Immediate Surgery or Surgery After Sunitinib Malate in Treating Patients With Metastatic Kidney Cancer

OBJECTIVES:

* To determine if immediate versus deferred nephrectomy has an effect on disease control in patients with resectable, synchronous, metastatic renal cell carcinoma treated with sunitinib malate.
* To identify potential response criteria based on histopathology and molecular research on tumor tissue.

OUTLINE: This is a multicenter study. Patients are stratified according to WHO performance status (0 vs 1), number of metastatic sites (1 vs 2 or more), and institution. Patients are randomized to 1 of 2 treatment arms.

* Arm I (immediate nephrectomy): Patients undergo cytoreductive nephrectomy. Beginning 4 weeks after surgery, patients receive oral sunitinib malate once daily on days 1-28. Treatment with sunitinib malate repeats every 6 weeks for 4 courses in the absence of disease progression or unacceptable toxicity.
* Arm II (deferred nephrectomy): Patients receive oral sunitinib malate once daily on days 1-28. Treatment repeats every 6 weeks for 3 courses in the absence of disease progression or unacceptable toxicity. About 1 day after completion of sunitinib malate, patients undergo cytoreductive nephrectomy. Patients then receive oral sunitinib malate once daily on days 1-28. Treatment repeats every 6 weeks for 2 courses in the absence of disease progression or unacceptable toxicity.

Some patients undergo tumor tissue collection at baseline and at time of surgery to assess possible differences in gene expression. Patients also undergo blood sample collection periodically to evaluate the potential impact of serum proteins on the clinical outcome. Samples are then stored for future studies.

After completion of study treatment, patients are followed periodically.

• timing of surgery (Procedure)
• gene expression analysis (Genetic)
• biologic sample preservation procedure (Other)
• laboratory biomarker analysis (Other)
• therapeutic conventional surgery (Procedure)

Primary outcomes

• Overall progression-free survival

Secondary outcomes

• Overall survival
• Morbidity
• Overall response to treatment in the deferred nephrectomy arm including the proportion of patients who become unresectable
• Effect of nephrectomy on early progression in both arms

Sex: All, ages: 18 Years to 120 Years

DISEASE CHARACTERISTICS:

* Histologically confirmed renal cell cancer (RCC)

  * Clear-cell subtype with a resectable asymptomatic in situ primary

    * Asymptomatic primary is defined as the absence of symptoms* which can be exclusively assigned to the primary tumor such as flank pain and/or gross hematuria necessitating blood transfusion NOTE: *Para-neoplastic symptoms cannot be assigned to the primary tumor alone in metastatic disease, they are not included in this definition.
    * No symptomatic primary tumor necessitating nephrectomy
* Resectable primary tumor

  * Bulky locoregional lymph node metastases larger than the primary tumor allowed provided resectability of the lymph nodes is surgically feasible
* Metastatic RCC

  * Distant metastases are not completely resectable at the time of surgery or during an additional intervention
  * No multiple distant lesions at one site
  * No bone-only metastases
* Measurable disease, both primary and metastatic, according to RECIST 1.1 criteria
* Planning to receive sunitinib malate as background therapy
* Patients with > 3 of the following surgical risk factors are not eligible:

  * Serum albumin CTCAE v 4.0 grade 2 or worse
  * Serum LDH > 1.5 times upper limit of normal
  * Liver metastases
  * Symptoms at presentation due to metastases
  * Retroperitoneal lymph node involvement
  * Supra-diaphragmatic lymph node involvement
  * Clinical stage T3 or T4 disease
* No clinical signs of CNS involvement

PATIENT CHARACTERISTICS:

* See Disease Characteristics
* WHO performance status 0-1
* Life expectancy > 3 months
* WBC > 3.0 x 10\^9/L
* Platelet count > 100 x 10\^9/L
* Hemoglobin > 10.0 g/dL
* PT/PTT or INR ≤ 1.2 times upper limit of normal (ULN)
* Bilirubin ≤ 1.5 times ULN
* ALT ≤ 2.5 times ULN (≤ 5 times ULN if liver lesions)
* Serum calcium < 10.0 mg/dL
* Calculated or measured creatinine clearance > 30 mL/min
* Not pregnant or nursing
* Negative pregnancy test
* Fertile patients must use effective contraception 2 weeks before and during study treatment
* LVEF normal by MUGA scan or ECHO
* 12-lead ECG normal
* No serious cardiac illness (myocardial infarction and/or treatable or untreatable angina pectoris not responding to treatment) within the past 12 months
* No uncontrolled, high BP (≥ 150/100 mm Hg) despite optimal medical therapy
* No current pulmonary disease
* No active or uncontrolled infections, serious illnesses, malabsorption syndrome, or medical conditions, including patients with a history of chronic alcohol abuse, hepatitis, HIV, and/or cirrhosis
* No malignancies within the past 5 years except renal cell carcinoma, basal or squamous cell carcinoma of the skin, carcinoma in situ of the cervix, resected incidental prostate cancer staged pT2 with Gleason Score ≤ 6 and postoperative PSA < 0.5 ng/mL, or patients with any history of malignancies who are disease-free for more than 5 years
* No psychological, familial, sociological, or geographical condition potentially hampering compliance with the study protocol and follow-up schedule

PRIOR CONCURRENT THERAPY:

* Prior local radiotherapy for bone lesions allowed
* No prior systemic therapy for metastatic RCC
* No prior partial or total nephrectomy
* No concurrent systemic corticosteroid and/or other immunosuppressive systemic therapies
* No concurrent radiotherapy, except palliative radiotherapy
* No concurrent participation in another clinical trial testing treatments for any disease including renal cell carcinoma
* No other concurrent investigational or systemic therapy for metastatic RCC

• Results publication: Bex A, Mulders P, Jewett M, Wagstaff J, van Thienen JV, Blank CU, van Velthoven R, Del Pilar Laguna M, Wood L, van Melick HHE, Aarts MJ, Lattouf JB, Powles T, de Jong Md PhD IJ, Rottey S, Tombal B, Marreaud S, Collette S, Collette L, Haanen J. Comparison of Immediate vs Deferred Cytoreductive Nephrectomy in Patients With Synchronous Metastatic Renal Cell Carcinoma Receiving Sunitinib: The SURTIME Randomized Clinical Trial. JAMA Oncol. 2019 Feb 1;5(2):164-170. doi: 10.1001/jamaoncol.2018.5543. PMID 30543350
• Results publication: Leon L, Garcia-Figueiras R, Suarez C, Arjonilla A, Puente J, Vargas B, Mendez Vidal MJ, Sebastia C. Recommendations for the clinical and radiological evaluation of response to treatment in metastatic renal cell cancer. Target Oncol. 2014 Mar;9(1):9-24. doi: 10.1007/s11523-013-0304-7. Epub 2013 Dec 12. PMID 24338498
• Results publication: Winquist E, Rodrigues G. Open clinical uro-oncology trials in Canada. Can J Urol. 2012 Dec;19(6):6587-91. No abstract available. PMID 23228299

• Axel Bex, Study chair, The Netherlands Cancer Institute
• John B.A.G. Haanen, Study chair, The Netherlands Cancer Institute