RAI Plus Immunotherapy for Recurrent/Metastatic Thyroid Cancers

Inclusion Criteria:

- Patients must have histologically or cytologically confirmed thyroid carcinoma of
follicular origin (including papillary, follicular, hurthle cell or poorly
differentiated subtypes and their respective variants).

- Diagnosis of recurrent and/or metastatic thyroid cancer

- At least one RAI-avid lesion identified on the most recent radioiodine scan (a
diagnostic, post-therapy, or post-ablation scan) prior to study registration. (Both
RAI-sensitive and RAI-refractory patients are eligible if at least one tumor with RAI
avidity of any degree can be identified within these parameters.)

- Patients must have measurable disease, defined as at least one lesion that can be
accurately measured in at least one dimension (longest diameter to be recorded for
non-nodal lesions and short axis for nodal lesions) as ≥ 20 mm with conventional
techniques or as ≥ 10 mm with CT scan, MRI, or calipers by clinical exam. See Section
11 for the evaluation of measurable disease. Tumors in previously irradiated fields
may be considered measureable if there is evidence of tumor progression after
radiation treatment.

- ECOG Performance Status (PS) 0 or 1. (or Karnofsky ≥60%)

- Age ≥ 18 years at time of study entry

- Adequate normal organ and marrow function as defined below:

- Hemoglobin ≥ 9.0 g/dL

- Absolute neutrophil count (ANC) ≥ 1.5 x 10^9/L (> 1500 per mm^3)

- Platelet count ≥ 100 x 10^9/L (>100,000 per mm^3)

- Serum bilirubin ≤ 1.5 x institutional upper limit of normal (ULN). (This will not
apply to subjects with confirmed Gilbert's syndrome (persistent or recurrent
hyperbilirubinemia that is predominantly unconjugated in the absence of hemolysis
or hepatic pathology), who will be allowed only in consultation with their
physician.)

- AST (SGOT)/ALT (SGPT) ≤ 2.5 x institutional upper limit of normal unless liver
metastases are present, in which case it must be ≤ 5x ULN

- Serum creatinine CL>40 mL/min by the Cockcroft-Gault formula (Cockcroft and Gault
1976) or by 24-hour urine collection for determination of creatinine clearance:

- Males:

Creatinine CL (mL/min) = Weight (kg) x (140 - Age) . 72 x serum creatinine (mg/dL)

- Females:

Creatinine CL (mL/min) = Weight (kg) x (140 - Age) x 0.85 72 x serum creatinine (mg/dL)

- Female subjects must either be of non-reproductive potential (i.e., post-menopausal by
history: ≥60 years old and no menses for ≥1 year without an alternative medical cause;
OR history of hysterectomy, OR history of bilateral tubal ligation, OR history of
bilateral oophorectomy) or must have a negative serum pregnancy test upon study entry.

- Subject is willing and able to comply with the protocol for the duration of the study
including undergoing treatment and scheduled visits and examinations including follow
up.

- Patients must agree to undergo two research biopsies of (a) malignant lesion(s). The
investigator must also judge that the patient has tumor(s) safely accessible for
biopsy. Patients may be exempt from the second biopsy if after the performance of the
first biopsy it is felt that a second biopsy would be unsafe for the patient. If the
patient has only one RECIST measureable target lesion for response assessment,
research biopsies must not be performed on that target lesion.

- Availability of archival tumor tissue from the thyroid cancer primary or metastasis (a
tissue block or a minimum of 30 unstained slides would be required. Patients with less
archival tissue available may still be eligible for the study after discussion with
the MSK Principal Investigator.)

Exclusion Criteria:

- 131I therapy < 6 months prior to initiation of therapy on this protocol. A diagnostic
study using < 10 mCi of 131I is not considered 131I therapy.

- Any previous treatment with a PD1 or PD-L1 inhibitor, including durvalumab.

- History of pneumonitis.

- External beam radiation therapy < 4 weeks prior to initiation of therapy on this
protocol.

- Chemotherapy, immunotherapy, targeted therapy, monoclonal antibodies, tumor
embolization, or other investigational agent within 28 days prior to the first dose of
study drug.

- Current or prior use of immunosuppressive medication within 28 days before the first
dose of durvalumab, with the exceptions of intranasal and inhaled corticosteroids or
systemic corticosteroids at physiological doses, which are not to exceed 10 mg/day of
prednisone, or an equivalent corticosteroid.

- Any unresolved toxicity CTCAE grade ≥ 2 from previous anti-cancer therapy. Exceptions
include hearing loss, peripheral neuropathy, and alopecia.

- Any prior Grade ≥3 immune-related adverse event (irAE) while receiving any previous
immunotherapy agent, or any unresolved irAE >Grade 1.

- Active or prior documented autoimmune disease within the past 2 years. NOTE: Subjects
with a history of autoimmune thyroid disease are not excluded. Subjects with vitiligo
or psoriasis not requiring systemic treatment (within the past 2 years) are not
excluded.

- Active or prior documented inflammatory bowel disease (e.g., Crohn's disease,
ulcerative colitis).

- History of primary immunodeficiency.

- History of allogeneic organ transplant.

- History of hypersensitivity to durvalumab or any excipient.

- History of hypersensitivity to thyrotropin alpha (Thyrogen).

- Patients unable to follow a low iodine diet or requiring medication with high content
in iodide (amiodarone).

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, uncontrolled hypertension, unstable
angina pectoris, cardiac arrhythmia, active peptic ulcer disease or gastritis, active
bleeding diatheses acute or chronic hepatitis B, hepatitis C or human immunodeficiency
virus (HIV), or psychiatric illness/social situations that would limit compliance with
study requirements or compromise the ability of the subject to give written informed
consent.

- Known history of active tuberculosis.

- Symptomatic brain metasteses, leptomeningeal carcinomatosis, or spinal cord
compression (treated metastatic brain, leptomeningeal carcinomatosis, or spinal cord
compression are allowed). Note: Patients must be off steroids used for brain
metasteses, leptomeningeal carcinomatosis, or spinal cord compression.

- Receipt of live attenuated vaccination within 30 days prior to study entry or within
30 days of receiving durvalumab.

- Female subjects who are pregnant, breast-feeding or male or female patients of
reproductive potential who are not employing an effective method of birth control.

- Any condition that, in the opinion of the investigator, would interfere with
evaluation of study treatment or interpretation of patient safety or study results

- Subjects with uncontrolled seizures.