This multicentric, randomised, Phase II trial will use a pick-the-winner design in order to evaluate the clinical and biological activity of atezolizumab when combined with pre-operative or post-operative radiotherapy in STS patients. Following Inform Consent Form (ICF) signature, eligible patients will be randomised (1:1:1) to receive: * Arm A: Radiotherapy followed by atezolizumab then surgery. * Arm B: Atezolizumab followed by surgery then radiotherapy. * Arm C: Radiotherapy then surgery followed by atezolizumab. The sequence of the study treatments is different among the 3 study arms. However, the dose regimens will be the same: * Atezolizumab will be administered to all patients at the dose of 1200mg, by IV injection, for 2 cycles (Q3W). * Radiotherapy will be administered to all patients at the dose of 2Gy/day, 5 days per week, for a total of 5 weeks and 50Gy. * Surgery will be performed as per institutional practice. Randomisation will be stratified according to histological subtypes as follows: Group 1: Liposarcoma (LPS), Undifferentiated Pleomorphic Sarcoma (UPS), Leiomyosarcoma (LMS), myxofibrosarcoma, angiosarcoma versus Group 2: all translocation sarcoma except Ewing, rhabdomyosarcoma (RMS) and myxoid LPS.
This trial is a European, multicenter, open-label, randomized, Phase II trial using a pick-the-winner design aiming to the clinical and biological activity of anti-PD-L1 (atezolizumab) in a population of operable localised soft tissue sarcomas (STS) patients to be treated with radiotherapy. Following inform consent signature and validation of eligibility criteria, patients will be randomized (1:1:1) into one of the 3 study arms: * Arm A: Pre-operative radiotherapy followed by 2 cycles of atezolizumab then surgery * Arm B: 2 cycles of atezolizumab followed by surgery then post-operative radiotherapy * Arm C: Pre-operative radiotherapy followed by surgery then 2 cycles of atezolizumab. The sequence of treatment is different between the study arms, but the regimen of study treatments are the same. All randomized patients will received: * The conventionally fractionated radiotherapy regimen of 2 Gy, 5 days a week up to a total dose of 50 Gy over 5 weeks. Radiotherapy will be either pre-(Arms A and C) or post-(Arm B) operative. * Two cycles of atezolizumab (1200mg, IV, Q3W) * Surgery will be performed as per institutional practice. Randomisation will be stratified according to histological subtypes as follows * Group 1: Leiomyosarcoma \[LMS\], Undifferentiated Pleomorphic Sarcoma \[UPS\], Liposarcoma \[LPS\], myxofibrosarcoma, angiosarcoma versus * Group 2: all translocation sarcoma except Ewing, rhabdomyosarcoma RMS and myxoid LPS. Following this sequence of treatment, all patients will be followed-up 2 weeks after the end of the treatment period then W18, W24 (=M6) then every 3 months until disease relapse, death, loss to follow-up. The minimal follow-up will be 1 year for the last randomized patient. During the study period, the following tumor samples will be also collected for all randomized patients: * A de novo tumor biopsy before study treatment start (pre-treatment tumor sample) * A fragment of the surgery specimen.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
62
W1,W2, W3, W4 \& W5: RADIOTHERAPY. A 3-dimensional conformal RT (3D-CRT) with photons ≥ 6MV will be realized based on the acquisition of a CT-scan performed in treatment position. Intensity modulated RT (IMRT), volumetric modulated arc therapy (VMAT) and tomotherapy are authorized. W6 and W9: ATEZOLIZUMAB IV INJECTION. 2 injections of 1200 mg of atezolizumab with a 3-week interval W11: SURGERY. Surgery should be performed as per Institutional practice by a surgeon with appropriate training in the treatment of sarcoma. The primary aim of surgery is to completely excise the tumor with a margin of normal tissue commonly accepted as 1 cm soft tissue, or equivalent
W1 and W4: ATEZOLIZUMAB IV INJECTION. 2 injections of 1200 mg of atezolizumab with a 3-week interval W6: SURGERY Surgery should be performed as per Institutional practice by a surgeon with appropriate training in the treatment of sarcoma. The primary aim of surgery is to completely excise the tumor with a margin of normal tissue commonly accepted as 1 cm soft tissue, or equivalent W7, W8, W9, W10 \& W11: RADIOTHERAPY A 3-dimensional conformal RT (3D-CRT) with photons ≥ 6MV will be realized based on the acquisition of a CT-scan performed in treatment position. Intensity modulated RT (IMRT), volumetric modulated arc therapy (VMAT) and tomotherapy are authorized.
W1,W2, W3, W4 \& W5: RADIOTHERAPY A 3-dimensional conformal RT (3D-CRT) with photons ≥ 6MV will be realized based on the acquisition of a CT-scan performed in treatment position. Intensity modulated RT (IMRT), volumetric modulated arc therapy (VMAT) and tomotherapy are authorized. W6: SURGERY Surgery should be performed as per Institutional practice by a surgeon with appropriate training in the treatment of sarcoma. The primary aim of surgery is to completely excise the tumor with a margin of normal tissue commonly accepted as 1 cm soft tissue, or equivalent W11 and W14: ATEZOLIZUMAB IV INJECTION. 2 injections of 1200 mg of atezolizumab with a 3-week interval
Institut Bergonie
Bordeaux, France
Centre Oscar Lambret
Lille, France
Centre Léon Bérard
Lyon, France
Institut Claudius Regaud
Toulouse, France
Institut Gustave Roussy
Villejuif, France
Royal Marsden Hospital
London, United Kingdom
Pathological impact of PD-L1 neutralisation (by atezolizumab) with or without radiotherapy versus radiotherapy alone in operable localised STS
Rate of pathological response (defined by at least 80°% of necrosis on surgery specimens) following PDL1 neutralisation with atezolizumab +/- radiotherapy versus RT alone
Time frame: 11 weeks
Rate of patients with complete or near-complete pathologic response
Rate of patients with complete or near-complete pathologic response defined as ≥ 95% of necrosis. All pathology slides will be subjected to local central review by a subspecialty sarcoma pathologist. Surgery specimens will be examined for determination of tumor necrosis percentage.
Time frame: 11 weeks
Rate of patients with at least 50% of necrosis
Rate of patients with at least 50% of necrosis on the surgery specimen
Time frame: 11 weeks
Percentage of residual viable cells
Percentage of residual viable cells will be calculated for all surgery specimens.
Time frame: 11 weeks
Objective Response Rate (ORR)
Rate of patients with Complete Response (CR) and Partial Response (PR) as per the Response Evaluation Criteria in Solid Tumors (RECIST) v1.1
Time frame: 11 weeks
Tumor volume change
Tumor volume change (before versus after pre-operative treatment)
Time frame: 11 weeks
Quality of resection
Quality of resection will be described per study arms
Time frame: 11 weeks
Local Recurrence Rate (LRR) at 1 year post-surgery:
Rate of local recurrence 1 year after surgery.
Time frame: as long as 1 year from date of surgery
Time To Relapse (TTR)
Time from inclusion to relapse of the disease.
Time frame: from date of inclusion to relapse, for a maximum of 36 months from first randomized patient
Disease Free Survival (DFS)
time alive without disease.
Time frame: Time after treatment ends that the patient survives without disease, for a maximum of 36 months from first randomized patient
the impact of study treatments on immune cell infiltration
Number of T cells (including but not limited to GmzB+/CD8+ T-cell, CD3+ T-cell), B cells (CD20, IgG), and Treg (FOXP3) on pre (tumor biopsy at inclusion) and post-treatment (surgery specimen) by immunofluorescence (IF)
Time frame: 11 weeks
Number of patients with a significant change (at least a 2-fold change) in number of immune cell infiltration
Number of patients with a significant change (at least a 2-fold change) in number of T cells and other immune subsets under study treatments
Time frame: 11 weeks
Frequency of adverse events
Frequency of Adverse Event (AE), Serious Adverse Event (SAE), AE of special interest (AESI) and SUSAR graded using Common Terminology Criteria for Adverse Events (CTCAE) V4.03.
Time frame: a maximum of 36 months from date of first randomized patient
Amputation rate
Amputation rate will be measured per study arms
Time frame: 11 weeks
Severity of adverse events
Severity of Adverse Event (AE), Serious Adverse Event (SAE), AE of special interest (AESI) and SUSAR graded using Common Terminology Criteria for Adverse Events (CTCAE) V4.03.
Time frame: a maximum of 36 months from date of first randomized patient
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