HYpofractionated, Dose-redistributed RAdiotherapy With Protons and Photons in HNSCC (HYDRA)

HYpofractionated, Dose-redistributed RAdiotherapy With Protons and Photons to Combat Radiation-induced Immunosuppression in Head and Neck Squamous Cell Carcinoma (HYDRA)

Radiotherapy for advanced-stage head and neck squamous cell carcinoma (HNSCC) results in an unfavorable 5-year overall survival of 40%, and there is a strong biological rationale for improving outcome by combinatorial treatment with immunotherapy. However, also immunosuppressive effects of radiotherapy have been reported and recently a randomized phase-III trial failed to show any survival benefit following the combination of a PD-L1 inhibitor with chemoradiotherapy. The hypothesis is that the combination of these individually effective treatments failed because of radiation-induced lymphodepletion and that the key therefore lies in reforming conventional radiotherapy, which typically consists of large lymphotoxic radiation fields of 35 fractions. By integrating modern radiobiology and individually established innovative radiotherapy concepts, the patient's immune system could be maximally retained. This will be achieved by 1) increasing the radiation dose per fraction so that the total number of fractions can be reduced (HYpofractionation), 2) by redistributing the radiation dose towards a higher peak dose within the tumor center and a lowered elective-field dose (Dose-redistribution) and 3) by using RAdiotherapy with protons instead of photons (HYDRA).

The objectives of this study are to determine the safety of HYDRA with protons and photons by conducting two parallel phase-I trials. HYDRA's efficacy will be compared to standard of care (SOC). The immune effects of HYDRA-protons will be evaluated by longitudinal immune profiling and compared to HYDRA-photons and SOC (with protons and photons). There will be a specific focus on actionable immune targets and their temporal patterns that can be tested in future hypofractionated-immunotherapy combination trials. This trial therefore is an important step towards future personalized immuno-radiotherapy combinations with the ultimate goal to improve survival for patients with HNSCC.

Study Overview

• Status: Recruiting
• Conditions: Head and Neck Squamous Cell Carcinoma; Radiotherapy; Proton Therapy; Hypofractionation; Immune System Suppression
• Intervention / Treatment: Radiation: HYpofractionated, Dose-redistributed RAdiotherapy (HYDRA); Radiation: conventional fractionated radiotherapy

Detailed Description

The HYDRA dose prescriptions are, in 20 fractions (instead of the conventional 35 fractions):

• Inhomogeneous focal boost on the macroscopic gross tumor volume (GTVprimary tumor and GTVnodes) on FDG-PET: mean dose 59Gy, max dose 63Gy.
• The mean dose of 59Gy corresponds to an equal late normal tissue toxicity probability after conventionally fractionated radiotherapy of 70Gy in 35 fractions, considering an α/β=3 for normal tissue.
• Simultaneous integrated boost (SIB) on the clinical target volume (CTV-P1 = GTV+5mm): 55Gy
• Elective field / CTV-P2 (GTV+10mm): 40Gy

Patients who receive the HYDRA intervention treatment, as well as patients who receive standard of care may require the addition of a concurrent radiosensitizer based on clinicopathological features according to standard of care. Currently, the only two registered radiosensitizers are platinum-based chemotherapy (cisplatin/carboplatin) and cetuximab. These radiosensitizers should be administered according to standard care treatment protocols.

• Study Type: Interventional
• Enrollment (Estimated): 100
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Joris BW Elbers, MD, PhD; Phone Number: 0031207041249; Email: j.elbers@erasmusmc.nl

Study Locations

• Netherlands
  • Zuid Holland
    • Rotterdam, Zuid Holland, Netherlands, 3015 GL
      • Recruiting
      • Erasmus MC
      • Contact: Jos Elbers; Phone Number: 0031107041249; Email: j.elbers@erasmusmc.nl

Participation Criteria

Eligibility Criteria

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

Description

In order to be eligible to participate in this study, a subject must meet all of the following criteria:

• ≥ 18 years old at time of signing informed consent.
• WHO 0-2
• Squamous cell carcinoma of the oropharynx, hypopharynx and larynx* proven by cytology / histology
• Patients amenable for curative intent proton therapy (by model-based selection criteria, according to the Dutch standard of care) or photon therapy.
• Radiotherapy with or without concurrent radiosensitizer.
• Ability to understand the requirements of the study and to give written informed consent, as determined by the treating physician.

• Written informed consent obtained.

  • Note: The HYDRA dose prescriptions should be applicable for all HNSCC patients and should therefore ideally be tested within the full range of treatment indications, e.g. multiple tumor subsites and both chemoradiotherapy and radiotherapy alone. There are several reports about acceptable acute toxicity following hypofractionated chemoradiotherapy in advanced stage HNSCC. However, concerns about late toxicity remain, especially for laryngeal carcinoma. Patients with laryngeal carcinoma are therefore initially excluded, until these patients are also considered eligible for treatment with HYDRA. The statistical considerations and interim safety analyses for this purpose and the decision-making / consultation are further described elsewhere.

Exclusion criteria

Patients who do not meet the inclusion criteria as specified in paragraph 4.2, and/or who meet the following additional criteria:

• Previously treated by irradiation on the same target volume
• Chronic inflammatory disease or immune disorders which, according to the principal investigator, may disturb the translational immune-read out.
• Patients currently under treatment for other malignant disease (unless in situ carcinoma or basal cell carcinoma of the skin), or treated for other malignant disease within the last 2 years.
• Any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule in the participating hospitals.
• Any other serious medical condition that could interfere with follow-up.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: HYDRA-protons; group 1, n=25, run at HollandPTC	Radiation: HYpofractionated, Dose-redistributed RAdiotherapy (HYDRA); 20 daily fractions, 5 times per week
Active Comparator: Conventional fractionated proton therapy; group 2, n=25, run at HollandPTC	Radiation: conventional fractionated radiotherapy; 35 daily fractions, 5 times per week
Experimental: HYDRA-photons; group 3, n=25 run at Erasmus MC	Radiation: HYpofractionated, Dose-redistributed RAdiotherapy (HYDRA); 20 daily fractions, 5 times per week
Active Comparator: Conventional fractionated photon therapy; group 4, n=25 run at Erasmus MC	Radiation: conventional fractionated radiotherapy; 35 daily fractions, 5 times per week

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Safety of HYDRA-protons and HYDRA-photons in terms of radiation-induced grade 3-4 late toxicity, physician-reported by CTCAE v5.0, monitored until 1 year after the last patient has completed HYDRA.	HYDRA is randomized with standard of care for translational research purposes; a direct comparison of toxicity will statistically not be conclusive and is outside the scope of this study.	month 1-36

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Objective response after HYDRA defined by radiological response on CT-scans or MRI in comparison to standard of care	Objective response rate 3 months after HYDRA (group 1 and 3), defined by radiological response on CT-scans or MRI using RECIST version 1.1 and/or histopathological confirmation of residual disease, in comparison to standard of care (group 2 and 4, respectively), 3 months after end of treatment	month 1-27
Efficacy of HYDRA in terms of in-field and nodal elective field tumor control at 1 year	Efficacy of HYDRA (group 1 and 3) in terms of in-field and nodal elective field tumor control, 1 year after the last patient is included, in comparison to group 2 and 4, respectively.	month 24-36
Immune profile (changes) between all 4 treatment groups	Numbers and phenotype of peripheral immune cell populations in blood at baseline, related to patient- and tumor characteristics, and differences between temporal changes of these immune markers during/after treatment at 6 timepoints in group 1-4.	month 1-27

Collaborators and Investigators

• Sponsor: Joris B.W. Elbers
• Collaborators: Erasmus Medical Center; HollandPTC
• Investigators: Principal Investigator: Joris BW Elbers, MD, PhD, Erasmus MC, Rotterdam / HollandPTC, Delft - The Netherlands

Study record dates

Study Major Dates

• Study Start (Actual): October 10, 2022
• Primary Completion (Estimated): June 1, 2025
• Study Completion (Estimated): June 1, 2026

Study Registration Dates

• First Submitted: April 28, 2022
• First Submitted That Met QC Criteria: May 3, 2022
• First Posted (Actual): May 6, 2022

Study Record Updates

• Last Update Posted (Actual): February 20, 2024
• Last Update Submitted That Met QC Criteria: February 16, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neoplasms by Histologic Type; Neoplasms; Neoplasms by Site; Neoplasms, Glandular and Epithelial; Head and Neck Neoplasms; Neoplasms, Squamous Cell; Carcinoma; Carcinoma, Squamous Cell; Squamous Cell Carcinoma of Head and Neck
• Other Study ID Numbers: HYDRA

Plan for Individual participant data (IPD)

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

Drug and device information, study documents

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