Clinical trial NCT04617457: Chemotherapy and Surgical Resection in Patients With Hepatic Oligometastatic Adenocarcinoma of the Pancreas
Official title: Open-label, Single Arm Phase II Trial Investigating the Efficacy, Safety and Quality of Life of Neoadjuvant Chemotherapy With Liposomal Irinotecan Combined With Oxaliplatin and 5-Fluorouracil/Folinic Acid Followed by Curative Surgical Resection in Patients With Hepatic Oligometastatic Adenocarcinoma of the Pancreas
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE2
Conditions: Pancreatic Cancer
Metastasis
Surgery
Oligometastatic Disease
Keywords: pancreatic cancer
NAPOX
chemotherapy
Lead sponsor: University of Cologne
Sponsor class: OTHER
Collaborators: name: Servier
First posted: 2020-11-05
Enrollment: 150
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: TREATMENT

Brief summary: This is an interventional, open-label, non-randomised, multicentre, single-arm phase II clinical trial.

Eligible patients with hepatic oligometastatic adenocarcinoma of the pancreas will receive neoadjuvant combination chemotherapy (liposomal irinotecan, oxaliplatin, 5-fluouracil, folinic acid (NAPOX)) in cycles of 14 days. Patients with tumour response or stable disease and a resectable primary tumour after the first 4 cycles will undergo explorative laparotomy and synchronous resection of the tumour and hepatic metastases, if feasible; these patients may receive 4 more cycles of neoadjuvant chemotherapy 2-4 weeks after the explorative laparotomy if the surgeon rated the primary tumour as non-resectable during the explorative laparotomy.

Detailed description: This is an interventional, open-label, non-randomised, multicentre, single-arm phase II clinical trial.

Eligible patients with hepatic oligometastatic adenocarcinoma of the pancreas will receive neoadjuvant NAPOX chemotherapy in cycles of 14 days.

In patients with progressive disease during or after the first 4 cycles, neoadjuvant chemotherapy will be permanently discontinued. Patients with tumour response or stable disease after the first 4 cycles according to RECIST v1.1 but a non-resectable primary tumour according to the evaluation of an interdisciplinary tumour board will receive 4 more cycles of neoadjuvant chemotherapy. Patients with tumour response or stable disease and a resectable primary tumour after the first 4 cycles will undergo explorative laparotomy and synchronous resection of the tumour and hepatic metastases, if feasible; these patients may receive 4 more cycles of neoadjuvant chemotherapy 2-4 weeks after the explorative laparotomy if the surgeon rated the primary tumour as non-resectable during the explorative laparotomy.

All patients who receive a total of 8 cycles and who then have tumour response or stable disease according to RECIST v1.1 will undergo exploratory laparotomy surgery and synchronous resection of the tumour and hepatic metastases, if feasible according to the surgeon, 2-6 weeks after the last investigational medicinal product (IMP) treatment.

The primary endpoint of the clinical trial is overall survival of patients with an R0/R1 resection after neoadjuvant chemotherapy.

The IMP treatment will be discontinued if tumour progression or inacceptable toxicity occurs or other termination criteria apply.

Adjuvant treatment will not be part of the trial treatment and may be given at the investigator's discretion in accordance with the Onkopedia guideline for pancreatic cancer.

Tumour, stool and blood samples will be collected before start and during the clinical trial for translational research if the patient gives his/her consent to participating in the translational research programme.

Eligibility criteria: Inclusion Criteria:

1. Histologically confirmed diagnosis of treatment-naïve limited hepatic metastatic adenocarcinoma of the pancreas Definition of limited hepatic metastasis: 1 to 5 metastases in CT/MRI and/or contrast-enhanced ultrasound scan, which are potentially resectable or treatable by ablative procedures (Note 1: Patients also fulfil this inclusion criterion if a hepatic metastasis was partly or entirely removed as part of the diagnosis and is thus not detectable by CT/MRI and/or contrast-enhanced ultrasound scan at screening. Note 2: If more than 5 metastases are unexpectedly detected during surgery, it is not a violation of this inclusion criterion if the excess metastases had not been detectable by CT/MRI and/or contrast-enhanced ultrasound scan at screening.)
2. Measurable disease according to RECIST v1.1
3. Eastern Cooperative Oncology Group (ECOG) performance status 0-1
4. Adequate renal, hepatic and bone marrow function, defined as

   * Calculated creatinine clearance ≥60 mL/min
   * Total bilirubin ≤2 mg/dL; patients with biliary stent may be included if bilirubin level decreased to ≤2 mg/dL after stent insertion
   * alanin-aminotransferase and aspartat-aminotransferase (ALT and AST) ≤5 × upper limit of normal (ULN)
   * Absolute neutrophil count (ANC) ≥1.5 × 109/L
   * Thrombocytes ≥100 × 109/L
   * Haemoglobin ≥9 g/dL
   * activated partial thromboplastin time (aPTT) ≤1.5 × ULN and Quick value ≥70%
5. Patients ≥18 years at the time of signing the informed consent
6. Females of childbearing potential (FCBPs) must agree to use highly effective contraceptive measures (Pearl index \<1) or practice true abstinence from any heterosexual intercourse for the duration of treatment and for at least 1 month after the last IMP administration (true abstinence is acceptable when this is in line with the preferred and usual lifestyle of the patient). A woman will be considered as being of childbearing potential unless she is at least 50 years old and, moreover, has gone through menopause for at least 2 years or has been surgically sterilised.
7. Males must agree to use condoms or practice true abstinence from any heterosexual intercourse for the duration of IMP treatment and at least 6 months after the last IMP administration (true abstinence is acceptable if this is in line with the patient's preferred and usual lifestyle). Male patients must furthermore refrain from donating sperm during the clinical trial until at least 6 months after the last IMP administration.
8. Patient's written informed consent prior to any trial-specific procedure
9. Patient's legal capacity to consent to participation in the clinical trial

Exclusion Criteria:

1. Acinar cell carcinoma and/or neuroendocrine carcinoma of the pancreas
2. Symptomatic clinically significant ascites
3. Evidence of any distant metastases other than limited hepatic metastasis as defined in inclusion criterion 1
4. Any tumour-specific pretreatment of the adenocarcinoma of the pancreas (including but not limited to surgery, radiation therapy, chemotherapy or ablative procedures)
5. Any malignancies other than adenocarcinoma of the pancreas in the 5 years before the start of the clinical trial except for adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, breast cancer, prostate cancer or superficial bladder tumours (Ta, Tis and T1)
6. Hypersensitivity to any of the IMPs or any of the excipients
7. Any major surgery within 4 weeks before the first IMP administration
8. Pregnant or breast-feeding female
9. Known chronic inflammatory bowel disease, bowel obstruction or chronic diarrhoea Grade ≥2 according to NCI CTCAE version 5.0
10. Peripheral polyneuropathy Grade ≥2 according to NCI CTCAE version 5.0
11. Known interstitial lung disease (ILD) or pulmonary fibrosis
12. Radiographic evidence of severe portal hypertension
13. Liver cirrhosis ≥ Child Pugh B
14. Cholestasis or cholangitis despite adequate biliary stenting; treatment with anti-infectious agents is permitted; patient must be disease-free and without anti-infectious treatment for 7 days before the first IMP administration
15. Active infection requiring systemic therapy
16. Known HIV seropositivity
17. Active or chronic Hepatitis B or Hepatitis C infection
18. Known glucuronidation deficiency (Gilbert's syndrome) (specific screening not required)
19. Known complete dihydropyrimidine dehydrogenase (DPD) deficiency (specific screening according to the recommendations of the Summary of Product Characteristics (SmPC) in effect for 5-FU; patients with a known complete DPD deficiency must be excluded; patients with a known partial DPD deficiency may be included
20. Clinically significant cardiovascular or vascular disease or disorder ≤6 months before enrolment into the clinical trial (e.g. myocardial infarction, unstable angina pectoris, chronic heart failure New York Heart Association (NYHA) ≥ Grade 2, uncontrolled arrhythmia, cerebral infarction)
21. Pulmonary embolism, deep venous thrombosis or arterial thromboembolism ≤6 months before before the first IMP administration
22. Any other severe concomitant disease or disorder, which could influence patient's ability to participate in the clinical trial and his/her safety during the trial or interfere with interpretation of results; e.g., severe hepatic, renal, pulmonary, cardiovascular, metabolic or psychiatric disorders
23. Requirement for live vaccination within 4 weeks before the first IMP administration and during neoadjuvant chemotherapy
24. Use of strong CYP3A4 inhibitors (Strong CYP3A4 inhibitors have to be discontinued at least one week prior to start of trial treatment.); use of strong UGT1A1 inhibitors or strong CYP3A4 inducers unless there are no therapeutic alternatives
25. Treatment with nucleoside analogues such as brivudine within 4 weeks before the first IMP administration or requirement for concomitant antiviral treatment with brivudine or analogues
26. Participation in a clinical trial or experimental drug treatment within 4 weeks before the first IMP administration or within a period of 5 half-lives of the substances administered in a clinical trial or during an experimental drug treatment before the first IMP administration, depending on which period is longest, or simultaneous participation in another clinical trial while taking part in this clinical trial
27. Continuing abuse of alcohol, drugs or medical drugs
28. Patient committed to an institution by virtue of an order issued either by the judicial or the administrative authorities
29. Patients possibly dependent from the investigator including the spouse, children and close relatives of any investigator at the discretion of the investigator)

Primary outcomes:
measure: Overall survival after R0/R1 resection (OS-res)
timeFrame: max 24 months follow-up
Secondary outcomes:
measure: R0/R1 resection rate after neoadjuvant chemotherapy
timeFrame: direct after operation
measure: Overall survival (OS)
timeFrame: max 24 months follow-up
measure: Progression-free survival (PFS) after R0/R1 resection according to RECIST v1.1
timeFrame: max 24 months follow-up
measure: Type, frequency and severity of adverse events (AE) with severity (SAE) according to NCI CTCAE version 5.0
timeFrame: direct after IMP administration up to 3 months after completion of study
measure: HR-QoL according to EORTC QLQ-C30
timeFrame: 90 days after operation
measure: Quality of life (QoL) according to EORTC QLQ-PAN-26
timeFrame: 90 days after operation
measure: QoL-adjusted OS
timeFrame: max 24 months follow-up
Other outcomes:
Locations:
city: Aachen
country: Germany
facility: University Aachen
city: Berlin
country: Germany
facility: University of Berlin, Charité, Campus Benjamin-Franklin
city: Bonn
country: Germany
facility: University of Bonn
city: Dresden
country: Germany
facility: Städtisches Klinikum Dresden
city: Düsseldorf
country: Germany
facility: University of Düsseldorf
city: Freiburg
country: Germany
facility: University of Freiburg
city: Halle (Saale)
country: Germany
facility: University of Halle (Saale)
city: Heidelberg
country: Germany
facility: University of Heidelberg
city: München
country: Germany
facility: Klinikum Großhadern, LMU München
city: München
country: Germany
facility: Klinikum Rechts der Isar Technische Universität München
city: Regensburg
country: Germany
facility: University of Regensburg
Study officials:
affiliation: University of Witten/Herdecke
name: Florian Gebauer, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Cologne
name: Dirk Waldschmidt
role: STUDY_DIRECTOR
References:
citation: Gebauer F, Damanakis AI, Popp F, Quaas A, Kutting F, Lutz K, Held S, Deuss B, Goser T, Waldschmidt D, Bruns C. Study protocol of an open-label, single arm phase II trial investigating the efficacy, safety and quality of life of neoadjuvant chemotherapy with liposomal irinotecan combined with Oxaliplatin and 5-fluorouracil/Folinic acid followed by curative surgical resection in patients with hepatic Oligometastatic adenocarcinoma of the pancreas (HOLIPANC). BMC Cancer. 2021 Nov 18;21(1):1239. doi: 10.1186/s12885-021-08966-3.