Stereotactic Ablative Radiotherapy (SABR) in Combination With Durvalumab and Tremelimumab in Patients With Cervical, Vaginal, or Vulvar Cancer

Inclusion Criteria:

1. Written informed consent obtained from subject prior to any protocol related
procedures

2. Adult female subjects (age 18 years or older) at time of study entry.

3. Performance status ECOG 0-1

4. Body weight >30 kg

5. Must have an average life expectancy of 6 months.

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

7. Histological diagnosis of recurrent or metastatic cervical, vaginal, or vulvar cancer

8. Metastatic disease in at least two distinct lesions (including the index lesion to be
treated) with at least one site outside of the radiation field and evaluable by RECIST
criteria for evaluation of response.

9. At least one index lesion to be treated measuring 1-7 cm amenable to hypofractionated
radiation therapy.

10. Staging CT scans done prior to enrollment.

11. Have had at least one line of prior platinum-based systemic chemotherapy once
diagnosed with recurrence or metastatic disease.

12. May have received 1 prior biologic regimen (i.e. avastin) but not within 4 weeks of
enrollment.

13. Full recovery from the acute effects of prior treatments, defined as effects having
resolved to NCI CTCAE v4.03 Grade 0 or 1 with the exception of alopecia and certain
laboratory values as outlined below. Subjects with irreversible toxicity that is not
reasonably expected to be exacerbated by Durvalumab and Tremelimumab may be included
(e.g., hearing loss, neuropathy) upon approval of the PI.

14. In patients with central nervous system (CNS) metastases, metastases must be
asymptomatic at the time of Day 1 of the study and meet the following criteria: (a)
Brain metastases should have been treated with either WBRT, SRS/Gamma-knife, or
surgical resection; (b) At least 28 days without progression of CNS metastases as
evidenced by magnetic resonance imaging (MRI) or computed tomography (CT) from last
day of treatment with radiation to the CNS metastases; (c) At least 3 months from
surgical resection (if had surgery) with stability on MRI brain at enrollment; (d) At
least 14 days since last dose of corticosteroids; (e) Must not have leptomeningeal
disease or cord compression

15. Adequate hepatic and renal function documented within 3 weeks prior to initial
treatment based on: (a) Aspartate aminotransferase (AST) and alanine aminotransferase
(ALT) and AST documented Gilbert's syndrome or liver metastasis, who must have a baseline total
bilirubin ≤ 3.0 mg/dl; (c) 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: Females: CreatinineCL (mL/min) = [(Weight (kg) x (140-Age)) /
(72 * serum creatinine (mg/dl)) ] * 0.85

16. Negative screening test results for hepatitis B, hepatitis C, and human
immunodeficiency virus

17. Adequate hematological function documented prior to initial treatment based on: (a)
Absolute neutrophil count (ANC) >/= 1,500 cells/ul without growth factor support; (b)
Hemoglobin >/= 9 g/dL; (c) Platelet count >/= 100,000 platelets/ul

18. Subjects must either be of non-reproductive potential (ie, post-menopausal by history;
OR history of hysterectomy, OR History of bilateral tubal ligation, OR History of
bilateral oophorectomy) or must have a negative serum or urine pregnancy test upon
study entry. Women will be considered post-menopausal if they have been amenorrheic
for 12 months without an alternative medical cause. The following age-specific
requirements apply:

19. Continued: (a) Women <50 years of age would be considered post-menopausal if they have
been amenorrheic for 12 months or more following cessation of exogenous hormonal
treatments and if they have luteinizing hormone and follicle-stimulating hormone
levels in the post-menopausal range for the institution or underwent surgical
sterilization (bilateral oophorectomy or hysterectomy); (b) Women >/= 50 years of age
would be considered post-menopausal if they have been amenorrheic for 12 months or
more following cessation of all exogenous hormonal treatments, had radiation-induced
menopause with last menses > 1 year ago, had chemotherapy-induced menopause with last
menses > 1 year ago, or underwent surgical sterilization (bilateral oophorectomy,
bilateral salpingectomy or hysterectomy).

20. Females of childbearing potential who are sexually active with a nonsterilized male
partner must use highly effective method of contraception from the time of screening,
and must agree to continue using such precautions for 180 days after the final dose of
Durvalumab and Tremelimumab. Cessation of contraception after this point should be
discussed with a responsible physician. They must also refrain from egg cell donation
for 180 days after the final dose of Durvalumab and Tremelimumab. Note: A highly
effective method of contraception is defined as one that results in a low failure rate
(i.e., less than 1% per year) when used consistently and correctly. The acceptable
methods of contraception include barrier methods (male condom plus spermicide, Copper
T intrauterine device, Levonorgestrel-releasing intrauterine system) or hormonal
methods (implants, hormone shot or injection, combined pill, minipill, patch).

Exclusion Criteria:

1. Involvement in the planning and/or conduct of the study.

2. Previous enrollment in the present study

3. Female patients who are pregnant or breastfeeding or male or female patients of
reproductive potential who are not willing to employ effective birth control from
screening to 90 days after the last dose of durvalumab monotherapy or180 days after
the last dose of durvalumab + tremelimumab combination therapy

4. Received more than 2 prior systemic chemotherapy regimens, including adjuvant systemic
chemotherapy following definitive chemoradiation (OUTBACK chemotherapy). Concurrent
chemotherapy with prior radiation treatment is not to be counted

5. Prior treatment with an anti-CTLA-4, including tremelimumab PD-1 or PD-L1 inhibitor,
including durvalumab.

6. Prior oncology vaccine therapy

7. Prior radiation treatment to the index lesion to be treated.

8. Prior radiation which overlaps and precludes hypofractionated treatment to the index
lesion.

9. Treatment with other investigational agent within 4 weeks to the first dose of
Tremelimumab or Durvalumab

10. Concomitant therapy with any of the following: IL-2, interferon, or other non-study
immunotherapy regimens; cytotoxic chemotherapy; immunosuppressive agents; other
investigational therapies; all such therapies must have been discontinued > 4weeks.

11. Any unresolved toxicity (CTCAE grade <2) from previous anti-cancer therapy. (Subjects
with irreversible toxicity that is not reasonably expected to be exacerbated by the
investigational product may be included (e.g., hearing loss, peripherally neuropathy)

12. Any prior Grade >/= 3 immune-related adverse event (imAE) while receiving any previous
immunotherapy agent, or any unresolved imAE > Grade 1

13. Treatment with a VEGF inhibitor within the last 6 weeks.

14. Major surgical procedure (as defined by the treating physician) within 28 days prior
to the first dose of Durvalumab and Tremelimumab or still recovering from prior
surgery

15. Active cardiac disease defined as unstable angina, uncontrolled hypertension,
myocardial infarction in the last six months (unless successfully treated with CABG or
PTCA), uncontrolled arrhythmia, or symptomatic congestive heart failure; > 3
heart-related hospitalizations in the past year.

16. Mean QT interval corrected for heart rate (QTc) >/= 470 ms calculated from 3
electrocardiograms (ECGs) using Fredericia's Correction.

17. Severe COPD requiring > 3 hospitalizations in the past year

18. Active or prior documented autoimmune or inflammatory disorders (including
inflammatory bowel disease [eg, colitis or Crohn's disease], diverticulitis [with the
exception of diverticulosis], systemic lupus erythematosus, Sarcoidosis syndrome, or
Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid
arthritis, hypophysitis, uveitis, etc]). The following are exceptions to this
criterion: (a) Patients with vitiligo or alopecia; (b) Patients with hypothyroidism
(eg, following Hashimoto syndrome) stable on hormone replacement; (c) Any chronic skin
condition that does not require systemic therapy; (d) Patients without active disease
in the last 5 years may be included but only after consultation with the study
physician; (e) Patients with celiac disease controlled by diet alone

19. Active or prior documented interstitial lung disease

20. Current or prior use of immunosuppressive medication within 14 days before the first
dose of Durvalumab and Tremelimumab with the exceptions of intranasal and inhaled
corticosteroids, systemic corticosteroids at physiologic doses not to exceed 10 mg/day
of prednisone or equivalent, or steroids used transiently to control contrast agent
allergies for radiographic studies.

21. History of allogeneic organ transplant

22. History of hypersensitivity to durvalumab or Tremelimumab or any CTLA4, PD1, or PDL-1
inhibitor.

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

24. Active infection including tuberculosis (clinical evaluation that includes clinical
history, physical examination and radiographic findings, and TB testing in line with
local practice), hepatitis B (known positive HBV surface antigen (HBsAg) result),
hepatitis C, or human immunodeficiency virus (positive HIV 1/2 antibodies). Patients
with a past or resolved HBV infection (defined as the presence of hepatitis B core
antibody [anti-HBc] and absence of HBsAg) are eligible. Patients positive for
hepatitis C (HCV) antibody are eligible only if polymerase chain reaction is negative
for HCV RNA

25. History of prior bowel fistula, ulcerations, or perforations.

26. Evidence of progressive or symptomatic central nervous system (CNS) metastases or
leptomeningeal disease.

27. Uncontrolled inter-current illness, including, but not limited to, ongoing or active
infection requiring systemic treatment, current or history of prior radiation induced
pneumonitis, interstitial lung disease, or psychiatric illness/social situations that
would limit compliance with study requirement or compromise the ability of the subject
to give written informed consent.

28. Other active invasive malignancy. History of non-invasive malignancies such as ductal
carcinoma in situ of the breast, non-melanomatous carcinoma of the skin, is allowed,
as is history of other invasive malignancy that is in remission for >/= 5 years after
treatment with curative intent.

29. Any medical, psychological, or social condition that, in the opinion of the treating
physician would interfere with evaluation of the investigational product or
interpretation of subject safety or study results