Unraveling tumor response and resistance to combined chemotherapy and PD-L1 inhibition with minimal invasive techniques in patients with advanced NSCLC with targetable disease

1. Provision of signed and dated, written informed consent.
2. Female and male subjects aged at least 18 years.
3. Subjects with histologically- or cytologically-documented non squamous NSCLC
with a documented driver mutation (such as EGFR, ALK, ROS, BRAF, MET, RET,
NTRK1-3, KRAS, NRG1, HER 2).
4. New (< 3 month old) tumor specimen (histology or cytology containing enough
tumor cells and tumor DNA for at least NGS and PD-L1 staining confirmed by a
pathologist). If the tumor specimen reveals a possible new targetable driver
than that has to be discussed with the subject as an option next to this study.
5. Locally advanced or metastatic NSCLC, not amenable to curative surgery or
radiotherapy.
6. Evidence of radiological disease progression following first line TKI or any
subsequent treatment lines with TKI only (for EGFR treated with either
osimertinib or failure of other TKIs 2nd line or later). Previous course of
chemotherapy is allowed, but not necessary as well.
7. ECOG performance status 0-1 with no deterioration over the previous 2 weeks
and a minimum life expectancy of 12 weeks.
8. At least one lesion, not previously irradiated and not chosen for biopsy
during the study screening period, that can be accurately measured at baseline
as >= 10mm in the longest diameter (except for pathological lymph nodes they
must be >= 15mm in short axis) with computerized tomography (CT) or magnetic
resonance imaging (MRI) which is suitable for accurate repeated measurements.
9. Adequate hematologic and end organ function, defined by the following
laboratory results obtained within <=14 days prior to study treatment:
o ANC >=1500 cells/µL (without granulocyte colony-stimulating factor support)
o WBC counts >2500/µL
o Lymphocyte count >=500/µL
o Platelet count >=100,000/µL (without transfusion)
o Hemoglobin >=9.0 g/dL. Patients may be transfused or receive erythropoietic
treatment to meet this criterion.
o AST, ALT, and alkaline phosphatase <= 2.5× the upper limit of normal (ULN),
with the following exceptions:
- Patients with documented liver metastases: AST and/or ALT <= 5 × ULN
- Patients with documented liver or bone metastases: alkaline phosphatase <= 5 ×
ULN
o Serum bilirubin <= 1.5 × ULN. Patients with known Gilbert disease who have
serum bilirubin level <= 3 × ULN may be enrolled.
o INR and aPTT <= 1.5 × ULN. This applies only to patients who are not receiving
therapeutic anticoagulation; patients receiving therapeutic anticoagulation
should be on a stable dose.
o Creatinine clearance >= 30 mL/min.
10. Females should be using adequate contraceptive measures, should not be
breast feeding and must have a negative pregnancy test prior to start of dosing
if of child-bearing potential or must have evidence of non-child-bearing
potential by fulfilling one of the following criteria at screening:
o Post-menopausal defined as aged more than 50 years and amenorrhoeic for at
least 12 months following cessation of all exogenous hormonal treatments.
o Women under 50 years old would be considered postmenopausal if they have been
amenorrhoeic for 12 months or more following cessation of exogenous hormonal
treatments and with Luteinizing Hormone (LH) and Follicle-Stimulating Hormone
(FSH) levels in the post-menopausal range for the institution.
o Documentation of irreversible surgical sterilization by hysterectomy,
bilateral ophorectomy or bilateral salpingectomy but not tubal ligation.
11. Male subjects should be willing to use barrier contraception ie, condoms.
12. Ability to comply with protocol.

1. Treatment with any other investigational agent or participation in another
clinical trial with therapeutic intent within 14 days prior to inclusion of the
study.
2. Prior treatment with CD137 agonists or immune checkpoint blockade therapies,
anti*PD-1, and anti*PD-L1 therapeutic antibodies.
• Patients who have had prior anti*CTLA-4 treatment may be enrolled, provided
the following requirements are met:
o Minimum of 6 weeks from the last dose of anti*CTLA-4
o No history of severe immune related adverse effects from anti*CTLA-4 (CTCAE
Grade 3 and 4).
3. CNS disease, treated brain metastases without the need for steroids are
allowed.
4. Leptomeningeal disease.
5. 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. Patients should be recovered from the effects of radiation. There
is no required minimum recovery period.
• Asymptomatic metastatic lesions whose further growth would likely cause
functional deficits or intractable pain (e.g., epidural metastasis that is not
currently associated with spinal cord compression) should be considered for
loco-regional therapy if appropriate prior to enrollment.
6. Uncontrolled pleural effusion, pericardial effusion, or ascites requiring
recurrent drainage procedures (once monthly or more frequently).
7. Malignancies other than NSCLC within 3 years prior with the exception of
those with a negligible risk of metastasis or death treated with expected
curative outcome (such as adequately treated carcinoma in situ of the cervix,
basal or squamous cell skin cancer, localized prostate cancer treated with
curative intent, ductal carcinoma in situ treated surgically with curative
intent).
8. Pregnant and lactating women.
9. History of severe allergic, anaphylactic, or other hypersensitivity
reactions to chimeric or humanized antibodies or fusion proteins.
10. Known hypersensitivity or allergy to biopharmaceuticals produced in Chinese
hamster ovary cell products or any component of the atezolizumab formulation.
11. History of autoimmune disease, including but not limited to myasthenia
gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus,
rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis
associated with antiphospholipid syndrome, Wegener*s granulomatosis, Sjögren*s
syndrome, Guillain-Barré syndrome, multiple sclerosis, vasculitis, or
glomerulonephritis.
• Patients with a history of autoimmune-related hypothyroidism on a stable dose
of thyroid replacement hormone may be eligible for this study.
• Patients with controlled Type I diabetes mellitus on a stable dose of insulin
regimen may be eligible for this study.
12. History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g.,
bronchiolitis obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or
evidence of active pneumonitis on screening chest CT scan.
• History of radiation pneumonitis in the radiation field (fibrosis) is
permitted.
13. Positive test for HIV.
14. Patients with active hepatitis B (chronic or acute; defined as having a
positive hepatitis B surface antigen [HBsAg] test at screening) or hepatitis C.
15. Patients with past hepatitis B virus (HBV) infection or resolved HBV
infection (defined as the presence of hepatitis B core antibody [HBcAb] and
absence of HBsAg) are eligible. HBV DNA test must be performed in these
patients prior to start of study treatment.
• Patients positive for hepatitis C virus (HCV) antibody are eligible
only if polymerase chain reaction is negative for HCV RNA.
16. Active tuberculosis.
17. Severe infections within 4 weeks prior to inclusion of the study, including
but not limited to hospitalization for complications of infection, bacteremia,
or severe pneumonia.
18. Signs or symptoms of infection within 2 weeks prior to inclusion of the
study.
19. Significant cardiovascular disease, such as New York Heart Association
cardiac disease (Class II or greater), myocardial infarction within the
previous 3 months, unstable arrhythmias, or unstable angina.
• Patients with known coronary artery disease, congestive heart failure not
meeting the above criteria, or left ventricular ejection fraction <50% must be
on a stable medical regimen that is optimized in the opinion of the treating
physician, in consultation with a cardiologist if appropriate.
20. Major surgical procedure other than for diagnosis within 28 days prior to
prior to inclusion of the study, or anticipation of need for a major surgical
procedure during the course of the study.
21. Prior allogeneic bone marrow transplantation or solid organ transplant.
22. Administration of a live, attenuated vaccine within 4 weeks prior to
inclusion of the study, or anticipation that such a live attenuated vaccine
will be required during the study.
• Influenza vaccination should be given during influenza season only (example:
approximately October to March in the Northern Hemisphere). Patients must not
receive live, attenuated influenza vaccine (e.g. FluMist®) at any time during
the study.
• corona vaccination is allowed.
23. Any other diseases, metabolic dysfunction, physical examination finding, or
clinical laboratory finding giving reasonable suspicion of a disease or
condition that contraindicates the use of an investigational drug or that may
affect the interpretation of the results or render the patient at high risk
from treatment complications.
24. Treatment with systemic immunostimulatory agents (including but not limited
to IFNs, IL-2).
25. Treatment with systemic immunosuppressive medications (including but not
limited to prednisone, cyclophosphamide, azathioprine, methotrexate,
thalidomide, and anti*tumor necrosis factor agents) within 2 weeks prior to
inclusion of the study.
• Patients who have received acute, low-dose, systemic immunosuppressant
medications (e.g. a one-time dose of dexamethasone for nausea) may be enrolled
in the study after discussion with and approval by the sponsor.
26. The use of inhaled corticosteroids for chronic obstructive pulmonary
disease, mineralocorticoids (e.g. fludrocortisone) for patients with
orthostatic hypotension, and low-dose supplemental corticosteroids for
adrenocortical insufficiency are allowed.

Exclusion criteria related to bevacizumab:
27. Inadequately controlled hypertension (defined as systolic blood pressure >
150 mmHg and/or diastolic blood pressure > 100 mmHg). Anti-hypertensive therapy
to achieve these parameters is allowable.
28. Prior history of hypertensive crisis or hypertensive encephalopathy
29. Significant vascular disease (e.g., aortic aneurysm requiring surgical
repair or recent peripheral arterial thrombosis) within 6 months prior to
randomization
30. History of hemoptysis (>= one-half teaspoon of bright red blood per episode)
within 1 month prior to randomization.
31. Evidence of bleeding diathesis or coagulopathy (in the absence of
therapeutic anticoagulation).
32. Current or recent (within 10 days of randomization) use of aspirin (> 325
mg/day) or treatment with dipyramidole, ticlopidine, clopidogrel, and clostazol.
33. Current use of full-dose oral or parenteral anticoagulants or thrombolytic
agents for therapeutic purposes that has not been stable for > 2 weeks prior to
randomization.
The use of full-dose oral or parenteral anticoagulants is permitted as long as
the INR or aPTT is within therapeutic limits (according to the medical standard
of the enrolling institution) and the patient has been on a stable dose of
anticoagulants for at least 2 weeks prior to randomization.
Prophylactic anticoagulation for the patency of venous access devices is
allowed, provided the activit