Clinical Trials /

IMMUNOtherapy and Stereotactic ABlative Radiotherapy (IMMUNOSABR) a Phase II Study

NCT03705403

Description:

This will be a phase II trial testing if the combination of stereotactic ablative body radiotherapy (SABR) and L19-IL2 improve the progression-free survival in patients with limited metastatic non-small cell lung cancer (NSCLC). The trial consists of one cohort with two arms; C-arm and an E-arm. Patients with oligometastatic disease will receive SABR to minimal 1 and max all metastatic sites (max 5 sites irradiated) and patients with diffuse metastatic lesions (6 to max 10) will receive radiotherapy to max 5 sites. In the experimental arm, immunotherapy will be given after irradiation.

Related Conditions:
  • Non-Small Cell Lung Carcinoma
Recruiting Status:

Recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: IMMUNOtherapy and Stereotactic ABlative Radiotherapy (IMMUNOSABR) a Phase II Study
  • Official Title: Stereotactic Ablative Body Radiotherapy (SABR) Combined With Immunotherapy (L19-IL2) in Stage IV NSCLC Patients, ImmunoSABR: a Multicentre, Randomised Controlled Open-label Phase II Trial

Clinical Trial IDs

  • ORG STUDY ID: UM2018IMMUNOSABR2RLPL
  • NCT ID: NCT03705403

Conditions

  • NSCLC Stage IV
  • Metastatic Disease

Interventions

DrugSynonymsArms
DarleukinL19 - IL2Experimental treatment

Purpose

This will be a phase II trial testing if the combination of stereotactic ablative body radiotherapy (SABR) and L19-IL2 improve the progression-free survival in patients with limited metastatic non-small cell lung cancer (NSCLC). The trial consists of one cohort with two arms; C-arm and an E-arm. Patients with oligometastatic disease will receive SABR to minimal 1 and max all metastatic sites (max 5 sites irradiated) and patients with diffuse metastatic lesions (6 to max 10) will receive radiotherapy to max 5 sites. In the experimental arm, immunotherapy will be given after irradiation.

Detailed Description

      IMMUNOSABR will include 126 patients. In this single-stage controlled randomised open-label
      phase II trial, we aim to demonstrate an absolute increase in progression-free survival
      (primary endpoint). PFS will be determined as the time between randomisation and disease
      progression, according to RECIST 1.1, death due to any cause or last patient contact alive
      and progression-free. Patients will be randomized between control (no immunocytokine) and
      experimental arms (with immunocytokine L19-IL2) in a 1:1 ratio. The accrual period will be 29
      months (or 2.41 years), and the minimum follow-up will be 18 months (or 1.5 years), making
      the total study duration 47 months. Comparison between control and experimental arms will be
      made using the Log-Rank statistic. This test for superiority will be one-sided with the
      desired type I error of 0.10 and power of 0.90.

      Patients enrolled in the trial will be randomised into the control arm (C-arm) or
      experimental arm (E-arm).

        -  C-arm: Standard of Care (SOC) according to the local and national guidelines: (wait and
           see or surgery and/or chemotherapy and/or standard (symptomatic) radiotherapy and/or
           SABR, oligometastatic disease.

        -  E-arm: Standard of Care (SOC) SABR (oligometastatic disease) or radiotherapy (diffuse
           disease) + L19-IL2 up to 6 cycles (+ aPD(L)1 if SOC)

      The expected 1.5-year PFS is 15% in the C-arm and 35% in the E-arm. A sample size of 116
      patients (58 patients per treatment arm) is needed to show this difference of 20% in PFS,
      using a logrank test with a two-sided alpha of 0.05 and power of 85%. Patients will be evenly
      divided over the two arms. Assuming a drop-out rate of 10%, a total of 126 patients (63 per
      arm) need to be included.

      Primary objective The main objective of the trial is to test if the activity of the
      combination of (SAB)R and L19-IL2 in patients with metastatic NSCLC will result in improved
      progression-free survival (PFS) compared to the SOC.

      Secondary Objectives

        -  Assessment of the PFS of the patient cohort, at 5 years after randomisation.

        -  Assessment of the overall survival of the patient cohort, at 5 years after
           randomisation.

        -  To assess the toxicity of this treatment schedule;

        -  To assess Quality of Life (QoL);

        -  To assess the occurrence of an Out of Field Radio-Immune (OFRI) response / abscopal
           effect using imaging;

        -  To assess the occurrence of an In Field Radio-Immune (IFRI) response using imaging;

        -  To perform correlative biomarker studies related to treatment response.

      Exploratory endpoints:

        -  Correlative biomarker studies:

             -  Tumour tissue: e.g EDB expression, non-synonymous mutations, immune monitoring;

             -  Blood: e.g. EDB expression, cfDNA, and immune monitoring;

             -  Radiomics on CT and if available MRI;

             -  Faeces: diversity in microbiota.

        -  iRECIST

        -  Tumour grow kinetics
    

Trial Arms

NameTypeDescriptionInterventions
ControlActive ComparatorStandard of Care (SOC) according to the local and national guidelines: (wait and see or surgery and/or chemotherapy and/or standard (symptomatic) radiation therapy and/or SABR (oligometastatic disease)
    Experimental treatmentExperimentalStandard of Care (SOC SABR (oligometastatic disease) or radiation therapy (diffuse disease) + L19-IL2 up to 6 cycles (Darleukin)
    • Darleukin

    Eligibility Criteria

            Inclusion criteria
    
            Oligometastatic disease (≤5 metastases)
    
              -  Histological confirmed limited metastatic adult NSCLC patients, regardless of the
                 PD-L1 status.
    
                   -  Maximum of 5 metastatic lesions, maximum two brain lesion with a total cumulative
                      diameter of 5cm is allowed.
    
            SOC baseline imaging e.g MRI and/or PET-CT and CT-brain or MRI brain and/or CT-scan with at
            least covering thorax-upper abdomen-brain, within 6 weeks prior to randomisation.
    
            If a patient has unclear lesions in the liver or brain an MRI would be advised following
            the ESMO guidelines.
    
            o In patients with 2 lung tumours, it can be unclear if the patient has 2 concurrent
            primary tumours or a primary lung tumour with 1 metastasis. In this case, the local
            multidisciplinary tumour board will decide whether the patient has an M1 disease or not.
    
            • Previous treatment: Prior cancer treatments are allowed but must be discontinued for at
            least 4 weeks before randomisation. In case of maintenance chemotherapy, this therapy will
            only be started after the end of the L19-IL2 treatment or only in case of Anti-PD(L)1
            treatment, during L19-IL2 therapy.
    
              -  Age of 18 years or older.
    
              -  WHO performance status 0-1;
    
              -  Adequate bone marrow function, evaluated in the local laboratory (Lab): Absolute
                 Neutrophil Count (ANC) of ≥ 1.0 x 109 /L, platelet count ≥ 100 x 109/L, Haemoglobin
                 (Hb) ≥ 6.0 mmol/L (or 9.67 g/dL) (it is allowed to give a blood transfusion if Hb is
                 initially too low);
    
              -  Adequate hepatic function (evaluated in the local lab): total bilirubin ≤ 1.5 x upper
                 limit of normal (ULN) for the institution; ALT, AST, and alkaline phosphatase ≤ 2.5 x
                 ULN for the institution or ≤ 5 in case of liver metastasis);
    
              -  Adequate renal function (evaluated in the local lab): creatinine clearance of at least
                 40 ml/min;
    
              -  The patient is capable of complying with study procedures;
    
              -  Life expectancy of at least 12 weeks;
    
              -  Negative serum pregnancy test for females of childbearing potential.
    
              -  Signed and dated written informed consent.
    
              -  Ability to comply with contraception requirements:
    
            Non-sterilised, sexually active male patient with a female partner who is of child-bearing
            age, must use two acceptable birth control methods like a condom combined with spermicidal
            cream or gel from the first dose of study medicine, during the study and at least up to 12
            weeks after the last administration of the study medicine and up to 5 months after the last
            dose of the medicine with anti-PDL)1 as an action mechanism (if you get this product
            besides the study medicine), as an addition to the use, by the female partner, of as
            described in the following section:
    
            Women of childbearing potential (WOCBP) and WOCBP partners of male patients must be using,
            from the screening to three months following the last study drug administration and 4 5
            months after last dose of anti-PD(L)1 maintenance treatment, effective contraception
            methods ((a) IUD (IUD) or intrauterine hormone delivery system (IUS), b) combined (with
            estrogen and progesterone) hormonal contraception associated with ovulation inhibition
            (oral, intravaginal, transdermal), c) hormonal contraception with progesterone only
            associated with ovulation inhibition (oral, injectable, implantable), as defined by the
            "Recommendations for contraception and pregnancy testing in clinical trials" issued by the
            Head of Medicine Agencies' Clinical Trial Facilitation Group (www.hma.eu/ctfg.html).
    
            Poly-metastatic disease (6 to 10 metastases)
    
            • Histological confirmed limited metastatic adult NSCLC patients, regardless of the PD-L1
            status.
    
            A minimum of 6 and maximum of 10 metastatic lesions, maximum two brain lesion with a total
            cumulative diameter of 5cm is allowed.
    
            At least one measurable lesion (according to RECIST 1.1) that has no overlap with the PTV
            of the lesion subjected to radiotherapy.
    
            • Previous treatment: The time between the last administration of chemo and/or
            immunotherapy (given as first or second line standard of care treatment) and the
            randomisation must be at least 4 weeks. In case of maintenance chemotherapy, this therapy
            will only be started after the end of the L19-IL2 treatment or only in case of Anti-PD(L)1
            treatment, during L19-IL2 therapy.
    
              -  Age of 18 years or older;
    
              -  WHO performance status 0-1;
    
              -  Adequate bone marrow function (evaluated in the local lab): Absolute Neutrophil Count
                 (ANC) of ≥ 1.0 x 109 /L, platelet count ≥ 100 x 109/L, Hb ≥ 6.0 mmol/L (or 9.67 g/dL)
                 (it is allowed to give a blood transfusion if Hb is initially too low);
    
              -  Adequate hepatic function (evaluated in the local lab): total bilirubin ≤ 1.5 x upper
                 limit of normal (ULN) for the institution; ALT, AST, and alkaline phosphatase ≤ 2.5 x
                 ULN for the institution or ≤ 5 in case of liver metastasis);
    
              -  Adequate renal function (evaluated in the local lab): creatinine clearance of at least
                 40 ml/min;
    
              -  The patient is capable of complying with study procedures;
    
              -  Life expectancy of at least 12 weeks;
    
              -  Negative serum pregnancy test for females of childbearing potential;
    
              -  Ability to comply with contraception requirements (see oligo)
    
              -  Signed and dated written informed consent.
    
            Exclusion criteria
    
              -  More than 10 metastatic lesions.
    
              -  More than 2 brain metastatic lesions.
    
              -  2 brain metastases with a cumulative diameter larger than 5 cm.
    
              -  Patients with non-infectious pneumonitis, uncontrolled thyroid disease, pleuritis,
                 pericarditis and peritonitis carcinomatosis.
    
              -  Patients who received live vaccines 30 days or fewer prior to enrolment.
    
              -  Patients who are already actively participating in another study.
    
              -  Patients who need simultaneous radiation on the primary tumour and metastatic
                 lesion(s). For these patients it might be an option to treat the primary tumour first
                 although this is not mandatory for this study. There must be minimal four weeks
                 between last treatment and randomisation.
    
              -  Whole brain radiotherapy (WBRT) is not allowed, although it is accepted when given at
                 least 4 weeks prior to randomisation or after the treatment period. Patients with
                 stable brain metastases are not excluded.
    
              -  Previous radiotherapy to an area that would be re-treated by (SAB)R, resulting in
                 overlap of the high dose areas.
    
              -  Maintenance therapy with Anti-PD(L)1 treatment combined with chemotherapy is not
                 allowed during treatment ((SAB)R and L19-IL2 cycles).
    
              -  Other active malignancy or malignancy within the last 2 years (except localised skin
                 basal/squamous cell carcinoma, non-muscle invasive carcinoma of the bladder or in situ
                 carcinoma from any site).
    
              -  Concomitantly administered glucocorticoids may decrease the activity of IL2 and
                 therefore should be avoided. However, patients who develop life-threatening signs or
                 symptoms may be treated with dexamethasone until toxicity resolves or reduces to an
                 acceptable level (generally grade 1 and 2, however must be based at the research
                 physician's discretion).
    
              -  History of allergy to intravenously administered proteins/peptides/antibodies/
                 radiographic contrast media.
    
              -  HIV positive; active HIV infection, or active hepatitis B or C (assessed in local
                 lab).
    
              -  Systemic treatment with either corticosteroid (>10 mg daily prednisone equivalents) or
                 Interferon alpha or immunosuppressive medications within 14 days prior to
                 randomisation. Topical or inhalation steroids are allowed. If a patient needs to take
                 unexpectedly immunosuppressive medication during the trial, it will be allowed but
                 decreasing the dose as soon as possible is strongly advised.
    
              -  Prior history of organ transplant, including autologous stem cell transplant.
    
              -  Acute or sub-acute coronary syndromes within the last year, acute inflammatory heart
                 disease, heart insufficiency NYHA > 2, or irreversible cardiac arrhythmias.
    
              -  A known impaired cardiac function defined as left ventricular ejection fraction (LVEF)
                 < 50 % (or below the study site's lower limit of normal) as measured by MUGA or ECHO.
    
              -  Uncontrolled hypertensive disease; (systolic blood pressure (SBP) ≥160 or diastolic
                 blood pressure (DBP) ≥100 mm Hg during two measurements).
    
              -  History or evidence of active autoimmune disease.
    
              -  Severe diabetic retinopathy (neoangiogenesis targeted by L19 outside the tumour).
    
              -  Major trauma, including oncologic surgery, but excluding smaller procedures like the
                 placement of porth-à-cath or surgical biopsy, within 4 weeks prior to randomisation
                 (neoangiogenesis targeted by L19 outside a tumour).
    
              -  Any underlying mental, medical or psychiatric condition which in the opinion of the
                 investigator will make administration of study drug hazardous or hinder the
                 interpretation of study results. Unstable or serious concurrent uncontrolled medical
                 conditions.
    
              -  Pregnancy or breast feeding; it is well known that ED-B, the target of both L19IL2, is
                 expressed in a variety of fetal tissues. Furthermore, anti-PD(L)1 treatment may
                 increase the risk of immune-mediated disorders. Therefore, it will be contra-indicated
                 for pregnant or lactating women.
          
    Maximum Eligible Age:N/A
    Minimum Eligible Age:18 Years
    Eligible Gender:All
    Healthy Volunteers:No

    Primary Outcome Measures

    Measure:Progression-free survival
    Time Frame:18 months after randomization of the last patient
    Safety Issue:
    Description:The main objective of the trial is to test the hypothesis that the combination of (SAB)R and L19-IL2 in patients with metastatic NSCLC will resulting in improved progression-free survival (PFS) compared to the SOC.

    Secondary Outcome Measures

    Measure:Overall survival
    Time Frame:18 months after randomization of the last patient
    Safety Issue:
    Description:Assesment of the overall survival of the patient cohort.
    Measure:Change in score of The EORTC quality of life questionnaire (QLQ) core module (C30)
    Time Frame:baseline and at 3, 6, 9, 12, 15, 18, 21, 24 months after treatment
    Safety Issue:
    Description:The EORTC QLQ assesses health-related QoL of cancer patients; it consists of 30 items and covers 9 domains + 6 single symptoms. There are 5 functional scales: physical, role functioning, cognitive, emotional, social; 3 symptom scales: fatigue, pain, nausea + vomiting; a global health and QoL scale, and 6 single items. Each item has four response alternatives: 1) not at all, 2) a little 3) quite a bit 4) very much (score 1-4 with range 3); except for the global health-status/quality of life scale, which has options ranging from 1) very poor to 7) excellent (score 1-7, range 6). Answers are combined into dimensions and scores are linearly transformed into a score of 0 to 100 according to the scoring manual of the EORTC QoL group. For functional and global QoL scales, higher scores mean better level of functioning. For symptom-oriented scales, a higher score means more severe symptoms. Scores are reported as mean and standard deviation. Scores will be used in multilevel-analysis.
    Measure:Change in score of The EORTC quality of life questionnaire (QLQ) - Lung cancer module (LC13)
    Time Frame:baseline and at 3, 6, 9, 12, 15, 18, 21, 24 months after treatment
    Safety Issue:
    Description:The EORTC QLQ-LC13 The Lung Cancer Module is a supplementary questionnaire module to be employed in conjunction with the QLQ-C30. The QLQ-LC13 incorporates one multi-item scale to assess dyspnoea, and a series of single items assessing pain, coughing, sore mouth, dysphagia, peripheral neuropathy, alopecia, and haemoptysis. All items are scored 1 to 4, giving range = 3. After linear transformation scores range from 0 to100. A high score represents a high level of symptomatology or problems.
    Measure:Change in score of The Euro Quality of Life - 5 dimensions - 5 levels (EQ-5D-5L)
    Time Frame:baseline and at 3, 6, 9, 12, 15, 18, 21, 24 months after treatment
    Safety Issue:
    Description:EQ-5D-5L is a standardized instrument developed by the EuroQol Group as a measure of general health-related quality of life that can be used in a wide range of health conditions and treatments. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems (score 1-5). The scores for the five dimensions are combined into a 5-digit number that describes the patient's health state.
    Measure:Change in score of The Euro Quality of Life (EQ) visual analogue scale (VAS)
    Time Frame:baseline and at 3, 6, 9, 12, 15, 18, 21, 24 months after treatment
    Safety Issue:
    Description:The EQ VAS records the patient's self-rated health on a vertical visual analogue scale from 0-100. This can be used as a quantitative measure of health outcome that reflects the patient's own judgement.
    Measure:Change in out of field radio-immune (OFRI) response
    Time Frame:at 3, 6, 9, 12, 15, 18, 21, 24 months after treatment
    Safety Issue:
    Description:To assess the occurrence of an out of field radio-immune (OFRI) response, with a scan. Assessment will be based on the RECIST criteria.
    Measure:Immunoresponse blood biomarkers by enzyme-linked immunosorbent assay (ELISA)
    Time Frame:baseline and at 3, 6 and 9 months after treatment
    Safety Issue:
    Description:To perform correlative biomarker studies related to treatment response immunoresponse blood biomarkers will be measured: osteopontin (OPN), carbonic anhydrase IX (CA-IX)], interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP), carcinoembryonic antigen (CEA), cytokeratin fragment 21-1 (Cyfra 21-1), alpha-2-macroglobulin (α2M), serum interleukin-2 receptor (sIL2r), toll-like receptor 4 (TLR4), vascular endothelial growth factor (VEGF), extradomain-B fibronectin (EDB). This part of the study is exploratory.

    Details

    Phase:Phase 2
    Primary Purpose:Interventional
    Overall Status:Recruiting
    Lead Sponsor:Maastricht University

    Last Updated

    March 31, 2020