EA8143 Kidney Cancer

ELIGIBILITY CRITERIA FOR PREREGISTRATION (STEP 0):

• Patients with a renal mass consistent with a clinical stage >= T2Nx renal cell carcinoma (RCC) or TanyN+ RCC for which radical or partial nephrectomy is planned
• If histological confirmation of RCC has not been done within 12 months prior to pre-registration (Step 0), patient must be willing to undergo a core biopsy for this purpose if randomized to Arm H
  • NOTE: This can be a (1) standard of care diagnostic biopsy or (2) a research biopsy following assignment to Arm H; if the biopsy performed following pre-registration (Step 0) clearly demonstrates a benign condition or a different type of cancer, the patient is not eligible for registration (Step 1); a non-diagnostic biopsy is considered a good faith effort and does not need to be repeated unless deemed clinically necessary by the treating investigator
  • NOTE: Patients randomized to Arm O are permitted to register to Step 1 (Arm B) immediately following pre-registration assignment to Arm O, regardless of if they have had or have not had standard of care diagnostic biopsy

• Patients must have no clinical or radiological evidence of distant metastases (M0) unless the presumed M1 disease can be resected/definitively treated (e.g., thermal ablation, stereotactic radiation) at the same time or within a 12 week window from the date of the initial procedure such that the patient is considered "no evidence of disease" (M1 NED)
  • Permitted sites of oligo-metastases: lung, adrenal, nodes, pancreas, soft tissue or skin; liver or bone metastases are not permitted
  • No more than 3 metastases are permitted and all must be able to be removed or definitively treated within 12 weeks of the primary tumor resection

• No prior systemic or local anti-cancer therapy for the current RCC is permitted; examples of these prohibited therapies include:
  • Partial nephrectomy for prior RCC
  • Mastectomy for RCC
  • Radiation therapy to the renal bed or any distant metastatic sites
  • Current or past antineoplastic systemic therapies for RCC: i.e., chemotherapy, hormonal therapy, immunotherapy, or standard or investigational agents for treatment of RCC
  • Prior treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-CTLA-4 antibody, or any other antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways

• Eastern Cooperative Oncology Group (ECOG) performance status: 0 or 1
• Women of childbearing potential and sexually active males must be strongly advised to use accepted and effective methods of contraception, as described in the informed consent form (ICF), or to abstain from sexual intercourse for the duration of their participation in the study; women of childbearing potential should use adequate methods to avoid pregnancy for 23 weeks after the last dose of nivolumab; sexually active males should use adequate methods to avoid pregnancy for 31 weeks after the last dose of nivolumab
• Patient must have no prior history of RCC that was resected with curative intent within the past 5 years
  • Patients with a prior RCC that was treated > 5 years before, are eligible if the current tumor is consistent with a new primary in the opinion of the treating investigator
  • Patients with bilateral synchronous RCCs are eligible if they can be resected or definitively treated at the same time or within a 12 week window from time of initial nephrectomy (partial or radical) or procedure and maintain adequate residual renal function; the patient is not eligible if both kidneys are completely removed and subsequent hemodialysis is required

• Permitted forms of local therapy for second tumor:
  • Partial or radical nephrectomy
  • If tumor is =< 3cm: thermal ablation (e.g., radiofrequency ablation, cryoablation or stereotactic radiosurgery)
• Patients must not have concurrent malignancies, with the following exceptions:
  • Adequately treated basal cell or squamous cell skin cancer
  • In situ cervical cancer

• A history of superficial Ta urothelial cancer is permitted (as long as not currently undergoing treatment) whereas T1 or greater disease is excluded if < 3 years from diagnosis; concurrent persistent disease is not permitted
• Adequately treated Stage I or II cancer from which the patient is currently in complete remission
• Any other cancer and stage from which the patient has been disease-free for at least 3 years prior to the time of pre-registration and as long as they are not receiving any current treatment (e.g. adjuvant or maintenance systemic or local therapy)
• Concurrent low risk prostate cancer on active surveillance

• No active known or suspected autoimmune disease; the following autoimmune disorders are permitted: patients with vitiligo, type I diabetes mellitus, controlled/stable hypothyroidism due to autoimmune or non-autoimmune conditions (hormone replacement is allowed), psoriasis not requiring systemic treatment, or other conditions not expected to recur
• No ongoing condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalent) or other immunosuppressive medications with the exceptions outlined below; no treatment with other immunosuppressive agents within 14 days prior to the first dose of study drug with the following exceptions:
  • Topical, ocular, intra-articular, intranasal, inhaled steroids and adrenal replacement steroid doses > 10 mg daily prednisone or the equivalent are permitted in the absence of active autoimmune disease
  • A brief (less than 3 weeks) course of corticosteroids (any amount) for prophylaxis (for example: contrast dye allergy) or for treatment of non-autoimmune conditions (for example: nausea, delayed-type hypersensitivity reaction caused by a contact allergen) is permitted

• No uncontrolled adrenal insufficiency
• No known chronic active liver disease or evidence of acute or chronic hepatitis B virus (HBV) or hepatitis C virus (HCV)
• No serious intercurrent illness, including ongoing or active infection requiring parenteral antibodies
• No known evidence of human immunodeficiency virus (HIV) infection
• No known medical condition (e.g. a condition associated with uncontrolled diarrhea such as ulcerative colitis or acute diverticulitis) that, in the investigator's opinion, would increase the risk associated with study participation or interfere with the interpretation of safety results
• No major surgery within 28 days prior to randomization
• No patients currently enrolled in other clinical trials testing a therapeutic intervention
• No history of severe hypersensitivity to a monoclonal antibody
• Signed, dated informed consent
• ELIGIBILITY CRITERIA FOR RANDOMIZATION (STEP 1):
• Patients must meet all Step 0 eligibility criteria at the time of their registration to Step 1
• In patients randomized to Arm H, core tumor biopsy must demonstrate RCC of any histology, including sarcomatoid, unclassified, or "unknown histology" (if preoperative biopsy was uninformative)
  • NOTE: A non-diagnostic biopsy is considered a good faith effort and does not need to be repeated unless deemed clinically necessary by the treating investigator

• Women must not be pregnant or breast-feeding; all females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria:
  • Has not undergone a hysterectomy or bilateral oophorectomy, or
  • Has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)

• White blood cells >= 2000/uL, within 8 weeks of registration
• Absolute neutrophil count (ANC) >= 1,500/mm^3, within 8 weeks of registration
• Platelet count >= 100,000/mm^3, within 8 weeks of registration
• Hemoglobin >= 9.0 g/dL, within 8 weeks of registration
• Serum creatinine =< 1.5 x upper limit of normal (ULN) (except subjects with Gilbert Syndrome, who can have total bilirubin < 3.0 x ULN), within 8 weeks of registration
• Total bilirubin =< 1.5 x ULN (except subjects with Gilbert syndrome, who can have total bilirubin < 3.0 x ULN), within 4 weeks of randomization
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN, within 8 weeks of registration