Re-irradiation With NBTXR3 in Combination With Pembrolizumab for the Treatment of Inoperable Locoregional Recurrent Head and Neck Squamous Cell Cancer

Study Overview
=================
Brief Summary
-----------------
This phase II trial studies the effect of re-irradiation with NBTXR3 in combination with pembrolizumab in treating patients with head and neck squamous cell cancer that cannot be removed by surgery (inoperable) and has come back (recurrent). NBTXR3 is a drug that is designed to improve the effectiveness (how well something works) of radiation therapy. The drug is injected into a tumor and activated (turned on) by radiation. Stereotactic body radiation therapy uses special equipment to position a patient and deliver radiation to tumors with high precision. This method may kill tumor cells with fewer doses over a shorter period and cause less damage to normal tissue. Radiation therapy, such as intensity modulated radiation therapy or intensity modulated proton therapy, uses high energy to kill tumor cells and shrink tumors. Immunotherapy with monoclonal antibodies, such as pembrolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving NBTXR3 activated by radiation together with pembrolizumab may help to control head and neck squamous cell cancer.

Detailed Description
-----------------
PRIMARY OBJECTIVES: I. To estimate progression free survival (PFS) and early clinical benefit in patients treated with hafnium oxide-containing nanoparticles NBTXR3 (NBTXR3) activated by stereotactic body radiation therapy (SBRT) reirradiation, with concurrent pembrolizumab. II. To assess the safety profile and estimate early clinical benefit of NBXTR3 activated by dose reduction intensity modulated radiation therapy (IMRT) or intensity modulated proton therapy (IMPT) reirradiation with concurrent pembrolizumab, in subjects with locoregional recurrent head and neck squamous cell carcinoma (HNSCC) not eligible for SBRT. SECONDARY OBJECTIVES: I. To evaluate tumor response after NBTXR3 activated by SBRT reirradiation with concurrent pembrolizumab. II. To evaluate tumor response after NBTXR3 activated by dose reduction IMRT/IMPT reirradiation with concurrent pembrolizumab. III. To evaluate the safety profile of NBTXR3 activated by SBRT reirradiation with concurrent pembrolizumab. IV. To evaluate time-to-event outcomes of NBTXR3 activated by SBRT reirradiation with concurrent pembrolizumab. V. To evaluate time-to-event outcomes of NBTXR3 activated by dose reduction IMRT/IMPT reirradiation with concurrent pembrolizumab. EXPLORATORY OBJECTIVES: I. To evaluate lymphedema/fibrosis & dysphagia-related toxicities and functional outcomes of treatment with NBTXR3 activated by SBRT or IMRT or IMPT reirradiation and concurrent pembrolizumab. II. To assess functional and patient reported outcomes (PRO) of treatment with NBTXR3 activated by SBRT or IMRT or IMPT reirradiation and concurrent pembrolizumab. III. To associate radiomic measurements with outcomes of treatment with NBTXR3 activated by SBRT or IMRT or IMPT reirradiation and concurrent pembrolizumab. IV. To evaluate biomarkers of response in subjects treated with NBTXR3 activated by SBRT or IMRT or IMPT reirradiation and concurrent pembrolizumab. OUTLINE: Patients are assigned to 1 of 2 cohorts. COHORT I: Patients receive NBTXR3 intratumorally (IT) on day 1. Patients then undergo SBRT every other day (QOD) on days 15-29. Beginning the first day of radiation therapy, patients also receive pembrolizumab intravenously (IV) over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 2 years in the absence of disease progression or unacceptable toxicity. COHORT II: Patients receive NBTXR3 IT on day 1. Patients then undergo IMRT/IMPT every day (QD) on days 15-50. Beginning the first day of radiation therapy, patients also receive pembrolizumab IV over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 2 years in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for up to 5 years.

Official Title
-----------------
A Phase II Study of Reirradiation With NBTXR3 in Patients With Inoperable Locoregional Recurrent Head and Neck Squamous Cell Carcinoma

Conditions
-----------------
Recurrent Head and Neck Squamous Cell Carcinoma, Unresectable Head and Neck Squamous Cell Carcinoma

Intervention / Treatment
-----------------
* Other: Hafnium Oxide-containing Nanoparticles NBTXR3
* Procedure: Intensity-Modulated Proton Therapy
* Radiation: Intensity-Modulated Radiation Therapy
* Biological: Pembrolizumab
* Other: Quality-of-Life Assessment
* Other: Questionnaire Administration
* Radiation: Stereotactic Body Radiation Therapy


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients with biopsy proven locoregional recurrent squamous cell carcinoma of the head and neck, or second primary HNSCC Previous documented receipt of at least 30 Gy and up to 70 Gy of radiation for HNSCC with overlapping fields based on actual dose, prescription percentage 30 Gy for conventional fractionation 15 Gy for hypofractionation 10 Gy for single fraction Time interval from prior radiotherapy to NBTXR3 injection (day 1) of at least 6 months Not eligible (unresectable) or poor candidate or patient refusal of surgery for HNSCC recurrence Amenable to undergo the image guided intratumoral/intranodal injection of NBTXR3 by Interventional Radiologist or ear, nose, and throat (ENT) surgeon, as per investigator or treating physician The target lesion(s) in the head and neck should be measurable as per Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1 on cross sectional imaging and repeated measurements at the same anatomical location should be achievable Up to 3 target lesions may be injected with NBTXR3 and radiated, including the primary tumor and involved lymph node(s) SBRT cohort: =< 60 cm^3 per site, total volume =< 120 cm^3 IMRT/IMPT cohort: =< 120 cm^3 per site, total volume =< 200 cm^3 Nodal target lesions must be >= 15mm (short axis) based on computed tomography (CT) (slice thickness of 5 mm or less) or magnetic resonance imaging (MRI) Age >= 18 years Eastern Cooperative Oncology Group (ECOG) performance status 0-2 Hemoglobin >= 9.0 g/dL Absolute neutrophil count (ANC) >= 1,000/mm^3 Platelet count >= 100,000/mm^3 Leukocytes >= 1500/mm^3 Creatinine =< 1.5 x upper limit of normal (ULN) Calculated (Calc.) creatinine clearance > 30 mL/min Total bilirubin =< 1.5 mg/dL Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 2.5 x upper limit of normal (ULN) Serum albumin > 3.5 g/L Negative urine or serum pregnancy test =< 7 days prior to NBTXR3 injection in all women of child-bearing potential (WOCBP). WOCBP must agree to follow instructions for method(s) of contraception for the duration the entire study period and 6 months after the last dose of pembrolizumab treatment. Local laws and regulations may require use of alternative and/or additional contraception methods. WOCBP who are continuously not heterosexually active are exempt from contraceptive requirements but should still undergo pregnancy testing Signed informed consent form (ICF) indicating that participant understands the purpose of, and procedures required for, the study and is willing to participate in the study Exclusion Criteria: Locoregional relapse with skin ulceration Head and neck carcinoma with radiographic evidence of metastasis at screening Surgery to the head and neck Excluding diagnostic biopsy History of severe immune-related adverse events observed with previous immunotherapy (anti-PD-1/L1) or known sensitivity (grade >= 3) to any excipients Has received any approved or investigational anti-neoplastic agent within 4 weeks prior to NBTXR3 injection Except anti-PD-1 therapy, which will not require a washout window Note: a reduced washout window may be considered for therapies with short half-lives (i.e., kinase inhibitors) after discussion with Nanobiotix and investigator Active autoimmune disease that has required systemic treatment in the past 2 years (i.e., with use of disease-modifying agents, corticosteroids, or immunosuppressive drugs) Replacement therapy (i.e., thyroxine, insulin, or physiologic corticosteroid replacement [=< 10 mg prednisone] therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment Has not recovered from adverse events (AEs) due to previous anti-neoplastic or immune-oncology therapy and/or interventions (including radiation) to =< grade 1 Participants with alopecia and =< grade 2 neuropathy may be eligible Any live-virus vaccine therapy used for prevention of infectious diseases administered within 4 weeks prior to NBTXR3 injection Except killed-virus Influenza vaccine Exception of other vaccines (e.g. pneumonia) is at the discretion of the treating physician after conducting a personalized risk assessment on a case by case basis Prior allogenic stem cell transplantation or organ allograft Known contraindication to iodine-based or gadolinium-based IV contrast Active malignancy, in addition to head and neck carcinoma, with the exception of basal cell carcinoma of the skin definitively treated and relapse free within at least 1 year since diagnosis or low risk prostate cancer Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, renal failure, cardiac arrhythmia, or psychiatric illness that would limit compliance with treatment Known active, uncontrolled (high viral load) human immunodeficiency virus (HIV) or hepatitis B or hepatitis C infection Female patients who are pregnant or breastfeeding Women of child-bearing potential and their male partners who are unwilling or unable to use an acceptable method of birth control to avoid pregnancy for the entire study period and up to 6 months, for females, and 220 days for males after the last dose of pembrolizumab Acceptable methods of contraception are those that, alone or in combination, result in a failure rate of < 1% per year when used consistently and correctly Any condition for which, in the opinion of the investigator, participation would not be in the best interest of the participant (e.g., compromise the well-being) or that could prevent, limit, or confound the protocol-specified assessments

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cohort I (NBTXR3, SBRT, pembrolizumab)<br>Patients receive NBTXR3 IT on day 1. Patients then undergo SBRT QOD on days 15-29. Beginning the first day of radiation therapy, patients also receive pembrolizumab IV over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 2 years in the absence of disease progression or unacceptable toxicity. | Other: Hafnium Oxide-containing Nanoparticles NBTXR3<br>* Given IT<br>* Other names: NBTXR3;Biological: Pembrolizumab<br>* Given IV<br>* Other names: SCH 900475;Other: Quality-of-Life Assessment<br>* Ancillary studies<br>* Other names: Quality of Life Assessment;Other: Questionnaire Administration<br>* Ancillary studies<br>Radiation: Stereotactic Body Radiation Therapy<br>* Undergo SBRT<br>* Other names: Stereotactic Ablative Body Radiation Therapy;|
| Experimental: Cohort II (NBTXR3, IMRT/IMPT, pembrolizumab)<br>Patients receive NBTXR3 IT on day 1. Patients then undergo IMRT/IMPT QD on days 15-50. Beginning the first day of radiation therapy, patients also receive pembrolizumab IV over 30 minutes on day 1. Cycles repeat every 3 weeks for up to 2 years in the absence of disease progression or unacceptable toxicity. | Other: Hafnium Oxide-containing Nanoparticles NBTXR3<br>* Given IT<br>* Other names: NBTXR3;Procedure: Intensity-Modulated Proton Therapy<br>* Undergo IMPT<br>* Other names: IMPT;Radiation: Intensity-Modulated Radiation Therapy<br>* Undergo IMRT<br>* Other names: Radiation, Intensity-Modulated Radiotherapy;Biological: Pembrolizumab<br>* Given IV<br>* Other names: SCH 900475;Other: Quality-of-Life Assessment<br>* Ancillary studies<br>* Other names: Quality of Life Assessment;Other: Questionnaire Administration<br>* Ancillary studies<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression free survival (PFS) | Will be estimated using the method of Kaplan-Meier. Median times and 95% confidence intervals will also be estimated. | From NBTXR3 injection to local or regional recurrence, local or regional progression, distant (outside the head and neck region) progression, or death from any cause, whichever occurs first, assessed up to 5 years | 
| Early clinical benefit activated by SBRT reirradiation | Defined as radiographic evidence of complete response (CR), partial response (PR) or stable disease (SD) | At 6-months post radiation therapy (RT) | 
| Incidence of acute adverse events activated by dose reduction IMRT or IMPT reirradiation | Will assess treatment related acute and late onset toxicities defined as any grade >= 3 adverse event (AE), excluding dermatitis and mucositis as per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (v) 5.0. | Up to 90 days post RT | 
| Incidence of late adverse events activated by dose reduction IMRT or IMPT reirradiation | Will assess treatment related acute and late onset toxicities defined as any grade >= 3 AE, excluding dermatitis and mucositis as per NCI CTCAE v 5.0. | From 90 days post RT to end of study (up to 5 years) From 90 days post RT to end of study (up to 5 years) | 
| Incidence of late adverse events activated by SBRT reirradiation | Will assess treatment related acute and late onset toxicities defined as any grade >= 3 AE, excluding dermatitis and mucositis as per NCI CTCAE v 5.0. | From 90 days post RT to end of study (up to 5 years) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Objective response rate | Defined as complete or partial response per RECIST v1.1 in the target lesion(s), which are those injected with NBTXR3 and irradiated. All other malignant lesions that have not received NBTXR3 injection will be evaluated as per RECIST v1.1, i.e. as measurable or non-measurable lesions (according to their characteristics) and included for the determination of best objective response. | Up to 5 years post treatment | 
| Overall response | Evaluated as per RECIST v1.1 | Up to 5 years post treatment | 
| Incidence of acute adverse events activated by SBRT reirradiation | Will assess treatment related acute and late onset toxicities defined as any grade >= 3 AE, excluding dermatitis and mucositis as per NCI CTCAE v 5.0. | Up to 90 days post RT | 
| Local PFS | Will be estimated using the method of Kaplan-Meier. Median times and 95% confidence intervals will also be estimated. | From NBTXR3 injection to the radiographic and/or histological confirmation of local (within 2 cm of the high-dose reirradiation treatment volume [PTV]) disease recurrence, local progression, or death from any cause, assessed up to 5 years | 
| Regional PFS | Will be estimated using the method of Kaplan-Meier. Median times and 95% confidence intervals will also be estimated. | From NBTXR3 injection to the radiographic and/or histological confirmation of regional disease recurrence, regional progression, or death from any cause, whichever occurs first, assessed up to 5 years | 
| Distant PFS | Will be estimated using the method of Kaplan-Meier. Median times and 95% confidence intervals will also be estimated. | From NBTXR3 injection to the radiographic and/or histological confirmation of a new lesion outside the head and neck region, or death from any cause, whichever occurs first, assessed up to 5 years | 
| Overall survival | Will be estimated using the method of Kaplan-Meier. Median times and 95% confidence intervals will also be estimated. | From NBTXR3 injection to death from any cause or EoS, whichever occurs first, assessed up to 5 years |