Disease and Stage: naïve metastatic kidney cancer. A multicenter, randomized, a Phase 2 BIOmarker driven trial with Nivolumab and Ipilimumab or VEGFR tKi in naïve metastatic Kidney cancer
Research Hypothesis: Molecular groups of ccrcc will define patients who will respond to nivolumab alone, nivolumab combined with ipilimumab, or VEGFR-TKI (sunitinib or pazopanib) in subjects with previously untreated metastatic renal cell carcinoma (mRCC). Conditions: * Advanced or metastatic RCC: previously untreated in metastatic setting. * Frozen tumor samples available for molecular group determination. * Determination of molecular subgroup prior to randomization. Product(s): * ARM A: nivolumab alone administered IV over 60 minutes at 240 mg every 2 weeks (molecular group 1 and 4). * ARM B : Nivolumab administered IV over 60 minutes at 3 mg/kg combined with ipilimumab administered IV over 30 minutes at 1 mg/kg every 3 weeks for 4 doses followed by nivolumab administered IV over 60 minutes at 240 mg every 2 weeks starting from the Cycle 7 possibility to switch from nivolumab 240 mg every 2 weeks to 480 mg every 4 weeks according to the Investigator's preference (Arm A and B), \- ARM C: TKI (molecular group 2 and 3), pazopanib or sunitinib according to investigator's choice until disease progression, unacceptable toxicity or other reasons specified in the protocol. Biological assessments: Molecular groups (1 to 4) will be determined for all patients from frozen tumor tissue samples or from fresh tumor samples immediately stored in "RNA later" medium. Further exploratory biological assessments will be performed in order to define predictive biomarkers of response to N+I, N alone or TKI (sunitinib or pazopanib) by analyzing tumor specimens and blood samples: * To assess gene expression of immune population markers in the primary tumor as well as in the metastases before beginning treatment, and at progression if safely achievable. * Gene expression analysis will be performed from frozen and FFPE tumor tissue in order to compare the two methods. * To assess the density and phenotype of selected immune populations (CD8, CD3/CD20, PD-1, TIM-3, LAG3, FoxP3) as well as the phenotype of tumor cells (PD-L1, PD-L2) by immunohistochemistry (IHC) in the primary tumor and metastases, before treatment initiation and at progression if safely achievable. * To assess the functional status of peripheral blood lymphocytes (PBL) by flow cytometry, before treatment initiation, during treatment, and at progression. * To quantify plasmatic angiogenesis-related (i.e. VEGF-A, VEGF-C its soluble receptors VEGFR-1 and 2 and co-receptors neuropilin 1 and 2, angiopoietins, SDF-1, PDGFs…)) and endothelial cell-derived molecules (i.e. endoglin, VE-cadherin) before treatment initiation, during treatment, and at progression. * To correlate plasmatic angiogenesis-related molecules with tumor vascularization studied by immunofluorescence (IF) and a multi-spectral analyzer (Vectra technology) on tumor tissue. * To investigate a predictive role of the response of CXCL7 and sCD146 to TKI, nivolumab and/or nivolumab+ipilimumab. * To determine whether the mutation and methylation analysis of circulating tumor DNA can be used as predictive biomarker of response, resistance to treatment or progression. * Identify genetic and epigenetic alterations associated with either response or resistance to immune checkpoint inhibitors and tyrosine kinase inhibitors * Evaluate association between immune cells composing tumor microenvironment and response and/or resistance to immune checkpoint inhibitors or tyrosine kinase inhibitors * Evaluate additional genetic and epigenetic tumor alterations at resistance/progression or after resection of residual mass. Statistical Considerations: An adaptative design will be used to ensure that conclusions can be made with a limited number of patients in each molecular group, which is the major constraint of the study. Sample Size: Approximately 150 patients are planned to be treated. Given an expected failure rate of molecular grouping of less than 20%, 150-200 patients must be included.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
200
For Arms 1A and 4A: Nivolumab alone administered IV over 60 minutes at 240 mg every 2 weeks until disease progression, unacceptable toxicity or other reasons specified in the protocol. For Arms 1B, 2B, 3B and 4B: Nivolumab administered IV over 60 minutes at 3 mg/kg combined with ipilimumab administered IV over 30 minutes at 1 mg/kg every 3 weeks for 4 doses followed by nivolumab administered IV over 60 minutes at 240 mg every 2 weeks until disease progression, unacceptable toxicity or other reasons specified in the protocol. Starting from the Cycle 7 possibility to switch from nivolumab 240 mg every 2 weeks to 480 mg every 4 weeks according to the Investigator's preference.
For Arms 1B, 2B, 3B and 4B: Ipilimumab administered IV over 30 minutes at 1 mg/kg every 3 weeks combined with Nivolumab administered IV over 60 minutes at 3 mg/kg for 4 doses until disease progression, unacceptable toxicity or other reasons specified in the protocol.
Hôpital Saint André, CHU de Bordeaux
Bordeaux, France
Centre Francois Baclesse
Caen, France
CHU Henri-Mondor
Créteil, France
ORR evaluation according to molecular groups (ccRCC1 to 4) and assigned treatment
ORR evaluation according to molecular groups (ccRCC1 to 4) and assigned treatment (nivolumab monotherapy, nivolumab combined with ipilimumab, or TKI: sunitinib or pazopanib), based on Investigator assessments.
Time frame: 54 months
Progression-free survival (PFS)
progression-free survival (PFS) in subjects with previously untreated mRCC according to molecular groups and assigned treatment, based on Investigator radiological assessments.
Time frame: 54 months
Overall Survival
To evaluate OS in subjects with previously untreated mRCC according to molecular groups and assigned treatment.
Time frame: 54 months
Objective response rate at 22 weeks
To evaluate objective response rate at 22 weeks as a surrogate of other endpoints according to molecular groups and assigned treatment.
Time frame: at 22 weeks
Duration of treatment (DOT)
To evaluate the duration of treatment (DOT) of nivolumab combined with ipilimumab or nivolumab alone or cabozantinib in subjects with previously untreated mRCC according to their molecular subgroup (1\&4 vs 2\&3).
Time frame: 54 months
Duration of response (DOR)
To evaluate the duration of response (DOR) of nivolumab combined with ipilimumab or nivolumab alone or cabozantinib in subjects with previously untreated mRCC according to their molecular subgroup (1\&4 vs 2\&3).
Time frame: 54 months
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For Arms 2C and 3C (TKI pazopanib or sunitinib): Pazopanib 800 mg orally QD until disease progression, unacceptable toxicity or other reasons specified in the protocol
For Arms 2C and 3C (TKI pazopanib or sunitinib): Sunitinib 50 mg orally QD until disease progression, unacceptable toxicity or other reasons specified in the protocol
Centre OSCAR LAMBRET LILLE
Lille, France
Institut Paoli Calmettes (IPC)
Marseille, France
Centre Antoine Lacassagne
Nice, France
Institut de Cancérologie du Gard - CHU Caremeau
Nîmes, France
Institut Mutualiste Montsouris
Paris, France
Hôpital Européen Georges Pompidou
Paris, France
Hôpital Cochin
Paris, France
...and 6 more locations
Number of Participants With Treatment-Related Adverse Events
To estimate the incidence of AEs associated with nivolumab combined with ipilimumab or nivolumab alone or cabozantinib in all treated subjects with previously untreated mRCC.
Time frame: 54 months
Gene expression of immune population markers
To assess gene expression of immune population markers in the primary tumor as well as in the metastases before beginning treatment, and at progression if safely achievable.populations (CD3, CD8...) and regulatory markers (PD-1, LAG-3…) within the primary tumor, and metastases whenever possible, using frozen and FFPE tumor tissue.
Time frame: at baseline at progression (36 months maximum)
Gene expression levels obtained from FFPE
Gene expression levels obtained from FFPE tumor tissue (exploratory method) will be compared to those obtained with frozen tumor tissue (standard method).
Time frame: at the end of the study (36 months)
Functional status of peripheral blood lymphocytes (PBL)
To assess the functional status of peripheral blood lymphocytes (PBL) by flow cytometry, before treatment initiation, during treatment, and at progression.
Time frame: at baseline, at cycle 2 and at progression (36 months maximum)
Association between non-immune tissue and circulating biomarkers and outcomes
To explore the association between non-immune tissue and circulating biomarkers and outcomes (ORR, ORR at 22 weeks, OS and PFS).
Time frame: 36 months maximum
Mutation and methylation analysis of circulating tumor DNA
The initial rate of ctDNA and its evolution will be correlated to the clinical evolution of patients and progression-free survival.
Time frame: 36 months maximum
Genetic and epigenetic alterations
To identify genetic and epigenetic alterations associated with either response or resistance to immune checkpoint inhibitors and tyrosine kinase inhibitors.
Time frame: 36 months maximum
association between immune cells composing tumor microenvironment and response and/or resistance
To evaluate the association between immune cells composing tumor microenvironment and response and/or resistance to immune checkpoint inhibitors or tyrosine kinase inhibitors.
Time frame: 36 months maximum
additional genetic and epigenetic tumor alterations
To evaluate additional genetic and epigenetic tumor alterations at resistance/progression or after resection of residual mass.
Time frame: 36 months maximum