Neoadjuvant Regorafenib in Combination With Nivolumab and Short-course Radiotherapy in Stage II-III Rectal Cancer (REGINA)

A Phase II Trial of Neoadjuvant Regorafenib in Combination With Nivolumab and Short-course Radiotherapy in Stage II-III Rectal Cancer

This is a multicenter, single-arm, phase II study of nivolumab in combination with regorafenib in subjects with locally-advanced rectal cancer who are eligible for a curative treatment including pre-operative SCRT and TME(or watch & wait approach). The study is based on the Simon's two-stage design and a maximum of 60 subjects will be enrolled. In addition to the standard efficacy interim analysis according to the statistical design, a safety interim analysis will be performed on the first 6 subjects who have completed the study treatment to ensure safe continuation of the study investigation.

Eligible subjects will be treated according to the following sequential treatment plan:

• Induction treatment: This consists of treatment with nivolumab (240 mg intravenously, on day 1 and 15) and regorafenib (80 mg/day orally, from day 1 to 14)
• Standard SCRT: This consists of 25 Gy delivered in 5 fractions (from day 22 to 26)
• Consolidation treatment: This consists of treatment with nivolumab (240 mg intravenously, on day 29, 43 and 57) and regorafenib (80 mg/day orally, from day 29 to 49)
• Surgery: Surgical resection will be performed according to the principles of TME (between day 74 and 87, i.e., between 7 to 8 weeks after completion of SCRT). As an alternative to surgery, subjects who achieve cCR can be offered a watch & wait approach.
• Adjuvant chemotherapy: Administration of adjuvant chemotherapy will be left to the discretion of the treating physician

The study also includes translational procedures (i.e. collection of tumour biopsies, blood samples and stool samples at pre-specified time points) for exploratory molecular and immune contexture analyses. These are mandatory for all study subjects.

Study Overview

• Status: Recruiting
• Conditions: Rectal Cancer Stage II; Rectal Cancer Stage III
• Intervention / Treatment: Drug: Nivolumab 10 MG/ML Intravenous Solution; Drug: Regorafenib 40 MG Oral Tablet; Radiation: Radiotherapy; Procedure: Surgery; Procedure: Non-operative Management

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Francesco Sclafani, MD; Phone Number: 0032 2 541 7397; Email: francesco.sclafani@bordet.be
• Study Contact Backup: Name: Chloé Velghe; Phone Number: 0032 2 541 7366; Email: ctsu.regina@bordet.be

Study Locations

• Belgium
  • Brussels, Belgium, 1000
    • Recruiting
    • Institut Jules Bordet
    • Contact: Alain Hendlisz, MD; Phone Number: 0032 2 541 31 11; Email: alain.hendlisz@bordet.be
  • Brussels, Belgium, 1070
    • Recruiting
    • Erasme
    • Contact: Jean-Luc Van Laethem, MD; Phone Number: 0032 2 555 3714; Email: jean-luc.van.laethem@ulb.ac.be
  • Bruxelles, Belgium, 1160
    • Recruiting
    • Chirec Delta
    • Contact: Francesco Puleo, MD; Phone Number: 0032 24 34 81 05; Email: francesco.puleo@chirec.be
  • Bruxelles, Belgium, 1200
    • Recruiting
    • Cliniques Universitaires Saint-Luc
    • Contact: Marc Van Den Eynde, MD; Phone Number: 0032 2 764 51 06; Email: marc.vandeneynde@uclouvain.be
  • Charleroi, Belgium, 6000
    • Recruiting
    • Grand Hôpital de Charleroi
    • Contact: Javier Carasco, MD; Phone Number: 0032 7 10 47 32; Email: javier.carrasco@ghdc.be
  • Edegem, Belgium, 2650
    • Recruiting
    • UZAntwerpen
    • Contact: Hans Prenen, MD; Phone Number: 0032 3 821 43 66
  • Gent, Belgium, 9000
    • Recruiting
    • UZ Gent
    • Contact: Karen Geboes, MD; Phone Number: 0032 9 332 23 71; Email: KAREN.GEBOES@uzGent.be
  • Kortrijk, Belgium, 8500
    • Recruiting
    • Az Groeninge
    • Contact: Philippe Vergauwe, MD; Phone Number: 0032 56 63 33 00; Email: philippe.vergauwe@azgroeninge.be
  • Mons, Belgium, 7000
    • Recruiting
    • CHU Ambroise Pare
    • Contact: Marie Diaz, MD; Phone Number: 0032 65 41 37 38; Email: marie.diaz@hap.be
  • Namur, Belgium, 5000
    • Recruiting
    • CHR Namur
    • Contact: Yeter Gökburun, MD; Phone Number: +32 81 72 78 30; Email: yeter.gokburun@chrsm.be
• France
  • Besancon, France, 25030
    • Not yet recruiting
    • Centre Hospitalier Regional Universitaire de Besancon - Hopital Jean Minjoz
    • Contact: Christophe BORG
  • Dijon, France, 21079
    • Not yet recruiting
    • Centre de Lutte Contre le Cancer Georges Francois Leclerc
    • Contact: François GHIRINGHELLI
  • Rouen, France, 76031
    • Not yet recruiting
    • Centre Hospitalier Universitaire de Rouen - Hôpital Charles Nicolle
    • Contact: Frederic DI FIORE

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Female or Male
2. Age ≥ 18 years old
3. Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1
4. Histologically or cytologically verified adenocarcinoma of the rectum
5. Tumour with distal border below the peritoneal reflection and within 15 cm from the anal verge
6. Stage cT3/T4a and Nany or cT1-2 and N+ as documented by baseline pelvic MRI
7. Absence of distant metastases as shown by baseline computed tomography (CT) of the thorax-abdomen or CT scan of the thorax and MRI of the abdomen
8. Adequate haematological function as defined by absolute neutrophil count (ANC) ≥1.5 × 109/L, platelet count ≥100 × 109/L, and haemoglobin ≥9 g/dL
9. Adequate hepatic function as defined by a total bilirubin level ≤1.5 × the upper limit of normal (ULN) range (excluding subjects with known Gilbert's syndrome), and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels ≤2.5 × ULN
10. Adequate renal function as defined by an estimated creatinine clearance ≥30 mL/min according to the Cockcroft-Gault or Wright formula
11. Negative serum pregnancy test at screening (up to 28 days before treatment start) for women of childbearing potential
12. Women of childbearing potential must agree to use of one highly effective method of contraception prior study entry, during the course of the study and at least 5 months after the last administration of study treatment.
13. Men with childbearing potential partner must agree to use condom during the course of this study and for at least 5 months after the last administration of the study treatment.
14. Absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial
15. Absence of clinical conditions that, in the opinion of the investigator, would contraindicate neoadjuvant therapy and/or surgery
16. Life expectancy of at least 3 months
17. Completion of all necessary screening procedures within 28 days prior to enrolment.
18. Signed Informed Consent form (ICF) obtained prior to any study related procedure.

Exclusion Criteria:

1. Any prior or concurrent surgery, chemotherapy, radiotherapy, immunotherapy, biologic or hormonal therapy for rectal cancer. Concurrent use of hormones for noncancer-related conditions (i.e., insulin for diabetes and hormone replacement therapy) is acceptable.
2. Any contraindication to pelvic irradiation as evaluated by the investigator
3. Prior organ transplantation, including allogeneic stem cell transplantation

4. Clinically significant acute or chronic infections including, among others:

   • known history of testing positive test for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS)
   • known history of testing positive for hepatitis B virus (HBV) surface antigen or anti-hepatitis C virus (HCV) antibody and confirmatory HCV ribonucleic acid (RNA) test
5. Active autoimmune disease that might deteriorate when receiving an immunostimulatory agent (subjects with diabetes type I, vitiligo, psoriasis, hypo- or hyperthyroid disease not requiring immunosuppressive treatment are eligible)
6. Systemic corticosteroids administered as hormone replacement or as immunosuppressants at doses exceeding 10 mg/day of prednisone or equivalent. Other immunosuppressive medications including, but not limited to methotrexate, azathioprine, and TNF-α blockers. Use of immunosuppressive medications for the management of treatment-related AEs or in subjects with contrast allergies is acceptable. A temporary period of steroids is allowed for different indications, at the discretion of the investigator (i.e., chronic obstructive pulmonary disease, radiation, nausea, etc.). Administration of steroids through a route known to result in a minimal systemic exposure [topical, intranasal, intro-ocular, or inhalation] is acceptable.
7. Known severe hypersensitivity reactions to the investigational treatments, or any excipients or non-investigational medicinal products or concomitant medications
8. Pregnant and/or lactating women
9. Clinically significant (i.e., active) cardiovascular disease: cerebral vascular accident/stroke, myocardial infarction, unstable angina, congestive heart failure, or serious cardiac arrhythmia requiring medication
10. Prior myocarditis
11. Known history of immune colitis, immune pneumonitis, pulmonary fibrosis or other medical conditions (for example, inflammatory bowel disease, uncontrolled asthma), which, in the opinion of the Investigator, might impair the subject's tolerance of trial treatment
12. Vaccination within 28 days of the first dose of study treatment and while on trial (except for administration of inactivated vaccines)
13. Other invasive malignancy within 2 years except for non-invasive malignancies such as cervical carcinoma in situ, non-melanomatous carcinoma of the skin or ductal carcinoma in situ of the breast that has/have been surgically cured. Anti-neoplastic treatment received in the past for malignancies cured 2 or more years before enrolment are permitted.
14. Any investigational anti-cancer therapy other than the protocol specified therapies.
15. Strong inhibitors of CYP3A4 activity (e.g. clarithromycin, grapefruit juice, itraconazole, ketoconazole, posaconazole, telithromycin and voriconazole), strong UGT1A9 inhibitors (e.g. mefenamic acid, diflunisal, and niflumic acid), and strong inducers of CYP3A4 (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital and St. John's wort) from 28 days before study enrolment up to the end of study treatment.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Single arm; Induction treatment: treatment with nivolumab (240 mg intravenously on day 1 and 15) and regorafenib (80 mg/day orally from day 1 to 14); Standard SCRT: consists of 25 Gy delivered in 5 fractions (from day 22 to 26); Consolidation treatment: treatment with nivolumab (240 mg intravenously on day 29, 43 and 57) and regorafenib (80 mg/day orally from day 29 to 49); Surgery: Surgical resection will be performed according to the principles of TME (between day 74 and 87, i.e., between 7 to 8 weeks after completion of SCRT). As an alternative to surgery, subjects who achieve cCR can be offered a watch & wait approach.; Adjuvant chemotherapy: Administration of adjuvant chemotherapy will be left to the discretion of the treating physician The study also includes translational procedures (collection of tumour biopsies, blood and stool samples at pre-specified time points) for exploratory molecular and immune contexture analyses. These are mandatory for all study subjects.

Drug: Nivolumab 10 MG/ML Intravenous Solution; Nivolumab will be given at a dose of 240 mg during the pre-operative phase only as indicated below: On day 1 and 15, during the "Induction treatment"; On day 29, 43 and 57, during the "Consolidation treatment"; Drug: Regorafenib 40 MG Oral Tablet; Regorafenib will be administered orally once a day at a dose of 80 mg/day (2 tablets of 40 mg), during the pre-operative phase only as indicated below: From day 1 to 14, during the "Induction treatment"; From day 29 to 49, during the "Consolidation treatment"; Radiation: Radiotherapy; All study subjects will receive 5 daily fractions of radiotherapy. Each fraction will consist of 5 Gy for a total dose of 25 Gy. Radiotherapy is to start on day 22 and to finish on day 26.; Procedure: Surgery; Subject will undergo surgical resection of the primary tumour in the rectum between day 74 and 87. Surgery must be performed according to the principles of total mesorectal excision as described by Heald et al. The type of surgical approach (low anterior resection or abdominoperineal resection, etc.) will be left to the discretion of the treating surgeon.; Procedure: Non-operative Management; Subjects who achieve cCR after pre-operative treatment can, after discussion with the local investigator, decline surgery and opt for a non-operative management. cCR will need to be confirmed between day 67 and 74 by the following procedures per local practise: Digital rectal examination; Rectal endoscopy; Rectal MRI Subjects who achieve near cCR at the first assessment time point after pre-operative treatment, can be re-assessed 6 to 8 weeks later with the same procedures. If cCR is diagnosed, they can opt for watch & wait, otherwise they would need to undergo surgical resection. Subjects who opt for a non-operative management will be followed for tumour recurrence and survival for 5 years after end of treatment visit. Follow-up for these subjects will be more intensive than that for subjects undergoing surgery

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	Measurement of the pathological response rate. This will be evaluated in the mITT population and defined as the absence of viable tumour cells in the surgical specimens. Rate of pCR will be presented as number of subjects and percentage, along with a 95% confidence interval.	immediately after the surgery

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Assessment of the toxicity according to the NCI CTCAE version 5.0.	The type, frequency and severity of adverse events will be analysed in the mITT population.	5 months after the last administration of study treatment
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	The Objective tumour response (ORR) will be evaluated in the mITT population and defined as the proportion of subjects who achieve a partial or complete response according to RECIST criteria version 1.1 and based on the pre-surgery, pelvic MRI.	Before surgery
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	The Event-free survival (EFS) will be evaluated in the mITT population and calculated from the date of registration to the date of occurrence of any of the following events: progression of disease that precludes surgery, local or distant recurrence, or death due to any cause. Kaplan Meier methods will be used to calculate EFS rates along with 95% confidence intervals.	5 years after end of treatment
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	The Overall survival (OS) will be evaluated in the mITT population and calculated from the date of registration to the date of death from any cause. Kaplan Meier methods will be used to calculate OS rates along with 95% confidence intervals.	5 years after end of treatment
Assessment of the proportion of subjects who complete systemic treatment, radiotherapy and surgery according (if perfomed) to the study protocol.	This is will be evaluated in the Intention to Treat (ITT) population to assess the feasibility of combining regorafenib with nivolumab in the setting of locally-advanced rectal cancer as demonstrated by subject compliance with the investigational strategy, SCRT and surgery (if performed)	immediately after the surgery (if performed)
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	RO resection rate will be analysed in the mITT population and defined as the proportion of subjects who undergo surgical resection of the tumour with clear margins (i.e., >1 mm).	immediately after the surgery (if performed)
Evaluation of the immune activation induced by the investigational treatment regorafenib with nivolumab	CD3 and CD8 T-cells infiltrate increase in post-treatment tumour tissue samples	Before (biopsy at week 3) and immediately after surgery (surgical specimen) (if performed)
Evaluation of the efficacy of the combination of nivolumab and regorafenib when administered before and after standard, pre-operative short-course radiation therapy.	The rate of complete/near complete pathological tumour regression will be evaluated in the mITT population and defined as the proportion of subjects who achieve pathological tumour regression grade (pTRG) 3 or 4 according to the Dworak pTRG score.	immediately after the surgery (if performed)

Collaborators and Investigators

• Sponsor: Jules Bordet Institute
• Investigators: Study Chair: Francesco Sclafani, MD, Jules Bordet Institute

Study record dates

Study Major Dates

• Study Start (Actual): March 25, 2021
• Primary Completion (Estimated): January 1, 2025
• Study Completion (Estimated): September 1, 2029

Study Registration Dates

• First Submitted: July 28, 2020
• First Submitted That Met QC Criteria: August 6, 2020
• First Posted (Actual): August 7, 2020

Study Record Updates

• Last Update Posted (Actual): September 22, 2023
• Last Update Submitted That Met QC Criteria: September 21, 2023
• Last Verified: September 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Intestinal Diseases; Intestinal Neoplasms; Rectal Diseases; Colorectal Neoplasms; Rectal Neoplasms; Molecular Mechanisms of Pharmacological Action; Antineoplastic Agents; Antineoplastic Agents, Immunological; Immune Checkpoint Inhibitors; Nivolumab
• Other Study ID Numbers: IJB-REGINA-2020

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No