Borderline Resectable Pancreatic Adenocarcinoma, Resectable Pancreatic Ductal Adenocarcinoma
Conditions
Brief summary
This pilot and feasibility study studies how well nivolumab and combination chemotherapy work before surgery in treating patients with pancreatic cancer that could possibly be removed by surgery. Immunotherapy with monoclonal antibodies, such as nivolumab, may help the body?s immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Drugs used in chemotherapy, such as fluorouracil, irinotecan hydrochloride, leucovorin calcium and oxaliplatin, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving nivolumab in combination with chemotherapy before surgery may work better in treating patients with pancreatic cancer compared to chemotherapy alone.
Detailed description
PRIMARY OBJECTIVES: I. To evaluate development of clinically relevant pancreatic fistula in the post-operative period after neoadjuvant treatment with nivolumab and fluorouracil, irinotecan hydrochloride, leucovorin calcium and oxaliplatin (FOLFIRINOX) (FFX). II. To evaluate pathologic complete response after neoadjuvant nivolumab and FOLFIRINOX (FFX). SECONDARY OBJECTIVES: I. To evaluate early efficacy measured by percent change of CA 19-9 response rate, R0 resection rate, overall response rate (ORR) and disease free survival (DFS). EXPLORATORY OBJECTIVES, OTHER ASSESSMENTS: I. To determine degree of changes in the tumor microenvironment (TME) of nivolumab and modified (m) FFX on cell proliferation and apoptosis. OUTLINE: Patients receive nivolumab intravenously (IV) over 60 minutes on day 1. Patients also receive fluorouracil IV over 10 minutes and over 46 hours, irinotecan hydrochloride IV over 90-120 minutes, leucovorin calcium IV over 120 minutes, and oxaliplatin IV over 120 minutes on days 1 and 15. Treatments repeat every 28 days for 3-6 cycles in the absence of disease progression or unacceptable toxicity. Within 2-4 weeks after treatment, patients with resectable disease undergo surgery. Within 8-12 weeks after surgery, patients with successful resection may receive 6 additional cycles of fluorouracil, irinotecan hydrochloride, leucovorin calcium, and oxaliplatin in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 2-3 months.
Interventions
DRUGFluorouracil
Given IV
DRUGIrinotecan
Given IV
DRUGIrinotecan Hydrochloride
Given IV
DRUGLeucovorin
Given IV
DRUGLeucovorin Calcium
Given IV
BIOLOGICALNivolumab
Given IV
DRUGOxaliplatin
Given IV
PROCEDURETherapeutic Conventional Surgery
Undergo surgery
Sponsors
Bristol-Myers Squibb
NovoCure Ltd.
Jonsson Comprehensive Cancer Center
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
* Histologically confirmed pancreatic adenocarcinoma * One of the following: * Borderline resectable disease. There are multiple definitions of borderline resectable pancreatic ductal adenocarcinoma (PDAC) including the MD Anderson definition and the criteria developed during the Consensus Conference sponsored by the American Hepato-Pancreato-Biliary Association, Society of Surgical Oncology, and Society for Surgery of the Alimentary Tract. Borderline resectable PDAC cases will be identified per the definition developed in the currently running inter-group pilot trial for borderline resectable pancreatic cancer (NCT01821612). Per this trial, borderline resectable PDAC is defined as the presence of any one or more of the following on computed tomography (CT): * An interface between the primary tumor and the superior mesenteric vein or portal vein (SMV-PV) measuring \>= 180 degrees of the circumference of the vessel wall * Short-segment occlusion of the SMV-PV with normal vein above and below the level of obstruction that is amenable to resection and venous reconstruction * Short segment interface (of any degree) between tumor and hepatic artery with normal artery proximal and distal to the interface that is amenable to resection and reconstruction * An interface between the tumor and superior mesenteric artery (SMA) measuring \< 180 degrees of the circumference of the vessel wall * Performance status of Eastern Cooperative Oncology Group (ECOG) of 0-1 * Therapy naive * Absolute neutrophil count (ANC) \>= 1500/mm\^3 * Platelets \>= 100,000/mm\^3 * Hemoglobin \>= 9 g/dl * Serum total bilirubin =\< 1.5 x upper limit of normal (ULN) * Alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase \[SGPT\]) and aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase \[SGOT\]) =\< 2.5 x ULN * Alkaline phosphatase =\< 2.5 x ULN * Serum creatinine (sCr) =\< 1.5 x ULN or creatinine clearance (Ccr) \>= 40 mL/min as calculated by the modified Cockcroft-Gault formula * Peripheral neuropathy \< grade 2
Exclusion criteria
* Locally advanced (clearly unresectable) or metastatic disease * Known status of human immunodeficiency virus (HIV) which is not well-controlled at the time of study eligibility * Untreated hepatitis B infection * Active infection or antibiotics within 48 hours prior to study * Currently active second primary malignancy or history of malignancy less than 5 years prior to the time of study eligibility (patients with history of skin cancers excluding melanoma will be eligible for participation) * Serious medical comorbidities such as New York Heart Association class III/IV cardiac disease, uncontrolled cardiac arrhythmias, myocardial infarction over the past 12 months * Known, existing uncontrolled coagulopathy. Patients who have had a venous thromboembolic event (e.g., pulmonary embolism or deep vein thrombosis) requiring anticoagulation are eligible IF: they are appropriately anticoagulated and have not had a grade 2 or greater bleeding episode in the 3 weeks before day 1 * Prior history of cerebrovascular accident or transient ischemic attack, or pre-existing carotid artery disease * Known pregnancy, nursing women or positive pregnancy test. Requirement for women of childbearing potential (WOCBP) must have a pregnancy test every 4 weeks and WOCBP must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin \[HCG\]) within 24 hours prior to the start of nivolumab * Any prisoners, or subjects who are compulsory detained are excluded * Any condition that would preclude informed consent, consistent follow-up and compliance for the study participation
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Clinically relevant pancreatic fistula in the post-operative period after neoadjuvant treatment with nivolumab and fluorouracil, irinotecan hydrochloride, leucovorin calcium and oxaliplatin (FOLFIRINOX) (mFFX) chemotherapy | Up to 3 years | Descriptive statistics with frequency and proportion will be used. |
| Pathologic complete response after nivolumab and mFFX treatment | Up to 3 years | Descriptive statistics with frequency and proportion will be used. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| R0 resection rate | Up to 3 years | — |
| Overall response rate (ORR) | Up to 3 years | Descriptive statistics with frequency and proportion will be used to analyze ORR. |
| Disease free survival (DFS) | Up to 3 years | Kaplan-Meier methods will be used to analyze DFS with median and 95% confidence interval (CI). |
| Delayed wound healing | Up to 3 years | — |
| Wound dehiscence | Up to 3 years | — |
| Wound infection | Up to 3 years | — |
| Incidence of adverse events | Up to 28 days after last dose of study drug | Will be categorized and graded according to National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.3. |
| Percent change of CA 19-9 response rate | Baseline up to 3 years | Descriptive statistics with frequency and proportion will be used to analyze the CA19-9 response rate. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Changes in immune cell infiltrates and cancer cell IFNgamma signaling in response to FOLFIRINOX and nivolumab treatment | Baseline up to 3 years | Will examine the tissue from baseline to post-therapy at the time of surgery or at the time of progression. Will use descriptive statistics and graphical displays to compare the percent change in stromal depletion overall and to describe the association with cell proliferation and death. In addition, will graphically explore the percent change in stromal depletion for patients who undergo surgery compared to those who have disease progression. |
| Signaling and metabolomic changes in pancreatic ductal adenocarcinoma (PDAC) cancer cells that respond to IFNgamma | Baseline up to 3 years | Will examine the tissue from baseline to post-therapy at the time of surgery or at the time of progression. Will use descriptive statistics and graphical displays to compare the percent change in stromal depletion overall and to describe the association with cell proliferation and death. In addition, will graphically explore the percent change in stromal depletion for patients who undergo surgery compared to those who have disease progression. |
Countries
United States
Outcome results
None listed