Sponsor: National Cancer Institute (NCI) (federal)
Phase: 1/2
Start date: April 7, 2020
Planned enrollment: 103
Peposertib (M3814; MSC2490484A; also referred to as nedisertib) is an oral, small‑molecule inhibitor of DNA-dependent protein kinase (DNA-PK), developed primarily as a radiosensitizer and chemosensitizer in solid tumors and as a potentiator of DNA double‑strand break (DSB)–inducing agents. Multiple early-phase clinical studies have reported on safety, pharmacokinetics/pharmacodynamics, and preliminary activity across monotherapy and combination settings. (pmc.ncbi.nlm.nih.gov, pubmed.ncbi.nlm.nih.gov)
Notes: As of September 2025, reported clinical activity for peposertib has generally been limited outside of early signals in specific settings; several studies highlight tolerability constraints when combined with chemoradiation and the need for optimized dosing or alternative combinations. (pubmed.ncbi.nlm.nih.gov, pmc.ncbi.nlm.nih.gov)
Last updated: Sep 2025
Goal: Define the safety, tolerability, and recommended phase 2 dose of the DNA-PK inhibitor peposertib combined with hypofractionated radiation and avelumab (phase I), and test whether adding peposertib to hypofractionated radiation plus avelumab improves efficacy versus radiation plus avelumab alone in advanced/metastatic hepatobiliary cancers, using objective response rate in non-irradiated lesions (phase II).
Patients: Phase I enrolls adults with metastatic or unresectable advanced solid tumors that have progressed after, are not candidates for, or decline standard therapy, ECOG 0–2, with at least one lesion suitable for palliative hypofractionated RT and at least one separate RECIST-measurable, non-irradiated lesion. Phase II enrolls adults with metastatic or unresectable cholangiocarcinoma or gallbladder carcinoma after progression on gemcitabine/cisplatin with durvalumab or pembrolizumab (TOPAZ-1 or KEYNOTE-966), meeting standard hematologic, renal, hepatic, and coagulation criteria, and willing to undergo mandated biopsies and biospecimen collection. Key exclusions include active autoimmune disease requiring significant immunosuppression, untreated/uncontrolled CNS disease, significant drug–drug interactions with CYP3A4/2C19 modulators or PPIs, recent live vaccination, and uncontrolled intercurrent illness or infection.
Design: Phase I dose-escalation of peposertib with fixed hypofractionated RT and avelumab to establish RP2D and characterize PK. Phase II randomized, active-controlled, parallel-group study in advanced/metastatic hepatobiliary tumors comparing hypofractionated RT plus avelumab (control) versus the same regimen with the addition of peposertib. Allocation is randomized; treatment continues in 28-day cycles until progression or unacceptable toxicity, with structured long-term follow-up.
Treatments: All arms incorporate hypofractionated radiation therapy delivered as 8 daily fractions between days −17 and −7 to one or two palliative targets, with systemic therapy starting day 1 of each 28‑day cycle. Avelumab is administered IV over 60 minutes on days 1 and 15. The experimental regimen adds oral peposertib twice daily on days 1–28 each cycle. Peposertib (M3814, nedisertib) is an oral inhibitor of DNA-dependent protein kinase (DNA-PKcs/PRKDC), a key mediator of non-homologous end-joining repair of DNA double-strand breaks. By blocking DNA-PK autophosphorylation and DSB repair, peposertib radiosensitizes tumor cells and can potentiate DSB-inducing therapies; pharmacodynamic effects include increased γH2AX foci. Early clinical studies show limited single-agent activity with disease stabilization and have defined tolerable combination doses with avelumab and with radiotherapy; toxicity can reflect radiosensitization (e.g., dermatitis, mucositis), necessitating careful dose selection. Avelumab is an anti–PD-L1 monoclonal antibody used as standard immunotherapy in several tumors; here it is combined with RT, with or without peposertib, to test for systemic responses outside the irradiated field.
Outcomes: Primary endpoints: Phase I maximum tolerated dose and recommended phase 2 dose of peposertib with RT and avelumab based on dose-limiting toxicities within 28 days; Phase II objective response rate by RECIST 1.1 in non-irradiated lesions up to 12 months. Secondary endpoints include safety (CTCAE v5.0), disease control rate, duration of response, progression-free survival (overall and outside irradiated field), overall survival, and pharmacokinetics of peposertib and avelumab (including trough levels). Translational/exploratory endpoints assess baseline DNA damage repair defects (γH2AX/pNBS1/pKAP1 IFA), tumor mutation and neoantigen burden (WES, RNAseq), immune landscape changes (MIBI, CyTOF), and TCR clonality, correlating these biomarkers with response and toxicity.
Burden on patient: Burden is high. Patients undergo hypofractionated RT requiring daily visits for 8 fractions before systemic therapy, IV avelumab infusions on days 1 and 15 each 28‑day cycle, and continuous twice-daily oral peposertib in the experimental arms. The protocol mandates fresh tumor biopsies at baseline and on-treatment collections, plus extensive blood sampling for pharmacokinetics (including intensive post-infusion timepoints in phase I) and immune correlative studies. Serial CT imaging and frequent safety assessments are required. Restrictions on concomitant medications (notably PPIs and strong CYP3A4/2C19 modulators) may necessitate regimen changes. Travel and time commitments are substantial, particularly early in treatment due to RT and PK schedules.
Inclusion Criteria:
* PHASE 1: Patients must have a histologically confirmed metastatic or locally advanced unresectable solid tumor that has progressed on or after available standard of care therapy or for which no acceptable standard of care therapy exists, or in which the patient declines standard of care therapy (each patient that declines standard of care therapy will be documented in the case report form)
* PHASE 2: Patients must have a histologically confirmed metastatic or locally advanced unresectable cholangiocarcinoma/gallbladder carcinoma that has progressed on gemcitabine, cisplatin, and durvalumab/pembrolizumab.
* Age \>= 18 years
* Because no dosing or adverse event data are currently available on the use of peposertib (M3814) in combination with avelumab in patients \< 18 years of age
* Eastern Cooperative Oncology Group (ECOG) performance status =\< 2 (Karnofsky \>= 60%)
* Patients with at least 1 index lesion to irradiate for whom palliative radiation treatment is indicated (including but not limited to pain and/or symptom control, prevention of disease -related complications, and preservation of organ function). Lung and liver lesions are preferred, though alternate lesions may be considered after discussion with trial principal investigator (PI). Up to 2 lesions may be considered for irradiation provided at least 1 lesion will receive the study treatment of total of 60 Gy and all prescribed irradiation will be completed within the radiation window
* Patients with at least 1 Response Evaluation Criteria in Solid Tumors (RECIST) measurable lesion (to be unirradiated) (defined as those accurately measured in at least one dimension, with the longest diameter to be recorded for non-nodal lesions and the shortest diameter for nodal lesions). Measurable is defined as at least 10 mm in longest diameter for solid tumors, at least 15 mm in shortest diameter for lymph nodes
* Patients must be willing to undergo fresh biopsies at baseline (as opposed to using archival tissue), in the event their baseline tissue was obtained \> 12 months prior to study consent and/or they are randomized to the gamma H2AX, pNBS1 and pKAP1 IFA with beta CATN segmentation assay
* Absolute neutrophil count (ANC) \>= 1,500/mcL
* Platelet count \>= 100,000/mcL
* Hemoglobin \>= 9.0 g/dL
* Serum creatinine =\< 1.5 x upper limit of normal (ULN) OR calculated serum creatinine clearance (glomerular filtration rate \[GFR\] can be used in place of creatinine or creatinine clearance) \>= 60 mL/min for participants with creatinine levels \> 1.5 x institutional ULN
* Calculate serum creatinine clearance using the standard Cockcroft-Gault formula
* Serum total bilirubin =\< 1.5 x ULN or direct bilirubin =\< ULN for participants with total bilirubin \> 1.5 x ULN
* Patients with known Gilbert disease with serum bilirubin level =\< 3 x ULN are eligible
* Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase \[SGOT\]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase \[SGPT\]) =\< 2.5 x ULN or =\< 5.0 x ULN for patients with hepatobiliary tumors/liver metastases
* Albumin \>= 2.8 g/L
* International normalized ratio (INR) or prothrombin time (PT) or activated partial thromboplastin time (aPTT) =\< 1.5 x ULN
* This applies only to patients not receiving therapeutic anticoagulation; patients receiving therapeutic anticoagulation should be on a stable dose
* Participants must have the ability to swallow and retain oral medication and not have any clinically significant gastrointestinal abnormalities that might alter absorption
* Female patients of childbearing potential must have a negative urine or serum pregnancy test. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required. The effects of peposertib (M3814) and avelumab on the developing human fetus are unknown and there is the potential for teratogenic or abortifacient effects. For this reason, women and men of child-bearing potential must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study treatment, and for 6 months after completion of peposertib (M3814) and avelumab administration. 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. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with peposertib (M3814) and avelumab, breastfeeding should be discontinued if the mother is treated with peposertib (M3814) and avelumab
* Ability to understand and the willingness to sign a written informed consent document. Participants with impaired decision-making capacity (IDMC) who have a close caregiver or legally authorized representative (LAR) and/or family member available will also be eligible
Exclusion Criteria:
* PHASE I: Patients who have received prior anti-CTLA-4, anti-PD-1, anti-PD-L1 or other immune checkpoint inhibitor therapeutic antibodies or pathway-targeting agents
* PHASE II: Patients who have received prior anti-CTLA-4, anti-PD-1, anti-PD-L1 or other immune checkpoint inhibitor therapeutic antibodies or pathway-targeting agents with the following exceptions:
* Patients who have only received previous durvalumab (anti-PD-L1) in combination with gemcitabine +/- cisplatin as part of first line therapy (TOPAZ-1 regimen) are eligible
* Patients who have only received previous pembrolizumab (anti-PD-1) in combination with gemcitabine +/- cisplatin as part of first line therapy (KEYNOTE-966 regimen) are eligible
* Patients who have had chemotherapy, definitive radiation, biological cancer therapy, or investigational agent/device within 21 days of first planned dose of study therapy (within 14 days for palliative radiation). Previously irradiated lesions may be re-irradiated provided there is disease progression in the irradiated lesion and the prescribed radiation dosage can safely be re- administered
* Patients who have not recovered from adverse events due to prior anti-cancer therapy (i.e., have residual toxicities \> Common Terminology Criteria for Adverse Events \[CTCAE\] grade 1) with the exception of alopecia
* Patients with untreated/uncontrolled central nervous system (CNS)/leptomeningeal disease. Patients with asymptomatic, treated CNS disease are eligible if the treating physician determines that immediate CNS specific treatment is not required and is unlikely to be required during the first cycle of therapy and the following criteria are met:
* Radiographic demonstration of clinical stability upon the completion of CNS-directed therapy and no evidence of interim progression between the completion of CNS-directed therapy and the screening radiographic study done \>= 4 weeks from completion of radiotherapy and \>= 2 weeks from discontinuation of corticosteroids
* No stereotactic radiation or whole-brain radiation within 28 days prior to randomization
* Patients with active autoimmune disease requiring systemic corticosteroids greater than the equivalent of prednisone 10 mg daily including but not limited to: systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, colitis, vascular thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis, Sjogren's syndrome, Bell's palsy, Guillain-Barre syndrome, multiple sclerosis, autoimmune thyroid disease, vasculitis, or glomerulonephritis, with the following exceptions:
* Patients with a history of autoimmune hypothyroidism on a stable dose of thyroid replacement hormone are eligible
* Patients with controlled type 1 diabetes mellitus on a stable insulin regimen are eligible
* Patients with eczema, psoriasis, lichen simplex chronicus of vitiligo with dermatologic manifestations only who require only low potency topical steroids (e.g., hydrocortisone 2.5%, hydrocortisone butyrate 0.1%, fluocinolone 0.01%, desonide 0.05%, alclometasone dipropionate 0.05%) are eligible
* Patients receiving treatment with systemic immunosuppressive medications (including, but not limited to, prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor necrosis factor \[TNF\] agents) within 6 weeks must discontinue these medications prior to starting peposertib (M3814) and avelumab on day 7, with the exception of:
* Patients with active autoimmune disease managed with systemic corticosteroids less than the equivalent of prednisone 10 mg daily
* Patients who have received acute, low dose, systemic immunosuppressant medications (e.g., a one-time dose of dexamethasone for nausea)
* The use of inhaled corticosteroids and mineralocorticoids (e.g., fludrocortisone) for patients with orthostatic hypotension and adrenocortical insufficiency
* Patients who have undergone prior solid organ or bone marrow transplant with the exception of patients with prior renal transplant for whom dialysis may be employed in the event of graft rejection
* Patients with uncontrolled intercurrent illness (e.g., including but not limited to uncontrolled hypertension \[HTN\] \[systolic blood pressure (BP) \> 150, diastolic BP \> 100\], symptomatic congestive heart failure \[CHF\], unstable angina pectoris, ischemic myocardial infarction \[MI\] within 6 months, cardiac arrhythmia, recent transient ischemic attack \[TIA or cerebrovascular accident (CVA)\]) within 6 months
* Patients with serious active infection (e.g. requiring hospitalization and/or intravenous \[IV\] antibiotics) within 4 weeks prior to starting peposertib (M3814) and avelumab, or signs/symptoms of infection or receiving oral or IV antibiotics for the treatment of active systemic infection within 2 weeks prior to starting peposertib (M3814) and avelumab. Patients receiving prophylactic antibiotics are eligible
* Patients with known chronic hepatitis B virus (HBV) infection must have an undetectable viral load on suppressive therapy if indicated. Patients with known chronic hepatitis C (HCV) infection must have been treated and cured. Patients who are currently on curative treatment are eligible if they have an undetectable HCV viral load
* Patients with known human immunodeficiency virus (HIV) are allowed on study provided they have:
* A stable regimen of highly active anti-retroviral therapy (HAART)
* No requirement for concurrent antibiotics or antifungal agents for the prevention of opportunistic infection
* A CD4 count above 250 cells/mcL
* An undetectable HIV viral load on standard polymerase chain reaction (PCR)-based testing
* Patients with history of idiopathic pulmonary fibrosis, pneumonitis (including drug induced), organizing pneumonia (e.g., bronchiolitis obliterans, cryptogenic organizing pneumonia), or evidence of active pneumonitis on screening chest computed tomography (CT) scan
* Patients with known concurrent malignancy that is expected to require active treatment within two years, or may interfere with the interpretation of the efficacy and safety outcomes of this study in the opinion of the treating investigator. Superficial bladder cancer, nonmelanoma skin cancers, and low-grade prostate cancer not requiring cytotoxic therapy should not exclude participation in this trial. Patients with chronic lymphocytic leukemia (CLL) may be enrolled if they do not require active chemotherapy and their hematologic, renal and hepatic function meets criteria previously mentioned
* Patients with psychiatric illness/social situations that would limit compliance with study requirements
* History of allergic reactions attributed to compounds of similar chemical or biologic composition to peposertib (M3814) or avelumab
* Patients unable to discontinue medications or substances that are potent inhibitors, inducers or sensitive substrates of CYP3A4/5 or CYP2C19 prior to starting peposertib (M3814) and avelumab are ineligible. Medications or substances that are strong inhibitors of CYP3A4/5 or CYP2C19 must be discontinued at least 1 week prior to first peposertib (M3814) dose. Strong inducers of CYP3A4/5 or CYP2C19 must be stopped at least 3 weeks prior to the first dose. Drugs mainly metabolized by CYP3A with a narrow therapeutic index as judged by the investigator must stop at least 1 day prior to first peposertib (M3814) dose. Because the lists of these agents are constantly changing, it is important to regularly consult a frequently updated medical reference. As part of the enrollment/informed consent procedures, the patient will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the patient is considering a new over-the-counter medicine or herbal product. The primary elimination mechanism of avelumab is proteolytic degradation, thus there are no contraindicated medications with respect to avelumab
* Patients who cannot discontinue concomitant proton-pump inhibitors (PPIs) prior to starting peposertib (M3814) and avelumab. These must be discontinued \>= 5 days prior to starting peposertib (M3814) and avelumab. Patients do not need to discontinue calcium carbonate. H2 blockers are allowed provided they are taken at least 2 hours after peposertib (M3814) dose
* Patients receiving sorivudine or any chemically related analogues (such as brivudine) and not able to discontinue prior to starting peposertib (M3814) and avelumab are excluded
* Pregnant and lactating women are excluded from this study because peposertib (M3814) and avelumab are agents with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with peposertib (M3814) and avelumab, breastfeeding should be discontinued if the mother is treated with peposertib (M3814) and avelumab
* Patients who have received live vaccination within 30 days before starting peposertib (M3814) and avelumab
Irvine, California, 92612, United States
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La Jolla, California, 92093, United States
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Orange, California, 92868, United States
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Sacramento, California, 95817, United States
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Aurora, Colorado, 80045, United States
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Derby, Connecticut, 06418, United States
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Fairfield, Connecticut, 06824, United States
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Glastonbury, Connecticut, 06033, United States
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Greenwich, Connecticut, 06830, United States
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Guilford, Connecticut, 06437, United States
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Hartford, Connecticut, 06105, United States
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New Haven, Connecticut, 06510, United States
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New Haven, Connecticut, 06520, United States
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North Haven, Connecticut, 06473, United States
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Stamford, Connecticut, 06902, United States
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Torrington, Connecticut, 06790, United States
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Trumbull, Connecticut, 06611, United States
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Waterbury, Connecticut, 06708, United States
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Waterford, Connecticut, 06385, United States
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Washington D.C., District of Columbia, 20007, United States
No email / 202-444-2223
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Washington D.C., District of Columbia, 20016, United States
[email protected] / 202-243-2373
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Aventura, Florida, 33180, United States
No email / 954-461-2180
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Coral Gables, Florida, 33146, United States
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Deerfield Beach, Florida, 33442, United States
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Miami, Florida, 33136, United States
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Miami, Florida, 33176, United States
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Plantation, Florida, 33324, United States
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Atlanta, Georgia, 30308, United States
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Atlanta, Georgia, 30322, United States
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Atlanta, Georgia, 30342, United States
No email / 404-851-7115
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Chicago, Illinois, 60611, United States
[email protected] / 312-695-1301
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Detroit, Michigan, 48201, United States
No email / No phone
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Farmington Hills, Michigan, 48334, United States
No email / No phone
Status: Active, not recruiting
New Brunswick, New Jersey, 08903, United States
No email / 732-235-7356
Status: Recruiting
New York, New York, 10016, United States
[email protected] / 646-754-4624
Status: Recruiting
New York, New York, 10016, United States
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Status: Recruiting
New York, New York, 10032, United States
[email protected] / 212-342-5162
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New York, New York, 10065, United States
No email / 212-746-1848
Status: Recruiting
Pittsburgh, Pennsylvania, 15232, United States
No email / 412-647-8073
Status: Recruiting
Westerly, Rhode Island, 02891, United States
[email protected] / 203-785-5702
Status: Recruiting
Nashville, Tennessee, 37232, United States
No email / 800-811-8480
Status: Recruiting
Salt Lake City, Utah, 84112, United States
[email protected] / 888-424-2100
Status: Recruiting
Richmond, Virginia, 23298, United States
[email protected] / 804-628-6430
Status: Recruiting
Madison, Wisconsin, 53718, United States
[email protected] / 800-622-8922
Status: Recruiting
Madison, Wisconsin, 53792, United States
[email protected] / 800-622-8922
Status: Recruiting