Fecal Microbiota Transfer in Liver Cancer to Overcome Resistance to Atezolizumab/Bevacizumab (FLORA) (FLORA)

The interventional, randomized, placebo-controlled, double-blind phase II-trial FLORA will assess safety and immunogenicity of fecal microbiota transfer in combination with standard of care immunotherapy in advanced hepatocellular carcinoma (HCC) in a parallel group design.

Subjects will be randomized 2:1 into either the FMT or placebo group.

Study Overview

• Status: Recruiting
• Conditions: Immunotherapy; HCC - Hepatocellular Carcinoma
• Intervention / Treatment: Drug: Fecal microbiota transfer; Drug: Atezolizumab + Bevacizumab; Drug: Vancomycin Oral Capsule; Drug: Placebo Vancomycin Oral Capsule; Drug: Placebo Fecal microbiota transfer

Detailed Description

Eligible HCC patients visiting the outpatient clinics at the study sites of the NCT Germany will be enrolled into the study after informed consent. Patients undergo 2:1 randomization into either the FMT or placebo group. Prior to the intervention, a sigmoidoscopy with mucosal biopsies will be performed. At day -3 to 0 oral Vancomycin 4x 250mg or placebo will be given. Atezolizumab/bevacizumab (A/B) will be administered as standard of care every 21 days, starting on day 0. At day 0 and 21, concurrent to the first and second cycle of A/B, encapsulated FMT or placebo will be administered on the same day. At day 40-42, before the third cycle of A/B, a tumor biopsy and a sigmoidoscopy will be performed. The first radiologic assessment will be performed after 4 cycles of A/B. Clinical efficacy and safety will be assessed as indicated per protocol analysis.

• Study Type: Interventional
• Enrollment (Estimated): 48
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Michael T Dill, PhD; Phone Number: 06221 568611; Email: michael.dill@med.uni-heidelberg.de
• Study Contact Backup: Name: Conrad Rauber, MD/PhD; Phone Number: 06221568611; Email: conrad.rauber@med.uni-heidelberg.de

Study Locations

• Germany
  • Augsburg, Germany, 86156
    • Not yet recruiting
    • University Hospital Augsburg
    • Contact: Alexander Reichart, Dr.
  • Essen, Germany, 45147
    • Not yet recruiting
    • University Hospital Essen
    • Contact: Leonie Jochheim, Dr.
  • Mannheim, Germany, 68167
    • Not yet recruiting
    • University Hospital Mannheim
    • Contact: Andreas Teufel, Prof.
  • Regensburg, Germany, 93053
    • Not yet recruiting
    • University Hospital Regensburg
    • Contact: Arne Kandulski, Prof.
  • Tübingen, Germany, 72076
    • Not yet recruiting
    • University Hospital Tübingen
    • Contact: Pavlos Missios, Dr.
  • Ulm, Germany, 89081
    • Not yet recruiting
    • University Hospital Ulm
    • Contact: Thomas J Ettrich, Dr.
  • Baden-Württemberg
    • Heidelberg, Baden-Württemberg, Germany, 69120
      • Recruiting
      • University Hospital Heidelberg
      • Contact: Michael Dill, PhD
      • Contact: Conrad Rauber, PhD

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

1. Age 18 years or older
2. Confirmed radiologic or histological diagnosis of HCC
3. Disease not amenable to resection, liver transplantation or loco-regionary therapy
4. Eligible for therapy with Atezolizumab / Bevacizumab according to standard of care
5. Measurable disease per RECIST 1.1
6. Preserved liver function with a Child-Pugh score A or B (maximally 7 points)
7. Performance status ECOG 0-1

Exclusion Criteria:

1. Use of immunosuppressive medication within 6 months prior to the first dose of Atezolizumab / Bevacizumab.
2. Active or prior documented autoimmune or inflammatory disorders
3. Prior exposure to immune-mediated therapy including, but not limited to, other anti-CTLA-4, anti-PD-1, anti-PD-L1, and anti-VEGF antibodies.
4. Known to have tested positive for human immunodeficiency virus (HIV) infection.
5. Co-infection of HBV and HCV. Subjects with a history of HCV infection but who are negative for HCV RNA by PCR will be considered non-infected with HCV.
6. Evidence by investigator assessment of varices at risk of bleeding on upper endoscopy undertaken within 12 months of randomization.
7. Refractory nausea and vomiting, chronic gastrointestinal disease, inability to swallow a formulated product, or previous significant bowel resection that would preclude adequate absorption, distribution, metabolism or excretion of investigational product.
8. Uncontrolled arterial hypertension defined by a systolic pressure > 150 mm Hg or diastolic pressure > 90 mm Hg or other hypertensive cardiovascular complications despite standard medical treatment.
9. Any history of nephrotic or nephritic syndrome.
10. Usage of systemic antibiotic therapy within 2 weeks prior to the first dose of Atezolizumab/Bevacizumab.
11. Usage of probiotic products/supplements within 1 week prior to the first dose of Atezolizumab/Bevacizumab.
12. Known fibrolamellar HCC, sarcomatoid HCC, infiltrative-type HCC, or mixed cholangiocarcinoma and HCC.
13. History of another primary malignancy.
14. Receipt of live attenuated vaccine within 30 days prior to the first dose of study intervention.
15. Pregnancy or lactation.
16. History of hypersensitivity to the investigational medicinal product or to any drug with similar chemical structure or to any excipient present in the pharmaceutical form of the investigational medicinal product.
17. Participation in other interventional clinical trials or observation period of competing clinical trials, respectively.
18. Held in an institution by legal or official order.
19. Legally incapacitated.
20. Known hypersensitivity to any component of the vancomycin, atezolizumab or bevacizumab formulation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vancomycin + A/B + FMT; Atezolizumab 1200mg i.v. & Bevacizumab 15mg/kg body weight i.v. (A/B) as standard of care (SOC).; Vancomycin orally (250 mg 4xd, day -3 to 0) for reduction of original patient gut microbiota.; Fecal microbiota transfer (FMT) via capsules (total 50 g of fecal matter) on day 0 and day 21.	Drug: Fecal microbiota transfer; FMT via capsule (50 g of fecal matter) on day 0 and day 21.; Other Names: FMT; INTESTIFIX 001; Drug: Atezolizumab + Bevacizumab; Atezolizumab 1200mg i.v. & Bevacizumab 15mg/kg body weight i.v. (A/B) as standard of care (SOC).; Other Names: A/B; Drug: Vancomycin Oral Capsule; Vancomycin orally (250 mg 4xd, day -3 to 0).
Placebo Comparator: Placebo Vancomycin + A/B + Placebo FMT; Atezolizumab 1200mg i.v. & bevacizumab 15mg/kg body weight i.v. (A/B) as standard of care (SOC).; Placebo vancomycin orally (4xd, day -3 to 0) for reduction of original patient gut microbiota.; Placebo fecal microbiota transfer (FMT) via capsules on day 0 and day 21.	Drug: Atezolizumab + Bevacizumab; Atezolizumab 1200mg i.v. & Bevacizumab 15mg/kg body weight i.v. (A/B) as standard of care (SOC).; Other Names: A/B; Drug: Placebo Vancomycin Oral Capsule; Placebo Vancomycin orally (4xd, day -3 to 0).; Drug: Placebo Fecal microbiota transfer; Placebo Fecal microbiota transfer (FMT) via capsule on day 0 and day 21.; Other Names: Placebo FMT; Placebo INTESTIFIX 001

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Assessment of immunogenicity	Tumoral CD8+ T cell infiltration after 2 cycles of treatment with Vancomycin, A/B + FMT in comparison to Vancomycin-placebo, A/B + FMT-placebo	6 weeks after treatment initiation
Safety of the therapeutic combination in advanced HCC	Occurence of Adverse Events (AE) & immune-related adverse events (irAE)	The observational period begins with the first administration of the 1st IMP (Vancomycin/Placebo) on day -3 and ends with either the Follow-up visit after 15 weeks (Day 105) or the initiation of a subsequent anticancer treatment.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Overall survival (OS)	To evaluate the efficacy of Vancomycin, A/B + INTESTIFIX 001 in comparison to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Overall Survival (OS). OS is defined as the time from start of treatment (first dose of A/B) to time of death from any cause in days. Administrative censoring is applied for patients who survive the end of the trial. Death cases will either become known during the clinical study treatment, or information will be obtained on the occasion of follow-up calls, or from e.g. treating physicians. Otherwise, patients for whom the date of death is unknown are censored at the last time point they are known to be alive.	From start of treatment until the date of death from any cause, assessed up to 4 years.
Progression free survival (PFS)	To evaluate the efficacy of Vancomycin, A/B + INTESTIFIX 001as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Progression Free Survival (PFS). PFS is defined as the time from start of treatment (first dose A/B) until objective tumor progression as determined by the radiologist per RECIST 1.1 or death, whichever occurs first.	From start of treatment until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 4 years.
Disease control (DC)	To evaluate the efficacy of Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Disease Control (DC). DC is defined as achieving complete response (CR), partial response (PR) or stable disease (SD) as best overall response during observation period as determined by the radiologist per RECIST 1.1 criteria.	From start of treatment until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 4 years.
Objective Response (OR)	To evaluate the efficacy of Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Objective Response (OR). OR is defined as tumor size reduction, meaning PR or CR, as determined by the radiologist per RECIST 1.1 criteria assessed by best overall response during the observation period.	From start of treatment until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 4 years.
Duration of Response (DoR)	To evaluate the efficacy of Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Duration of Response (DoR). DoR is defined as the time from first documented response (either PR or CR per RECIST 1.1, whichever is recorded first) to first subsequent progression (first assessment of PD per RECIST 1.1 or death). DoR is only defined for the patients who experienced a response.	From start of treatment until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 4 years.
AFP serological response rate	To evaluate the efficacy Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to AFP serological response rate. AFP serological response rate is defined as defined as a >20% de- crease in serum AFP (ng/ml)	From start until end of treatment (11 weeks).
Hepatic Function measured by model of end-stage liver disease (MELD) score	To evaluate the efficacy Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Hepatic function measured by model of end-stage liver disease (MELD) score (Range 6-40 points, with higher points indicating worsening of function). The hepatic function endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).
Hepatic Function measured by Child-Pugh score	To evaluate the efficacy Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Hepatic function measured by Child-Pugh Score (CPS) (Range 5-15, with higher scores indicating worsening). The CPS endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).
Hepatic Function measured by ALBI grade	To evaluate the efficacy Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Hepatic function measured by ALBI grade (Range 1-3, with higher scores indicating worsening). The ALBI grade endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).
Hepatic Function measured by Psychometric Hepatic Encephalopathy Score (PHES)	To evaluate the efficacy Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo with respect to Hepatic function measured Psychometric Hepatic Encephalopathy Score (PHES) questionnaire (Range -15 tp +15, with higher scores indicating better cognitive function). The PHES endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).
Health-related quality of life - general	To evaluate the effect of Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo in respect to Health-related quality of life. Patient reported outcomes (PRO) via are assessed by questionnaire (EORTC QLQ-C30) and are collected during treatment. Final scores are transformed such that they range from 0 to 100, where higher scores indicate greater level of symptoms. The PRO endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).
Health-related quality of life - disease-specific	To evaluate the effect of Vancomycin, A/B + INTESTIFIX 001 as relative to Vancomycin-placebo, A/B + INTESTIFIX 001-placebo in respect to Health-related quality of life. Patient reported outcomes (PRO) are assessed by HCC-specific questionnaire (EORTC QLQ-HCC18) and are collected during treatment. Final scores are transformed such that they range from 0 to 100, where higher scores indicate greater level of symptoms. The PRO endpoints are the absolute scores at all assessed time points as well as the change to baseline.	From start until end of treatment (11 weeks).

Collaborators and Investigators

• Sponsor: Michael Dill
• Collaborators: University of Cologne; German Cancer Research Center; Heidelberg University; Universitätsmedizin Mannheim; National Center for Tumor Diseases, Heidelberg
• Investigators: Principal Investigator: Michael T Dill, PhD, University Hospital Heidelberg, Heidelberg, Baden-Württemberg 69120

Study record dates

Study Major Dates

• Study Start (Actual): July 16, 2025
• Primary Completion (Estimated): March 1, 2028
• Study Completion (Estimated): March 1, 2028

Study Registration Dates

• First Submitted: December 13, 2022
• First Submitted That Met QC Criteria: January 9, 2023
• First Posted (Actual): January 19, 2023

Study Record Updates

• Last Update Posted (Actual): August 6, 2025
• Last Update Submitted That Met QC Criteria: August 5, 2025
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Keywords: immunotherapy; HCC; gut microbiota; tumor microenvironment; fecal microbiota transfer
• Additional Relevant MeSH Terms: Neoplasms by Site; Neoplasms; Neoplasms by Histologic Type; Digestive System Neoplasms; Digestive System Diseases; Liver Diseases; Neoplasms, Glandular and Epithelial; Adenocarcinoma; Carcinoma; Carcinoma, Hepatocellular; Liver Neoplasms; Antineoplastic Agents, Immunological; Immune Checkpoint Inhibitors; Anti-Bacterial Agents; Anti-Infective Agents; Antineoplastic Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Angiogenesis Inhibitors; Angiogenesis Modulating Agents; Growth Substances; Growth Inhibitors; Bevacizumab; Atezolizumab; Vancomycin
• Other Study ID Numbers: Version 3.1/11.02.2025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: all IPD that underlie results in a publication
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ICF

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