Conditions: Kidney Cancer Renal Cell Carcinoma Metastatic Renal Cell Carcinoma
Allocation: NON_RANDOMIZED | Intervention model: SINGLE_GROUP
Enrollment: 22
Healthy volunteers: no

Brief summary:
To assess whether changes in quantitative tumor perfusion parameters after 3 or 6 weeks of treatment, as measured by power Doppler ultrasound, can predict initial objective response, defined by current standard-of-care, to therapy at 12 weeks after start of treatment

Detailed description:

Arms:
arm 1: Patients are planned to be treated with vascular endothelial growth factor 2 (VEGFR2) tyrosine kinase inhibitor (TKI) plus immune checkpoint inhibitor (ICI) arm 2: Patients are planned to be treated with non-ICI therapy

Interventions: intervention 1: Doppler Ultrasound intervention 2: SIEMENS S3000 and Verasonics Vantage 256 intervention 3: Standard-of-care Vascular Endothelial Growth Factor Receptor 2 (VEGFR2) tyrosine kinase inhibitor (TKI) plus immune checkpoint inhibitor (ICI) intervention 4: Standard-of-care non-immune checkpoint inhibitor (ICI) such as single-agent VEGFR2 TKI
Intervention descriptions: intervention 1: Power Doppler measurements will be made intervention 2: Vantage 256 used for power Doppler ultrasound, manufactured by Verasonics intervention 3: Standard-of-care Vascular Endothelial Growth Factor Receptor 2 (VEGFR2) tyrosine kinase inhibitor (TKI) plus immune checkpoint inhibitor (ICI). intervention 4: Standard-of-care non-immune checkpoint inhibitor (ICI) such as single-agent VEGFR2 TKI

Protocol document:
Prot_001.pdf: 
TITLE: 
EARLY THERAPEUTIC MONITORING OF RESPONSE TO THERAPY 
WITH SERIAL ULTRASOUND IN METASTATIC RENAL CELL CARCINOMA 
Document History 
Notes 
Version 1.0 
Date: 19 Aug, 2020 
Initial Approval 
Version 2.0 
Date: 16 Jan, 2021 
Revisions include: 
•
updated list of co-investigators
•
relaxation of allowable time window for 6-week US exam (+/-
15 days instead of +/- 8 days)
•
option added to obtain consent from Legally Authorized
Representatives (LARs)
•
option added to obtain written consent from English-speaking
participants/LARs online via RedCAP
Version 3.0 
Date: 28 Apr, 2021 
Revisions include: 
•
updated list of co-investigators
•
clarification of inclusion criteria (section 3.1)
•
inclusion of other ultrasound transducers
Version 4.0 
Date: 28 Jun, 2021 
Revisions include: 
•
updated list of co-investigators
•
correction of protocol title
Version 5.0 
Date: 12 Jul, 2022 
Revisions include: 
•
updated list of co-investigators
•
additional exploratory study arm 2 defined: patients receiving
any non-immune checkpoint inhibitor treatment (e.g., TKI
monotherapy, combination of TKI with other kinase inhibitor,
localized tumor therapy such as radiation, chemo- or
radioembolization)
•
participant population expanded to patients referred to
Stanford from outside institutions for participation in this
study
•
clarification added to study calendar on definition of start of
treatment
•
minimum time period of 10 days between ‘week-3’ and
‘week-6’ ultrasound exams defined in study calendar
•
use of RedCAP for electronic signatures on consent forms
replaced by Adobe Sign
•
correction of typos and unclear wording
Version 5.0 
Date: 27 Jul, 2022 
(revisions after start of SRC review) 
Revisions include: 
•
triple eligibility check replaced by single eligibility check by
treating provider (incl. APPs)
Version 6.0 
Date: 4 Oct, 2022 
Revisions include: 
•
updated list of co-investigators
•
option added for non-licensed, qualified staff to perform
research ultrasound exams
Version 7.0 
Date: 21 Nov, 2022 
Revisions include: 
•
AE evaluation schedule revised, now tied to study procedures
instead of SOC visits
Version 8.0 
Date: 30 Jan, 2023 
Revisions include: 
•
management of ultrasound imaging data and associated PHI
clarified (section 8.2)
•
Appendix A: lines for provider initials and date for subjective
exclusion criterion added
NCT04508725


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 2 of 31 
1 May 2023 
Version 9.0 
Date: 1 May, 2023 
Revisions include: 
•
updated list of co-investigators
•
criteria for removal from study clarified (section 5.1)
•
data management procedures upon study closure clarified
(section 8.2)


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 3 of 31 
1 May 2023 
Protocol Directors 
 
Alice C. Fan, M.D. 
Assistant Professor of Medicine (Oncology) 
Department of Medicine - Division of Oncology 
Stanford University School of Medicine 
Center for Clinical Sciences Research (CCSR) 
269 Campus Drive 
Stanford, CA 94305 
Telephone: 650-498-6000 
Fax: 650-724-1231 
E-mail: afan@stanford.edu 
 
Jeremy Dahl, Ph.D. 
Associate Professor of Radiology (Pediatric Radiology) 
Department of Radiology – Division of Pediatric Radiology 
Stanford University School of Medicine 
3155 Porter Drive 
Palo Alto, CA 94304 
Telephone: 650-724-3022 
Fax:  650-721-6921 
E-mail: jeremy.dahl@stanford.edu 
 
 
 
Co-Investigators 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 4 of 31 
1 May 2023 
 
 
 
 
 
 
 
Biostatistician 
 
 
 
 
 
 
 
 
 
Study Coordinator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SRC Initial Approval Date: September 10, 2020 (Version 1.0 dated August 19, 2020) 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 5 of 31 
1 May 2023 
TABLE OF CONTENTS 
 
PROTOCOL SYNOPSIS .............................................................................................................................. 7 
SCHEMA ....................................................................................................................................................... 8 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ....................................................................... 9 
1. 
OBJECTIVES ................................................................................................................................. 10 
1.1 PRIMARY OBJECTIVE ........................................................................................................................ 10 
1.2 SECONDARY OBJECTIVES ................................................................................................................. 10 
2. 
BACKGROUND ............................................................................................................................. 10 
2.1 STUDY DISEASE ............................................................................................................................... 10 
2.2 IMAGING PROCEDURE ....................................................................................................................... 11 
2.3 CLINICALTRIALS.GOV ........................................................................................................................ 11 
2.4 RATIONALE ...................................................................................................................................... 11 
2.5 PRELIMINARY RESULTS ..................................................................................................................... 13 
2.6 STUDY DESIGN ................................................................................................................................. 13 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES .............................................. 14 
3.1 INCLUSION CRITERIA ......................................................................................................................... 14 
3.2 EXCLUSION CRITERIA ....................................................................................................................... 14 
3.3 INFORMED CONSENT PROCESS ......................................................................................................... 14 
3.4 STUDY TIMELINE .............................................................................................................................. 15 
3.5 STUDY COMPLETION ......................................................................................................................... 15 
4. 
IMAGING PROCEDURE INFORMATION ...................................................................................... 15 
5. 
STUDY PROCEDURES ................................................................................................................. 16 
5.1 CRITERIA FOR REMOVAL FROM STUDY .............................................................................................. 16 
5.2 ALTERNATIVES ................................................................................................................................. 16 
6. 
STUDY CALENDAR ....................................................................................................................... 17 
7. 
ADVERSE EVENTS AND REPORTING PROCEDURES .............................................................. 18 
7.1 POTENTIAL ADVERSE EVENTS ........................................................................................................... 18 
7.2 ADVERSE EVENT REPORTING............................................................................................................ 18 
8. 
REGULATORY CONSIDERATIONS ............................................................................................. 19 
8.1 INSTITUTIONAL REVIEW OF PROTOCOL .............................................................................................. 19 
8.2 DATA MANAGEMENT PLAN ................................................................................................................ 19 
8.3 DATA AND SAFETY MONITORING PLAN............................................................................................... 20 
9. 
MEASUREMENTS ......................................................................................................................... 20 
9.1 PRIMARY OUTCOME MEASURES ........................................................................................................ 20 
9.1.1 MEASUREMENT METHODS ................................................................................................................ 21 
9.1.2 MEASUREMENT TIME POINTS ............................................................................................................ 21 
9.1.3 RESPONSE REVIEW .......................................................................................................................... 21 
9.2 SECONDARY OUTCOME MEASURES ................................................................................................... 21 
9.2.1 MEASUREMENT METHODS ................................................................................................................ 22 
9.2.2 MEASUREMENT TIME POINTS ............................................................................................................ 22 
9.2.3 RESPONSE REVIEW .......................................................................................................................... 22 
10 
STATISTICAL CONSIDERATIONS ............................................................................................... 22 
10.1 STATISTICAL DESIGN ........................................................................................................................ 22 
10.2 DESCRIPTIVE STATISTICS AND EXPLORATORY DATA ANALYSIS ........................................................... 22 
10.3 PRIMARY ANALYSIS .......................................................................................................................... 22 
10.3.1 
ANALYSIS POPULATION ............................................................................................................ 22 
10.3.2 
ANALYSIS PLAN ....................................................................................................................... 23 
10.4 SECONDARY ANALYSIS ..................................................................................................................... 24 
10.4.1 
ANALYSIS POPULATION ............................................................................................................ 24 
10.4.2 
ANALYSIS PLAN ....................................................................................................................... 24 
10.5 SAMPLE SIZE ................................................................................................................................... 25 
10.6 ACCRUAL ESTIMATES ........................................................................................................................ 25 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 6 of 31 
1 May 2023 
10.7 CRITERIA FOR FUTURE STUDIES ........................................................................................................ 25 
11 
REFERENCES ............................................................................................................................... 27 
APPENDIX A: PARTICIPANT ELIGIBILITY CHECKLIST ........................................................................ 30 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 7 of 31 
1 May 2023 
PROTOCOL SYNOPSIS 
TITLE 
Early therapeutic monitoring of response to 
therapy with serial ultrasound in metastatic 
RCC 
STUDY PHASE 
Pilot  
INDICATION 
Metastatic Renal Cell Carcinoma (mRCC) 
INVESTIGATIONAL PRODUCT 
OR PROCEDURE 
Study of power Doppler ultrasound for early 
detection of therapeutic response after 
initiating therapy with: 
arm 1: tyrosine kinase (TKI) inhibitor plus 
immune checkpoint inhibitor (ICI) 
arm 2: non-ICI therapy (e.g., TKI monotherapy, 
combination of TKI with other kinase inhibitor, 
localized tumor therapy such as radiation, 
chemo- or radioembolization) 
PRIMARY OBJECTIVE(S) 
To assess whether changes in quantitative 
tumor perfusion parameters after 3 weeks of 
treatment, as measured by LEAD ultrasound, 
can predict initial objective response, defined 
by current standard-of-care, to therapy at 12 
weeks after start of treatment   
SECONDARY OBJECTIVE(S) 
To evaluate if there is an optimal ultrasound 
imaging modality (power Doppler or LEAD 
ultrasound) or optimal time point to predict initial 
objective response, to assess the correlation of 
tumor perfusion parameters with change in 
overall tumor burden, change in diameter on a 
per-lesion 
basis 
and 
with 
12-month 
progression-free survival (PFS). 
STUDY PROCEDURE 
SUMMARY 
power Doppler and LEAD ultrasound of 
subjects taking targeted therapy medication, 
measured at treatment ‘baseline’, 3-4 weeks, 
and 6-8 weeks after initiating treatment  
SAMPLE SIZE  
arm 1: 20 subjects 
arm 2: up to 10 subjects 
STATISTICAL 
CONSIDERATIONS 
We will evaluate the predictive ability of each 
model using area under the curve (AUC). For 
this pilot study, assuming that 59% of patients 
in arm 1 have an objective response to 
treatment, a predictive model with a true AUC 
of 0.7 will have a margin of error of 0.14 so 
that the estimated AUC can range from 0.56 to 
0.84. 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 8 of 31 
1 May 2023 
SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with metastatic 
renal cell carcinoma (RCC) 
Inclusion Criteria 
 
1. 18 years of age or older 
2. pathology-confirmed diagnosis of RCC 
3. at least one tumor lesion greater than 1 cm in 
diameter, amenable to ultrasound imaging 
4. written informed consent 
5. arm 1: planned to be treated with vascular 
endothelial growth factor 2 (VEGFR2) tyrosine 
kinase inhibitor (TKI) plus immune checkpoint 
inhibitor (ICI) 
6. arm 2: planned to be treated with non-ICI therapy 
Exclusion Criteria 
 
1. any comorbid condition that, in 
the opinion of the treating 
provider or the Protocol 
Directors, compromises the 
participant’s ability to 
participate in the study (e.g., 
compromised consent 
capacity) 
‘Baseline’ exam 
Power Doppler and Long Ensemble Angular-coherence Doppler 
(LEAD) ultrasound exam of selected lesions prior  (up to 28 days) 
to initiating treatment 
Start of treatment per standard of care 
On-treatment exam #1 
Repeat power Doppler and LEAD ultrasound exam of up to 5 
lesions (selected based on results of ‘baseline’ exam) 3 weeks 
(+/- 8 days) after start of treatment  
Diagnostic imaging per standard of care, 12 weeks (+/- 4 weeks) after start of treatment to 
determine overall response according to RECIST v1.1 
 
Primary outcome: initial objective response per RECIST v1.1 (8-16 weeks after start of treatment) 
Primary objective: prediction of primary outcome based on change in LEAD ultrasound 
measurements between ‘baseline’ and 3 weeks after initiating treatment 
On-treatment exam #2 
Repeat power Doppler and LEAD ultrasound exam of the same 
up to 5 lesions 6 weeks (+/- 15 days) after start of treatment  


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 9 of 31 
1 May 2023 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
AE 
Adverse Event 
AUC 
Area Under the Curve 
CART 
Classification And Regression Tree 
CEUS 
Contrast-Enhanced Ultrasound 
CR 
Complete Response 
CRF 
Case Report Form 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse 
Events 
CTLA-4 
Cytotoxic T-Lymphocyte-Associated Protein 4 
DSMC 
Data and Safety Monitoring Committee 
FDA 
United States Food and Drug Administration 
GCP 
Good Clinical Practice 
ICI 
Immune Checkpoint Inhibitor 
IDE 
Investigational Device Exemption 
IRB 
Institutional Review Board 
Lasso 
Least absolute shrinkage and selection operator 
LEAD 
Long Ensemble Angular-coherence Doppler 
mRCC 
Metastatic Renal Cell Carcinoma 
OS 
Overall Survival 
PD 
Progressive Disease 
PD-1 
Programmed Cell Death Protein-1 
PD-L1 
Programmed Death Ligand-1 
PET 
Positron Emission Tomography 
PFS 
Progression-Free Survival 
PR 
Partial Response 
RECIST 
Response Evaluation Criteria In Solid Tumors 
RCC 
Renal Cell Carcinoma 
SAE 
Serious Adverse Event 
SD 
Stable Disease 
SOP 
Standard Operating Procedure 
SRC 
Scientific Review Committee 
TKI 
Tyrosine Kinase Inhibitor 
VEGFR2 
Vascular Endothelial Growth Factor Receptor 2 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 10 of 31 
1 May 2023 
1. OBJECTIVES 
 
1.1 Primary Objective  
Our primary objective is to assess whether in arm 1, changes in quantitative tumor 
perfusion parameters 3 weeks after start of treatment of metastatic renal cell 
carcinoma (mRCC) patients with tyrosine kinase inhibitor (TKI) plus immune 
checkpoint inhibitor (ICI), as measured by LEAD ultrasound, can predict initial 
objective response to therapy at 12 weeks after start of treatment defined by 
current standard-of-care Response Evaluation Criteria In Solid Tumors (RECIST 
v1.1)1. 
 
1.2 Secondary Objectives 
 
Our secondary objectives are to evaluate in arm 1, if there is an optimal ultrasound 
imaging modality (power Doppler or LEAD ultrasound), or optimal time point to 
predict initial objective response. We will assess how well 1) changes in tumor 
perfusion parameters 6 weeks after start of treatment by imaging modality or 2) 
tumor perfusion parameters at a single time point (treatment ‘baseline’, 3 weeks, 
or 6 weeks after start of treatment), predict initial objective response (at 12 weeks) 
per RECIST v1.1. 
 
Additional exploratory objectives in both arms are to assess the correlation of 
tumor perfusion parameters with change in overall tumor burden (defined as sum 
of the longest diameters of all measurable lesions defined by RECIST v1.1) 12 
weeks after start of treatment, with change in diameter on a per-lesion basis 
(correlation between perfusion parameters of a single lesion with change in 
diameter of that lesion), and with 12-month progression-free survival (PFS). 
 
 
2. BACKGROUND 
 
2.1 Study Disease 
Renal cancer is the 8th most common cancer in the U.S. and patients with 
metastatic RCC (mRCC) have a 5-year overall survival (OS) rate of 12%2. There 
are 17 FDA-approved drugs for mRCC, which include TKIs of vascular endothelial 
growth factor receptor 2 (VEGFR2, a key mediator of angiogenesis), and 
antibodies that target immune checkpoint proteins such as programmed cell death 
protein-1 (PD-1), programmed death ligand-1 (PD-L1), or cytotoxic T-lymphocyte-
associated protein 4 (CTLA-4)3–10. 
 
In April 2019, the FDA approved the combinations of a TKI (axitinib) with an ICI 
(pembrolizumab or avelumab) for first-line treatment of mRCC and additional TKI 
plus ICI combination therapies (cabozantinib plus nivolumab, lenvatinib plus 
pembrolizumab) have been approved more recently11,12. TKI plus ICI has become 
the new standard-of-care first-line treatment that improves OS for patients with 
mRCC11. 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 11 of 31 
1 May 2023 
2.2 Imaging Procedure 
Power Doppler ultrasound is an ideal non-invasive modality for serial 
measurements because it can be performed at bedside during routine oncology 
visits. However, due to the relatively large depths at which some organs such as 
the kidneys are located and the low frequencies utilized to image deep structures, 
the ability to detect the smaller vasculature of tumors and the potential changes 
in tumor vasculature becomes increasingly difficult. Hence, in addition to the 
commercially available power Doppler imaging mode, we will incorporate 
advanced power Doppler imaging techniques that improve the sensitivity to 
slower flow and smaller vessels in our study. Specifically, this advanced power 
Doppler mode utilizes long Doppler ensembles combined with short-lag angular 
coherence beamforming to achieve high sensitivity to slow flow and small vessels 
(Long Ensemble Angular-coherence Doppler [LEAD] ultrasound). The long 
Doppler ensemble increases the sensitivity to flow by utilizing high frame rates 
(~300 Hz) to boost the signal-to-noise ratio of the blood signal13. Moreover, 
angular coherence beamforming is utilized in LEAD ultrasound studies to 
suppress motion/flash artifact over the long ensemble while also suppressing 
incoherent noise due to reverberation and thermal noise14,15. 
 
For the ultrasound exams at treatment ‘baseline’ and 3 and 6 weeks after initiating 
treatment in this pilot study, lesions are imaged with B-mode and power Doppler 
ultrasound using a portable Siemens Acuson S3000 ultrasound scanner and a 
6C1 or similar transducer (FDA-approved for clinical ultrasound exams but used 
only for research exams for this study). Measurements are performed in the long 
axis and short axis planes, if possible by tumor localization. For LEAD ultrasound 
exams, the same views are obtained using a Verasonics Vantage 256 scanner 
with a C5-2v or similar transducer (research ultrasound scanner). 
 
2.3 Clinicaltrials.gov  
The Verasonics system operates under an abbreviated Investigational Device 
Exemption (IDE) approved by the Stanford IRB. The device has non-significant 
risk. The study is registered at clinicaltrials.gov under registration number 
NCT04508725. 
 
2.4 Rationale 
Unfortunately, not all mRCC patients respond to first-line treatment, yet all 
patients endure the side effects of treatment (fatigue, nausea, diarrhea, and/or 
liver inflammation) while awaiting standard-of-care imaging (typically computed 
tomography, CT) to assess response after approximately 12 weeks of therapy16–
22. Evaluation of efficacy currently requires this time period because molecular 
and cellular changes induced by therapy require about 12 weeks to result in 
definitive changes in tumor diameters on CT scans. Patients may respond to 
subsequent lines of therapy; yet approximately 40% of patients never receive 
second-line therapy despite 13 additional drugs available23–25. Thus, rapid 
detection of response or resistance to RCC therapy is required to minimize use 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 12 of 31 
1 May 2023 
of ineffective drugs and to allow patients to cycle through drugs to arrive at 
effective therapy22. 
 
Increased angiogenesis and immune system evasion are intrinsic to RCC. Clear 
cell RCC occurs when the von-Hippel Lindau tumor suppressor is lost, resulting 
in upregulation of angiogenesis and suppression of immune signaling. In RCC, 
blood vessels increase in number but have abnormal porosity26–29. The abnormal 
porosity prevents T cells from exiting blood vessels to infiltrate and attack tumors. 
Immune checkpoint inhibition normalizes blood vessel porosity, allowing T cell 
egress27,30,31. Hence changes in tumor vascularity may be especially important in 
RCC patients receiving TKI therapy (alone or in combination with other drugs). 
 
We have previously found that imaging-based biomarkers (e.g., perfusion CT, 
‘4D-CT’ scans, or novel positron emission tomography [PET] tracers such as F18-
FPPRGD2 that binds blood vessels) may have the capability of detecting early 
response to anti-angiogenic therapy in mRCC32,33. However, due to renal 
dysfunction and often only a solitary remaining kidney after resection of the initial 
kidney primary lesion, patients are not always eligible for perfusion CT, which 
requires potentially nephrotoxic iodinated contrast. A limitation of PET imaging is 
that nuclear imaging does not provide measurements of blood flow. Hence, there 
is an important clinical need for complimentary, non-nephrotoxic imaging that can 
be serially repeated without exposure to ionizing radiation, to predict response 
and resistance to TKI plus ICI and other mRCC therapies. 
 
In addition, not all patients can tolerate TKI plus ICI combination therapy, so we 
have added an exploratory arm 2 to investigate the ability of Doppler ultrasound 
to detect changes in tumor perfusion in patients who are planned to receive non-
ICI therapies. These include, but are not limited to: TKI monotherapy, combination 
of TKI with another kinase inhibitor (e.g., mTOR inhibitor), localized tumor therapy 
such as radiation, radioembolization, chemoembolization. (Patients receiving 
ICI/ICI combination therapy or ICI monotherapy are enrolled in the parallel 
ultrasound study ‘Serial Ultrasound to Detect Early Response to Immunotherapy 
in Advanced Renal Cell Carcinoma’ (RENAL0045). The choice of treatment is 
made by the treating medical oncologist based on clinical considerations per 
standard-of-care (e.g., comorbidities and performance status, need for immediate 
control over tumor growth versus long-lasting tumor control, response to previous 
treatments, tolerance of previous treatments). Patients are assigned to a study 
arm based on the treatment plan at the time of enrollment. 
 
Contrast-enhanced ultrasound (CEUS) has been used for the identification of 
renal focal lesions and has shown some promise in preliminary studies to monitor 
changes with therapy34,35. However, CEUS has not widely been explored as a 
methodology to monitor anti-angiogenesis or combination therapy. Furthermore, 
the use of CEUS to monitor therapeutic response may be unnecessary, as recent 
advances in power Doppler imaging have yielded non-contrast, high-sensitivity 
perfusion imaging  by using novel filter and ultrasound beamforming design13,36–


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 13 of 31 
1 May 2023 
41. Such methods have also been applied to monitor cancer therapy response in 
the liver39,42. Doppler ultrasound is an ideal modality for serial measurements 
because it can be performed at bedside during routine oncology visits, without 
requiring placement of an intravenous catheter for administration of contrast. In 
this pilot study, we use conventional power Doppler and LEAD ultrasound imaging 
to non-invasively assess changes in tumor perfusion parameters performed in 
real time, with the ultimate goal to accelerate detection of response to combined 
TKI plus ICI therapy. 
  
2.5 Preliminary results 
We have previously demonstrated good performance of LEAD ultrasound in 
neonates to show highly detailed brain vasculature and suppression of flash- and 
motion-artifact15. In addition, we used this technique for deep imaging within the 
liver (~22 cm), which overcomes difficulties of imaging large or obese individuals 
with high body mass index (unpublished results, see Figure). 
 
Figure: Demonstration of LEAD applied to the liver of a high BMI 
individual. This power Doppler-style image shows sensitivity to a wide 
range of vasculature deep within the liver. The smallest vessels visualized 
are on the order of 1 mm in diameter. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.6 Study Design 
This is a pilot, single group imaging study, testing a new method of therapeutic 
response assessment, power Doppler ultrasound, in mRCC patients treated with TKI 
plus ICI (arm 1) or non-ICI therapy (arm 2). A total of 30 subjects will be enrolled for a 
two-arm, open-label cohort. No randomization is used. Rather, subjects receiving the 
treatment as part of their standard of care are followed with the ultrasound studies. 
Since this is an exploratory pilot study and we are not formally testing a specific 
research hypothesis, the sample size for each arm has been chosen based on 
practical considerations and estimated feasibility. 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 14 of 31 
1 May 2023 
3. PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
 
3.1 Inclusion Criteria 
The participant population consists of patients treated at Stanford Healthcare or 
patients referred to Stanford from outside institutions for participation in this study. 
Patients must meet all of the following general inclusion criteria: 
• 18 years of age or older 
• pathology-confirmed diagnosis of RCC 
• at least one tumor lesion greater than 1 cm in diameter, amenable to ultrasound 
imaging 
• written informed consent. 
 
In addition, patients must meet the following specific inclusion criteria for the 
respective study arm: 
 
Arm 1: TKI plus ICI Treatment 
• planned to be treated with combination of VEGFR2 tyrosine kinase inhibitor 
(TKI) plus immune checkpoint inhibitor (ICI)* 
 
* prior use of either class of drugs is not necessarily excluded, and patients may be included with 
the approval of the Protocol Director 
 
Arm 2: Non-ICI Treatment 
• planned to be treated with non-ICI therapy** 
 
** including, but not limited to: TKI monotherapy, other kinase inhibitors (e.g., mTOR inhibitors) 
alone or in combination with TKIs, localized tumor therapy such as radiation, chemo- or 
radioembolization 
 
Subjects may participate in the study more than once at the discretion of the 
Protocol Director, for example, if they receive different lines of treatment that all 
qualify for the study. 
 
3.2 Exclusion Criteria 
Any comorbid condition*** that, in the opinion of the treating provider or the 
Protocol Directors, compromises the participant’s ability to participate in the study. 
 
*** Examples: any mental condition that compromises the ability to follow a consent discussion or 
to make informed decisions (except if represented by a Legally Authorized Representative [LAR]) 
or to have ultrasound exams. 
 
3.3 Informed Consent Process 
No advertisements are utilized. All participants must be provided a consent form 
describing the study with sufficient information for participants to make an 
informed decision regarding their participation. Participants are consented by a 
member of the study personnel at Stanford Healthcare, Stanford University, or 
remotely. Remote consent discussions will take place via telephone or video 
conferencing services (e.g., Stanford instance of Zoom, EpiC video visit). The 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 15 of 31 
1 May 2023 
remote consent process does not waive the requirement for written consent and 
the investigators must follow the Stanford Cancer Institute’s SOP ‘Remote 
Consenting for Adults’ to obtain written consent. Participants or their Legally 
Authorized Representative (LAR) must sign the IRB-approved informed consent 
prior to participation in any study specific procedure. Written consent may be 
obtained electronically via Adobe Sign. The participant must receive a copy of the 
signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file. 
 
 
3.4 Study Timeline 
The study will reach primary completion 2 years from the time the study opens to 
accrual. 
 
3.5 Study Completion 
The study will reach study completion 3 years from the time the study opens to 
accrual. 
 
 
4. IMAGING PROCEDURE INFORMATION 
The ultrasound exams must be performed either by a licensed professional 
(technologist, fellow, or attending) or by a qualified member of the research staff (e.g., 
research scholar, fellow), if all of the following criteria (approved by the Stanford 
School of Medicine Department of Radiology and Stanford Healthcare) are fulfilled: 
• 
delegated individual holds a sonography certification 
• 
task is delegated by the Protocol Director and this is documented on the 
Delegation of Responsibility Log 
• 
a California-licensed radiologist interprets the sonography (not applicable to this study, 
as the study does not include any formal interpretation of the ultrasound exams) 
• 
the clinical ultrasound machine is set up with a research function to keep clinical 
care and research separate (not applicable to this study, as all scanners are exclusively used 
for research). 
Performing the exam includes holding the transducer, providing patient care related 
to the exam in collaboration with the investigators, and documenting the encounter in 
the patient’s Stanford Healthcare medical record. Investigators with expertise in 
ultrasound are allowed to be present and provide assistance with operating the 
instrument to the licensed professional. Assistance may include image review, 
instrument operation during the scan, but not providing any patient-related care or 
holding the transducer. 
 
The selected lesions (see section 10.3.2) are imaged in B-mode and with power 
Doppler ultrasound using a portable Siemens Acuson S3000 ultrasound scanner and 
a 6C1 or similar transducer, in the long axis and short axis planes, if possible by 
localization. For LEAD ultrasound exams, the same views using a Verasonics Vantage 
256 scanner with a C5-2v or similar transducer are obtained. The ultrasound exams 
take place during standard-of-care or research-only clinic visits at Stanford 
Healthcare. 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 16 of 31 
1 May 2023 
 Each participant has three ultrasound exams, each with both scanners: at treatment 
‘baseline’ and 3 and 6 weeks after initiating treatment. 
 
 
5. STUDY PROCEDURES 
 
5.1 Criteria for Removal from Study 
Subjects are removed from active study participation (i.e., no further ultrasound 
exams), if 
• they are non-compliant with study procedures; 
• their treatment plan changes before the first ultrasound exam such that the 
new treatment plan does not qualify for this study; 
• they start a different treatment during the active study participation period; 
• for participants in arm 1, they receive less than 4 weeks of TKI treatment 
during the first 12 weeks after initiating TKI plus ICI therapy (i.e. minimum 4 of 
12 weeks of TKI treatment and minimum one dose of ICI required for continued 
study participation); 
• for participants in arm 2, they receive less than 4 weeks of systemic therapy 
druing the first 12 weeks after initiating treatment. (For localized therapies, the 
minimum treatment requirements are determined by the Protocol Director.) 
 
Subjects removed from active study participation with valid written consent are 
followed up per study protocol, so that data acquired by study procedures up to 
that time point can still be used for analysis. 
 
5.2 Alternatives 
As an alternative to this study, the patient may elect not to participate. Patients 
will continue to receive standard care through their oncologist. 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 17 of 31 
1 May 2023 
6. STUDY CALENDAR 
 
   
Pre-Study 
Baseline 
(up to 28 
days prior to 
initiating 
therapy)h 
Standard-Of-Care Therapy 
Week 3 
(+/- 8 days)i 
Week 6 
(+/- 15 days)i 
Week 12 
(+/- 4 weeks)h 
Before Study 
Completionj 
Informed consent 
X 
 
 
 
 
 
Doppler ultrasound examsa 
 
X 
X 
X 
 
 
Standard-of-care imagingb 
X 
 
 
 
X 
 
Adverse event evaluationc 
 
X 
 
Recording of age, race, ethnicity, 
sex, diagnosis, cancer stage, tumor 
histology, and drug treatmentd,e 
 
X (just once during any study timepoint) 
Documentation of lesions selected 
for ultrasound exam, scanners and 
modalities used, and imaged axis 
planes 
 
X 
X 
X 
 
 
Quantification of tumor perfusion 
parametersf 
 
 
 
 
 
X 
Tumor diameter measurementsg 
 
 
 
 
 
X 
Optional recording of medical 
history and other diagnoses, 
concurrent treatment and 
medication, additional treatment, 
follow-up, and survival data for 
future correlation studiese 
 
X -------------------------------------------------------------------------------------- X 
a) 
Doppler ultrasound exams: power Doppler and LEAD ultrasound exams, performed during standard-of-care clinic visit or 
at research-only visit; if exam can be performed only with one of the two ultrasound scanners, only in one axis, or if one 
time point is missed entirely, subsequent exams may still be performed in full within their allowed time window. 
b) 
Standard-of-care imaging: The baseline standard-of-care scan is generally within 6 weeks prior to initiating therapy, but 
may be greater than 6 weeks prior to therapy, if this is the scan that the treating physician chooses to use as reference 
for response evaluation. Preferably, this is a CT Chest-Abdomen-Pelvis (CAP) scan (with or without contrast), but it may 
also be an MRI or PET/CT or a combination of MRI and CT.  At the discretion of the treating oncologist, the standard-of-
care scan at week 12 may be performed outside of the +/- 4-week window. 
c) 
Adverse event (AE) evaluation: Only AEs that are attributed to the study procedures are recorded and reported. During 
study procedures, study coordinator reminds patient to contact the clinical care team, if they experience any symptoms 
during the exam or afterwards. If the participant expresses to the coordinator that they have experienced symptoms 
during or after the exam, the coordinator will alert  the clinical care team on the same day to contact the patient for AE 
evaluation and management. During baseline through week 12, patient will continue with standard-of-care provider visits 
at or outside of Stanford (generally, every 2-6 weeks, at the discretion of the treating clinical care team) including adverse 
event management. At week 12, a retrospective chart review will document any undisclosed study-related late adverse 
events and assure there are no ongoing study-related adverse events. If there is no adequate information in the medical 
record at week 12, patient will be contacted if needed to complete this documentation. Therefore, at minimum, there is 
one documented AE evaluation at week 12. 
d) 
to be recorded once between baseline and study completion 
e) 
may be obtained until study completion, even after a participant’s death; patients or their outside medical providers may 
be contacted as needed to obtain the clinico-demographic data, if not available in the Stanford medical record. 
f) 
to be quantified and recorded for all ultrasound exams from this study 
g) 
RECIST measurements to be recorded for all imaging studies used for response evaluation (CT, MRI or PET/CT as 
described in footnote (b).  Performed at minimum at baseline and 12 weeks. RECIST measurements will also be recorded 
for other subsequent standard-of-care studies that the treating MD obtains at any interval to evaluate treatment response 
(until 12 months after initiating treatment or until end of the treatment that is being studied, whichever occurs first) 
h) 
For combination treatments, initiation of therapy is typically defined by the day of starting treatment with the second drug, 
however another day (such as the start of treatment with the first drug) may be defined as start of treatment at the 
discretion of the Protocol Director; date considered start of treatment will be documented in the research procedure note 
in the electronic medical record. 
i) 
10 days is the minimum time period between week-3 and week-6 power Doppler ultrasound exams; similarly, 10 days is 
the minimum time period between week-3 and week-6 LEAD ultrasound exams; it is not required that power Doppler and 
LEAD ultrasound exams are performed on the same date. 
j) 
Before end of study (3 years from date of study opening) 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 18 of 31 
1 May 2023 
7. ADVERSE EVENTS AND REPORTING PROCEDURES 
 
7.1 Potential Adverse Events 
There are no known risks from ultrasound as a diagnostic tool in its 60 years of 
use. The Verasonics system used for LEAD ultrasound exams operates the same 
way as a regular ultrasound system, except the investigators are performing the 
acoustic output measurements instead of the manufacturer. The system has also 
been cleared by Clinical Engineering. Therefore, the risks are no different than a 
clinical ultrasound scanner such as the FDA-approved Siemens system used for 
the conventional power Doppler ultrasound exams. We have also previously used 
the Verasonics system in several IRB-approved protocols in studies involving 
imaging of adult liver, adult heart, adult thyroid, and neonatal brain. There have 
been no adverse events in any of these studies or subjects/patients. 
 
Possible adverse events from the procedure include discomfort or tenderness in 
some cases from slightly pressing the transducer against the tumor site. However, 
protocol directors are available in the event of an unforeseen adverse event or 
the need for medical intervention. 
 
7.2 Adverse Event Reporting 
For this study, only Adverse Events (AEs) attributed to ultrasound use are 
reported. 
During study procedures, the study coordinator reminds patient to contact the 
clinical care team, if they experience any symptoms during the exam or 
afterwards. If the participant expresses to the coordinator that they have 
experienced symptoms during or after the exam, the coordinator will alert the 
clinical care team on the same day to contact the patient for AE evaluation and 
management. During baseline through week 12, patient will continue with 
standard-of-care provider visits at or outside of Stanford (generally, every 2-6 
weeks, at the discretion of the treating clinical care team) including adverse event 
management. At week 12, a retrospective chart review will document any 
undisclosed study-related late adverse events and assure there are no ongoing 
study-related adverse events. If there is no adequate information in the medical 
record at week 12, patient will be contacted if needed to complete this 
documentation. Therefore, at minimum, there is one documented AE evaluation 
at week 12. 
 
AEs are graded according to CTCAE v5.0. Both Serious and Non-Serious study-
related AEs are clearly noted in source documentation and listed on study specific 
Case Report Forms in RedCAP. The Protocol Director or designee assess each 
AE to determine whether it is unexpected according to the Informed Consent or 
Protocol Document and related to the investigation. All study-related Serious 
Adverse Events (SAEs) are tracked until resolution. AEs and SAEs related to 
standard-of-care procedures or medication, including the studied drug therapy for 
RCC, are not recorded or reported. 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 19 of 31 
1 May 2023 
8. REGULATORY CONSIDERATIONS 
 
8.1 Institutional Review of Protocol 
The protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) 
must be reviewed and approved by the Stanford IRB and Scientific Review 
Committee (SRC). Any changes made to the protocol will be submitted as a 
modification to be approved by the IRB and SRC prior to implementation. The 
Protocol Director will disseminate the protocol amendment information to all 
participating investigators. 
 
8.2 Data Management Plan 
An alphanumeric study code is selected by the study coordinator for each 
participant. Source documents and analytic data are used to complete the 
electronic Case Report Forms (eCRFs) in the Stanford RedCAP database. An  
eCRFs needs to be completed for each enrolled patient and, at minimum, needs 
to contain the following data: 
- 
study code 
- 
age, race, ethnicity, sex, diagnosis, cancer stage, tumor histology, and drug 
treatment 
- 
identification of lesions selected for ultrasound exams and for response 
evaluation 
- 
identification of time points and modality of ultrasound exams and standard-
of-care radiographic imaging 
- 
tumor perfusion parameters quantified from ultrasound studies 
- 
tumor diameter measurements quantified from standard-of-care radiographic 
imaging studies 
- 
primary and secondary outcomes measures. 
 
The digital ultrasound images including PHI may be stored on the ultrasound 
scanners for the duration for the study. Ultrasound image files that are transferred 
off the scanners have coded file names and the files are stored on Dr. Dahl’s lab 
servers or using cloud storage services that are certified for PHI (e.g., Stanford 
Medicine Box). Other source documents need to be included in the regulatory 
binder. The Stanford's Data & Safety Monitoring Committee (DSMC) will routinely 
review the source documentation (incl. the raw imaging files on Dr. Dahl’s lab 
servers) and verify the corresponding data entered in the eCRFs. All entered, 
changed, and final data shall be available with a validated audit trail or data extract 
report. The eCRFs shall be considered complete when all expected data has been 
entered and all discrepancies have been resolved or documented. 
 
Source documents, other documents containing HIPAA identifiers, clinico-
demographic or analytic data linked to the participants’ identity (i.e., Protected 
Health Information, PHI), and information linking study codes to participant 
identities may be additionally maintained in paper form or electronically on co-
investigators’ computers or using cloud storage services that are certified for PHI 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 20 of 31 
1 May 2023 
(e.g., OnCore, Stanford Medicine Box) until study completion. All computers need 
to comply with Stanford University IT security standards. Access to files and 
folders with PHI (paper or electronic) must be restricted to the study personnel.  
 
Upon study closure, all PHI not stored in the regulatory binder (physical and 
electronic), regulatory database (i.e., OnCore), or eCRFs must be destroyed, for 
example by de-identifying the data and files in accordance with the HIPAA Privacy 
Rule. Ultrasound data must be removed from the ultrasound scanners upon study 
closure. However, ultrasound images with PHI may be retained in the electronic 
medical record at Stanford Healthcare at the discretion of the study radiologists 
as long as they are clearly designated as research data and not associated with 
a formal interpretation. 
 
The Protocol Directors have ultimate responsibility for collection and reporting of 
all clinical safety and study data entered in the eCRFs and any other data 
collection forms (source documents) and ensuring that they are attributable, 
legible, contemporaneous (timely), original, and accurate as well as complete, 
consistent, and available when required. 
 
8.3 Data and Safety Monitoring Plan 
During the clinical investigation, the Protocol Directors will evaluate the progress 
of the trial, including periodic assessments of data quality and timeliness, 
adherence to the data management plan, participant recruitment, accrual and 
retention, participant risk versus benefit, performance of trial sites, and other 
factors that can affect study outcome.   
 
The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will 
audit study-related activities at least annually in accordance with the DSMC SOP 
to determine whether the study has been conducted in accordance with the 
protocol, local standard operating procedures, FDA regulations, and Good Clinical 
Practice (GCP). This may include review of regulatory binders, case report forms, 
eligibility checklists, and source documents. In addition, the DSMC will regularly 
review serious adverse events and protocol deviations associated with the 
research to ensure the protection of human subjects. Results of DSMC audits will 
be communicated to the IRB and the appropriate regulatory authorities at the time 
of continuing review, or in an expedited fashion, as needed. 
 
 
9. MEASUREMENTS 
 
9.1 Primary Outcome Measures 
The primary endpoint is initial objective response per RECIST v1.1 assessed 8-
16 weeks after start of treatment, using standard-of-care imaging. expressed as 
a number and proportion without dispersion. 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 21 of 31 
1 May 2023 
Initial objective response (yes/no): defined as having either Complete Response 
(CR) or Partial Response (PR) per RECIST v1.1 at first on-treatment response 
evaluation 8-16 weeks after initiating treatment. 
 
9.1.1 Measurement Methods 
Tumor diameter measurements: Where possible, the same lesions that 
were selected for repeat LEAD ultrasound exams are used as target 
lesions for response evaluation per RECIST. Different lesions may be 
selected at the discretion of the radiologist designated to review response 
evaluation. 
 
9.1.2 Measurement Time Points 
At treatment ‘baseline’ (prior to starting treatment) and 12 weeks after start 
of treatment (+/- 4 weeks) standard-of-care radiographic imaging is 
performed for initial response evaluation. 
No further follow-up is required for the primary endpoint. 
 
9.1.3 Response Review 
Response evaluation per RECIST v1.1 is reviewed by a designated 
radiologist, who may be the same person that performs the tumor diameter 
measurements. 
 
 
9.2 Secondary Outcome Measures  
 
Secondary endpoints are: 
1) initial relative change in tumor burden (continuous): defined as relative 
change (i.e., difference between time points divided by value at time point 
1, expressed as percentage) in the sum of all tumor diameters between 
treatment ‘baseline’ and first on-treatment response evaluation 8-16 weeks 
after start of treatment, using RECIST v1.1 for tumor diameter 
measurements, expressed as mean +/- standard deviation and median with 
interquartile range 
2) initial lesion response (continuous): defined as the relative change in 
tumor diameter of a single lesion between treatment ‘baseline’ and first on-
treatment response evaluation 8-16 weeks after start of treatment, using 
RECIST v1.1 for tumor diameter measurements, expressed as mean +/- 
standard deviation and median with interquartile range. 
3) 12-month progression-free survival (PFS) (yes/no): defined as not 
having experienced any PD per RECIST v1.1 within the first 12 months after 
initiating treatment (day 1 will be treatment start date), as a number and 
proportion without dispersion. 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 22 of 31 
1 May 2023 
9.2.1 Measurement Methods 
Tumor diameter measurements: same as for primary endpoint 
Progression-free survival: determined by medical record review and 
contacting participants or their outside medical providers as needed. 
 
9.2.2 Measurement Time Points 
Initial response evaluation is performed by radiographic imaging at the 
same timepoints as for the primary endpoint. For repeat response 
evaluations on treatment, standard-of-care restaging imaging studies will 
be used. These, as well as determination of 12-month PFS, require follow-
up at 12 months after initiation of treatment.  
 
9.2.3 Response Review 
Response evaluation per RECIST v1.1 is reviewed by a designated 
radiologist, who may be the same person that performs the tumor diameter 
measurements. 
 
 
 
10 
STATISTICAL CONSIDERATIONS 
 
10.1 Statistical Design 
This is a pilot study to evaluate how well changes in tumor perfusion 
parameters, assessed by LEAD ultrasound 3 weeks after initiating treatment 
with TKI plus ICI, predict initial objective response, as determined by standard-
of-care radiographic imaging 8-16 weeks after start of treatment. All secondary 
endpoints are exploratory and are intended for generating hypotheses that will 
require follow-up studies. 
 
10.2 Descriptive Statistics and Exploratory Data Analysis 
We will characterize the study population by providing demographic and clinical 
characteristics. Categorical data will be presented as frequencies and 
percentages. For continuous data, mean, standard deviation, median, 25th and 
75th percentiles will be presented. In addition, we will use graphical techniques 
to show the distribution of ultrasound parameters by the primary endpoint.  
 
 
10.3 Primary Analysis 
 
10.3.1 Analysis Population 
The population for primary analysis consists of all study participants who 
have completed the LEAD ultrasound exams at treatment ‘baseline’ and 
after 3 weeks of treatment, who received at least 4 weeks of TKI and at 
least one dose of ICI therapy, and for whom initial response can be 
evaluated per RECIST v1.1. If fewer than 20 of the 20 initially enrolled 
patients in arm 1 fulfill these criteria, additional patient may be enrolled 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 23 of 31 
1 May 2023 
at the discretion of the Protocol Directors to have a complete dataset 
from 20 patients in arm 1 for primary analysis. 
 
10.3.2 Analysis Plan 
To address our primary objective, we will conduct a Least absolute 
shrinkage and selection operator (Lasso) regression as our primary 
analysis. Specifically, our outcome, initial objective response, will be 
regressed on the change in each of the LEAD ultrasound tumor 
perfusion parameters after 3 weeks of treatment and relevant 
demographic and clinical characteristics. The measurement of LEAD 
ultrasound tumor perfusion parameters and the definition of their change 
are described in more detail below. We will not use selection techniques 
to choose variables. Rather, we will include all factors in our model 
jointly. We will evaluate the predictive ability of our model using area 
under the curve (AUC) and calculate a 95% confidence interval for the 
AUC. Since our sample size is too small to allow for separate training 
and testing datasets, we will utilize cross-validation techniques for 
evaluating predictive performance. 
 
Selection of lesions for LEAD ultrasound exams: 
Before the first ultrasound exam, the treating medical oncologist, a 
Protocol Director, or a designated radiologist selects up to 5 lesions per 
patient (target lesions per RECIST v1.1). At the treatment ‘baseline’ 
LEAD ultrasound exam (up to 28 days prior to start of treatment), 
perfusion of these 5 lesions is measured. Additional lesions may be 
assessed at the discretion of the investigators, so that in the end up to 
5 lesions are selected for repeat ultrasound exams that in the opinion of 
the investigators lend themselves to reproducible tumor perfusion 
measurements. LEAD ultrasound tumor perfusion measurements of the 
up to 5 lesions that were selected for ultrasound studies at the treatment 
‘baseline’ exam are performed again 3 weeks (+/- 8 days) after start of 
treatment. 
 
Quantification of tumor perfusion parameters: 
The following parameters are computed from the LEAD ultrasound 
measurements for each lesion: 
• 
overall tumor perfusion: the integrated power within the tumor 
• 
average red cell flux: the integrated power within the tumor 
normalized by tumor size 
• 
tumor-to-background perfusion ratio: the ratio of the integrated 
power within the tumor to the integrated power in a same sized 
region in nearby healthy tissue. 
 
 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 24 of 31 
1 May 2023 
Changes in tumor perfusion parameters after 3 weeks of treatment: 
Defined as relative change in these parameters, i.e., difference between 
time points divided by value at time point 1, expressed as percentage. 
For determining the relative change in several lesions of the same 
patient, the average of the relative changes in the up to 5 individual 
lesions is calculated. 
 
 
10.4 Secondary Analysis 
 
10.4.1 Analysis Population 
All patients who have completed at least one LEAD and Doppler ultrasound 
exam at any time point. For correlation analyses, patients are included for 
each analysis based on availability of data points for specific analyses. If 
fewer than 20 patients in arm 1 and 10 patients in arm 2 fulfill these criteria 
for any secondary analysis, additional patient may be enrolled at the 
discretion of the Protocol Directors to have a complete dataset from 20 and 
10 patients for this analysis, respectively. 
 
10.4.2 Analysis Plan 
To address our secondary objective, i.e., evaluating if there is an optimal 
ultrasound modality to predict initial objective response in arm 1, we will utilize 
the same analysis approach as outlined above for the primary analysis. Here, 
we will use change in tumor perfusion parameters at 6 weeks as our 
independent variables and conduct two regression analyses: (1) using power 
Doppler measurements and (2) using LEAD ultrasound measurements. 
AUCs between the two models will be compared using the nonparametric 
approach of DeLong for correlated AUC curves43. In addition, we will compare 
AUCs between these models to the predictive model for the primary analysis. 
 
To assess if there is an optimal time point for predicting initial objective 
response in arm 1, we will conduct Lasso regression models using tumor 
perfusion parameters for each time point (treatment ‘baseline’, 3 weeks, 6 
weeks) separately for each imaging modality using a similar approach as 
outlined above. Given the exploratory nature of these analyses, we will not 
adjust for multiple testing. 
 
For each arm, we will conduct correlation analysis for change in perfusion 
parameters at 3 and 6 weeks and initial relative change in tumor burden 
(overall and per-lesion), initial overall response, best overall response, and  
PFS until 12 months after initiating treatment by calculating either the 
Pearson r or Spearman rank correlation, as appropriate. PFS is estimated 
using the Kaplan-Meier method and the Kaplan-Meier curves will be 
presented. 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 25 of 31 
1 May 2023 
Selection of lesions for ultrasound exams: 
The up to 5 lesions that were selected for ultrasound studies for the primary 
analysis are re-assessed 6 weeks (+/- 15 days) after start of treatment and 
each lesion is assessed with both LEAD and power Doppler ultrasound at all 
3 time points (treatment ‘baseline’, 3 weeks, and 6 weeks after initiating 
treatment. 
 
Quantification and change of tumor perfusion parameters: defined in the 
same way as for the primary analysis for both power Doppler and LEAD 
ultrasound. 
 
10.5 Sample Size 
Since this is an exploratory pilot study and we are not formally testing a specific 
research hypothesis, the sample size for each arm has been chosen based on 
practical considerations and estimated feasibility. However, for the primary analysis 
(arm 1), we consider a predictive model with a true AUC of at least 0.7 promising for 
predicting initial objective response. With 20 patients and assuming that 59% of 
patients have an objective response to treatment, a predictive model with a true AUC 
of at least 0.7 will have a margin of error of 0.14 so that the empirically determined 
AUC can range from 0.56 to 1. 
 
10.6 Accrual estimates 
 
 
We estimate that 15 patients yearly are eligible for arm 1 and approximately 10 
patients for arm 2. By experience from previous similar imaging studies, patients are 
motivated to participate in such studies, especially when they do not require extra 
study visits. However, taking into account attrition, we conservatively estimate that 
it will take 2 years to accrue 20 patients in arm 1 and up to 10 patients in arm 2 who 
complete all ultrasound exams, receive treatment over the minimum period, and will 
have an evaluable response per RECIST. 
 
10.7 Criteria for future studies 
An AUC of at least 0.7 will be the minimum needed to design a follow-up study and 
the predictive model that yields the best AUC will be selected for future studies. If 
different predictive models give equivalent AUCs, we will consider additional 
analyses (for example, random forests or Classification and Regression Tree 
[CART]) to evaluate these models to determine if a specific model can be selected 
for further studies. 
If any predictive model from this pilot study has an AUC of at least 0.7, the next step 
will be to conduct a larger follow-up study in an independent cohort to validate the 
predictive model and determine its AUC with a smaller margin of error. The sample 
size and operating characteristics of the follow-up study will be determined based 
on findings from this pilot study and other data available at the time of designing the 
follow-up study. If the larger follow-up study is also deemed a success (AUC at least 
0.7), to determine if tumor perfusion measurements by ultrasound are suitable for 
implementation, an adequately powered randomized clinical trial will be required to 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 26 of 31 
1 May 2023 
test if an early therapy switch based on ultrasound imaging improves outcomes, 
compared to current standard of care. 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 27 of 31 
1 May 2023 
11 
REFERENCES 
 
1. Eisenhauer, E. A. et al. New response evaluation criteria in solid tumours: 
revised RECIST guideline (version 1.1). Eur. J. Cancer 45, 228–247 (2009). 
2. Kidney 
and 
renal 
pelvis 
statistics. 
American 
Cancer 
Society 
https://cancerstatisticscenter.cancer.org/#!/cancer-
site/Kidney%20and%20renal%20pelvis (accessed April 21, 2020). 
3. Heng, D. Y. et al. Primary anti-vascular endothelial growth factor (VEGF)-
refractory metastatic renal cell carcinoma: clinical characteristics, risk factors, 
and subsequent therapy. Ann. Oncol. 23, 1549–1555 (2012). 
4. Bedke, J. et al. Systemic therapy in metastatic renal cell carcinoma. World J. 
Urol. (2016) doi:10.1007/s00345-016-1868-5. 
5. Choueiri, T. K. et al. Cabozantinib versus everolimus in advanced renal cell 
carcinoma (METEOR): final results from a randomised, open-label, phase 3 
trial. Lancet Oncol. 17, 917–927 (2016). 
6. Sitohy, B., Nagy, J. A. & Dvorak, H. F. Anti-VEGF/VEGFR therapy for cancer: 
reassessing the target. Cancer Res. 72, 1909–1914 (2012). 
7. Buti, S., Leonetti, A., Dallatomasina, A. & Bersanelli, M. Everolimus in the 
management of metastatic renal cell carcinoma: an evidence-based review of 
its place in therapy. Core Evid. 11, 23–36 (2016). 
8. Motzer, R. J. et al. Nivolumab versus Everolimus in Advanced Renal-Cell 
Carcinoma. N. Engl. J. Med. 373, 1803–1813 (2015). 
9. Calvo, E., Schmidinger, M., Heng, D. Y. C., Grünwald, V. & Escudier, B. 
Improvement in survival end points of patients with metastatic renal cell 
carcinoma through sequential targeted therapy. Cancer Treat. Rev. 50, 109–
117 (2016). 
10. Motzer, R. J. et al. Nivolumab plus Ipilimumab versus Sunitinib in Advanced 
Renal-Cell Carcinoma. N. Engl. J. Med. 378, 1277–1290 (2018). 
11. Rini, B. I. et al. Pembrolizumab plus Axitinib versus Sunitinib for Advanced 
Renal-Cell Carcinoma. N. Engl. J. Med. 380, 1116–1127 (2019). 
12. Motzer, R. J. et al. Avelumab plus Axitinib versus Sunitinib for Advanced Renal-
Cell Carcinoma. N. Engl. J. Med. (2019) doi:10.1056/NEJMoa1816047. 
13. Bercoff, J. et al. Ultrafast compound Doppler imaging: providing full blood flow 
characterization. IEEE Trans. Ultrason. Ferroelectr. Freq. Control 58, 134–147 
(2011). 
14. Li, Y. L. & Dahl, J. J. Angular coherence in ultrasound imaging: Theory and 
applications. J. Acoust. Soc. Am. 141, 1582 (2017). 
15. Jakovljevic, M., Yoon, B. J., Abou-Elkacem, L., Rubesova, E. & Dahl, J. Tracking 
blood flow changes in the brains of neonates using angular-coherence-based 
power doppler. in Medical Imaging 2019: Ultrasonic Imaging and Tomography 
vol. 10955 109550G (International Society for Optics and Photonics, 2019). 
16. Signoretti, S., Flaifel, A., Chen, Y.-B. & Reuter, V. E. Renal Cell Carcinoma in 
the Era of Precision Medicine: From Molecular Pathology to Tissue-Based 
Biomarkers. J. Clin. Oncol. JCO2018792259 (2018). 
17. Ciccarese, C. et al. The prospect of precision therapy for renal cell carcinoma. 
Cancer Treat. Rev. 49, 37–44 (2016). 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 28 of 31 
1 May 2023 
18. Incorvaia, L. et al. Beyond evidence-based data: scientific rationale and tumor 
behavior to drive sequential and personalized therapeutic strategies for the 
treatment of metastatic renal cell carcinoma. Oncotarget 7, 21259–21271 
(2016). 
19. Chan, J. Y., Choudhury, Y. & Tan, M.-H. Predictive molecular biomarkers to 
guide clinical decision making in kidney cancer: current progress and future 
challenges. Expert Rev. Mol. Diagn. 15, 631–646 (2015). 
20. Haddad, A. Q. & Margulis, V. Tumour and patient factors in renal cell carcinoma-
towards personalized therapy. Nat. Rev. Urol. 12, 253–262 (2015). 
21. Garcia-Donas, J., Rodriguez-Antona, C. & Jonasch, E. Molecular markers to 
predict response to therapy. Semin. Oncol. 40, 444–458 (2013). 
22. Chen, V. J. et al. Time on Therapy for at Least Three Months Correlates with 
Overall Survival in Metastatic Renal Cell Carcinoma. Cancers  11, (2019). 
23. Stukalin, I. et al. Fourth-Line Therapy in Metastatic Renal Cell Carcinoma 
(mRCC): Results from the International mRCC Database Consortium (IMDC). 
KCA 2, 31–36 (2018). 
24. Wells, J. C. et al. Third-line Targeted Therapy in Metastatic Renal Cell 
Carcinoma: Results from the International Metastatic Renal Cell Carcinoma 
Database Consortium. Eur. Urol. 71, 204–209 (2017). 
25. Choueiri, T. K. et al. Cabozantinib versus sunitinib as initial therapy for 
metastatic renal cell carcinoma of intermediate or poor risk (Alliance A031203 
CABOSUN randomised trial): Progression-free survival by independent review 
and overall survival update. Eur. J. Cancer 94, 115–125 (2018). 
26. Jain, R. K. Antiangiogenesis strategies revisited: from starving tumors to 
alleviating hypoxia. Cancer Cell 26, 605–622 (2014). 
27. Pircher, A. et al. Synergies of Targeting Tumor Angiogenesis and Immune 
Checkpoints in Non-Small Cell Lung Cancer and Renal Cell Cancer: From Basic 
Concepts to Clinical Reality. Int. J. Mol. Sci. 18, (2017). 
28. Donnadieu, E. Defects in T Cell Trafficking and Resistance to Cancer 
Immunotherapy. (Springer, 2016). 
29. Arreola, A. & Rathmell, W. K. Biology of Renal Cell Carcinoma (Vascular 
Endothelial Growth Factor, Mammalian Target of Rapamycin, Immune 
Aspects). in Renal Cell Carcinoma: Clinical Management (eds. Campbell, S. C. 
& Rini, B. I.) 231–247 (Humana Press, 2013). 
30. Zheng, X. et al. Increased vessel perfusion predicts the efficacy of immune 
checkpoint blockade. J. Clin. Invest. 128, 2104–2115 (2018). 
31. Kandalaft, L. E., Motz, G. T., Busch, J. & Coukos, G. Angiogenesis and the 
tumor vasculature as antitumor immune modulators: the role of vascular 
endothelial growth factor and endothelin. Curr. Top. Microbiol. Immunol. 344, 
129–148 (2011). 
32. Fan, A. C. et al. Early Changes in CT Perfusion Parameters: Primary Renal 
Carcinoma Versus Metastases After Treatment with Targeted Therapy. Cancers 
vol. 11 608 (2019). 
33. Toriihara, A. et al. 18F-FPPRGD2 PET/CT in patients with metastatic renal cell 
cancer. Eur. J. Nucl. Med. Mol. Imaging 46, 1518–1523 (2019). 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 29 of 31 
1 May 2023 
34. Lassau, N. et al. Metastatic Renal Cell Carcinoma Treated with Sunitinib: Early 
Evaluation of Treatment Response Using Dynamic Contrast-Enhanced 
Ultrasonography. Clinical Cancer Research vol. 16 1216–1225 (2010). 
35. Williams, R. et al. Dynamic Microbubble Contrast-enhanced US to Measure 
Tumor Response to Targeted Therapy: A Proposed Clinical Protocol with 
Results from Renal Cell Carcinoma Patients Receiving Antiangiogenic Therapy. 
Radiology vol. 260 581–590 (2011). 
36. Kim, M., Abbey, C. K., Hedhli, J., Dobrucki, L. W. & Insana, M. F. Expanding 
Acquisition and Clutter Filter Dimensions for Improved Perfusion Sensitivity. 
IEEE Trans. Ultrason. Ferroelectr. Freq. Control 64, 1429–1438 (2017). 
37. Baranger, J. et al. Adaptive Spatiotemporal SVD Clutter Filtering for Ultrafast 
Doppler Imaging Using Similarity of Spatial Singular Vectors. IEEE Trans. Med. 
Imaging 37, 1574–1586 (2018). 
38. Kim, M., Zhu, Y., Hedhli, J., Dobrucki, L. W. & Insana, M. F. Multidimensional 
Clutter Filter Optimization for Ultrasonic Perfusion Imaging. IEEE Trans. 
Ultrason. Ferroelectr. Freq. Control 65, 2020–2029 (2018). 
39. Tierney, J., Baker, J., Borgmann, A., Brown, D. & Byram, B. Non-contrast power 
Doppler 
ultrasound 
imaging 
for 
early 
assessment 
of 
trans-arterial 
chemoembolization of liver tumors. Sci. Rep. 9, 13020 (2019). 
40. Bayat, M., Alizad, A. & Fatemi, M. Multi-rate higher order singular value 
decomposition for enhanced non-contrast ultrasound Doppler imaging of slow 
flow. 2018 IEEE 15th International Symposium on Biomedical Imaging (ISBI 
2018) (2018) doi:10.1109/isbi.2018.8363781. 
41. Demene, C. et al. Spatiotemporal Clutter Filtering of Ultrafast Ultrasound Data 
Highly Increases Doppler and fUltrasound Sensitivity. IEEE Transactions on 
Medical Imaging vol. 34 2271–2285 (2015). 
42. Gee, M. S. et al. Doppler ultrasound imaging detects changes in tumor perfusion 
during antivascular therapy associated with vascular anatomic alterations. 
Cancer Res. 61, 2974–2982 (2001). 
43. DeLong, E. R., DeLong, D. M. & Clarke-Pearson, D. L. Comparing the areas 
under two or more correlated receiver operating characteristic curves: a 
nonparametric approach. Biometrics 44, 837–845 (1988). 
 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 30 of 31 
1 May 2023 
APPENDIX A: PARTICIPANT ELIGIBILITY CHECKLIST  
Protocol Title: 
Early Therapeutic Monitoring of Response to Therapy 
with Serial Ultrasound in Metastatic RCC 
Protocol Number: 
55742 
Principal Investigators: 
Alice Fan, M.D. and Jeremy Dahl, Ph.D. 
 
II. Subject Information: 
Subject Name & MRN: 
 
Legal Sex:    
 Male     
 Female 
 
III. Study Information: 
SRC Approved 
 
IRB Approved 
 
 
IV. Inclusion/Exclusion Criteria 
General Inclusion Criteria 
(From IRB approved protocol) 
Yes 
No 
Supporting 
Documentation* 
1. 18 years of age or older 
 
 
 
2. Pathology-confirmed diagnosis of 
RCC 
 
 
 
3. At least one tumor lesion greater 
than 1 cm in diameter, amenable to 
ultrasound imaging 
 
 
 
4. Written informed consent 
 
 
 
 
 
Specific Inclusion Criteria for Arm 1 (TKI + ICI Treatment) 
Planned to be treated with combination 
of VEGFR2 tyrosine kinase inhibitor 
plus immune checkpoint inhibitor 
 
 
 
Specific Inclusion Criteria for Arm 2 (Non-ICI Treatment) 
Planned to be treated with non-immune 
checkpoint inhibitor  
 
 
 
 
 
 
 
Exclusion Criteria 
(From IRB approved protocol) 
Yes 
No 
Supporting 
Documentation* 
Any comorbid condition that, in the 
opinion of the treating provider or the 
Protocol Directors, compromises the 
participant’s ability to participate in the 
study. 
 
 
 
 
Initials & Date 
Treating Provider: 
______   __________ 
*All subject files must include supporting documentation to confirm subject eligibility. The method 
of confirmation can include, but is not limited to, laboratory test results, radiology test results, 
subject self-report, and medical record review. 
 


Early Therapeutic Monitoring of Response to Therapy with Serial Ultrasound in Metastatic Renal Cell 
Carcinoma 
Version 9.0 
Page 31 of 31 
1 May 2023 
IV.  Statement of Eligibility 
 
By signing this form of this trial, I verify that this subject is [
 eligible / 
 ineligible] for 
participation in the study. This study is approved by the Stanford Cancer Institute Scientific 
Review Committee, the Stanford IRB, and has finalized financial and contractual agreements as 
required by Stanford School of Medicine’s Research Management Group. 
 
Treating Medical Provider** Signature: 
Date: 
Printed Name: 
 
** Treating Physician or treating Advanced Practice Provider (APP)