A Study of NALIRIFOX in Combination With Radiation Therapy in People With Pancreatic Ductal Adenocarcinoma (PDAC)

Study Overview
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Brief Summary
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The researchers are doing this study to find out whether using the chemotherapy regimen NALIRIFOX in combination with ablative dose radiation therapy (AD-XRT) and the standard chemotherapy drug capecitabine is an effective treatment approach for people with locally advanced or borderline resectable pancreatic ductal adenocarcinoma (PDAC) before surgery. This type of treatment approach is called total neoadjuvant therapy (TNT). The researchers will also look at whether the sequence of the treatment approach (NALIRIFOX + ADXRT and capecitabine followed by surgery, when it is possible) is effective and causes few or mild side effects in participants. An important purpose of the study is to see how the study treatment (NALIRIFOX + AD-XRT and capecitabine) affects participants' quality of life. The researchers will measure quality of life by having participants fill out questionnaires

Official Title
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Total Neoadjuvant NALIRIFOX Plus Ablative Dose Radiation Therapy for Borderline Resectable and Locally Advanced Pancreatic Adenocarcinoma

Conditions
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Pancreatic Ductal Adenocarcinoma

Intervention / Treatment
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* Drug: NALIRIFOX
* Combination Product: AD-XRT and Capecitabine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subject has been informed about the nature of the study, has agreed to participate in the study, and has signed the informed consent form before participation in any study-related activities. Individuals with a history of other malignancies are eligible if they have been disease-free for at least 2 years and are deemed by the investigator to be at low risk for recurrence of that malignancy. Individuals with the following cancers are eligible if diagnosed and treated within the past 5 years: cervical cancer in situ, DCIS, stage I prostate cancer, and basal cell or squamous cell carcinoma of the skin. A multidisciplinary discussion has been undertaken/planned which can include (a) discussion with medical/surgery oncology, (b) Hepatopancreaticobiliary Disease Management Team conference presentation, (c) direct consultation, with confirmation on consensus plan for TNT strategy and potential for future surgery. This plan needs to be documented in the medical record prior to initiation of treatment. Male or nonpregnant and nonlactating female aged ≥18 years. Women of child-bearing potential (i.e., fertile, following menarche, and until becoming postmenopausal unless permanently sterile; permanent sterilization methods include hysterectomy, bilateral salpingectomy, and bilateral oophorectomy) must test negative for pregnancy at the time of screening on the basis of a urine or serum pregnancy test. Postmenopausal women are defined as those who have had an absence of menstruation for at least 2 years. If necessary, follicle-stimulating hormone results >50 IU/L at screening are confirmatory in the absence of a clear postmenopausal history. Female subjects of reproductive potential must agree to use two effective methods of birth control during the study and for 9 months after the last dose of study medication. Male subjects must agree to use condoms during the study and for 4 months after the last dose of study medication' Disease-specific inclusion criteria: Histologically or cytologically confirmed PDAC that has not been previously treated. Radiographically BR or LA PDAC in accordance with the NCCN 2.2021 definition, without evidence of distant metastases by CT. Inoperable status after surgical exploration due to presence of locally advanced, unresectable disease without metastases, in patients who have recovered from surgery, is allowed. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Hematological, biochemical, and organ function inclusion criteria: Absolute neutrophil count (ANC) ≥1500/mm^3 without the use of hemopoietic growth factors within 7 days before treatment Platelet count ≥100,000/mm^3 . International normalized ratio (INR) <1.5 unless the patient is receiving anticoagulation therapy, in which case a therapeutic INR is acceptable. Anticoagulation therapy with low-molecularweight heparin or warfarin, whether medically indicated, is permitted. Adequate renal function, as evidenced by serum/plasma creatinine level <1.6 mg/dL Exclusion Criteria: Presence of metastatic pancreatic cancer (M1 disease) Any other medical or social condition deemed by the investigator to be likely to interfere with a subject's ability to sign informed consent, cooperate, and participate in the study or who is likely to interfere with the interpretation of the results. Unwilling or unable to comply with study procedures and/or study visits. Medical co-morbidities, that preclude major abdominal surgery Histologic diagnosis other than adenocarcinoma; however, adenosquamous variants are acceptable. Receipt of chemotherapy, prior abdominal radiotherapy, and/or definitive resection for pancreatic cancer. Grade >2 neuropathy. Pregnant and/or nursing. Uncontrolled active infection, which would preclude with the exception of resolving cholangitis which in the investigator opinion would render the treatment hazardous. Known hypersensitivity to any of the components of the chemotherapeutic agents Receipt of concurrent investigational therapy or within 30 days of protocol initiation. Additional criterion for the immunoPET imaging sub-study (n=20) Previous anaphylactic reaction to human, humanized or chimeric antibody. Refusal or inability to tolerate the scanning procedure (e.g. due to claustrophobia).

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
Intervention Model: Single Group Assignment
Interventional Model Description: This study is a single-arm, phase II study.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: NALIRIFOX + AD-XRT and capecitabine<br>Patients will receive neoadjuvant chemotherapy for 4 months. Patients will undergo a CT scan at 8 weeks and 16 weeks after the start of neoadjuvant chemotherapy to assess treatment response. Patients without disease progression will then undergo AD-XRT for 15 to 25 fractions (3 to 5 weeks). | Drug: NALIRIFOX<br>* Patients will receive NALIRIFOX for a total of 4 months. NALIRIFOX will be administered on days 1 and 15 of a 4-week cycle for 4 cycles, until intolerable toxicity, or until the development of criteria for removal from the study. Liposomal irinotecan: 50 mg/m2 IV over the course of 90 minutes (±10 minutes) on days 1 and 15 of every 4-week cycle. Oxaliplatin: 60 mg/m2 IV over the course of 120 minutes (±10 minutes) on days 1 and 15 of every 4-week cycle. Leucovorin: 400 mg/m2 IV over the course of 30 minutes (±5 minutes) on days 1 and 15 of every 4-week cycle. 5-FU: 2400 mg/m2 IV over the course of 46 hours (±60 minutes) on days 1 and 15 of every 4-week cycle<br>Combination Product: AD-XRT and Capecitabine<br>* The interval between completion of induction chemotherapy and initiation of AD-XRT will be 2-6 weeks. The patient will be concurrently treated with capecitabine 825 mg/m2 BID PO Monday to Friday with radiation, as chemoradiotherapy is the standard approach at MSK.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| event-free survival (EFS) | events defined as: 1) progression [local or systemic progression, per RECIST], 2) recurrence [recurrent disease following resection], or 3) death due to any cause | up to 16 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| overall survival (OS) rate | defined as the time from enrollment to death from any cause. Patients alive are censored at the date of last contact | up to 5 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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NALIRIFOX, Ablative Dose Radiation, 23-027