Nivolumab in Combination With Chemo-Immunotherapy for the Treatment of Newly Diagnosed Primary Mediastinal B-Cell Lymphoma

Study Overview
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Brief Summary
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This phase III trial compares the effects of nivolumab with chemo-immunotherapy versus chemo-immunotherapy alone in treating patients with newly diagnosed primary mediastinal B-cell lymphoma (PMBCL). Immunotherapy with monoclonal antibodies, such as nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of cancer cells to grow and spread. Treatment for PMBCL involves chemotherapy combined with an immunotherapy called rituximab. Chemotherapy drugs work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Rituximab is a monoclonal antibody. It binds to a protein called CD20, which is found on B cells (a type of white blood cell) and some types of cancer cells. This may help the immune system kill cancer cells. Giving nivolumab with chemo-immunotherapy may help treat patients with PMBCL.

Detailed Description
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PRIMARY OBJECTIVE: I. To determine if nivolumab + chemo-immunotherapy results in a superior long term progression-free survival (PFS) (events defined as disease progression confirmed by central review or death) when compared with chemo-immunotherapy alone in patients with newly diagnosed primary mediastinal B-cell lymphoma. SECONDARY OBJECTIVES: I. To compare the rates of efficacy-related event-free survival (EFS) (eEFS) (events defined as progression, change in therapy due to finding that led to concern about efficacy, biopsy + disease after 6 cycles of therapy, or death) between chemo-immunotherapy alone and chemo-immunotherapy + nivolumab in patients with newly diagnosed PMBCL. II. To compare the rates of therapy-related EFS (tEFS) (events defined as relapse/progression, change in therapy for any reason, biopsy + disease after 6 cycles of therapy, secondary malignancy [SMN] or death) between chemo-immunotherapy alone and chemo-immunotherapy + nivolumab in patients with newly diagnosed PMBCL. III. To compare the rates of overall survival (OS) between chemo-immunotherapy alone and chemo-immunotherapy + nivolumab in patients with newly diagnosed PMBCL. IV. To establish the rate of a positive positron emission tomography (PET)-computed tomography (CT) (defined as Deauville score 4 or 5) at the completion of 6 cycles of nivolumab + rituximab (R)- cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP)/dose-adjusted (DA)-etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (EPOCH)-R and R-CHOP/DA-EPOCH-R in patients with newly diagnosed PMBCL and evaluate the prognostic significance of such a finding. EXPLORATORY OBJECTIVES: I. To bank radiology images for further studies. II. To bank specimens for future correlative studies. III. Characterize the immune profile of patients treated with nivolumab + chemo-immunotherapy to identify markers predictive of response. IV. Define the rate of complete response at the completion of initial planned therapy. OUTLINE: Patients are randomly assigned to backbone therapy or backbone therapy + nivolumab within each of 6 strata. The strata are determined by physician's choice of backbone (DA-EPOCH-R versus [vs.] R-CHOP vs. R-CHOP + RT) and whether or not the patient had 1 prior cycle of therapy. ARM A (DA-EPOCH-R): Patients receive prednisone or prednisolone orally (PO) once daily (QD) on days 1-5 and rituximab intravenously (IV) or rituximab and hyaluronidase human subcutaneously (SC) over 5 minutes on day 1 or 5. Patients also receive etoposide phosphate, doxorubicin hydrochloride, and vincristine sulfate IV over 96 hours on days 1-4 and cyclophosphamide IV over 30-60 minutes on day 5. Beginning 24-72 hours after completing cyclophosphamide, patients receive filgrastim or pegylated filgrastim SC daily until absolute neutrophil count (ANC) is >= 500/uL after the expected nadir. Treatment repeats every 21 days for up to 6 cycles (5 if the patient had 1 prior cycle of treatment) in the absence of disease progression or unacceptable toxicity. Patients undergo echocardiography (ECHO) during screening and as clinically indicated and alumbar puncture (LP) for cerebral spinal fluid (CSF) collection optionally during screening. Patients also undergo computed tomography (CT) or positron emission tomography (PET)/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. ARM B (DA-EPOCH-R + NIVOLUMAB): Patients receive treatment as in Arm A. Patients also receive nivolumab IV over 30 minutes on day 1. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. ARM C (R-CHOP): Patients receive prednisone or prednisolone PO QD on days 1-5 and rituximab IV or rituximab and hyaluronidase human SC over 5 minutes on day 1 or 5. Patients also receive cyclophosphamide IV over 30-60 minutes, doxorubicin hydrochloride IV over 1-15 minutes or up to 60 minutes, and vincristine sulfate IV over 1 or up to 60 minutes on day 1. Treatment repeats every 21 days for up to 6 cycles (5 if the patient had 1 prior cycle of treatment) in the absence of disease progression or unacceptable toxicity. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. ARM D (R-CHOP + NIVOLUMAB): Patients receive treatment as in Arm C. Patients also receive nivolumab IV over 30 minutes on day 1. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. ARM E (R-CHOP + RADIOTHERAPY): Patients receive treatment as in Arm C. Within 6-8 weeks after completion of chemotherapy, patients undergo radiation therapy over 25 fractions. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. ARM F (R-CHOP + RADIOTHERAPY + NIVOLUMAB): Patients receive treatment as in Arm D. Within 6-8 weeks after completion of chemotherapy, patients undergo radiation therapy over 25 fractions. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. After completion of study treatment, patients are followed up every 3 months for year 1, every 6 months for years 2-3, and annually thereafter.

Official Title
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A Randomized Phase 3 Trial of Nivolumab (NSC# 748726) in Combination With Chemo-Immunotherapy for the Treatment of Newly Diagnosed Primary Mediastinal B-Cell Lymphoma

Conditions
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Primary Mediastinal Large B-Cell Lymphoma

Intervention / Treatment
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* Procedure: Biospecimen Collection
* Procedure: Bone Marrow Aspiration
* Procedure: Bone Marrow Biopsy
* Procedure: Computed Tomography
* Drug: Cyclophosphamide
* Drug: Doxorubicin Hydrochloride
* Procedure: Echocardiography
* Drug: Etoposide Phosphate
* Biological: Filgrastim
* Procedure: Lumbar Puncture
* Biological: Nivolumab
* Biological: Pegfilgrastim
* Procedure: Positron Emission Tomography
* Drug: Prednisolone
* Drug: Prednisone
* Radiation: Radiation Therapy
* Biological: Rituximab
* Biological: Rituximab and Hyaluronidase Human
* Drug: Vincristine Sulfate


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >= 2 years Patient must have histologically confirmed primary mediastinal B-cell lymphoma (PMBCL) as defined by World Health Organization (WHO) criteria Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2 or ECOG performance status of 3 if poor performance is related to lymphoma Children's Oncology Group (COG) Institutions: Use Karnofsky for patients >= 17 and < 18 years of age and Lansky for patients < 17 years of age Adults (age 18 or older): Creatinine clearance >= 30 mL/min, as estimated by the Cockcroft and Gault formula. The creatinine value used in the calculation must have been obtained within 28 days prior to registration. Estimated creatinine clearance is based on actual body weight Pediatric Patients (age < 18 years): The following must have been obtained within 14 days prior to registration: Measured or calculated (based on institutional standard) creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70 ml/min/1.73 m^2, or Serum creatinine =< 1.5 x institutional upper limit of normal (IULN), or a serum creatinine based on age/gender as follows: Age : 2 to < 6 year; Maximum serum creatinine (mg/dL): 0.8 (male; 0.8 (female) Age : 6 to < 10 years; Maximum serum creatinine (mg/dL): 1 (male); 1 (female) Age : 10 to < 13 years; Maximum serum creatinine (mg/dL): 1.2 (male); 1.2 (female) Age : 13 to < 16 years; Maximum serum creatinine (mg/dL): 1.5 (male); 1.4 (female) Age : >= 16 years to < 18 years; Maximum serum creatinine (mg/dL): 1.7 (male); 1.4 (female) Patients with abnormal liver function will be eligible to enroll if the lab abnormality is thought to be due to the lymphoma or Gilbert's syndrome Age >= 18 years: Ejection fraction of >= 50% by echocardiogram Age < 18 years: Shortening fraction of >= 27% by echocardiogram, or ejection fraction of >= 50% by radionuclide angiogram Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial 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. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load All patients and/or their parents or legal guardians must sign a written informed consent All institutional, Food and Drug Administration (FDA), and National Cancer Institute (NCI) requirements for human studies must be met Exclusion Criteria: Administration of prior anti-cancer therapy except as outlined below: A short course (=< 2 weeks) of corticosteroids for the relief of lymphoma-related symptoms A single course of COP (cyclophosphamide, vincristine, and prednisone) One cycle of chemo-immunotherapy including R-CHOP, DA-EPOCH-R, a pediatric mature B-cell non-Hodgkin lymphoma (B-NHL) induction therapy (such as ANHL1131), or intrathecal chemotherapy that has not started more than 21 days prior to enrollment Active ischemic heart disease or heart failure Active uncontrolled infection Central nervous system (CNS) involvement of lymphoma Previous cancer that required systemic chemotherapy and/or thoracic radiation. Other cancers will be permitted if in remission x 3 years Active autoimmune disease that has required systemic treatment (such as disease modifying agents, corticosteroids, or immunosuppressive agents) in the past 2 years. Replacement therapy such as thyroxine, insulin or physiologic corticosteroid for adrenal or pituitary insufficiency is not considered a form of systemic treatment In patients < 18 years of age hepatitis B serologies consistent with past or current infections Patients with severe hepatic impairment (Child-Pugh class C or serum total bilirubin > 5.0 mg/dL) unless thought to be due to lymphoma or Gilbert's syndrome Female patients who are pregnant since fetal toxicities and teratogenic effects have been noted for several of the study drugs. A pregnancy test is required for female patients of childbearing potential Sexually active patients of reproductive potential who have not agreed to use a highly effective contraceptive method (failure rate of < 1% per year when used consistently and correctly) for the duration of their study participation Lactating females are not eligible unless they have agreed not to breastfeed their infants starting with the first dose of study therapy and for at least 6 months after the last dose of rituximab

Ages Eligible for Study
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Minimum Age: 2 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Arm A (DA-EPOCH-R)<br>See Detailed Description | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Drug: Etoposide Phosphate<br>* Given IV<br>* Other names: Etopophos;Biological: Filgrastim<br>* Given SC<br>* Other names: Zarxio;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Biological: Pegfilgrastim<br>* Given SC<br>* Other names: Ziextenzo;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;|
| Experimental: Arm B (DA-EPOCH-R, nivolumab)<br>Patients receive treatment as in Arm A. Patients also receive nivolumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 6 cycles (5 if the patient had 1 prior cycle of treatment) in the absence of disease progression or unacceptable toxicity. Patients undergo ECHO and LP for CSF collection during screening. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Drug: Etoposide Phosphate<br>* Given IV<br>* Other names: Etopophos;Biological: Filgrastim<br>* Given SC<br>* Other names: Zarxio;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Biological: Nivolumab<br>* Given IV<br>* Other names: Opdivo;Biological: Pegfilgrastim<br>* Given SC<br>* Other names: Ziextenzo;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;|
| Active Comparator: Arm C (R-CHOP)<br>Patients receive prednisone or prednisolone PO QD on days 1-5 and rituximab IV or rituximab and hyaluronidase human SC over 5 minutes on day 1 or 5. Patients also receive cyclophosphamide IV over 30-60 minutes, doxorubicin hydrochloride IV over 1-15 minutes or up to 60 minutes, and vincristine sulfate IV over 1 or up to 60 minutes on day 1. Treatment repeats every 21 days for up to 6 cycles (5 if the patient had 1 prior cycle of treatment) in the absence of disease progression or unacceptable toxicity. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;|
| Experimental: Arm D (R-CHOP, nivolumab)<br>Patients receive treatment as in Arm C. Patients also receive nivolumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 6 cycles (5 if the patient had 1 prior cycle of treatment) in the absence of disease progression or unacceptable toxicity. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Biological: Nivolumab<br>* Given IV<br>* Other names: Opdivo;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;|
| Active Comparator: Arm E (R-CHOP, radiation therapy)<br>Patients receive treatment as in Arm C. Within 6-8 weeks after completion of chemotherapy, patients undergo radiation therapy over 25 fractions. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Radiation: Radiation Therapy<br>* Undergo radiation therapy<br>* Other names: Therapy, Radiation;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;|
| Experimental: Arm F (R-CHOP, nivolumab, radiation therapy)<br>Patients receive treatment as in Arm D. Within 6-8 weeks after completion of chemotherapy, patients undergo radiation therapy over 25 fractions. Patients undergo ECHO during screening and as clinically indicated and LP for CSF collection optionally during screening. Patients also undergo CT or PET/CT throughout the trial. Additionally, patients undergo bone marrow biopsy and aspiration optionally during screening and as clinically indicated on study. Patients undergo blood sample collection on study. | Procedure: Biospecimen Collection<br>* Undergo blood and CSF sample collection<br>* Other names: Specimen Collection;Procedure: Bone Marrow Aspiration<br>* Undergo bone marrow biopsy and aspiration<br>Procedure: Bone Marrow Biopsy<br>* Undergo bone marrow biopsy and aspiration<br>* Other names: Biopsy, Bone Marrow;Procedure: Computed Tomography<br>* Undergo CT or PET/CT<br>* Other names: tomography;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR-138719;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Procedure: Echocardiography<br>* Undergo ECHO<br>* Other names: EC;Procedure: Lumbar Puncture<br>* Undergo LP<br>* Other names: Spinal Tap;Biological: Nivolumab<br>* Given IV<br>* Other names: Opdivo;Procedure: Positron Emission Tomography<br>* Undergo PET/CT<br>* Other names: PT;Drug: Prednisolone<br>* Given PO<br>* Other names: Sterane;Drug: Prednisone<br>* Given PO<br>* Other names: SK-Prednisone;Radiation: Radiation Therapy<br>* Undergo radiation therapy<br>* Other names: Therapy, Radiation;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Biological: Rituximab and Hyaluronidase Human<br>* Given SC<br>* Other names: Rituximab/Hyaluronidase Human;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression-free survival (PFS) | The primary analysis will be a one-sided Log-rank test stratified by choice of backbone and radiation therapy and whether the patient had a cycle of therapy prior to enrolling. | From enrollment on the study to first occurrence of relapse/progression or death, assessed up to 7 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Efficacy-related event-free survival | Will be analyzed using a one-sided stratified Log-rank test at alpha = 0.05 or 0.025, as appropriate, with events defined as progression, change in therapy due to a finding that led to concern about efficacy, biopsy + disease after 6 cycles of therapy, and death. | Up to 7 years | 
| Therapy-related event-free survival | Will be analyzed using a one-sided stratified Log-rank test at alpha = 0.05 or 0.025, as appropriate, with events defined as progression, change in therapy due to a finding that led to concern about efficacy, biopsy + disease after 6 cycles of therapy, and death. | Up to 7 years | 
| Overall survival | Will be analyzed using a one-sided stratified Log-rank test at alpha = 0.05 or 0.025, as appropriate, with events defined as only death. | Up to 7 years | 
| Proportion of positive positron emission tomography (PET) scans | Will be analyzed descriptively with a point estimate and Clopper-Pearson 95% confidence interval in the trial overall and in each treatment arm separately. The prognostic significance of positive PET after 6 cycles of therapy will be evaluated using a Cox proportional hazards regression on PFS with PET result (positive versus [vs.] negative), choice of backbone (rituximab [R]-cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] + radiation therapy [RT] regardless of end-of-therapy imaging vs. R-CHOP without RT unless biopsy positive at end-of-therapy vs. dose-adjusted [DA]-etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin [EPOCH]-R without RT unless biopsy positive at end of therapy), and assignment to nivolumab (yes vs. no) as covariates. | Up to 6 cycle (1 cycle = 21 days) |