A Pilot Randomized Study of Lymphocyte Depletion & Change in Lymphocyte Functionality During Lung Stereotactic Body Radiation (SBRT) Therapy Treatment by Selectively Reducing Irradiation of Immune Rich Organs Compared to Standard of Care Control Group
Phase: NA
Conditions: Lymphocyte Depletion
Sponsor: University of Virginia

 
A pilot randomized study of lymphocyte 
depletion and change in lymphocyte 
functionality during lung stereotactic body 
radiation therapy (SBRT) treatment by selectively 
reducing irradiation of circulating blood 
compared to standard of care control group  
HSR IRB #: 21718 
National Clinical Trial (NCT) Identified Number: NCT04273893 
Version Date: 25 April 2022 
 
 

Lymphocyte Depletion and Change in Functionality with SBRT for NSCLC 
 
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ProtTITLE: A pilot randomized study of lymphocyte depletion and change in lymphocyte 
functionality during lung stereotactic body radiation therapy (SBRT) treatment by 
selectively reducing irradiation of circulating blood compared to standard of care control 
group 
Study disease:  Non-small cell lung cancer (NSCLC)  
Corresponding Organization: University of Virginia  
 
Key Roles and Study Governance 
Principal Investigator 
 
 
Krishni Wijesooriya, PhD.  
434-094-5741 
Kw5wx@virginia.edu 
 
Sub-Investigators  
 
James Larner, MD            
Jml2p@virginia.edu 
  
 
Kara Romano, MD 
ked7c@virginia.edu 
 
 
Timothy Showalter, MD 
TNS3B@hscmail.mcc.virginia.edu 
 
Christopher McLaughlin, MD 
cm9rs@virginia.edu 
 
Paul Read, MD, PhD   
pwr3u@virginia.edu 
 
 
 
 
Lawrence G. Lum, MD.      
434-243-1375 
LGL4F@hscmail.mcc.virginia.edu 
 
Archana Thakur, PhD. 
434-243-1397 
at2fx@hscmail.mcc.virginia.edu 
Biostatistician: 
 
Mark Conaway, PhD  
434-924-8510   
 
Mrc6j@virginia.edu 
 
 
 
 
 
 
 
 
 
 
         
 
 
Confidentiality Statement 
The information contained in this document is the property of the University of Virginia Cancer 
Center Office of Clinical Research and the Department of Radiation Oncology.  Distributing, 
copying, or disclosing information contained in this document requires prior authorization from the 
University of Virginia Cancer Center, except that this document may be disclosed to the 
appropriate institutional review boards or other regulatory agencies as required by law.   
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INVESTIGATOR’S AGREEMENT 
The trial will be conducted in accordance with International Conference on Harmonisation Good Clinical Practice (ICH 
GCP).  The Principal Investigator will assure that no deviation from, or changes to the protocol will take place without 
prior agreement from the Institutional Review Board (IRB), except where necessary to eliminate an immediate hazard(s) 
to the trial participants.  
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be submitted to the IRB 
for review and approval.  Approval of both the protocol and the consent form must be obtained before any participant 
is enrolled.  Any amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  All changes to the consent form will be IRB approved; a determination will be made regarding 
whether a new consent needs to be obtained from participants who provided consent, using a previously approved 
consent form. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Principal Investigator 
 
______________________ 
 
_______________________            __________ 
Name (print)  
 
 
Signature 
 
 
 
Date 
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11/9/2022
Krishni Wijesooriya

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SCHEMA 
 
Arm A  (25 patients) 
 
 
 
 
 
 
 
 
  Early stage NSCLC with  
  SBRT alone   
  10-12 Gy x 5 fractions 
  (50 patients) 
Arm B  (25 patients) 
Control Group: no additional 
treatment planning dose optimization 
criteria to minimize decrease in 
lymphocyte count beyond dosimetric 
criteria from RTOG 0915/0813 
SBRT trials 
 
 
 
 
Additional treatment planning dose 
optimization criteria to minimize 
decrease in lymphocyte count 
beyond dosimetric criteria from 
RTOG 0915/0813 SBRT trials 
Patients will be stratified by 
peripheral and central tumor 
location  
RANDOMIZE 
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Abbreviations 
AE 
Adverse Event 
AJCC 
American Joint Committee on Cancer 
AP/Lat 
Anterior Posterior/Lateral 
CBC 
Complete blood count 
CBCT 
Cone beam computed tomography 
CC DSMC 
Cancer Center Data and Safety Monitoring Committee 
cGy 
Centigray 
CI 
Confidence interval 
CRF 
Case report form 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTL 
Cytotoxic T lymphocyte 
CTV 
Clinical target volume 
EDC 
Electronic Document Capture  
ELISA 
Enzyme linked immunosorbent tube assay 
E/T 
Effector to target ratio 
FACS 
Fluorescent Activated Cell Sorting 
FFF 
Flattening Filter Free 
FSH 
Follicle stimulating hormone 
GBM 
Glioblastoma 
GCP 
Good clinical practices 
GTV 
Gross tumor volume 
Gy 
Grays 
HIV 
Human immunodeficiency virus 
HR 
Hazard ratio 
HRT 
Hormone replacement therapy 
ICH GCP 
International Conference on Harmonisation Good Clinical Practice 
IFN- 
Interferon gamma 
IgG 
Immunoglobulin G 
IGRT 
Image-guided radiation therapy 
IL 
Interleukin 
IMRT 
Intensity modulated radiation therapy 
IRB-HSR 
Institutional Review Board-Health Sciences Research 
ITV 
Internal target volume 
IUD 
Intrauterine device 
MAbs 
Monoclonal antibodies 
MLC 
Multi Leaf Collimator 
NIH 
National Institutes of Health 
NSCLC 
Non-small cell lung cancer 
NTCP 
Normal tissue complication probabilities 
OARs 
Organs-at-risk 
Oncore 
ON-line Clinical Oncology Research Environment 
OS 
Overall Survival 
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PBMC 
Peripheral blood mononuclear cells 
PET 
Positron emission tomography  
PFT 
Pulmonary function test 
PRC 
Protocol Review Committee 
PTV 
Planning target volume 
RT 
Radiation therapy 
RTOG 
Radiation therapy oncology group 
SAE 
Serious adverse event 
SBRT 
Stereotactic body radiation therapy 
SOC 
Standard of care 
SVC 
Superior vena cava 
TLC 
Total lymphocyte count 
TRL 
Treatment related lymphopenia 
UVA 
University of Virginia 
WOCBP 
Women of childbearing potential 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table of Contents 
1. 
SYNOPSIS ......................................................................................................................... 9 
2. 
INTRODUCTION ...............................................................................................................13 
3. 
OBJECTIVES ....................................................................................................................15 
3.1 
Primary Objectives ......................................................................................................15 
 
Performance of Algorithm to Predict Decrease in Lymphocyte Count Post-SBRT 15 
 
Impact of Lymphocyte-Sparing SBRT Planning Objectives on Post-SBRT 
Lymphocyte Count .............................................................................................................15 
3.2 
Secondary Objectives .................................................................................................16 
 
Safety ..................................................................................................................16 
 
Performance of Algorithm to Predict Decrease in Lymphocyte Count Post-SBRT 16 
 
Impact of Lymphocyte-Sparing SBRT Planning Objectives on Post-SBRT 
Lymphocyte Counts ...........................................................................................................16 
 
Lymphocyte Phenotype and Function ..................................................................17 
3.3 
Exploratory Objectives ................................................................................................17 
 
Lymphocyte Phenotype and Function (additional) ................................................17 
 
Overall Survival ....................................................................................................17 
 
Correlation between Lymphocyte Depletion and Function and Radiation Dosimetry
 
17 
 
Optimization of Predictive Algorithm ....................................................................17 
 
Description of Changes in Lymphocyte Subtypes ................................................18 
4. 
PATIENT SELECTION .......................................................................................................18 
4.1 
Eligibility ......................................................................................................................18 
 
Inclusion Criteria ..................................................................................................18 
 
Exclusion Criteria .................................................................................................19 
 
Contraception Requirements ...............................................................................19 
5. 
STATISTICAL CONSIDERATIONS ...................................................................................20 
6. 
REGISTRATION PROCEDURES ......................................................................................22 
6.1 
Patient Registration & Randomization .........................................................................22 
6.2 
Patient Stratification ....................................................................................................22 
7. 
RADIATION THERAPY TREATMENT PLAN .....................................................................22 
7.1 
Dose Specifications ....................................................................................................23 
 
PTV Dose Prescription .........................................................................................23 
 
Normal Tissue Organs-At-Risk (OARs) ................................................................23 
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Great Vessels and Heart ......................................................................................23 
 
Dose Fractionation ...............................................................................................23 
7.2 
Technical Factors........................................................................................................23 
7.3 
Localization, Simulation, and Immobilization ...............................................................23 
 
Patient Positioning ...............................................................................................23 
 
Inhibition of Effects of Internal Organ Motion .......................................................24 
 
Localization ..........................................................................................................24 
7.4 
Treatment Planning/Target Volumes ...........................................................................24 
 
Image Acquisition ................................................................................................24 
 
Dosimetry ............................................................................................................25 
7.5 
Radiation Treatment Plan Pre-treatment Quality Assurance .......................................25 
7.6 
Image Guided Treatment ............................................................................................26 
7.7 
Discontinuation/Withdrawal of Therapy .......................................................................26 
7.8 
Definition of Evaluable and Replacement of Study Participants ..................................26 
8. 
STUDY ASSESSMENTS AND PROCEDURES .................................................................26 
8.1 
Clinical Assessments ..................................................................................................26 
 
Assessment of Adverse Events............................................................................26 
 
Complete Blood Count (CBC) with Differential .....................................................27 
 
Concomitant Medications .....................................................................................27 
 
Review of Medical Record ...................................................................................27 
8.2 
Research Blood ..........................................................................................................27 
8.3 
Correlative Studies ......................................................................................................27 
 
Lymphocyte functionality in vitro assays ..............................................................28 
 
Lymphocyte Subsets and Activation Phenotypes .................................................28 
 
Evaluation of Specific Antibody Response Against Recall Antigens in Serum ......28 
 
Evaluation of IFN-ɣ secreting T cells specific to tumor using an EliSpot assay .....28 
9. 
STUDY CALENDAR OF ASSESSMENTS .........................................................................29 
10. 
DATA AND SAFETY MONITORING PLAN ....................................................................29 
 
DSMC Meetings and Audits .................................................................................29 
10.2 
Adverse Events and Serious Adverse Events .............................................................30 
 
Definition of Adverse Events (AE) ........................................................................30 
 
Definition of Serious Adverse Events (SAE) .........................................................30 
 
Classification of an Adverse Event .......................................................................30 
 
Time Period and Frequency for Event Assessment and Follow-Up ......................32 
 
Adverse Event Reporting .....................................................................................32 
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Serious Adverse Event Reporting ........................................................................33 
10.3 
Reporting Events to Participants .................................................................................33 
10.4 
Unanticipated Problems ..............................................................................................33 
 
Definition of Unanticipated Problems (UP) ...........................................................33 
 
Unanticipated Problem Reporting ........................................................................34 
 
Reporting Unanticipated Problems to Participants ...............................................34 
10.5 
Data Breach ................................................................................................................34 
 
Definition of Data Breach .....................................................................................34 
 
Reporting a Data Breach .....................................................................................34 
10.6 
Protocol Deviation .......................................................................................................34 
 
Definition of Protocol Deviation ............................................................................34 
 
Reporting of a Protocol Deviation .........................................................................34 
10.7 
Participant Withdrawals/Dropouts Prior to Study Completion ......................................35 
11. 
REGULATORY AND OPERATIONAL CONSIDERATIONS ...........................................35 
11.1 
Regulatory and Ethical Considerations .......................................................................35 
 
Consent Procedures and Documentation .............................................................35 
 
Confidentiality and Privacy ...................................................................................35 
 
Future Use of Stored Specimens and Data ..........................................................36 
 
Safety Oversight ..................................................................................................36 
11.2 
Data Handling and Record Keeping ............................................................................37 
11.3 
UVA Institutional Review Board for Health Sciences Research ...................................37 
12. 
REFERENCES ...............................................................................................................38 
13. 
APPENDICES ................................................................................................................39 
13.1 
Appendix 1: ECOG Performance Status .....................................................................40 
13.2 
Appendix 2: RECIST 1.1 Criteria .................................................................................41 
13.3 
Appendix 3: Summary of Changes to Protocol ............................................................42 
 
 
 
 
 
 
 
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1. 
SYNOPSIS 
Title 
A pilot randomized study of lymphocyte depletion and change in lymphocyte functionality during 
lung stereotactic body radiation therapy (SBRT) treatment by selectively reducing irradiation of 
circulating blood compared to standard of care control group 
 
Study Description 
Lymphopenia, a known consequence of radiation therapy to virtually every part of the body, was 
first described in the early 20th century shortly after the discovery of X-rays1.   Radiation therapy 
(RT) can induce lymphopenia in the absence of concomitant chemotherapy or steroids and 
even when neither bone marrow nor lymphatic tissue is included in the treatment field. It is 
highly possible that irradiation of blood rich organs such as the great vessels, would reduce the 
lymphocyte count significantly. Given this known radiation-induced toxicity, circulating blood 
should be considered an organ at risk during irradiation, and efforts should be made to 
understand the toxicity from radiation to circulating blood -normal tissue complication 
probabilities (NTCP) so that this may be included in the optimization strategy during radiation 
treatment. Additionally, recent data have suggested that lymphocyte subsets exhibit differential 
sensitivity to radiation, with helper CD4+ T cells being more sensitive than cytotoxic CD8+ T 
cells in glioblastoma (GBM) treated with RT and temozolomide2, and naïve T cells more 
sensitive than memory T cells in prostate cancer3. 
Based on existing data on the effects of irradiation on total lymphocyte count and the effects on 
subsets of T cells, we have created a lymphodepletion predictive algorithm. In this clinical trial, 
we will test whether optimized SBRT plans lead to lower lymphocyte depletion and whether the 
algorithm can accurately predict lymphocyte decreases following SBRT. Optimized SBRT plans 
will meet all standard of care dose-volume objectives for SBRT and for protection of organs-at-
risk (OAR), but will also reduce radiation to the regional great vessels, lungs, and heart beyond 
what is currently optimized to reduce the integral dose to circulating blood/lymphocytes. This 
study will allow us to evaluate the performance of our predictive algorithm for post-SBRT 
decrease in lymphocyte count and to determine whether additional steps in SBRT planning will 
deliver lower risk of post-SBRT decreases in lymphocyte count. 
Objectives and Endpoints 
Table 1:  Objectives and Endpoints 
Objective 
Endpoint(s) 
Primary 
Assess if the lymphodepletion predictive 
algorithm developed by UVA coupled with 
the existing optimization algorithm in 
radiation treatment planning software 
predicts the magnitude of lymphocyte 
depletion in a prospective cohort of patients 
treated with lung SBRT. 
After randomization and completion of treatment 
planning, the algorithm will predict the decrease 
in lymphocyte count for each participant (in 
Arms A and B) at 4 weeks after SBRT. The 
endpoints are:  
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a) the within patient difference in the change 
from baseline in predicted and observed 
lymphocyte counts 
b) the within patient difference in the percent 
change from baseline in predicted and observed 
lymphocyte counts 
 
Determine if lymphocyte-sparing SBRT 
planning (Arm A, investigational) results in 
less in vivo lymphocyte depletion compared 
to controls who receive standard SBRT 
planning (Arm B, control). 
Observed changes in lymphocyte count from 
baseline and 4 weeks after completion of lung 
SBRT for participants in each arm. Expected 
lymphocyte nadir time point of 4 weeks following 
SBRT will be used to estimate both the actual 
and percentage decreases in lymphocyte counts 
seen in each arm. 
Secondary 
Describe the adverse event profile of 
participants treated with and without 
lymphocyte-sparing SBRT planning (Arms A 
and B).  
Frequency, severity, and duration of adverse 
events according to CTCAE version 5.0 
Determine if our lymphodepletion predictive 
algorithm coupled with the existing 
optimization algorithm in radiation treatment 
planning software predicts the magnitude 
and trajectory of lymphocyte depletion in a 
prospective cohort of patients treated with 
lung SBRT. 
After randomization and completion of treatment 
planning, the algorithm will predict the decrease 
in lymphocyte count for each participant (in 
Arms A and B) for each follow-up time point (at 
end of SBRT, and 4 weeks and 6 months after 
SBRT). The predicted time course of lymphocyte 
count will be compared with both the actual and 
percentage decrease in lymphocyte count 
observed. 
Determine if lymphocyte-sparing SBRT 
planning (Arm A, investigational) results in 
less in vivo lymphocyte depletion after lung 
SBRT compared to controls who receive 
standard SBRT planning without extra efforts 
to reduce lymphocyte exposure (Arm B, 
control). We will quantify peripheral blood 
mononuclear cells collected at baseline 
through 6 month follow-up. 
Observed changes in lymphocyte count from 
baseline to 6 months after completion of lung 
SBRT for participants in each arm. We will 
quantify peripheral blood mononuclear cells 
collected at baseline through follow-up (end of 
SBRT, 4 weeks and 6 months after lung SBRT). 
Determine the phenotype and function of 
lymphocytes in vitro in Arm A versus Arm B 
patients.  
1. T and B cell responses to pokeweed mitogen 
in polyclonal in vitro immunoglobulin 
synthesis; and 
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2. Serum levels of immunoglobulin G (IgG) to 
specific recall antigens (tetanus toxoid) 
Exploratory 
Determine the phenotype and function of 
lymphocytes in vitro in Arm A versus Arm B 
patients. 
Specific anti-tumor interferon gamma (IFN-) 
EliSpot responses to lung cancer cell lines.  
 
To evaluate overall survival (OS) after lung 
SBRT for up to 30 months after SBRT. 
Overall survival after lung SBRT (every 6 
months for the first year, then annually). 
Identify correlations between lymphocyte 
depletion and functional impairment with 
dose to great vessels, lung tissue, heart, and 
other normal tissue containing large amounts 
of circulating blood.  
1. Dose to circulating blood 
2. TLC and functionality of T cell sub types. 
 
Improve our existing simulation algorithm to 
predict the total lymphocyte loss for a given 
RT beam plan using the clinical trial data. 
This model will take into account patient specific 
(i) total blood volume, (ii) initial lymphocyte 
count, (iii) tumor volume, (iv) the organs from the 
Thorax CT data set, and (v) time dependent 
dose map through each organ for a given 
delivery system.  These data will be combined 
with general information from published 
literature such as (i) varying blood output to 
organs (ii) blood velocity for all organs (iii) 
random mixing of blood after each trip through 
the exposed dose area, with the remaining blood 
volume of the body. 
Describe the changes in lymphocyte 
subtypes following SBRT in Arms A and B 
Quantity of lymphocyte subtypes (e.g. CD4, 
CD8) prior to and 4 weeks following SBRT 
 
Study Population 
Patients who decline surgery or are considered to be medically inoperable with (American Joint 
Committee on Cancer (AJCC) edition 8 clinical stage NSCLC lung cancer that are clinically 
node negative by positron emission tomography computed tomography (PET CT) imaging and 
have planned treatment with SBRT as definitive therapy. 
Phase of Study 
Pilot 
Study Sites 
This is a single site study being conducted at the University of Virginia (UVA). 
 
Intervention 
Participants will receive standard of care SBRT using standard technology (treatment planning 
software and delivery system) that meets all requirements for tumor coverage and sparing of 
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dose to organs-at-risk. Participants will be randomized to one of two arms, with Arm A 
participants receiving lung SBRT plans that are also optimized to reduce risk and/or magnitude 
of decreases in lymphocyte count through reduced treatment of the great vessels beyond 
standard treatment objectives. Arm B participants will not receive this additional optimization 
(standard of care).  
Study Duration 
We expect it will take about 36 months to reach target accrual and data analysis/publication is 
expected to take an additional 12 months.  
 
Participant Duration 
Participants will be assessed prior to SBRT and then will be followed for 6 months following 
SBRT in order to assess changes in lymphocyte count and lymphocyte subsets. Overall survival 
will be assessed every 6 months for 1 year following SBRT and then annually. Results from 
CBC blood tests will also be collected (for participants with results available by standard of care) 
every 6 months. 
  
Accrual Goal 
In order to have 50 evaluable participants, as defined in section 7.8, up to 65 participants will be 
enrolled.   
 
 
 
 
 
 
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2. 
INTRODUCTION  
Lymphopenia, a known consequence of radiation therapy to virtually every part of the 
body, was first described in the early 20th century shortly after the discovery of X-rays1.   
Radiation therapy (RT) can induce lymphopenia in the absence of concomitant chemotherapy or 
steroids and even when neither bone marrow nor lymphatic tissue is included in the treatment 
field.  Studies have shown that irradiation of the brain, which contains neither bone marrow nor 
lymphatic tissue, can cause a greater than 60% decrease in lymphocyte count4.  One study 
demonstrated that irradiation of circulating blood with cesium placed inside a shielded dialysis 
unit caused a 60% to 80% decrease in the number of circulating lymphocytes that persisted for 
many years after radiation exposure5.  Therefore, it is highly possible that irradiation of blood 
rich organs, such as the great vessels, would reduce the lymphocyte count significantly. Given 
this known radiation-induced toxicity, circulating blood should be considered an organ at risk 
during irradiation, and efforts should be made to understand the toxicity from radiation to 
circulating blood (normal tissue complication probabilities) so that this may be included in the 
optimization strategy during radiation treatment.  
It has also been demonstrated that in addition to radiation’s direct toxicity to 
lymphocytes, RT also affects the immune system by altering cytokine production. In patients 
who have human immunodeficiency virus (HIV) or are receiving chemotherapy, there are 
increased levels of interleukin – 7 (IL-7).  IL-7 is known to stimulate lymphocyte proliferation. 
However, in glioma patients who were treated with radiation and temozolomide, there was no 
increase in IL-7 production that would be expected given the patients’ severe lymphopenia6.  
  
Recent studies have shown a correlation between treatment-induced lymphopenia and 
inferior survival in patients with glioblastoma, advanced stage non-small cell lung cancer 
(NSCLC), pancreatic cancer and squamous cell carcinoma of the head and neck2,7-10. In a study 
published in the Journal of the National Comprehensive Cancer Network, investigators collected 
and analyzed data from 4 independent solid tumor sites from 297 patients with newly diagnosed 
malignant glioma, resected and un-resected pancreatic cancer, and stage III NSCLC and 
recorded lymphocyte count, prognostic factors, treatment and survival.  They defined treatment 
related lymphopenia (TRL) as <500 cells/mm3 and found an increased risk for death attributed 
to TRL in each cohort (gliomas: hazard ratio [HR], 1.8; 95% confidence interval (CI), 1.13–2.87; 
resected pancreas: HR, 2.2; 95% CI, 1.17–4.12; unresected pancreas: HR, 2.9; 95% CI, 1.53–
5.42; lung: HR, 1.7; 95% CI, 0.8–3.61) and in the entire study population regardless of 
pathologic findings (HR, 2.1; 95% CI, 1.54–2.78; P <.0001). They observed severe TRL in 40% 
of patients two months after the initiation of chemoradiation and found that it was independently 
associated with shorter survival from tumor progression11. See Figure 1.  
RT-induced lymphopenia is likely due to the repeated exposure of radiosensitive 
lymphocytes to radiation, and possibly the expansion of regulatory T cells and elaboration of 
immunosuppressive cytokines in response to radiation. Notably, recent data have suggested 
that lymphocyte subsets exhibit differential sensitivity to radiation, with helper CD4+ T cells 
being more sensitive than cytotoxic CD8+ T cells in GBM treated with RT and temozolomide2, 
and naïve T cells more sensitive than memory T cells in prostate cancer3. We will test the 
hypothesis that in optimized SBRT plans, lower lymphocyte depletion may lead to smaller 
decreases of lymphocyte functions. 
 
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Figure 1: Relationship between survival and grade III/IV treatment-related lymphopenia in 297 
patients with solid tumors.11  
 
SBRT is a technique that allows high doses of radiation to be delivered to highly-focused 
extra-cranial targets by utilizing respiratory motion correction and daily image guidance12. SBRT 
provides an ideal setting to study radiation’s effect on lymphocyte counts and function, due to 
the smaller target volumes which allow for flexibility in treatment planning options regarding 
entry and exit dose. Additionally, since this treatment does not usually include concurrent 
chemotherapy, it allows one to specifically evaluate radiation effects. SBRT lung optimization to 
reduce dose to the great vessels, lung, and heart are currently focused on maximal dose 
delivered to a small volume of the great vessel walls, and to the heart to reduce radiation injury 
to the vessel wall and intrathoracic hemorrhage. In the current study, we will continue to 
maintain the critical dose constraints to the heart, lung, and great vessels in both study arms, 
but we will also further optimize plans in the study group to reduce radiation to the regional great 
vessels, lungs, and heart beyond what is currently optimized to reduce the integral dose to 
circulating blood/lymphocytes.  
While recent studies show that decreased fractionation is inversely related to total 
lymphocyte count (TLC) after treatment4, there are currently no tools to predict the decrease in 
lymphocyte count that should be expected with different radiation treatment plans. There was no 
clinical data available until our recent retrospective research13,14 showed a correlation of dose to 
different organs in the thorax and lymphocyte depletion.  We used this data to develop an 
algorithm that predicts the decrease in TLC after lung SBRT treatment and we will test this model 
prospectively in this study.  Data from this study will be used to refine the algorithm to make it 
more clinically robust by including functional lymphocyte effects in addition to absolute lymphocyte 
count effects.   Ultimately, the goal will be to use the algorithm during SBRT planning to guide 
radiation dose optimization via utilization of predicted immune normal tissue complication 
probabilities in addition to dose optimization of other regional organs-at-risk (OAR) including the 
heart, esophagus, spinal cord, tracheobronchial system, lungs, chest wall, and brachial plexus. 
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Rationale for Clinical Trial – Based upon the background described above, our work to date has 
shown that our algorithm can predict decrease in lymphocyte count after lung SBRT based upon 
radiation doses delivered to vasculature during standard of care lung SBRT. By accounting for 
radiation dose to circulating lymphocytes, we have also shown that we can generate SBRT plans 
that both (1) meet all standard of care dose-volume objectives for lung SBRT and (2) result in 
substantially lower risk of post-SBRT lymphopenia by reducing dose to circulating lymphocytes 
within great vessels. We have developed this pilot clinical trial of 50 evaluable participants to 
evaluate prospectively the biological consequences of optimized plans that reduce integral dose 
to circulating blood during lung SBRT (and also meet national treatment planning constraints to 
all OAR) compared to controls with standard of care treatment with SBRT plans that meet national 
treatment planning constraints to all OAR. This study will allow us to evaluate the performance of 
our predictive algorithm for post-SBRT decrease in lymphocyte count and to determine whether 
additional steps in SBRT planning will deliver a lower risk of post-SBRT lymphopenia.   
SBRT Summary - Participants in both arms (all 50 evaluable participants) will receive standard of 
care SBRT using standard technology (treatment planning software and delivery system) that 
meets all requirements for tumor coverage and sparing of dose to OAR for lung SBRT. 
Participants will be randomized to one of two arms. Arm A (25 evaluable participants) will receive 
lung SBRT plans that meet all standard of care SBRT requirements and are optimized to reduce 
risk of lymphopenia through reduced treatment of the great vessels further beyond standard 
treatment objectives. Participants randomized to Arm B (25 evaluable participants) will have 
standard lung SBRT without the addition of investigational planning steps to reduce exposure to 
circulating lymphocytes within the great vessels.  
3. 
OBJECTIVES 
3.1 
Primary Objectives 
 Performance of Algorithm to Predict Decrease in Lymphocyte Count Post-SBRT 
Determine if the lymphodepletion predictive algorithm developed by UVA coupled with the 
existing optimization algorithm in radiation treatment planning software predicts the magnitude 
of lymphocyte depletion in a prospective cohort of patients treated with lung SBRT.  
Hypothesis: We hypothesize that our predictive algorithm, which estimates risk of post-SBRT 
lymphopenia based upon estimation of radiation dose to blood vessels, can accurately predict 
change in lymphocyte count at 4 weeks following SBRT in a prospective cohort of lung SBRT 
patients. 
Endpoint: After randomization and completion of treatment planning, the algorithm will predict 
the decrease in lymphocyte count for each participant (in Arms A and B) at 4 weeks after SBRT. 
The predicted decrease will be compared with the actual decrease in lymphocyte count 
observed.  
 Impact of Lymphocyte-Sparing SBRT Planning Objectives on Post-SBRT 
Lymphocyte Count 
Determine if lymphocyte-sparing SBRT planning (Arm A, investigational) results in less in vivo 
lymphocyte depletion compared to controls who receive standard SBRT planning (Arm B, 
control).  
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Hypothesis: We hypothesize that we can generate treatment plans that both meet standard of 
care objectives for organs-at-risk (OAR) and result in a smaller reduction in lymphocyte count by 
reducing exposure of circulating lymphocytes in great vessels. 
Endpoint: Observed changes in lymphocyte count from baseline and 4 weeks after completion 
of lung SBRT for participants in each arm. Expected lymphocyte nadir time point of 4 weeks 
following SBRT will be used to assess changes in lymphocyte counts in each arm.  
3.2 
Secondary Objectives 
 Safety 
Describe the adverse event profile of participants treated with and without lymphocyte-sparing 
SBRT planning (Arms A and B).  
Hypothesis: We hypothesize that the adverse event profile of participants treated with and 
without lymphocyte-sparing SBRT planning will be similar, except that those treated in Arm Awill 
have less frequency and/or severity of decrease in lymphocyte count 
Endpoints: Frequency, severity, and duration of adverse events according to CTCAE version 
5.0 
 Performance of Algorithm to Predict Decrease in Lymphocyte Count Post-SBRT 
Determine if our lymphodepletion predictive algorithm coupled with the existing optimization 
algorithm in radiation treatment planning software predicts the magnitude and trajectory of 
lymphocyte depletion in a prospective cohort of patients treated with lung SBRT.  
Hypothesis: We hypothesize that our predictive algorithm, which estimates risk and magnitude 
of post-SBRT decrease in lymphocyte count based upon estimation of radiation dose to blood 
vessels, can accurately predict the time course of changes in lymphocyte counts in a 
prospective cohort of lung SBRT patients. 
Endpoint: After randomization and completion of treatment planning, the algorithm will predict 
the decrease in lymphocyte count for each participant (in Arms A and B) for each follow-up time 
point (at end of SBRT, and 4 weeks and 6 months after SBRT). The predicted time course of 
lymphocyte count will be compared with the actual decrease in lymphocyte count observed. 
 Impact of Lymphocyte-Sparing SBRT Planning Objectives on Post-SBRT 
Lymphocyte Counts 
Determine if lymphocyte-sparing SBRT planning (Arm A, investigational) results in less in vivo 
lymphocyte depletion after lung SBRT compared to controls who receive standard SBRT 
planning without extra efforts to reduce lymphocyte exposure (Arm B, control). We will quantify 
peripheral blood mononuclear cells collected at baseline through 6 month follow-up.  
Hypothesis: We hypothesize that we can generate treatment plans that both meet standard of 
care objectives for organs-at-risk (OAR) and result in a smaller reduction in lymphocyte count by 
reducing exposure of circulating lymphocytes in great vessels. 
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Endpoint: Observed changes in lymphocyte count from baseline to 6 months after completion of 
lung SBRT for participants in each arm. We will quantify peripheral blood mononuclear cells 
collected at baseline through follow-up (end of SBRT, 4 weeks and 6 months after lung SBRT). 
 Lymphocyte Phenotype and Function 
Determine the phenotype and function of lymphocytes in vitro in Arm A versus Arm B patients.  
Endpoints:  
1. T and B cell responses to pokeweed mitogen in polyclonal in vitro immunoglobulin 
synthesis; and 
2. Serum levels of immunoglobulin G (IgG) to specific recall antigens (tetanus toxoid)  
3.3 
Exploratory Objectives 
 Lymphocyte Phenotype and Function (additional) 
Determine the phenotype and function of lymphocytes in vitro in Arm A versus Arm B patients.  
Endpoint: Specific anti-tumor interferon gamma (IFN-) EliSpot responses to lung cancer cell 
lines.  
 Overall Survival 
To overall survival (OS) after lung SBRT for up to 30 months after SBRT.  
Endpoints: Overall survival after lung SBRT (every 6 months for the first year, then annually).  
 Correlation between Lymphocyte Depletion and Function and Radiation Dosimetry 
Identify correlations between lymphocyte depletion and functional impairment with dose to great 
vessels, lung tissue, heart, and other normal tissue containing large amounts of circulating 
blood.  
Endpoints:  
1. Dose to circulating blood 
2. TLC and functionality of T cell sub types. 
 Optimization of Predictive Algorithm 
Improve our existing simulation algorithm to predict the total lymphocyte loss for a given RT 
beam plan using the clinical trial data.  
Endpoints: This model will take into account patient specific (i) total blood volume, (ii) initial 
lymphocyte count, (iii) tumor volume, (iv) the organs from the Thorax CT data set, and (v) time 
dependent dose map through each organ for a given delivery system.  These data will be 
combined with general information from published literature such as (i) varying blood output to 
organs (ii) blood velocity for all organs (iii) random mixing of blood after each trip through the 
exposed dose area, with the remaining blood volume of the body.  
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 Description of Changes in Lymphocyte Subtypes 
Describe the changes in lymphocyte subtypes following SBRT in Arms A and B 
Endpoint: Quantity of lymphocyte subtypes (e.g. CD4, CD8) prior to and 4 weeks following 
SBRT  
 
4. 
PATIENT SELECTION 
     
 
Figure 2: Definition of proximal bronchial tree, for the distinction of centrally located tumors from 
peripheral tumors (taken from Radiation Therapy Oncology Group (RTOG) 0915 protocol).  
4.1 
Eligibility 
 Inclusion Criteria 
1. Willingness and ability to provide written informed consent and to comply with the study 
protocol. 
2. Diagnosis of biopsy confirmed non-small cell lung cancer (NSCLC) with planned 
treatment with SBRT as definitive therapy OR imaging confirmed lung lesion for which 
SBRT is planned for primary lung cancer (when clinician determines biopsy is not 
indicated), Registration should occur within 5 business days (before or after) of planning 
CT. 
3. Patients must decline surgery or tumor(s) must be considered to be medically inoperable  
4. Location and size of tumor- Participants must have either: 
 
peripherally located tumors (> 2 cm in all directions from the proximal bronchial tree; 
see Figure 2 above) as defined by RTOG 0915, OR 
 
centrally located tumors (tumor size ≤ 5 cm, tumors within or touching the zone of the 
proximal bronchial tree or adjacent to mediastinal or pericardial pleura) as defined by 
RTOG 0813. 
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5. Patients with recurrence of prior surgically treated lung cancers are eligible if no further 
surgery is planned and they otherwise meet the eligibility criteria. 
6. Measurable disease on chest CT, PET CT, CT simulation at diagnosis (must be within 8 
weeks of SBRT).  
7. Pre- radiation therapy total lymphocyte count > 0.5k/µL on blood count drawn within 2 
weeks prior to registration. 
8. In the opinion of the treating clinician, patient is medically able to tolerate the study 
SBRT treatment of 50-60 Gy in 5 fractions. 
9. ECOG performance status of 0-2.  
10. Age ≥ 18 years.  
11. If participant is a woman of childbearing potential (WOCBP), agreement to adhere to 
contraception requirements from the time of consent through completion of SBRT (see 
section 4.1.3). 
 Exclusion Criteria 
1. Prior history of radiation therapy within 2 years of registration, however radiation therapy 
for skin cancer is allowed  
2. Systemic anti-cancer therapy within the last year prior to registration or planned use 
during or within 6 months post SBRT follow up timeframe (see study calendar). 
3. Major surgery within the last 30 days before registration and/or planned before the 
completion of the 6 months post SBRT follow up timeframe (see study calendar). 
4. Subject is a prisoner. 
5. Subject is a pregnant woman. 
6. Subject is not medically able to tolerate the study SBRT treatment of 50-60 Gy in 5 
fractions or cannot comply with other aspects of the study including serial bloodwork.  
7. Subject has HIV, AIDS, any type of hepatitis and/or any blood borne infectious disease 
for which the research lab cannot receive blood samples.  
 
 
 Contraception Requirements 
Women of childbearing potential must agree to use adequate contraception prior to study entry 
and through completion of SBRT.   
Women of childbearing potential (WOCBP) includes any female who has experienced menarche 
and who has not undergone successful surgical sterilization (hysterectomy, bilateral tubal ligation 
or bilateral oophorectomy) or is not postmenopausal [defined as amenorrhea ≥ 12 consecutive 
months]; or women on hormone replacement therapy (HRT) with documented serum follicle 
stimulating hormone (FSH) level > 35 mIU/mL 
[1]  Prior to study enrollment, WOCBP must be advised of the importance of avoiding pregnancy 
during trial participation and the potential risk factors for an unintentional pregnancy   
[2]  The following birth control methods are allowed during the study: 
a. Barrier methods: 
[1]  Intra-uterine device (IUD) 
[2]  Diaphragm with spermicide 
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[3]  Cervical 
cap with spermicide 
[4]  Condom with spermicide 
b. Abstinence (no heterosexual activity) 
5. 
STATISTICAL CONSIDERATIONS 
Study populations  Any participant who initiates either standard or optimized SBRT will be 
considered evaluable for adverse events.  Participants with observed changes in lymphocyte 
counts at any of the follow-up times will be considered evaluable for the analyses of changes in 
lymphocyte counts.  
Randomization and stratification 
Participants will be randomized to standard or optimized SBRT in a 1:1 ratio using randomly 
permuted blocks. Block sizes of 2 or 4 will be randomly chosen with equal probability. The 
randomization will be stratified by central or peripheral lung lesion (section 4.1.1)  
Sample size and power The first aim is to compare the actual and predicted values from the 
simulations.  We will calculate the empirical distribution function of the difference between 
predicted and actual, both in terms of lymphocyte counts and percent change from pre-
treatment counts.   Current simulation is able to predict to 17% accuracy, with a standard 
deviation of 15%.  The model will be considered an improvement if 80% of the predictions are 
within 10% of the actual counts or percent changes.     With a sample of size 50 evaluable, the 
one-sample t-test has 95% power, with a one-sided significance level of 5%, for testing whether 
the mean percent difference is less than 17%, when the true mean is 10%.    
 
The second aim is to compare standard 
versus optimized SBRT on the basis of 
the primary outcome, lymphocyte drop at 
4 weeks.   The sample size was chosen 
to have sufficient power for comparing the 
groups using a repeated measures model 
for comparing the groups.  Estimates of 
effect sizes and variation were based on 
repeated measures models, with change 
points at 4 and 12 weeks, fit to 
retrospective data on lymphocyte drop 
within 24 weeks following standard SBRT.    
A spatial-power model was used for the 
covariance matrix of percentage changes 
from baseline in lymphocyte counts, 
yielding an estimated standard deviation of 10.5 percentage points and a within-subjects 
correlation estimate of 0.40 for observations taken 1 week apart.   The fitted model, overlaid on 
the individual patient profiles is displayed above. 
Figure 3 
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With n=25 patients, measured at 
baseline and 4  and 24 weeks 
months post radiation, the F-test in 
the repeated measures model 
provides 80% power for comparing 
the mean lymphocyte depletion 
profile over the follow-up period 
between the groups.   For the 
power calculation, we assumed 
that in the optimized dose 
participants,  mean lymphocytes 
relative to baseline are equal to  Δ 
+ (1-Δ)µ(t), where µ(t) is the mean 
estimated from historical controls 
at time t = 0, 4, or 24 weeks. With 
this, Δ = 0 means no effect of the 
optimization; Δ = 1 means no 
lymphocyte depletion with optimized SBRT treatment. Figure 3 displays the mean profile for Δ = 
0.60, a profile for which n = 25 per group yields 80% power for the F-test, with a 2-sided 
significance level of 5%.  For the specific comparison at 4 weeks, a contrast in the repeated 
measures model has more than 99% power for the assumed profile.   We computed power for 
the comparing the entire trajectory, and not just at 4 weeks, because of the uncertainty in the 
point at which the maximum drop and the maximum difference between the groups will occur.  
To allow for 10% dropout, 55 patients will be enrolled in the study.   
Analyses.  For the first aim, which compares the actual and predicted lymphocyte counts, the 
empirical distribution function of the differences, both in terms of the lymphocyte count and the 
percentage change from baseline, will be tabulated. We will assess the proportion of cases in 
which the predicted values is within 10% of the actual value.   In addition to computing the 
empirical distribution functions, exploratory analyses will assess patient characteristics 
associated with the magnitude of the deviation between predicted and actual values.  
For the second aim, repeated measures models will be used to compare the groups with 
respect to the percentage drop in lymphocyte counts.  The stratification factor will be used as a 
covariate in the model.  Contrasts will be used to compare the groups at specific time points, 
including the 4 week post-treatment time point, where we anticipate there will be the greatest 
difference between the standard and optimized SBRT groups.   The sample size was based on 
an assumed spatial power covariance structure, but we will consider other covariance matrices 
as well, such as random effects models.   In exploratory analyses will tabulate local control as 
well as adverse events (see section 8) and estimate differences these between groups.  
Kaplan–Meier curves will be used to summarize overall survival in each of the standard and 
optimized SBRT groups. 
Quantitative analysis of blood counts and radiation dose to the great vessels 
We will collect blood, serum and PBMC at baseline and at end of treatment, weeks 4, and 24 
after treatment for all study patients. The reference point for post-treatment blood collection will 
be the start date of radiation therapy to permit intergroup comparisons between the two study 
arms. This comparison framework was selected based on our available preliminary data, which 
Figure 4 
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suggests that RT-induced lymphocyte effects occur as early as one week following radiation 
initiation due to the high radiosensitivity of circulating lymphocytes. We will quantify absolute 
neutrophils, hemoglobin, platelet, and lymphocyte counts for all patients at these time points 
and compare the changes between the groups and also compare the lymphocyte count results 
to what was predicted by the simulation algorithm.  We will perform a multivariate analysis to 
identify the correlation between TRL and mean/integral radiation dose to the great vessels. 
Since substantial circulating blood is also present in the heart and lungs we will also correlate 
mean heart and lung dose with TRL. Measurement of the magnitude of lymphocyte depletion 
and correlation with great vessel, lung, and heart integral dose will be performed and compared 
to the predicted levels for the simulation algorithm. 
6. 
 REGISTRATION PROCEDURES 
Participants cannot be registered until institutional IRB approval of the protocol and consent are 
obtained. Registration and randomization should occur around the time of planning CT (+/- 5 
business days). SBRT must begin within 4 weeks after registration/randomization. 
6.1 
Patient Registration & Randomization 
All participants must sign the consent form prior to determination of eligibility for this study.  
Patients will be screened and evaluated to meet all eligibility criteria before being registered on 
the trial.  Once a patient is determined to be eligible for the study, study staff will register the 
patient in the UVA Cancer Center OnCore database in accordance with the Clinical Trial 
Management System Policy, via the UVA OnCore Resources link in Oncore.  Participants will 
be associated with a UVA unique identifier, such as UVA SBRT-001, that will represent the 
participant in the study.  This will be listed as the participant’s sequence number in the OnCore 
database and will be on all research blood samples collected from participants. 
Randomization will be discussed with participants during the process of informed consent and 
informed consent must be documented prior to randomization. Participants will be randomized 
1:1 to Arm A or Arm B using randomly permuted blocks, with block sizes of 2 or 4 randomly 
chosen with equal probability. Stratification is described below. Randomization will be performed 
using custom randomization software (RAND) that incorporates the randomization scheme 
generated by the study statistician. Clinical research staff and treating clinicians will be aware of 
arm assignment and participants may be made aware of their arm assignment. The labels on 
research blood will not include the treatment arm on which the participant is assigned and this 
information will not be provided to lab investigators and staff. 
6.2 
Patient Stratification 
Participants will be stratified as having peripheral or central lung lesions and the randomization 
process will ensure equal numbers of participants with peripheral or central lung lesions on each 
arm of the study.   
7. 
RADIATION THERAPY TREATMENT PLAN 
Intensity modulated radiation therapy (IMRT) is the only acceptable form of treatment planning 
allowed for this protocol.  
SBRT radiation treatment planning overview 
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For each participant, we will determine the tissue-specific radiation dose to vital body structures 
using SBRT planned treatments. SBRT treatments will be planned using normal tissue dose 
constraints according to national lung SBRT clinical trials (RTOG 0915 (peripheral tumors) and 
RTOG 0813 (central tumors)). 
Prediction of lymphocyte depletion using our current simulation algorithm 
Using the existing simulation algorithm, we will predict the in vivo lymphocyte depletion for each 
participant on both arms to test the robustness of the algorithm.   
7.1 
Dose Specifications 
 PTV Dose Prescription 
The tumor will be prescribed 50-60 Gy in 5 fractions to the planning target volume (PTV). 
 Normal Tissue Organs-At-Risk (OARs) 
For participants in Arm B, plans will meet standard of care tissue dose constraints as described 
above.  For participants in Arm A, plans will meet standard of care tissue dose constraints 
(described above) and additional planning constraints to reduce the dose to the great vessels , 
including the circulating blood within them, to as low as achievable while still meeting the other 
RTOG 0915 and RTOG 0813 dose constraints. These constraints will be reported in the 
radiation planning score card and treatment plan per standard of care institutional policy.   
 Great Vessels and Heart 
The great vessels and heart will be contoured using mediastinal windowing on CT to correspond 
to the vascular wall and all muscular layers out to the fatty adventitia. The great vessels should 
be contoured starting at least 5 cm above the superior extent of the PTV and continuing on 
every CT slice to at least 5 cm below the inferior extent of the PTV. 
 Dose Fractionation 
Participants on both Arm A and Arm B will receive 50-60 Gy in 5 fractions to the PTV.  
Treatments should be delivered within 5-10 business days (excluding the weekend(s) and 
holidays when the clinic is closed).  
7.2 
Technical Factors 
Only photon (x-ray) beams produced by linear accelerators with photon energies of 4-10 MV will 
be allowed.  
7.3 
Localization, Simulation, and Immobilization 
 Patient Positioning 
Patients will be positioned in a stable position using the BodyFix system (Medical Intelligence, 
Munich, Germany), with suction to reduce mobility, allowing accurate reproducibility of the target 
position from treatment to treatment.  
Patient immobilization must be reliable enough to ensure that, in combination with the 
techniques used to inhibit target motion, the gross tumor volume (GTV) does not deviate 
beyond the confines of the planning target volume (PTV).  
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 Inhibition of Effects of Internal Organ Motion 
Special considerations will be made to account for the effect of internal organ motion (e.g., 
breathing) on target positioning and reproducibility. Accelerator beam gating with the respiratory 
cycle for tumors that move >8mm, and treating the FULL_ITV (internal target volume) for others 
will be utilized. All systems used to account for internal organ motion will be consistent with 
standard of care lung SBRT at UVA.  
Internal organ inhibition maneuvers must be reliable enough to ensure that the GTV does not 
deviate beyond the confines of the PTV as defined in Section 7.4. 
 Localization 
Isocenter or reference point port localization images should be obtained on the treatment unit 
immediately before treatment to ensure proper alignment of the geometric center (i.e., 
isocenter) of the simulated fields.  All participants in both arms will follow the exact same pre-
treatment image-guided radiation therapy (IGRT) protocol.  On the first day of the treatment, 
planar kV imaging orthogonal images will be acquired to align the bony anatomy to the planning 
CT bony anatomy. Secondly, a cone beam CT image will be acquired and aligned to the 
planning, time averaged CT image. They will be registered such that soft tissue registration for 
the lung tumor is applied. The deviations between bony anatomy registration and soft tissue 
registration should be ≤7mm. In case of deviations >7mm, an additional cone beam computed 
tomography (CBCT) will be acquired to verify the target localization.  OAR contours from the 
planning data set, such as the great vessels, and lung positioning, will be verified daily 
prior to radiation delivery.    
In case of gated treatment, following the above mentioned two pre-treatment imaging 
verifications, a gated anterior posterior/lateral (AP/Lat) image would be taken to verify the tumor 
location within the gated window.  For all participant treatments in all machines, agreement 
between the treatment unit isocenter and imaging isocenter will be verified each day to be within 
1mm.  
7.4 
Treatment Planning/Target Volumes 
 Image Acquisition 
Computed tomography (CT) will be the image platform for targeting and treatment planning. 
Axial acquisitions with spacing = 3.0 mm should be utilized. 4-dimensional CT image-guided 
(4DCT) internal target volume (ITV) around the GTV will take tumor motion into consideration 
and will be the primary method of target volume definition. This target will also be the clinical 
target volume (CTV)].  
The target lesion will be outlined by an appropriately trained physician, using a maximum 
intensity projections (MIP) image of 4DCT and designated to be the internal target volume (ITV). 
The target will generally be drawn using CT pulmonary windows.  
The PTV will include the ITV plus an additional 0.5 cm margin uniformly applied to the ITV.  Up 
to an 8mm margin may be applied in the craniocaudad direction per the treating radiation 
oncologist preference.  The planning CT would be the time averaged CT image from the four 
dimensional CT. 
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 Dosimetry 
IMRT coplanar or non-coplanar beam arrangements will be custom designed for each case to 
deliver highly conformal prescription dose distributions. Non-opposing, non-coplanar beams are 
preferable. Typically, approximately 10 beams of radiation will be used with roughly equal 
weighting. For arc rotation techniques, partial arcs or full arcs could be utilized. In order to 
obtain acceptable coverage, field aperture size and shape should correspond nearly identically 
to the projection of the PTV along a beam’s eye view (i.e., no additional “margin” for dose 
buildup at the edges of the blocks or multi leaf collimator (MLC) jaws beyond the PTV).  
Prescription lines covering the PTV will typically be the 60-90% line (where the maximum dose 
is 100%). 
For purposes of dose planning and calculation of monitor units for actual treatment, this protocol 
will require tissue density heterogeneity corrections. Algorithm used for heterogeneity 
corrections must be credentialed by the RTOG.  
For patients in Arm A, the beam energy would be 6 X –FFF (flattening filter free) to minimize 
overall treatment time, and for angles whether it is arcs, or step and shoot, IMRT should be 
carefully selected such that overall lymphocyte reduction is at the maximum dictated by the 
prediction algorithm. An example of a planning study is given in Figure 5 below. 
Example Treatment Plans of a Central Tumor: 
Aorta integral dose went from 721.1 x 181.63 = 1.3 x105 cGy cc to 322.2x181.63 = 5x104 cGy cc 
superior vena cava (SVC) integral dose went from 1769.7x19.16 = 3.4 x104 cGy cc to 438.3x 
19.16= 8.4x103 cGy cc.   
This resulted in a reduction to the total great vessel dose from 1.6x105 cGy cc to 0.6x105 cGy 
cc.  
 
 
Figure 5: Axial slice of a patient’s lung SBRT sample plan.  On the left is a RTOG 0813 
followed plan (as used in Arm B).  Note the dose through the great vessels, aorta (orange), and 
superior vena cava (blue), compared to the plan on the right (as used in Arm A), where 
additional constraints were imposed on the dose to the great vessels.  
7.5 
Radiation Treatment Plan Pre-treatment Quality Assurance 
All institutional standard of care SBRT quality assurance measurements and calculations will be 
made and the plan must pass these quality assurance processes within institutional standards 
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of care and be approved by the treating medical physicist and radiation oncologist prior to 
treatment delivery.  
7.6 
Image Guided Treatment 
During pre-treatment IGRT for each fraction, the image registration procedure should include 
the proximal great vessels and heart location in addition to the treated tumor. This information 
will be recorded in the treatment notes by the therapist. 
7.7 
Discontinuation/Withdrawal of Therapy 
Participants may withdraw or be discontinued from the study at any time for any of the following 
reasons: 
 
Inter-current illness that prevents further treatment 
 
Subject decides to withdraw from the study 
 
Unacceptable adverse events(s) 
 
Requirement of medication listed in the exclusion criteria 
 
If the investigator feels it is no longer in the participant’s interest to continue participation 
 
Death 
 
Participant does not comply with study procedures 
The primary reason for discontinuation or withdrawal should be entered into OnCore. All 
participants that discontinue or withdraw from the study will continue to receive standard of care 
treatment. Participants removed from study treatment for unacceptable adverse events will be 
followed until resolution or stabilization of the adverse event. Participants who have withdrawn 
consent will not be followed for any reason.  
A participant’s participation is considered completed when the subject has received all study 
treatments and has completed all follow-up procedures (or other milestone to define a 
completed subject). 
7.8 
Definition of Evaluable and Replacement of Study Participants 
Participants that discontinue from the study prior to the 4-week post-SBRT blood draw will be 
considered unevaluable for the analyses of lymphocyte counts and will be replaced.  These 
participants will be evaluable for the tabulation of adverse events.  
8. 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
Clinical Assessments 
Some data will be accessed via the participant’s medical chart or results of diagnostic tests 
performed as part of the participant’s regular medical care. These data may be used for 
screening or as part of collection of trial data.   
 Assessment of Adverse Events 
Each participant will be evaluated by a licensed clinician at each study visit.  The NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 5 will be used for the characterization 
and grading of adverse events.  
•  
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 Complete Blood Count (CBC) with Differential 
A CBC with differential should be collected and processed at all time-points as designated in the 
Study Calendar of Assessments in section 9.  
 Concomitant Medications 
For this protocol, a prescription medication is defined as a medication that can be prescribed only 
by a properly authorized/licensed clinician. Medications to be reported in the Case Report Form 
(CRF) are concomitant prescription medications, over-the-counter medications, and herbal 
supplements. Whenever possible, corticosteroids/immune modulators should be avoided, 
especially around the time of CBC or research blood draws, as they can affect the lymphocyte 
count.  If a participant requires any medication listed in the exclusion criteria during or in the 6 
months following SBRT, he or she will no longer be followed for the study and no additional blood 
will be drawn for research purposes. If this occurs within the 4 weeks following SBRT, the patient 
will be replaced. These medications have been shown to affect the way white blood cells respond 
to radiation. There are no other prohibited medications related to study participation. Medications 
should be collected from 28 calendar days before registration through 6 months following SBRT. 
 Review of Medical Record 
In this patient population, the following assessments are frequently completed as part of 
standard clinical care. If they are completed during the timeframes described below, 
accompanying results should be entered in the designated EDC system as study data.  
Assessment 
Estimated Timeframe(s) 
PET with FDG 
Within 8 wks prior to SBRT and if there is a suspicion of tumor 
recurrence (prior to first recurrence following study 
participation) 
CT scan with contrast 
Within 8 wks prior to SBRT and within 24 months after SBRT 
Tumor response eval 
At SOC intervals until first recurrence during 30 months of 
follow-up 
Hospitalization history 
Within 12 wks prior to SBRT and at SOC intervals until first 
recurrence during 30 months of follow-up 
 
8.2 
Research Blood 
Research blood will be collected according to the study calendar of assessments in section 9. 
40 ml of blood will be collected at two time points (pre SBRT and 1 month after SBRT) in green 
top tubes. Following collection, the blood will be transported at room temperature to Dr. 
Lawrence Lum’s laboratory for processing and analysis. 
Blood will be analyzed in Dr. Lum’s lab.  Research tubes will be labeled directly with a unique 
identifier ID and associated with the UVA IRB HSR number.  All leftover research blood will be 
stored in Dr. Lum’s lab at UVA once analysis described in the sections below is completed.    
8.3 
Correlative Studies 
In addition to the following, additional assays may be performed for proliferation, function and 
subtypes depending on study findings. 
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 Lymphocyte functionality in vitro assays 
These assays will be run on all participants in both arms at each blood draw time-point. 
 Lymphocyte Subsets and Activation Phenotypes 
The T cell subsets and activation will be measured by flow cytometry using multiple markers to 
identify T cell subpopulations. The PBMC will be stained for central memory (including but not 
limited to CD4+/CD45RO+/CCR7-/CD62L+; CD8+/CD45RO+/CCR7-/CD62L+), memory 
(including but not limited to CD4+/CD45/RO+/ CCR7-/CD62L-; CD8+/CD45RO+/CCR7-/CD62L-
), and effector (including but not limited to CD4+/CD45RO+/CCR7-/CD27+; CD8+/ CD45 
RO+/CCR7-/CD27+) CD4+ and CD8+ T cells, CD68 for monocyte, CD33+/CD11b+ for MDSC. 
Briefly, PBMC will be stained for 30 minutes on ice with the cocktails of fluorescently conjugated 
monoclonal antibodies (mAbs) or isotype-matched controls, washed twice with Fluorescent 
Activated Cell Sorting (FACS) buffer. Cells will be analyzed on a FACScalibur (BD Biosciences) 
and data will be acquired using CellQuest software (BD Biosciences).  
 Evaluation of Specific Antibody Response Against Recall Antigens in Serum 
To determine whether SBRT affects humoral immune responses, serum samples will be 
analyzed for IgG anti-tetanus toxoid antibody.  Briefly, antibodies against pooled peptides of 
tetanus toxoid will be used to capture specific IgG anti-tetanus toxoid antibodies in participant 
serum, followed by detection of bound antibodies using goat-anti-human IgG by enzyme linked 
immunosorbent type assay (ELISA). In addition, we will also test the T and B cell responses to 
pokeweed mitogen in a polyclonal T-dependent in vitro B cell antibody synthesis assay. The IgG 
antibody titers to tetanus toxoid at different time points after radiation will be compared to 
baseline measurements.   
 Evaluation of IFN-ɣ secreting T cells specific to tumor using an EliSpot assay 
To determine whether SBRT affects the tumor specific cytotoxic T cells, PBMC will be isolated 
from whole heparinized blood by Ficoll-hypaque density gradient centrifugation and 
cryopreserved until use. PBMC will be exposed to a cocktail of stimulating tumor cells (either 
lung cancer cell lines-A549, H292 and H520 or liver cancer cell lines-SK-HEP-1, SNU-423 and 
SNU-475) in plates coated with anti-human IFN-γ antibody.  The interferon gamma (IFN-) 
EliSpot assay measures the CD8-mediated cytotoxic T lymphocyte (CTL) activity and CD4-
mediated helper responses.  IFN- EliSpots produced by PBMC will be assessed after 18 hours 
of stimulation with the above listed cocktail of cell lines as well as spontaneous IFN- EliSpots 
(non-stimulated PBMC) produced by PBMC at an effector to target ratio (E/T) of 1:1. This will 
allow for detection of tumor specific IFN- cytokine producing activated T cells.  The 
quantification of IFN- secreting specific T cells will be performed by EliSpot CTL software.     
The results of the lymphocyte functionality in vitro analyses will be compared between Arms A 
and B and correlated to integral or mean great vessel radiation dose, mean heart dose, and 
mean lung dose.  
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9. 
STUDY CALENDAR OF ASSESSMENTS 
Procedures 
Screening/Baseline1 
 
SBRT (5 clinic days) 
Completion of SBRT5 
4 weeks +/-2 weeks 
following SBRT 
3 months +/-2 weeks 
following SBRT 
6 to 9 months 
following SBRT 
Overall Survival 
(every 6 months for 
one year and then 
annually, by phone 
or medical record 
review) 
Informed consent 
X 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
Randomization 
X7 
 
 
 
 
 
 
Concomitant medication 
review 
X8 
 
X--------------------------------------------X 
 
Physical exam  
X 
 
X 
 
X 
 
 
COVID-19 Questions 
X 
 
X 
 
X 
X 
 
Vital signs 
X 
 
X 
 
X 
 
 
Height 
X (last 
recorded for 
standard 
clinical care) 
 
 
 
 
 
 
Weight 
X 
 
 
X6 -------------------------------------------- X6 
 
Performance status 
X 
 
X 
 
 
X 
 
Serum or urine 
pregnancy test (Women 
of Childbearing 
Potential Only) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Overall Survival (OS) 
 
 
 
 
 
 
X  
Hematology- CBC with 
Diff 
X 
 
X4 
X 
 
X 
X3 
Research Blood 
X2 
 
 
X 
 
 
 
Planning/Chest CT 
scan with contrast 
X (w/in 8 
wks of 
SBRT)7 
 
 
 
 
X6 
 
 
Review of Medical 
Record (see section 
8.1.4) 
X 
 
X 
 
 
X 
X 
X 
Adverse event review 
and evaluation 
X----------------------------------------------------------------------X 
 
SBRT 
 
X 
 
 
 
 
 
 
1 All screening procedures should occur up to 1 month prior to registration unless otherwise specified  
2 Research blood should be completed following confirmation of eligibility/registration and before beginning SBRT.  
3 If the participant is followed at UVA and CBC results are available in Epic, these should be entered in the designated EDC system 
(q 6 months +/- 1 month). 
4 Complete within 3 days after completion of SBRT (can be immediately following completion of SBRT) 
5 Complete within 5 business days (before or after) of completion of SBRT unless otherwise stated 
6Only collected if part of standard clinical care. Not collecting this information during/following SBRT is not considered a deviation 
7Registration and randomization should occur around the time of planning CT (+/- 5 business days). SBRT must begin within 4 
weeks after registration/randomization. 
8 Medications should be collected from 28 calendar days before registration 
10. DATA AND SAFETY MONITORING PLAN   
 DSMC Meetings and Audits 
The UVA CC DSMC will meet every month for aggregate review of data. Tracking reports of the 
meetings are available to the PI for review. Issues of immediate concern by the DSMC are 
brought to the attention of the sponsor (and if appropriate to the PRC and IRB) and a formal 
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response from the sponsor is requested. Per the UVA Cancer Center NIH approved institutional 
plan, this study will be audited approximately every year. The audit may include direct access to 
source data/documents. 
10.2 Adverse Events and Serious Adverse Events 
 Definition of Adverse Events (AE) 
Adverse event means any untoward medical occurrence associated (at least possibly related) 
with the use of a medical  intervention in humans. 
 Definition of Serious Adverse Events (SAE) 
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of 
either the investigator or sponsor, it results in any of the following outcomes:  
 
death,  
 
a life-threatening adverse event,  
 
inpatient hospitalization or prolongation of existing hospitalization,  
 
a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or  
 
a congenital anomaly/birth defect.  
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the participant and may require medical or surgical intervention to prevent 
one of the outcomes listed in this definition. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, or the development of 
drug dependency or drug abuse. 
A planned medical or surgical procedure is not, in itself, an SAE. 
 Classification of an Adverse Event 
10.2.3.1 Severity of Event 
For adverse events (AEs) not included in CTCAE version 5, the following guidelines will be used 
to describe severity.  
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s 
daily activities.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
• 
Severe – Events interrupt a participant’s usual daily activity and may require systemic 
drug therapy or other treatment. Severe events are usually potentially life-threatening or 
incapacitating.  Of note, the term “severe” does not necessarily equate to “serious”. 
10.2.3.2 Relationship to Study Intervention 
All adverse events (AEs) must have their relationship to study intervention (both SBRT and 
blood draws that are completed solely for the research study) assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her clinical 
judgment. The degree of certainty about causality will be graded using the categories below. In 
a clinical trial, the study product must always be suspect. 
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 
Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event, including an abnormal 
laboratory test result, occurs in a plausible time relationship to study intervention 
administration and cannot be explained by concurrent disease or other drugs or 
chemicals. The response to withdrawal of the study intervention (dechallenge) should be 
clinically plausible. The event must be pharmacologically or phenomenologically definitive, 
with use of a satisfactory rechallenge procedure if necessary. 
 
 
Probably Related – There is evidence to suggest a causal relationship, and the influence 
of other factors is unlikely. The clinical event, including an abnormal laboratory test result, 
occurs within a reasonable time after administration of the study intervention, is unlikely 
to be attributed to concurrent disease or other drugs or chemicals, and follows a clinically 
reasonable response on withdrawal (dechallenge). Rechallenge information is not 
required to fulfill this definition. 
 
 
Possibly Related – There is some evidence to suggest a causal relationship (e.g., the 
event occurred within a reasonable time after administration of the trial medication). 
However, other factors may have contributed to the event (e.g., the participant’s clinical 
condition, other concomitant events). Although an AE may rate only as “possibly related” 
soon after discovery, it can be flagged as requiring more information and later be upgraded 
to “probably related” or “definitely related”, as appropriate. 
 
Unlikely to be related – A clinical event, including an abnormal laboratory test result, 
whose temporal relationship to study intervention administration makes a causal 
relationship improbable (e.g., the event did not occur within a reasonable time after 
administration of the study intervention) and in which other drugs or chemicals or 
underlying disease provides plausible explanations (e.g., the participant’s clinical 
condition, other concomitant treatments). 
 
 
Not Related – The AE is completely independent of study intervention administration, 
and/or evidence exists that the event is definitely related to another etiology. There must 
be an alternative, definitive etiology documented by the clinician 
10.2.3.3 Expectedness 
The treating clinician will be responsible for determining whether an adverse event (AE) is 
expected or unexpected.  An AE will be considered unexpected if the nature, severity, or 
frequency of the event is not consistent with the risk information previously described for the 
study intervention. 
The following side effects are considered expected from a standard blood draw, in order of 
likelihood: pain, bruising, fainting or passing out, or infection. SBRT radiation side effects should 
be consistent with standard clinical care. The likely SAEs from SBRT are described in Bezjak et 
al from RTOG 0813, which included patients receiving SBRT radiation for centrally located 
NSCLC15. In addition to these SAEs from SBRT, participants may experience a drop in 
lymphocyte count, lung fibrosis, fatigue and/or skin irritation/skin changes.  
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 Time Period and Frequency for Event Assessment and Follow-Up  
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the 
attention of study personnel during study visits and interviews of a study participant presenting 
for medical care, or upon review by a study monitor. 
 
All reportable AEs including local and systemic reactions not meeting the criteria for SAEs will be 
captured on the appropriate case report form (CRF). Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study product 
(assessed only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event. All AEs occurring while on study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution. 
 
Any medical condition (including a laboratory abnormality) that is present at the time that the 
participant is screened will be considered as baseline and not reported as an AE. However, if the 
study participant’s condition deteriorates at any time during the study, it will be recorded as an 
AE. For the purposes of this study, laboratory abnormalities (at baseline or during the study) will 
not be recorded and are not reportable, except for hematological laboratory abnormalities in a 
complete blood count (with or without differential), as these are the only laboratory results that 
have any likelihood of being related to SBRT/study intervention.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of 
the event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
Study staff will record all reportable events with start dates occurring any time after informed 
consent is obtained until the 6 month visit following SBRT (for non-serious AEs) or anytime (for 
SAEs considered related to the study intervention).  At each study visit, the investigator will 
inquire about the occurrence of AE/SAEs since the last visit.  Events will be followed for 
outcome information until resolution or stabilization. 
 Adverse Event Reporting 
AEs considered related to either a research-only blood draw or SBRT must be recorded into the 
University of Virginia Cancer Center’s designated EDC database in accordance with the Clinical 
Trial Management System Policy Note that the AE Reporting Table below has been revised in 
the following ways from the standard AE Reporting table for Low Risk Studies: 
 
Reporting for grade 4-5 unrelated AEs was updated to “Not Required” because this 
study includes participants that may have severe/serious AEs due to their disease that 
are completely unrelated to SBRT or blood draws. All treatment meets standard of care 
guidelines. 
 
Reporting for Grade 1-2 (expected and unexpected) was updated to “30 days”, as 
investigators are interested in reviewing ALL related AEs for feasibility/equivalence of 
safety. 
 
Reporting for laboratory AEs is limited to complete blood count (with or without 
differential), as these are the only laboratory adverse events that would have any 
possibility of relationship with SBRT 
Table C: Low Risk Studies  
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 Serious Adverse Event Reporting 
The study clinician will record any serious adverse event, whether or not considered study 
intervention related, including those listed in the protocol, and must include an assessment of 
whether there is a reasonable possibility that the study intervention caused the event.  
 
All serious adverse events (SAEs) will be followed until satisfactory resolution or until the site 
investigator deems the event to be chronic or the participant is stable. 
 
Internal Events Resulting in death that are deemed DEFINITELY related to (caused by) 
study participation 
 
Report to the UVA IRB-HSR within 24 hours.  Report within 24 hours using IRB 
Online and a phone call. 
 
 
Internal, Serious, Unexpected, Related to Study Intervention 
o Report to the UVA IRB-HSR within 7 days from the time the study team receives 
knowledge of the event.  Timeline includes submission of signed hardcopy of AE 
form.  Report using IRB Online.   
10.3 Reporting Events to Participants 
If there is any new information relevant to the participant’s willingness to continue to participate in 
the study, such as if there are new risks of the study treatment identified that were not included 
on the consent form that the participant signed, the study team will contact the participant to 
discuss this information. If the participant is still receiving study treatment, the study team will 
present the participant with an updated consent and confirm that he or she wants to continue 
receiving study treatment. The PI will determine whether new risks are applicable to participants 
who are in follow-up, whether participants need to be notified, and whether re-consenting is 
required. 
10.4 Unanticipated Problems 
 Definition of Unanticipated Problems (UP) 
The Office for Human Research Protections (OHRP) considers unanticipated problems 
(UPs)(may include a data breach) involving risks to participants or others to include, in general, 
any incident, experience, or outcome that meets all of the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 
Reporting requirements for AEs that occur within 6 months of the last protocol specified treatment/intervention 
 
Grade 1-2 
Grade 1-2 
Grade 3 
Grade 4-5 
 Expected  
Unexpected  
 
 Expected or 
Unexpected  
Expected or  
Unexpected 
 
Without 
hospitalization 
With 
hospitalization 
Unrelated 
 
Not required 
 
Not required 
Not required  
Not required 
Not required  
Related 
30 days** 
30 days** 
 
30 days** 
15 days** 
 (24-hrs)* 
15 days** 
*Enter into  Cancer Center database  within 24 hours if unexpected and definitely related to protocol specified treatment 
Hospitalization defined as an inpatient hospital stay or prolongation of a hospital stay equal to or greater than 24 hours 
** The only laboratory AEs that need to be reported are hematological studies, as SBRT will not affect other laboratory results 
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• 
Related or possibly related to participation in the research (“possibly related” means 
there is a reasonable possibility that the incident, experience, or outcome may have 
been caused by the procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously known 
or recognized. 
 Unanticipated Problem Reporting 
 
Report UPs that are not adverse events, protocol deviations, or data breaches (see 
section 10.5.2 Error! Reference source not found. for reporting for data breaches) to 
the UVA IRB-HSR within 7 calendar days from the time the study team receives 
knowledge of the event.  Report using the Unanticipated Problem Report form. 
 
Report UPs that are SAEs in accordance with the guidelines for SAE reporting. 
 Reporting Unanticipated Problems to Participants 
If during the course of the study there is an unanticipated problem that affects current or past 
participants, affected participants will be contacted if needed. 
10.5 Data Breach 
 Definition of Data Breach 
An unauthorized acquisition, access, or use of protected health information (PHI) that 
compromises the security or privacy of such information. 
 Reporting a Data Breach 
 
Report to the UVA Corporate Compliance and Privacy Office as soon as possible and no 
later than 24 hours from the time the incident is identified.  Report by telephone. 
 
 
Report to InfoSec if the breach involves electronic data.  Report as soon as possible and 
no later than 24 hours from the time the incident is identified.  Refer to the following for 
details:  http://security.virginia.edu/report-information-security-incident. 
 
 
Report to UVA police if the breach includes such things as stolen computers.  Report by 
telephone. 
10.6 Protocol Deviation 
 Definition of Protocol Deviation 
A protocol deviation is defined as any change, deviation, or departure from the study design or 
procedures of a research project that is NOT approved by the institution’s IRB prior to its 
initiation or implementation, OR deviation from  standard operating procedures, Good Clinical 
Practices (GCPs), federal, state or local regulations. Protocol violations may or may not be 
under the control of the study team or UVa staff. These protocol violations may be major or 
minor violations. 
 Reporting of a Protocol Deviation 
It is the responsibility of the site investigator to use continuous vigilance to identify and report 
deviations. All deviations must be addressed in study source documents and reported as 
follows: 
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 
Report to the UVA IRB-HSR major deviations within 7 calendar days from the time the 
study team received knowledge of the event.  Report using the Protocol Deviation and 
Protocol Exception Reporting Form. 
 
 
For minor deviations, please reference the IRB-HSR for tips for recording minor deviations 
10.7 Participant Withdrawals/Dropouts Prior to Study Completion 
Participants who withdraw consent and those dropping out of the study secondary to an AE will 
be reported to the UVA IRB yearly on the IRB continuation form. 
11. REGULATORY AND OPERATIONAL CONSIDERATIONS 
11.1 Regulatory and Ethical Considerations 
 Consent Procedures and Documentation 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in 
the study and continues throughout the individual’s study participation. Consent forms will be 
Institutional Review Board (IRB)-approved and the participant will be asked to read and review 
the document. A member of the study team will explain the research study to the participant and 
answer any questions that may arise. A verbal explanation will be provided in terms suited to 
the participant’s comprehension of the purposes, procedures, and potential risks of the study 
and of their rights as research participants.  Participants will have the opportunity to carefully 
review the written consent form and ask questions prior to signing. The participants should have 
the opportunity to discuss the study with their family or surrogates or think about it prior to 
agreeing to participate. The participant will sign the informed consent document prior to any 
procedures being done specifically for the study. Results from procedures completed prior to 
consent for standard of care purposes may be used for research purposes. Participants must be 
informed that participation is voluntary and that they may withdraw from the study at any time, 
without prejudice. A copy of the informed consent document will be given to the participants for 
their records. The informed consent process will be conducted and documented in the source 
document (including the date), and the form signed, before the participant undergoes any study-
specific procedures. The rights and welfare of the participants will be protected by emphasizing 
to them that the quality of their medical care will not be adversely affected if they decline to 
participate in this study. 
 Confidentiality and Privacy 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s) and their interventions. This confidentiality is extended to cover 
testing of biological samples and genetic tests in addition to the clinical information relating to 
participants. Therefore, the study protocol, documentation, data, and all other information 
generated will be held in strict confidence. Consents will be maintained in a confidential manner 
in accordance with the code of federal regulations and HIPAA. When possible, specimens will 
be coded with IDs (not MRN or name). No information concerning the study or the data will be 
released to any unauthorized third party without prior written approval of the sponsor.  
All research activities will be conducted in as private a setting as possible. 
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The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), regulatory agencies or pharmaceutical company supplying 
study product may inspect all documents and records required to be maintained by the 
investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the participants in this study. The clinical study site will permit access to 
such records. 
The study participant’s contact information will be securely stored at each clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure 
location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements. 
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored at the University of Virginia. The study data entry and 
study management systems used by research staff will be secured and password protected.  
 Future Use of Stored Specimens and Data 
With the participant’s approval and as approved by local Institutional Review Boards (IRBs), 
coded and linked biological samples will be stored in Dr. Lawrence Lum’s Tissue Bank for 
Future Cell Therapy Studies biorepository in Dr. Lum’s lab at UVA. These samples could be 
used to research the causes of cancer, its complications and other conditions for which 
individuals with cancer are at increased risk, and to improve treatment.  
During or after the conduct of the study, an individual participant can choose to withdraw 
consent to have biological specimens stored for future research.  
When the study is completed, access to study data and/or samples will be provided through the 
Tissue Bank for Future Cell Therapy Studies. At the end of the current study, all study 
data/specimens will be maintained according to institutional policies. 
 Safety Oversight 
The University of Virginia Cancer Center Data and Safety Monitoring Committee (CC DSMC) 
will provide oversight of the conduct of this study.  The CC DSMC will report to the UVA 
Protocol Review Committee (PRC). 
The UVA CC DSMC will review the following: 
 
All adverse events 
 
Audit results 
 
Application of study designed stopping/decision rules 
 
Whether the study accrual pattern warrants continuation/action 
 
Protocol violations 
The UVA CC DSMC will meet according to their approved plan as described in section 10.1.1. 
Any study under the purview of the University of Virginia HSR-IRB is subject to review. Studies 
are chosen for Post-approval Monitoring either a) at random or b) requested by a study team 
member or any member of the IRB-HSR.   
 
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The purpose of Post-approval Monitoring audits is to ensure that documentation of clinical 
research studies is of the highest quality, verify protocol adherence, and ensure that all Federal 
and local rules concerning clinical research are being fulfilled.  Post-approval monitoring is done 
by staff within the office of the Vice President for Research (VPR) in accordance with their 
Standard Operating Procedures. The conduct of an on-site review may include but is not limited 
to: 
 
requests for progress reports from investigators, 
 
examinations of research records, including signed informed consent documents, protocol 
modifications, and unexpected, serious, and/or related adverse experience reports, 
 
contacts with research participants, or 
 
observation of the consent process and/or research procedures. Examples of when 
observation of the consent process could occur are: 
 
Full board IRB determines during review of a project that a conflict of interest exists 
such that the informed consent process should be observed by a neutral party; 
 
IRB is made aware of a complaint or concern with regard to the informed consent 
process; or 
 
IRB determines as a result of the monitoring process that the consent process is 
insufficient and education/training is required for conduct of consent. 
11.2 Data Handling and Record Keeping 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of 
the site investigator. The investigator is responsible for ensuring the accuracy, completeness, 
legibility, and timeliness of the data reported.  
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.   
Data will be collected using a password-protected, centralized electronic case report form called 
ON-line Clinical Oncology Research Environment = Oncore and/or ForteEDC. Data recorded in 
the electronic case report form (eCRF) derived from source documents should be consistent 
with the data recorded on the source documents.  
11.3 UVA Institutional Review Board for Health Sciences Research 
The UVA Institutional Review Board for Health Sciences Research (UVA IRB-HSR) will approve 
all aspects of this study, including the clinical trial protocol, informed consent documents, and 
patient materials. Modifications to the protocol or consent form will be reviewed and approved 
by the UVA IRB-HSR prior to implementation, except when necessary to eliminate apparent 
immediate hazards to the study participants. The study will undergo continuing IRB review 
based on the level of risk as assessed by the IRB. This review will take place no less than 
annually. Reporting to the UVA IRB-HSR will occur as specified above. 
 
 
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12. REFERENCES 
1 
J., S. Some theoretical considerations on the present status of roentgen therapy. N Engl J Med 175, 321-
327 (1916). 
2 
Grossman, S. A. et al. Immunosuppression in patients with high-grade gliomas treated with radiation and 
temozolomide. Clin Cancer Res 17, 5473-5480, doi:10.1158/1078-0432.CCR-11-0774 (2011). 
3 
Tabi, Z. et al. Resistance of CD45RA- T cells to apoptosis and functional impairment, and activation of 
tumor-antigen specific T cells during radiation therapy of prostate cancer. J Immunol 185, 1330-1339, 
doi:10.4049/jimmunol.1000488 (2010). 
4 
MacLennan, I. C. & Kay, H. E. Analysis of treatment in childhood leukemia. IV. The critical association 
between dose fractionation and immunosuppression induced by cranial irradiation. Cancer 41, 108-111 
(1978). 
5 
Weeke, E. The development of lymphopenia in uremic patients undergoing extracorporeal irradiation of 
the blood with portable beta units. Radiat Res 56, 554-559 (1973). 
6 
Ellsworth, S. et al. Sustained CD4(+) T cell-driven lymphopenia without a compensatory IL-7/IL-15 
response among high-grade glioma patients treated with radiation and temozolomide. Oncoimmunology 
3, e27357, doi:10.4161/onci.27357 (2014). 
7 
Balmanoukian, A., Ye, X., Herman, J., Laheru, D. & Grossman, S. A. The association between treatment-
related lymphopenia and survival in newly diagnosed patients with resected adenocarcinoma of the 
pancreas. Cancer Invest 30, 571-576, doi:10.3109/07357907.2012.700987 (2012). 
8 
Campian, J. L., Sarai, G., Ye, X., Marur, S. & Grossman, S. A. Association between severe treatment-related 
lymphopenia and progression-free survival in patients with newly diagnosed squamous cell head and neck 
cancer. Head Neck 36, 1747-1753, doi:10.1002/hed.23535 (2014). 
9 
Campian, J. L., Ye, X., Brock, M. & Grossman, S. A. Treatment-related lymphopenia in patients with stage 
III non-small-cell lung cancer. Cancer Invest 31, 183-188, doi:10.3109/07357907.2013.767342 (2013). 
10 
Wild, A. T. et al. The Association Between Chemoradiation-related Lymphopenia and Clinical Outcomes in 
Patients With Locally Advanced Pancreatic Adenocarcinoma. Am J Clin Oncol 38, 259-265, 
doi:10.1097/COC.0b013e3182940ff9 (2015). 
11 
Grossman, S. A. et al. Survival in Patients With Severe Lymphopenia Following Treatment With Radiation 
and Chemotherapy for Newly Diagnosed Solid Tumors. J Natl Compr Canc Netw 13, 1225-1231 (2015). 
12 
Potters, L. et al. American Society for Therapeutic Radiology and Oncology (ASTRO) and American College 
of Radiology (ACR) practice guideline for the performance of stereotactic body radiation therapy. Int J 
Radiat Oncol Biol Phys 76, 326-332, doi:10.1016/j.ijrobp.2009.09.042 (2010). 
13 
T McMullen, S. L., C Alonso, K Wijesooriya. in 2017 Annual AAPM meeting Vol. 44  (ed Medical Physics) 
3118 (Denver, CO, 2017). 
14 
Wijesooriya, K. et al. in ESTRO annual meeting Vol. 133  (ed Radiotherapy and Oncology) S406-S407 
(Milan, IT, 2019). 
15 
Bezjak, A. et al. Safety and Efficacy of a Five-Fraction Stereotactic Body Radiotherapy Schedule for 
Centrally Located Non-Small-Cell Lung Cancer: NRG Oncology/RTOG 0813 Trial. J Clin Oncol 37, 1316-
1325, doi:10.1200/JCO.18.00622 (2019). 
 
 
 
 
 
 
 
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13. APPENDICES 
Appendix 1: ECOG Performance Status 
Appendix 2: RECIST 1.1 Criteria 
Appendix 3: Summary of Changes 
 
 
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13.1 Appendix 1: ECOG Performance Status 
 
 
 
 
 
 
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13.2 Appendix 2: RECIST 1.1 Criteria 
Please refer to the following publication for evaluation of clinical response by RECIST 1.1. 
 
E.A. Eisenhauer et al.  New response evaluation criteria in solid tumours: Revised RECIST 
guideline (version 1.1).  European Journal of Cancer, 2009, 45: 228-247. PMID:  19097774 
 
 
 
 
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13.3 Appendix 3: Summary of Changes to Protocol 
Changes from protocol version date 10/20/21 to 4/25/2022 
Section(s) 
Description 
9.Study Calendar of Assessments 
Change the timeframe for one of the 
collections of CBC with differential from 6 
months +/-2 weeks following SBRT to 6 to 
9 months following SBRT. 
Rationale: Timeframe was adjusted to account for subject scheduling changes. 
 
Changes from protocol version date 4/9/2021 to 10/20/2021 
Section(s) 
Description 
Accrual Goal 
Increased the accrual goal to 65 subjects 
from 53 subjects. 
Rationale: To better account for screen failures and replacements needed for subjects who 
are discontinued before the 4 week blood collection, in order to obtain 50 evaluable subjects.  
4.1.2 Eligibility Criteria- Exclusion Criteria 
Updated exclusion criteria #1 to include a 
2 year timeframe for prior radiation and to 
include subjects who’ve had prior 
radiation therapy for skin cancer (at any 
time) are eligible 
Rationale: Radiation therapy performed 2 year prior to lung SBRT and skin cancer radiation 
therapy is not expected to impact the objectives of the study.  
4.1.2 Eligibility Criteria- Exclusion Criteria 
Added exclusion criteria #7 in which 
subjects with HIV, AIDS, any type of 
Hepatitis, and/or any blood borne 
infectious disease Dr. Lum’s research lab 
cannot process blood samples for are 
ineligible for the study. 
Rationale: Dr. Lum’s research lab is a BSL-2 level laboratory however, the lab cannot accept 
samples from individuals with a known diagnosis of HIV, AIDS, and/or any type of Hepatitis. 
Since the research blood from these subjects would not be analyzed, these subjects are 
ineligible for the study. This exclusion criteria will be assessed via review of the subject’s 
medical record and/or subject acknowledgement. No diagnostic tests will be required to 
determine/confirm diagnosis of these diseases.  
9 Study Calendar of Assessments 
Adjusted 4 week Follow up timeframe 
allowance to +/- 2 weeks from +/- 1 week. 
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Rationale: Timeframe was adjusted to account for scheduling changes. Widening this 
timeframe is not expected to have a significant impact on the lymphocyte count data. 
9 Study Calendar of Assessments 
Removed Hemoglobin A1C test 
Rationale: Subjects with diabetes (even uncontrolled diabetes) are not excluded from the 
study. In addition, the values are not being recorded as data. Collecting Hemoglobin A1C 
data only at baseline is not necessary for the study objectives.   
9 Study Calendar of Assessments 
Adjusted study calendar for AE collection 
timeframe to include Screening/Baseline 
and SBRT. 
Rationale: To accurately reflect that AE capture starts at the time of informed consent  
8.1.4 Adverse Events and Serious Adverse 
Events 
Updated definition of an adverse event to 
“Adverse event means any untoward 
medical occurrence associated (at least 
possibly related) with the use of a medical  
intervention in humans” 
Rationale:  The new definition streamlines the capture of AEs without underreporting. This 
definition captures pertinent standard clinical care and intervention related AEs of any 
category. 
 
Changes from protocol version date 4/5/2021 to 4/9/2021 
Section(s) 
Description 
Abbreviation Table 
9 Study Calendar of Assessments 
10.2.5 AE Reporting 
8.1.4 Review of Medical Record 
11.2 Data Handling and Record Keeping 
updated  “Oncore” references to “ 
designated EDC system” 
Rationale: Oncore is no longer the exclusive data entry system for the study. ForteEDC will 
also be used to capture data and adverse events. 
 
Changes from protocol version date 10/2/2020 to 4/5/2021 
Section(s) 
Description 
4.1.2 Exclusion Criteria 
Updated Exclusion Criteria 2 & 3 to 
include “planned before the completion of 
the 6 month post SBRT follow up 
timeframe 
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Rationale:  Systemic cancer therapies and surgery can affect the lymphocyte counts. Blood 
draws to record the lymphocyte counts occur up until the 6 month follow up timeframe. The 
goal is to minimize the impact to the counts from procedures not a part of the study’s 
treatment. 
9 Study Calendar of Assessments 
Added 3 month Follow up visit to the 
protocol and included corresponding 
assessments 
Rationale: To align with SOC scheduling. Patients usually have a 3 month follow up for SOC. 
Since an office visit with their physician will not be required at 1 month, assessments that 
were being collected for the 1 month will now be collected at the 3 month visit. Blood draws 
will still be collected at the 1 month. 
8.2 Research Blood 
9 Study Calendar of Assessments 
Updated the  assessments required for 1 
month Follow up visit to just the blood 
draws 
Rationale: To align with SOC scheduling.  The 1 month follow up visit is only SOC when the 
patient experiences side effects. The 1 month study goal is just to collect the blood draws.  
9 Study Calendar of Assessments 
Added the collection of COVID screening 
questions.  
Rationale: Infections and vaccines could affect the lymphocyte counts. Information for COVID 
is being collected to assess potential impact to the study data. 
10.2.5 Adverse Event Reporting 
AE reporting table was updated from 30 
days to 6 months 
Rationale: To align with section 10.2.4 Time period and Frequency for Event Assessment and 
Follow up 
8.1.3 Concomitant Medications 
Reworded the Con Meds section to 
include “immune modulators” 
Rationale: For clarity to indicate that corticosteroids are not the only immune modulating 
medications 
 
 
 
Changes from protocol version date 1/15/2020 to 10/02/2020 
Page(s) 
Section(s) 
Description 
1 
Title page  
Personnel were updated to include 
additional key investigators and remove 
some of the contact information 
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Rationale: Additional investigators will take a greater role in the project, and contact 
information (address, etc) is not necessary for all investigators, as this is a single site study 
Throughout 1 Synopsis, Schema, 2 
Introduction, 3.1.2 Impact of 
Lymphocyte-Sparing SBRT 
Planning Objectives on Post-SBRT 
Lymphocyte Count, 3.2.1 Safety, 
3.2.2 Performance of Algorithm to 
Predict Decrease in Lymphocyte 
Count Post-SBRT, 3.2.3 Impact of 
Lymphocyte-Sparing SBRT 
Planning Objectives on Post-SBRT 
Lymphocyte Counts, 3.2.4 
Lymphocyte Phenotype and 
Function, 3.3.1 Lymphocyte 
Phenotype and Function 
(Additional), 3.3.5 Description of 
Changes in Lymphocyte Subtypes, 
6.1 Patient Registration and 
Randomization, 7.1.2 Normal 
Tissue Organs-At-Risk (OARs), 
7.1.4 Dose Fractionation, 7.4.2 
Dosimetry, 8.3.4 Evaluation of IFN-
ɣ secreting T cells specific to tumor 
using an EliSpot assay 
Arm 1 has been updated to Arm A and 
Arm 2 has been updated to Arm B 
Rationale: To be consistent with the electronic case report form system (OnCore) 
18 
4.1.1 Inclusion Criteria 
Added “business” to “business days”  
Revised #6 to clarify that chest CT, PET 
CT and CT simulation are all acceptable 
scans 
Revised #7 to make it consistent with lab 
results in the medical record 
Rationale: To allow a little more flexibility, clarity, and consistency 
20 
4.1.2 Exclusion Criteria 
Exclusion criterion # 2 was removed.  
Rationale: The concerns related to exposures that may significantly affect lymphocyte count 
or function are addressed by the remaining criteria. 
22 
6.1 Patient Registration & 
Randomization 
Revised sentence regarding blinding 
Rationale: Participants may be told about their arm assignment, but this is not required 
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8.1.1 Assessment of Adverse 
Events 
Removed “Toxicity diaries will be 
distributed to participants and reviewed 
by study personnel” 
Rationale: Toxicity diaries are not used in this study; participants are assessed for side effects 
and symptoms by clinicians according to standard clinical care 
29 
9 Study Calendar of Assessments 
Physical exam, vitals, and performance 
status at time of SBRT may be within 5 
days before/after completion of SBRT 
Weight during SBRT and following SBRT 
is not essential for the endpoints, except 
for the purposes of AEs. Weight should 
be collected according to standard clinical 
care from SBRT and during follow-up, 
and not collecting weight during this 
period is not a deviation.  
Footnotes were revised 
Overall survival may be collected by 
phone or from the medical record 
Rationale: For clarity, flexibility and to be consistent with standard clinical care 
31 
10.2.3.3 Expectedness 
Revised wording and organization 
Rationale: For improved clarity 
32 
10.2.4 Time Period and Frequency 
for Event Assessment and Follow-
Up 
Added “reportable” 
Rationale: For internal consistency with reporting standards 
31-32 
10.2.4 Time Period and Frequency 
for Event Assessment and Follow-
Up 
10.2.5 Adverse Event Reporting 
Added a sentence clarifying that non-
hematological laboratory abnormalities 
are not reportable and do not need to be 
reported as adverse events 
Rationale: The only laboratory AEs that need to be reported are hematological studies, as 
SBRT will not affect other laboratory results 
 
Changes from protocol version date 1/10/2020 to 1/15/2020 
Page(s) 
Section(s) 
Description 
19 
4.1.2 Exclusion Criteria 
Exclusion Criteria #3: “Chemotherapy” was revised 
to “Systemic anti-cancer therapy” and “or planned 
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27 
7.7 Discontinuation/ 
Withdrawal of Therapy 
8.1.3 Concomitant 
Medications 
use during or within 6 months following SBRT” was 
added 
Exclusion Criteria #4 and #6 were removed  
The concomitant medications section and the 
Discontinuation section were revised to indicate 
that if drugs listed in the exclusion criteria were 
necessary for a participant within the 6 months 
following SBRT, the participant would no longer be 
followed for the study and no additional blood 
would be drawn for research.  
Rationale: Certain medications have been shown to affect lymphocyte count and would affect 
the accuracy of the designed algorithm 
22 
6.1 Patient Registration & 
Randomization 
Language regarding blinding was revised to clarify 
that investigators involved with lab research will be 
blinded to treatment arm 
Rationale: Clarification 
29 
9 Study Calendar of 
Assessments 
Removed recurrence free survival (RFS) from the 
calendar 
Rationale: This was mistakenly missed in the 1/10/2020 version 
 
Changes from protocol version date 6/24/19 to 1/10/2020 
Page(s) 
Section(s) 
Description 
3 
9 
15 
32 
Schema 
1 Synopsis 
2 Introduction 
3 Objectives  
10.2.3.3 Expectedness 
The term “lymphopenia” was replaced with 
“decrease in lymphocyte count” or other similar 
language. 
Rationale: Lymphopenia is a clinical term for particular levels of lymphocytes. In this study, 
the amount of decrease in lymphocytes is under study. 
3 
Schema 
“so there are equal numbers of patients in each 
arm” was deleted 
Rationale: This repetitive with the information already available in the schema 
9-10 
15-16 
1 Synopsis 
3.1 Primary Objectives 
The objectives and endpoints have been re-
worded. “Local control” and “Recurrence free 
survival” were removed from the objectives.  
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3.2 Secondary Objectives 
3.3.2 Local Control and 
Overall Survival 
Rationale: For clarification and because local control/DFS/RFS are beyond the scope of this 
study. 
19 
4.1.2 Exclusion Criteria 
Exclusion criteria were added and revised  
Rationale: To more specifically identify the population that the algorithm is likely to predict 
decrease in lymphocyte count. Recent use of certain drugs or recent diagnoses or 
procedures can affect the lymphocyte count.  
20-21 
23 
 
27 
5 Statistical Considerations 
6.1 Patient Registration & 
Randomization 
7.8 Definition of Evaluable 
and Replacement of Study 
Participants 
Additional information was added to clarify the 
Study Population and process of Randomization 
and stratification.  
Additional clarifications were added to these 
sections to provide additional information. 
Rationale: For clarification 
26 
7.6 Image Guided 
Treatment 
This section was added to clarify that the image 
registration procedure should include the proximal 
great vessels and heart location in addition to the 
treated tumor and that this should be recorded in 
the treatment notes.  
Rationale: The algorithm is based on treating the great vessels and heart as organs at risk. 
27 
8.1.3 Concomitant 
Medications 
“restricted” was changed to “prohibited” regarding 
the fact that there are no prohibited medications 
related to study participation. 
A sentence was added to discourage use of 
corticosteroids, especially around the time of CBC 
or research blood draws 
Rationale: Use of corticosteroids can affect the lymphocyte count, especially from about 4 
hours after administration through about 48 hours after administration  
27-28 
 
30 
8.1.4 Review of Medical 
Record 
9 Study Calendar of 
Assessments 
Removed chest x ray, lung-specific assessments, 
and Charlson Index from the assessments that will 
be recorded from the medical record. 
Rows were added to the study calendar to list 
“Review of Medical Record” and “HbA1c” 
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Rationale: The removed assessments are beyond the scope of this study but “Review of 
Medical Record” was added to the study calendar for clarification. “HbA1c” was added to the 
calendar, as uncontrolled diabetes can affect lymphocyte count 
28 
8.3 Correlative Studies 
A sentence was added to clarify that additional 
assessments related to proliferation, function, and 
subtypes may be completed 
Rationale: To better describe the potential studies that may be completed based on study 
findings 
 
 
 
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