Perioperative Therapy for Resectable and Borderline-Resectable Pancreatic Adenocarcinoma With Molecular Correlates

Study Overview
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Brief Summary
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The objective of this study is to estimate the R0 resection rate in patients with Resectable Pancreatic Ductal Adenocarcinoma (R-PDAC) as well as those with Resectable Pancreatic Ductal Adenocarcinoma (BR-PDAC) independently in response to neoadjuvant sequential therapy of combination nab-paclitaxel and gemcitabine followed by stereotactic body radiotherapy (SBRT).

Detailed Description
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Patients in both cohorts will receive a total of 3 cycles of neoadjuvant combination chemotherapy of nab-paclitaxel and gemcitabine, followed by re-staging CT scan, if re-staging CT does not show evidence of metastatic disease. Patients will receive SBRT and definitive surgical resection. Subsequently, patients will receive 3 cycles of adjuvant combination chemotherapy of nab-paclitaxel and gemcitabine. Each cycle of combination chemotherapy will be a total of 4 weeks. Patients will be evaluated for response at completion of the 3 cycles of neoadjuvant combination chemotherapy with CT scans of chest, abdomen and pelvis. Patients will undergo surveillance CT scan at 3-month intervals until evidence of disease progression.

Official Title
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Perioperative Therapy for Resectable Pancreatic Adenocarcinoma and Borderline Resectable Pancreatic Adenocarcinoma With Molecular Correlates

Conditions
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Pancreatic Cancer, Pancreatic Adenocarcinoma, Pancreas Ductal Adenocarcinoma

Intervention / Treatment
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* Drug: Nab-paclitaxel and gemcitabine for R-PDAC Patients
* Drug: Nab-paclitaxel and gemcitabine for BR-PDAC Patients


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically confirmed resectable or borderline resectable pancreatic adenocarcinoma. No evidence of distant metastasis representing stage IV metastatic disease. R-PDAC: No evidence of distant metastasis and tumor mass showing no extension to superior mesenteric artery (SMA) and hepatic artery. There must be a clearly defined fat plane between SMA and celiac axis. Patent superior mesenteric vein (SMV/portal vein (PV) with no distortion of venous architecture. BR-PDAC: defined as localized PDAC with 1 or more of the following features: a) an interface between the primary tumor and superior mesenteric vein (SMV)-portal vein (PV) measuring 180o or greater of the circumference of the vein wall, and/or b) 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 and/or c) 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 arterial reconstruction and/or d) an interface between the tumor and SMA or celiac trunk measuring less than 180o of the circumference of the artery wall. Age > 18 years old Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 Patients must have adequate bone marrow function: Platelets >100,000 cells/mm3 Hemoglobin > 9.0 g/dL Absolute Neutrophil Count > 1,500 cells/mm3 Patients must have adequate liver function: aspartate aminotransferase (AST) and Alanine Aminotransferase (ALT) < 2.5 X upper limit of normal Alkaline phosphatase < 2.5 X upper limit of normal, unless bone metastasis is present in the absence of liver metastasis Total bilirubin < 1.5 mg/dL Patients must have adequate renal function: creatinine <1.5 mg/dL is recommended; however, institutional norms are acceptable. Creatinine within institutional limits of normal or creatinine clearance (CrCl) > 50 mL/min calculated using the Cockcroft-Gault equation. Women of childbearing potential and sexually active males must use an effective contraception method during treatment and for three months after completing treatment. Negative serum or urine β-human chorionic gonadotropin (hCG) pregnancy test at screening for patients of childbearing potential. Patients must have < Grade 2 pre-existing peripheral neuropathy (per CTCAE 4.03). Ability to understand and willingness to sign a written informed consent. Exclusion Criteria: Patients with locally advanced surgically unresectable PDAC. Patients with evidence of distant metastatic PDAC. Prior chemotherapy or radiation therapy of any kind for treatment of pancreas adenocarcinoma. Prior major surgery within 4 weeks of starting study drug administration. Patient unable or not willing to perform all study related biopsies and blood draws for exploratory endpoints will not be enrolled on study as all study related procedures are mandatory. Concomitant treatment with full dose warfarin (coumadin) is NOT allowed. However, treatment with low molecular weight heparin (LMWH) (such as enoxaparin or dalteparin) or rivaroxaban is allowed. Patients on full dose warfarin (coumadin) must be transitioned to either LMWH or rivaroxaban prior to administration of any study related drugs. Recent or ongoing clinically significant gastrointestinal disorder (e.g., malabsorption, bleeding, inflammation, emesis, diarrhea >grade 1). Patients with clinically significant cardiac disease (New York Heart Association Classification III or IV and cardiac arrhythmias not well controlled with medication), or myocardial infarction within the previous six months. Serious, uncontrolled, concurrent infection(s) requiring antibiotics. Pregnant or breastfeeding women: positive pregnancy test within 7 days of starting treatment. Treatment for other carcinomas within the last five years, except cured non-melanoma skin and treated in-situ cervical cancer. Participation in any investigational drug study within 4 weeks preceding the start of study treatment. Patients with external biliary drains.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 101 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: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Nab-paclitaxel/Gemcitabine for R-PDAC<br>Nab-paclitaxel and gemcitabine, for R-PDAC patients enrolled in this trial, will be given in combination as neoadjuvant combination chemotherapy, followed by SBRT. This is will be followed up by surgical resection and an additional combination chemotherapy of nab-paclitaxel and gemcitabine as adjuvant chemotherapy. | Drug: Nab-paclitaxel and gemcitabine for R-PDAC Patients<br>* Nab-paclitaxel and gemcitabine, for R-PDAC patients, will be given in combination as neoadjuvant and adjuvant chemotherapy. Nab-paclitaxel will be administered by IV infusion at a dose of 125 mg/m2 over 30 minutes on Days 1, 8, and 15 of every 28-day cycle. Gemcitabine will be administered by IV infusion, immediately after the administration of nab-paclitaxel, at a dose of 1000 mg/m2 over 30 minutes on Days 1, 8 and 15 of every 28-day cycle.<br>* Other names: difluorodeoxycytidine;|
| Experimental: Nab-paclitaxel/Gemcitabine for BR-PDAC<br>Nab-paclitaxel and gemcitabine, for BR-PDAC patients enrolled in this trial, will be given in combination as neoadjuvant combination chemotherapy, followed by SBRT. This is will be followed up by surgical resection and an additional combination chemotherapy of nab-paclitaxel and gemcitabine as adjuvant chemotherapy. | Drug: Nab-paclitaxel and gemcitabine for BR-PDAC Patients<br>* Nab-paclitaxel and gemcitabine, for BR-PDAC patients, will be given in combination as neoadjuvant and adjuvant chemotherapy. Nab-paclitaxel will be administered by IV infusion at a dose of 125 mg/m2 over 30 minutes on Days 1, 8, and 15 of every 28-day cycle. Gemcitabine will be administered by IV infusion, immediately after the administration of nab-paclitaxel, at a dose of 1000 mg/m2 over 30 minutes on Days 1, 8 and 15 of every 28-day cycle.<br>* Other names: difluorodeoxycytidine;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| R0 resection rates in each cohort as measured by macroscopically complete tumor removal with negative microscopic surgical margins | R0 resection rates will be measured in patients with resectable PDAC and with patients with borderline-resectable PDAC, independently in response to neoadjuvant sequential therapy of combination of nab-paclitaxel and gemcitabine and SBRT, as perioperative therapy. R0 resection is determined by macroscopically complete tumor removal with negative microscopic surgical margins in the bile duct, pancreatic parenchyma, and superior mesenteric artery (SMA). | surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants with treatment related adverse events as assessed by CTCAE v.4.03 |  | 24 months | 
| Number of participants with progression-free occurence | The progression-free survival (PFS) will be assessed for all participants using Response Evaluation Criteria in Solid Tumors (RECIST v1.1). | Up to 5 years | 
| Number of participants with disease recurrence | Disease-free survival will be assessed for all participants using Response Evaluation Criteria in Solid Tumors (RECIST v1.1). | Up to 5 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stereotactic Body Radiation Therapy, Perioperative Therapy, Resectable Pancreas Ductal Adenocarcinoma, Borderline Resectable Pancreas Ductal Adenocarcinoma, Nab-paclitaxel, Abraxane, Gemcitabine, Neoadjuvant Therapy, Adjuvant Therapy