Pancreatic Cancer
Conditions
Brief summary
This multi-institutional trial aims to evaluate the potential benefit and side effects of adding fractionated stereotactic body radiotherapy/surgery (SBRT) before and after chemotherapy with gemcitabine for locally advanced pancreatic cancer.
Detailed description
Treatment on this protocol requires placement of 3-5 gold (99.9% pure, 1-5 mm length, or visicoils) fiducials for targeting purposes. The fiducials will be used as surrogates for targeting the daily tumor position during treatment. The fiducials will be placed directly into the tumor and/or periphery under endoscopic ultrasound or CT guidance. Gemcitabine prior to SBRT is optional. If given, up to 3 weeks in a 6-week period is allowable, and may be given prior to study enrollment. Administration should be on a 3-week on, 1-week off schedule, weekly at 1,000 mg/m2. Simulation should be done 5 days or more following placement of fiducials. For simulation patients will be positioned supine in an Alpha Cradle or equivalent immobilization device will be custom made for each patient. Standard free-breathing CT and respiratory-correlated 4-D pancreatic protocol CT will be obtained on each patient The 4D-CT scan will be used for characterizing target motion during quiet respiration. Following simulation, patients may be treated either in a respiratory gated (Trilogy, Elekta, Novalis) or a respiratory tracking (Cyberknife) manner. The selection of which radiotherapy treatment machine to use is left to each investigator. All patients will receive 5 fractions of 6.6 Gy delivered over a five-day period. Ideally all 5 fractions should be delivered Monday through Friday, however it may be delivered over 2 weeks as long as the patient receives at least 2 fractions a week. Gemcitabine, cycles should resume up to 4 weeks following SBRT on a 3-week on, 1-week off schedule, administered weekly at 1,000 mg/m2.A detailed medical history with physical examination and quality of life assessment will be performed at 4 months, 6 months, 9 months and 1 year. A follow-up visit at 4 weeks is optional and may be done by patient's Medical Oncologist. Scans may be done at 4-6 week visit if patient is being re-evaluated for resection. In years 2-5 the follow up interval will be every 3-6 months, as determined by the investigator at each participating institution. Follow up intervals may also be more frequent as indicated clinically. A complete blood count (CBC), comprehensive chemistry panel, tumor marker studies, and quality of life assessment will be performed at each follow-up interval until death. As permitted by each participating institution, separate samples of blood will be drawn and retained for research efforts to develop novel serum biomarkers.
Interventions
DEVICECyberKnife based stereotactic radiotherapy
1. Initial orthogonal images will be obtained to confirm location of fiducial seeds. 2. Synchrony respiratory tracking system must be used to correct for respiratory associated tumor motion. This system utilizes a series of optical diodes placed upon the patient's chest wall. While the orthogonal images are obtained, the computer generates a model correlating the position of the chest wall with the position of the internal fiducials. This model is continuously updated during treatment to correct for subtle changes in tumor location. 3. Quality assurance will be performed as per standard practice at each participating institution.
DRUGGemcitabine
Treatment calculated per the needs of each patient and given at the instruction of the investigator; iv (intravenous).
DRUGFludeoxyglucose (18F) (FDG)
FDG-PET/CT scan is used in treatment planning. Treatment with 18F-FDG is calculated per the needs of each patient and given at the instruction of the investigator; iv
Sponsors
Johns Hopkins University
Stanford University
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
3.1.1 Histologically confirmed adenocarcinoma of the pancreas. 3.1.2 Unresectable disease as determined by a pancreatic cancer surgeon and assessment at a GI oncology tumor board (JHU - Johns Hopkins University, SU - Stanford University, or MSKCC - Memorial Sloan Kettering Cancer Center). 3.1.3 Up to 3 weeks of gemcitabine chemotherapy is allowed prior to SBRT. 3.1.4 Pancreatic tumors must be less than 7.5 cm in greatest axial dimension (or \<1000 cc in volume) at the time of treatment planning. 3.1.5 No prior upper abdominal or liver radiation therapy. 3.1.6 No chemotherapy within 2 weeks of radiotherapy, or chemotherapy within parameters set by Investigator for each institution. 3.1.7 Age \>=18 years. 3.1.8 No infections requiring systemic antibiotic treatment. 3.1.9 Karnofsky \>= 70% (see Appendix III). 3.1.10 Patients must have acceptable organ and marrow function as defined below (within 1 month prior to radiotherapy): * leukocytes: \>=3,000/microliter (uL) * absolute neutrophil count: \>=1,500uL * platelets: \>=100,000/uL * total bilirubin: within 1.5 times (1.5X) normal institutional limits * AST (aspartate aminotransferase)(SGOT -Serum glutamic oxaloacetic transaminase)/ALT(alanine aminotransferase)(SGPT-serum glutamic-pyruvic transaminase): \<=2.5 X institutional upper limit of normal * creatinine: within normal institutional limits OR \- creatinine clearance: \>=60 mL/min/1.73 m\^2 for patients with creatinine levels above institutional normal 3.1.11 The effects of radiation on the developing human fetus at recommended therapeutic doses can result in death of the fetus. If a woman is of child-bearing potential, a negative urine or serum pregnancy test must be demonstrated prior to treatment. Women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) for the duration of study participation and for up to 4 weeks following the study. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. 3.1.12 Ability to understand and the willingness to sign a written informed consent document. 3.1.13 Life expectancy \> 6 months
Exclusion criteria
3.2.1 Patients who have had prior radiotherapy to the upper abdomen. 3.2.2 Patients receiving more than 1 cycle of gemcitabine chemotherapy or other therapy prior to SBRT. 3.2.3 Children are excluded because pancreatic tumors rarely occur in this age group. Furthermore, treatment requires a great deal of patient cooperation including the ability to lie still for several hours in an isolated room. 3.2.4 No laboratory personnel will be included. 3.2.5 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. 3.2.6 Any concurrent malignancy other than non-melanoma skin cancer, non-invasive bladder cancer, or carcinoma in situ of the cervix. Patients with a previous malignancy without evidence of disease for \> 5 years will be allowed to enter the trial. 3.2.7 Pregnant and breastfeeding women are excluded. Women of child-bearing potential who are unwilling or unable to use an acceptable method of birth control to avoid pregnancy for the entire study period and for up to 4 weeks after the study are excluded. This applies to any woman who has experienced menarche and who has not undergone successful surgical sterilization or is not postmenopausal (defined as amenorrhea for at least 12 consecutive months, or women on hormone replacement therapy with serum FSH (follicle stimulating hormone) levels greater than 35 IU/mL (international units/milliliter). A negative urine or serum pregnancy test must be obtained within 72 hours prior to the start of study medication in all women of childbearing potential. Male subjects must also agree to use effective contraception for the same period as above.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| To Determine the Rate of (Grade 2 or Greater) Gastrointestinal Toxicity Attributable to Gemcitabine and Fractionated SBRT at One Year. | One year. | Grade 2 or greater late gastritis, fistula, enteritis, or ulcer or late grade 3-4 gastrointestinal toxicity at one year. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Evaluate Acute Gastrointestinal Toxicity up to 3 Months of Treatment. | Within 3 months of treatment. | Acute grade 2 or greater gastritis, fistula, enteritis, or ulcer or any other grade 3-4 gastrointestinal toxicity within 3 months of treatment. |
| To Evaluate Progression Free Survival Following Gemcitabine and SBRT for up to 5 Years of Follow up . | Up to 5 years of follow up. | Time to progression free survival is measured from start of SBRT treatment until first progression event or death, which ever comes first. If the patient did not have an event, then the patient was censored at the last follow up. The analysis was a Kaplan-Meier curve and the outcome was the median time to progression free survival. |
| To Determine the Overall Survival in Pancreatic Cancer Patients Treated With Gemcitabine and SBRT for up to 5 Years of Follow up. | Up to 5 years of follow up. | Time to death was measured from start of treatment to until death. If death was not observed, the patient was censored at last follow up. |
| Proportion of Participants Achieving Freedom From Local Progression (FFLP) in Patients Treated With Gemcitabine Followed by Fractionated Stereotactic Body Radiotherapy (SBRT) for up to 5 Years of Follow up. | Up to 5 years of follow up. | Freedom from local progression is defined as the time from start of SBRT treatment to local progression, with death as a competing risk. If the patient neither died nor experienced local progression, then patient was censored at last follow up. The data was analyzed in a competing risk model and the outcome reported was the 1 year cumulative incidence rate. |
Countries
United States
Participant flow
Recruitment details
Patients were recruited during new patient clinical visits between 10/22/2009 - 08/14/2013 at Stanford University, Johns Hopkins University and Memorial Sloan-Kettering Cancer Center. Study details were explained by the physician and consent was obtained by the physician or study coordinator according to good clinical practices.
Participants by arm
| Arm | Count |
|---|---|
| SBRT and Gemzar Before stereotactic Body Radiotherapy (SBRT) 3-5 gold fiducials are placed by endoscopic ultrasound or CT guidance. A simulation FDG-PET/CT (Fludeoxyglucose (18F)) scan will be used for treatment planning purposes (standard free-breathing CT and respiratory-correlated 4-D pancreatic protocol CT). Patients are treated by either respiratory gated (Trilogy, Elekta, Novalis) or by respiratory tracking (CyberKnife). SBRT is delivered in 5 fractions of 6.6 Gy by LINAC-based or CyberKnife based radiotherapy over a five-day period. Gemcitabine, cycles should resume/start up to 4 weeks following SBRT on a 3-week on, 1-week off schedule. Initial follow up is at 4, 6, 9 and 12 months and then for years 2-5 is every 3-6 months.
Device: CyberKnife based stereotactic radiotherapy | 49 |
| Total | 49 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Did not meet dose constraints for SBRT | 5 |
| Overall Study | Lost to Follow-up | 1 |
| Overall Study | Other illness precluded treatment | 2 |
| Overall Study | Rapid tumor progression | 2 |
Baseline characteristics
| Characteristic | SBRT and Gemzar |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 33 Participants |
| Age, Categorical Between 18 and 65 years | 16 Participants |
| Age, Continuous | 67 Years |
| Baseline Cancer Antigen 19-9 (CA19-9) CA 19-9 < 90 U/mL | 18 Participants |
| Baseline Cancer Antigen 19-9 (CA19-9) CA 19-9 >= 90 U/mL | 27 Participants |
| Eastern Cooperative Oncology Group performance status (ECOG PS) ECOG 0 | 21 Participants |
| Eastern Cooperative Oncology Group performance status (ECOG PS) ECOG 1 | 28 Participants |
| Region of Enrollment United States | 49 participants |
| Sex: Female, Male Female | 18 Participants |
| Sex: Female, Male Male | 31 Participants |
| Treating Institutions Johns Hopkins University | 32 Participants |
| Treating Institutions Memorial Sloan-Kettering Cancer Center | 3 Participants |
| Treating Institutions Stanford University | 14 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 25 / 49 |
| serious Total, serious adverse events | 6 / 49 |
Outcome results
Primary
To Determine the Rate of (Grade 2 or Greater) Gastrointestinal Toxicity Attributable to Gemcitabine and Fractionated SBRT at One Year.
Grade 2 or greater late gastritis, fistula, enteritis, or ulcer or late grade 3-4 gastrointestinal toxicity at one year.
Time frame: One year.
Population: The whole cohort was analyzed.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SBRT and Gemzar | To Determine the Rate of (Grade 2 or Greater) Gastrointestinal Toxicity Attributable to Gemcitabine and Fractionated SBRT at One Year. | 5 Number of toxicities. |
Secondary
Evaluate Acute Gastrointestinal Toxicity up to 3 Months of Treatment.
Acute grade 2 or greater gastritis, fistula, enteritis, or ulcer or any other grade 3-4 gastrointestinal toxicity within 3 months of treatment.
Time frame: Within 3 months of treatment.
Population: Whole cohort.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SBRT and Gemzar | Evaluate Acute Gastrointestinal Toxicity up to 3 Months of Treatment. | 14 Number of toxicities. |
Secondary
Proportion of Participants Achieving Freedom From Local Progression (FFLP) in Patients Treated With Gemcitabine Followed by Fractionated Stereotactic Body Radiotherapy (SBRT) for up to 5 Years of Follow up.
Freedom from local progression is defined as the time from start of SBRT treatment to local progression, with death as a competing risk. If the patient neither died nor experienced local progression, then patient was censored at last follow up. The data was analyzed in a competing risk model and the outcome reported was the 1 year cumulative incidence rate.
Time frame: Up to 5 years of follow up.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SBRT and Gemzar | Proportion of Participants Achieving Freedom From Local Progression (FFLP) in Patients Treated With Gemcitabine Followed by Fractionated Stereotactic Body Radiotherapy (SBRT) for up to 5 Years of Follow up. | 0.78 Proportion of participants with FFLP |
Secondary
To Determine the Overall Survival in Pancreatic Cancer Patients Treated With Gemcitabine and SBRT for up to 5 Years of Follow up.
Time to death was measured from start of treatment to until death. If death was not observed, the patient was censored at last follow up.
Time frame: Up to 5 years of follow up.
Population: The entire cohort.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| SBRT and Gemzar | To Determine the Overall Survival in Pancreatic Cancer Patients Treated With Gemcitabine and SBRT for up to 5 Years of Follow up. | 13.9 Months |
Secondary
To Evaluate Progression Free Survival Following Gemcitabine and SBRT for up to 5 Years of Follow up .
Time to progression free survival is measured from start of SBRT treatment until first progression event or death, which ever comes first. If the patient did not have an event, then the patient was censored at the last follow up. The analysis was a Kaplan-Meier curve and the outcome was the median time to progression free survival.
Time frame: Up to 5 years of follow up.
Population: The whole cohort.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| SBRT and Gemzar | To Evaluate Progression Free Survival Following Gemcitabine and SBRT for up to 5 Years of Follow up . | 7.8 Months |