: Small cell lung cancer (SCLC), accounting for 10% of all lung cancers (Torre et al., 2015), shows poor outcomes with 7-10 months of median survival in advanced cases (Jett et al., 2013). Despite novel treatment strategies including targeted therapy and immunotherapy for non-small cell lung cancer (NSCLC) have been introduced, the treatment options for SCLC still remain limited. Many clinical trials, which tested the efficacy of molecular targeted agents for SCLC, failed to show clinical benefit compared with conventional platinum-based chemotherapy (Koinis et al., 2016). Nevertheless, recent studies demonstrated that immunotherapy using anti-CTLA-4 or anti-PD1 monoclonal antibody can be novel therapeutic strategies for SCLC (Ott et al., 2015; Reck et al., 2013; SJ et al., 2015).
In recent years, many studies have shown that radiation therapy can be a useful treatment as a combining treatment with immunotherapy. The abscopal effect refers to the ability of radiation delivered radiation delivered to a local site to treat the other diseases outside radiation field (Tang et al., 2014). A recent study described that abscopal effect was observed in a malignant melanoma patient treated with CTLA4 antagonist and radiotherapy (Postow et al., 2012). Moreover, an animal study presented that blockade of PD-L1 and ionizing radiation showed synergism (Deng et al., 2014). Based on these emerging evidences, we hypothesized that local radiation therapy can enhance the effect of anti-PD-L1 monoclonal antibody through increasing T-cell effector function against tumors. Atezolizumab, which is a humanized anti-PD-L1 monoclonal antibody, act as an inhibitor the interaction between PD-L1 and PD-1, and eventually restore suppressed T-cell immunity leading elimination of cancer cells. In this study, we will investigate the combining effect of hypofractionated-sublethal dose of radiation therapy followed by anti-PD-L1 monoclonal antibody, atezolizumab, for SCLC patients who are recurrent or refractory for initial platinum-based chemotherapy.

Treatment

Radiation therapy will be delivered to the largest or most representative lesion among primary and metastatic lesions every other day since D1 of 1st cycle of atezolizumab. The total radiation dose will be 24 Gy in 4 fractions of 6 Gy. 
After induction RT, atezolizumab at a fixed dose of 1200 mg will be administered intravenously on Day 1 of each 21-day cycle.

Arm Label

Target Number of Participant

Arm Type

Arm Description

This is a single arm phase II study of sequential hypofractionated radiotherapy followed by atezolizumab in patients with recurrent or refractory SCLC previously treated with platinum-based chemotherapy. A total of 35 eligible patients will be enrolled. All toxicities are graded according to the National Cancer Institute Common Toxicity Criteria Version 4.0. 
Radiation therapy will be delivered to the largest or most representative lesion among primary and metastatic lesions every other day since D1 of 1st cycle of atezolizumab. The total radiation dose will be 24 Gy in 4 fractions of 6 Gy. After induction RT, atezolizumab at a fixed dose of 1200 mg will be administered intravenously on Day 1 of each 21-day cycle

Gender

Age

Description

1)	Male or female patient aged 18 years or older 
2)	Histologically confirmed SCLC and available tumor tissues for PD-L1 staining 
3)	Progression during or after platinum-based chemotherapy.
4)	At least one target tumor lesion that has not been irradiated within the past three months and that can accurately be measured in at least one dimension with longest diameter 
≥10 mm (by CT scan, MRI, caliper measurement) or ≥20 mm (by chest X-ray). (RECIST 1.1)
5)	Life expectancy of at least three months
6)	Performance status of 0, 1, 2 on the ECOG criteria
7)	Adequate hematologic and end-organ function, defined by the following laboratory results obtained within 14 days prior to the first dose of atezolizumab:
ANC ≥1500 cells/µL (without granulocyte colony stimulating factor support within 2 weeks of laboratory test used to determine eligibility)
WBC counts ≥ 2500/µL
Lymphocyte count ≥ 500/µL 
Serum albumin ≥ 2.5 g/dL
Platelet count ≥ 100,000/µL (without transfusion within 2 weeks of laboratory test used to determine eligibility)
Hemoglobin ≥ 9.0 g/dL; Patients may be transfused or receive erythropoietic treatment to meet this criterion.
AST, ALT, and alkaline phosphatase ≤ 2.5 x ULN with the following exceptions:
Patients with documented liver metastases: AST and/or ALT ≤ 5 x ULN
Patients with documented liver or bone metastases:  alkaline phosphatase ≤ 5 x ULN
Serum bilirubin ≤ 1.5 x ULN
Patients with known Gilbert’s disease who have serum bilirubin level ≤ 3 x ULN may be enrolled.
INR and aPTT ≤ 1.5 x ULN 
This applies only to patients who are not receiving therapeutic anticoagulation; patients receiving therapeutic anticoagulation should be on a stable dose for at least 1 week prior to the first dose of atezolizumab.
Creatinine clearance ≥ 30 mL/min
Cockcroft-Gault, CKD EPI, or MDRD formulas may be used for creatinine clearance calculation.  Note that 24-hour urine collection is not required but is allowed.
8)	Patient has given written informed consent which must be consistent with the International Conference on Harmonization – Good Clinical Practice (ICH-GCP) and local legislation

1)	Previous therapy with anti-PD-1 or –PD-L1 inhibitors 
2)	Persistence of clinically relevant therapy related toxicities from previous chemotherapy and/or radiotherapy
3)	Chemotherapy, treatment with tyrosine kinase inhibitors, or radiotherapy (except for brain and extremities) within the past 3 weeks prior to treatment with the trial drug i.e., the minimum time elapsed since the last anticancer therapy and the first radiotherapy must be 3 weeks
4)	Treatment with other investigational drugs or treatment in another clinical trial within the past three weeks before start of therapy or concomitantly with this trial
5)	Concomitant yellow fever vaccination
6)	Active or untreated CNS metastases as determined by CT or MRI evaluation during screening and prior radiographic assessments
Patients with a history of treated asymptomatic CNS metastases are eligible, provided they meet all of the following criteria:
-	Measurable disease outside the CNS
-	Only supratentorial metastases allowed (i.e., no metastases to midbrain, pons, cerebellum, medulla, or spinal cord)
-	No history of intracranial hemorrhage
-	No ongoing requirement for corticosteroids as therapy for CNS disease; anticonvulsants at a stable dose allowed
-	No stereotactic radiation within 7 days or whole-brain radiation within 14 days prior to Cycle 1, Day 1
-	No evidence of interim progression between the completion of CNS-directed therapy and the screening radiographic study
Note: Patients with new asymptomatic CNS metastases detected at the screening scan must receive radiation therapy and/or surgery for CNS metastases. Following treatment, these patients may then be eligible without the need for an additional brain scan prior to enrollment, if all other criteria are met.
7)	Spinal cord compression not definitively treated with surgery and/or radiation or previously diagnosed and treated spinal cord compression without evidence that disease has been clinically stable for ≥2 weeks prior to randomization
8)	Leptomeningeal disease
9)	Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrent drainage procedures
10)	Uncontrolled tumor-related pain
-	Patients requiring pain medication must be on a stable regimen at study entry.
-	Symptomatic lesions amenable to palliative radiotherapy (e.g., bone metastases or metastases causing nerve impingement) should be treated prior to enrollment.
-	Asymptomatic metastatic lesions whose further growth would likely cause functional deficits or intractable pain (e.g., epidural metastasis that is not presently associated with spinal cord compression) should be considered for loco-regional therapy if appropriate prior to enrollment.
11)	Uncontrolled hypercalcemia (>1.5 mmol/L ionized calcium or Ca >12 mg/dL or corrected serum calcium >ULN) or symptomatic hypercalcemia requiring continued use of bisphosphonate therapy or denosumab
-	Patients who are receiving bisphosphonate therapy or denosumab specifically to prevent skeletal events and who do not have a history of clinically significant hypercalcemia are eligible.
-	Patients who are receiving denosumab prior to enrollment must be willing and eligible to discontinue its use and replace it with a bisphosphonate instead while in the study.
12)	Significant cardiovascular diseases (i.e., hypertension not controlled by medical therapy, unstable angina, history of myocardial infarction within the past 12 months, congestive heart failure > NYHA II, serious cardiac arrhythmia, pericardial effusion)
13)	Proteinuria CTCAE grade 2 or greater
14)	Significant weight loss (> 10 %) within the past 6 weeks prior to treatment in the present trial
15)	Current peripheral neuropathy ≥ CTCAE(version4.0) Grade 2 except due to trauma
16)	Major injuries and/or surgery with incomplete wound healing within the past ten days prior to enrollment
17)	Serious infections requiring systemic antibiotic (e.g. antiviral, antimicrobial, antifungal) therapy
18)	Active hepatitis C and/or B infection
19)	Known human immunodeficiency virus (HIV) seropositivity
20)	Serious illness or concomitant non-oncological disease such as neurologic-,psychiatric-, infectious disease or active ulcers (gastro-intestinal tract, skin) or laboratory abnormality that may increase the risk associated with study participation or study drug administration and in the judgment of the investigator would make the patient inappropriate for entry into the study
21)	Patients who are sexually active and unwilling to use a medically acceptable method of contraception (e.g. such as implants, injectables, combined oral contraceptives, some intrauterine devices or vasectomized partner for participating females, condoms for participating males) during the trial and for at least 5 months after end of active therapy
22)	Pregnancy or breast feeding
23)	Psychological, familial, sociological or geographical factors potentially hampering compliance with the study protocol and follow-up schedule
24)	Patients unable to comply with the protocol
25)	Active alcohol or drug abuse
26)	Other malignancy within the past three years other than basal cell skin cancer or carcinoma in situ of the cervix

Objective Response rate using RECIST v1.1

every 2 cycle

Overall survival

the number of days from the date of study treatment start to the date of death.

Progression-free survival

the time from the date of study treatment start to the date of progression or to the date of death, whichever occurs first.

Toxicity

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