Combination Chemotherapy Before or After Surgery in Treating Patients With Colorectal Cancer With Liver Metastases That Could Be Removed By Surgery

Study Overview
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Brief Summary
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RATIONALE: Drugs used in chemotherapy work in different ways to kill tumor cells or stop them from growing. Giving combination chemotherapy before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. Giving combination chemotherapy after surgery may kill any remaining tumor cells. It is not yet known whether giving combination chemotherapy before and after surgery is more effective than giving combination chemotherapy after surgery. PURPOSE: This randomized phase III trial is studying giving combination chemotherapy before and after surgery to see how well it works compared to giving combination chemotherapy after surgery in treating patients with colorectal cancer with liver metastases that could be removed by surgery.

Detailed Description
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OBJECTIVES: Primary To evaluate the difference in recurrence-free survival (RFS) of patients with potentially resectable hepatic colorectal metastases receiving perioperative (preoperative plus postoperative) adjuvant chemotherapy vs only postoperative adjuvant chemotherapy following liver resection for colorectal metastases. Secondary To compare the proportion of patients between study arms who are R0 or R1 resected, alive, and free of recurrence at 6 months. To compare RFS between study arms in the cohort of patients event-free at 6 months. To compare overall survival between study arms. To evaluate the difference in R0 and combined R0 + R1 resection rates in patients receiving neoadjuvant therapy and those undergoing initial surgical resection. To compare the postoperative morbidity profile between study arms. To evaluate the safety and toxicity profile of postoperative and perioperative administration of chemotherapy and bevacizumab. Tertiary To evaluate the relationship of baseline circulating tumor cells (CTC) to RFS. To evaluate the relationship of baseline CTC to R0 resection. To evaluate the relationship of pre-resection CTC in the preoperative therapy group only with RFS and R0 resection. OUTLINE: This is a multicenter study. Patients are stratified by number of liver metastases (1-3 vs 4+), chemotherapy regimen* (mFOLFOX6 vs FOLFIRI), and synchronous** primary colorectal cancer (yes vs no). Patients are randomized to 1 of 2 treatment arms. NOTE: *Patients who have not received previous oxaliplatin receive mFOLFOX6 chemotherapy comprising oxaliplatin IV over 2 hours, leucovorin calcium IV over 2 hours, and fluorouracil IV over 46 hours on day 1. Patients who have received previous oxaliplatin receive FOLFIRI chemotherapy comprising irinotecan hydrochloride IV over 2 hours, leucovorin calcium IV over 2 hours, and fluorouracil IV over 46 hours on day 1. NOTE: **Synchronous is defined as the detection (by imaging) of suspicious liver metastases within 90 days before or after the date of histologic diagnosis of the primary colon or rectal cancer. Arm 1 (postoperative): Patients undergo hepatic resection. Beginning 31-56 days after surgery, patients receive mFOLFOX6 or FOLFIRI chemotherapy IV on day 1 over 3 hours. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats every 2 weeks for 12 courses. Arm 2 (perioperative): Patients receive mFOLFOX6 or FOLFIRI chemotherapy IV over 3 hours on day 1. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats for every 2 weeks for 6 courses. Patients then undergo hepatic resection. Beginning 31-56 days after surgery, patients receive an additional 6 courses of mFOLFOX6 or FOLFIRI chemotherapy. Blood and tumor tissue samples may be collected periodically for correlative studies. After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for 3 years.

Official Title
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A Phase III Study Evaluating the Role of Perioperative Chemotherapy in Patients With Potentially Resectable Hepatic Colorectal Metastases

Conditions
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Colorectal Cancer, Metastatic Cancer

Intervention / Treatment
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* Procedure: Postoperative chemotherapy
* Procedure: Perioperative chemotherapy


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Histologically confirmed colorectal adenocarcinoma Hepatic metastasis (no histologic confirmation required) and no evidence of extrahepatic metastatic disease within the past 4 weeks by one of the following imaging studies*: PET/CT scan with contrast PET scan AND CT scan with contrast PET scan AND MRI with contrast PET/CT scan without contrast AND MRI with contrast NOTE: *If findings noted in imaging study reports are equivocal, the determination of whether or not the findings represent extrahepatic disease will be at the investigator's discretion. No history of or concurrent evidence of extrahepatic metastases Patients with regional nodes that are suspicious on imaging and are associated with the primary colorectal tumor are eligible provided the nodes will be resected with the primary tumor after randomization No radiographic evidence of metastases to portal lymph nodes (node > 1 cm in diameter) unless the node(s) are proven by biopsy to be negative No anal, small bowel, or appendiceal carcinoma No sarcoma, lymphoma, or carcinoid colorectal malignant diseases Within 4 weeks before randomization, the liver metastases must be determined by a hepatic surgeon to be resectable based on meeting both of the following criteria: A complete resection can be performed in a single operation There are ≥ 2 uninvolved contiguous segments of the liver Meets one of the following criteria: Primary tumor and regional nodes resected with clear surgical margins and no evidence of extrahepatic disease Unresected primary tumor with plans to resect the primary tumor before randomization Unresected primary tumor with plans to resect the primary tumor and the liver metastases in a single surgical procedure performed after randomization No unresected primary tumor in the colon or rectum with significant symptoms related to obstruction or that will require radiotherapy PATIENT CHARACTERISTICS: Eastern Cooperative Oncology Group (ECOG) performance status 0-1 Life expectancy ≥ 5 years (excluding the diagnosis of metastatic CRC) absolute neutrophil count (ANC) ≥ 1,200/mm^3 Platelet count ≥ 100,000/mm^3 Hemoglobin ≥ 10 g/dL Total bilirubin ≤ upper limit of normal (ULN) aspartate aminotransferase (AST) ≤ 5.0 times ULN Alkaline phosphatase ≤ 5.0 times ULN Serum creatinine ≤ ULN OR calculated creatinine clearance ≥ 30 mL/min Not pregnant or nursing Negative pregnancy test Fertile patients must use effective contraception during and for ≥ 180 days after completion of study treatment Considered a potential candidate for a major hepatic surgical procedure No grade 3 or 4 anorexia, grade 3 nausea, or vomiting ≥ grade 2 (per CTCAE v4.0) related to metastatic disease No paresthesias, peripheral sensory neuropathy, or peripheral motor neuropathy ≥ grade 2 per Common Toxicity Criteria for Adverse Effects (CTCAE) v4.0 (patients with grade 2 neuropathy who will receive FOLFIRI are eligible) No uncontrolled high BP defined as systolic BP ≥ 160 mm Hg OR diastolic BP ≥ 100 mm Hg, with or without antihypertensive medication (patients with initial BP elevations are eligible provided initiation or adjustment of BP medication lowers pressure to meet this criteria) Documented history of congestive heart failure requiring chronic medical therapy No active inflammatory bowel disease No active infection or chronic infection requiring chronic suppressive antibiotics No known bleeding diathesis or coagulopathy No symptomatic interstitial pneumonitis OR definitive evidence of interstitial pneumonitis described on CT scan, MRI, or chest x-ray in asymptomatic patients No other malignancies unless the patient is considered to be disease-free and has completed therapy for the malignancy ≥ 1 year ago Patients with carcinoma in situ of the cervix, CRC in situ, melanoma in situ, or basal cell or squamous cell carcinoma of the skin diagnosed and treated at any time before study treatment are eligible No known Gilbert syndrome Not known to be homozygous for the UGT1A1 allele (for patients who will receive FOLFIRI chemotherapy) No prior serious hypersensitivity reaction to any of the agents administered as part of study treatment (determination of serious is at the investigator's discretion) No other serious concurrent medical condition that, in the opinion of the investigator, would compromise the safety of the patient or compromise the patient's ability to participate in the study, or cause a delay in the initiation of therapy (surgery or chemotherapy) longer than 4 weeks following randomization No psychiatric or addictive disorders or other conditions that, in the opinion of the investigator, would preclude the patient from meeting the study requirements No pre-existing chronic hepatic disease (e.g., chronic active hepatitis, cirrhosis) that, in the opinion of the investigator and hepatic surgeon, would limit the patient's ability to undergo hepatic metastasectomy PRIOR CONCURRENT THERAPY: See Disease Characteristics No previous hepatic-directed therapy, including hepatic resection and/or ablation, hepatic arterial infusion therapy, or hepatic radiotherapy Patients who have only had an incision or excisional biopsy are eligible No previous chemotherapy or any other systemic therapy for metastatic colorectal cancer (CRC) No prior or concurrent portal vein embolization or other hepatic preconditioning techniques At least 30 days since prior investigational products No intent to use ablation to treat any hepatic lesion No concurrent therapeutic doses of coumadin or equivalent

Ages Eligible for Study
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Minimum Age: 18 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 |
| --- | --- |
| Experimental: Arm 1: Postoperative chemotherapy<br>Patients undergo hepatic resection. Beginning 31-56 days after surgery, patients receive mFOLFOX6 or FOLFIRI chemotherapy IV on day 1 over 3 hours. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats every 2 weeks for 12 cycles. | Procedure: Postoperative chemotherapy<br>* Patients undergo hepatic resection. Beginning 31-56 days after surgery, patients receive mFOLFOX6 or FOLFIRI chemotherapy IV on day 1 over 3 hours. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats every 2 weeks for 12 cycles.<br>|
| Experimental: Arm 2: Perioperative chemotherapy<br>Patients receive mFOLFOX6 or FOLFIRI chemotherapy IV over 3 hours on day 1. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats for every 2 weeks for 6 cycles. Patients then undergo hepatic resection. Beginning 31-56 days after surgery, patients receive an additional 6 cycles of mFOLFOX6 or FOLFIRI chemotherapy. | Procedure: Perioperative chemotherapy<br>* Patients receive mFOLFOX6 or FOLFIRI chemotherapy IV over 3 hours on day 1. Patients receive an additional dose of fluorouracil over 46 hours using a portable pump. Treatment repeats for every 2 weeks for 6 cycles. Patients then undergo hepatic resection. Beginning 31-56 days after surgery, patients receive an additional 6 cycles of mFOLFOX6 or FOLFIRI chemotherapy.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recurrence-free Survival (RFS) | Time to recurrence or death | From study entry until the date of recurrence or death or for a maximum of 5 years. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| RFS of Patients Event-free |  | From study entry until the date of recurrence or for a maximum of 6 months. | 
| Overall Survival |  | From study entry until the time of death or for a maximum of 5 years. | 
| The Difference in R0 and Combined R0 + R1 Resection Rates Between the Two Arms. |  | Assessed at the time of surgery | 
| Frequencies of Selected Postoperative Surgical Complications and Other Adverse Events Within 30 Days of Surgery |  | Assessed within 30 days from the time of surgery | 
| Frequencies of Adverse Events as Assessed by the NCI CTCAE v4.0 |  | From study entry through 3 months after the last treatment dose. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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stage IV colon cancer, adenocarcinoma of the colon, stage IV rectal cancer, adenocarcinoma of the rectum, liver metastases