Vancomycin in Patients With Unresectable Fibrolamellar Hepatocellular Carcinoma (FLC) Oral
Vancomycin in Patients With Unresectable Fibrolamellar Hepatocellular Carcinoma (FLC) Oral
Background:

 Fibrolamellar Hepatocellular Carcinoma (FLC) is a rare liver cancer. It most often occurs in
 young people who have no history of liver disease. Unresectable FLC most often does not
 improve with surgery. Researchers think gut bacteria may affect liver cancer control. They
 want to see if a drug that controls a type of bacteria can help.

 Objective:

 To test if vancomycin is safe and tolerable for and can treat people with unresectable FLC.

 Eligibility:

 People ages 18 and older with FLC that isn t responsive to treatment

 Design:

 Participants will be screened with a medical history, physical exam, blood and urine tests,
 and CT or MRI scans. They will provide a tumor sample: If they do not have one, they will
 have a biopsy.

 Participants will take vancomycin 3 times a day. They will take the drug by mouth. They will
 take the drug in 28-day cycles. They will take the drug daily for the first 3 weeks. They
 will not take the drug the last week.

 Participants will keep a medication diary.

 Participants will have blood and urine tests each cycle. They may provide stool samples.

 Participants will have a biopsy before they start treatment. Then they will have one on day 1
 of cycle 2.

 Participants will have scans on day 1 of cycle 2. Then they will have scans about every 8
 weeks.

 Participants will continue treatment until their cancer gets worse or they can no longer
 tolerate the side effects.

 Participants will have a follow-up visit about a month after they finish treatment. Then they
 will be followed every 6 months by phone or email.
Background:

 -  Fibrolamellar hepatocellular carcinoma (FLC) is a rare liver cancer (0.5-9% of primary
 liver cancers), which affects younger age groups and is not associated with underlying
 liver disease or elevated serum alpha fetoprotein (AFP) levels.

 -  Surgery, either liver resection (LR) or liver transplantation (LT), is the only
 potentially curative treatment for FLC patients with resectable disease. Disease
 recurrence after complete resection is high (33-100%). In patients with unresectable
 disease, median survival is less than 12 months; with no patient expected to survive
 beyond 5 years.

 -  The role of systemic chemotherapy and radiotherapy is poorly defined, and has been
 reported to have only a modest or no therapeutic effect. To date no targeted therapy has
 been shown to be of any value in FLC.

 -  In mouse models, oral vancomycin alters gut commensal bacteria thereby inducing a
 liver-selective anti-tumor effect by increasing hepatic CXCR6+ NKT cells via increased
 CXCL16 expression of liver sinusoidal endothelial cells.

 Objective:

 -To evaluate the effect of oral vancomycin therapy on the relative CXCR6 gene expression
 levels in the liver in paired pre- and on-treatment biopsy samples from hepatic lesions in
 patients with unresectable FLC

 Eligibility:

 -  Histologically confirmed FLC, not amenable to potentially curative resection,
 transplantation or ablation.

 -  Liver lesion measurable by RECIST criteria, accessible for biopsy.

 -  Age greater than or equal to 18 years

 -  ECOG performance status less than or equal to 2

 -  Acceptable renal and normal liver function.

 -  Willingness to undergo pre- and on-treatment biopsies of liver tumor.

 Design:

 -  This is a phase II study of oral vancomycin in patients with unresectable FLC.

 -  Up to 14 patients will be treated with oral vancomycin 500 mg tid daily (1,500 mg total
 daily dose) from days 1 to 21, in a 28-day cycles. After completion of the first cycle,
 initiation of concurrent treatment will be allowed. Patients will receive oral
 vancomycin until off treatment criteria are met.

 -  Patients will be evaluated for toxicity every 4 weeks by CTCAE v5.0, and for response at
 the end of the first cycle and thereafter every 8 (+/-3) weeks by RECIST 1.1.
-  INCLUSION CRITERIA:

 -  Patients must have histopathological confirmation of FLC by the NCI Laboratory of
 Pathology.

 -  Patients must have disease that is not amenable to potentially curative resection,
 transplantation or ablation.

 -  Patients must be greater than or equal to 18 years of age. Children are excluded from
 this study because this study has two mandatory biopsies performed for research
 purposes only and we do not want to put children into additional risk of biopsies.

 -  Patients must have evaluable or measurable hepatic disease per RECIST 1.1

 -  Patients must have hepatic lesion accessible for biopsy and be willing to undergo pre-
 and post-treatment mandatory biopsies.

 -  ECOG performance status of less than or equal to 2

 -  Adequate renal function defined by:

 -  Creatinine <1.5 x institution upper limit of normal (ULN)

 -  Creatinine clearance (CrCl) greater than or equal to 50 mL/min/1.73 m2 by 24
 hours urine collection or eGFR as estimated using the chronic kidney disease
 (CKD)-EPI equation for participant with creatinine levels > 1.5 X institutional
 ULN.

 -  Adequate hepatic function defined by:

 -  Total bilirubin level with upper limit of normal less than or equal to 1
 (SqrRoot) ULN,

 -  AST level <5(SqrRoot) ULN, and

 -  ALT level <5 (SqrRoot) ULN.

 -  Adequate hematological function defined by:

 --Absolute neutrophil count (ANC) greater than or equal to 1.5 (SqrRoot) 109/L.

 -  Subjects must be co-enrolled onto protocol 11C0112.

 -  Ability of subject or Legally Authorized Representative to understand and the
 willingness to sign a written informed consent document.

 EXCLUSION CRITERIA:

 -  Patients who have had standard-of-care anti-cancer therapy (e.g.,
 chemotherapy,immunotherapy, endocrine therapy, targeted therapy, biologic therapy,
 tumor embolization, monoclonal antibodies or other investigation agents) within 2
 weeks of enrollment; or, therapy with investigational agents, large field
 radiotherapy, or major surgery within 4 weeks prior to enrollment.

 -  Patients who are currently receiving any other investigational agents for any
 indication.

 -  Patients who are actively receiving broad-spectrum antibiotics or have received such
 within 4 weeks prior to enrollment.

 -  Patients with history of recurrent C. diff colitis

 -  Patients who are on anti-coagulation or anti-platelet medication that cannot be
 interrupted prior to study-specified biopsies, including:

 -  Aspirin that cannot be discontinued for 7 days prior to biopsy

 -  Clopidogrel and ticagrelor that cannot be discontinued for 5 days prior to biopsy

 -  Ticlopidine that cannot be discontinued for 10 days prior to biopsy

 -  Prasugrel that cannot be discontinued for 7 days prior to biopsy

 -  Dipyridamole that cannot be discontinued for at least 2 days prior to biopsy

 -  Cilostazol that cannot be discontinued for at least 3 days prior to biopsy

 -  Coumadin that cannot be discontinued for 7 days prior to biopsy

 -  Low molecular weight heparin (LMWH) that cannot be discontinued >24 hours prior
 to biopsy and unfractionated heparin (UFH) that cannot be discontinued >4 hours
 prior to biopsy. NOTE: LMWH or UFH may be used to transition patients on and off
 the above anti-coagulants, if deemed appropriate by the treating physician.

 -  Oral direct thrombin inhibitor (dabigatran) or direct Factor Xa inhibitor
 (rivaroxaban, apixaban, and edoxaban) that cannot be discontinued for 4 days
 prior to biopsy

 -  Any other uncontrolled intercurrent illness or medical condition that per PI
 discretion would limit compliance with study requirements.

 -  Pregnant women are excluded from this study because this study has two mandatory
 biopsies performed for research purposes only and biopsies can have abortifacient
 effect.