Conditions: Stomach Neoplasms Esophageal Neoplasms
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 67
Healthy volunteers: no

Brief summary:
This phase II trial studies how well combination chemotherapy works in treating patients with advanced stomach, gastroesophageal, or esophageal cancer. Drugs used in chemotherapy, such as irinotecan hydrochloride, oxaliplatin, leucovorin calcium, and fluorouracil, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) may kill more tumor cells.

Detailed description:

Arms:
arm 1: Irinotecan 180 mg/m2 IV on Days 1 \& 15.

Oxaliplatin 85 mg/m2 IV on Days 1 \& 15.

Leucovorin 400 mg/m2 IV on Days 1 \& 15.

Fluorouracil 400 mg/m2 bolus and 2400 mg/m2 CIVI over 46 hours beginning on Day 1 and Day 15. arm 2: Trastuzumab 8 mg/kg on Cycle 1 Day 1 then 4 mg/kg on Day 15 and Day 1 of all future cycles.

Irinotecan 180 mg/m2 IV on Days 1 \& 15.

Oxaliplatin 85 mg/m2 IV on Days 1 \& 15.

Leucovorin 400 mg/m2 IV on Days 1 \& 15.

Fluorouracil 400 mg/m2 bolus and 2400 mg/m2 CIVI over 46 hours beginning on Day 1 and Day 15.

Interventions: intervention 1: Irinotecan intervention 2: Trastuzumab intervention 3: Oxaliplatin intervention 4: Leucovorin intervention 5: Fluorouracil
Intervention descriptions: intervention 1: None intervention 2: None intervention 3: None intervention 4: None intervention 5: None

Protocol document:
Prot_SAP_000.pdf: 
Protocol Version: Amendment 12; 12/21/17 
 
Page 1 of 52 
 
 
Phase II study of FOLFIRINOX chemotherapy for treatment of advanced gastric, gastro-
esophageal junction, and esophageal tumors 
 
Washington University School of Medicine, Division of Oncology 
660 South Euclid Avenue, Campus Box 8056 
St. Louis, MO  63110 
 
Protocol#:  201309035 
Version Date: 12/21/2017 
 
Principal Investigator: 
 
Haeseong Park, M.D. 
Phone:  (314) 454-5102 
E-mail:  haeseongpark@wustl.edu 
 
Sub-Investigators 
 
 
 
Affiliation 
Seth Crosby, M.D. 
 
 
 
GPS@WU 
Kenneth Krajewski, M.D. 
 
 
Medical Oncology 
Christopher Maher, Ph.D. 
 
 
Genome Institute at Washington University 
Joel Picus, M.D. 
 
 
 
Medical Oncology 
Robert Pufahl, Ph.D.  
 
 
Medical Oncology 
Caron Rigden, M.D.  
 
 
Medical Oncology 
Rama Suresh, M.D. 
 
 
 
Medical Oncology 
Benjamin Tan, M.D.  
 
 
Medical Oncology 
Andrea Wang-Gillam, M.D., Ph.D.  
Medical Oncology 
Kathryn Trinkaus, Ph.D. 
 
 
Biostatistics 
 
Study Drug(s): 
 
Oxaliplatin 
Leucovorin 
5-FU 
Irinotecan 
 
IND #: 
119551 EXEMPT 
130274 ACTIVE (as of 04/11/16) 
Clinical Trials.gov #: 
NCT01928290 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to 
obtain informed consent, may not be disclosed to another party unless law or regulations require such 
disclosure.  Persons to whom the information is disclosed must be informed that the information is 
confidential and may not be further disclosed by them 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
Page 2 of 52 
 
Phase II study of FOLFIRINOX chemotherapy for treatment of advanced gastric, gastro-
esophageal junction, and esophageal tumors 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
08/20/2013 
Amendment #1 Version 
 
 
 
 
 
 
02/17/2014 
Amendment #2 Version 
 
 
 
 
 
 
06/27/2014 
Amendment #3 Version 
 
 
 
 
 
 
08/01/2014 
Amendment #4 Version 
 
 
 
 
 
 
10/14/2014 
Amendment #5 Version 
 
 
 
 
 
 
02/11/2015 
Amendment #6 Version 
 
 
 
 
 
 
05/18/2015 
Amendment #7 Version 
 
 
 
 
 
 
11/10/2015 
Amendment #8 Version 
 
 
 
 
 
 
02/12/2016 
Amendment #9 Version 
 
 
 
 
 
 
04/18/2016 
Amendment #10 Version 
 
 
 
 
 
 
03/02/2017 
Amendment #11 Version 
 
 
 
 
 
 
08/02/2017 
Amendment #12 Version 
 
 
 
 
 
 
12/21/2017 


Protocol Version: Amendment 12; 12/21/17 
 
Page 3 of 52 
SCHEMA 
 
 
 
Routine HER2 testing 
HER2-positive patients 
(expected to be approximately 
20% or patients tested) 
HER2-negative patients 
(41 evaluable patients) 
FOLFIRINOX + trastuzumab 
for up to 4 cycles following 
maximal disease response 
FOLFIRINOX for up to 
4 cycles following 
maximal disease 
response 
PET/CT or CT 
every 8 weeks for 
response 
AEs assessed during 
treatment and for 30 
days post-treatment 
Biopsy-proven and inoperable 
locally advanced, recurrent, or 
metastatic cancer of the esophagus, 
stomach, or gastro-esophageal 
junction 


Protocol Version: Amendment 12; 12/21/17 
 
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Glossary of Abbreviations 
 
ADCC 
Antibody dependent cellular cytotoxicity 
ADL 
Activities of daily living 
AE 
Adverse event 
ALT (SGPT) 
Alanine transaminase (serum glutamate pyruvic transaminase) 
ANC 
Absolute neutrophil count 
AST (SGOT) 
Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
AUC 
Area under the curve 
B-HCG 
Beta human chorionic gonadotropin  
CBC 
Complete blood count 
CMP 
Comprehensive metabolic panel 
CNS 
Central nervous system 
CR 
Complete response 
CRF 
Case report form 
CSF 
Cerebrospinal fluid 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
DNA 
deoxyribonucleic acid 
DSM 
Data and Safety Monitoring  
ECOG 
Eastern Cooperative Oncology Group 
EGFR 
Epidermal growth factor receptor 
FDA 
Food and Drug Administration 
G-CSF 
Granulocyte colony stimulating factor, filgrastim (Neupogen) 
GEJ 
Gastroesophageal junction 
GI 
Gastrointestinal 
GPS 
Genomic and Pathology Services 
HIV 
Human Immunodeficiency Virus 
HR 
Hazard ratio 
HRPO 
Human Research Protection Office (IRB) 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IULN 
Institutional upper limit of normal 
IV 
Intravenous 
LFT 
Liver function test 
LVEF 
Left ventricular ejection fraction 
MRI 
Magnetic resonance imaging 
MS 
Median survival 
MUGA 
Multiple uptake gated acquisition 
NCCN 
National Cancer Center Network 
NCI 
National Cancer Institute 


Protocol Version: Amendment 12; 12/21/17 
 
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NIH 
National Institutes of Health 
OHRP 
Office of Human Research Protections  
ORR 
Overall response rate 
OS 
Overall survival 
PD 
Progressive disease 
PET 
Positron emission tomography 
PFS 
Progression-free survival 
PI 
Principal investigator 
PO 
Per os (by mouth) 
PR 
Partial response 
QASMC 
Quality Assurance and Safety Monitoring Committee 
RECIST 
Response Evaluation Criteria in Solid Tumors (Committee) 
RR 
Response rate 
SAE 
Serious adverse event 
SCC 
Siteman Cancer Center 
SD 
Stable disease 
SEER 
Surveillance Epidemiology and End Results 
TTP 
Time to progression 
UPN 
Unique patient number 
US 
Ultrasound 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
Page 6 of 52 
Table of Contents 
 
SCHEMA ........................................................................................................................................ 3 
1.0 
BACKGROUND AND RATIONALE ................................................................................ 8 
1.1 
Esophageal and Gastric Cancers ...................................................................................... 8 
1.2 
Combination Regimens for the Treatment of Esophagogastric Cancers ......................... 8 
1.3 
HER2 Expression ............................................................................................................. 9 
1.4 
Trastuzumab (Herceptin).................................................................................................. 9 
1.5 
Study Rationale .............................................................................................................. 10 
1.6 
Correlative Studies Background..................................................................................... 10 
2.0 
OBJECTIVES .................................................................................................................... 13 
2.1 
Primary Objective .......................................................................................................... 13 
2.2 
Secondary Objectives ..................................................................................................... 13 
3.0 
PATIENT SELECTION .................................................................................................... 13 
3.1 
Inclusion Criteria ............................................................................................................ 13 
3.2 
Exclusion Criteria ........................................................................................................... 14 
3.3 
Inclusion of Women and Minorities............................................................................... 15 
4.0 
REGISTRATION PROCEDURES ................................................................................... 15 
4.1 
Confirmation of Patient Eligibility ................................................................................. 16 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database ........................... 16 
4.3 
Assignment of UPN ....................................................................................................... 16 
5.0 
TREATMENT PLAN ........................................................................................................ 16 
5.1 
Assessment of HER2 Status ........................................................................................... 16 
5.2 
Premedication Administration........................................................................................ 16 
5.3 
Agent Administration ..................................................................................................... 16 
5.4 
General Concomitant Medication and Supportive Care Guidelines .............................. 17 
5.5 
Women of Childbearing Potential .................................................................................. 17 
5.6 
Duration of Therapy ....................................................................................................... 18 
5.7 
Duration of Follow-up .................................................................................................... 19 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS .................................................................... 19 
6.1 
Dose Reductions ............................................................................................................. 19 
6.2 
Hematologic Toxicities .................................................................................................. 19 
6.3 
Gastrointestinal Toxicities.............................................................................................. 21 
6.4 
Neurotoxicity .................................................................................................................. 22 
6.5 
Dose Modification for Obese Patients ........................................................................... 22 
6.6 
Dose Modifications for Non-Hematological Toxicities ................................................. 22 
6.7 
Management of Trastuzumab Side Effects .................................................................... 22 
7.0 
REGULATORY AND REPORTING REQUIREMENTS ............................................... 23 
7.1 
Definitions ...................................................................................................................... 23 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington University
 
25 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee (QASMC) at 
Washington University .............................................................................................................. 26 
7.4 
Reporting to the FDA ..................................................................................................... 26 
7.5 
Timeframe for Reporting Required Events .................................................................... 26 
8.0 
PHARMACEUTICAL INFORMATION .......................................................................... 27 


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8.1 
Irinotecan (Camptosar®) ................................................................................................ 27 
8.2 
Leucovorin ..................................................................................................................... 29 
8.3 
Oxaliplatin (Eloxatin®) .................................................................................................. 31 
8.4 
5FU (5-fluorouracil) ....................................................................................................... 33 
8.5 
Trastuzumab (Herceptin)................................................................................................ 34 
9.0 
CORRELATIVE STUDIES .............................................................................................. 36 
9.1 
Archived Tumor Tissue for Analysis by GPS@WUSTL .............................................. 36 
9.2 
Tumor Tissue Correlates – OPTIONAL ........................................................................ 37 
9.3 
Peripheral Blood Correlates -- OPTIONAL................................................................... 37 
10.0 STUDY CALENDAR ....................................................................................................... 39 
11.0 DATA SUBMISSION SCHEDULE ................................................................................. 40 
12.0 MEASUREMENT OF EFFECT........................................................................................ 40 
12.1 Antitumor Effect – Solid Tumors................................................................................... 40 
12.2 Disease Parameters ......................................................................................................... 40 
12.3 Methods for Evaluation of Measurable Disease ............................................................ 41 
12.4 Response Criteria ........................................................................................................... 44 
13.0 DATA AND SAFETY MONITORING ............................................................................ 46 
14.0 STATISTICAL CONSIDERATIONS............................................................................... 47 
15.0 REFERENCES .................................................................................................................. 49 
APPENDIX 1: ECOG Performance Status Scale ......................................................................... 52 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Esophageal and Gastric Cancers 
 
Esophageal and gastro-esophageal tumors have been on the rise since 1975 per the SEER 
database while gastric cancers have remained stable [1].  The American Cancer Society 
estimates 38,500 new cases of esophageal and gastric cancer are diagnosed annually in 
the United States [2].  Esophageal cancer has an approximate 86% fatality rate and the 
gastric cancer fatality rate is approximately 48% [2].  Esophageal cancer presents as 
incurable locally advanced or metastatic disease in approximately 60% of cases.  In the 
US during 2012, this corresponds to an estimated 17,460 new esophageal cancer cases 
with a staggering 15,070 expected deaths [3].  Poor long-term survival rates are also seen 
in advanced gastric cancer; in the United States, approximately 21,320 patients are 
diagnosed annually, while 10,540 are expected to die from the disease [3].  Most 
symptomatic gastric cancer patients in the United States already have incurable disease at 
time of diagnosis.  The high mortality rate from these cancers reflects aggressive biology, 
advanced stage at diagnosis, and lack of effective multimodality therapies.  As the goal of 
therapy is palliation in the majority of cases, the current environment presents many 
opportunities for improvement.   
 
1.2 
Combination Regimens for the Treatment of Esophagogastric Cancers 
 
Standard first-line chemotherapy for metastatic or locally advanced gastroesophageal 
cancers usually involves a two- or three-drug regimen, typically including a combination 
of a fluoropyrimidine (5-FU or capecitabine) and a platinum agent (such as cisplatin or 
oxaliplatin) [4].  Per NCCN, two-drug cytotoxic regimens are preferred because of lower 
toxicity.  Although three-drug cytotoxic regimens are acknowledged for medically fit 
patients with a good performance status, it also requires access to frequent toxicity 
evaluations.  Preferred regimens with category 1 data are DCF (docetaxel, cisplatin, and 
fluorouracil), ECF (epirubicin, cisplatin and fluorouracil), and lastly the combination of a 
fluoropyridine (fluorouracil or capecitabine) and cisplatin [5, 6].   
 
Based on the 2008 study for Cunningham et al, capecitabine and oxaliplatin for advanced 
esophagogastric cancer is as effective as fluorouracil and cisplatin when compared in this 
randomized trial [7].  Therefore, combining a fluoropyrimidine with either cisplatin or 
oxaliplatin are accepted options.  A randomized phase III trial of irinotecan/5-fluorouracil 
showed borderline noninferiority to cisplatin/5-fluorouracil in naïve patients with 
advanced adenocarcinoma of the stomach or esophagogastric junction and a second-line 
study evaluating irinotecan demonstrated a survival benefit for patients receiving this 
medication [8] [9]. Taken together, the efficacy of oxaliplatin and irinotecan has been 
demonstrated in these cancers and are included in the NCCN guidelines. 
 
The combination of oxaliplatin, irinotecan, fluorouracil, and leucovorin (FOLFIRINOX) 
has become more commonly used in gastrointestinal malignancies in recent years.  In 
2011, the New England Journal of Medicine published a study of FOLFIRINOX versus 


Protocol Version: Amendment 12; 12/21/17 
 
Page 9 of 52 
gemcitabine for metastatic pancreatic cancer [10].  The study randomized 342 patients to 
receive either FOLFIRINOX or single agent gemcitabine (standard of care).  The median 
overall survival was 11.1 months in the FOLFIRINOX group compared to 6.8 months in 
the gemcitabine group (HR death, 0.57; 95% confidence 0.45-0.73; P<0.001). Also in 
this study, the objective response rate was 31.6% in the FOLFIRINOX group versus 
9.4% in the gemcitabine group (P<0.001). More adverse events were noted in the 
FOLFIRINOX group, specifically 5.4% percent with febrile neutropenia.  
 
Similarly, a phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and 
irinotecan (FOLFOXIRI) was used as first line treatment for metastatic colorectal cancer 
[11].  The study randomized 244 patients to receive either FOLFOXIRI or FOLFIRI.  
The study noted an increase in grade 3 to 4 neutropenia, but not a statistically significant 
increase in febrile neutropenia with FOLFOXIRI.  Both the progression-free survival 
(PFS) and overall survival (OS) were both significantly improved in the FOLFOXIRI 
arm (median PFS, 6.9 v 9.8 months, hazard ratio [HR], 0.63; P = 0.0006; median OS, 
16.7 v 22.6 months; HR, 0.70; P=0.032). Responses, as assessed by investigators were 
41% vs. 66% for FOLFIRI and FOLFOXIRI respectively (P = .0002). Response 
confirmed by an external panel was 34% versus 60% (P < .0001).       
 
We hypothesize that FOLFIRINOX will result in a similar increase of overall response 
rate and survival in patients with gastroesophageal cancers. 
 
1.3 
HER2 Expression  
 
The HER-2 receptor is a member of the epidermal growth receptor (EGFR) family of 
receptors which participate in activation of pathways controlling epithelial cell growth 
and differentiation [12]. Amplification of HER2 or overexpression of its protein product 
has been widely used as a target for therapy in breast cancer.  HER-2 positivity has been 
identified in 23.7% of gastric cancers, providing the opportunity to target HER2 
positivity in advanced disease (4).   
 
1.4 
Trastuzumab (Herceptin) 
 
Trastuzumab is a recombinant DNA-derived humanized monoclonal antibody against 
HER2 and is approved by FDA for treatment of metastatic and early stage breast cancer 
that overexpresses HER2.  It has also been approved by FDA for use with chemotherapy 
in the treatment of gastric and gastroesophageal tumors that are HER2-positive. 
 
A recent international phase 3 study trastuzumab for Gastric Cancer (ToGA) compared 
capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six 
cycles compared to chemotherapy in combination with trastuzumab as first line treatment 
of HER2-positive advanced gastric or gastro-esophageal junction cancer [13].  The 
median survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus 
chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy 
alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046) [13].  This pivotal study led to the 
approval of trastuzumab for the treatment of HER-2 expressing gastroesophageal cancers. 


Protocol Version: Amendment 12; 12/21/17 
 
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1.5 
Study Rationale 
 
FOLFIRINOX has been shown to provide marked increases in response rates and 
survival in patients with cancers of the lower gastrointestinal tract such as colorectal 
cancer.  We hypothesize that this regimen will be tolerated and that similar effects will be 
seen in patients with cancers of the upper gastrointestinal tract.  This study proposes a 
phase II clinical trial FOLFIRINOX chemotherapy for treatment of advanced gastric, 
gastro-esophageal junction, and esophageal tumors.  Because of the statistically 
significant improvement in outcomes identified in the ToGA trial, trastuzumab will be 
added to the FOLFIRINOX regimen for patients who are HER2-positive.  To our 
knowledge, that regimen has not been previously administered to patients, so safety and 
tolerability will be monitored and reported.  Disease response parameters from the 
HER2-positive patients will be collected for future analysis. 
 
1.6 
Correlative Studies Background 
 
It is readily accepted that mutations acquired during cancer initiation and progression can 
result in altered proteins that contribute to transformation.[14-17] Alternatively, many 
passenger mutations are acquired as byproducts of the genomic instability accompanying 
cellular transformation. In either scenario, these genomic alterations may result in the 
expression of mutant proteins that are perceived as foreign proteins by the immune 
system and are more exploitable targets for immune-mediated tumor control.[18, 19] 
Abnormal proteins that arise as a consequence of somatic mutations, termed neoantigens, 
when recognized by T cells can lead to an immune-mediated anti-tumor response in 
patients.[20, 21] It has been clinically demonstrated that checkpoint blockade 
immunotherapy facilitates the expansion of preexisting T cells specific for tumor 
neoantigens and that mutation-associated neoantigen recognition is an important 
component of the endogenous antitumor immune response.[22] Therefore the likelihood 
of generating tumor neoantigens appears to be roughly proportional to the number of 
somatic mutations present within a given tumor. Our working hypothesis is that the 
response rates to checkpoint inhibitors may be enhanced by elevating the expression of 
tumor neoantigens through effective chemotherapy. 
 
1.6.1 Evidence supporting that chemotherapy enhances immune response 
 
Standard cancer chemotherapy can promote tumor immunity by inducing 
immunogenic cell death as part of its intended therapeutic effect and by disrupting 
tumoral immune evasion. Chemotherapy drugs at their standard doses and 
schedule can mediate their antitumor effects by inducing immunogenic cell death 
involving the concomitant release of tumor antigens and the emission of danger-
associated molecular patterns (DAMP) in the tumor microenvironment.[23] 
However, 
multiple 
factors 
including 
tumor 
biology, 
the 
particular 
chemotherapeutic agent and dose/schedule, may influence whether tumor cell 
death is immunogenic, and which cell death pathway is activated. Other forms of 
immunogenic chemotherapy-induced cell death include autophagy.[24, 25] It has 


Protocol Version: Amendment 12; 12/21/17 
 
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been suggested that the generation of endogenous immune mediated anti-tumor 
responses 
may 
be 
required 
for 
durable 
success 
of 
conventional 
chemotherapies.[26] This hypothesis has led to considerable interest in combining 
immunotherapy with conventional chemotherapy, even though the optimal 
methods of combining these treatment strategies are incompletely understood. 
 
Immunotherapy concepts that favor combinations with chemotherapy to augment 
efficacy include chemotherapy induced enhancement of tumor antigen 
presentation by upregulating the expression of tumor antigens themselves, or of 
the MHC class I molecules to which the antigens bind. Alternatively, 
chemotherapy may upregulate costimulatory molecules (e.g. B7-1) or 
downregulate coinhibitory molecules (PD-L1/B7-H1 or B7-H4) expressed on the 
tumor cell surface, enhancing the strength of effector T-cell activity. 
Chemotherapy may also render tumor cells more sensitive to T cell–mediated 
lysis through fas-, perforin-, and Granzyme B–dependent mechanisms.[27, 28] 
Numerous reports confirm the expected synergy between conventional 
chemotherapy and immune therapy, and as above, the synergy is mediated by 
diverse mechanisms including preferential depletion of regulatory T reg cells[29-
31], liberation of homeostatic or inflammatory cytokines[32, 33] and enhanced 
immunogenicity of chemotherapy treated tumors.[25, 34] In the context of 
vaccines targeting self-antigens, chemotherapy given prior to or during[35] 
vaccination can yield synergy and enhanced survival.[31, 36] In a phase III trial, 
ipilimumab, a fully human monoclonal antibody against CTLA-4, was used in 
combination with chemotherapy in patients with metastatic melanoma.  Patients 
receiving ipilimumab in combination with dacarbazine had significantly improved 
overall survival compared with patients receiving dacarbazine alone.[37] 
Additionally, a phase II trial in patients with advanced staged lung cancers 
combined ipilimumab with standard chemotherapy. Treatment timing in this study 
showed that a ‘phased regimen’ in which immunotherapy began after 
chemotherapy resulted in substantially improved progression-free survival (PFS) 
compared with chemotherapy alone.[38, 39] This study also showed that the 
clinical effects of administering immunotherapy in combination with 
chemotherapy may be dependent on the sequencing of treatment. 
 
Conversely, however, other clinical trials have shown that certain standard 
chemotherapies may also inhibit immunotherapy. One concern has been that the 
chemotherapy will preferentially kill rapidly proliferating cells - in this case the T 
cell response required for immune-mediated anti-tumor activity. In clinical trials 
of pancreatic and prostate cancers, specific vaccine/chemotherapy sequencing 
strategies may have impaired vaccine-induced immunity.[40, 41] Thus, the 
optimal integration of immunotherapies with standard cancer therapies to 
minimize antagonistic interactions and engage potential synergies is therefore of 
great importance. One strategy is to give immunotherapy in the setting of minimal 
residual disease, after the tumor mass has been optimally reduced with surgery or 
effective systemic chemotherapy. This sequencing strategy minimizes the 
negative impact of tumor bulk (e.g. via tumor-expressed immunosuppressive 


Protocol Version: Amendment 12; 12/21/17 
 
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factors) on the potency of the antitumor immune response. It also allows 
chemotherapy to modulate the immune phenotype of any residual tumor cells. 
Several preclinical and clinical studies have shown improved responses to 
immunotherapy in the setting of either lower tumor burden or in combination with 
preparative regimens aimed at cytoreduction.[42, 43] However, the use of distinct 
chemotherapy drugs which can have differing immune effects, adds to the 
complexity of determining the relationships between chemotherapy treatments 
and immune response (reviewed in [27, 44]). 
 
1.6.2 Correlative Study Procedures 
 
Patients undergoing highly active chemotherapy will undergo extensive immune 
profiling with aim towards characterizing the immune response to this 
chemotherapy to inform future immunotherapy studies and aid in optimizing these 
treatments. Assessment of the tumor, tumor microenvironment and immune 
system will be characterized at baseline, after 2 cycles of chemotherapy and at 
time of progression.  
 
Biopsies from primary or metastatic lesions: Ten consenting patients with 
accessible metastatic lesions will undergo optional paired core biopsies from one 
metastatic lesion prior to the start of FOLFIRINOX chemotherapy and after 2 
cycles of therapy.  At the time of tumor progression, patients will be approached 
about having a biopsy of an accessible site of metastatic disease.. Four to 8 cores 
will be taken at each time point. Biopsy of metastases will be obtained by core 
needle and will be performed under ultrasound or CT-guidance via interventional 
radiology. These specimens will be used to characterize changes in biomarkers 
and immune parameters associated with tumoral response or resistance.  
  
Peripheral blood testing: Participating patients will undergo phlebotomy at the 
specified time points: Pre-chemotherapy then post-chemotherapy at 2-week 
intervals at the time of standard-of-care phlebotomy for a maximum of 8 blood 
draws. Blood will again be drawn at the time of documented tumor progression.  
 
Tumor immune correlates: Analysis will be performed by co-investigators from 
the Center for Human Immunology and Immunotherapy Programs (CHiiPs) and 
the McDonnell Genome Institute (MGI).  Expression of PD-1, PD-L1, PD-L2, 
and CTLA-4 (an alternative checkpoint pathway) will be determined by IHC on 
tumor cells and tumor infiltrating leukocytes (TIL). Tumor samples obtained from 
primary or metastatic biopsies will be analyzed for these biomarkers. Expression 
levels of checkpoint molecules (PD-1, PD-L1, PD-L2, and CTLA-4) will be 
compared in paired primary and metastatic biopsies.  Each patient will serve as is 
its own comparator.  The frequency of concordant or discrepant expression of 
various mechanisms of checkpoint inhibition between primary and metastatic 
disease sites will be defined.  
 
Single cell suspensions will be made from fresh tissue to characterize the 


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phenotype of various populations of infiltrating leukocytes (T cells, B cells, NK 
cells, monocytes/macrophages, dendritic cells) by multi-parametric flow 
cytometry (FACS) and mass cytometry (CyTOF). Expression of various 
activation and inhibitory markers on the TIL will also be assessed. 
    
Tumor neoantigen assessments: Mutation burden will be determined by whole 
exome sequencing. PBMCs will be used to obtain germline sequences for 
comparison to isolated tumor from tissue biopsies (somatic mutations).  
- 
Tumor cells will be microdissected from tissue biopsies and sent for whole 
exome sequencing and RNAseq to quantify the mutational landscape as a 
surrogate of antigenic burden. Whole exome sequencing and RNAseq will be 
performed on tissue samples to identify potential neoepitopes via MHC class I 
and II prediction algorithms. Identified neoepitopes will be validated in 
peptide-specific autologous peripheral blood mononuclear stimulation assays. 
- 
Tumor neoantigen identification and definition by established techniques. 
MHC tetramers against the specific identified tumor neoantigens will allow 
the qualitative evaluation of the T cells that are potentially responsible for 
tumor rejection.  
 
2.0 
OBJECTIVES 
 
2.1 
Primary Objective 
 
To determine the objective response rate (defined as CR + PR by RECIST 1.1 criteria) of 
FOLFIRINOX in advanced gastric, GEJ, or esophageal cancer. 
 
2.2 
Secondary Objectives 
 
1. To determine the progression-free survival (PFS) of patients treated with 
FOLFIRINOX. 
2. To determine time to progression (TTP) in patients treated with FOLFIRINOX.  
3. To determine the overall survival (OS) of patients treated with FOLFIRINOX.  
4. To determine the clinical benefit rate of patients treated with FOLFIRINOX.  Clinical 
benefit rate is the percentage of combined patients who have achieved complete 
response, partial response, and stable disease.   
5. To determine the duration of response of patients treated with FOLFIRINOX. 
6. To evaluate toxicity and tolerability of FOLFIRINOX +/- trastuzumab as measured 
by CTCAE version 4.0 
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. Biopsy-proven and inoperable locally advanced, recurrent, or metastatic cancer of the 
esophagus, stomach, or gastro-esophageal junction – adenocarcinoma type. 


Protocol Version: Amendment 12; 12/21/17 
 
Page 14 of 52 
 
2. Measurable disease defined as lesions that can be accurately measured in at least one 
dimension (longest diameter to be recorded) as >10 mm with CT scan, as >20 mm by 
chest x-ray, or >10 mm with calipers by clinical exam. 
 
3. Prior single modality radiation therapy is allowed.   
 
4. At least 18 years of age. 
 
5. ECOG performance status < 2 (see Appendix 1) 
 
6. Normal bone marrow and organ function as defined below: 
a. Absolute neutrophil count > 1,500/mcl 
b. Platelets > 100,000/mcl 
c. AST(SGOT)/ALT(SGPT) < 2.5 x IULN unless there is known liver metastases in 
these instances AST(SGOT)/ALT(SGPT) < 5 x IULN 
d. Creatinine ≤ IULN         
OR 
Creatinine clearance > 60 mL/min/1.73 m2 for patients with creatinine levels 
above institutional normal 
e. Total bilirubin ≤ 1.5 mg/dL. 
 
7. HER-2 status may be pending at initiation of FOLFIRINOX, but must be known prior 
to starting Trastuzumab.  If HER-2 is positive, patients must have an LVEF ≥ 
50%.  HER-2 negative patients are not excluded. 
 
8. Women of childbearing potential and men must agree to use adequate contraception 
(hormonal or barrier method of birth control, abstinence) prior to study entry and for 
the duration of study participation.  Should a woman become pregnant or suspect she 
is pregnant while participating in this study, she must inform her treating physician 
immediately. 
 
9. Ability to understand and willingness to sign an IRB approved written informed 
consent document (legally authorized representative is allowed). 
 
10. Patients already receiving treatment with FOLFIRINOX +/- trastuzumab may 
participate in the study and have their data collected retrospectively if they met 
inclusion criteria at the start of therapy and sign consent for study participation 
moving forward. 
 
3.2 
Exclusion Criteria 
 
1. Chemotherapy in the 6 months prior to registration. 
 
2. Any active malignancy within 3 years that may alter the course of esophageal cancer. 
(Apparently cured localized malignancy or advanced, but indolent malignancy with 


Protocol Version: Amendment 12; 12/21/17 
 
Page 15 of 52 
significantly more favorable prognosis are allowed).  
 
3. Receiving any other investigational agents at the time of registration. 
 
4. Known untreated brain metastases.  These patients must be excluded from this 
clinical trial because of their poor prognosis and because they often develop 
progressive neurologic dysfunction that would confound the evaluation of neurologic 
and other adverse events. 
 
5. A history of allergic reactions attributed to compounds of similar chemical or biologic 
composition to the agents used in the study. 
 
6. Previous therapy for metastatic gastroesophageal cancer. Previous perioperative 
chemotherapy is allowed as long as the duration without treatment has been greater 
than 6 months. 
 
7. A history of congestive heart failure, transmural myocardial infarction, symptomatic 
valvular disease, or high-risk arrhythmia. 
 
8. Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia, or psychiatric illness/social situations that would limit compliance with 
study requirements. 
 
9. Pregnant and/or breastfeeding.  Patient must have a negative urine pregnancy test 
within 14 days of study entry. 
 
10. Known HIV-positivity and on combination antiretroviral therapy because of the 
potential for pharmacokinetic interactions with trastuzumab.  In addition, these 
patients are at increased risk of lethal infections when treated with marrow-
suppressive therapy.  Appropriate studies will be undertaken in patients receiving 
combination antiretroviral therapy when indicated. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this 
trial. 
 
 
4.0 
REGISTRATION PROCEDURES 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 
 
 
The following steps must be taken before registering patients to this study: 


Protocol Version: Amendment 12; 12/21/17 
 
Page 16 of 52 
 
1. Confirmation of patient eligibility  
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
 
4.1 
Confirmation of Patient Eligibility 
 
Confirm patient eligibility collecting the information listed below: 
 
1. The registering MD’s name 
2. Patient’s race, sex, and DOB 
3. Three letters (or two letters and a dash) for the patient’s initials 
4. Copy of signed consent form 
5. Completed eligibility checklist, signed and dated by a member of the study team 
6. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
All patients must be registered through the Siteman Cancer Center OnCore database. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  All 
data will be recorded with this identification number on the appropriate CRFs. 
 
 
5.0 
TREATMENT PLAN 
 
5.1 
Assessment of HER2 Status 
 
A new biopsy is not required for patient participation. However, if a patient does not have 
adequate tissue to assess HER2 status, then a fresh biopsy will be necessary as a 
determination of HER2 status is part of the standard of care therapy. 
 
5.2 
Premedication Administration 
 
Given the high incidence of nausea and vomiting associated with the FOLFIRINOX 
regimen, a combination of aprepitant, 5-HT3 antagonist, and dexamethasone before 
chemotherapy is strongly recommended. 
 
5.3 
Agent Administration 
 
The FOLFIRINOX regimen used for this study is the following drugs given on a 28-day 
cycle: 
• Irinotecan 180 mg/m2 IV on Days 1 and 15 
• Oxaliplatin 85 mg/m2 IV on Days 1 and 15 


Protocol Version: Amendment 12; 12/21/17 
 
Page 17 of 52 
• Leucovorin 400 mg/m2 IV on Days 1 and 15 
• 5FU 400 mg/m2 bolus and 2,400 mg/m2 continuous infusion over 46 hours 
beginning on Days 1 and 15 
 
In order for a patient to be treated, his/her total bilirubin must be < 1.5 x ULN and his/her 
AST (SGOT)/ALT (SGPT) must be < 3.0 x ULN.  Patients with elevated liver function 
tests may be enrolled (i.e., if they have a biliary obstruction), but their values must have 
resolved as described above prior to initiation of Cycle 1 treatment with FOLFIRINOX. 
 
For HER2-positive patients, trastuzumab will be administered intravenously with a 
loading dose of 6 mg/kg on Cycle 1 Day 1, followed by a dose of 4 mg/kg every 2 weeks 
(Day 15 and Day 1 of all future cycles).  In the event a participant’s HER2 status is 
pending at the time treatment is initiated, trastuzumab will be added to the study regimen 
with the next cycle after determining HER2-positive status.  
 
All study drugs will be administered every 2 weeks on a 28-day cycle as described above.  
Trastuzumab will be administered first (for patients who are HER2-positive only), 
followed by irinotecan. Oxaliplatin and leucovorin are then administered concurrently.  
Lastly, the 5-FU bolus will be given, followed by the 5-FU continuous infusion.  In the 
event of a leucovorin shortage, levoleucovorin may be substituted at a dose of 200 
mg/m2.  When supplies of leucovorin become available, change to the protocol-specified 
dose.  If neither leucovorin nor levoleucovorin are available, treatment without 
leucovorin would be acceptable but should be re-addressed with each treatment. 
 
5.4 
General Concomitant Medication and Supportive Care Guidelines 
 
Supportive care: Patients should receive full supportive care, including transfusions of 
blood and blood products, antibiotics, anti-nausea/diarrhea, etc., when appropriate.  
 
Diarrhea management: Patients should be closely monitored for diarrhea. Dose 
modification for diarrhea is clearly outlined under Section 6.0. Patients should be 
instructed to take loperamide at the first sign of poorly formed or loose stools. Patients 
should take loperamide in the following fashion: 4 mg at the first onset of diarrhea, then 2 
mg every 2 hours until diarrhea resolved. The total dose of loperamide should not exceed 
16mg/day. Patients are instructed to notify their treating physicians if diarrhea is not 
resolved within 24 hours.  Additional antidiarrheal medications including Lomotil, 
tincture of opium, or octreotide can be used. 
 
Palliative radiation therapy: Palliative radiation therapy may not be administered 
concurrently with the trial chemotherapy. The need for palliative radiation therapy will be 
considered evidence of progressive disease, and patients will be taken off study. 
 
5.5 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 


Protocol Version: Amendment 12; 12/21/17 
 
Page 18 of 52 
precludes withdrawal bleeding, and women who have had a tubal ligation) are required to 
have a negative urine pregnancy test within 14 days prior to Cycle 1 Day 1.   
 
Female and male patients (along with their female partners) are required to use two forms 
of acceptable contraception, including one barrier method, during participation in the 
study and for 30 days following the last dose of any of the study agents.  
 
If a patient is suspected to be pregnant, all study agents should be immediately 
discontinued.  In addition a positive urine test must be confirmed by a serum pregnancy 
test.  If it is confirmed that the patient is not pregnant, the patient may resume dosing. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy 
or within 30 days after the last dose of any of the study agents, the investigator must be 
notified in order to facilitate outcome follow-up. 
 
5.6 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 
protocol therapy should be discontinued and the reason(s) for discontinuation 
documented in the case report forms. 
 
In the absence of treatment delays due to adverse events, treatment may continue for up 
to 4 cycles following disease maximal response (based on CT imaging) or until one of the 
following criteria applies: 
 
• Documented and confirmed disease progression 
• Death 
• Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drug 
• General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
• Suspected pregnancy 
• Serious non-compliance with the study protocol 
• Lost to follow-up 
• Patient withdraws consent 
• Investigator removes the patient from study 
• The Siteman Cancer Center decides to close the study 
 
If the treating physician determines that a maximal response has been achieved and 
would like to simplify the study regimen in order to mitigate toxicities for a maintenance 
strategy, possible options can include but are not limited to modified FOLFOX-6 (with 
trastuzumab for HER2 positive patients), combination 5-FU/leucovorin (with 
trastuzumab for HER2 positive patients), FOLFIRI (with trastuzumab for HER2 positive 
patients), irinotecan (with trastuzumab for HER2 positive patients), or trastuzumab alone 
(for HER2 positive patients only). Maintenance therapy may also include drugs not 


Protocol Version: Amendment 12; 12/21/17 
 
Page 19 of 52 
specifically part of the FOLFIRINOX regimen.  Patients will continue to have follow up 
radiological assessments according to treating physician’s discretion, until documented 
progression. Study coordinator should be notified of scans so RECIST can be requested.  
 
A patient who remains on any component of the study regimen or on maintenance 
therapy will be considered still on study as long as disease progression has not occurred. 
 
Patients who prematurely discontinue treatment for any reason will be followed as 
indicated in the study calendar. 
 
5.7 
Duration of Follow-up 
 
Patients will be followed for toxicities for up to 30 days after the end of study treatment 
and until death for survival assessment.  Patients removed from study for unacceptable 
adverse events will be followed until resolution or stabilization of the adverse event. 
 
 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS 
 
6.1 
Dose Reductions 
 
Agent 
Level 1 
(starting dose)  
Dose Reduction -1 
Dose Reduction -2 
5FU bolus  
400 mg/m2 
320 mg/m2 
270 mg/m2 
5FU infusion 
over 46-48 
hours 
2400 mg/m2 
1900 mg/m2 
1600 mg/m2 
Oxaliplatin  
85 mg/m2 
65 mg/m2 
50 mg/m2 
Irinotecan  
180 mg/m2 
150 mg/m2 
120 mg/m2 
Leucovorin* 
400 mg/m2 
400 mg/m2 
400 mg/m2 
 
* If 5FU is skipped, then leucovorin will also not be administered. 
               
6.2 
Hematologic Toxicities 
 
The hematologic toxicities associated with FOLFIRINOX are known, based on the large 
Phase III ACCORD study as well as the institutional experience.    
  
 
 


Protocol Version: Amendment 12; 12/21/17 
 
Page 20 of 52 
 
CTCAE Version 4 
Terminology 
CTCAE 
Version 
4 Grade 
FOLFIRINOX 
Note: If any patient requires a dose delay > 21 days cumulatively during Cycle 1 or > 
14 days cumulatively during Cycle 2, s/he will be removed from the study. 
Dose modifications will be based on AEs which have occurred either between 
treatments or on the scheduled treatment day. Patients will not have more than two 
dose reductions of each agent. 
Neutrophil count 
decreased 
(ANC < 999-500/mm3) * 
Grade 3 
Delay dose until recovered to 1,200/mm3.  
Reduce dose level of 5FU bolus and 
irinotecan by one dose level for all 
subsequent cycles. 
Neutrophil count 
decreased  
(ANC < 500/mm3) * 
Grade 4 
Delay dose until recovered to 1,200/mm3.  
Reduce dose level of 5FU bolus and 
irinotecan by one dose level for all 
subsequent cycles. 
Platelet count decreased 
(49,999-25,000/mm3) 
Grade 3  
Delay dose until recovered to 100,000/mm3. 
Reduce dose level of 5FU (bolus and 
infusion), oxaliplatin, and irinotecan by one 
dose level for all subsequent cycles. 
Platelets count decreased 
(< 25,000/mm3) 
Grade 4  
Delay dose until recovered to 100,000/mm3. 
Reduce dose level of 5FU (bolus and 
infusion), oxaliplatin, and irinotecan by one 
dose level for all subsequent cycles. 
 
*There need not be any dose reduction for grade 3 or 4 neutropenia because patients may 
receive G-CSF.  However, dose reduction for grade 3 or 4 neutropenia in addition to or in 
place of receiving G-CSF may occur at the PI’s discretion. 
   
 
 


Protocol Version: Amendment 12; 12/21/17 
 
Page 21 of 52 
 
6.3 
Gastrointestinal Toxicities 
               
CTCAE Version 4 
Terminology 
CTCAE 
Version 
4 Grade 
FOLFIRINOX 
Note: If any patient requires a dose delay > 21 days cumulatively during Cycle 
1 or > 14 days cumulatively during all subsequent cycles, s/he will be removed 
from the study. 
 
All treatment will be delayed until toxicities resolve to < Grade 1. 
Diarrhea 
(despite administration 
of antidiarrheal(s)) 
Grade 3/4 Reduce 5FU (bolus and infusion) and 
irinotecan by one dose level for all 
subsequent cycles. 
Mucositis 
 
Grade 3 
Reduce 5FU (bolus and infusion) by one 
dose level for all subsequent cycles. 
Grade 4 
Reduce 5FU (bolus and infusion) and 
irinotecan by one dose level for all 
subsequent cycles. 
Vomiting 
(despite administration 
of anti-emetic(s)) 
Grade 3/4 Reduce dose level of 5FU (bolus and 
infusion), oxaliplatin, and irinotecan by 
one dose level for all subsequent cycles. 
Other clinically 
significant AE 
Grade 3/4 Reduce dose level of 5FU (bolus and 
infusion), oxaliplatin, and irinotecan by 
one dose level for all subsequent cycles. 
Blood bilirubin 
increased 
OR 
Aspartate 
aminotransferase 
increased 
OR 
Alkaline phosphatase 
increased 
OR 
Alanine 
aminotransferase 
increased 
Grade 
2** 
Reduce dose level of irinotecan by one 
dose level for all subsequent cycles. 
Grade 
3** 
Reduce dose level of 5FU (bolus and 
infusion) and irinotecan by one dose level 
for all subsequent cycles. 
Grade 
4** 
Discontinue FOLFIRINOX. * 
 
* Patients who develop elevated LFTs should be carefully evaluated to rule out the 
possibility of biliary obstruction. If grade 4 toxicities in LFTs are deemed to be caused by 
treatment, then patient will be removed from the study. 
** For patients who have liver metastases with elevated AST, ALT, and/or bilirubin 
during screening dose modifications should be given based off treating MD discretion.  
 
 


Protocol Version: Amendment 12; 12/21/17 
 
Page 22 of 52 
6.4 
Neurotoxicity 
 
Modify dose of oxaliplatin in the event of neurotoxicity as follows: 
 
CTCAE Version 4 Terminology 
1-7 days  
More than 7 days 
Grade 1 paresthesia or dysesthesia 
(mild sensory alteration) 
Maintain dose. 
Maintain dose. 
Grade 2 paresthesia or dysesthesia 
(moderate sensory alteration which 
limits instrumental ADL) 
Maintain dose. 
Reduce dose by 
one dose level for 
all subsequent 
cycles. 
Grade 3 paresthesia or dysesthesia 
(severe sensory alteration which 
limits self-care ADL) 
First episode: 
Reduce dose by one 
dose level for all 
subsequent cycles. 
Second episode: 
Stop oxaliplatin  
Stop oxaliplatin. 
 
6.5 
Dose Modification for Obese Patients 
 
All chemotherapy dosing will be calculated with actual body weight on the day of 
treatment.  The body weight at time of registration can be used for Cycle 1 treatment if 
the changes in the weight are less than 10%. 
 
6.6 
Dose Modifications for Non-Hematological Toxicities 
 
Treatment may be held and suspect drug(s) may be reduced by one level for all 
subsequent cycles for any grade 3 or 4 non-hematological toxicity, or any grade 2 non-
hematological toxicity of particular concern which the investigator believes is related to 
the study therapy. 
 
6.7 
Management of Trastuzumab Side Effects 
 
For the first (loading) dose of trastuzumab, premedication with acetaminophen 650 mg 
PO will be given. 
 
Patients should not miss more than one q 2 week dose of trastuzumab consecutively.  
Patients do not have to make up missed doses. 
 
6.7.1 Dose Modifications for Trastuzumab 
 
Dose modification of trastuzumab is not permitted. 
 
6.7.2 Infusion-associated Symptoms with Trastuzumab 
 
Infusion reactions consist of a symptom complex characterized by fever and 


Protocol Version: Amendment 12; 12/21/17 
 
Page 23 of 52 
chills, and on occasion nausea, vomiting, pain (in some cases at tumor sites), 
headache, dizziness, hypotension, rash, and asthenia.  In postmarketing reports, 
serious and fatal infusion reactions have been reported.  Severe reactions which 
include 
bronchospasm, 
anaphylaxis, 
angioedema, 
hypoxia, 
and 
severe 
hypotension were usually reported during or immediately following the initial 
infusion.  However, the onset and clinical course were variable including 
progressive worsening, initial improvement followed by clinical deterioration, or 
delayed post-infusion events with rapid clinical deterioration.  For fatal events, 
death occurred within hours to days following a serious infusion reaction. 
 
Interrupt trastuzumab infusion in all patients experiencing dyspnea, clinically 
significant hypotension, and intervention of medical therapy administered, which 
may include: epinephrine, corticosteroids, diphenhydramine, bronchodilators, and 
oxygen.  Patients should be evaluated and carefully monitored until complete 
resolution of signs and symptoms.  The rate of infusion should be decreased for 
mild or moderate (CTCAE grade 1 or 2) infusion reactions.  Permanent 
discontinuation should be strongly considered in all patients with severe (grade 3 
or 4) infusion reactions. 
 
 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outline below. 
 
The Washington University Human Research Protection Office (HRPO) requires that all events 
meeting the definition of unanticipated problem or serious noncompliance be reported as 
outlined in Section 7.2. 
 
The FDA requires that all serious and unexpected adverse events be reported as outlined in 
Section 7.4.  In addition, any fatal or life-threatening adverse experiences where there is a 
reasonable possibility of relationship to study intervention must be reported. 
 
7.1 
Definitions 
 
7.1.1 Adverse Events (AEs) 
 
Definition: any unfavorable medical occurrence in a human subject including any 
abnormal sign, symptom, or disease.  Note: For the purposes of this study, 
abnormal lab values will only be considered adverse events if they are clinically 
significant. 
 
Grading: the descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized 
for all toxicity reporting.  A copy of the CTCAE version 4.0 can be downloaded 
from the CTEP website. 


Protocol Version: Amendment 12; 12/21/17 
 
Page 24 of 52 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for 
the terms listed that should be used are those provided by the Department of 
Health and Human Services’ Office for Human Research Protections (OHRP).  A 
copy of this guidance can be found on OHRP’s website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
7.1.2 Serious Adverse Event (SAE) 
 
Definition:  any adverse drug experience occurring at any dose that results in any 
of the following outcomes: 
o Death 
o A life-threatening adverse drug experience 
o Inpatient hospitalization or prolongation of existing hospitalization 
o A persistent or significant disability/incapacity (i.e., a substantial 
disruption of a person’s ability to conduct normal life functions) 
o A congenital anomaly/birth defect 
o Any other experience which, based upon appropriate medical judgment, 
may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed above 
 
All unexpected SAEs must be reported to the FDA. 
 
7.1.3 Unexpected Adverse Experience 
 
Definition: any adverse drug experience, the specificity or severity of which is 
not consistent with the current investigator brochure (or risk information, if an IB 
is not required or available). 
 
Events that are both serious AND unexpected must be reported to the FDA.  
 
7.1.4 Life-Threatening Adverse Experience  
 
Definition: any adverse drug experience that places the subject (in the view of the 
investigator) at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that, had it occurred in a more severe form, might have 
caused death. 
 
Life-threatening adverse experiences must be reported to the FDA. 
 
7.1.5 Unanticipated Problems 
 
Definition: 
 
• unexpected (in terms of nature, severity, or frequency) given (a) the 
research procedures that are described in the protocol-related documents, 


Protocol Version: Amendment 12; 12/21/17 
 
Page 25 of 52 
such as the IRB-approved research protocol and informed consent 
document; and (b) the characteristics of the subject population being 
studied; 
• related or possibly related to participation in the research (in this guidance 
document, possibly related means there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures 
involved in the research); and 
• suggests that the research places subjects or others at a greater risk of 
harm (including physical, psychological, economic, or social harm) than 
was previously known or recognized. 
 
7.1.6 Noncompliance 
 
Definition: failure to follow any applicable regulation or institutional policies that 
govern human subjects research or failure to follow the determinations of the 
IRB.  Noncompliance may occur due to lack of knowledge or due to deliberate 
choice to ignore regulations, institutional policies, or determinations of the IRB. 
 
7.1.7 Serious Noncompliance 
 
Definition: noncompliance that materially increases risks, that results in 
substantial harm to subjects or others, or that materially compromises the rights or 
welfare of participants. 
 
7.1.8 Protocol Exceptions 
 
Definition: A planned deviation from the approved protocol that are under the 
research team’s control. Exceptions apply only to a single participant or a singular 
situation. 
 
Pre-approval of all protocol exceptions must be obtained prior to the event.   
 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington 
University 
 
The PI is required to promptly notify the IRB of the following events: 
 
• Any unanticipated problems involving risks to participants or others which occur 
at WU, any BJH or SLCH institution, or that impacts participants or the conduct 
of the study. 
• Noncompliance with federal regulations or the requirements or determinations of 
the IRB. 
• Receipt of new information that may impact the willingness of participants to 
participate or continue participation in the research study. 
 
These events must be reported to the IRB within 10 working days of the occurrence of 


Protocol Version: Amendment 12; 12/21/17 
 
Page 26 of 52 
the event or notification to the PI of the event.  The death of a research participant that 
qualifies as a reportable event should be reported within 1 working day of the occurrence 
of the event or notification to the PI of the event. 
 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The PI is required to notify the QASMC of any unanticipated problem occurring at WU 
or any BJH or SLCH institution that has been reported to and acknowledged by HRPO as 
reportable.  (Unanticipated problems reported to HRPO and withdrawn during the review 
process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via email to 
a QASMC auditor. 
 
7.4 
Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements.  
PLEASE NOTE THAT REPORTING REQUIREMENTS FOR THE FDA DIFFER 
FROM REPORTING REQUIREMENTS FOR HRPO/QASMC.  It is the 
responsibility of the investigator to report any unanticipated problem to the FDA as 
follows: 
 
• Report any unexpected fatal or life-threatening adverse experiences (Section 
7.1.4) associated with use of the drug by telephone or fax no later than 7 calendar 
days after initial receipt of the information.   
• Report any serious, unexpected adverse experiences (Section 7.1.2), as well as 
results from animal studies that suggest significant clinical risk within 15 
calendar days after initial receipt of this information.  
 
All MedWatch forms will be sent by the investigator or investigator’s team to the FDA at 
the following address or by fax: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Oncology Drug Products 
5901-B Ammendale Rd. 
Beltsville, MD 20705-1266 
FAX: 1-800-FDA-0178 
 
7.5 
Timeframe for Reporting Required Events  
 
Adverse events will be tracked for 30 days following the last day of study treatment.  For 
the purposes of this study, abnormal lab values will only be collected and documented on 
CRFs if they are clinically significant.  Once a patient begins maintenance therapy, 
adverse events will no longer be collected and documented on CRFs. 


Protocol Version: Amendment 12; 12/21/17 
 
Page 27 of 52 
 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Irinotecan (Camptosar®) 
 
8.1.1 Irinotecan Description 
 
Irinotecan is an antineoplastic agent of the topoisomerase I inhibitor class.  It is 
indicated for the treatment of patients with metastatic carcinoma of the colon or 
rectum whose disease has recurred or progressed following 5FU-based therapy. 
 
Molecular formula: C33H38N4O6•HCl•3H2O. 
Chemical 
name: 
(4S)-4, 
11-diethyl-4-hydroxy-9-[(4-piperidino-piperidino) 
carbonyloxy]-1H-pyrano[3’,4’:6,7] 
indolizino 
[1,2-b]quinoline-3,14(4H, 
12H)dione hydrochloride trihydrate. 
Molecular weight: 677.19. 
 
8.1.2 Clinical Pharmacology 
 
Irinotecan is a derivative of camptothecin. Camptothecins interact specifically 
with the enzyme topoisomerase I which relieves torsional strain in DNA by 
inducing reversible single-strand breaks. Irinotecan and its active metabolite SN-
38 bind to the topoisomerase I-DNA complex and prevent religation of these 
single-strand breaks. Current research suggests that the cytotoxicity of irinotecan 
is due to double-strand DNA damage produced during DNA synthesis when 
replication enzymes interact with the ternary complex formed by topoisomerase I, 
DNA, and either irinotecan or SN-38. Mammalian cells cannot efficiently repair 
these double-strand breaks. 
 
Irinotecan serves as a water-soluble precursor of the lipophilic metabolite SN-38. 
SN-38 is formed from irinotecan by carboxylesterase-mediated cleavage of the 
carbamate bond between the camptothecin moiety and the dipiperidino side chain. 
SN-38 is approximately 1000†times as potent as irinotecan as an inhibitor of 
topoisomerase I purified from human and rodent tumor cell lines. In vitro 
cytotoxicity assays show that the potency of SN-38 relative to irinotecan varies 
from 2- to 2000-fold. However, the plasma area under the concentration versus 
time curve (AUC) values for SN-38 are 2% to 8% of irinotecan and SN-38 is 95% 
bound to plasma proteins compared to approximately 50% bound to plasma 
proteins for irinotecan. The precise contribution of SN-38 to the activity of 
irinotecan is thus unknown. Both irinotecan and SN-38 exist in an active lactone 
form and an inactive hydroxy acid anion form. A pH-dependent equilibrium exists 
between the two forms such that an acid pH promotes the formation of the 
lactone, while a more basic pH favors the hydroxy acid anion form. 
 
Administration of irinotecan has resulted in antitumor activity in mice bearing 


Protocol Version: Amendment 12; 12/21/17 
 
Page 28 of 52 
cancers of rodent origin and in human carcinoma xenografts of various 
histological types. 
 
8.1.3 Pharmacokinetics and Drug Metabolism 
 
After intravenous infusion of irinotecan in humans, irinotecan plasma 
concentrations decline in a multiexponential manner, with a mean terminal 
elimination half-life of about 6 to 12 hours. The mean terminal elimination half-
life of the active metabolite SN-38 is about 10 to 20 hours. The half-lives of the 
lactone (active) forms of irinotecan and SN-38 are similar to those of total 
irinotecan and SN-38, as the lactone and hydroxy acid forms are in equilibrium. 
 
The metabolic conversion of irinotecan to the active metabolite SN-38 is 
mediated by carboxylesterase enzymes and primarily occurs in the liver. SN-38 
subsequently undergoes conjugation to form a glucuronide metabolite. SN-38 
glucuronide had 1/50 to 1/100 the activity of SN-38 in cytotoxicity assays using 
two cell lines in vitro. The disposition of irinotecan has not been fully elucidated 
in humans. The urinary excretion of irinotecan is 11% to 20%; SN-38, <1%; and 
SN-38 glucuronide, 3%. The cumulative biliary and urinary excretion of 
irinotecan and its metabolites (SN-38 and SN-38 glucuronide) over a period of 48 
hours following administration of irinotecan in two patients ranged from 
approximately 25% (100 mg/m2) to 50% (300 mg/m2). 
 
8.1.4 Supplier(s) 
 
Irinotecan is considered standard of care for this indication and is commercially 
available. 
 
8.1.5 Dosage Form and Preparation 
 
Irinotecan is supplied as a sterile, pale yellow, clear, aqueous solution. It is 
available in two single-dose sizes: 2 mL-fill vials contain 40 mg irinotecan 
hydrochloride and 5 mL-fill vials contain 100 mg irinotecan hydrochloride. Each 
milliliter of solution contains 20 mg of irinotecan hydrochloride (on the basis of 
the trihydrate salt), 45 mg of sorbitol NF powder, and 0.9 mg of lactic acid, USP. 
The pH of the solution has been adjusted to 3.5 (range, 3.0 to 3.8) with sodium 
hydroxide or hydrochloric acid. Irinotecan is intended for dilution with 5% 
Dextrose Injection, USP (D5W), or 0.9% Sodium Chloride Injection, USP, prior 
to intravenous infusion. The preferred diluent is 5% Dextrose Injection, USP. 
 
The dosage given for this study is 180 mg/m2. 
 
8.1.6 Storage and Stability 
 
The solution is physically and chemically stable for up to 24 hours at room 
temperature (approximately 25ºC) and in ambient fluorescent lighting. Solutions 


Protocol Version: Amendment 12; 12/21/17 
 
Page 29 of 52 
diluted in 5% Dextrose Injection, USP, and stored at refrigerated temperatures 
(approximately 2° to 8°C), and protected from light are physically and chemically 
stable for 48 hours. 
 
8.1.7 Administration 
 
Irinotecan is administered intravenously over the course of 90 minutes.  Irinotecan 
is emetogenic. It is recommended that patients receive premedication with 
antiemetic agents. In clinical studies of the weekly dosage schedule, the majority 
of patients received 10 mg of dexamethasone given in conjunction with another 
type of antiemetic agent, such as a 5-HT3 blocker (e.g., ondansetron or 
granisetron). Antiemetic agents should be given on the day of treatment, starting 
at least 30 minutes before administration of irinotecan. Physicians should also 
consider providing patients with an antiemetic regimen (e.g., prochlorperazine) 
for subsequent use as needed. 
 
8.1.8 Special Handling Instructions 
 
As with other potentially toxic anticancer agents, care should be exercised in the 
handling and preparation of infusion solutions prepared from irinotecan injection. 
The use of gloves is recommended. If a solution of irinotecan contacts the skin, 
wash the skin immediately and thoroughly with soap and water. If irinotecan 
contacts the mucous membranes, flush thoroughly with water. 
 
8.2 
Leucovorin 
 
8.2.1 Leucovorin Description 
 
Leucovorin is indicated after high dose methotrexate therapy in osteosarcoma.  It 
is also indicated for use in combination with 5FU to prolong survival in the 
palliative treatment of patients with advanced colorectal cancer. 
 
Molecular formula: C20H21CaN7O7. 
Chemical name: Calcium N –[p –[[[(6RS)-2-amino-5-formyl-5,6,7,8-tetrahydro-
4-hydroxy-6-pteridinyl]methyl]amino]benzoyl]-L-glutamate(1:1). 
Molecular weight: 511.51. 
 
8.2.2 Clinical Pharmacology 
 
Leucovorin 
is 
readily 
converted 
to 
another 
reduced 
folate, 
5,10-
methylenetetrahydrofolate, 
which 
acts 
to 
stabilize 
the 
binding 
of 
fluorodeoxyuridylic acid to thymidylate synthase and thereby enhances the 
inhibition of this enzyme. 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
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8.2.3 Pharmacokinetics and Drug Metabolism 
 
The mean peak of 5-methyl-THF was 258 ng/mL and occurred at 1.3 hours. The 
terminal half-life for total reduced folates was 6.2 hours. The area under the 
concentration versus time curves (AUCs) for l-leucovorin, d-leucovorin and 5-
methyltetrahydrofolate were 28.4 ± 3.5, 956 ± 97 and 129 ± 12 (mg.min/L ± 
S.E.). 
 
8.2.4 Supplier(s) 
 
Leucovorin is considered standard of care for this indication and is commercially 
available. 
 
8.2.5 Dosage Form and Preparation 
 
Leucovorin is indicated for intravenous or intramuscular administration and is 
supplied as a sterile lyophilized powder. The 350 mg vial is preservative free. The 
inactive ingredient is sodium chloride 140 mg/vial for the 350 mg vial. Sodium 
hydroxide and/or hydrochloric acid are used to adjust the pH to approximately 8.1 
during manufacture. One milligram of leucovorin calcium contains 0.002 mmol of 
leucovorin and 0.002 mmol of calcium. 
 
Leucovorin Calcium for Injection is supplied in sterile, single-use vials. 
 
The dosage given for this study is 400 mg/m2. 
 
8.2.6 Storage and Stability 
 
Store at 25°C (77°F); excursions permitted to 15-30°C (59°-86°F). Protect from 
light. 
 
8.2.7 Administration 
 
Leucovorin will be administered intravenously over the course of 120 minutes. 
 
Because of the calcium content of the leucovorin solution, no more than 160 mg 
of leucovorin should be injected intravenously per minute (16 mL of a 10 mg/mL, 
or 8 mL of a 20 mg/mL solution per minute). 
 
8.2.8 Special Handling Instructions 
 
None. 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
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8.3 
Oxaliplatin (Eloxatin®) 
 
8.3.1 Oxaliplatin Description 
 
IV Oxaliplatin is FDA approved in combination with infusional 5FU and 
leucovorin (FOLFOX) for the treatment of patients with metastatic carcinoma of 
the colon or rectum whose disease has recurred or progressed during or within 6 
months of completion of first line therapy with the combination of bolus 
5FU/leucovorin and irinotecan. 
 
Molecular formula: C8H14N2)4Pt. 
Chemical name: cis- [(1R,2R)-1,2-cyclohexanediamine-N, N’] [oxaloto (2-)-O, 
O’] platinum. 
Molecular weight: 397.3. 
 
8.3.2 Clinical Pharmacology 
 
Oxaliplatin is a newer platinum derivative with an oxalo ligand group.  Although 
the exact mechanism of oxaliplatin remains unclear, the cytotoxicity of platinum 
compounds is thought to result from inhibition of DNA synthesis.  Intrastrand 
platinum DNA adducts, the main cytotoxic lesions, are formed by cross-linking 
activated platinum species and specific base sequences, notably two adjacent 
guanine residues or two adjacent guanine-adenine bases. 
 
8.3.3 Pharmacokinetics and Drug Metabolism 
 
Time to peak concentration with a single 2-hour infusion of oxaliplatin 85mg/m2 
yielded a peak plasma concentration of 0.814 mcg/mL.  The area under the curve 
for total plasma platinum was 207-290 mg/L per hour.  Ultrafiltrable plasma 
platinum was 11.9-13.6 mg/L per hour.  Oxaliplatin has 70-95% platinum-protein 
binding while 37% represents total platinum taken up by red blood cells (addition 
of oxaliplatin to whole blood).  The volume of distribution is 440 L after a single 
2 hour infusion of 85 mg/m2 oxaliplatin.  It undergoes rapid and extensive (30%) 
nonenzymatic biotransformation.  In vitro studies indicate no cytochrome P450-
mediated metabolism.  Its metabolites include approximately 17 different 
platinum containing derivatives with some being cytotoxic.  It is not known 
whether oxaliplatin is excreted into breastmilk.  Renal clearance is 9.3-17 liters 
per hour.  Elimination half-life: intravenous, total plasma platinum, alpha half-life 
(0.2-0.43 hours), beta half-life (15-16.8 hours), gamma half-life (252-391 hours).  
The decline of ultrafiltrable platinum levels is tri-exponential with a  relatively 
short alpha and beta half-life (0.43 and 16.8 hours) and a long terminal gamma 
half-life (391 hours). 
 
 


Protocol Version: Amendment 12; 12/21/17 
 
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8.3.4 Supplier(s) 
 
Oxaliplatin is considered standard of care for this indication and is commercially 
available. 
 
8.3.5 Dosage Form and Preparation 
 
Oxaliplatin is formulated as a white freeze-dried powder in amber glass vials and 
contains 50 mg or 100 mg of oxaliplatin in lactose monohydrate.  Each vial is 
sealed with a stopper with a crimped aluminum cap. 
 
The freeze-dried powder is reconstituted by adding 10-20 mL (for the 50 mg vial) 
or 20-40 mL (for the 100 mg vials) of sterile water for injection or 5% dextrose 
solution and then by diluting in an infusion solution of 250 mL or 500 mL of 5% 
dextrose solution.  These manipulations cannot be performed with aluminum 
needles.  The reconstitution or final dilution can’t ever be performed with a 
sodium chloride solution. 
 
The dosage given for this study is 85 mg/m2. 
 
8.3.6 Storage and Stability 
 
Oxaliplatin is a freeze-dried powder and may be stored at room temperature as 
long as it is protected from light for up to 3 years.  It should not be combined with 
alkaline medications or media, which cause oxaliplatin to degrade.  Do not use 
needles or IV infusion sets containing aluminum items (risk of degradation of 
oxaliplatin upon contact with aluminum) for the preparation or administration of 
oxaliplatin.  Oxaliplatin should not be mixed with sodium chloride or other 
chloride containing solutions.  Reconstituted solution must be prepared in a 5% 
dextrose solution of sterile water for injection in the original vial.  This solution 
may be stored for 24-48 hours at 2-80ºC.  Infusion solution: after dilution in 5% 
dextrose solution, the shelf-life is 24 hours at room temperature. 
 
8.3.7 Administration 
 
Oxaliplatin will be administered intravenously over the course of 2 hours.  
Antiemetic premedication (5-HT3 blocker with or without dexamethasone) is 
recommended.  Cold temperatures can precipitate/exacerbate neurological 
symptoms which should be avoided during the infusion of oxaliplatin.   
 
8.3.8 Special Handling Instructions 
 
Oxaliplatin should never be reconstituted/diluted with a chloride-containing 
solution, and aluminum parts should be avoided when mixing or preparing 


Protocol Version: Amendment 12; 12/21/17 
 
Page 33 of 52 
oxaliplatin.  Oxaliplatin is incompatible with alkaline media (i.e., solutions of 
5FU).  Oxaliplatin should be prepared in 250-500 mL D5W. 
 
8.4 
5FU (5-fluorouracil) 
 
8.4.1 5FU Description 
 
Fluorouracil is effective in the palliative management of carcinoma of the colon, 
rectum, breast, stomach, and pancreas. 
 
Molecular formula: C4H3FN2O2. 
Chemical name: 5-fluoro-2,4 (1H,3H)-pyrimidinedione. 
Molecular weight: 130.08. 
 
8.4.2 Clinical Pharmacology 
 
The precise mechanisms of action of fluorouracil have not been fully elucidated.  
The main mechanism is thought to be the binding of the deoxyribonucleotide of 
the drug (FdUMP) and the folate cofactor, N5-10-methylenetetrahydrofolate, to 
thymidylate synthase (TS) to form a covalently bound ternary complex, which 
inhibits the formation of thymidylate from uracil, thereby interfering with DNA 
synthesis.  In addition FUTP can be incorporated into RNA in place of uridine 
triphosphate (UTP), producing a fraudulent RNA and interfering with RNA 
processing and protein synthesis. 
 
8.4.3 Pharmacokinetics and Drug Metabolism 
 
Absorption: Following IV administration of fluorouracil, no intact drug is 
detected in plasma after 3 hours. 
 
Distribution: Fluorouracil is distributed into tumors, intestinal mucosa, bone 
marrow, liver, and other tissues. Despite its limited lipid solubility, the drug 
readily crosses the blood-brain barrier and distributes into CSF and brain tissue. 
Distribution studies in humans and animals have usually shown a higher 
concentration of the drug or its metabolites in the tumor than in surrounding tissue 
or in corresponding normal tissue. It has also been shown that there is a longer 
persistence of fluorouracil in some tumors than in the normal tissues of the host, 
perhaps due to impaired uracil catabolism. From these data, it has been suggested 
that the drug may possibly have some specificity against certain tumors in 
comparison with normal tissues. 
 
Elimination: Following IV administration, the plasma elimination half-life 
averages about 16 minutes (range: 8-20 minutes) and is dose dependent. A small 
portion of fluorouracil is anabolized in the tissues to 5-fluoro-2-deoxyuridine and 
then to 5-fluoro-2-deoxyuridine-5-monophosphate, the active metabolite of the 
drug. The major portion of the drug is degraded in the liver. The metabolites are 


Protocol Version: Amendment 12; 12/21/17 
 
Page 34 of 52 
excreted as respiratory carbon dioxide and as urea, α-fluoro-β-alanine, α -fluoro- 
β -guanidopropionic acid, and α -fluoro- β -ureidopropionic acid in urine. 
Following a single IV dose of fluorouracil, approximately 15% of the dose is 
excreted in urine as intact drug within 6 hours; over 90% of this is excreted in the 
first hour. 
 
8.4.4 Supplier(s) 
 
5FU is considered standard of care for this indication and is commercially 
available. 
 
8.4.5 Dosage Form and Preparation 
 
Inspect for precipitate; if found, agitate or gently heat in water bath. Bolus 
injections are prepared using undiluted drug. Continuous infusions of fluorouracil 
should be prepared for administration via ambulatory infusion pump according to 
the individual institution’s standards. These solutions may be prepared in D5W or 
0.9% NaCl.  
 
The dosage given for this study is 400 mg/m2 bolus and 2,400 mg/m2 continuous 
infusion over 46 hours. 
 
8.4.6 Storage and Stability 
 
Intact vials should be stored at room temperature and protected from light. Slight 
yellow discoloration does not usually indicate decomposition. 5-FU is stable in 
syringes for up to 72 hours. Stability in ambulatory pumps varies according to the 
pump, manufacturer of drug, concentration and dilution. Please refer to 
appropriate reference sources for additional information.  
 
8.4.7 Administration 
 
5-FU will be administered intravenously, first in as a bolus and then as a 
continuous 46 hour infusion.  Fluorouracil should be administered only 
intravenously, taking care to avoid extravasation.  No dilution is required. 
 
8.4.8 Special Handling Instructions 
 
None. 
 
8.5 
Trastuzumab (Herceptin) 
 
8.5.1 Description  
 
Trastuzumab (Herceptin) is a recombinant DNA-derived humanized monoclonal 
antibody that selectively binds with high affinity to the extracellular domain of 


Protocol Version: Amendment 12; 12/21/17 
 
Page 35 of 52 
HER2 (Kd = 5 nM)[45, 46].  The antibody is an IgG1 kappa that contains human 
framework regions with the complementarity-determining regions of a murine 
antibody (4D5) that binds to HER2. 
  
8.5.2 Pharmacokinetics and Drug Metabolism 
 
Trastuzumab 
administered 
once 
weekly 
demonstrated 
dose-dependent 
pharmacokinetics. Mean half-life increased and clearance decreased with 
increasing dose level. The half-life averaged 1.7 and 12 days at the 10 and 500 mg 
dose 
levels, 
respectively. 
Trastuzumab’s 
volume 
of 
distribution 
was 
approximately that of serum volume (44 mL/kg). At the highest weekly dose 
studied (500 mg), mean peak serum concentrations were 377 mcg/mL.  
 
In studies using a loading dose of 4 mg/kg followed by a weekly maintenance 
dose of 2 mg/kg, a mean half-life of 5.8 days (range = 1 to 32 days) was observed. 
Between Weeks 16 and 32, trastuzumab serum concentrations reached a steady 
state with a mean trough and peak concentrations of approximately 79 
microgram/mL and 123 microgram/mL, respectively.  
 
Data suggest that the disposition of Trastuzumab is not altered based on age or 
serum creatinine (up to 2.0 mg/dL). No formal interaction studies have been 
performed.  
 
8.5.3 Supplier(s) 
 
Trastuzumab is the standard of care in this patient population and is commercially 
available.   
 
8.5.4 Dosage Form and Preparation 
 
The diluent provided has been formulated to maintain the stability and sterility of 
trastuzumab for up to 28 days. Other diluents have not been shown to contain 
effective preservatives for trastuzumab. Each vial of trastuzumab should be 
reconstituted with ONLY 20 mL of BWFI, USP, 1.1% benzyl alcohol 
preserved, as supplied, to yield a multi-dose solution containing 21 mg/mL 
Trastuzumab. Use of all 30 mL of diluent results in a lower-than-intended dose of 
trastuzumab. THE REMAINDER (approximately 10 mL) OF THE DILUENT 
SHOULD BE DISCARDED. Immediately upon reconstitution with BWFI, the 
vial of trastuzumab must be labeled in the area marked "Do not use after:" with 
the future date that is 28 days from the date of reconstitution.  
 
Trastuzumab is supplied as a lyophilized, sterile powder nominally containing 
440 mg Trastuzumab per vial under vacuum.  
 
Each carton contains one vial of 440 mg trastuzumab and one 30 mL vial of 
Bacteriostatic Water for Injection, USP, 1.1% benzyl alcohol. NDC50242-134-60.  


Protocol Version: Amendment 12; 12/21/17 
 
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8.5.5 Storage and Stability 
 
Vials of trastuzumab are stable at 2-8°C (36-46°F) prior to reconstitution. Do not 
use beyond the expiration date stamped on the vial. A vial of trastuzumab 
reconstituted with BWFI, as supplied, is stable for 28 days after reconstitution 
when stored refrigerated at 2-8°C (36-46°F), and the solution is preserved for 
multiple use. Discard any remaining multi-dose reconstituted solution after 28 
days. If unpreserved SWFI (not supplied) is used, the reconstituted trastuzumab 
solution should be used immediately and any unused portion must be discarded. 
DO NOT FREEZE HERCEPTIN THAT HAS BEEN RECONSTITUTED. 
  
The solution of trastuzumab for infusion diluted in polyvinylchloride or 
polyethylene bags containing 0.9% Sodium Chloride Injection, USP, may be 
stored at 2-8°C (36-46°F) for up to 24 hours prior to use. Diluted trastuzumab has 
been shown to be stable for up to 24 hours at room temperature (2-25°C). 
However, since diluted trastuzumab contains no effective preservative, the 
reconstituted and diluted solution should be stored refrigerated (2-8°C).  
 
8.5.6 Administration 
 
Treatment may be administered in an outpatient setting by administration of a 6 
mg/kg loading dose by intravenous (IV) infusion over 90 minutes.  The 
maintenance dose is 4 mg/kg every 2 weeks after the loading dose.  DO NOT 
ADMINISTER AS AN IV PUSH OR BOLUS.  Patients should be observed for 
fever and chills or other infusion-associated symptoms. 
 
8.5.7 Special Handling Instructions 
 
None. 
 
 
9.0 
CORRELATIVE STUDIES 
 
9.1 
Archived Tumor Tissue for Analysis by GPS@WUSTL 
 
Archived tissue will be sent for genetic testing though the Genomics and Pathology 
Services at Washington University School of Medicine in St. Louis (GPS@WUSTL).  
The testing evaluates for mutations in 28 genes associated with a variety of cancers 
involving blood, lymph nodes, and solid tumors.  These 28 genes were chosen by 
GPS@WUSTL as they all have implications in cancer therapy.  We hope to identify other 
possible relationships between treatment outcomes in this study and “actionable” gene 
mutations noted from the GPS profiling. These results may be useful to select future 
treatments for the participating patients or help to inform future clinical trials.   
 
Archived specimens from consenting patients will be sent to: 


Protocol Version: Amendment 12; 12/21/17 
 
Page 37 of 52 
Genomic & Pathology Services 
CORTEX Building, 2nd Floor, Room 209  
4320 Forest Park Avenue  
St. Louis, MO 63108 
 
9.2 
Tumor Tissue Correlates – OPTIONAL 
 
Ten consenting patients with accessible metastatic lesions (regardless of whether they are 
receiving FOLFIRINOX alone or with trastuzumab) will undergo paired core biopsies 
from the metastatic lesion at the following time points: 
• baseline (prior to the start of FOLFIRINOX chemotherapy) 
• end of Cycle 2 of FOLFIRINOX 
• time of progression (optional even if the patient consented to the paired biopsies) 
 
These specimens will be used to quantify expression of PD-1, PD-L1, PD-L2, and 
CTLA-4 by IHC on tumor cells and tumor infiltrating leukocytes.  Additionally, mutation 
burden will be determined by whole exome sequencing, with somatic mutations being 
detected by comparing isolated tumor from tissue biopsies to peripheral blood 
mononuclear cells (see Section 9.3). Specimens will be evaluated for tumor infiltrating 
lymphocytes (TIL) to assess possible interplay between these effector and suppressive 
subsets in determining the response or resistance to chemotherapy. 
 
9.2.1 Specimen Collection 
 
Four to 8 cores will be taken at each time point by ultrasound or CT-guidance. 
 
9.2.2 Processing Instructions 
 
Tissues will be collected and submitted to the TPC.  Following processing in the 
TPC, DNA will be extracted and transported to MGI for sequencing and analysis.  
Remaining specimens will be stored per standard pathology protocol. 
 
9.3 
Peripheral Blood Correlates -- OPTIONAL 
 
Ten consenting patients will have blood drawn at the following time points: 
• baseline (prior to start of FOLFIRINOX) 
• Day 1 of Cycles 2, 3, and 4 
• Day 15 of Cycles 1, 2, 3, and 4 
• time of progression 
 
PBMCs will be used to quantify and characterize the immunologic landscape at baseline 
and various time points during treatment.  The T cell repertoire and reactivity to existing 
and induced neoantigens, pre- and post-treatment will be further characterized by a multi-
parametric flow cytometry, spectratyping, and next-generation sequencing. Assessments 
of various cytokines/chemokines throughout treatment will be performed to assess both 
temporal and quantitative expression.  This will be performed using multiplex-based 


Protocol Version: Amendment 12; 12/21/17 
 
Page 38 of 52 
assays and gene expression profiling.  Multiplex analysis and QPCR to assess the 
following cytokines: IFN-gamma, IFN-alpha, IFN-beta, IL-2, TNF-alpha, IL-2, IL-4, IL-
5, IL-13, IL-10, IL-6, TGF-beta as well as chemokines such as CCL2, CXCL9, CXCL10. 
 
9.3.1 Specimen Collection 
 
Sixty mL of blood will be drawn into 6 10-mL BD Vacutainer® sodium heparin 
(green top) tubes at each time point. 
 
9.3.2 Processing Instructions 
 
Specimens will be transported to the Tissue Procurement Core within one hour of 
collection.  PBMC single cell suspensions will be obtained and isolated by Ficoll-
Hypaque gradient centrifugation and cryopreserved in 10% DMSO according to 
standard procedures. 
 
 
 


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10.0 
STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 14 days prior to start of protocol therapy.  Scans 
must be done no more than 4 weeks prior to the start of the protocol therapy.  There is a window 
of +/- 2 days for visits and +/- 5 days for scans.  
 
 
Screening 
Day 1 
of each 
cyclej 
Day 15 
of each 
cyclej 
End of 
every 2nd 
cycle 
End of 
every 3rd 
cycle 
Progression F/Ue 
Informed consent 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
Physical exam 
X 
Xa 
Xa 
 
 
 
 
CBC 
X 
X 
X 
 
 
 
 
CMP 
X 
X 
X 
 
 
 
 
Pregnancy testb 
X 
 
 
 
 
 
 
Echocardiogram or MUGAd, i 
X 
 
 
 
X 
 
 
PET/CT or CTl 
X 
 
 
X 
 
 
 
Archival tissue for GPS@WUSTL 
X 
 
 
 
 
 
 
Confirmation of HER2 expressionc 
X 
 
 
 
 
 
 
Trastuzumabd,h 
 
X 
X 
 
 
 
 
FOLFIRINOXh 
 
X 
X 
 
 
 
 
Research blood collectionp 
Xm 
Xq 
Xr 
 
 
X 
 
Research tissue collectionp 
Xm 
 
 
Xn 
 
Xo 
 
Adverse event assessmentf,g 
 
X ----------------------------------- X 
 
 
a: Cycle 1 Day 1, Cycle 1 Day 15, and Cycle 2 Day 1 only; thereafter at treating physician’s discretion 
b: Women of childbearing potential only 
c: Can be done either via analysis of archival or freshly collected tissue, but will not be necessary if results are available from prior 
analysis.  HER2 status may be pending at initiation of FOLFIRINOX, but must be known prior to starting trastuzumab.  If HER2 is 
positive, patient must have an LVEF ≥ 50% by echocardiogram or MUGA. 
d: HER2-positive patients only 
e: Patients should be followed for survival until death.  This will occur approximately monthly. 
f: Abnormal lab values will be considered AEs and will be captured in the CRFs only if they are clinically significant. 
g: Note that once a patient begins maintenance treatment, s/he will no longer be followed for toxicity. 
h: Please review Section 5.6 for information regarding maintenance therapy. 
i: Echocardiogram/MUGA may have been completed within 60 days prior to the start of protocol therapy, unless the patient has had a 
cardiac intervention within the last 6 months. 
j: Labs may be collected up to 3 days prior to Day 1 and Day 15 of each cycle 
l: CT may be used in follow up even if PET/CT was used at baseline 
m: May take place at any time between confirmation of eligibility and initiation of FOLFIRINOX 
n: End of Cycle 2 only 
o: Optional 
p: 10 consenting patients only 
q: Cycles 2, 3, and 4 only 
r: Cycles 1, 2, 3, and 4 only 
 
 
 
 


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11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
Registration Form 
Eligibility Form 
On-Study Form 
Prior to starting treatment 
Treatment Record 
Every cycle 
Toxicity Form 
Continuous through 30 days post-completion of treatment with 
FOLFIRINOX +/- trastuzumab (toxicities need not be collected on 
patients undergoing maintenance therapy) 
Treatment Summary Form Completion of treatment 
Tumor Measurement Form Baseline, end of every even numbered cycles, and end of treatment 
Correlatives Form 
Baseline 
Day 15 of Cycles 1, 2, 3, and 4 
Day 1 of Cycles 2, 3, and 4 
End of Cycle 2 
Time of progression 
MedWatch Form 
See Section 7.0 for reporting requirements 
Survival Form 
Monthly until death 
 
 
12.0 
MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 8 
weeks. 
 
Response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) 
guideline (version 1.1) [47].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant 
lymph nodes are used in the RECIST criteria. 
 
12.2 
Disease Parameters 
 
Measurable disease:  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as >20 mm by chest 
x-ray, as >10 mm with CT scan, or >10 mm with calipers by clinical exam.  All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 


Protocol Version: Amendment 12; 12/21/17 
 
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Malignant lymph nodes:  To be considered pathologically enlarged and measurable, a 
lymph node must be >15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable disease:  All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor non-measurable) 
since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same patient, these are preferred for selection as target 
lesions. 
 
Target lesions:  All measurable lesions up to a maximum of 2 lesions per organ and 5 
lesions in total, representative of all involved organs, should be identified as target 
lesions and recorded and measured at baseline.  Target lesions should be selected on the 
basis of their size (lesions with the longest diameter), be representative of all involved 
organs, but in addition should be those that lend themselves to reproducible repeated 
measurements.  It may be the case that, on occasion, the largest lesion does not lend itself 
to reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected.  A sum of the diameters (longest for non-
nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and 
reported as the baseline sum diameters.  If lymph nodes are to be included in the sum, 
then only the short axis is added into the sum.  The baseline sum diameters will be used 
as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions:  All other lesions (or sites of disease) including any measurable 
lesions over and above the 5 target lesions should be identified as non-target lesions and 
should also be recorded at baseline.  Measurements of these lesions are not required, but 
the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
12.3 
Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers.  All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks before the beginning of the 
treatment. 


Protocol Version: Amendment 12; 12/21/17 
 
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The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up with the exception of 
PET/CT and CT scans. CT scans may be used in follow up if a PET/CT scan was used at 
baseline. Imaging-based evaluation is preferred to evaluation by clinical examination 
unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam. 
 
Clinical lesions:  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as 
assessed using calipers (e.g., skin nodules).  In the case of skin lesions, documentation by 
color photography, including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have 
slice thickness greater than 5 mm, the minimum size for a measurable lesion should be 
twice the slice thickness.  MRI is also acceptable in certain situations (e.g. for body 
scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement.  Furthermore, the 
availability of MRI is variable globally.  As with CT, if an MRI is performed, the 
technical specifications of the scanning sequences used should be optimized for the 
evaluation of the type and site of disease.  Furthermore, as with CT, the modality used at 
follow-up should be the same as was used at baseline and the lesions should be 
measured/assessed on the same pulse sequence.  It is beyond the scope of the RECIST 
guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases.  Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT:  At present, the low dose or attenuation correction CT portion of a combined 
PET-CT is not always of optimal diagnostic CT quality for use with RECIST 
measurements.  However, if the site can document that the CT performed as part of a 
PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), 
then the CT portion of the PET-CT can be used for RECIST measurements and can be 
used interchangeably with conventional CT in accurately measuring cancer lesions over 
time.  Note, however, that the PET portion of the CT introduces additional data which 
may bias an investigator if it is not routinely or serially performed.   
 
Ultrasound:  Ultrasound is not useful in assessment of lesion size and should not be used 
as a method of measurement.  Ultrasound examinations cannot be reproduced in their 
entirety for independent review at a later date and, because they are operator dependent, it 


Protocol Version: Amendment 12; 12/21/17 
 
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cannot be guaranteed that the same technique and measurements will be taken from one 
assessment to the next.  If new lesions are identified by ultrasound in the course of the 
study, confirmation by CT or MRI is advised.  If there is concern about radiation 
exposure at CT, MRI may be used instead of CT in selected instances. 
 
Endoscopy, Laparoscopy:  The utilization of these techniques for objective tumor 
evaluation is not advised.  However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers:  Tumor markers alone cannot be used to assess response.  If markers 
are initially above the upper normal limit, they must normalize for a patient to be 
considered in complete clinical response. 
 
Cytology, Histology:  These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease. 
 
FDG-PET:  While FDG-PET response assessments need additional study, it is 
sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT 
scanning in assessment of progression (particularly possible 'new' disease).  New lesions 
on the basis of FDG-PET imaging can be identified according to the following algorithm:  
 
• Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion. 
• No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive 
FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this 
is PD.  If the positive FDG-PET at follow-up is not confirmed as a new site of 
disease on CT, additional follow-up CT  scans are needed to determine if there is 
truly progression occurring at that site (if so, the date of PD will be the date of the 
initial abnormal FDG-PET scan).  If the positive FDG-PET at follow-up 
corresponds to a pre-existing site of disease on CT that is not progressing on the 
basis of the anatomic images, this is not PD. 
• FDG-PET may be used to upgrade a response to a CR in a manner similar to a 
biopsy in cases where a residual radiographic abnormality is thought to represent 
fibrosis or scarring.  The use of FDG-PET in this circumstance should be 
prospectively described in the protocol and supported by disease-specific medical 
literature for the indication.  However, it must be acknowledged that both 
approaches may lead to false positive CR due to limitations of FDG-PET and 
biopsy resolution/sensitivity. 
  


Protocol Version: Amendment 12; 12/21/17 
 
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Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image. 
 
12.4 
Response Criteria 
 
12.4.1 Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to 
<10 mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of 
target lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters 
of target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase 
of 20%, the sum must also demonstrate an absolute increase of at least 5 mm.  
(Note:  the appearance of one or more new lesions is also considered 
progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while 
on study. 
 
12.4.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and 
normalization of tumor marker level.  All lymph nodes must be non-pathological 
in size (<10 mm short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions.  Unequivocal progression 
should not normally trump target lesion status.  It must be representative of 
overall disease status change, not a single lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and the 
progression status should be confirmed at a later time by the review panel (or 
Principal Investigator). 


Protocol Version: Amendment 12; 12/21/17 
 
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12.4.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).  The 
patient's best response assignment will depend on the achievement of both 
measurement and confirmation criteria. 
    
For Patients with Measurable Disease (i.e., Target Disease) 
Target Lesions Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
>4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
>4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once >4 
wks. from baseline** 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
Note: 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as “symptomatic 
deterioration.”  Every effort should be made to document the objective progression even after 
discontinuation of treatment. 
 
                                      For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
*  ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised 
 
 
12.4.4 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured 
from the time measurement criteria are met for CR or PR (whichever is first 


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recorded) until the first date that recurrent or progressive disease is objectively 
documented (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are 
first met for CR until the first date that progressive disease is objectively 
documented.  
 
Duration of stable disease:  Stable disease is measured from the start of the 
treatment until the criteria for progression are met, taking as reference the 
smallest measurements recorded since the treatment started, including the baseline 
measurements.  
 
12.4.5 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of 
progression or death, whichever occurs first. 
 
12.4.6 Overall Survival 
 
OS is defined as the time interval from date of diagnosis to date of death from any 
cause. 
 
12.4.7 Response Review 
 
Response rate is the primary endpoint.  All responses will be reviewed by an 
expert(s) independent of the study (such as IRAC) at the study’s completion.  
 
 
13.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, 
the Principal Investigator will provide a Data and Safety Monitoring (DSM) report to the 
Washington University Quality Assurance and Safety Monitoring Committee (QASMC) semi-
annually beginning six months after accrual has opened (if at least five patients have been 
enrolled) or one year after accrual has opened (if fewer than five patients have been enrolled at 
the six-month mark). 
 
The Principal Investigator will review all patient data at least every six months, and provide a 
semi-annual report to the Quality Assurance and Safety Monitoring Committee (QASMC). This 
report will include: 
• HRPO protocol number, protocol title, Principal Investigator name, data coordinator 
name, regulatory coordinator name, and statistician 
• Date of initial HRPO approval, date of most recent consent HRPO approval/revision, date 
of HRPO expiration, date of most recent QA audit, study status, and phase of study 


Protocol Version: Amendment 12; 12/21/17 
 
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• History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• Study-wide target accrual and study-wide actual accrual 
• Protocol activation date 
• Average rate of accrual observed in year 1, year 2, and subsequent years 
• Expected accrual end date 
• Objectives of protocol with supporting data and list the number of participants who have 
met each objective 
• Measures of efficacy 
• Early stopping rules with supporting data and list the number of participants who have 
met the early stopping rules 
• Summary of toxicities 
• Abstract submissions/publications 
• Summary of any recent literature that may affect the safety or ethics of the study  
 
The study principal investigator and Research Patient Coordinator will monitor for serious 
toxicities on an ongoing basis. Once the principal investigator or Research Patient Coordinator 
becomes aware of an adverse event, the AE will be reported to the HRPO and QASMC 
according to institutional guidelines. 
 
 
14.0 
STATISTICAL CONSIDERATIONS 
 
In prior studies of the FOLFOX regimen in patients with gastroesophageal cancer, an objective 
response rate (ORR) of approximately 40% and median survival (MS) of 9.6 months has been 
observed [48-50]. In prior studies in other cancers (i.e. colorectal cancer), the addition of 
oxaliplatin to FOLFIRI increased the ORR in the treated patients by approximately 20% in 
comparison to other standard therapies [11]. We therefore propose a favorable response rate of 
≥60% for the study regimen (FOLFIRINOX). This Phase II study will use a two-stage Simon 
MinMax accrual design to ensure that the total number of the patients exposed to this therapy is 
minimized [51]. A total of 41 evaluable HER2-negative patients will be enrolled in this study.  
HER2-positive patients will not be considered part of the enrollment goal of 41 evaluable 
patients.  Because approximately 20% of these patients are expected to be HER2-positive, we 
anticipate enrolling 65 patients total. 
  
If there is evidence that the true underlying overall response rate (CR, PR) is at least 60% in 
these patients, then the routine administration of the study regimen to patients with this 
malignancy will be warranted and should be investigated in subsequent trials. However, if the 
ORR for FOLFIRINOX is lower than 40% in these patients, then the study should be terminated 
early. Initially, 28 eligible patients will be entered into the study. If there are fewer than 12 
responses in these first 28 patients, the trial will be terminated with the conclusion that there is 
little evidence to suggest that the overall response rate would reach 60%. A sample size of 41 
patients will provide a 56% chance to terminate the trial early if the true response rate is 40% or 
less. If there are 12 or more responses in these first 28 patients, the trial will continue until 41 
patients have been treated. If there are 21 or more responses in these 41 patients, then the study 


Protocol Version: Amendment 12; 12/21/17 
 
Page 48 of 52 
will be completed and future studies utilizing this regimen could be considered. This design has a 
one-sided alpha of 0.10 and a power of 0.90. That is, the probability of declaring a successful 
trial (RR≥60%) is at least 0.90 if the true ORR rate is ≥ 55%; and the probability of declaring an 
unsuccessful trial (RR<40%) is at least 0.90 if the true RR rate is no more than 40%. 
 
The regimen containing FOLFIRINOX plus trastuzumab will only be administered to patients 
who are HER2-positive. To our knowledge that regimen has not been previously administered to 
patients. HER2-positive patient disease response results will not be included in this proposed 
analysis.  Their clinical data will be collected to provide information for possible future studies. 
  
Other Statistical Analysis Plan: Demographic information such as age and race will be tabulated. 
Descriptive statistics, including means, standard deviations and ranges for continuous 
parameters, as well as percentages and frequencies for categorical parameters, will be presented. 
Adverse medical events will be tabulated. NCI toxicity Grade 3 and Grade 4 laboratory 
abnormalities will be listed.  AEs occurring in patients treated with trastuzumab will be included. 
 
Exploratory endpoints: The quantified tumor-associated and systemic biomarkers and immune 
responses obtained through tumor tissue biopsies and peripheral blood at baseline (pre-
chemotherapy), post-chemotherapy, and at disease progression. Paired t-test and/or paired-
sample Wilcoxon Signed Rank test will used to compare the antitumor immune responses before 
and after chemotherapy.  
 
Power Analysis and Sample Size: For the exploratory analysis, approximately 10 patients will be 
needed. The proposed sample size was chosen to minimize the potential risk to study participants 
and was not based on either statistical modeling or methods to obtain adequate power for any 
immune endpoint analysis. However this correlative study design is a pre and post treatment 
comparison with the same patient being measured twice. The magnitude of TSA changes at 
baseline and after therapy is unknown. If we assume the pre-treatment and post-treatment TSA 
magnitude to increase by 50%, with a 10% significance level, we need 10 patients to achieve 
80% of power to detect a post-treatment TSA increase compared with the pre-treatment 
measurements, using a 2-sided one sample paired t test.  
 
 
 
 
 
 


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APPENDIX 1: ECOG Performance Status Scale 
 
 
Grade 
 
 
Description 
0 
Normal activity.  Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory.  Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time.  Ambulatory and capable of all self-care, but 
unable to carry out any work activities.  Up and about more than 50% 
of waking hours. 
3 
 
In bed >50% of the time.  Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
 
4 
100% bedridden.  Completely disabled.  Cannot carry on any self-care.  
Totally confined to bed or chair. 
5 
 
Dead.