Borderline Pancreatic Inoperable Cancer, Locally Advanced Pancreatic Cancer, Pancreatic Cancer
Conditions
Keywords
advanced pancreatic cancer, inoperable pancreatic cancer, Folfirinox, Gemcitabine-Abraxane, Gemcitabine-nab-Paclitaxel, Stereotactic Body Radiotherapy
Brief summary
This study will implement a new treatment regimen for patients with advanced and inoperable pancreatic cancer using chemotherapy combinations of Folfirinox or gemcitabine-nab paclitaxel (abraxane) followed by a short course of high dose radiation called Stereotactic Body Radiation Therapy (SBRT). While the chemotherapy is standard of care, the strategy of adding SBRT has not been investigated. An increase in the percentage of patients who can proceed to have surgery to remove their disease is anticipated with this approach.
Detailed description
This pilot study will evaluate safety and tolerability of neoadjuvant chemotherapy followed by SBRT. Patients with locally advanced pancreatic cancer (LAPC) and borderline pancreatic inoperable cancer will be assigned to one of two treatment arms based upon performance status and physician's discretion. The two treatment arms are: Folfirinox or gemcitabine-nab paclitaxel (abraxane). There are no study drugs as all treatments are based on standard clinical pathways. After two cycles of treatment patients will be restaged with CT scans or imaging. If the tumor remains resectable, borderline, or unresectable without progression of disease, then the patient will proceed to SBRT. Follow-up visits will continue every three months for up to one year or until progression of disease.
Interventions
DRUGFolfirinox
SBRT will follow Folfirinox at the completion of Cycle 2 (if eligible).
DRUGGemcitabine nab-Paclitaxel
SBRT will follow Gemcitabine nab-Paclitaxel at the completion of Cycle 2 (if eligible).
Sponsors
University of Alabama at Birmingham
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Patients will be assigned to one of two treatment arms: Arm 1 is Folfirinox (5FU/Leucovorin/Irinotecan/Oxaliplatin) and Arm 2 is Gemcitabine-nab-Paclitaxel (Abraxane). Either arm will be followed with SBRT for eligible patients.
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* Histologically or cytologically proven adenocarcinoma of the pancreas. Patients with mixed tumor with predominant adenocarcinoma pathology can be enrolled. * Subjects will be staged according to the 2010 American Joint Committee on Cancer (AJCC) staging system with pathologic stage T1-4, being eligible; and have a primary tumor of the pancreas (either pancreatic head, neck, uncinate process, or body/tail) * The tumor must be deemed as being borderline/unresectable. Final CT confirmation of surgical staging/ eligibility will be at the discretion of the pancreatic surgeon of the patient. * Disease must be confined to loco-regional site as confirmed by CT imaging and/or diagnostic staging laparoscopy to avoid occult peritoneal deposits. Diagnostic laparoscopy will be performed only if absolutely required * Measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST v1.1) on imaging studies CT * Karnofsky performance status greater than or equal to 70 or Eastern Cooperative Oncology Group (ECOG) performance of 0-2. * Age \>18 * Estimated life expectance \>12 weeks * If female patient is of child bearing potential, she must have a negative serum pregnancy test (βhCG) documented up to 72 hrs prior to administration of first study drug * Patient has screening blood work performed which includes the following (should be drawn ≤14 days prior to enrollment) * Absolute neutrophil count (ANC) \>1.5 x 109/L * Platelet count ≥100,000/mm3 * Hemoglobin (Hgb) ≥ 9g/dL * Aspartate aminotransferase (AST), Alanine Aminotransferase (ALT) ≤ 2.5 x upper limit of normal (ULN) Total Bilirubin ≤1.5 ULN * Serum Cr within normal limits (WNL) * Prothrombin Time and International Normalized Ratio (PT/INR) and Partial Thromboplastin Time (PTT) within normal limits (±15%). * Disease must be encompassed in a reasonable SBRT portal as defined by the treating radiation oncologist
Exclusion criteria
* Ineligible Histology including non-adenocarcinomas, adenosquamous carcinoma, islet cell carcinomas, cystadenomas, cystadenocarcinomas, carcinoid tumors, duodenal carcinomas, distal bile duct and ampullary carcinomas * Patients must not have received prior pancreatic surgery, radiation therapy, chemotherapy or any investigational therapy for pancreatic cancer. * Patients with tumors extending or invading duodenum or gastric are not eligible. * Evidence of distant metastasis on upright chest x-ray, CT or other staging studies * Subjects with recurrent disease are not eligible * Prior radiation therapy to the upper abdomen or liver at the discretion of the treating radiation oncologist could impair delivery of the prescribed radiation treatment * Patients with scleroderma, ulcerative colitis or other systemic conditions deemed risky for radiation treatment. Therefore, will be excluded. * Prior chemotherapy * Subjects in their reproductive age who are breast feeding or have a positive pregnancy test * Any co-morbid condition such as but not limited to congestive heart failure, cardiac arrhythmia or psychiatric illness of sufficient severity to limit full compliance with the protocol per assessment by the individual treating physician * Concurrent active infection * No prior malignancy allowed except cervical cancer in situ, adequately treated basal cell or squamous cell carcinoma of skin or treated low risk prostate cancer * Patient with known historical or active infection with HIV, Hepatitis B or Hepatitis C * Patient who has undergone recent major surgery, other than diagnostic surgical procedure within 4 weeks prior to enrollment. * Patient who has a history of allergy or hypersensitivity to any of the study drugs. * Patients with a history of interstitial lung disease, history of slowly progressive dyspnea and unproductive cough, sarcoidosis, silicosis, interstitial pulmonary fibrosis, pulmonary hypersensitivity pneumonitis or multiple allergies * Patients with greater than grade 2 peripheral neuropathy at the time of enrollment are not eligible.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of participants with adverse events as a measure of safety and tolerability | Baseline up to two years | Initial dose of drug until 4 weeks following completion of therapy which may or may not include SBRT and follow-up. Adverse event reporting will be graded following the National Cancer Institute of Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4.0. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of participants undergoing surgery after preoperative chemoradiation therapy | Baseline to two years | Comparison of participants who underwent surgery versus those that did not following preoperative chemoradiation therapy |
| Progression-free survival | Baseline up to two years | Progression-free survival is the duration of time from study entry to time of disease progression or death, whichever comes first. |
| Overall survival | Baseline to two years | Overall survival is the duration of time from study entry to time of death or the date of last contact. |
| Rate of preoperative chemotherapy + radiotherapy completion | Baseline to two years | The rate will be determined from the measurement of lesions (maximum of 2 per organ with no more than 5 lesions total) from CT scans and magnetic resonance imaging within the study time frame. |
Countries
United States
Outcome results
None listed