Phase I+Phase II Clinical Study of PRaG Therapy in Combination With Chemotherapy (AG Regimen) for Neoadjuvant Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma (PDAC) (NeoPRAG Study)
Phase: PHASE1
Conditions: Pancreatic Ductal Adenocarcinoma
Sponsor: Second Affiliated Hospital of Soochow University

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Phase I+Phase II Clinical Study of 
PRaG Therapy in Combination With 
Chemotherapy (AG Regimen) for 
Neoadjuvant Treatment of Locally 
Advanced Pancreatic Ductal 
Adenocarcinoma (PDAC) (NeoPRAG 
Study) 
 
Research unit: The Second Affiliated Hospital of Soochow 
University 
Project leader: Chen Wei 
Department: Department of Hepatobiliary Surgery, 
Oncology Centre 
Tel：18626205529 
 
 
Study Year: January 2024-October 2026 
Version number: V1.0 
Version date: 22 September 2023 
 

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Catalogue 
1.0 Title of the Study ..................................................................................................... 1 
2.0 Purpose of the Study ............................................................................................... 3 
2.1 Primary objective ..................................................................................................... 3 
2.2 Secondary objectives ............................................................................................... 3 
3.0 Study Endpoints ...................................................................................................... 3 
3.1 Primary research endpoints ...................................................................................... 3 
3.2 Secondary Research Endpoints ................................................................................ 3 
4.0 Rationale for the project .......................................................................................... 4 
5.0 Selection of Study Population ................................................................................ 18 
5.1 Inclusion Criteria ................................................................................................... 18 
5.2 Exclusion Criteria .................................................................................................. 19 
6.0 Study Treatment ..................................................................................................... 20 
6.1 Overview of the treatment protocol ....................................................................... 20 
6.2 Treatment Options .................................................................................................. 21 
6.3 Radiotherapy Delivery ........................................................................................... 25 
6.4 Combination of Medications .................................................................................. 26 
7.0 Research Assessment ............................................................................................. 26 
8.0 Annual Study Plan.................................................................................................. 28 
9.0 Study Design and Statistical Analysis.................................................................... 28 
9.1 Study design and sample size calculation .............................................................. 28 
9.2 Statistical Analyses ................................................................................................ 29 
 

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1.0 Research Title 
Phase I+Phase II Clinical Study of PRaG Therapy in Combination With Chemotherapy 
(AG Regimen) for Neoadjuvant Treatment of Locally Advanced Pancreatic Ductal 
Adenocarcinoma (PDAC) (NeoPRAG Study) 
2.0 Purpose of the study 
2.1 Primary purpose 
Exploring the safety and efficacy of the PRaG treatment modality combined with 
chemotherapy neoadjuvant therapy for locally advanced pancreatic cancer 
2.2 Secondary purpose 
Exploring the local control and survival benefit of the PRaG treatment modality 
combined with neoadjuvant chemotherapy for locally advanced pancreatic cancer 
Evaluating markers for efficacy prediction 
3.0 Research endpoint 
3.1 Primary study endpoints 
Phase I: safety and tolerability 
Adverse events，AE 
Serious adverse events，AE 
Phase II：1-year overall survival，OS 
3.2 Secondary research endpoints 
（1）Objective Response Rate (ORR): The percentage of the total number of 
patients exhibiting an optimal therapeutic response of Complete Response (CR) and 
Partial Response (PR) after treatment, out of the total number of evaluable cases with 
lesions evaluated according to RECIST 1.1 criteria. 
（2） Disease Control Rate (DCR): The percentage of the total number of patients 
showing an optimal treatment response of CR, PR, and Stable Disease (SD) after 
treatment, out of the total number of evaluable cases, assessing the lesions according to 
RECIST 1.1 criteria. 
（3）Progression Free Survival (PFS): The time from the start of treatment to the 
observation of disease progression or the occurrence of death from any cause. Patients 
alive at the time of analysis will have the date of their last contact as the cut-off date. 

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（4）Overall Survival (OS): The duration from the first date of enrollment to the time 
of death from any cause. Patients alive at the time of analysis will have the date of their 
last contact as the cut-off date. 
（5）R0 Excision Rate: The rate at which the tumor was completely removed during 
surgery, with negative margins on microscopic examination. 
（6）Other Exploratory Research Endpoints: The exploratory translational study 
metrics for this study include T-lymphocyte subsets, tumor-associated cytotoxic T-cells, 
activated cytotoxic T-lymphocytes, activated memory T-cells, monocytes, dendritic 
cells, and T-cell antigen receptor (TCR) examination. It is required that peripheral blood 
and/or tissue specimens be retained at study-specified time points whenever possible, 
and that these specimens be processed as specified in the protocol for subsequent 
translational studies. 
 
4.0 Rationale for the project 
4.1 Current status of surgical treatment of pancreatic ductal adenocarcinoma 
(PDAC) 
Pancreatic ductal adenocarcinoma (PDAC) is highly malignant and aggressive, 
posing a significant threat to human health. According to GLOBOCAN data, in 2020, 
there were over 400,000 new cases of pancreatic cancer and related deaths globally, 
with an incidence rate of approximately 6.4 per 100,000 people. The incidence and 
mortality rates of pancreatic cancer are rising in most countries, with the 5-year survival 
rate in the United States at only 12% and in China at about 7.2% [1-3]. The standard 
treatment for PDAC involves surgical resection combined with chemotherapy. 
However, real-world clinical data indicate that the 5-year overall survival (OS) rate for 
patients who have undergone resection is around 20% (increased from less than 5% in 
2011), while it remains less than 1% for those who have not had surgery (consistent 
with rates from 10 years ago) [4]. Large cohort studies report that approximately 20% of 
patients undergoing surgical resection experience recurrence within 6 months, and 40% 
within the first year post-surgery, even in cases with no residual tumor at the margin 
(R0) [5]. Consequently, there is a growing consensus that the biological nature of PDAC 

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differs from its early stages. Even in cases of resectable pancreatic ductal 
adenocarcinoma at an early stage, the disease is considered systemic, where surgery 
alone does not ensure complete tumor clearance. This necessitates a multimodal 
approach and an integrated, multidisciplinary model of treatment [6]. 
In 2006, the US National Comprehensive Cancer Network (NCCN) classified non-
metastatic pancreatic ductal adenocarcinoma (PDAC) into three categories: resectable 
(R-PDAC), borderline resectable (BR-PDAC), and unresectable (UR-PDAC) [7]. 
Current guidelines recommend surgery as the initial treatment for patients with R-
PDAC. For those with BR-PDAC, neoadjuvant chemotherapy (NACT) using 5-
fluorouracil, calcium folinate, irinotecan, and oxaliplatin (mFOLFIRINOX), or 
Gemcitabine + Capecitabine, is the preferred regimen. NACT is not typically 
recommended for patients with UR-PDAC and metastatic PDAC (M-PDAC). However, 
recent advancements in neoadjuvant regimens have shown promising results, enabling 
more patients with locally advanced (LA) and metastatic tumors to undergo surgery. 
Conversion rates for surgery have ranged from 0% to 40% for LA-PDAC and from 4% 
to 9% for M-PDAC [5]. 
4.2 Current status of research on neoadjuvant treatment modalities for pancreatic 
ductal adenocarcinoma (PDAC) 
Over the past five years, neoadjuvant therapy has emerged as a pivotal topic in the 
treatment of pancreatic cancer. Increasing high-quality, evidence-based medical 
research indicates that neoadjuvant therapy can suppress early micro-metastasis of 
tumors, enhance the rate of surgical resection, and subsequently improve patient 
prognosis. The benefits of neoadjuvant therapy include:  
1. Early inhibition of micrometastases, aiding in controlling tumor recurrence and 
metastasis. 
2. Reduction of tumor burden, facilitating R0 resection. 
3. Improved patient tolerance and compliance, addressing intolerance to 
postoperative adjuvant therapy. 
4. Pre-screening of patients with highly aggressive tumors to avert unnecessary 
surgery. 

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This development in neoadjuvant therapy represents a synergistic progression of 
medical and surgical procedures, broadening the surgical candidate pool and integrating 
resources for individualized treatment strategies. 
5. Employing neoadjuvant therapy in healthier patients may allow a multimodal 
treatment approach for all patients, reducing the need for withdrawal due to 
postoperative complications. 
BR-PDAC (borderline resectable pancreatic ductal adenocarcinoma) is defined by 
the International Society of Pancreatic Diseases based on anatomical, biological, and 
clinical criteria [7]. Anatomically, BR-PDAC involves lesions at high risk for positive 
R1 and R2 resections due to proximity to major blood vessels. Criteria include a contact 
angle ≥180° with the portal vein or superior mesenteric vein (SMV), any contact 
with the inferior vena cava, and/or contact angle <180° with a major artery. This 
definition, unlike the NCCN guidelines, excludes jejunal branches extending into the 
SMV, mainly due to high anatomical variability [8]. 
The ESPAC-5F28 phase II study randomly assigned BR-PDAC patients to either 
initial surgery or NACT (using FOLFIRINOX or AG regimens) or to radiotherapy 
followed by surgery and AG. No significant difference was observed in the R0/R1 
resection rate (44% vs. 41% post-NACT, P=0.668), nor in the number of patients 
receiving adjuvant therapy. However, 1-year overall survival (OS) significantly favored 
NACT (77% vs. 42%, HR=0.28; P<0.001), with 1-year OS rates of 84% for 
FOLFIRINOX, 79% for GA, and 64% for radiotherapy. Retrospective studies suggest 
comparable efficacy between FOLFIRINOX and GA, with no significant differences 
in median survival (37.3 vs. 31.9 months) or R0 resection rates (82.8% vs. 81.8%) [9]. 
FOLFIRINOX and GA are thus preferred NACT regimens for BR-PDAC when patient 
conditions permit [9]. 
UR-LA (locally advanced) PDAC includes cases with non-reconstructable venous 
involvement or contact ≥180° with the superior mesenteric artery (SMA) or celiac 
artery, or involvement of the first jejunal branch artery of the SMA. In such cases, 
prognosis remains poor due to high rates of local recurrence and systemic progression, 
even if atherectomy is technically feasible [10]. Palliative systemic therapy is 

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recommended for UR-LA patients. However, various studies report successful surgical 
conversion post-chemotherapy, with or without radiation therapy. Median OS was 
notably higher in successful conversion surgeries (15.3 vs. 8.5 months, P<0.0001), 
irrespective of chemotherapy regimen [11]. It is important to note that these studies 
included only UR-PDAC, not BR-PDAC. 
A cohort analysis of 680 patients, comprising 29.3% with BR-PDAC and 60.7% 
with UR-LA-PDAC, revealed that after clinical, radiological, and biological 
assessments, 23.9% underwent surgical exploration, with an overall resection rate of 
15.1%. This rate represented 24.1% of BR-PDAC cases and 9% of UR-LAPDAC cases. 
Factors influencing resection included age, BR-PDAC status, completion of 
chemotherapy, and responsive imaging. The median OS was 12.8 months for the entire 
cohort, extending to 41.8 months for UR-LA-PDAC patients who underwent 
transformative surgery. No pre- or post-treatment factors were linked to survival post-
pancreatectomy [12]. 
4.3 Current status of radiotherapy and immunotherapy in the neoadjuvant 
treatment modality of pancreatic ductal adenocarcinoma (PDAC) 
Neoadjuvant radiotherapy is recommended for borderline resectable pancreatic 
ductal adenocarcinoma (BR-PDAC) in the US NCCN guidelines [8]. However, its value 
in BR-PDAC remains a subject of debate. Radiotherapy regimens and intensities differ 
significantly in their effects. Conventional radiotherapy, typically administered in small 
doses over 3 to 6 weeks with a broader irradiation range, contrasts with Stereotactic 
Body Radiotherapy (SBRT). SBRT, delivered in 3-5 doses over 1-2 weeks, uses larger 
doses and targets the tumor exclusively. High-dose irradiation, while effective in killing 
tumor cells, often alters local tissue reactivity and impacts local tumor resection. SBRT 
is increasingly adopted as a neoadjuvant approach for patients with BR/LA-PDAC. 
Reyngold et al. [13] demonstrated that increasing the radiotherapy dose and utilizing 
ablative radiotherapy, with either SBRT or conventional methods, enhances local 
control rates. 
The CONKO-007 study, a phase III clinical trial involving 495 patients with 
locally advanced pancreatic cancer (LAPC), showed that adding radiotherapy post-

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induction chemotherapy significantly increased the rate of negative peripheral margins 
and pathological remission. This improvement markedly enhanced the prognosis for 
patients with R0 resection, showing a 5-year survival rate of up to 35.9% [14]. While 
radiotherapy aids in local tumor control, further research is needed to determine the 
optimal radiotherapy regimen, intensity, and dose, minimizing serious complications. 
The impact of radiotherapy on overall survival also warrants further investigation 
through prospective studies. 
Advances in precision radiotherapy technologies have popularized Hyperfraction 
Radiotherapy (HFRT) and SBRT in clinical settings. HFRT, compared to conventional 
fractionation doses, induces immune activation through direct actions on tumor cell 
DNA, in situ tumor seeding effects, and alterations in the tumor microenvironment, 
leading to irreversible DNA damage and resulting in apoptosis, necrosis, senescence, 
or mitotic failure of tumor cells [15,16]. Additionally, radiotherapy can elevate PD-L1 
expression in tumor cells, potentially increasing their sensitivity to PD-1/PD-L1 
inhibitors. The combination of radiotherapy with PD-1/PD-L1 inhibitors has shown 
promise in improving patient outcomes and prolonging survival, as evidenced by 
several clinical studies in various metastatic malignancies [15-19]. 
However, PDAC typically presents an immune-desert microenvironment, 
characterized by a high number of M2-type macrophages that suppress the immune 
system, a scarcity of lymphocytes and regulatory T-cells (Tregs), and a low tumor 
mutational burden (TMB), rendering it poorly responsive to immune checkpoint 
inhibitors (ICIs) [20]. Preclinical and metastatic clinical trial data suggest that cytotoxic 
chemotherapy and radiotherapy can enhance the immunogenicity of PDAC, potentially 
transforming the tumor microenvironment (TME) from an immunologically 'cold 
tumor' to a 'hot tumor' [21,22]. 
Recent studies, such as the one by Du et al., have explored this further. They 
published a single-arm, phase II exploratory trial of perioperative tirilizumab combined 
with GA and SBRT. Their pre-specified exploratory analyses included factors such as 
eosinophil count (associated with immunotherapy response in triple-negative breast 
cancer), CA 19-9 levels, circulating tumor DNA (ctDNA), neutrophil-to-lymphocyte 

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ratio (NLR), and TMB. Among the 29 patients with locally advanced (LA) or borderline 
resectable (BR) PDAC in the study, 25 completed the treatment. The results showed an 
objective response rate (ORR) of 60% and a disease control rate (DCR) of 100%. The 
12-month overall survival (OS) rate was 72%, and the progression-free survival (PFS) 
rate was 64%, with no reported serious immune-related adverse events (irAEs) [23]. 
Further trials are planned or ongoing, focusing on neoadjuvant immune checkpoint 
inhibitors (ICIs), often in combination with standard care chemotherapy and/or 
radiotherapy. 
Figure 1 Ongoing foreign studies of neoadjuvant immunotherapy for pancreatic 
cancer 
4.4 Pre-exploration of the PRaG Treatment Model 
Dendritic cells' presentation of tumor antigens to T cells to activate adaptive 
immunity is a crucial step in the tumor immune cycle. Granulocyte-macrophage 
colony-stimulating factor (GM-CSF), a commonly used immunosensitizing cytokine, 
promotes the differentiation and activity of monocyte/M1 macrophages and dendritic 
cells (DCs), enhancing their activity, antigen presentation, and the overall immune 
effect. Combining GM-CSF with PD-1 inhibitors can also improve efficacy. 
Preliminary results for patients with advanced cholangiocarcinoma who received PD-1 
inhibitors combined with GM-CSF showed a 35% progression-free survival (PFS) at 6 
months of treatment and 7% grade 3 or higher adverse reactions. This suggests that the 
combination of PD-1 inhibitors with GM-CSF is safe and has achieved good near-term 
efficacy [24]. Additionally, GM-CSF can extend the immune effect of radiotherapy. 
Prospective clinical studies have shown that local radiotherapy combined with GM-

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CSF for patients with advanced solid tumors induced a distant effect and improved 
patient prognosis [25]. 
Based on this, our center was the first to propose the "PRaG protocol" (PRaG 1.0) 
[26], which is the combination of a PD-1 inhibitor followed by GM-CSF with large 
fractionated radiotherapy in patients with advanced solid tumors that have progressed 
after first- and second-line chemotherapy. Fifty-four patients were enrolled in the study 
with a median follow-up of 16.4 months. The objective remission rate reached 16.7%, 
and the disease remission rate was 46.3%; the median PFS was 4.0 months, and the 
median overall survival (OS) was 10.5 months. The overall tolerability of patients 
receiving the Bragg regimen was good, with 5 patients experiencing grade 3 treatment-
related adverse events (TRAEs) and only 1 patient experiencing a grade 4 TRAE, 
suggesting that the PRaG regimen is an effective therapeutic option for salvaging 
patients with advanced recurrent solid tumors. 
4.5 Advances in Dual Immunity and Dual Antibody Research 
Checkpoint inhibitors have proliferated in clinical use as immunotherapies 
targeting adaptive immune responses, unleashing the immune system and making it 
more potent in generating a response against tumor cells. The CTLA-4 and PD-1 
pathways, linked to tumors' ability to evade the host immune system, are most widely 
used in clinical practice. However, the number of clinical cases and efficacy of anti-
PD-1/PD-L1 or anti-CTLA-4 monotherapy in pancreatic cancer is limited. The 
objective response rates (ORRs) for monotherapy with immune checkpoint inhibitors 
and anti-PD-1/CTLA-4 combination therapy in pancreatic cancer were 0% and 3%, 
respectively. These disappointing results contrast with the remarkable effectiveness of 
immune checkpoint inhibitors in other solid tumors. In other tumors, the double-
immunity treatment modality of nabulizumab combined with ibritumomab improved 
the ORR of malignant melanoma to 57%, significantly better than the 19% and 44% 
for monotherapy 
[27]. Dual-immunotherapy with nabulizumab combined with 
ipilizumab resulted in a higher ORR (23% vs. 10%) [28]. CheckMate 227 reported that 
the dual-immunotherapy modality of nabulizumab combined with ipilizumab resulted 
in 36.2 months of prolonged survival in advanced non-small cell lung cancer [29]. The 

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double-immunotherapy modality has also achieved good results in malignancies such 
as colorectal, renal, and gastric/esophageal cancers. Pancreatic cancer, a typical 
immunologically "cold tumor," requires a transformation from a "cold tumor" to a "hot 
tumor" to unlock the potential of immunotherapy treatment. The current methods to 
achieve this transformation include chemotherapy, radiotherapy, and other therapies [30-
32]. Preclinical and small-sample clinical studies have shown that anti-PD-1 and anti-
CTLA-4 antibodies enhance the immune response induced by ablative monotherapy by 
blocking regulatory checkpoints, offering a new strategy for immunotherapy in 
pancreatic cancer [33]. The 2021 ASCO reported data from a phase II clinical study of 
Cunningham & Gerard KN046 combined with chemotherapy in advanced pancreatic 
cancer, with an ORR of 55.6% and a disease control rate (DCR) of 88.9% [34]. The ORR 
of KN046 combination chemotherapy was significantly higher than that of the AG 
regimen alone. Subsequently, the NMPA approved a multicenter, randomized, double-
blind phase III clinical study of the efficacy and safety of KN046 (anti-PD-L1/CTLA-
4 dual-antibody) combined with albumin-paclitaxel and gemcitabine versus placebo 
combined with albumin-paclitaxel and gemcitabine in patients with advanced 
pancreatic cancer (ENREACH-PDAC-01, NCT05149326). 
4.5.1 Mechanism of action of the investigational drug cardunolizumab 
Cardunilizumab is a tetravalent IgG-ScFv bispecific antibody [35]. It contains a 
point mutation in its constant region that prevents the binding of complement protein 
C1q and the Fcγ receptor involved in cytotoxic effects. Expressed in a Chinese hamster 
ovary cell line, cardunilizumab has a total molecular weight of approximately 200 kDa, 
including oligosaccharides. It is a humanized immunoglobulin G1 (IgG1) bispecific 
antibody (BsAb) with a crystallizable fragment (Fc) mutation that eliminates Fc 
receptor and complement-mediated cytotoxic effects. Cardunilizumab binds both 
programmed cell death receptor-1 (PD-1) and cytotoxic T-lymphocyte-associated 
antigen-4 (CTLA-4), blocking the interactions of PD-1/programmed cell death ligand-
1 (PD-L1), PD-1/PD-L2, CTLA-4/B7.1, and CTLA-4/B7.2. For more information on 
safety findings from clinical studies of combination therapy with anti-PD-1/L1 and 
anti-CTLA-4 antibodies, refer to the Investigator's Manual. 

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On 29 June 2022, China's State Drug Administration approved the New Drug 
Marketing Application for Kaitanib® (cardunculizumab injection), developed by 
Kangfang Bio. It is the world's first PD-1/CTLA-4 bispecific antibody tumor 
immunotherapy new drug for treating patients with recurrent or metastatic cervical 
cancer (R/MCC) who have failed prior platinum-containing chemotherapy treatment. 
Cetanib® is the first dual immune checkpoint inhibitor dual antibody for tumors 
approved for marketing globally, filling a gap in immune drug treatment for advanced 
cervical cancer in China and in the development of bispecific antibodies. 
4.5.2 Pharmacokinetic and pharmacodynamic study of cardunolizumab 
The pharmacokinetic properties of cardunilizumab were investigated in Crab-
Eating Monkeys. After single intravenous administration of 1, 4, and 16 mg/kg of 
cardunilizum 
ab to the cynomolgus monkeys, the observed clearance (Cl) was 2.2, 1.6, and 1.9 
ml/h/kg, respectively, and the apparent volume of distribution (Vss_obs) was 91, 92, 
and 113 ml/kg, respectively. This suggests significant distribution of cardunilizumab in 
tissues. The half-life (t1/2) after administration of 4 mg/kg was 47.9 h, approximately 
1/3 to 1/2 that of typical antibodies. The volume of distribution of cardunilizumab in 
the monkeys was significantly greater than that of the blood, indicating significant 
tissue distribution. Rapid clearance from the bloodstream reduces non-specific (off-
target) cytotoxicity. The preferential distribution of cardunilizumab in tumor tissue may 
result in a better safety profile compared to conventional anti-PD-1 and anti-CTLA-4 
antibodies. 
An approximately proportional dose-to-dose increase in exposure (Cmax and AUC) 
was observed in the dose range of 1 to 16 mg/kg. The increase in exposure (AUClast) 
of cardunilizumab was dose-proportional with a power function model β of 1.05, 
suggesting a linear pharmacokinetic profile of cardunilizumab. 
A multiple administration PK study of cardunilizumab was performed in crab-
eating monkeys. After 4 weeks of weekly intravenous administration of 4 mg/kg, the 
ratios of AUC 0-168h and Cmax after the last and first administration were 0.554 and 
0.230, respectively. This suggests that the antidrug antibody may interfere with the 

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detection of analytes or accelerate the clearance of cardunilizumab, resulting in lower 
exposure to the drug after the last administration compared with that after the first 
administration. 
The dose determination of cardunilizumab at 6 mg/kg Q2W in this study was based 
on safety data from a Phase Ia dose-escalation trial conducted in Australia and a Phase 
I/II clinical study conducted in China. In the Australian study, cardunilizumab 
monotherapy was initiated at a ramp-up dose of 0.2 mg/kg, followed by dose escalations 
of 0.5 mg/kg, 1 mg/kg, 2 mg/kg, 4 mg/kg, 6 mg/kg, and 10 mg/kg Q2W, with extensions 
to both the 6 mg/kg and 450 mg dose groups. As of 7 January 2020, 97 subjects were 
enrolled in the 6 mg/kg Q2W dose group, no drug-related dose-limiting toxicities (DLTs) 
were observed, the majority of drug-related adverse reactions were Grade 1, Grade 3 or 
higher treatment-related adverse events (TRAEs) were observed in 11 patients (11.3%), 
and no Grade 5 TRAEs occurred. The safety profile of cardunilizumab monotherapy 
was well tolerated. Currently, the ORR of cardunculizumab monotherapy is about 20% 
in each tumor, and among 8 patients who failed previous PD-1/PD-L1 treatment, 3 
cases showed lesion shrinkage. According to pharmacokinetic (PK) data, a 6mg/kg 
Q2W administration at that time could maintain the trough concentration at ~5ug/ml 
and ensure the saturation of receptor occupancy (RO) in the in vitro assay. Ki67, as a 
pharmacodynamic (PD) marker for CTLA-4 and PD-1 blockade, was dose-dependently 
increased in the expression of Ki67 in the peripheral blood CD4+ T-cells after 
administration of Cardunilizumab on the eighth day. Moreover, the approved dose of 
cardunilizumab for the indication of advanced recurrent cervical cancer is 6 mg/kg 
Q2W. 
Therefore, this study will first consider the option of treatment with cardunilizumab 
6 mg/kg Q2W, and if DLT occurs, the investigators will discuss and make a decision 
about continuing, revising, or discontinuing the study. 
4.5.3 Safety summary of cardunolizumab 
Combining preclinical studies conducted in China and abroad, as of 10 July 2020, 
a total of 277 patients were treated with cardunilizumab with dose escalation from 0.2 
mg/kg Q2W to 25 mg/kg Q3W. Only one subject in the 1.0 mg/kg dose group 

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experienced a dose-limiting toxicity (DLT) event: a grade 3 aspartate aminotransferase 
(AST) elevation. For the 15 mg/kg Q3W dose climb, no DLT was observed. For the 25 
mg/kg Q3W dose climb, no DLT was observed. The incidence of drug treatment-related 
adverse events (TRAEs) was 73.6%, and all TRAEs recovered and resolved with 
suspension of the drug as well as with symptomatic supportive care. As of 29 September 
2020, 12 subjects with advanced solid tumors who had failed standard therapy were 
treated with cardunilizumab (15 mg/kg Q3W), with a 75% (9/12) incidence of 
treatment-related adverse events (TRAEs), all of which were Common Terminology 
Criteria for Adverse Events (CTCAE) grades 1-2, and only one grade 3 TRAE, colitis, 
which resolved rapidly with treatment. There were no TRAEs leading to drug 
discontinuation and no TRAEs leading to death. The incidence of Grade 3 and higher 
TRAEs was 12.6%. Common TRAEs (≥2 occurrences) during the study period in the 
15 mg/kg Q3W dose group across all dose groups included rash, infusion reactions, 
fatigue, nausea, itching, elevated alanine transaminase (ALT)/AST, fever, and 
hyperthyroidism, the majority of which were Grade 1-2. Regarding the preliminary 
antitumor activity of the cardunilizumab 15mg/kg Q3W dose group, 5 out of 10 
assessable subjects with advanced solid tumors who had failed systemic therapy 
achieved partial remission (PR) with an ORR of 50%. These results indicate that the 
cardunilizumab 15mg/kg Q3W dosing regimen has a good safety and tolerability profile, 
as well as significant antitumor activity. 
4.5.4 Risk/benefit assessment 
The potential risks associated with cardunilizumab and related molecules 
primarily involve immune-mediated reactions. These potential immune-related adverse 
events (irAEs) might resemble those arising from the use of anti-PD-1/L1 and/or anti-
CTLA-4 drugs. Such reactions could include, but are not limited to, infusion-related 
reactions (fever, rash, pruritus, hypotension, dyspnea, chest discomfort, wheezing, 
tachycardia, rigors), dermatotoxicity (rash, pruritus, vitiligo), endocrine toxicity 
(hyperglycemia, hypothyroidism, hyperthyroidism, primary hypoadrenalism, pituitary 
gland inflammation), hepatotoxicity (hepatitis, elevated aspartate aminotransferase, 
elevated alanine aminotransferase, elevated bilirubin), gastrointestinal toxicity 

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(diarrhea, colitis), pulmonary toxicity (pneumonitis, pulmonary nodulosis), 
rheumatoid/skeletal muscle toxicity (rheumatoid arthritis, myositis, myalgia), 
neurotoxicity (myasthenia gravis, aseptic meningitis, encephalitis, transverse myelitis, 
Guillain-Barre syndrome), hematotoxicity (autoimmune hemolytic anemia, aplastic 
anemia, immune thrombocytopenia, acquired hemophilia), nephrotoxicity (nephritis, 
renal 
insufficiency), 
cardiotoxicity 
(myocarditis, 
pericarditis, 
cardiovascular 
anomalies), and ophthalmic toxicity (uveitis, scleritis). To date, the safety events 
identified in clinical studies with cardunilizumab are consistent with tumor 
immunotherapy targeting PD-1 and/or CTLA-4, with no new adverse events reported. 
Preliminary data from the Phase Ia clinical trial of cardunilizumab indicate that it 
is safe and well-tolerated in patients with advanced tumors, showing preliminary 
antitumor activity and clear pharmacological activity. Given recent data suggesting 
significant benefits of anti-PD-1 and anti-CTLA-4 antibody double-immunity therapy 
in multiple tumor types, it is proposed that the anti-PD-1 and CTLA-4 bispecific 
antibody cardunilizumab may also be effective in similar patients. 
Furthermore, tumor-infiltrating lymphocytes co-expressing PD-1 and CTLA-4 
receptors exhibit higher levels of these receptors compared to lymphocytes in normal 
tissue and peripheral blood. Cardunilizumab, targeting both PD-1 and CTLA-4, has a 
tetravalent structure and a short half-life. Its low toxicity, as observed in the Crab-Eating 
Monkey study, suggests it might be more effective and/or safer than combination 
therapy with anti-PD-1/L1 and anti-CTLA-4 antibodies alone. 
The current study is informed by the preliminary efficacy demonstrated by 
Corning Jericho KN046 (anti-PD-L1/CTLA-4 dual antibody) in combination with 
albumin paclitaxel and gemcitabine in patients with advanced pancreatic cancer. As of 
26th May 2021, 22 patients had undergone at least one tumor assessment, showing an 
objective remission rate (ORR) of 50.0%, a disease control rate (DCR) of 95.5%, and 
a 6-month progression-free survival rate (PFS-6M Rate) of 62.3%. Four patients, who 
met the criteria for surgical resection by multidisciplinary team (MDT) assessment after 
4-6 cycles of treatment, underwent surgery. The study explores the use of the approved 
and marketed cadaverine monoclonal antibody (PD-1/CTLA-4 dual-antibody) in 

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combination with mFOLFIRINOX chemotherapy for the translational treatment of 
patients with locally progressive pancreatic ductal adenocarcinoma. 
In summary, the study aims to enroll patients with critically resectable pancreatic 
ductal adenocarcinoma to explore potential markers for patients suitable for 
neoadjuvant therapy. This approach will be through the Bragg treatment modality in 
combination with the neoadjuvant treatment modality of chemotherapy. 
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17 
 
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18 
 
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022-01761-9. 
 
5.0 Selection of study population 
5.1 Inclusion Criteria 
5.1.1 Age ≥ 18 ≤ 75 years；no gender limitations 
5.1.2 Histopathologically and/or cytologically confirmed ductal adenocarcinoma of the 
pancreas, the patient has fresh pathological tissue and the tumour is located in the head 
and neck or body of the pancreas. 
5.1.3 Locally advanced pancreatic cancer, borderline resectable or unresectable, 
without metastases. 
5.1.4 Life expectancy >= 3 months. 
5.1.5 ECOG score 0-1. 
5.1.6 Have at least 1 measurable lesion according to RECIST 1.1 criteria. 
5.1.7 No prior treatment with abdominal radiotherapy, chemotherapy and PD-1/PD-
L1 antibody. 
5.1.8 Adequate organs functions as defined by the following laboratory values 
(completed within 14 days prior to registration):  

19 
 
(1) haemoglobin >= 90 g/L (no blood transfusion within 14 days)；  
(2) neutrophil count > 1.5x10^9/L；  
(3) platelet count >= 100x10^9/L；  
(4) total bilirubin <= 1.5xULN (upper limit of normal)；  
(5) blood glutamic transferase (ALT) or blood glutamic transferase (AST) <= 
2.5xULN  
(6) endogenous creatinine clearance >= 60 ml/min (Cockcroft's AST). (ALT) or blood 
albumin transaminase (AST) <= 2.5xULN；  
(6) endogenous creatinine clearance >= 60 ml/min (Cockcroft-Gault formula)；  
(7) cardiac Doppler ultrasound assessment: left ventricular ejection fraction 
(LVEF) >= 50%.  
(8) International normalised ratio (INR) of prothrombin time ≤ 1.5 and partial 
thromboplastin time (APTT) ≤ 1.5 times the upper limit of normal in patients who 
have not received anticoagulation. Patients receiving full or parenteral anticoagulant 
therapy may enter a clinical trial as long as the dose of anticoagulant has been stable 
for at least 2 weeks prior to entry into the clinical study and the results of coagulation 
assays are within the limits of local therapy.  
5.1.9 No congestive heart failure, unstable angina, unstable arrhythmia in the last 6 
months. 
5.1.10 No previous severe haematopoietic, cardiac, pulmonary, hepatic or renal 
abnormalities or immunodeficiencies. 
5.1.11 Patient must be able to understand the potential risks and benefits associated 
with this study. Patient able to give informed consent and would likely to comply with 
the study parameters. 
Exclusion Criteria: 
5.2.1 Pregnant or breastfeeding women. 
5.2.2 Patients with a history of other malignant diseases in the last 5 years, except cured 
skin cancer and cervical cancer in situ. 
5.2.3 Patients with a history of uncontrolled epilepsy, central nervous system disease or 
psychiatric disorders whose clinical severity, in the judgement of the investigator, may 

20 
 
prevent the signing of informed consent or affect the patient's adherence to drug therapy. 
5.2.4 Severe heart disease, such as symptomatic coronary heart disease, New York 
Heart Association (NYHA) class II or worse congestive heart failure or severe 
arrhythmia requiring pharmacological intervention, or a history of myocardial 
infarction within the last 12 months. 
5.2.5 Organ transplants requiring immunosuppressive therapy 
5.2.6 Active infection or, in the investigator's judgement, significant haematological, 
renal, metabolic, gastrointestinal, endocrine function or metabolic disorders, or other 
serious uncontrolled concomitant disease 
5.2.7 Allergy to any of the study drug ingredients. 
5.2.8 History of immunodeficiency, including HIV-positive or other acquired or 
congenital immunodeficiency diseases, or history of organ transplantation, or other 
immune-related diseases requiring long-term oral hormone therapy. 
5.2.9 During acute or chronic tuberculosis infection (patients with a positive T-spot test 
and suspicious tuberculosis foci on chest radiographs). 
5.2.10 Other conditions considered by the investigator to be unsuitable for enrolment. 
5.3 Exit criteria 
5.3.1. 
Patients who, in the judgement of the investigator, will not benefit from 
continued medication after medical imaging has shown progression of the disease 
5.3.2. 
Those whose toxicity remains intolerable to the patient after suspension of 
drug therapy; 
5.3.3. 
The patient withdrew informed consent and asked to be withdrawn; 
5.3.4. 
Other situations where the researcher felt it was necessary to withdraw from 
the study. 
 
6.0 Research treatment 
6.1 Research design 
Phase I clinical study

21 
 
 
                          Fig. 2 Flowchart of the study design 
Phase I clinical studies are divided into phases Ia+Ib. Phase Ia is a dose-climbing 
trial, which is divided into two cohorts of 3+3 patients each according to the 
radiotherapy dose. Phase Ib is a sample size expansion phase, for which priority is given 
to choosing the best-tolerated regimen in terms of safety among the phase Ia regimens, 
followed by choosing regimens with high surgical conversion rates. 
6.2 Treatment programme 
Dose-climbing experimental stage 
6.2.1 Phase I: PRaG treatment 
Group I n=3+3 
First cycle of PRaG treatment  
Radiotherapy：24Gy：8Gy*3f d4-d6 
GM-CSF treatment: GM-CSF 200 μg subcutaneously daily for 7 days starting on 
the day of radiotherapy; d1-d7 
Immunotherapy: cardunculizumab 375mg within one week after radiotherapy 
Second cycle of PRaG treatment 
Radiotherapy：24Gy：8Gy*3f d4-d6 
GM-CSF treatment: GM-CSF 200 μg subcutaneously daily for 7 days starting on 
the day of radiotherapy; d1-d7 
Immunotherapy: cardunculizumab 375mg within one week after radiotherapy 
Group II n=3+3 

22 
 
Radiotherapy：40Gy：8Gy*5f d3-d7 
GM-CSF treatment: GM-CSF 200 μg subcutaneously daily for 7 days starting on 
the day of radiotherapy; d1-d7 
Immunotherapy: cardunculizumab 375mg within one week after radiotherapy 
6.2.2 Phase II: 3 cycles of neoadjuvant immunotherapy combined with 
chemotherapy 
After 3 weeks of phase I immunotherapy 
Cardunolizumab 375mg d1  
Albumin-bound paclitaxel 125mg/m2 d1,d8 
Gemcitabine 1000mg/m2 d1,d8 
6.2.3 Phase III: Surgical treatment 
First Surgical Evaluation: After three cycles of neoadjuvant immuno-combination 
AG regimen, tumor indices and imaging examinations are improved, followed by a 
multidisciplinary discussion to decide on the feasibility of surgery. 
Second Surgical Evaluation: For patients deemed inoperable after the first 
evaluation, an additional three cycles of the immuno-combination AG regimen are 
administered. Surgery is re-evaluated upon completion of these chemotherapy cycles. 
For patients with preoperative total bilirubin ≤102.6 mmol/L, yellowing can be 
reduced with the help of PTCD or a biliary stent. 
Patients who are resectable after neoadjuvant therapy undergo radical surgical 
treatment, such as radical pancreaticoduodenectomy, radical paracentesis modular 
pancreas splenectomy, and radical total pancreatectomy with regional lymph node 
dissection. 
6.2.4 Phase IV: 3 cycles of immuno-combination chemotherapy 
Patients who have undergone surgery, as well as those assessed as inoperable after 
three cycles of chemotherapy combined with immunotherapy, continue with three 
cycles of immune-combination chemotherapy. 
Cardunolizumab 375mg d1  
Albumin-bound paclitaxel 125mg/m2 d1,d8 
Gemcitabine 1000mg/m2 d1,d8 

23 
 
6.2.5 Imaging Evaluation 
Pre-treatment imaging assessment is performed, followed by the first imaging 
assessment after two cycles of treatment and the second imaging assessment after 
three cycles of AG combination immunotherapy. The third imaging assessment 
occurs after completion of six cycles of adjuvant therapy. Multi-stage enhanced CT is 
preferred, with CT thin-layer reconstruction performed whenever possible. However, 
imaging often fails to reflect biological attributes such as tumor heterogeneity, 
activity, blood supply, and immune cell infiltration. As pancreatic cancer is rich in 
mesenchyme, the tissue around the tumor also produces an inflammatory reaction and 
fibrosis after neoadjuvant therapy. Even if the therapy is effective, the size of the 
tumor and the extent of involvement of important blood vessels often do not 
significantly change. It is often difficult to accurately assess the effect of neoadjuvant 
therapy for pancreatic cancer and the resectability of the tumor with the RECIST 1.1 
criteria. Therefore, dynamic enhanced MRI, PET-CT, and CA199 assessments are 
combined for comprehensive evaluation. 
6.2.6 Pathological evaluation 
Pathologists perform post-surgical imaging to assess margins, lymph node status, 
etc. For patients who do not undergo surgery, re-puncture for pathology retention is 
conducted at the end of six chemotherapy cycles. 
6.2.7 Collection of specimens 
Collection includes 10 ml of fresh pathological tissue and peripheral blood 
samples before treatment, 10 ml of peripheral blood samples after Bragg treatment, 10 
ml of peripheral blood samples after the first immuno-combination chemotherapy, 10 
ml of peripheral blood specimens after the fourth cycle of AG-combination 
immunotherapy, 10 ml of fresh surgical tissue specimens and peripheral blood after the 
surgery, and 10 ml of peripheral blood specimens after completion of six cycles of 
adjuvant therapy. 
6.2.8 Decision-making in the dose-climbing phase 
The Data Review Panel, consisting of investigators, medical supervisors, 
physicians, clinical representatives, and statisticians, determines whether to increase 

24 
 
the Phase I dose based on the presence or absence of DLTs. Before deciding to increase 
the dose, the panel reviews all relevant adverse event data, including non-DLT 
toxicities, laboratory evaluations, and other safety assessments, as well as any data 
described in the Dose Reduction Plan. Quality control of critical safety data is also 
outlined in the dose reduction plan, including ongoing study monitoring visits, review 
of clinical databases, and confirmation of data accuracy and completeness by site 
investigators. Dose reduction decisions and rationale are documented in writing and 
maintained at each study site. 
Group I receives a radiotherapy dose of 8Gy*3f before surgical treatment. If no 
patient among the first three subjects develops DLT, the original dose continues for 
three more cases. If there is still no DLT or only one case develops DLT, enrollment in 
Group II proceeds. If one of the first three patients in Group I develops a DLT, then 
three additional patients receive the same dose. If two or three patients develop DLT, 
the dose is deemed to exceed the maximum tolerated dose (MTD) of the drug, and no 
further enrollment in Group II occurs. The mode and dose of Bragg treatment in the 
next extended sample size phase are determined based on the safety and tolerability of 
the two groups. If the safety profiles of the two groups are similar, the mode and dose 
for the next phase are decided based on the surgical conversion rate and R0 resection 
rate. 
6.3 Radiotherapy delivery 
The pancreas is selected for radiotherapy, administered once daily. 
6.3.1 Posture fixation 
The patient is placed in a comfortable position, fixed with a thermoplastic body 
wrap, and positioned under CT simulation. The scanning scope covers the target area 
and all critical organs, extending at least 5-10 cm to the cephalad and foot side of the 
target area boundary. 
6.3.2 Definition of target area 
Gross Tumor Volume (GTV): Tumors visible by imaging and clinical examination, 
including physical examination, fiberoptic colonoscopy, ultrasound, CT, MRI, and PET. 
Internal Target Volume (ITV): Considers respiratory motion or organ-moving 

25 
 
tumor foci. 
Planning Target Volume (PTV): GTV/ITV + postural error. 
6.3.3 Prescribed dose for target area 
Prescribed dose: 48Gy/8Gy/6f, irradiated once daily. Image-guided radiotherapy 
(IGRT) is required for each session. 
6.3.4 Safe dose for normal tissues 
Safe dose for normal tissues（Refer to AAPM Task Group 101 document）。 
Tandem organ 
Volumes 
Maximum dose by 
volume（Gy） 
Maximum point 
dose（Gy） 
Adverse events (≥ grade 3) 
cauda equina 
<5cc 
21.9Gy(7.3Gy/Fx) 
24Gy(8Gy/Fx) 
neuritis 
sacral plexus 
<5cc 
22.5Gy(7.5Gy/Fx) 
24Gy(8Gy/Fx) 
neuropathy 
esophagus 
<5cc 
17.7Gy(5.9Gy/Fx) 
25.2Gy(8.4Gy/Fx) 
Stenosis/fistula 
brachial plexus 
<3cc 
20.4Gy(7.5Gy/Fx) 
24Gy(8Gy/Fx) 
neuropathy 
Heart/Pericardium 
<15cc 
24Gy(8Gy/Fx) 
30Gy(10Gy/Fx) 
pericarditis 
capillary blood 
vessels 
<10cc 
39Gy(13Gy/Fx) 
45Gy(15Gy/Fx) 
aneurysm 
Trachea and main 
bronchi 
<4cc 
15Gy(5Gy/Fx) 
30Gy(10Gy/Fx) 
Stenosis/fistula 
Bronchial 
branches 
<0.5cc 
18.9Gy(6.3Gy/Fx) 
23.1Gy(7.7Gy/Fx) 
stenosis with atelectasis 
Ribs 
<1cc 
<1cc 
28.8Gy(9.6Gy/Fx) 
30.0Gy(10.0Gy/Fx) 
36.9Gy(12.3Gy/Fx) 
Pain or fracture 
Skin 
<10cc 
30Gy(10Gy/Fx) 
33Gy(11Gy/Fx) 
ulcers 
Stomach 
<10cc 
16.5Gy(5.5Gy/Fx) 
22.2Gy(7.4Gy/Fx) 
Ulcers/fistulas 
Bile ducts 
 
 
35.7Gy(11.9Gy/Fx) 
narrower 
Duodenum 
<5cc 
<10cc 
16.5Gy(5.5Gy/Fx) 
11.4Gy(3.8Gy/Fx) 
22.2Gy(7.4Gy/Fx) 
ulcers 
Jejunum/Ileum 
<5cc 
17.7Gy(5.9Gy/Fx) 
25.2Gy(8.4Gy/Fx) 
Inflammation/obstruction 
colon 
<20cc 
24Gy(8Gy/Fx) 
28.2Gy(9.4Gy/Fx) 
Colitis/fistula 
rectum 
<20cc 
24Gy(8Gy/Fx) 
28.2Gy(9.4Gy/Fx) 
Proctitis/fistula 
ureter 
 
 
48.9Gy(16.3Gy/Fx) 
narrower 
Femoral head 
(left/right) 
<10cc 
21.9Gy(7.3Gy/Fx) 
 
Necrosis 
Renal 
portal/vascular 
<2/3 
volume 
18.6Gy(6.2Gy/Fx) 
 
malignant hypertension 

26 
 
trunk 
parallel organ 
critical 
volume 
Critical Volume 
Maximum Dose
（Gy） 
 
Adverse events (≥ grade 
3) 
Lungs (left/right) 
1500cc 
11.6Gy(2.9Gy/Fx) 
 
baseline lung function 
Lungs (left/right) 
1000cc 
12.4Gy(3.1Gy/Fx) 
 
inflammation of the 
lungs 
liver 
700cc 
19.2Gy(4.8Gy/Fx) 
 
Basic liver function 
Renal cortex 
(left/right) 
200cc 
16.0Gy(4.0y/Fx) 
 
Basic renal function 
6.4 Combination of drugs 
1) Medications deemed consistent with the protocol by the Investigator, such as 
those used for treating disease-related symptoms or managing various adverse 
events (AEs) associated with the treatment, are permitted. 
2) Subjects requiring long-term medication for pre-existing medical conditions, 
such as hypertension or diabetes, may continue their medication regimen. 
3) The use of topical glucocorticoids, including dermal applications, eye drops, 
nasal sprays, and inhalations, is allowed. 
4) Routine administration of non-steroidal anti-inflammatory drugs (NSAIDs) is 
permitted. 
 
7.0 Research and Evaluation 
7.1 Evaluation of toxic reactions during radiotherapy and immunotherapy 
Toxicity reactions are evaluated using the Common Terminology Criteria for 
Adverse Events (CTCAE) version 5.0, the European Society for Medical Oncology 
(ESMO) Clinical Practice Guidelines for the Management of Toxicity in 
Immunotherapy, ESMO Diagnosis, Treatment and Follow-up, and the Chinese Society 
of Clinical Oncology (CSCO) Guidelines for the Management of Toxicity in 
Immunotherapy, as detailed in the Case Report Form (CRF) table. 
7.2 Evaluation of the efficacy of treatment 
Patients were examined periodically during and after treatment to assess their 
outcome and prognosis, and the items and time points are shown in the table below: 

27 
 
 
Baseline 
before 
treatment 
Before 
each 
treatment 
cycle 
during 
treatment 
After 3 
cycles of 
treatment 
After 6 
cycles of 
treatment 
 
One month 
after surgery 
clinical examination 
X 
X 
X 
X 
X 
routine blood test 
X 
X 
X 
X 
X 
liver 
and 
kidney 
function 
X 
X 
X 
X 
X 
Tumour indicators 
X 
X 
X 
X 
X 
Thyroid function 
X 
X 
X 
X 
X 
Myocardial Enzyme 
Profile 
X 
X 
X 
X 
X 
glycated 
haemoglobin 
X 
X 
X 
X 
X 
electrocardiography 
X 
/ 
X 
X 
/ 
cardiac ultrasound 
X 
/ 
X 
X 
/ 
spirometry 
X 
/ 
X 
X 
/ 
Enhanced CT Chest 
X 
/ 
X 
X 
X 
Enhanced 
CT 
Abdomen 
X 
/ 
X 
X 
X 
Enhanced CT of the 
pelvis 
X 
/ 
X 
X 
X 
Abdominal 
Enhanced MR 
unconditi
onal 
/ 
unconditio
nal 
unconditio
nal 
/ 
PET-CT 
unconditi
onal 
/ 
unconditio
nal 
unconditio
nal 
/ 
Quality 
of 
life 
assessment 
X 
X 
X 
X 
X 
Toxicity 
response 
evaluation 
X 
X 
X 
X 
X 
Efficacy assessment: assessed using RECIST 1.1 criteria, respectively. 
 

28 
 
8.0 Annual Research Programme 
2024.01-2024.10 
Perform patient enrolment and follow-up 
2024.11-2025.10 
Perform patient enrolment and follow-up 
2025.11-2026.10 
Completion of patient enrolment and follow-up 
2026.11- 
Data collation and analysis, research summaries, 
publications 
 
9.0 Research Design and Statistical Analysis 
9.1 Study design and sample size calculation 
Phase I: This study is a Phase I clinical trial, divided into Phase Ia and Ib. Phase 
Ia, a dose-escalation experiment, is split into two cohorts based on radiotherapy dosage, 
each with 3+3 patients, totaling 12 patients across three groups. Phase Ib, an expansion 
phase, plans to enroll 11 patients. From the three protocols in Phase Ia, the one with the 
highest safety tolerability is preferred, followed by the protocol with a high surgical 
conversion rate. It is proposed to enroll a total of 23 patients. Considering a 10% loss-
to-follow-up rate, the total sample size is projected to be 26 patients. 
Phase II Study: The primary endpoint is the 1-year overall survival (OS) rate. 
Based on the ESPAC-5F28 Phase II study, the 1-year OS rate for patients undergoing 
direct surgery is approximately 40%. This study aims to increase the 1-year OS rate to 
60%. Using PASS software, Tests for One Proportion, P0=0.40, P1=0.60, α=0.05, 1-
β=0.8, the sample size was calculated to be 36 cases. Factoring in a 10% loss-to-follow-
up rate, a total of 40 patients are proposed to be enrolled. 
9.2 Statistical analysis 
Data analysis will be conducted using SPSS25.0 statistical software. The residuals 
will be tested for normality using the Shapiro-Wilk line test, with a test level α>0.05. 
Indicators conforming to normal distribution will be analyzed using random area group 
ANOVA, while those not conforming will be tested with the random area group design 
rank-sum test, with a test level α<0.05. This analysis will compare changes in leukocyte 
counts before and after radiotherapy, including granulocyte and lymphocyte count 
changes, and alterations in cytokines. In conjunction with survival time, Cox regression 

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will analyze the effects of changes in leukocyte counts, granulocyte counts, 
lymphocytes, tumor markers, their classified cell number alterations, and cytokine 
changes before and after radiotherapy on patient survival. The Kaplan-Meier method 
will be used to analyze the difference in survival rates between patients with and 
without various markers, and to study the relationship between patient survival rates 
and factors such as relevant cytokines and changes in tumor cells. 
 
 
 
 
                                
Signature of the principal investigator： 
                                                                           Date：