Combined-modality treatment of localized muscle invasive bladder cancer including transurethral resection (TUR), radiotherapy and dual checkpoint inhibition immunotherapy could achieve pathological complete response in some patients. These patients could avoid to undergone radical surgery with radical cystectomy and preserve their bladder, without the side-effects associated with chemotherapy and surgery. This study has been design to determine the efficacy of durvalumab plus tremelimumab with concurrent radiotherapy in terms of pathological response rate in patients with localized muscle invasive bladder cancer treated with bladder preservation intent.
The treatment consisted of initial TUR of the tumor, with multiple random biopsies of normal-appearing bladder urothelium, followed by durvalumab 1500 mg i.v. plus tremelimumab 75 mg i.v., every 4 weeks for a total of 3 doses. Two weeks after the initiation of immunotherapy, normofractionated external-beam radiotherapy with high-energy photons will be started. Radiotherapy will be administered concurrently with immunotherapy at doses of 46 Gy to the minor pelvis and 64-66 Gy to the bladder. Six weeks after the end of radiotherapy, ALL patients will undergo a new cystoscopy with biopsies of the tumor bed and all residual present lesions as an efficacy determination. In patients with persistent prominent inflammatory reaction at this moment, the cystoscopy can be performed 1-2 weeks later (6 to 8 weeks after the end of radiotherapy). Response is defined as an absence of invasive cancer at post immunotherapy biopsy (≤cT1). Patients with response to immunotherapy will be candidates to bladder preservation, whereas in those with residual muscle invasive tumor the possibility of salvage radical cystectomy must be evaluated. Patients developing an isolated bladder invasive relapse during follow-up will be also possible candidates to salvage cystectomy, whereas those developing a superficial relapse in the preserved bladder will be managed with TUR and intravesical BCG. Patients will be followed up every 3 months the first year, every 4 months the second year and every 6 months thereafter with abdomen and pelvis CT scan, Rx thorax, urine cytology. Additionally, the mandatory efficacy cystoscopy and bladder biopsy (6w post RT), other cystoscopy and bladder biopsy will be performed in case of detection abnormalities in the cytology or imaging studies. The study will be closed 2 years after the last patient inclusion.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
32
All patients will receive durvalumab (MEDI4736) (1500mg Q4W) in combination with tremelimumab (75 mg IV Q4W) for up to 3 doses/cycles each, unless there is unacceptable toxicity, withdrawal of consent, or another discontinuation criterion is met. If a patient's weight falls to 30kg or below the patient should receive weight-based dosing equivalent to 20 mg/kg of durvalumab Q4W and 1mg/kg tremelimumab Q4W until the weight improves to \>30 kg, at which point the patient should start receiving the fixed dosing of durvalumab 1500mg plus tremelimumab 75 mg Q4W.
All patients will receive durvalumab (MEDI4736) (1500mg Q4W) in combination with tremelimumab (75 mg IV Q4W) for up to 3 doses/cycles each, unless there is unacceptable toxicity, withdrawal of consent, or another discontinuation criterion is met. If a patient's weight falls to 30kg or below the patient should receive weight-based dosing equivalent to 20 mg/kg of durvalumab Q4W and 1mg/kg tremelimumab Q4W until the weight improves to \>30 kg, at which point the patient should start receiving the fixed dosing of durvalumab 1500mg plus tremelimumab 75 mg Q4W.
Radiotherapy at doses of 46 Gy to the minor pelvis and 64-66 Gy to the bladder.
Instituto Catalán de Oncología Badalona
Badalona, Barcelona, Spain
Centro Oncológico de Galicia
A Coruña, Spain
Instituto Catalán de Oncología L'Hospitalet
Barcelona, Spain
Hospital Universitario 12 de Octubre
Madrid, Spain
H.U. Virgen del Rocío
Seville, Spain
Hospital Universitario y Politécnico La Fe
Valencia, Spain
Instituto Valenciano de Oncología
Valencia, Spain
Proportion of Patients With Pathological Response
Pathological response is defined as the absence of muscle- invasive bladder cancer at post-treatment biopsy (≤cT1). Cystoscopy and bladder biopsy six weeks since the end of radiotherapy.
Time frame: 12 weeks
Rate of Patients With Bladder Preserved
Number of patients whom bladder has been preserved after cytoscopic evaluation.
Time frame: 24 months
Rate of Immediate Salvage Cystectomies
Number of patients with indication of salvage cystectomies after first trial-related cystoscopic evaluation.
Time frame: 24 months
Rate of Late Salvage Cystectomies
Number of patients with indication of salvage cystectomies based on follow-up cystoscopic evaluation.
Time frame: 24 months
Survival With Bladder Preserved Free of Tumor
Time from the start of immunotherapy to either the date of cystectomy or the date of recurrence of muscle- invasive bladder carcinoma or metastasis. Here we report the estimated rate of patients free of event at 24 months after the start of immunotherapy. Estimation by kaplan meier method.
Time frame: 24 months
Disease-free Survival
Time from treatment start to tumour relapse or distant progression (without Salvage cystectomy). Bladder relapse with salvage cystectomy is not considered as an event. Deaths are also considered as events. Here we report the estimated rate of patients free of events at 24 months after the start of the immunotherapy. Estimation by kaplan meier method.
Time frame: 24 months
Overall Survival
Time from the start of immunotherapy to the date of death due to any cause. The reported outcome is the estimated ratio of patients alive at 24 months after start of immunotherapy using kaplan meier method.
Time frame: 24 months
Number of Participants With Treatment-related Adverse Events as Assessed by CTCAE v4.0
Frequency, nature and number of patients developing adverse events throughout follow up
Time frame: 24 months
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