Durvalumab and Chemotherapy Induction Followed by Durvalumab and Radiotherapy in Large Volume Stage III NSCLC

Standard treatment for stage III Non-Small Cells Lung Cancer (NSCLC) not eligibile for surgery is concomitant chemoradiotherapy. However median progression free survival and overall survival is still poor with only 15% of patients alive at 5 years. The addition of maintenance therapy with durvalumab after chemoradiation showed a significant benefit in PFS and OS, with good tolerability and no concerns in terms of safety. However, about 30% of patients with stage III are not eligible to concurrent chemoradiotherapy because of large volumes of the tumor. To date, these patients are initially treated with chemotherapy with the aim of reducing tumor volumes and allowing sequential radiotherapy. Response rate ranges between 25-30% and majority of patients will not become suitable for radiotherapy.

The combination of immunotherapy plus standard chemotherapy in advanced stages doubles response rates and provides major tumor shrinkage compared to standard chemotherapy alone. For these reasons, the investigators want to exploit the synergistic effect of immunotherapy combined with chemotherapy in the induction phase, in order to render suitable for radiotherapy a larger number of patients, and in a second phase the synergistic effect with radiotherapy.

Based on these premises the investigators designed a single arm, phase 2 trial to determine the efficacy and safety of combining immunotherapy with the drug durvalumab in association with standard chemotherapy and subsequently with standard radiotherapy, followed by a treatment of maintenance with only durvalumab.

The study population includes patients with NSCLC not eligible for surgery or concurrent chemoradiation at diagnosis because of large tumor volumes.

BRIDGE trial aims to evaluate the proportion of patients who did not progress and who achieved a mean lung dose \<20 Gy and/or a lung V20\<35% (response) after part 1. The primary objective of the study is to increase the proportion of patients eligible for immunotherapy plus radiotherapy after induction with durvalumab and chemotherapy, in comparison with historical controls.

This study will last approximately 60 months and will include approximately 65 eligible patients in 3 international cancer centres of excellence.

Standard treatment for stage III Non-Small Cells Lung Cancer (NSCLC) not eligibile for surgery is concomitant chemoradiotherapy. However median progression free survival and overall survival is still poor with only 15% of patients alive at 5 years. The addition of maintenance therapy with durvalumab after chemoradiation showed a significant benefit in PFS and OS, with good tolerability and no concerns in terms of safety. However, about 30% of patients with stage III are not eligible to concurrent chemoradiotherapy because of large volumes of the tumor. To date, these patients are initially treated with chemotherapy with the aim of reducing tumor volumes and allowing sequential radiotherapy. Response rate ranges between 25-30% and majority of patients will not become suitable for radiotherapy.

The combination of immunotherapy plus standard chemotherapy in advanced stages doubles response rates and provides major tumor shrinkage compared to standard chemotherapy alone. For these reasons, the investigators want to exploit the synergistic effect of immunotherapy combined with chemotherapy in the induction phase, in order to render suitable for radiotherapy a larger number of patients, and in a second phase the synergistic effect with radiotherapy.

Based on these premises the investigators designed a single arm, phase 2 trial to determine the efficacy and safety of combining immunotherapy with the drug durvalumab in association with standard chemotherapy and subsequently with standard radiotherapy, followed by a treatment of maintenance with only durvalumab.

The study population includes patients with NSCLC not eligible for surgery or concurrent chemoradiation at diagnosis because of large tumor volumes.

The study consists of 3 parts:

* Part 1: induction with durvalumab plus chemotherapy.
* Part 2: patients with a sufficient tumor shrinkage to be considered eligible for part 2 and they will be treated concomitantly with durvalumab and radiotherapy.
* Part 3: patients with partial response or stable disease after part 2 will be eligible for durvalumab maintenance, for up to 2 years or until disease progression or unacceptable toxicity.

BRIDGE trial aims to evaluate the proportion of patients who did not progress and who achieved a mean lung dose \<20 Gy and/or a lung V20\<35% (response) after part 1. The primary objective of the study is to increase the proportion of patients eligible for immunotherapy plus radiotherapy after induction with durvalumab and chemotherapy, in comparison with historical controls.

This study will last approximately 60 months and will include approximately 65 eligible patients in 3 international cancer centres of excellence.

Eligibility Criteria:
Inclusion Criteria

FOR PART 1 (INDUCTION CHEMOTHERAPY IN ASSOCIATION WITH DURVALUMAB):

1. Capable of giving signed informed consentwhich includes compliance with the requirements and restrictions listed in the informed consent form (ICF) and in this protocol. Written informed consent and any locally required authorization (eg, European Union \[EU\] Data Privacy Directive in the EU) obtained from the patient/legal representative prior to performing any protocol-related procedures, including screening evaluations.
2. Age \> 18 years at time of study entry
3. Histologically- or cytologically-documented NSCLC, in locally advanced (Stage III-v.8 IASLC)
4. Eligible for platinum-based chemotherapy (platinum - pemetrexed for non-squamous and platinum-vinorelbine for squamous histology)
5. Patients not eligible for surgery and chemoradiation for Dosimetry not meeting the following constraints to organs at risk (Kong 2011, Marks 2010, De Ruysscher 2017, Marks 2010, Gagliardi 2010, Wang 2017, Antonia 2017, Kirkpatrick 2010):

   * Total mean lung dose (Right Lung+Left Lung-GTV) \< 20 Gy and/or
   * Lung V20 defined as percentage of normal parenchyma receiving 20 Gy or more (Right Lung+Left Lung-PTV) \< 35%
   * Heart V45 \<30% and/or Mean Heart Dose \<20 Gy

   If the dosimetry criteria are met, other clinical conditions for avoiding concurrent chemoradiation are:
   * Bilateral supraclavicular involvement
   * Contralateral mediastinal and/or hilar involvement
   * Primary tumor \> 7 cm or several nodules in different lobes of the same lung or bulky mediastinal lymphonodes.

   Each patient will be discussed in a web multidisciplinary team among all the three involved Cancer Core Europe \[CCE\] centers. If dosimetry criteria are met, patient not eligible for surgery and chemoradiation due to other clinical condition(s) will be specifically defined and confirmed by at least 2 out of 3 CCE
6. Tumor sample requirements: availability of an archived tumour tissue block (or unstained slides to perform local PDL1 assessment following protocol procedure)
7. Patient's willingness to undergo blood draws to provide plasma and blood samples for analysis according to study objectives
8. Patients without history of previous radiotherapy. Patients with previous radiotherapy performed to the thorax, including radiotherapy for breast cancer, especially in the last 10 years, have to be discussed case by case in the Multidisciplinary Team Meeting
9. Life expectancy ≥12 weeks at the start of treatment
10. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
11. Evidence of post-menopausal status or negative urinary or serum pregnancy test for female pre-menopausal patients. Women will be considered post-menopausal if they have been amenorrheic for 12 months without an alternative medical cause. The following age-specific requirements apply:

    1. Women \<50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of exogenous hormonal treatments and if they have luteinizing hormone and follicle- stimulating hormone levels in the post-menopausal range for the institution or underwent surgical sterilization (bilateral oophorectomy or hysterectomy).
    2. Women ≥50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments, had radiation-induced menopause with last menses \>1 year ago, had chemotherapy-induced menopause with last menses \>1 year ago, or underwent surgical sterilization (bilateral oophorectomy, bilateral salpingectomy or hysterectomy).
12. Patient willing and able to comply with the protocol for the duration of the study including undergoing treatment and scheduled visits and examinations including follow up.
13. Adequate normal organ and marrow function as defined below:

    * Haemoglobin ≥9.0 g/dL (5.59 mmol/L)
    * Absolute neutrophil count (ANC) \> 1.5 x 109/L (\> 1500/mm3)
    * Platelet count ≥100 x 109/L (100000/mm3)
    * Serum bilirubin ≤1.5 x institutional upper limit of normal (ULN). This will not apply to patients with confirmed Gilbert's syndrome (persistent or recurrent hyperbilirubinemia that is predominantly unconjugated in the absence of hemolysis or hepatic pathology), who will be allowed only in consultation with their physician.
    * AST (SGOT)/ALT (SGPT) ≤2.5 x institutional upper limit of normal
    * Adequate renal function defined as normal serum creatinine levels or calculated creatinine clearance (according to Cockroft-Gault or by 24 hour-urine collection): ≥60 ml/min for patient receiving cisplatin ≥45 ml/min for patient receiving carboplatin.
14. Body weight \> 30 Kg
15. Absence of a known severe hypersensitivity (≥ Grade 3) to any of the study chemotherapy agents and/or to durvalumab and/or to any of their excipients.

FOR PART 2 (RADIOTHERAPY CONCURRENTLY WITH DURVALUMAB):

1. Absence of progressive disease by RECIST 1.1 together with evidence of tumor shrinkage at the evaluation conducted at the end of part 1. Whether the degree of tumor shrinkage will be sufficient to consider the patient eligible for part 2 will be discussed in a web multidisciplinary team among involved CCE centers.
2. ECOG Performance Status of 0 - 1
3. Absence of dyspnea of minimal exertion or oxygen requirement after CT+D
4. Sufficient PFTs performed after the last cycle of CT+D:

   * FEV1 \> 1L or ≥ 30%
   * DLCO \> 30%
5. The patient's dosimetry must meet the following constraints to organs at risk (Kong 2011, Marks 2010, De Ruysscher 2017, Marks 2010, Gagliardi 2010, Wang 2017, Antonia 2017, Kirkpatrick 2010):

   * Spinal cord maximum dose \< 50 Gy
   * Total mean lung dose (Right Lung+Left Lung-GTV) \< 20 Gyand/or
   * Lung V20 defined as percentage of normal parenchyma receiving 20 Gy or more (Right Lung+Left Lung-PTV) \< 35%
   * Heart V45 \<30% and/or Mean Heart Dose \<20 Gy
6. In case of dosimetry criteria met before part 1, confirmed resolution of clinical condition(s) that led to initial inegibility. The resolution of the clinical condition is discussed in the multidisciplinary team, at least 2 out of 3 CCE must agree.

FOR PART 3 (MAINTENANCE WITH DURVALUMAB):

1. Evidence of partial response or stable disease at the evaluation conducted at the end of Part 2
2. Absence of grade 2-3 pneumonitis

Exclusion Criteria:

1. Stage IV NSCLC
2. Patient amenable to curative intent surgery or concurrent chemoradiation
3. Mixed small cell and non-small cell lung cancer histology
4. Patients who already received therapy for locally advanced NSCLC
5. Dyspnea of minimal exertion or oxygen requirement
6. Recent medical history of cardiac events during the last 6 months (ischemic or congestive heart failure)
7. Pancoast tumors
8. Prior exposure to any anti-PD-1 or anti-PD-L1 antibody, including durvalumab
9. Participation in another clinical study with an investigational product during the last 4 weeks, unless it is an observational (non-interventional) clinical study or during the follow-up period of an interventional study
10. Any concurrent chemotherapy, immunotherapy, biologic, or hormonal therapy for cancer treatment. Concurrent use of hormonal therapy for non-cancer-related conditions (e.g., hormone replacement therapy) is acceptable.
11. Active or prior documented autoimmune disease within the past 2 years or inflammatory disorders (including inflammatory bowel disease \[e.g., colitis or Crohn's disease\], diverticulitis \[with the exception of diverticulosis\], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome \[granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc\]). The following are exceptions to this criterion:

    1. Patients with vitiligo or alopecia
    2. Patients with Grave's disease not requiring systemic treatment within the past 2 years
    3. Patients with hypothyroidism (e.g., following Hashimoto syndrome) stable on hormone replacement
    4. Any chronic skin condition that does not require systemic therapy (e.g. patients with psoriasis not requiring systemic treatment within the past 2 years)
    5. Patients without active disease in the last 2 years may be included but only after consultation with the study physician
    6. Patients with celiac disease controlled by diet alone
12. Uncontrolled intercurrent illness including, but not limited to, symptomatic congestive heart failure, uncontrolled hypertension, unstable angina pectoris, cardiac arrhythmia, active peptic ulcer disease or gastritis, active bleeding diatheses, ongoing or active infection, including any patient known to have evidence of acute or chronic hepatitis B (positive HBV surface antigen (HBsAg) result), hepatitis C, human immunodeficiency virus (HIV) (positive HIV 1/2 antibodies) or tuberculosis (clinical evaluation that includes clinical history, physical examination and radiographic findings, and TB testing in line with local practice), psychiatric illness/social situations that would limit compliance with study requirements or compromise the ability of the patient to give written informed consent. \[Patients with a past or resolved HBV infection (defined as the presence of hepatitis B core antibody \[anti-HBc\] and absence of HBsAg) are eligible. Patients positive for hepatitis C (HCV) antibody are eligible only if polymerase chain reaction is negative for HCV RNA.\]
13. History of another primary malignancy except for

    1. Malignancy treated with curative intent and with no known active disease ≥3 years before the first dose of study drug and of low potential risk for recurrence
    2. Adequately treated non-melanoma skin cancer or lentigo maligna without evidence of disease
    3. Adequately treated carcinoma in situ without evidence of disease, e.g. cervical cancer in situ
    4. Superficial bladder cancer without evidence of disease
14. Female patients who are pregnant or breastfeeding or male or female patients of reproductive potential who are not willing to employ effective birth control from screening to 90 days after the last dose of durvalumab monotherapy
15. Any unresolved toxicity NCI CTCAE Grade ≥2 from previous anticancer therapy with the exception of alopecia, vitiligo, and the laboratory values defined in the inclusion criteria

    1. Patients with Grade ≥2 neuropathy will be evaluated on a case-by-case basis after consultation with the Study Physician.
    2. Patients with irreversible toxicity not reasonably expected to be exacerbated by treatment with durvalumab may be included only after consultation with the Study Physician.
16. Major surgical procedure (as defined by the Investigator) within 28 days prior to the first dose of investigational product.
17. History of allogenic organ transplantation.
18. Mean QT interval corrected for heart rate using Fridericia's formula (QTcF) ≥470 ms
19. History of active primary immunodeficiency
20. Current or prior use of immunosuppressive medication within 14 days before the first dose of durvalumab. The following are exceptions to this criterion:

    1. Intranasal, inhaled, topical steroids, or local steroid injections (e.g., intra articular injection)
    2. Systemic corticosteroids at physiologic doses not to exceed 10 mg daily of prednisone or its equivalent
    3. Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication) Systemic steroid administration required as prophylaxis against or to manage toxicities arising from chemotherapy and/or radiotherapy delivered as part of therapy for locally advanced NSCLC is allowed
21. Receipt of live attenuated vaccine within 30 days prior to the first dose of IP. Note: Patients, if enrolled, should not receive live vaccine whilst receiving IP and up to 30 days after the last dose of IP.
22. Known allergy or hypersensitivity to any of the study drugs or any of the study drug excipients.
23. Judgment by the investigator that the patient is unsuitable to participate in the study and the patient is unlikely to comply with study procedures, restrictions and requirements.