurrent chemoradiation for 5 weeks.
2. Three LNSC sessions (patients 4, 5, and 6): 2 sessions of LNSC administered at 2-week
intervals, followed by concurrent chemoradiation for 5 weeks. During week 4 of
chemoradiation, they will receive a session of LNSC.
3. Four LNSC sessions (patients 7, 8, and 9): 2 sessions of LNSC administered at 2-week
intervals, followed by concurrent chemoradiation for 5 weeks. During week 2 and week 4
of chemoradiation, they will receive LNSC (i.e. - 2 sessions during chemoradiation).
- No DLTs: If no patient develops a DLT, then the investigators will enroll an
additional 3 patients to receive 4 LNSC sessions as described earlier, in order to
confirm safety.
- 1 DLT: If 1 of 3 patients develops a DLT, then the investigators will enroll 3
additional patients to receive LNSC at that dose. If any of the additionally
enrolled patients develop a DLT, the investigators will enroll 3 patients at the
previous dose, to confirm safety of the lower dose frequency.
- 2 DLTs: At a given dose frequency interval, if 2 of 3 patients develop a DLT, then
the investigators will enroll 3 patients at the previous dose, to confirm safety of
the lower dose frequency.
Definition of Adverse Events (AEs) and Dose Limiting Toxicity (DLT) We will define adverse
AEs based on the American Society of Gastrointestinal Endoscopy (ASGE) lexicon (Appendix 2).
The relationship of the AE to LNSC will be classified using the following 4 categories:
definitely related, likely related, unlikely related, and definitely not related. DLT will be
defined as any severe or fatal adverse event that is definitely or likely related to the
cryotherapy procedure (i.e. - unplanned admission > 10 nights, intensive care unit admission
> 1 night, surgery for an adverse event, permanent disability due to an adverse event, or
death). A member of the study team will contact patients and review their medical records 48
hours after the procedure, and 1 week after the procedure to assess for mild, moderate, and
severe adverse events (AEs). In addition to recording any AEs, the study coordinator will
contact a physician investigator if any AEs are reported in order to direct appropriate
clinical management. An independent data safety monitoring (DSM) committee will review AEs
every 3 months for the duration of the study to determine whether the AE was definitely or
likely related to the LNSC procedure. Additionally, if a serious adverse event (SAE) is
reported, then the DSM will meet within one week to determine if the SAE represents a DLT.
Tissue morphology, flow cytometry, and immunohistochemistry (IHC) The investigators will
obtain peripheral blood and 6 mucosal biopsies (2 mm X 2 mm) immediately prior to the first
and second session of cryotherapy, and at the end of chemoradiation. The investigators will
obtain half the biopsies from the center, and half the biopsies from the periphery of the
tumor. If the patient proceeds directly to surgery following chemoradiation without
endoscopy, then the investigators will obtain archival tissue from the explant specimen. The
investigators will place 2 biopsies in 4% paraformaldehyde (PFA) for TILs analysis (1 center
and 1 periphery), 2 biopsies in 4% PFA for IHC analysis (1 center and 1 periphery), and 2
biopsies for exploratory analyses/backup. To assess for evidence of immunogenic cell death,
the investigators will perform IHC on biopsy specimens for CRT, and ELISA on peripheral blood
for HMBG1. A pathologist blinded to patient demographics, and treatment allocation will grade
overall inflammation using standard criteria and as sparse, moderate, or pronounced TILs. To
assess the immune infiltrate, the investigators will construct tissue microarray (TMA) blocks
and analyze in an automated immunostainer for antibodies against the following antigens: CD3,
CD8, CD45R0/FoxP3, and Pan-CK.
Other Data Collection Baseline variables: Baseline variables will include age, gender,
ethnicity, tumor histology and TNM stage, location and length of tumor, presence or absence
of critical organ invasion (i.e. - aorta, trachea, heart, and vertebral body), ECOG
performance status, baseline Mellow-Pinkas dysphagia score, and a validated measure of
quality of life in esophageal cancer, the EORTC QLQ-OES18.
Assessment of pathologic/clinical complete response: At the completion of neo-adjuvant
chemoradiation, results of the re-staging PET-CT and surgical explant will be abstracted to
document presence or absence of a pathologic complete response. As is standard protocol at
our institutions, patients who do not undergo surgery will undergo upper endoscopy with
biopsies along with PET-CT to assess for the presence or absence of a clinical complete
response.
Assessment of palliation efficacy: A member of the study team will contact each patient at
1-week after each LNSC procedure to update the Mellow-Pinkas dysphagia score and EORTC
QLQ-OES18. The investigators will also document if there was any need for an esophageal
stent, enteral feeding tube, or parenteral nutrition support during chemoradiation.
