Ultrasound-Guided Photodynamic Therapy With Photofrin & Gemcitabine for Patients With Locally Advanced Pancreatic Cancer

Study Overview
=================
Brief Summary
-----------------
This phase I trial studies the side effects and best dose of ultrasound-guided photodynamic therapy with porfimer sodium when given together with gemcitabine hydrochloride in treating patients with locally advanced pancreatic cancer. Photodynamic therapy uses a drug, porfimer sodium, that becomes active when it is exposed to a certain kind of light. When the drug is active, cancer cells are killed. Drugs used in chemotherapy, such as gemcitabine hydrochloride, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving photodynamic therapy together with gemcitabine hydrochloride may be effect in patients with pancreatic cancer.

Detailed Description
-----------------
PRIMARY OBJECTIVES: I. To determine the safety of increasing porfimer sodium (PHO) dose and total energy by endoscopic ultrasound (EUS)-guided photodynamic therapy (PDT) for locally advanced unresectable pancreatic cancer (PC) in humans. SECONDARY OBJECTIVES: I. Quantify computed tomography (CT) detected volume of tumor necrosis produced by EUS-PDT. II. Quantify rates of tumor size stabilization or decrease by EUS PDT and determine objective response rate per Response Evaluation Criteria in Solid Tumors (RECIST) criteria. III. Determine surgical downstaging off of abdominal vessels and resectability. IV. Determine changes in serum cancer antigen (CA) 19-9 levels with treatment. V. Evaluate progression-free and overall survival. OUTLINE: This is a dose-escalation study of EUS-PDT with porfimer sodium. Patients receive porfimer sodium intravenously (IV) on day 1 and undergo EUS-PDT on days 1, 3, 8, and 21. After completion of EUS-PDT, patients receive gemcitabine hydrochloride IV over 30 minutes on days 1, 8, and 15 of courses 1 and 2 and on day 22 of courses 3 and 5. During courses 1-5, treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity. After course 5, treatment with gemcitabine hydrochloride repeats every 2 months in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up periodically.

Official Title
-----------------
Open-label, Single-center, Non-randomized, Phase I, Dose-ranging Study of Endoscopic Ultrasound (EUS) Guided Photodynamic Therapy (PDT) With Photofrin® in Locally Advanced Pancreatic Cancer

Conditions
-----------------
Acinar Cell Adenocarcinoma of the Pancreas, Duct Cell Adenocarcinoma of the Pancreas, Stage III Pancreatic Cancer

Intervention / Treatment
-----------------
* Drug: porfimer sodium
* Procedure: endoscopic ultrasonography
* Procedure: photodynamic therapy
* Drug: gemcitabine hydrochloride


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Unresectable, locally advanced measurable (at least bidirectional) adenocarcinoma of the pancreas (regardless of site) proven by biopsy or cytology and confirmed by surgical consultation Informed consent and authorization for the release of health information signed by the patient Karnofsky performance status >= 70% Life expectancy >= 3 months Females of childbearing potential and males must use an effective method of contraception Exclusion Criteria: Metastatic (stage IV) disease (including involvement of the colon, adrenals, or kidney, or radiographic evidence of peritoneal seeding or pulmonary metastases) Previous chemotherapy, radiotherapy of other treatment for PC Gastric or duodenal wall invasion by the primary PC as assessed by CT or MRI and EUS staging Gastric or duodenal ulcer (at least 10 mm in size) within 10 mm of expected endoscopy puncture site(s) for PDT Esophageal or gastric varices Cystic component >= 25% the total volume of the tumor Ascites detected by CT, ultrasound (US) or MRI; (trace ascites will not be an exclusion) Bulky celiac adenopathy (i.e., >= 2.5 cm in diameter) Diagnosis of islet cell tumor, lymphoma, metastatic lesion, acinar cell (or other atypical pathologic malignancy) History of other malignancy in the past 2 years except carcinoma in situ of the cervix or bladder, non-melanomatous skin cancer or localized/early stage prostate cancer Unable to receive or previously intolerant of moderate and/or deep sedation Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) >= 3 x upper limit of normal (ULN) Total bilirubin >= 3 x ULN Alkaline phosphatase >= 3 x ULN International normalized ratio (INR) >= 1.5 Partial thromboplastin time (PTT) ratio >= 1.5 Serum creatinine >= 2.0 mg/dL Hematocrit =< 28% or hemoglobin =< 9 g/dL, but may have red blood cell (RBC) transfusion Platelet count =< 100,000/microliter (uL) Absolute neutrophil count (ANC) =< 1500/uL Clinically significant pancreatitis within 12 weeks of treatment with protocol therapy Contraindication to EUS-guided needle puncture into the pancreas History of coagulopathy or known thrombophilias Use of anticoagulants that cannot be discontinued both 5 days before and 5 days after EUS Clinical evidence of active infection of any type, including hepatitis B or C virus Pregnant or lactating women Experimental medications within the last 4 weeks prior to day 1 Any surgery (including diagnostic laparoscopy and/or biliary +/- duodenal palliative bypass for inoperable PC) within the 2 weeks prior to day 1 of study protocol Chronic systemic corticosteroid use at superphysiologic doses (>= 10 mg prednisone per day or equivalent) Inability to avoid exposure of skin or eyes to direct sunlight or bright indoor light for at least 30 days Porphyria Inability to obtain venous access in the antecubital region to administer PHO or sedation for endoscopy procedures Significant concurrent medical or psychiatric illness which, in the opinion of the principal investigator would interfere with trial participation

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: porfimer sodium, EUS-PDT, gemcitabine<br>Patients receive porfimer sodium IV over 3-5 minutes on day 1 and undergo endoscopic ultrasonography-photodynamic therapy (EUS-PDT) on days 1, 3, 8, and 21. After completion of EUS-PDT, patients receive gemcitabine hydrochloride IV over 30 minutes on days 1, 8, and 15 of courses 1 and 2 and on day 22 of courses 3 and 5. During courses 1-5, treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity. After course 5, treatment with gemcitabine hydrochloride repeats every 2 months in the absence of disease progression or unacceptable toxicity. | Drug: porfimer sodium<br>* Given IV<br>* Other names: Porfimer;Procedure: endoscopic ultrasonography<br>* Undergo EUS-PDT<br>* Other names: EUS;Procedure: photodynamic therapy<br>* Undergo EUS-PDT<br>* Other names: therapy, photodynamic;Drug: gemcitabine hydrochloride<br>* Given IV<br>* Other names: LY-188011;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluate the number of subjects with adverse events which occur when up to 3 sites within the pancreas are treated with PDT using a total dose of 50 or 100 J per site | Adverse events will be graded using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) v4.0 which uses a scale of 1 (mild) to 5 (caused death). | Up to 4 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| CT- or MRI-detected volume of tumor necrosis | Will be compared using paired t-tests or Wilcoxon rank sum tests as appropriate and changes will be plotted by maximal total energy of treatment to explore for dose-response effects. | Week 2 | 
| Rates of tumor size stabilization or decease by EUS-PDT | Will be compared using paired t-tests or Wilcoxon rank sum tests as appropriate and changes will be plotted by maximal total energy of treatment to explore for dose-response effects. | Up to 4 years | 
| Objective response rate per RECIST |  | Up to 4 years | 
| Surgical downstaging off of abdominal vessels or change in tumor unresectability |  | Up to 4 years | 
| Change in CA 19-9 levels | Will be compared using paired t-tests or Wilcoxon rank sum tests as appropriate and changes will be plotted by maximal total energy of treatment to explore for dose-response effects. | Baseline to up to 4 years | 
| Progression-free survival | A Kaplan-Meier plot will be produced. | From the date of initial treatment to the earliest date of disease progression, resection of measurable tumor or death for patients who fail; and to the date of disease evaluation for patients who remain at risk for failure, assessed up to 4 years | 
| Overall survival | A Kaplan-Meier plot will be produced. | From the day of first treatment to the earlier of death (from any cause) and the last date of patient contact, assessed up to 4 years |