Clinical Study of Camrelizumab Combined With APatinib and Albumin Paclitacxel in Patients With Advanced Lung Adenocarcinoma

This study is a single arm, open label, national multicenter study, to explore the efficacy and safety of the combination of Camrelizumab, apatinib and albumin paclitaxel in advanced untreated EGFR Wild Type and ALK-negative Lung Adenocarcinoma. The study does not consider PD-L1 expression, but tumor samples need to be explored by PD-L1 detection and other exploratory analysis.

Primary outcome:

1. progression free survival (PFS) evaluated according to RECIST1.1.

Secondary outcome:

1. Objective Response Rate (ORR), Overall Survival (OS), Disease Control Rate (DCR), Duration of Response (DOR) evaluated according to RECIST1.1, and Quality of Life(QOL).
2. The overall incidence of adverse events (AE); the incidence of grade 3 or above AE; the incidence of serious adverse events (SAE); the incidence of AE leading to the termination of the trial drug; the incidence of AE leading to the suspension of the trial drug.
3. Exploratory analysis of potential biomarkers related to efficacy. The characteristics of tumor tissue PD-L1expression, panel-captured next generation sequencing(NGS), RNA-seq, T-Cell Repertoire (TCR), multiple immunofluorescence and other biomarkers, and the correlation analysis of biomarkers with efficacy and safety.

Eligibility Criteria:
Inclusion Criteria:

* 1. Age\>=18 years, both men and women can be enrolled 2. Histologically confirmed adenocarcinoma (does not contain small cell components).

  3. Locally advanced, untreated recurrent or metastatic lung adenocarcinoma not suitable for radical surgery or radiotherapy. Previous neoadjuvant and adjuvant radiochemotherapy can be accepted (chemotherapy/radiotherapy, non-immunotherapy), tumor progression ≥6 months before the end of neoadjuvant / adjuvant therapy is required .

  4. ECOG score of physical condition was 0-1, and there was no deterioration in the first 2 weeks. Expected survival over 12 weeks.

  5. According to the RECIST1.1 criteria, it is required that at least one measurable treatment naive lesion (has not been treated with radiotherapy in the past and will not receive local therapy such as radiotherapy throughout the treatment); If the lesion has been treated with radiotherapy then the progress of this lesion need to be confirmed by imaging, before being used as the target lesion.

  6. Laboratory certified by CAP reported negative in EGFR and ALK mutation-sensitive mutations.

  7. Clinical laboratory examination indicators meet the following standards:
  1. Platelet ≥100×109/L
  2. Absolute neutrophil count (ANC) ≥1.5×109/L, or absolute white blood cell count (WBC) ≥3.5×109/L
  3. Hemoglobin (Hgb) ≥ 100 g/L (without blood transfusion or erythropoietin use within 4 weeks)
  4. Total bilirubin ≤ 1.5 times the upper limit of normal value (ULN) (If there is liver metastasis, allow ≤2.5 times ULN)
  5. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5 times ULN
  6. Creatinine ≤1.5 times ULN or Creatinine clearance ≥50 mL/min (Calculated according to the Cockcroft Gault formula)
  7. Serum amylase ≤ 2 times ULN or pancreatic amylase ≤ 1.5 times ULN
  8. Serum lipase ≤ 1.5 times ULN
  9. patients who did not take anticoagulants, or those who had previously used anticoagulants, had been discontinued for 28 days before enrollment, and the international normalized ratio (INR) ≤ 1.5 and activated partial thromboplastin time (APTT) ≤ 1.5 times ULN.

     8. Able to swallow oral medication. 9. Enough tissue specimens for PD-L1 detection or exploratory analysis.

     Exclusion Criteria:
* 1.The histological component of NSCLC containing small cell lung cancer or squamous cell carcinoma was excluded.

  2. Previously untreated or symptomatic central nervous system (CNS) metastases or meningeal diseases, spinal cord compression, meningeal metastases and brain metastases with obvious symptoms, etc. For those who have received radiotherapy and/or surgery, patients with no evidence of CNS disease progression ≥ 2 weeks after the end of treatment, patients who had not been treated with corticosteroids for more than 2 weeks before the start of treatment were eligible.

  3. Clinically significant hemoptysis (at least 0.5 teaspoons of fresh blood) or tumor bleeding occurred within 2 weeks before the first dose of study treatment.

  4. There is imaging evidence of invasion/infiltration of large vessels. Due to the potential risk of severe bleeding associated with tumor shrinkage/necrosis after apatinib treatment, the degree of tumor invasion/infiltration of major blood vessels should be considered.

  5. Cancerous thrombus with clinical significance, and the use of anticoagulant drugs within 28 days before enrollment.

  6. Clinically uncontrollable pleural effusion/abdominal effusion. 7. Glucocorticoid treatment 28 days before the first dose (equivalent dose of \>10 mg prednisone per day).

  8. Having active autoimmune diseases, which require systemic treatment in the past 2 years (ie using disease-modifying drugs, corticosteroids or immunosuppressive drugs). Replacement therapy (for example, thyroxine, insulin, or physiological corticosteroid replacement therapy due to adrenal or pituitary insufficiency, etc.) is not considered as systemic therapy and is allowed.

  9. History of other malignant tumors in the past 5 years. 10. Has received previous systemic chemotherapy or other targeted or biological anti-tumor treatment for its metastatic NSCLC (As long as treatment is completed at least 6 months before diagnosis of metastatic NSCLC, prior chemotherapy and/or radiotherapy is allowed as part of neoadjuvant/adjuvant therapy for non-metastatic NSCLC).

  11. Previously received anti-PD-1, anti-PD-L1, anti-PD-L2 and other drugs or drugs acting on another stimulatory or co-suppressive T cell receptor (eg CTLA-4, OX 40, CD137 ) therapy, or cell biological therapy, etc.

  12. Previously received treatment with apatinib, or received systemic medication with a clear anti-tumor mechanism.

  13. Allogeneic tissue/solid organ transplantation has been performed. 14. In addition to hair loss and stable peripheral neurotoxicity below grade 2, any clinical toxicity associated with prior treatment before enrollment did not return to pre-treatment levels or grade 1.

  15. pregnancy status (positive blood HCG) and lactation. 16. Previously suffering from interstitial lung disease, drug-induced interstitial lung disease, radiation pneumonitis requiring hormone therapy, or any active interstitial lung disease with clinical evidence.

  17. Known liver diseases of clinical significance, including active viral hepatitis, alcoholic hepatitis or other hepatitis, liver cirrhosis, hereditary liver disease.( patients who have been cured of previous HBV infection (defined as hepatitis B core antibody \[HBcAb\] positive and HBsAg negative) can participate in this study. Before entering the group, HBV DNA testing must be performed on this class of patients and well-controlled hepatitis B (peripheral HBV DNA testing is less than 103/ml) can be considered for this experiment, and antiviral treatment should be given. Previous patients infected with hepatitis C virus (HCV) had positive HCV antibody test results, They were eligible for this study only if the HCV RNA polymerase chain reaction test result was negative (below the detection limit).) 18. Patients who are suspected or have demonstrated an impaired immune function or infection, including:
  * Evidence that active or latent tuberculosis (TB) is determined by locally approved screening methods. If the screening results require treatment in accordance with local treatment guidelines or clinical practice, the patient is disqualified.
  * Chronic or active hepatitis B or hepatitis C.
  * Known history of human immunodeficiency virus (HIV) infection. During the screening period, the local test result was positive.
  * There are any other medical conditions (such as active infections that have been treated or not treated) that the investigator believes that the patient has an unacceptable risk if receiving immunomodulatory therapy(Patients with local diseases that are unlikely to cause systemic infections (such as chronic nail fungal infections) are allowed to be enrolled).

    19. Allogeneic bone marrow or organ transplantation. 20. Any immunomodulator with systemic effects. 21. Known mental illness or substance abuse disorders that interfere with a subject's ability to comply with research requirements.

    22. Previous severe allergy to mAb treatment or known allergy or intolerance to any component of study medication (apatinib, caririzumab).