Nivolumab, Cisplatin, and Pemetrexed Disodium or Gemcitabine Hydrochloride in Treating Patients With Stage I-IIIA Non-small Cell Lung Cancer That Can Be Removed by Surgery

PRIMARY OBJECTIVES:

I. To estimate major pathologic response (mpCR) in patients with newly diagnosed and
untreated non-small cell lung cancer (NSCLC) stage I-IIIA treated with three courses of
induction nivolumab added to either cisplatin/pemetrexed or cisplatin/gemcitabine prior to
surgery.

SECONDARY OBJECTIVES:

I. Safety. II. Complete pathologic response at all sites of disease. III. Major pathologic
response rate at primary site. IV. Clinical complete response rate. V. 1 year progression
free survival (PFS). VI. Overall survival.

TERTIARY OBJECTIVES:

I. To explore whether PDL1 expression is associated with treatment response. II. To explore
whether there is a net change in the Th1/Th2 ratio (IFN-gamma, IL-4, IL10, etc.) or cell
subset frequencies (M2 monocytes, myeloid-derived suppressor cells, etc.) within a patient's
peripheral blood either at baseline or in response to treatment is associated with treatment
response.

III. To explore whether exosomes or other immune related serum biomarkers change after
combination therapy.

IV. To explore the predictive value of serial cell free deoxyribonucleic acid (DNA) levels
and response.

V. PD-L1 assessment in tumor.

Inclusion Criteria:

- Pathologically confirmed non small cell lung cancer (NSCLC), not previously treated,
with a plan to undergo surgery

- Stage I-IIIA (stage I tumors must be >= 4 cm) per AJCC 8th edition

- Tumor sample must be available for PD-L1 testing; archival tissue within 3 months of
study enrollment will be used; if archival tissue is unavailable, a fresh biopsy will
be taken

- Eastern Cooperative Oncology Group (ECOG) performance status 0-1

- While blood cells 2000/ul or more

- Absolute neutrophil count 1500/ul or more

- Platelets 100,000/ul or more

- Hemoglobin 9 g/dl or more; (transfusion permitted)

- Bilirubin less than or equal to 1.5 x the upper limit of normal (except subjects with
Gilbert syndrome, who can have total bilirubin < 3 mg/dl)

- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) less than or equal
to 3 x the upper limit of normal

- Glomerular filtration rate (GFR) greater than or equal to 40 ml/min using the
Cockcroft-Gault formula or serum creatinine less than or equal to 1.5 x (ULN) upper
limit of normal

- Women of reproductive potential should have a negative serum or urine pregnancy test
(minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin
[HCG]) within 21 days of the study enrollment

- Women of reproductive potential must use highly effective contraception methods to
avoid pregnancy for 23 weeks after the last dose of study drugs; "women of
reproductive potential" is defined as any female who has experienced menarche and who
has not undergone surgical sterilization (hysterectomy or bilateral oophorectomy) or
who is not postmenopausal; menopause is defined clinically as 12 months of amenorrhea
in a woman over 45 in the absence of other biological or physiological causes; in
addition, women under the age of 55 must have a documented serum follicle stimulating
hormone (FSH) level less than 40 mIU/mL

- Men of reproductive potential who are sexually active with women of reproductive
potential must use any contraceptive method with a failure rate of less than 1% per
year; men who are receiving the study medications will be instructed to adhere to
contraception for 31 weeks after the last dose of study drugs; men who are azoospermic
do not require contraception

- All subjects must be able to comprehend and sign a written informed consent document

Exclusion Criteria:

- Patients who have participated in a study with an investigational agent or device
within 2 weeks of enrollment

- Any prior radiotherapy to the lung

- Any prior treatment for NSCLC

- Epidermal growth factor receptor (EGFR) or alkaline phosphatase (ALK) activating
alteration

- Any prior therapy with anti-PD-1, anti-PD-L2, anti-CTLA-4 antibody, or any other
antibody or drug specifically targeting T-cell co-stimulation or immune checkpoint
pathways

- Any history of a sever hypersensitivity reaction to any monoclonal antibody

- Any history of allergy to the study drug components

- Any concurrent malignancies- exceptions include- basal cell carcinoma of the skin,
squamous cell carcinoma of the skin, superficial bladder cancer or in situ cervical
cancer that has undergone potentially curative therapy; patients with a history of
other prior malignancy must have been treated with curative intent and must have
remained disease-free for 3 years post-diagnosis

- Any diagnosis of immunodeficiency or receiving systemic steroid therapy or any other
form of immunosuppressive therapy within 14 days of initiation of therapy (excludes
emergency steroid use at discretion of the treating physician)

- Patients that have an active autoimmune disease requiring systemic treatment within
the past 3 months or a documented history of clinically severe autoimmune disease, or
a syndrome that requires systemic steroids (> 10 mg daily prednisone equivalents) or
immunosuppressive agents; subjects with vitiligo, type I diabetes mellitus, or
resolved childhood asthma/atopy would be an exception to this rule; subjects that
require intermittent use of bronchodilators or local steroid injections would not be
excluded from the study; subjects with hypothyroidism stable on hormone replacement or
Sjorgen's syndrome will not be excluded from the study

- Patients with evidence of interstitial lung disease or active, non-infectious
pneumonitis. Patients with a history of interstitial lung disease or non-infectious
pneumonitis requiring treatment with steroids are also excluded.

- Patients with a known human immunodeficiency virus infection (HIV 1/2 antibodies) or
acquired immunodeficiency syndrome (HIV/AIDS), active hepatitis B (e.g., hepatitis B
surface antigen [HBsAg] reactive) or hepatitis C (e.g., hepatitis C virus [HCV]
ribonucleic acid [RNA] [qualitative] is detected)

- Patients who have received a live vaccine within 30 days prior initiation of the
systemic regimen

- Patients must not be receiving any other investigational agents

- Patients with uncontrolled intercurrent illnesses including, but not limited to an
active infection requiring systemic therapy or a known psychiatric or substance abuse
disorder(s) that would interfere with cooperation with the requirements of the trial

- Women must not be pregnant (as above) or breastfeeding