Neoadjuvant Anti PD-1 Immunotherapy in Resectable Non-small Cell Lung Cancer

Phase 2

Completed

Conditions: Non-small Cell Lung Cancer (NSCLC)

Interventions: Drug: Pembrolizumab

Registration Number: NCT03197467

Lead Sponsor: AIO-Studien-gGmbH

Brief Summary: NEOMUN is designed as an open-label, single arm, prospective, monocenter, phase II study of pembrolizumab in a neoadjuvant setting in patients with non-small cell lung cancer of Stage II/IIIA suitable for curative intent surgery.

Detailed Description: The study is designed as an open-label, single arm, prospective, monocenter, phase II study of pembrolizumab in a neoadjuvant setting in patients with resectable NSCLC stage II/IIIA suitable for curative intent surgery, taking place in Germany. Planned sample size is N=30.

Investigational drug is Pembrolizumab at fixed dose, given 200 mg q3w i.v. for 2 cycles. After completion of immunotherapy lobectomy/ bilobectomy with curative intent is scheduled.

Primary objectives are to assess feasibility and safety of a neoadjuvant application of pembrolizumab and to assess antitumor activity of pembrolizumab with regard to clinical and pathologic tumor response. Secondary objective is to assess the impact of neoadjuvant pembrolizumab on patient disease free and overall survival. Exploratory objective is o explore potential predictive biomarkers for pembrolizumab efficacy (immune cell imaging).

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 30

Inclusion Criteria

Cooperation and willingness to complete all aspects of the study
Signed and dated written informed consent must be given prior to study inclusion
Histological or cytological confirmed NSCLC
Clinical stage II-IIIA according to the TNM classification, 7th edition:

stage IIIa: T1/T2 N2 (IIIa1-3 Robinson classification)
Adequate disease staging by PET/CT and brain MRI
At least 1 measurable lesion according to RECIST 1.1
Age ≥ 18 years
ECOG performance status 0 - 1
Female subjects of childbearing potential must be willing to use an adequate method of contraception for the course of the study through 120 days after the last dose of study medication. Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject. Female subject of childbearing potential should have a negative urine or serum pregnancy within 72 hours prior to receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required.
Male subjects of childbearing potential must agree to use an adequate method of contraception, starting with the first dose of study therapy through 120 days after the last dose of study therapy. Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject
Adequate bone marrow function, liver and renal function:
1. Absolute neutrophil count ≥ 1.5 x 109/L
2. Thrombocytes ≥ 100 x 109/L
3. Hemoglobin ≥ 9 g/dL without transfusion or EPO dependency (within 7 days of assessment)
4. INR < 1.4 ULN and PTT < 40 seconds during the last 7 days before therapy
5. Bilirubin < 1.5 x upper limit of normal
6. AST (GOT) and ALT (GPT) < 2.5 x ULN
7. Albumin >2.5 mg/dL
8. Serum creatinine OR Measured or calculated creatinine clearance (GFR can also be used in place of creatinine or CrCl): ≤1.5 X upper limit of normal (ULN) OR ≥60 mL/min for subject with creatinine levels > 1.5 X institutional ULN
Adequate lung and cardiac function for intended lung resection according to German S3 guideline

Exclusion Criteria

Anticancer treatment during the last 30 days prior to start of treatment, including systemic therapy, radiotherapy or major surgery
Participation in a clinical trial within the last 30 days prior to study treatment
History of allogeneic tissue/solid organ transplant
Has a history of (non-infectious) pneumonitis that required steroids or current pneumonitis.
Evidence of interstitial lung disease.
cT4 tumor
Symptomatic acute cardiovascular or cerebrovascular disease
Known active HBV, HCV or HIV infection
Has any other active infection requiring systemic therapy.
Patients with active tuberculosis
Prior therapy with an anti-Programmed cell death protein 1 (anti-PD-1), anti-PD-L1, anti-Programmed cell death-ligand 2 (anti-PD-L2), anti-CD137 (4-1BB ligand, a member of the Tumor Necrosis Factor Receptor [TNFR] family), or anti-Cytotoxic T-lymphocyte-associated antigen-4 (anti-CTLA-4) antibody (including ipilimumab or any other antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways)
A diagnosis of immunodeficiency or patient is receiving chronic systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment.
Patient has had a prior monoclonal antibody within 4 weeks prior to study Day 1
Patient has had prior chemotherapy, targeted small molecule therapy, or radiation therapy in history.
Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement or Sjorgen's syndrome will not be excluded from the study.
Has received a live vaccine within 30 days prior to the first dose of trial treatment. [Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines are live attenuated vaccines, and are not allowed.]
Has known hypersensitivity to pembrolizumab or any of the constituents of the product.
Other active malignancy requiring treatment Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer.
Lactating or pregnant women, women of child-bearing potential who do not agree to the usage of highly effective contraception methods (allowed methods of contraception, meaning methods with a rate of failure of less than 1% per year are implants, injectable contraceptives, combined oral contraceptives, intrauterine pessars (only hormonal devices), sexual abstinence or vasectomy of the partner). Women of childbearing potential must have a negative pregnancy test (serum β-hCG) at Screening.
Any psychiatric illness that would affect the patient's ability to understand the demands of the clinical trial
Patient has already been recruited in this trial
Patient who has been incarcerated or involuntarily institutionalized by court order or by the authorities § 40 Abs. 1 S. 3 Nr. 4 AMG.
Patients who are unable to consent because they do not understand the nature, significance and implications of the clinical trial and therefore cannot form a rational intention in the light of the facts [§ 40 Abs. 1 S. 3 Nr. 3a AMG].

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Pembrolizumab	Pembrolizumab	Pembrolizumab at fixed dose: 200 mg q3w i.v. for 2 cycles

Primary Outcome Measures

Name	Time	Method
Number of Patients Treated in Compliance With Protocol	From screening until surgery, ca. 6-8 weeks	The definition for this endpoint was neoadjuvant pembrolizumab treatment followed by successful curative intent tumor resection.
Tumor Response According to RECIST 1.1 Criteria	From screening until pre-surgery radiologic assessment, ca. 6-8 weeks	Radiologic tumor assessments were performed at screening and pre-surgery.
Tumor Response Evaluation - Pathologic Response	From screening until surgery, ca. 6-8 weeks	Pathologic regression grading according to Junker criteria. The following grades are defined: Grade I No tumor regression or only spontaneous tumor regression in the sections of the primary tumor and mediastinal lymph nodes. Grade IIa Morphological signs of therapy-induced tumor regression in the sections of the primary tumor and/or mediastinal lymph nodes: More than 10% vital tumor tissue Grade IIb Morphological signs of therapy-induced tumor regression: Less than 10% vital tumor tissue Grade III Complete tumor regression, no evidence of vital tumor in the sections of the primary tumor and/or mediastinal lymph nodes. Regression grades IIb and III suggest a good response to neoadjuvant therapy. Reference: Junker K, Langner K, Klinke F, Bosse U, Thomas M. Grading of tumor regression in non-small cell lung cancer : morphology and prognosis. Chest 2001; 120:1584-91.
Tumor Response Evaluation - Δ Tumor Size	From screening until pre-surgery radiologic assessment, ca. 6-8 weeks	Δ tumor size was defined as the difference \[mm\] between longest diameter at baseline and pre-surgery.
Tumor Response - Δ PET Activity	From screening until pre-surgery radiologic assessment, ca. 6-8 weeks	Δ PET activity (standardized uptake value \[SUV\]). This method uses radiolabeled tracer 82-deoxy-2-\[18F\]fluoro-D-glucose, FDG) during PET imaging of the tumor and accumulation of radiolabeled FDG measured by the PET scanner. Accumulation of FDG relative to normal tissue is related to the proliferative activity of malignant tissue and to the number of viable tumor cells. The endpoint is based on per-patient changes in tumor maximal standardized uptake value during PET examinations of the tumor before the start of treatment and after 2 cycles of neoadjuvant immunotherapy, i.e. between screening and shortly before surgery. Reduction of proliferative activity or of the number of viable tumor cells results in negative values.

Secondary Outcome Measures

Name	Time	Method
Disease-free Survival at 12 Months	12 months after surgery, i.e. circa 14 months after treatment start	Probability of disease-free survival (DFS) was calculated from date of surgery until tumor recurrence or death using Kaplan-Meier statistics. Follow-up was until 24 months after last-patient-out.
Overall Survival at 24 Months	24 months after surgery, i.e. circa 26 months after treatment start	Probability of overall survival (OS) was calculated from date of surgery until date of death using Kaplan-Meier statistics. Follow-up was until 24 months after last-patient-out.
Disease-free Survival at 6 Months	6 months after surgery, i.e. circa 8 months after treatment start	Probability of disease-free survival (DFS) was calculated using Kaplan-Meier statistics from date of surgery to the date until tumor recurrence or death. Follow-up was until 24 months after last-patient-out.
Overall Survival at 12 Months	12 months after surgery, i.e. circa 14 months after treatment start	Probability of overall survival (OS) was calculated from date of surgery until date of death using Kaplan-Meier statistics. Follow-up was until 24 months after last-patient-out.
Overall Survival at 18 Months	18 months after surgery, i.e. circa 20 months after treatment start	Probability of overall survival (OS) was calculated from date of surgery until date of death using Kaplan-Meier statistics. Follow-up was until 24 months after last-patient-out.