Testing the Addition of Stereotactic Radiation Therapy With Immune Therapy for the Treatment of Patients With Unresectable or Metastatic Renal Cell Cancer, SAMURAI Study
Purpose
This phase II trial tests whether the addition of radiation to the primary tumor, typically given with stereotactic ablative radiation therapy (SABR), in combination with standard of care immunotherapy improves outcomes in patients with renal cell cancer that is not recommended for surgery and has spread to other places in the body (metastatic). Radiation therapy uses high energy photons to kill tumor cells and shrink tumors. Stereotactic body radiation therapy uses special equipment to position a patient and deliver radiation to tumors with high precision. This method may kill tumor cells with fewer doses of radiation over a shorter period and cause less damage to normal tissue. Immunotherapy with monoclonal antibodies, such as nivolumab, ipilimumab, avelumab, and pembrolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Axitinib, cabozantinib, and lenvatinib are in a class of medications called antiangiogenic agents. They work by stopping the formation of blood vessels that bring oxygen and nutrients to tumor. This may slow the growth and spread of tumor. Giving SABR in combination with standard of care immunotherapy may help shrink or stabilize the cancer in patients with renal cell cancer.
Conditions
- Metastatic Renal Cell Carcinoma
- Stage III Renal Cell Cancer AJCC v8
- Stage IV Renal Cell Cancer AJCC v8
- Unresectable Renal Cell Carcinoma
Eligibility
- Eligible Ages
- Over 18 Years
- Eligible Genders
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- Pathologically (histologically or cytologically) proven diagnosis of renal cell carcinoma prior to registration - Node-positive unresectable (TxN1Mx) or metastatic (TxNxM1) based on the following diagnostic workup: - History/physical examination within 45 days prior to registration - CT/magnetic resonance imaging (MRI) of the chest/abdomen/pelvis within 45 days prior to registration - Patients must have IMDC intermediate (1-2 factors) or poor risk disease (>= 3 factors) - Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial - Patients with measurable disease (node positive or metastatic) as defined by RECIST version 1.1 excluding the primary renal tumor - Patient not recommended for or refused immediate cytoreductive nephrectomy - Candidate for standard of care therapy with either immuno-oncology (IO)-IO or IO-VEGF combination regimen - Primary renal tumor measuring 20 cm or less in anterior to posterior dimension only on axial imaging - Age >= 18 - Karnofsky performance status >= 60 within 45 days prior to registration - Hemoglobin >= 8 g/dL (transfusions are allowed) (within 45 days prior to registration) - Platelet count >= 50,000/mm^3 (within 45 days prior to registration) - Absolute neutrophil count (ANC) >= 1500/mm^3 (within 45 days prior to registration) - Calculated (Calc.) creatinine clearance >= 30 mL/min (within 45 days prior to registration) - For African American patients specifically whose renal function is not considered adequate by the formula above, an alternative formula that takes race into account (Chronic Kidney Disease Epidemiology Collaboration CKD-EPI formula) should be used for calculating the related estimated glomerular filtration rate (GFR) with a correction factor for African American race creatinine clearance for trial eligibility, where GFR >= 30 mL/min/1.73m^2 will be considered adequate - Total bilirubin =< 1.5 x upper limit of normal (ULN) (except subjects with Gilbert Syndrome, who can have total bilirubin < 3.0 mg/dL) (within 45 days prior to registration) - Aspartate aminotransferase and alanine aminotransferase (AST and ALT) =< 3 x upper limit of normal (ULN) or < 5 x ULN if hepatic metastases present (within 45 days prior to registration) - Patients with known human immunodeficiency virus (HIV) on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial. Testing is not required for entry into protocol - For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated - Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. Patients with HCV infection who are currently on treatment are eligible if they have an undetectable HCV viral load - The patient must agree to use a highly effective contraception, including men with vasectomies if they are having sex with a woman of childbearing potential or with a woman who is pregnant, while on study drug and for 6 months following the last dose of study drug. Childbearing potential is defined as any person who has experienced menarche and who has not undergone surgical sterilization (hysterectomy or bilateral oophorectomy) or who is not postmenopausal - The patient or a legally authorized representative must provide study-specific informed consent prior to study entry and, for patients treated in the United States (U.S.), authorization permitting release of personal health information
Exclusion Criteria
- Patients with planned treatment of all metastatic disease with definitive therapy including either surgery, ablative (non-palliative) doses of radiation, or intervention of some type (definitive interventional radiology techniques) to ALL metastatic sites rendering the patient without extra-renal measurable disease. Patients NOT planned for definitive treatment of all metastatic sites are eligible. Lesions radiated palliatively are not eligible for response assessment - Patients with untreated or unstable brain metastases or cranial epidural disease - Note: Patients who have been adequately treated with radiotherapy, radiosurgery, or surgery and stable for at least 4 weeks prior to registration as documented by MRI or CT imaging or deemed stable by clinical investigator are eligible. Treated brain metastases are defined as having no ongoing requirement for steroids and no evidence of progression or hemorrhage after treatment for at least 4 weeks prior to registration as documented by MRI or CT imaging or deemed stable by clinical investigator - Prior radiotherapy to the kidney that would result in overlap of radiation therapy fields treatment of the primary tumor - Any systemic therapy for metastatic renal cell carcinoma (RCC) that was initiated > 90 days before registration, note that prior chemotherapy for a different cancer is allowed (completed > 3 years prior to registration) - Severe, active comorbidity defined as follows: - Active autoimmune disease requiring ongoing therapy including systemic treatment with corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications daily. Inhaled steroids and adrenal replacement steroid doses > 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease - History of severe allergic, anaphylactic or other hypersensitivity reactions to chimeric or humanized antibodies - Active tuberculosis (purified protein derivative [PPD] response without active tuberculosis [TB] is allowed) - Uncontrolled hypertension (systolic blood pressure [BP] > 190 mmHg or diastolic BP > 110 mmHg) - Major surgery requiring hospital admission ≤ 28 days prior to registration. - Any serious (requiring hospital stay or long-term rehab) non-healing wound, ulcer, or bone fracture within 45 days prior to registration - Any arterial thrombotic (ST elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction [NSTEMI], cerebrovascular accident [CVA], etc) events within 180 days prior to registration - Active New York (NY) Heart Association class 3-4 heart failure symptoms - Moderate or severe hepatic impairment (Child-Pugh B or C) - Any history of untreated pulmonary embolism or deep venous thrombosis (DVT) within 180 days prior to registration. (Any asymptomatic or treated pulmonary embolism or asymptomatic treated deep venous thrombosis > 30 days prior to registration is allowed) - Unstable cardiac arrhythmia within 180 days prior to registration - History of abdominal fistula, gastrointestinal perforation, intra-abdominal abscess, bowel obstruction, or gastric outlet obstruction within 180 days prior to registration - History of or active inflammatory bowel disease - Malabsorption syndrome within 45 days prior to registration - Pregnancy and individuals unwilling to discontinue nursing. For women of child bearing potential must have a negative pregnancy test =< 45 days prior to registration
Study Design
- Phase
- Phase 2
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel Assignment
- Primary Purpose
- Treatment
- Masking
- None (Open Label)
Arm Groups
Arm | Description | Assigned Intervention |
---|---|---|
Active Comparator Arm I (standard of care immunotherapy) |
Patients receive one of the following immunotherapy regimens per physician discretion: nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes every 3 weeks for 4 doses followed by nivolumab IV over 30 minutes every 2 or 4 weeks; pembrolizumab IV over 30 minutes every 3 or 6 weeks and axitinib PO BID; avelumab IV over 60 minutes every 2 weeks and axitinib PO BID; nivolumab IV over 30 minutes every 2 or 4 weeks and cabozantinib PO QD; OR pembrolizumab IV over 30 minutes every 3 or 6 weeks and lenvatinib PO QD. Treatment with immunotherapy continues in the absence of disease progression or unacceptable toxicity. |
|
Experimental Arm II (SABR, standard of care immunotherapy) |
Patients undergo SABR on 3 different days over 1-3 weeks and receive immunotherapy as in Arm I. |
|
Recruiting Locations
Birmingham, Alabama 35233
Little Rock, Arkansas 72205
Site Public Contact
501-686-8274
Encinitas, California 92024
Site Public Contact
760-536-7700
La Jolla, California 92093
San Diego, California 92103
San Luis Obispo, California 93401
Jacksonville, Florida 32224-9980
Site Public Contact
855-776-0015
Miami, Florida 33176
Site Public Contact
786-596-2000
Alton, Illinois 62002
Site Public Contact
618-463-7323
Centralia, Illinois 62801
Chicago, Illinois 60611
Danville, Illinois 61832
Decatur, Illinois 62526
Decatur, Illinois 62526
DeKalb, Illinois 60115
Effingham, Illinois 62401
Effingham, Illinois 62401
Geneva, Illinois 60134
Lake Forest, Illinois 60045
Mattoon, Illinois 61938
Shiloh, Illinois 62269
Springfield, Illinois 62702
Site Public Contact
217-545-7929
Springfield, Illinois 62702
Site Public Contact
800-444-7541
Springfield, Illinois 62781
Urbana, Illinois 61801
Urbana, Illinois 61801
Warrenville, Illinois 60555
Ames, Iowa 50010
Site Public Contact
515-956-4132
Ames, Iowa 50010
Metairie, Louisiana 70006
Metairie, Louisiana 70006
New Orleans, Louisiana 70112
New Orleans, Louisiana 70112
Baltimore, Maryland 21201
Site Public Contact
800-888-8823
Columbia, Maryland 21044
Site Public Contact
443-546-1300
Glen Burnie, Maryland 21061
Site Public Contact
410-553-8100
Boston, Massachusetts 02115
Site Public Contact
617-724-5200
Boston, Massachusetts 02215
Site Public Contact
877-442-3324
Ann Arbor, Michigan 48106
Ann Arbor, Michigan 48109
Site Public Contact
800-865-1125
Brighton, Michigan 48114
Brighton, Michigan 48114
Canton, Michigan 48188
Canton, Michigan 48188
Chelsea, Michigan 48118
Chelsea, Michigan 48118
Dearborn, Michigan 48124
Site Public Contact
248-551-7695
Farmington Hills, Michigan 48336
Site Public Contact
248-551-7695
Lansing, Michigan 48912
Site Public Contact
517-364-9400
Livonia, Michigan 48154
Royal Oak, Michigan 48073
Site Public Contact
248-551-7695
Troy, Michigan 48085
Site Public Contact
248-551-7695
Ypsilanti, Michigan 48197
Bemidji, Minnesota 56601
Rochester, Minnesota 55905
Site Public Contact
855-776-0015
Cape Girardeau, Missouri 63703
Columbia, Missouri 65212
Site Public Contact
573-882-7440
Creve Coeur, Missouri 63141
Saint Louis, Missouri 63110
Saint Louis, Missouri 63129
Saint Louis, Missouri 63136
Saint Peters, Missouri 63376
Camden, New Jersey 08103
Site Public Contact
856-325-6757
Lakewood, New Jersey 08701
Long Branch, New Jersey 07740
Mount Laurel, New Jersey 08054
New Brunswick, New Jersey 08903
Site Public Contact
732-235-7356
Toms River, New Jersey 08755
Albuquerque, New Mexico 87102
Albuquerque, New Mexico 87109
Glens Falls, New York 12801
Site Public Contact
518-926-6700
Stony Brook, New York 11794
Site Public Contact
800-862-2215
Chapel Hill, North Carolina 27599
Bismarck, North Dakota 58501
Fargo, North Dakota 58122
Fargo, North Dakota 58122
Avon, Ohio 44011
Site Public Contact
800-641-2422
Beachwood, Ohio 44122
Centerville, Ohio 45459
Centerville, Ohio 45459
Cleveland, Ohio 44106
Columbus, Ohio 43210
Dayton, Ohio 45409
Site Public Contact
937-276-8320
Dayton, Ohio 45409
Dayton, Ohio 45415
Dayton, Ohio 45415
Franklin, Ohio 45005-1066
Franklin, Ohio 45005
Greenville, Ohio 45331
Site Public Contact
937-569-7515
Mentor, Ohio 44060
Parma, Ohio 44129
Ravenna, Ohio 44266
Troy, Ohio 45373
Oklahoma City, Oklahoma 73104
Allentown, Pennsylvania 18103
Beaver, Pennsylvania 15009
Carlisle, Pennsylvania 17015
Erie, Pennsylvania 16505
Harrisburg, Pennsylvania 17109
Mechanicsburg, Pennsylvania 17050
New Castle, Pennsylvania 16105
Pittsburgh, Pennsylvania 15213
Site Public Contact
412-647-2811
Pittsburgh, Pennsylvania 15215
Site Public Contact
412-784-4900
Pittsburgh, Pennsylvania 15232
Site Public Contact
412-647-8073
Pittsburgh, Pennsylvania 15232
Site Public Contact
412-621-2334
Pittsburgh, Pennsylvania 15237
Site Public Contact
412-367-6454
Pittsburgh, Pennsylvania 15243
Site Public Contact
412-502-3920
West Reading, Pennsylvania 19611
Site Public Contact
610-988-9323
Williamsport, Pennsylvania 17754
York, Pennsylvania 17408
Site Public Contact
717-724-6760
Charleston, South Carolina 29425
Sioux Falls, South Dakota 57104
Sioux Falls, South Dakota 57117-5134
Dallas, Texas 75237
Dallas, Texas 75390
Fort Worth, Texas 76104
Richardson, Texas 75080
Burlington, Vermont 05401
Burlington, Vermont 05405
Charleston, West Virginia 25304
Site Public Contact
304-388-9944
Antigo, Wisconsin 54409
Eau Claire, Wisconsin 54701
Madison, Wisconsin 53792
Site Public Contact
800-622-8922
Marshfield, Wisconsin 54449
Menomonee Falls, Wisconsin 53051
Site Public Contact
262-257-5100
Milwaukee, Wisconsin 53226
Site Public Contact
414-805-3666
Minocqua, Wisconsin 54548
Mukwonago, Wisconsin 53149
Oak Creek, Wisconsin 53154
Site Public Contact
414-805-0505
Oconomowoc, Wisconsin 53066
Site Public Contact
262-928-7878
Rhinelander, Wisconsin 54501
Rice Lake, Wisconsin 54868
Stevens Point, Wisconsin 54481
Stevens Point, Wisconsin 54482
Waukesha, Wisconsin 53188
Wausau, Wisconsin 54401
Site Public Contact
877-405-6866
West Bend, Wisconsin 53095
Site Public Contact
414-805-0505
Weston, Wisconsin 54476
Wisconsin Rapids, Wisconsin 54494
Site Public Contact
715-422-7718
More Details
- NCT ID
- NCT05327686
- Status
- Recruiting
- Sponsor
- NRG Oncology
Detailed Description
PRIMARY OBJECTIVE: I. To determine whether the addition of stereotactic ablative radiotherapy (SABR) to the primary tumor in combination with immunotherapy improves outcomes compared to immunotherapy alone in patients with metastatic, unresected, renal cell carcinoma (RCC). The primary endpoint is nephrectomy and radiographic progression-free survival (nrPFS) with progression determined as per iRECIST criteria. SECONDARY OBJECTIVES: I. To assess the safety, toxicity and tolerability of the two treatment strategies as defined by Common Terminology Criteria for Adverse Events (CTCAE) version 5 in each treatment arm. II. To assess the objective response rate (ORR) by Immune-related Response Evaluation Criteria in Solid Tumors (iRECIST) in each treatment arm. III. Nephrectomy and radiographic progression-free survival excluding nephrectomies that were performed for non-protocol specified indications (nephrectomy and radiographic progression-free survival [nrPFS]2). IV. Radiographic progression-free survival (rPFS). V. To assess overall survival (OS) in each treatment arm. VI. To assess the time to subsequent second-line therapy or death in each treatment arm. VII. To assess the rate of cytoreductive nephrectomy in each treatment arm. VIII. To assess treatment-free survival in patients who discontinue therapy for reason other than radiographic disease progression. IX. To assess the ORR by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 and iRECIST in the primary renal mass. EXPLORATORY OBJECTIVES: I. To assess composite nrPFS in the predefined histological subgroups below: Ia. Clear cell versus non-clear cell histology. Ib. International Metastatic RCC database consortium (IMDC) intermediate versus poor risk group. Ic. Systemic treatment with immunotherapy-immunotherapy combination versus immunotherapy-vascular endothelial growth factor (VEGF) targeted therapy combination. Id. Sarcomatoid versus non sarcomatoid variant. II. To identify prognostic and predictive biomarkers of response to SABR in the context of immunotherapy based treatment via assessment of tissue and blood based biomarkers. III. To evaluate the abscopal effect of SABR with systemic therapy. IIIa. Compare ORR in non-irradiated target lesions in the control arm patients undergoing immunotherapy alone to the experimental arm undergoing SABR + immunotherapy. IV. To evaluate the impact of treatment on level of inferior vena cava (IVC) thrombus. V. To compare accruing center identified iRECIST progression and centrally identified iRECIST progression events on computed tomography (CT). OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Patients receive one of the following immunotherapy regimens per physician discretion: nivolumab intravenously (IV) over 30 minutes and ipilimumab IV over 30 minutes every 3 weeks for 4 doses followed by nivolumab IV over 30 minutes every 2 or 4 weeks; pembrolizumab IV over 30 minutes every 3 or 6 weeks and axitinib orally (PO) twice daily (BID); avelumab IV over 60 minutes every 2 weeks and axitinib PO BID; nivolumab IV over 30 minutes every 2 or 4 weeks and cabozantinib PO once daily (QD); OR pembrolizumab IV over 30 minutes every 3 or 6 weeks and lenvatinib PO QD. Treatment with immunotherapy continues in the absence of disease progression or unacceptable toxicity. ARM II: Patients undergo SABR on 3 different days over 1-3 weeks and receive immunotherapy as in Arm I. After completion of study treatment, patients are followed up every 6 months for 5 years, and then annually for 3 years.