RecruitingPhase 2NCT06133062

Atezolizumab and Bevacizumab with Proton Radiotherapy for Unresectable Hepatocellular Carcinoma

Investigation of Antitumor Immune Response in Patients with Unresectable Hepatocellular Carcinoma Undergoing Proton Radiotherapy Combined with Atezolizumab and Bevacizumab

Sponsor

Chang Gung Memorial Hospital

Enrollment

45 participants

Start Date

Nov 16, 2023

Study Type

INTERVENTIONAL

Conditions

Hepatocellular Carcinoma Non-resectable

Summary

Atezolizumab (anti-programmed death-ligand 1; anti-PD-L1) in conjunction with bevacizumab (anti-vascular endothelial growth factor; anti-VEGF) has become the established standard first-line systemic treatment for unresectable hepatocellular carcinoma (HCC). Despite an improved objective response rate (ORR) of 27%, the majority of patients face HCC progression and liver failure \[Finn et al., N Engl J Med 2020\]. Developing a new combined treatment strategy to overcome resistance to anti-PD-L1 and anti-VEGF is essential to improve patient outcomes. Radiation treatment (RT) is notably effective in managing localized solid tumors and is a fundamental component of unresectable HCC treatment. Recent retrospective cohorts have demonstrated that proton RT targeting all hepatic tumors, along with PD-L1/programmed death-1 (PD-1) blockade, enhances ORR and progression-free survival for unresectable HCC patients, displaying a favorable safety profile (Su et al., Am J Cancer Res. 2022). Our preclinical study (Hsieh et al., Sci Immunol 2022) showcased that RT combined with PD-L1/PD-1 blockade stimulates immunogenic cell death and antigen cross-presentation in murine tumor models, promoting systemic antitumor T cell responses. Nonetheless, it is crucial to verify whether the combined therapy of proton RT, atezolizumab, and bevacizumab triggers synergistic antitumor effects and systemic immune activation in clinical trials for unresectable HCC. This phase II non-randomized trial aims to prospectively evaluate therapeutic efficacy, safety, and immunological responses in patients with unresectable HCC treated with atezolizumab/bevacizumab combined with proton radiotherapy.

Eligibility

Min Age: 18 Years

Inclusion Criteria19

Participants must have diagnosis of HCC that is deemed unsuitable for surgical resection or transplant. Participants may have multiple lesions with a total maximal tumor dimension of \< 20 cm, and no one lesion \> 15 cm. Diagnosis should be confirmed by at least 1 criterion listed below:
Histologically or cytologically proven diagnosis of HCC.
Typical arterial enhancement and delayed washout on multiphasic CT or MRI.
Age ≥18 years at the time of signing informed consent document.
ECOG performance status 0-1.
Barcelona Clinic Liver Cancer (BCLC) stages Intermediate (B) or Advanced (C).
Child-Pugh score 5-6 liver function within 28 days of study registration.
Documented virology status of hepatitis B virus (HBV), as confirmed by screening HBV serology test.
Documented virology status of hepatitis C virus (HCV), as confirmed by screening HCV serology test.
Ability to understand and the willingness to sign a written informed consent document
Adequate bone marrow, liver, and renal function within 4 weeks before study registration
Hemoglobin ≥ 9.0 g/dL
Absolute neutrophil count (ANC) ≥ 1,000/mm3
Platelet count ≥ 50,000/μL
Total bilirubin \< 2.5 mg/dL
Serum albumin \>2.8 g/dL
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 3 × upper limit of normal (ULN)
Prothrombin time ≤ 6 seconds prolonged
Serum creatinine ≤ 1.5 mg/dL

Exclusion Criteria21

Prior invasive malignancy unless disease free for a minimum of 2 years
Prior radiotherapy to the region of the liver that would result in overlap of radiation therapy fields
Prior selective internal radiotherapy/hepatic arterial yttrium therapy, at any time
Untreated active hepatitis B or hepatitis C
Moderate to severe or intractable ascites
Presence of distant metastases that cannot be encompassed by proton radiotherapy
Untreated or incomplete treated esophageal or gastric varices
Severe, active co-morbidity, defined as follows:
Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months prior to registration
Myocardial infarction within the last 6 months prior to study entry
Acute bacterial or fungal infection requiring intravenous antibiotics within 28 days prior to study entry
A bleeding episode within 6 months prior to study entry due to any cause.
Thrombolytic therapy within 28 days prior to study entry.
Known bleeding or clotting disorder.
Uncontrolled psychotic disorder
Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception
Prior solid organ transplantation.
Prior or active autoimmune disease (AID) including autoimmune hepatitis, inflammatory bowel disease, myasthenia gravis, systemic lupus erythematosus, rheumatoid arthritis, antiphospholipid antibody syndrome, Wegener granulomatosis, Sjogren's syndrome, Guillain-Barre syndrome, and multiple sclerosis.
Prior or active thrombotic or bleeding disorders, hemoptysis, cerebral vascular accident, significant cardiac disease (ischemic or congestive heart failure), or gastrointestinal perforation.
Inability to treat all sites of disease by proton radiotherapy (such as extrahepatic metastases or massive liver tumors whereby the liver constraints \[ULV/SLV \>40%\] cannot be met for covering all sites of liver tumors using proton radiotherapy.)
Known HIV infection.

Interventions

DRUGAtezolizumab

Atezolizumab 1200 mg will be administered as an IV infusion on Day 1 of each cycle, with cycles occurring every 3 weeks. The initial dose will be delivered over 60 (± 15) minutes, and if well-tolerated, subsequent infusions may be given over 30 minutes. For patients who achieve a complete response (CR) within one year of treatment, atezolizumab should be continuously used for a year. For patients who experience a partial response (PR), atezolizumab should be continued until achieving CR or experiencing progressive disease (PD). Patients with stable disease should receive atezolizumab for 6 months. In the case of PD, atezolizumab should be discontinued at the time when PD is confirmed.

DRUGBevacizumab

Bevacizumab 15 mg/kg will be administered as an IV infusion on Day 1 of each 3-week cycle. The initial dose will be delivered over 90 minutes (±15 minutes), and if well-tolerated, subsequent infusions may be given over 60 minutes. For patients who achieve a complete response (CR) within one year of treatment, bevacizumab should be continuously used for a year. In the case of patients experiencing a partial response (PR), bevacizumab should be continued until achieving CR or experiencing progressive disease (PD). Patients with stable disease should receive bevacizumab for 6 months. In the event of PD, bevacizumab should be discontinued when PD is confirmed. Temporary withholding or dose reduction of bevacizumab is permitted if patients experience adverse events such as bleeding episodes, severe hypertension, or proteinuria at the discretion of the treating physician.

RADIATIONProton radiotherapy

* 72.6 CGE in 22 fractions for tumors ≤1 cm from the hepatic hilum, bowel, and heart. * 66 CGE in 10 fractions for tumors \>1 cm from the hepatic hilum, bowel, and heart.