Accelerated Radio-Immunotherapy for Lung Cancer (AIRING)

A Phase II Trial Evaluating Conformational Intensity Modulated Radiotherapy With Concomitant Nivolumab Followed by Nivolumab for Patients With Locally Advanced Non-small Cell Lung Cancer

Radiotherapy (RT), at a total dose of 60-66 Gy over 6 weeks, combined with platinum-based chemotherapy, is the standard of care for stage III Non-Small Cell Lung Cancers (NSCLC) patients with unresectable or inoperable disease. However, the long-term outcomes are poor, with a 5-year overall survival (OS) rate of 15-35% for stage IIIA, and 5-10% for stage IIIB patients. The recent association of immunotherapy has been proven to improve Progression Free Survival (PFS) and OS for these patients and durvalumab consolidation following chemoradiotherapy (CT-RT) is now the new standard of care.

Compared to older technics (2Dimensions(D) and 3D-RT), intensity-modulated radiotherapy (IMRT) allows for improved organs-at-risk sparing, owing to the high dose conformation to the target volume, thus reducing toxicity rates.

In regard to the recent results of adjuvant immunotherapy, the benefits of concomitant chemotherapy with radiotherapy could be re-evaluated. With the changing landscape in the standard treatment of Local Advanced NSCLC (LA-NSCLC), the reduction in treatment-induced toxicity, while maintaining optimal tumor control, has become a priority, thereby warranting access to adjuvant immunotherapy for these patients. Due to the toxicity of the chemoradiotherapy, a large subset of patients may be unfit for the adjuvant immunotherapy. The use of immunotherapy concomitant to radiotherapy without chemotherapy may be the next step. Nevertheless, as immune cells are highly sensitive to conventional RT doses, the paradigm of the standard irradiation volumes should be reconsidered. In this context, the introduction of IMRT to spare lymphatic tissues and bone marrow deserves evaluation in prospective trials.

A strong body of evidence supports the combination of RT with immunotherapy such as a Programmed cells Death-1 (PD1) inhibitor. Radiation alone can modify the immune response in several ways to allow for synergistic effects when combined with immunotherapy.

The reduction in treatment-induced toxicity while maintaining optimal tumor control has become a priority, thereby warranting access to adjuvant immunotherapy for these patients. In this context, the introduction of IMRT to spare lymphatic tissues and bone marrow deserves evaluation in prospective trials.

The timing of administration of immunotherapy seems to be a major point. Previous data in mice showed that an improved survival benefit with concurrent anti-PD-Ligand1 (PD-L1) and RT versus sequential administration. Moreover, for sequential schedule, an improved survival outcome was found for patients receiving first dose of durvalumab within 14 days of last radiotherapy fraction compared to 14 days or greater.

Furthermore, immunotherapy combined with radiotherapy appears to be safe, without increase of the toxicity.

In summary, there is a strong rationale for testing this new paradigm of accelerated IMRT combined with concurrent and maintenance nivolumab for locally advanced non-small lung cancer, due to:

• The unmet medical need for new Standard Of Care (SOC) better tolerated and " as " or " more " effective treatment than CT-RT
• The need to decrease radiation-induced toxicity
• The limit of CT-RT followed by durvalumab consolidation, leading to a high rate of recurrence within the 18 months (18-month PFS rate of 44.2%)
• The strong rationale to combine RT and PD-1 inhibition

It is hypothesized this innovative concept to be safe in the context of this study for the following reasons:

• The use of moderate accelerated intensity-modulated radiotherapy (H-IMRT) allows decreasing both the Overall Treatment Time (OTT) and the dose to the organs at risk
• The decrease of the OTT (24 fractions instead of 33 fractions) combined with a decrease of the toxicity should represent a potential clinical benefit.

Study Overview

• Status: Completed
• Conditions: Non Small Cell Lung Cancer Stage III
• Intervention / Treatment: Combination product: Nivolumab and Intensity Modulated Radiotherapy (IMRT)

• Study Type: Interventional
• Enrollment (Actual): 8
• Phase: Phase 2

Contacts and Locations

Study Locations

• France
  • Brest, France
    • Centre Hospitalier de Brest
  • Caen, France, 14076
    • Centre de Lutte Contre le Cancer François Baclesse
  • Lille, France
    • Centre de Lutte contre le Cancer Oscar Lambret
  • Rennes, France, 35042
    • Valérie JOLAINE
  • Saint-Herblain, France, 44805
    • Institut de Cancérologie de l'Ouest

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Stage III non-small lung cancer;

• Patient with at least one of these fragility criteria:

  • Status ECOG 1 with multiple comorbidities, at least 2 pathologies with grade ≥ 2 (renal and/or cardiac and/or vascular and/or hepatic, and/or neurologic, and/or pulmonary)
  • Status ECOG = 2
  • Age > 74 years
  • Age ≥ 70, unfit to receive chemotherapy
• Eligible to radiotherapy, defined by multidisciplinary tumor board;
• Performance Status Eastern Cooperative Oncology Group (ECOG) 0-2;
• Age ≥ 18 years;
• Metastasis (M)0 based on clinical, Magnetic Resonance Imaging (MRI) of brain and FluoroDeoxyGlucose (FDG)/ Positron Emission Tomography (PET)- computerized tomography (CT) examinations;
• Written informed consent

Exclusion Criteria:

• Patients eligible to surgery
• Any prior or current treatment for invasive lung cancer
• History of other malignancy within the last 3 years (exception of in situ carcinoma, skin carcinomas, localized prostate carcinoma Gleason 6 and in situ breast carcinoma)
• Significant disease which, in the judgment of the investigator, as a result of the medical interview, physical examinations, or screening investigations would make the patient inappropriate for entry into the trial
• Known hypersensitivity reaction to nivolumab
• Prior organ transplantation including allogenic stem-cell transplantation
• Any social, personal, medical and/or psychologic factor(s) that could interfere with the observance of the patient to the protocol and/or the follow-up and/or the signature of the informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Nivolumab and accelerated IMRT

Combination product: Nivolumab and Intensity Modulated Radiotherapy (IMRT); Every included patient will receive the experimental treatment regimen as follows: Combination of IMRT 66 Gray (Gy)/24 fractions of 2.75 Gy) and immunotherapy with 3 doses of nivolumab, 240 mg (1th, 3th and 5th week of IMRT) during 5 weeks; Maintenance treatment by nivolumab 240 mg (Q2W) during 6 months, or until progression and severe toxicity leading to definitive treatment interruption.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Evaluation of the efficacy (disease control rate) of accelerated IMRT combined with nivolumab as a first treatment line for patients with a locally advanced non-small cell lung cancer unfit for concomitant or sequential chemoradiotherapy and surgery.	Control of the disease one year after treatment start

Collaborators and Investigators

• Sponsor: Center Eugene Marquis
• Collaborators: Bristol-Myers Squibb
• Investigators: Principal Investigator: Joël Castelli, MD, Centre Régional de Lutte Contre le Cancer Eugène Marquis

Study record dates

Study Major Dates

• Study Start (Actual): March 30, 2021
• Primary Completion (Actual): April 15, 2023
• Study Completion (Actual): April 15, 2023

Study Registration Dates

• First Submitted: September 30, 2020
• First Submitted That Met QC Criteria: September 30, 2020
• First Posted (Actual): October 8, 2020

Study Record Updates

• Last Update Posted (Actual): February 7, 2024
• Last Update Submitted That Met QC Criteria: February 6, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: Immunotherapy; Accelerated Intensity Modulated Radiotherapy
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Neoplasms; Lung Diseases; Neoplasms by Site; Respiratory Tract Neoplasms; Thoracic Neoplasms; Carcinoma, Bronchogenic; Bronchial Neoplasms; Lung Neoplasms; Carcinoma, Non-Small-Cell Lung; Molecular Mechanisms of Pharmacological Action; Antineoplastic Agents; Antineoplastic Agents, Immunological; Immune Checkpoint Inhibitors; Nivolumab
• Other Study ID Numbers: 2017-1-39-007

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No