Patient case: 50-year-old female with Lung cancer. Genetic variant: EGFR (L858R). Other conditions: Lupus.

Clinical trial: Immune Checkpoint Inhibition (Tremelimumab and/or MEDI4736) in Combination With Radiation Therapy in Patients With Unresectable Pancreatic Cancer

Summary: Background:
  - Stereotactic body radiation therapy (SBRT) is used to treat cancer. It is a way of giving very focused beams of radiation to tumors. Researchers think the drugs used in this study might work better used with SBRT in people with pancreatic cancer.
  Objective:
  - To study the safety and effectiveness of MEDI4736 and/or tremelimumab with SBRT.
  Eligibility:
  - People 18 and older who have pancreatic cancer that has not responded to chemotherapy. They must be candidates for radiation but not resection.
  Design:
  -  Participants will be screened with medical history and physical exam. They will have blood tests. Their tumor will be measured using computerized tomography (CT) or magnetic resonance imaging (MRI).
  -  Participants will have their tumor biopsied with a needle. They will have also have a biopsy after cycle 1.
  -  Participants will get 1 of 2 drugs.
  -  MEDI4736 therapy will be given in 28-day cycles. Participants will get the drug through an intravenous (IV) infusion twice in each cycle.
  -  For tremelimumab, therapy for the first 6 cycles will each last 28 days. Then cycles will each last 12 weeks. Participants will get the drug through an IV once in each cycle.
  -  All participants will have SBRT. Some will get 1 dose of radiation and some will get 5. CT scans will map their tumor.
  -  Participants will have medical history, physical exam, and blood tests in each cycle. They will have a CT scan or MRI every 8 weeks. Cycles will continue for up to 12 months.
  -  Participants will be contacted yearly for follow-up.

Detailed description: Background:
  -Tremelimumab is a monoclonal antibody against CTLA4. Anti-CTLA4 therapy has been
  shown to enhance anti-tumor immunity by blocking tumor-induced immune suppression of cytotoxic T cells.
  -  MEDI4736 is a human monoclonal antibody directed against PD-L1. Blockage of ligation between PD-L1 and PD1 induces local immune activation and prevent anergy and exhaustion of effectors T-cells.
  -  Several studies have documented an increase in peripheral antitumor immunity following radiation. This effect is evidently too weak to be clinically relevant, but has the potential to be boosted by immune modulation.
  -  The underlying hypothesis of this study is that the effect of Immune Checkpoint inhibitor
  (Tremelimumab and/or MEDI4736) treatment can be enhanced by radiation in patients with advanced pancreatic carcinoma.
  Objective:
  To determine the safety, tolerability and feasibility of immune checkpoint inhibition (comprising either MEDI4736 alone (Cohort A), Tremelimumab (Cohort B) or combined MEDI4736 and Tremelimumab (Cohort C)] in combination with stereotactic body radiation therapy (SBRT) in patients with unresectable pancreatic cancer.
  Eligibility:
  -  Histologically confirmed metastatic pancreatic cancer with primary in-situ (or locallyrecurrent) with at least 1 measurable metastatic lesion by RECIST 1.1 criteria and accessible for biopsy. No prior radiation therapy to the pancreas allowed. There is no limit to the number of prior chemotherapy regimens received.
  -  Patients must be greater than or equal 18 years of age and have a performance status (ECOG) less than or equal to 1
  -  Life expectancy of greater than 3 months.
  -  Acceptable organ and bone marrow function.
  -  Patients must not have had standard of care chemotherapy, radiotherapy, or major surgery within the last 2 weeks prior to entering the study. For recent experimental therapies a 28 day period of time must have elapsed before commencing protocol treatment.
  -  No active or prior documented autoimmune or inflammatory disorders (including inflammatory bowel disease, diverticulitis with the exception of diverticulosis, celiac disease, irritable bowel disease; Wegner syndrome; Hashimoto syndrome; Graves disease; rheumatoid arthritis, hypophysitis, uveitis, etc.) within the past 3 years prior to the start of treatment.
  -  No active or history of inflammatory bowel disease (colitis, Crohn s), irritable bowel disease, celiac disease, or other serious, chronic, gastrointestinal conditions associated with diarrhea.
  -  No active or history of systemic lupus erythematosus, Wegener s granulomatosis.
  Design:
  -3 separate cohorts will be enrolled sequentially:
  -  Cohort A: anti-PDL1 (MEDI4736) in combination with Radiation
  -  Cohort B: anti-CTLA4 (tremelimumab) in combination with Radiation
  -  Cohort C: anti-PDL1 (MEDI4736) and anti-CTLA4 (tremelimumab) in combination with Radiation. Cohort C will only proceed following NCI IRB approval of updated safety information of ongoing studies evaluated tremelimumab in combination with MEDI4736.

Eligibility: -  INCLUSION CRITERIA:
  -  Patients must have histopathological confirmation of pancreatic adenocarcinoma prior to entering this study OR histopathological confirmation of carcinoma in the setting of clinical and radiological characteristics which, together with the pathology, are consistent with a diagnosis of pancreatic carcinoma.
  -  Patients must have disease that is not amenable to potentially curative resection. Primary in-situ (or locally-recurrent) tumor must be present and, in the opinion of radiation oncology, be amenable to radiation therapy as planned in the protocol. Each case will be discussed at GI tumor board with multidisciplinary team.
  -  Patients must have at least 1 measurable metastatic lesion by RECIST1.1 criteria and accessible for biopsy.
  -  No prior radiation therapy to the pancreas allowed. There is no limit to the number of prior chemotherapy regimens received. Patients must have received at least one line of prior systemic chemotherapy for advanced unresectable and/or metastatic disease.
  -  Age > 18 years
  -  Life expectancy of greater than 3 months.
  -  ECOG performance status 0-1
  -  Patients must have normal organ and marrow function as defined below:
  -  absolute neutrophil count - > 1,000/mcL
  -  Platelets - greater than or equal to 100,000/mcL
  -  total bilirubin - Bili should be less than or equal to 2 x ULN (patients with Gilbert's Syndrome must have a total bilirubin less than 3.0 mg/dL)
  -  serum albumin - greater than or equal 2.5 g/dl
  Patients are eligible with ALT or AST up to 3 x ULN. (up to 5 x ULN if liver metastases present)
  --Creatinine - < 2X institution upper limit of normal
  OR
  --creatinine clearance - > 45 mL/min/1.73 m(2), for patients with creatinine levels above institutional normal
  -  Patients must have recovered from any acute toxicity related to prior therapy, including surgery. Toxicity should be less than or equal to grade 1 or returned to baseline.
  -  Patient must be able to understand and willing to sign a written informed consent document.
  EXCLUSION CRITERIA:
  -  Malignant ascites that is clinically detectable by physical examination or is symptomatic. Evidence of radiographic ascites that is not clinically significant will not be an exclusion criterion.
  -  Any prior Grade greater than or equal to 3 irAE while receiving immunotherapy, including anti-CTLA4 treatment, or any unresolved irAE > Grade 1. Note: Active or history of vitiligo will not be a basis for exclusion.
  -  Patients must not have had standard of care chemotherapy, radiotherapy, or major surgery within the last 2 weeks prior to entering the study. Note: Local surgeries for isolated lesions for palliative intent are acceptable. For recent experimental therapies a 28 day period of time must have elapsed before commencing protocol treatment.
  -  Patients with known brain metastases will be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events.
  -  Uncontrolled intercurrent illness, including, but not limited to, ongoing or active infection, current pneumonitis, symptomatic congestive heart failure, uncontrolled hypertension, unstable angina pectoris, cardiac arrhythmia, interstitial lung disease, or psychiatric illness/social situations that would limit compliance with study requirement, substantially increase risk of incurring adverse events from MEDI4736 or tremelimumab, or compromise the ability of the subject to give written informed consent.
  -  Active or prior documented autoimmune or inflammatory disorders (including inflammatory bowel disease, diverticulitis with the exception of diverticulosis, celiac disease, irritable bowel disease; Wegner syndrome; Hashimoto syndrome; Graves disease; rheumatoid arthritis, hypophysitis, uveitis, etc.) within the past 3 years prior to the start of treatment. The following are exceptions to this criterion:
  -  Subjects with vitiligo or alopecia
  -  Requirement for intermittent use of bronchodilators or local steroid injections
  -  Subjects with hypothyroidism (eg, following Hashimoto syndrome) stable on hormone replacement, or psoriasis not requiring systemic treatment
  -  History of primary immunodeficiency or history of active tuberculosis. Note: Latent tuberculosis will not be a basis for exclusion.
  -  Diverticulitis (either active or history of) within the past 2 years. Note that diverticulosis is permitted.
  -  Dementia or significantly altered mental status that would prohibit the understanding or rendering of Information and Consent and compliance with the requirements of the protocol.
  -  True positive test results for hepatitis A (IgM positive). Subjects with a history of hepatitis A with IgG blood test are not excluded. True positive test results hepatitis B, or C infection.
  -  Active or history of inflammatory bowel disease (colitis, Crohn s), irritable bowel disease, celiac disease, or other serious, chronic, gastrointestinal conditions associated with diarrhea. Active or history of systemic lupus erythematosus or Wegener s granulomatosis.
  -  Current or prior use of immunosuppressive medication within 14 days before the first dose of MEDI4736 and tremelimumab. The following are exceptions to this criterion:
  -  Intranasal, inhaled, and topical steroids
  -  Systemic corticosteroids at physiologic doses not to exceed 10 mg/day of prednisone or equivalent
  -  Steroids as premedication for hypersensitivity reactions (eg, CT scan premedication)
  -  History of sarcoidosis syndrome.
  -  Patients should not be vaccinated with live attenuated vaccines within 1 month of starting Tremelimumab and MEDI4736 treatment. Subjects, if enrolled, should not receive live vaccine during the study and 180 days after the last dose of both drugs.
  -  HIV-positive patients receiving anti-retroviral therapy are excluded from this study due to the possibility of pharmacokinetic interactions between antiretroviral medications and Tremelimumab or MEDI4736. HIV positive patients not receiving antiretroviral therapy are excluded due to the possibility that Tremelimumab or MEDI4736 may worsen their condition and the likelihood that the underlying condition may obscure the attribution of adverse events.
  -  History of hypersensitivity reaction to human or mouse antibody products.
  -  Pregnancy and breast feeding are exclusion factors. The effects of Tremelimumab and MEDI4736 on the developing human fetus are unknown. Enrolled patients must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, the duration of study participation and 180 days (female patients) or 90 days (male patients) after the end of the treatment. In addition male patients must refrain from sperm donation for 90 days after the final dose of investigational product. Female patients must refrain from egg cell donation for 180 days after the final dose of investigational product. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.
  -  Any condition that, in the opinion of the investigator, would interfere with evaluation of the investigational product or interpretation of subject safety or study results.

Relevance to patient case: not relevant