This is an open-label, single-arm, phase 2a trial with a safety run-in cohort followed by a Simon two-step design expansion cohort, of two checkpoint blockage treatments and radiotherapy in the treatment of locally advanced or metastatic NSCLC who have failed first-line immunotherapy (alone or as a combination regimen with chemotherapy). Study objectives: Objective of the safety run-in phase: • To evaluate safety of the triple combination of irradiation -Durvalumab - Tremelimumab Co-Primary objectives of the entire study: * To evaluate safety of the triple combination (as for the run-in phase). * To evaluate response rate on study drug compared to historical data of response to first-line platinum-doublet chemotherapy and 2nd-line docetaxel. Secondary objective: • To evaluate PFS and OS compared to historical data . Exploratory objectives: * Examine the mechanism of resistance to first-line immunotherapy . * Examine the immune response in irradiation -Durvalumab - Tremelimumab treated patients and identify potential predictors of clinical benefit.
A cycle is defined as 28 days. Eligible patients who have a radiologically confirmed progressive disease on first line Immunotherapy treatment will receive an intravenous injection of 300 mg Tremelimumab at D1 and 12 weeks later a second dose of 300 mg tremelimumab, and an intravenous injections of 1500 mg Durvalumab q4w (starting from D1) . Treatment duration is until objective radiological disease progression as per RECIST 1.1 assessed by the local radiologist, and as long as the patients are benefiting from treatment according to the investigator's opinion and they do not meet any other discontinuation criteria. 21 days after the first immunotherapy treatment, a radiotherapy course of 11 fractions of 3 Gy (total of 33 Gy) will be administrated to metastatic or primary lesion/s over two weeks and one day. The second durvalumab treatment will be administered at the beginning of the 2nd week of radiotherapy, one week after radiotherapy start day. Following patients consent, a fresh biopsy specimen will be obtained (if not previously obtained after PD) for correlative studies, preferably from site of disease progression on first line immunotherapy. In addition, tissue samples will be obtained from both existing archived biopsy (diagnostic specimen), if available. An optional newly biopsied tissue sample will be taken 20 weeks after initiation of study treatment and at the time of progression on study treatment. Biopsy at PD is mandatory if can be performed with no significant risk. Blood and microbiome samples for correlative studies will be taken at predefined intervals, to explore predictive biomarkers for clinical efficacy, determine pharmacodynamic effects on immune cells, determine immune response signatures. Tumor imaging should be acquired by CT and include the chest, abdomen, and pelvis with and without IV contrast and with oral contrast. CT should be performed at baseline and every 8 weeks until objective radiological disease progression assessed as per RECIST 1.1. Patients who have discontinued treatment should be seen at end of treatment and 28 days post discontinuation for the evaluations outlined in the study schedule. Patients will be contacted every 90 days following discontinuation visit to capture survival status. Any patient who discontinues study treatment for reasons other than objective radiological progression should continue to undergo scheduled objective tumor assessments according to the study schedule in order to assess objective radiological progression of disease.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
29
Durvalumab administered IV over 60 minutes at a dose of 1500 mg every 4 weeks
Tremelimumab administered IV over 60 minutes at a dose of 300 mg , twice: at C1D1 and C4D1
21 days after the first immunotherapy treatment 11 fractions of 3 Gy will be administrated to metastatic or primary lesion/s over 2 weeks and one day
Sheba Medical Centre
Ramat Gan, Israel
treatment-related toxicity leading to treatment discontinuation (TRTLTD), as assessed by CTC-AE version 5.0.
number of patients with TRTLTD will be evaluated during the safety run-in phase
Time frame: Approximately 2 years
Incidence of Treatment-Emergent Adverse Events, as assessed by CTCAE version 5.0
Adverse events will be coded using the Medical Dictionary for Regulatory Activities (MedDRA, most updated version) terminology and presented in tables by System Organ Class (SOC) and Preferred Term (PT).
Time frame: From day of subject's written consent until study termination, approximately 4.5 years
Response rate on study treatment (according to investigator assessment, per RECIST 1.1)
Proportion of subjects showing best overall response of complete response (CR) or partial response (PR)
Time frame: Up to 5 months from treatment initiation, approximately 4.5 years overall
PFS on study treatment (according to investigator assessement, per RECIST 1.1
Duration of time from start of treatment to time of progression or death, whichever occurs first.
Time frame: From first dose of immunotherapy until first progression, approximately 4.5 years
Overall survival (OS)
Duration of time from diagnosis until death (or date of last documentation of being alive). Survival data may be obtained via contact with the patient, patient's family, or through a review of the patient's notes, or through the use of public records.
Time frame: From documented metastatic disease until death (or date of last documentation of being alive), approximately 4.5 years
Change in biomarkers
Blood, tumor and microbiome samples will be analyzed for various biomarkers. Initial biomarkers to be tested include proteins such as PDL-1, immune cell composition, cfDNA, microRNA proteomics and bacteria populations
Time frame: 5 years
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