Efficacy of FOLFOX Alone, FOLFOX Plus Bevacizumab and FOLFOX Plus Panitumumab in Patients With Resectable Liver Metastases

Study Overview
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Brief Summary
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Patients presenting with multiple innumerable liver metastases will probably never come to resection, however, for all others, including patients with numerous multiple metastases or large metastases,resection should be considered after limited chemotherapy. There is consensus for a backbone chemotherapy consisting of fluoropyrimidine + oxaliplatin. FOLFOX was used in the previous EORTC study and is again recommended. The addition of targeted agents to standard chemotherapy in the perioperative strategy for mCRC might increase the ORR and R0 resectability, without significant increase in toxicity, therefore translating to a better outcome. It was therefore decided to design an open label, randomized, multi-center, 3-arm late phase II study. Arm A: (standard) mFOLFOX6 + Surgery Arm B: (experimental) mFOLFOX6 + Bevacizumab + Surgery Arm C: (experimental) mFOLFOX6 + Panitumumab + Surgery

Official Title
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Randomized Phase II Trial Evaluating the Efficacy of FOLFOX Alone, FOLFOX Plus Bevacizumab and FOLFOX Plus Panitumumab as Perioperative Treatment in Patients With Resectable Liver Metastases From Wild Type KRAS/NRAS Colorectal Cancer

Conditions
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Colorectal Cancer Metastatic, Liver Metastases, KRAS Wild Type Colorectal Cancer

Intervention / Treatment
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* Drug: FOLFOX6
* Biological: Bevacizumab
* Biological: Panitumumab
* Procedure: Surgery


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically proven CRC with 1 to 8 metachronous or synchronous liver metastases considered to be completely resectable. Primary tumor (or liver metastasis) of CRC must be KRAS and NRAS status wild type. Patients must have undergone complete resection (R0) of the primary tumor at least 4 weeks before randomization. Or for patients with synchronous metastases the primary tumor can be resected (R0) at the same time as the liver metastases if: the patient has a non-obstructive primary tumor and is able to receive preoperative chemotherapy (3-4 months) before surgery. Measurable hepatic disease by RECIST version 1.1. Patients must be 18 years old or older. A WHO performance status of 0 or 1. Radiotherapy alone is allowed if given pre or post protocol treatment. Previous adjuvant chemotherapy for primary CRC is allowed if completed at least 12 months before inclusion in this study. All the following tests should be done within 4 weeks prior to randomization: Absolute neutrophil count ≥ 1.5 x 109/L, platelets ≥ 100 x 109/L, hemoglobin ≥ 9 g/dL and white blood cell count (WBC) ≥ 3 x 109/L. Serum creatinine ≤ 1.5 times the upper limit of normal (ULN) (to exclude severe renal impairment); no significant proteinuria (urine protein < 1g/24 hours urine collection) OR urine protein/creatinine ratio < 1.0 OR 1+ proteinuria on urine dipstick. Absence of major hepatic insufficiency (bilirubin ≤ 1.5 x ULN and aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) ≤ 5 x ULN). Magnesium ≥ lower limit of normal (LLN) Patients with a buffer range from the normal values of +/- 5% for hematology and +/- 10% for biochemistry are acceptable. This will not apply for Renal Function, including Creatinine. Women of child bearing potential (WOCBP) must have a negative serum (or urine) pregnancy test within 14 days prior to the first dose of study treatment. Patients of childbearing / reproductive potential should use adequate birth control measures, as defined by the investigator, during the study treatment period and for at least 6 months after the last study treatment. A highly effective method of birth control is defined as those which result in low failure rate (i.e. less than 1% per year) when used consistently and correctly. Female subjects who are breast feeding should discontinue nursing prior to the first dose of study treatment and until 6 months after the last study treatment. Before patient registration/randomization, written informed consent must be given according to ICH/GCP, and national/local regulations. Exclusion Criteria: Evidence of extra-hepatic metastasis (of CRC). Previous chemotherapy for metastatic disease or surgical treatment (e.g. surgical resection or radiofrequency ablation) for liver metastasis. Previous exposure to EGFR or VEGF/VEGFR targeting therapy within the last 12 months. Major surgical procedure, open biopsy, or significant traumatic injury within 4 weeks prior to randomization. Regular use of aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). Bleeding diathesis (e.g. hemoptysis of ≥ 1/2 teaspoon or 2.5mL), coagulopathy, or need for administration of full-dose anti-coagulant(s). Clinically significant cardiovascular disease, including: uncontrolled hypertension, New York Heart Association (NYHA) class II-IV heart failure, myocardial infarction or unstable angina pectoris, cerebrovascular accident or transient ischemic attack within the past 12 months, peripheral vascular disease ≥ grade 2, serious cardiac arrhythmia requiring medication and other clinically significant cardiovascular disease. Peripheral neuropathy > grade 1 (Common Terminology Criteria for Adverse Events, v4.0) serious wound complications, ulcers, or bone fractures. Symptomatic diverticulitis or active or uncontrolled gastroduodenal ulceration. History or evidence of interstitial lung disease (e.g. pneumonitis, pulmonary fibrosis) Significant disease that, in the investigator's opinion, would exclude the patient from the study. Including known allergy or any other adverse reaction to any of the study drugs (including any of the excipients) or to any related compound, including hypersensitivity to Chinese hamster ovary (CHO) cell products or other recombinant human or humanized antibodies. Presence of any psychological, familial, sociological, or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial. Participation in another clinical study (except sub studies of this protocol) within the 30 days before randomization and during this study.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Arm A: modified FOLFOX6 and Surgery<br>6 cycles before and 6 cycles after surgery consisting in: Hour 0: Oxaliplatin 85 mg/m² IV 2-h infusion Hour 0: Folinic Acid 400 mg/m² (DL form) or 200 mg/m2 (L form) IV 2-h infusion Hour 2: 5-FU 400 mg/m² IV bolus over 2-4 minutes Hour 2: 5-FU 2400 mg/m² given as a continuous infusion over 46h. On day 1 of a 14 day cycle | Drug: FOLFOX6<br>* 5-FU, folinic acid, oxaliplatin<br>* Other names: Chemotherapy;Procedure: Surgery<br> <br> |
| Experimental: Arm B: modified FOLFOX6 + Bevacizumab and Surgery<br>6 cycles before and 6 cycles after surgery consisting in: Hour 0: Oxaliplatin 85 mg/m2 2-h infusion Hour 0: Folinic Acid 400 mg/m2 (DL form) or 200 mg/m2 (L form) 2-h infusion Hour 2 (before 5-FU bolus): Bevacizumab 5 mg/kg IV over 90 minutes infusion*. Hour 3.5: 5-FU bolus 400 mg/m2 IV bolus over 2-4 minutes Hour 3.5: 5-FU 2400 mg/m² given as a continuous infusion over 46h. On day 1 of a 14 day cycle | Drug: FOLFOX6<br>* 5-FU, folinic acid, oxaliplatin<br>* Other names: Chemotherapy;Biological: Bevacizumab<br>* Targeted therapy<br>* Other names: Avastin;Procedure: Surgery<br> <br> |
| Experimental: Arm C: modified FOLFOX6 + Panitumumab and Surgery<br>Experimental: Arm B: modified FOLFOX6 + Bevacizumab and Surgery 6 cycles before and 6 cycles after surgery consisting in: Hour - 1 (pre chemotherapy): Panitumumab 6 mg/kg IV over 60 minutes (≤ 1000 mg) or 90 minutes (> 1000 mg) +/- 15 min. infusion*. Hour 0: Oxaliplatin 85 mg/m² IV 2-h infusion Hour 0: Folinic Acid 400 mg/m² (DL form) or 200 mg/m2 (L form) IV 2-h infusion Hour 2: 5-FU 400 mg/m² IV bolus over 2-4 minutes Hour 2: 5-FU 2400 mg/m² given as a continuous infusion over 46h. On day 1 of a 14 day cycle | Drug: FOLFOX6<br>* 5-FU, folinic acid, oxaliplatin<br>* Other names: Chemotherapy;Biological: Panitumumab<br>* Targeted therapy<br>* Other names: Vectibix;Procedure: Surgery<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression free survival | Increase in progression free survival rate at 1 year in each experimental arm (mFOLFOX6 + bevacizumab or panitumumab) compared to mFOLFOX6 alone arm. | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pathological response rate | Increase in major pathological response rate between mFOLFOX6 alone arm and each experimental arm. | 4 years | 
| Resection rate | Compare the percentage of patients with total resection with these three treatments. | 4 years | 
| Overall survival | Overall survival is defined as the time interval between the date of randomization and the date of death. Patients who are still alive when last traced will be censored at the date of last follow-up. | 8 years | 
| Safety | All adverse events will be recorded; the investigator will assess whether those events are drug related (reasonable possibility, no reasonable possibility) and this assessment will be recorded in the database for all adverse events. | 4 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Liver metastases, Colorectal Cancer, KRAS wild type, FOLFOX, Bevacizumab, Panitumumab, Randomized, Phase II, Perioperative treatment, Adjuvant, Neo-adjuvant, Surgery, Progression Free Survival