Nivolumab and Temozolomide in Treating Patients With Recurrent or Refractory Small-Cell Lung Cancer or Advanced Neuroendocrine Cancer

PRIMARY OBJECTIVES:

I. To evaluate the efficacy (using response rate per RECIST v1.1) of nivolumab and
temozolomide for the treatment of patients with either small cell lung cancer that have
progressed or recurred after prior platinum-based chemotherapy (cohort 1), or progressive
metastatic neuroendocrine carcinoma of any grade or primary site in any line of therapy
(cohort 2).

SECONDARY OBJECTIVES:

I. To evaluate the safety profile and toxicity of combination nivolumab and temozolomide as
per Common Terminology Criteria for Adverse Events (CTCAE) version (v.) 5.0.

II. To evaluate the progression free survival (PFS) and overall survival (OS) of patients
treated with combination nivolumab and temozolomide.

III. To evaluate the central nervous system (CNS) PFS of patients with small cell lung cancer
(SCLC) treated with nivolumab and temozolomide.

EXPLORATORY OBJECTIVES:

I. To determine whether treatment with nivolumab and temozolomide leads to a decrease in
immune-suppressive cell populations (ie myeloid-derived suppressor cells [MDSC]) in
peripheral blood.

II. To determine whether objective response rate (ORR), PFS, OS vary by tumor
O6-methylguanine deoxyribonucleic acid (DNA) methyltransferase (MGMT) methylation at
baseline.

III. To determine whether baseline tumor mutational burden is predictive of response to
therapy in patients with SCLC treated with nivolumab and temozolomide.

IV. To determine whether changes in blood based mutation burden during treatment may predict
clinical benefit.

V. To determine whether a composite immune and tumor cell staining score can be developed
with or without PD-L1 by immunohistochemistry (IHC) to predict response in the SCLC cohort.

OUTLINE:

Patients receive nivolumab intravenously (IV) on day 1 of a 28 day cycle. Patients also
receive temozolomide orally (PO) on days 1-5. Courses repeat every 28 days in the absence of
disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up at 30 days, every 8 weeks for
12 months, then every 12 weeks thereafter.

Inclusion Criteria:

- Be willing and able to provide written informed consent/assent for the trial

- For Cohort 1: Have histologically or cytologically-documented diagnosis of advanced
(metastatic and/or unresectable) small cell lung cancer and have progressed or
recurred after platinum-based chemotherapy. Eligible patients will be defined as
follows:

- Sensitive disease: Patients who had one previous line of chemotherapy and
relapsed after > 90 days of completion of treatment

- Refractory disease: Patients with no response to first-line chemotherapy or
progression < 90 days after completing treatment.

- For cohort 1: maximum of 2 prior lines of therapy is allowed (ie second or third
line treatment)

- For Cohort 2: Have histologically or cytologically-documented diagnosis of advanced
(metastatic and/or unresectable) neuroendocrine tumor/carcinoma of any grade (World
Health Organization [WHO] Grade 1-3) of any origin, in any line of therapy (ie both
treatment na?ve and pre-treated patients allowed), and have clinical or biochemical or
radiographic progression in the 12 months prior to study registration. Concomitant use
of a somatostatin analogue is allowed, as long as patients have been on a stable dose
for at least 2 months

- Have measurable disease based on Response Evaluation Criteria in Solid Tumors (RECIST)
1.1.

- For Cohort 1: Availability of a recent formalin-fixed, paraffin-embedded (FFPE) tumor
tissue block. A recently obtained archival FFPE tumor tissue block from a primary or
metastatic tumor resection or biopsy can be provided if it was obtained within 1 year
of trial screening. Patients with tumor specimens older than 1 year may still be
eligible if deemed so by study sponsor. For Cohort 2: archival tissue as above is
preferred, but not required for trial entry. Verification of tumor burden in the
biopsy is encouraged. For optimal biomarker results, tumor content should be > 30% of
total tissue area

- Be willing to provide peripheral blood samples at screening and day 1 of cycles 1, 2
and 3 as well as at progressive disease for correlative studies

- Have a performance status of 0 or 1 on the Eastern Cooperative Oncology Group (ECOG)
performance scale

- Life expectancy greater than 3 months

- Ability to swallow and retain oral medication

- Absolute neutrophil count (ANC) >= 1,500 /mcL (performed within 28 days of treatment
initiation)

- Platelets >= 100,000 / mcL (performed within 28 days of treatment initiation)

- Serum creatinine =< 2.0 x upper limit of normal (ULN) OR measured or calculated
creatinine clearance (CrCl) (glomerular filtration rate [GFR] can also be used in
place of creatinine or CrCl) >= 50 mL/min as estimated by Cockcroft and Gault formula
for subject with creatinine levels > 2 X institutional ULN (performed within 28 days
of treatment initiation)

- Creatinine clearance should be calculated per institutional standard

- Serum total bilirubin =< 1.5 x ULN OR direct bilirubin =< ULN for subjects with total
bilirubin levels > 1.5 ULN (performed within 28 days of treatment initiation)

- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) and
Alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 x
ULN OR =< 5 x ULN for subjects with liver metastases (performed within 28 days of
treatment initiation)

- Both values must be in the specified range

- Albumin >= 2.5 mg/dL (performed within 28 days of treatment initiation)

- International normalized ratio (INR) or prothrombin time (PT) =< 1.5 x ULN unless
subject is receiving anticoagulant therapy as long as PT or partial thromboplastin
time (PTT) is within therapeutic range of intended use of anticoagulants (performed
within 28 days of treatment initiation)

- Activated partial thromboplastin time (aPTT) =< 1.5 x ULN unless subject is receiving
anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use
of anticoagulants (performed within 28 days of treatment initiation)

- Female subject of childbearing potential should have a negative urine or serum
pregnancy within 72 hours prior to receiving the first dose of study medication. If
the urine test is positive or cannot be confirmed as negative, a serum pregnancy test
will be required

- Female subjects of childbearing potential should be willing to use 2 methods of birth
control or be surgically sterile, or abstain from heterosexual activity for the course
of the study through 120 days after the last dose of study medication. Subjects should
agree to ongoing pregnancy testing during the course of the study and after the end of
study therapy. Female subjects of childbearing potential are those who have not been
surgically sterilized or have not been free from menses for > 1 year

- Male subjects should agree to use an adequate method of contraception starting with
the first dose of study therapy through 120 days after the last dose of study therapy.
Males must refrain from donating sperm during study participation and for 120 days
after the last dose of study medication.

Exclusion Criteria:

- Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy or used an investigational
device within 4 weeks of the first dose of treatment

- Has received prior temozolomide therapy

- Prior immunotherapy with checkpoint inhibitors (including antibodies to PD-1, PD-L1,
or CTLA-4) is not allowed

- Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any
other form of immunosuppressive therapy within 7 days prior to the first dose of trial
treatment

- Has a known history of active TB (Bacillus Tuberculosis)

- Hypersensitivity to nivolumab or temozolomide or any of their excipients

- Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 2 weeks prior to study day 1 or who has not recovered (i.e., =< grade 1 or at
baseline) from adverse events due to a previously administered agent

- Note: Subjects with =< grade 2 neuropathy due to chemotherapy are an exception to
this criterion and may qualify for the study

- Note: If subject received major surgery, they must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting therapy

- Has a known additional malignancy that is progressing or requires active treatment

- Has symptomatic central nervous system (CNS) metastases and/or carcinomatous
meningitis. Subjects with asymptomatic lesions will be eligible if considered
appropriate by the treating physician. Subjects with previously treated brain
metastases may participate provided they are stable (without evidence of progression
by imaging for at least two weeks prior to the first dose of trial treatment and any
neurologic symptoms have returned to baseline), have no evidence of new or enlarging
brain metastases, and are not requiring steroids (or are on a stable or decreasing
dose of steroids equivalent to 10 mg prednisone or less) for at least 7 days prior to
trial treatment. This exception does not include carcinomatous meningitis which is
excluded regardless of clinical stability

- Has active autoimmune disease, including myasthenic syndrome, which has required
systemic treatment in the past 2 years (i.e. with use of disease modifying agents,
corticosteroids or immunosuppressive drugs). Replacement therapy (eg., thyroxine,
insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary
insufficiency, etc.) is not considered a form of systemic treatment

- Has an active infection requiring systemic therapy

- Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject?s
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator

- Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial

- Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the pre-screening or screening visit
through 5 months (for females) or 7 months (for males) after the last dose of trial
treatment

- Has a known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies)

- Has known active hepatitis B (e.g., hepatitis B surface antigen [HBsAg] reactive) or
hepatitis C (e.g., hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] is
detected)

- Any condition which in the Investigator?s opinion deems the participant an unsuitable
candidate to receive study drug