SAbR Induced Innate Immunity in Urothelial Carcinoma, Melanoma, and Cervical Carcinoma

Within 2 weeks of planned SAbR, patients will have a core biopsy of the lesion to receive
SAbR. Laboratory values will be obtained prior to biopsy. Once the laboratory values are
found to be within the safe margin for biopsy, multiple (approximately 5) core biopsies will
be obtained with an 18-guage or 19-gauge needle under CT or US guidance. Tissue will be snap
frozen with liquid nitrogen and immediately transferred to the laboratory of Dr. Zhijian
"James" Chen, PhD, Professor, Department of Molecular Biology.

SAbR will be administered as per the guidelines of UTSW with a single 24-27Gy or three 10-14
Gy/fraction fractions totaling 33-48Gy. Lesions receiving SAbR will be called "radiated"
lesions. Prior irradiated lesions will be excluded. SABR will be administered within 2 weeks
of the study initial core biopsy. The SAbR dose and fractionation scheme is generated to
deliver a potent dose to ablate the targeted lesions and at the same time maximize an immune
response. Since multiple studies have shown an influx of lymphocytes and monocytes after
tumor irradiation and since these cells play a critical role in antigen presentation and
initiation of an adaptive immune response, multiple fraction irradiation which would kill
these infiltrating immunocytes, is discouraged. Therefore a single fraction or a three
fraction treatment regimen is recommended, and a single fraction treatment is preferred over
three fractions. Due to normal organ toxicity and limits of dose constraints, sometimes a
three fraction treatment must be undertaken and in those cases it is recommended that the
treatment course is completed within 7-10 days-preferably 5 business days. Radiation
dose-immune response studies have shown a linear increase in immune response with increased
dose per fraction of radiation without demonstration of a plateau. Two studies comparing 15Gy
x 1 vs 5Gy x3, and 20Gy x1 vs 5Gy x4 have shown a superior immune response generated by the
single fraction radiation. Clinical experience with oligometastatic patients treated at 1-5
sites of disease has also showed an increase in progression-free survival with the increasing
radiation dose per fraction. A dose of less than 7.5 Gy per fraction has demonstrated lower
induction of systemic IFN-γ producing cells, and a previous phase II study of mRCC patients
treated with HD IL-2 and singe fraction of 8Gy irradiation to a single lesion did not show an
overall improvement in response rate. Therefore 8Gy per fraction is the lowest permitted dose
for this study and can be used only when administering the three fraction regimen as
described in the prescription dose table below. Investigators will have discretion in
choosing from either of the biologically equivalent dose levels using one or three fractions,
although a single fraction is preferred over three fraction treatments. Treating physician
will have further discretion in selecting the number and location of sites to treat if
multiple sites of disease are present. Maximum number of lesions treated is deemed as
feasible per the treating radiation oncologist. However, for the purposes of this protocol,
only a single site will be studied and must be safely amenable to repeat core biopsy. Thus,
the single site for the study will be either in subcutaneous tissues, nodes, isolated masses
or liver. The gross target/tumor volume--GTV should be at least 2 cm3 in size, corresponding
to roughly a 1.5 cm diameter tumor. This is to ensure that adequate tumor volume for therapy
and for biopsy and therefore adequate tumor cells roughly 108 -109 cells/cm3 are killed for
antigen presentation. Treating physicians should choose their dose based on established
planning guidelines at their center including their ability to respect normal tissue
tolerance.

Within 24 + 6 hours of the first SAbR, a second core biopsy of the "target" irradiated lesion
will be performed identically to the first biopsy.

Inclusion Criteria:

- Histologic diagnosis of advanced/metastatic urothelial carcinoma, melanoma, or
cervical carcinoma.

- Planned treated with SAbR.

- Age greater than or equal to 18 years.

- Lesion to receive SAbR safely accessible for core biopsy—mass >1.5cm diameter and
located in node, liver, or soft tissues.

- Hgb >10g/dL before or after transfusion.

- Platelets >50,000/L

- INR <1.5

- If contrast enhanced CT needed to locate the lesion for core biopsy, then derived
creatinine clearance >30cc/min

- Ability to understand and the willingness to sign a written informed consent.

Exclusion Criteria:

- Prior radiation therapy to target lesion.

- Target lesion not safely accessible for core biopsies.