Human stem cell derived neuron

A Randomized, Double-Blinded, Pilot Trial of Neoadjuvant Checkpoint Inhibition Followed by Combination Adjuvant Checkpoint Inhibition in Children and Young Adults With Recurrent or Progressive High Grade Glioma (PNOC019)


The phase I trial will evaluate the safety and efficacy of nivolumab and ipilimumab before and after surgery in treating children and young adults with recurrent or progressive high grade glioma (HGG, WHO grades III-IV) who are candidates for surgical resection of the tumor. 

The timing of how, and when, immunotherapy is initiated may be critical for an optimal immune response. Neoadjuvant immunotherapy with nivolumab and ipilimumab, prior to surgery, may help the body's immune system attack the cancer, and may interfere with growth and spread of tumor cells. Both nivolumab and ipilipmumab are intravenously administered. 

Nivolumab is an antibody-based immunotherapy that helps energize a patient’s immune system against tumor cells. It’s been approved for use in several cancers, and is currently being investigated for glioblastoma. 

Nivolumab is designed to block the activity of PD-1, a protein that normally protects the body from attacking itself. PD-1 prevents immune cells from attacking by detecting a molecular signal (called PD-L1) made by various cells across the body. Some cancer cells take advantage of this protection mechanism making the protective signal themselves. Nivolumab directly binds PD-L1, thus blocking the activity of PD-1. This allows the immune system to activate its T-cells and recognize the tumor as cells to be attacked.

Ipilimumab an antibody-based immunotherapy that works to activate the immune system by targeting CTLA-4, a protein found on T-cells. Ipilimumab is a checkpoint inhibitor that binds to CTLA-4 and blocks the mediated downregulation of T-cell activation. This leads to a cytotoxic T-lymphocyte (CTL)-mediated immune response against cancer cells. CTLA4, an inhibitory receptor and member of the immunoglobulin superfamily, plays a key role in the downregulation of the immune system.

This phase I study will evaluate the safety and efficacy of nivolumab and ipilimumab before and after surgery in treating children and young adults with recurrent or progressive high grade glioma. Eligible participants will all receive the same combination of nivolumab and ipilimumab after surgery, however the participants will be randomized into the following groups for neoadjuvant treatment before surgery:

  • Experimental Group A: [Before surgery] Nivolumab + placebo
  • Experimental Group B: [Before surgery] Nivolumab + ipilimumab
  • Experimental Group C: [Before surgery] Placebo + ipilimumab


Inclusion Criteria
  1. Participants with recurrent or progressive HGG (World Health Organization (WHO) grade III or grade IV) who are candidates for surgical tumor debulking will be enrolled in this trial
  2. All assessments are to occur within 14 days of registration except where otherwise noted. The participant and their legal parent/guardian must be thoroughly informed about all aspects of the study, including the study visit schedule and required evaluations and all regulatory requirements for informed consent. The written informed consent must be obtained from the participant and legal parent/guardian prior to enrollment
  3. Have a history of previously treated histologically confirmed World Health Organization grade III or IV HGG. Previous first line therapy with radiation and/or chemotherapy
  4. Have evidence of recurrence or progression of disease by MRI scan
  5. Participants must be adequate medical candidates for surgical resection. The intent of surgical resection is to allow both cytoreduction and tumor debulking as part of standard of care, and also collect a minimum of 100 mg of tumor tissue for the study tissue endpoints
  6. A primary goal of surgery must be cytoreduction, and not solely on diagnostic biopsy
  7. Karnofsky >= 50 for participants > 16 years of age and Lansky >= 50 for participants =< 16 years of age. Participants who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score
  8. Prior Therapy: Participants must have fully recovered from the acute toxic effects of all prior anti-cancer therapy and must meet the following minimum duration from prior anti-cancer directed therapy prior to enrollment. If after the required timeframe, the defined eligibility criteria are met, e.g. blood count criteria, the patient is considered to have recovered adequately
    1. Cytotoxic chemotherapy or other anti-cancer agents known to be myelosuppressive. At least 21 days after the last dose of cytotoxic or myelosuppressive chemotherapy (42 days if prior nitrosourea)
    2. An interval of at least 12 weeks from the completion of radiation therapy to registration unless there is unequivocal histologic confirmation of tumor progression
    3. Hematopoietic growth factors: At least 14 days after the last dose of a long-acting growth factor (e.g. pegfilgrastim) or 7 days for short acting growth factor. For agents that have known adverse events occurring beyond 7 days after administration, this period must be extended beyond the time during which adverse events are known to occur. The duration of this interval must be discussed with the study chair
    4. Anti-cancer agents not known to be myelosuppressive (e.g. not associated with reduced platelet or absolute neutrophil count [ANC] counts): At least 7 days after the last dose of agent
    5. Interleukins, interferons and cytokines (other than hematopoietic growth factors): >= 21 days after the completion of interleukins, interferon or cytokines (other than hematopoietic growth factors)
    6. Antibodies: >= 21 days must have elapsed from infusion of last dose of antibody, and toxicity related to prior antibody therapy must be recovered to grade =< 1
    7. Participants must not have received prior exposure to PD-1, PD-L1 or CTLA4 inhibitors
    8. Stem cell infusion (with or without total-body irradiation (TBI)):
      1. Allogeneic (non-autologous) bone marrow or stem cell transplant, or any stem cell infusion including donor lymphocyte infusions (DLI) or boost infusion: >= 100 days after infusion, no evidence of graft versus host disease (GVHD) and no requirement for immunosuppression
      2. Autologous stem cell infusion including boost infusion: >= 42 days
  9. Participants must be willing to forego cytotoxic anti-tumor therapies except study-defined therapy while being treated on study
  10. Peripheral absolute neutrophil count (ANC) >= 1000/mm^3
  11. Platelet count >= 100,000/mm^3
  12. Creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70 mL/min/1.73 m^2 OR a serum creatinine based on age/gender as follows:
    1. Age: Maximum Serum Creatinine (mg/dL)
    2. 6 months to < 3 years: 0.6 (male and female)
    3. 3 to < 6 years: 0.8 (male and female)
    4. 6 to < 10 years: 1 (male and female)
    5. 10 to < 13 years: 1.2 (male and female)
    6. 13 to < 16 years: 1.5 (male), 1.4 (female)
    7. >= 16 years: 1.7 (male), 1.4 (female)
  13. Bilirubin (sum of conjugated and unconjugated) =< 1.5 x upper limit of normal (ULN) for age (except participants with Gilbert syndrome who must have a total bilirubin level of < 3.0
  14. Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 3.0 x ULN
  15. Serum albumin >= 2
  16. Pregnancy: The effects of nivolumab and ipilimumab on the developing human fetus are unknown. For this reason women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and 4 months after completion of therapy. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately
  17. MRI within 28 days prior to registration

For the most up-to-date list of criteria, please visit

Exclusion Criteria
  1. Current or planned participation in a study of an investigational agent or using an investigational device
  2. Has a diagnosis of immunodeficiency
  3. Has tumor primarily localized to the brainstem or spinal cord
  4. Has presence of diffuse leptomeningeal disease or extracranial disease
  5. Has received systemic immunosuppressive treatments (such as methotrexate, chloroquine, azathioprine, etc.), aside from anti-neoplastic chemotherapy or systemic corticosteroids within six months of registration
  6. Participants with a concurrent condition requiring systemic treatment with either corticosteroids (> 0.25 mg/kg daily prednisone equivalent) or other immunosuppressive medications within 14 days of start of study treatment. Inhaled or topical steroids, and adrenal replacement steroid doses > 0.25 mg/kg daily prednisone equivalent, are permitted in the absence of active autoimmune disease
  7. Unable to taper steroids due to ongoing mass effect; a maximum dexamethasone dose of 0.1 mg/kg/day is allowed, but preferably have been discontinued (inhaled or topical use of steroids is allowed)
  8. Has a known history of active TB (Bacillus tuberculosis)
  9. Has a known additional malignancy that is progressing or requires active treatment within 3 years of registration. Exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy
  10. Has active autoimmune disease that has required systemic treatment in the past 2 years (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
  11. Has known history of, or any evidence of active non-infectious pneumonitis
  12. Has an active infection requiring systemic therapy
  13. Has a known hypersensitivity to any of the study therapy products
  14. Has a known history of positive test for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS)
    1. NOTE: Testing for HIV must be performed at sites where mandated locally
  15. Any prior positive test result for hepatitis B virus or hepatitis C virus indicating presence of virus, e.g., hepatitis B surface antigen (HBsAg, Australia antigen) positive, or hepatitis C antibody (anti-HCV) positive (except if HCV-ribonucleic acid (RNA) negative)
  16. Any serious or uncontrolled medical disorder that, in the opinion of the investigator may increase the risk associated with study participation or study drug administration, impair the ability of the participant to receive protocol therapy or interfere with interpretation of study results

For the most up-to-date list of criteria, please visit


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