Nivolumab and Ipilimumab +/- UV1 Vaccination as Second Line Treatment in Patients With Malignant Mesothelioma (NIPU)

Primary Outcome Measures

1. Evaluation of efficacy of ipilimumab and nivolumab With or without UV1 vaccine in patients With inoperable malignant pleural mesothelioma progressing after first-line platinum-based chemotherapy. [ Time Frame: Monitoring for change in imaging evalated tumor lesions indicating progression throughout the trial until 5 years of follow-up has past. ]

Secondary Outcome Measures

1. Response evaluation [ Time Frame: Throughout the trial. Radiological assessments every 6th week during the first year, every 12th week for the next 5 years. ]
   Comparison of response rate according to Response Evaluation Criteria in Solid Tumors, version 1.1 (Modified RECIST), in patients who receive nivolumab and ipilimumab with patients who receive nivolumab and ipilimumab in combination with UV1.
2. Evaluation of patient reported outcomes (PRO) [ Time Frame: every other week for the first 12 weeks, every 6th week thereafter ]
   To evaluate changes from baseline in patient-reported outcomes (PROs) in patients who receive nivolumab and ipilimumab compared to patients who receive nivolumab and ipilimumab in combination with UV1.
3. Evaluation of Adverse Events and discontinuation rate of patients [ Time Frame: Continuously, and until 90 days after discontinuation of study treatment. ]

   To determine the safety and tolerability of patients receiving ipilimumab and nivolumab With or without UV1 vaccination by monitoring AEs and study drug discontinuation due to AEs.

   tolerability in patients who receive nivolumab and ipilimumab compared to patients who receive nivolumab and ipilimumab in combination with UV1, measured by adverse events (AE) and study drug discontinuations due to AEs.

Other Outcome Measures

1. Assessment of repertoire of TCR specificities induced by UV1 vaccination [ Time Frame: blood samples collected at screening, week 6, week 12 and week 18/19. ]
   Generating TCR repertoire data and comparing differences pre- and post treatment between the two treatment arms
2. Investigate whether there is a correlation between baseline tumor mutational burden (TMB) and response to therapy [ Time Frame: In tissue collected at screening, week 5/6, and study completion, at most 2 years. ]
   Characterization of TMB pre- and post-treatment by DNA analyses of tumor and normal tissue to identify tumor-specific somatic mutations, and comparing results to clinical outcome data.
3. investigate whether there is a difference in the immune cell infiltrate in the tumor pre- and post treatment With UV1 and check point inhibition. [ Time Frame: In tissue collected at screening, week 5/6, and study completion, at most 2 years. ]
   By characterizing qualitative and quantitative differences in markers of immune activation within tumor samples pre and post therapy by immunohistochemistry.
4. Investigate whether UV1 vaccination induces hTERT-specific T cells in the blood of patients treated. [ Time Frame: blood samples collected at pre-defined evaluation points throughout study completion, at most 2 years. ]
   By detection of vaccine-specific T cells in PBMC harvested from patients by T cell proliferation assays
5. Investigate whether DTH response correlates With detection of a vaccine-specific T cell response in blood [ Time Frame: blood samples collected atat pre-defined evaluation points throughout study completion, at most 2 years. ]
   The trial will compare DTH measurements With vaccine-specific T-cell response in blood.
6. Investigate whether there is a correlation between the microenvironment in feces and treatment response. [ Time Frame: blood samples collected at at pre-defined evaluation points throughout study completion, at most 2 years. ]
   Stool samples will be collected and data on microbial gut composition for each patient will be correlated With treatment outcome.

Inclusion Criteria

• Histologically and/or cytologically confirmed malignant pleural mesothelioma.
• Unresectable disease
• Measurable disease, defined as at least 1 lesion (measurable) that can be accurately assessed at baseline by computed tomography (CT) or magnetic resonance imaging (MRI) and is suitable for repeated assessment (modified RECIST).
• Available unstained archived tumor tissue sample in sufficient quantity to allow for analyses. At least fifteen unstained slides or a tumor block (preferred). NOTE: A fine needle aspiration sample is not sufficient to make the patient eligible for enrollment. Given the complexity of mesothelioma pathological diagnosis , it is expected that they will have a core needle biopsy or surgical tumor biopsy as part of their initial diagnostic work up.
• Age ≥ 18 years.
• Eastern Cooperative Oncology Group (ECOG) performance status of 0 – 1.
• Willing to provide archived tumor tissue and blood samples for research.
• Adequate organ function as defined below
  1. Haemoglobin ≥ 9.0 g/dL
  2. Absolute neutrophil count (ANC) 1.5 (or 1.0) x (> 1500 per mm3)
  3. Platelet count ≥100 (or 75) x 109/L (>75,000 per mm3)
  4. Serum bilirubin ≤1.5 x institutional upper limit of normal (ULN).
  5. AST (SGOT)/ALT (SGPT) ≤2.5 x institutional upper limit of normal unless liver metastases are present, in which case it must be ≤5x ULN
  6. Measured creatinine clearance (CL)
     1. >40 mL/min
     2. Calculated creatinine CL>40 mL/min (Cockcroft-Gault formula)
     3. 24-hour urinecollection for determination of CL
• Males: Creatinine CL (mL/min) =Weight (kg) x (140 – Age) 72 x serum creatinine (mg/dL)
• Females:Creatinine CL (mL/min)=Weight (kg) x (140 – Age)x0.85 72 x serum creatinine (mg/dL)
• Previously treated with at least one line of platinum -pemetrexed

Exclusion Criteria

• Disease suitable for curative surgery
• Previous treatment with a PD-1 or PD-L1 inhibitor, including nivolumab or any other agent targeting immune checkpoints.
• Non-pleural mesothelioma e.g. mesothelioma arising in peritoneum, tunica vaginalis or any serosal surface other than the pleura.
• Active second malignancy other than non-melanoma skin cancer or cervical carcinoma in situ.
• Symptomatic or uncontrolled brain metastases requiring concurrent treatment, inclusive of but not limited to surgery, radiation and/or corticosteroids (prednisone >10 mg or equivalent). Surgery, radiation and/or corticosteroids (any dose >10 mg prednisone equivalent) must have been completed ≥ 2 weeks prior to registration.
• Uncontrolled seizures.
• Current or prior use of immunosuppressive medication within 28 days before the first dose of nivolumab, with the exceptions of intranasal and inhaled corticosteroids or systemic corticosteroids at physiological doses, which are not to exceed 10 mg/day of prednisone, or an equivalent corticosteroid. Standard steroid premedication given prior to chemotherapy or as prophylaxis for imaging contrast allergy should not be counted for this criterion.
• Active or prior documented autoimmune or inflammatory disorders (including inflammatory bowel disease, diverticulitis with the exception of diverticulosis, celiac disease, irritable bowel disease; Wegner syndrome) within the past 2 years. Subjects with vitiligo, alopecia, Grave’s disease, or psoriasis not requiring systemic treatment (within the past 3 years) are not excluded.
• History of primary immunodeficiency.
• History of allogeneic organ transplant.
• Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, uncontrolled hypertension, unstable angina pectoris, cardiac arrhythmia, active peptic ulcer disease or gastritis, active bleeding diatheses including any subject known to have psychiatric illness/social situations that would limit compliance with study requirements or compromise the ability of the subject to give written informed consent.
• Active infection including tuberculosis (clinical evaluation including: physical examination findings, radiographic findings, positive PPD test, etc.), hepatitis B (known positive HBV surface antigen [HBsAg] result), hepatitis C, or human immunodeficiency virus (positive HIV 1/2 antibodies as defined by a positive ELISA test). Patients with a past or resolved HBV infection (defined as the presence of hepatitis B core antibody [anti-HBc] and absence of HBsAg) are eligible. Patients positive for hepatitis C (HCV) antibody are eligible only if polymerase chain reaction is negative for HCV RNA. HIV testing is not required in the absence of clinical suspicion.
• Known history of leptomeningeal carcinomatosis.
• Pregnant or lactating women
• Live attenuated vaccination within 30 days prior to study entry or within 30 days of receiving nivolumab.
• Any condition that, in the opinion of the investigator, would interfere with the evaluation of study treatment or interpretation of patient safety or study results.
• History of allergy or hypersensitivity to any of the active substances or excipients in the study drug.