Atezolizumab + Stereotactic Radiation in Triple-negative Breast Cancer and Brain Metastasis
Condition: Breast Cancer
MeSH terms: Breast Neoplasms; Triple Negative Breast Neoplasms; Brain Neoplasms
Intervention: Atezolizumab; Stereotactic radiosurgery (SRS)
Intervention description: Atezolizumab is a protein that affects your immune system by blocking the PD-L1 pathway; Stereotactic radiosurgery (SRS) is a standard procedure used to treat patients with cancer in the brain. SRS uses many precisely focused radiation beams to treat tumors
Intervention MeSH terms: Atezolizumab
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 6.0
Sex: Female
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Breast Cancer

Summary:

      This research study is studying the combination of a drug called atezolizumab and a radiation
      procedure called stereotactic radiosurgery (SRS) as a possible treatment for triple-negative
      breast cancer that has spread to the brain.

      The interventions involved in this study are:

        -  Atezolizumab

        -  Stereotactic radiosurgery (SRS)
    

Eligibility criteria:

        Inclusion Criteria:

          -  Participants must have histologically or cytologically confirmed Stage IV invasive
             breast cancer. Participants without pathologic or cytologic confirmation of metastatic
             disease should have unequivocal evidence of metastasis from physical examination or
             radiologic evaluation.

          -  Either the primary tumor and/or metastatic tumor must be triple-negative as defined
             below:

               -  Hormone receptor status: the invasive tumor must be ER- and PR-negative, or
                  staining present in <1% by immunohistochemistry (IHC)

               -  HER2 status: the invasive tumor must be Human Epidermal Growth Factor Receptor 2
                  Negative (HER2-negative) by the ASCO CAP guidelines

          -  In cases where both primary tumor and metastatic sample(s) have been tested for ER,
             PR, and HER2, the triple-negative status of the most recent sample should be used.

          -  Participants must have a diagnosis of brain metastases for which SRS is indicated, as
             determined by a radiation oncologist.

          -  The contrast-enhancing intraparenchymal brain metastases(s) must be well circumscribed
             and must have a maximum diameter of ≤ 3.0 cm in any direction on the enhanced scan.

          -  Participants must not have more than 5 new or progressive lesions in the brain
             requiring SRS treatment (greater than 5 total brain lesions are allowed as long as no
             more than 5 lesions require SRS treatment).

          -  Participants must have measurable extracranial disease as defined by RECIST 1.1.

          -  Participants must be willing to undergo a research biopsy at baseline and at Cycle 2
             Day 1 if extracranial metastases are safely accessible. Participants for whom biopsies
             cannot be safely performed must be willing to submit an archival primary and/or
             metastatic specimen. The biopsies may be waived with prior PI approval for the first 6
             participants enrolled to the safety run in phase.

          -  Prior systemic therapy:

               -  Participants must have discontinued systemic therapy at least 14 days prior to
                  initiating protocol therapy.

               -  There is no limit to the number of prior lines of systemic therapy. Participants
                  who have not received any systemic therapy for metastatic disease are also
                  eligible.

               -  Participants may initiate or continue bisphosphonate therapy on study.

          -  Prior local therapy:

          -  Prior surgery, whole brain radiation or SRS is allowed as long as the most recent
             brain progression is amenable to SRS treatment.

          -  Resolution of all chemotherapy-related or radiation-related toxicities to Grade 1
             severity or lower, except for stable sensory neuropathy (≤ Grade 2 allowed) and
             alopecia (of any grade).

          -  Participant is ≥18 years old.

          -  ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A)

          -  Stable dose of dexamethasone 2mg or less for at least 7 days prior to initiation of
             treatment

          -  Participants must have normal organ and marrow function as defined below:

               -  absolute neutrophil count ≥1,000/μl

               -  platelets ≥75,000/μl

               -  hemoglobin ≥9 g/dL

               -  total bilirubin ≤1.5mg/dL (≤2.0 in patients with known Gilberts syndrome)

               -  AST(SGOT)/ALT(SGPT) ≤2.5 × institutional ULN. ≤5.0 × institutional ULN for
                  patients with documented liver metastases.

               -  albumin >2.5mg/dL

               -  serum creatinine ≤1.5mg/dL or calculated GFR ≥60 mL/min

          -  Female subjects of childbearing potential must have a negative serum or urine
             pregnancy test within 8 days of initiating protocol therapy.

          -  For women of childbearing potential: agreement to remain abstinent (refrain from
             heterosexual intercourse) or use contraceptive methods that result in a failure rate
             of < 1% per year during the treatment period and for at least 90 days after the last
             dose of study treatment. A woman is considered to be of childbearing potential if she
             is postmenarcheal, has not reached a postmenopausal state (≥ 12 continuous months of
             amenorrhea with no identified cause other than menopause), and has not undergone
             surgical sterilization (removal of ovaries and/or uterus). Examples of contraceptive
             methods with a failure rate of < 1% per year include bilateral tubal ligation, male
             sterilization, established, proper use of hormonal contraceptives that inhibit
             ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices.
             The reliability of sexual abstinence should be evaluated in relation to the duration
             of the clinical trial and the preferred and usual lifestyle of the patient. Periodic
             abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and
             withdrawal are not acceptable methods of contraception. The effects of atezolizumab on
             the developing human fetus are unknown and radiotherapy has known teratogenic effects
             so women of child-bearing potential and men must agree to use adequate contraception
             (barrier method of birth control; abstinence) prior to study entry and for the
             duration of study participation and 4 months after completion of atezolizumab
             administration.

          -  The subject is capable of understanding and complying with the protocol and has signed
             the informed consent document

        Exclusion Criteria:

          -  CNS complications for whom urgent neurosurgical intervention is indicated (e.g.,
             resection, shunt placement).

          -  Known leptomeningeal or brainstem metastases. The presence of leptomeningeal
             enhancement alone, without associated clinical manifestations and/or positive CSF
             cytology, will not be constituted as known leptomeningeal metastases.

          -  Treatment with high dose systemic corticosteroids defined as dexamethasone >2mg/day or
             bioequivalent within 7 days of initiating therapy.

          -  Patients unable to undergo gadolinium contrast-enhanced MRI or receive IV contrast for
             any reason (e.g., due to pacemaker, ferromagnetic implants, claustrophobia, extreme
             obesity, hypersensitity).

          -  Participants who are receiving any other investigational agents.

          -  Previous treatment with any anti-PD-1, PD-L1, or PD-L2 agent.

          -  Subjects with a history of hypersensitivity to compounds of similar biologic
             composition to atezolizumab or any constituent of the product

          -  The participant has an uncontrolled intercurrent illness, including, but not limited
             to uncontrolled hypertension, unstable angina pectoris, uncontrolled cardiac
             arrhythmia, congestive heart failure-New York Heart Association Class III or IV,
             active ischemic heart disease, myocardial infarction within the previous six months,
             uncontrolled diabetes mellitus, gastric or duodenal ulceration diagnosed within the
             previous 6 months, severe malnutrition or psychiatric illness/social situations that
             would limit compliance with study requirements.

          -  Participant has a medical condition that requires chronic systemic steroid therapy or
             on any other form of immunosuppressive medication. For example, patients with
             autoimmune disease that requires systemic steroids or immunosuppression agents should
             be excluded. Replacement therapy (eg., thyroxine, insulin, or physiologic
             corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is
             not considered a form of systemic treatment.

          -  Has evidence of active, noninfectious pneumonitis that requires treatment with
             steroids.

          -  Has a history of interstitial lung disease.

          -  The participant is known to be positive for the human immunodeficiency virus (HIV),
             HepBsAg, or HCV RNA. HIV-positive participants on combination antiretroviral therapy
             are ineligible because of the potential for pharmacokinetic interactions with
             atezolizumab.

          -  Individuals with a history of different malignancy are ineligible except for the
             following circumstances. Individuals with a history of other malignancies are eligible
             if they have been disease-free for at least 3 years or are deemed by the principal
             investigator to be at low risk for recurrence of that malignancy.

          -  Has received a live vaccine within 28 days of planned start of study therapy.

          -  The participant is pregnant or breast-feeding.