Atezolizumab, Oxaliplatin, and Fluorouracil in Treating Patients With Esophageal or Gastroesophageal Cancer

PRIMARY OBJECTIVES:

I. Atezolizumab in combination with oxaliplatin and fluorouracil (5-FU) (modified
fluorouracil/leucovorin calcium/oxaliplatin [FOLFOX]) therapy in the neoadjuvant setting will
achieve a pathological complete response of approximately 20% in patients with localized
esophageal and gastroesophageal (gastroesophageal junction [GEJ]) adenocarcinoma.

SECONDARY OBJECTIVES:

I. To evaluate safety and toxicity profile of intravenous atezolizumab in combination with
oxaliplatin and 5-FU (FOLFOX) therapy.

II. To assess the efficacy of the combination by tumor regression grade scoring in the
surgical specimen.

III. To assess the overall safety and tolerability of adjuvant atezolizumab in subjects with
resected esophageal and GEJ cancer.

IV. To evaluate disease free survival (DFS) and overall survival (OS).

V. To explore changes in tumor stroma profile before and after immunotherapy in combination
with chemotherapy.

OUTLINE:

Patients receive oxaliplatin intravenously (IV) over 2 hours, fluorouracil IV continuously
over 48 hours, and atezolizumab IV over 30-60 minutes on days 1 and 15. Treatment repeats
every 28 days for 3 courses in the absence of disease progression or unacceptable toxicity.
Within 4-6 weeks of treatment completion, patients undergo surgical resection. Beginning 6
weeks after surgery, patients continue to receive oxaliplatin IV over 2 hours, fluorouracil
IV continuously over 48 hours, and atezolizumab IV over 30-60 minutes on days 1 and 15.
Treatment repeats every 28 days for 3 courses in the absence of disease progression or
unacceptable toxicity. Patients then receive atezolizumab monotherapy IV over 30-60 minutes
on day 1. Treatment repeats every 21 days for up to 4 courses in the absence of disease
progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 90 days and then every 3
months thereafter.

Inclusion Criteria:

- Signed informed consent form

- Ability to comply with the study protocol, in the investigator's judgment

- Histologically or cytologically confirmed esophageal or gastroesophageal type I or II
adenocarcinoma

- No prior therapy including chemotherapy or radiation therapy

- Patients with T1N1, and T2-3 with any N will be eligible

- Eastern Cooperative Oncology Group (ECOG) performance status of 0-1

- Absolute neutrophil count (ANC) >= 1.5 x 10^9/L (1500/uL) without granulocyte
colony-stimulating factor support (obtained within 14 days prior to initiation of
study treatment)

- Lymphocyte count >= 0.5 x 10^9/L (500/uL) (obtained within 14 days prior to initiation
of study treatment)

- Platelet count >= 100 x 10^9/L (100,000/uL) without transfusion (obtained within 14
days prior to initiation of study treatment)

- Hemoglobin >= 90 g/L (9 g/dL); patients may be transfused to meet this criterion
(obtained within 14 days prior to initiation of study treatment)

- Aspartate aminotransferase (AST) =< 2.5 x upper limit of normal (ULN) (obtained within
14 days prior to initiation of study treatment)

- Alanine aminotransferase (ALT) =< 2.5 x ULN (obtained within 14 days prior to
initiation of study treatment)

- Alkaline phosphatase (ALP) =< 2.5 x ULN (obtained within 14 days prior to initiation
of study treatment)

- Serum bilirubin =< 1.5 x ULN with the following exception:

- Patients with known Gilbert disease: serum bilirubin level =< 3 x ULN (obtained
within 14 days prior to initiation of study treatment)

- Serum creatinine =< 1.5 x ULN [or] creatinine clearance >= 70 mL/min (calculated using
the Cockcroft-Gault formula) (obtained within 14 days prior to initiation of study
treatment)

- Serum albumin >= 25 g/L (2.5 g/dL) (obtained within 14 days prior to initiation of
study treatment)

- For patients not receiving therapeutic anticoagulation: international normalized ratio
(INR) or activated partial thromboplastin time (aPTT) =< 1.5 x ULN (obtained within 14
days prior to initiation of study treatment)

- For patients receiving therapeutic anticoagulation: stable anticoagulant regimen

- Medically fit for surgery

- No supraclavicular, or para-aortic nodal enlargement unless biopsy negative

- Male or female but both sexes must practice adequate contraception while on therapy

- Women of childbearing potential (WOCBP) must have a negative serum or urine pregnancy
test (minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin
[HCG]) within 14 days prior to the start of study drug. Women must not be
breastfeeding

- Availability of a representative tumor specimen that is suitable for determination of
PDL-1 via central testing. A formalin-fixed paraffin-embedded (FFPE) tumor specimen in
a paraffin block (preferred) or at least 10 slides containing unstained, freshly cut,
serial sections should be submitted along with an associated pathology report prior to
study enrollment. If < 10 slides are available, the patient may still be eligible for
the study, after principal investigator approval has been obtained. If archival tumor
tissue is unavailable or is determined to be unsuitable for required testing, tumor
tissue must be obtained from a biopsy performed at screening

Exclusion Criteria:

- Patients with T1aN0, T4b, or M1 cancer will be excluded

- Squamous cell carcinoma histology

- Invasion into nearby organs (T4b) with or increased risk for fistula

- Significant comorbid conditions (defined as uncontrolled diabetes, active angina or
heart failure, uncontrolled hypertension, or active psychiatric condition that
prevents consistent participation and compliance)

- More than grade 1 neuropathy

- Unable to comprehend the requirements of the study or comply with it

- Active bleeding from primary tumor requiring radiation therapy

- Uncontrolled or symptomatic hypercalcemia (> 1.5 mmol/L ionized calcium or calcium >
12 mg/dL or corrected serum calcium > ULN)

- Active or history of autoimmune disease or immune deficiency, including, but not
limited to, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus
erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid
antibody syndrome, Wegener granulomatosis, Sjogren's syndrome, Guillain-Barre
syndrome, or multiple sclerosis with the following exceptions: Patients with a history
of autoimmune-related hypothyroidism who are on thyroid replacement hormone are
eligible for the study. Patients with controlled type 1 diabetes mellitus who are on
an insulin regimen are eligible for the study

- Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with
dermatologic manifestations only (e.g., patients with psoriatic arthritis are
excluded) are eligible for the study provided all of following conditions are met:

- Rash must cover < 10% of body surface area

- Disease is well controlled at baseline and requires only low-potency topical
corticosteroids

- No occurrence of acute exacerbations of the underlying condition requiring
psoralen plus ultraviolet A radiation, methotrexate, retinoids, biologic agents,
oral calcineurin inhibitors, or high potency or oral corticosteroids within the
previous 12 months

- History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis
obliterans), drug-induced pneumonitis, or idiopathic pneumonitis, or evidence of
active pneumonitis on screening chest computed tomography (CT) scan

- Positive human immunodeficiency virus (HIV) test at screening

- Active hepatitis B virus (HBV) infection (chronic or acute), defined as having a
positive hepatitis B surface antigen (HBsAg) test at screening

- Patients with a negative HBsAg test and a positive total hepatitis B core antibody
(HBcAb) test at screening, are eligible for the study

- Active hepatitis C virus (HCV) infection, defined as having a positive HCV antibody
test followed by a positive HCV ribonucleic acid (RNA) test at screening. The HCV RNA
test will be performed only for patients who have a positive HCV antibody test

- Active tuberculosis

- Significant cardiovascular disease, such as New York Heart Association class II or
greater cardiac disease, myocardial infarction, or cerebrovascular accident within 3
months prior to initiation of study treatment, unstable arrhythmia, or unstable angina

- Major surgical procedure other than for diagnosis within 4 weeks prior to initiation
of study treatment, or anticipation of need for a major surgical procedure during the
course of the study

- History of other malignancy within 5 years prior to screening, with the exception of
those with a negligible risk of metastasis or death (e.g., 5-year OS of > 90%), such
as adequately treated carcinoma in situ of the cervix, non-melanoma skin carcinoma,
localized prostate cancer, ductal carcinoma in situ, or stage I uterine cancer

- Severe infection within 4 weeks prior to initiation of study treatment, including, but
not limited to, hospitalization for complications of infection, bacteremia, or severe
pneumonia

- Treatment with therapeutic oral or IV antibiotics within 2 weeks prior to initiation
of study treatment. Patients receiving prophylactic antibiotics (e.g., to prevent a
urinary tract infection or chronic obstructive pulmonary disease exacerbation) are
eligible for the study

- Any other disease, metabolic dysfunction, physical examination finding, or clinical
laboratory finding that contraindicates the use of an investigational drug, may affect
the interpretation of the results, or may render the patient at high risk from
treatment complications

- Prior allogeneic stem cell or solid organ transplantation

- Treatment with a live, attenuated vaccine within 4 weeks prior to initiation of study
treatment, or anticipation of need for such a vaccine during the course of the study
or within 5 months after the last dose of atezolizumab

- Treatment with investigational therapy within 28 days prior to initiation of study
treatment

- Prior treatment with CD137 agonists or immune checkpoint blockade therapies, including
anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic antibodies

- Treatment with systemic immunostimulatory agents (including, but not limited to,
interferon and interleukin 2 [IL-2]) within 4 weeks or five half-lives of the drug
(whichever is longer) prior to initiation of study treatment

- Treatment with systemic immunosuppressive medication (including, but not limited to,
corticosteroids, cyclophosphamide, azathioprine, methotrexate, thalidomide, and
anti-TNF-agents) within 2 weeks prior to initiation of study treatment, or
anticipation of need for systemic immunosuppressive medication during the course of
the study, with the following exceptions: Patients who received acute, low-dose
systemic immunosuppressant medication or a one-time pulse dose of systemic
immunosuppressant medication (e.g., 48 hours of corticosteroids for a contrast
allergy) are eligible for the study after principal investigator approval. Patients
who received mineralocorticoids (e.g., fludrocortisone), corticosteroids for chronic
obstructive pulmonary disease (COPD) or asthma, or low-dose corticosteroids for
orthostatic hypotension or adrenal insufficiency are eligible for the study

- History of severe allergic anaphylactic reactions to chimeric or humanized antibodies
or fusion proteins

- Known hypersensitivity to Chinese hamster ovary cell products or to any component of
the atezolizumab formulation

- Known allergy or hypersensitivity to any component of the oxaliplatin or 5-FU
formulation

- Pregnant or breastfeeding, or intending to become pregnant during the study or within
5 months for atezolizumab