Neoadjuvant mFolfirinox With or Without Preoperative Concomitant Chemoradiotherapy in Patients With Borderline Resectable Pancreatic Carcinoma (PANDAS-PRODIGE 44)

Two Arm, Prospective, Multicenter Randomized Phase II Trial of Neoadjuvant Modified Folfirinox Regimen, With or Without Preoperative Concomitant Chemoradiotherapy in Patients With Borderline Resectable Pancreatic Carcinoma

This is a prospective, randomized phase II trial. The aim of this study is to assess the efficacy of two therapeutics strategies. Patients with borderline-resectable pancreatic cancer (BRPC) will be randomly in two arms : neoadjuvant mFolfirinox followed with or without preoperative chemoradiotherapy with capecitabine.

Study Overview

• Status: Active, not recruiting
• Conditions: Pancreatic Carcinoma
• Intervention / Treatment: Drug: mFolfirinox; Radiation: Chemoradiotherapy; Procedure: surgery; Drug: Adjuvant chemotherapy

Detailed Description

Surgery, especially if followed by adjuvant chemotherapy, offers the only chance of cure of pancreatic cancer. At first diagnosis, after careful assessment, only 10 to 15% of patients are considered to be candidates for surgical resection and about 7% have a potentially resectable disease. These potentially resectable tumors called "borderline resectable pancreatic cancer" (BRPC) are conceptualized as those that involve the mesenteric vasculature to a limited extent and those for which resection, while possible, would likely be compromised by positive surgical margins (R1) in the absence of neoadjuvant treatment. R0 resection is indeed considered as an independent prognostic factor for survival when the surgical procedures, histological examination and definition of microscopic invasion are standardized.

The objectives of neoadjuvant treatments of BRPC is to reduce tumor volume before surgery in order to improve the chances of radical (R0) resection and to reduce the rate of lymph node positivity and recurrences. The primary outcome in published studies is usually R0 resection rate, but these results also depend on the number of margins examined and the definition of microscopic margin involvement. Prospective studies with consistent selection criteria and standardized assessment criteria are needed.

Different neoadjuvant therapeutic strategies have been tested in pilot studies: preoperative chemoradiotherapy or neoadjuvant chemotherapy, followed or not by a preoperative (chemo)radiotherapy. Due to the lack of randomized studies, the best sequence of treatment administration has not been established.

The aim of this prospective, randomized, multicenter, trial is to evaluate the R0 resection rate with neoadjuvant Folfirinox, followed or not by radiochemotherapy for patients with borderline resectable pancreatic cancers.

• Study Type: Interventional
• Enrollment (Actual): 130
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Jean Louis MERLIN, MdPharma; Phone Number: 03 83 65 60 62; Email: jl.merlin@nancy.unicancer.fr
• Study Contact Backup: Name: Marie Aude HERMAN; Phone Number: 03 83 59 86 68; Email: m.herman@nancy.unicancer.fr

Study Locations

• France
  • Bordeaux, France
    • Institut Bergonié
  • Bordeaux, France
    • Polyclinique Bordeaux Nord
  • Clichy, France, 92110
    • Hopital Beaujon
  • Colmar, France
    • Chu Colmar
  • Creteil, France
    • Hôpital Henri Mondor (APHP)
  • Lille, France
    • CHRU Lille
  • Lille, France
    • Centre Oscar Lambret
  • Lyon, France
    • Infirmerie Protestante de Lyon
  • Marseille, France
    • Institut Paoli Calmettes
  • Marseille, France
    • Hôpital La Timone
  • Marseille, France
    • Hôpital Européen Marseille
  • Montpellier, France
    • Institut Du Cancer de Montpellier
  • Nantes, France
    • CHU Nantes
  • Paris, France
    • Institut Mutualiste Montsouris
  • Paris, France
    • Hôpital Cochin (APHP)
  • Paris, France
    • Pitié Salpêtrière (APHP)
  • Pessac, France
    • Hôpital Haut-Lévêque
  • Reims, France
    • CHU Reims
  • Rennes, France
    • Centre Eugene Marquis
  • Rouen, France
    • CHU Rouen
  • Saint Grégoire, France
    • CHP Saint Gregoire
  • Saint-Herblain, France
    • Institut de cancerologie de l'ouest
  • Tours, France
    • CHRU Tours
  • Vandoeuvre-les-nancy, France
    • CHRU Nancy
  • Vandoeuvre-les-nancy, France
    • Institut de Cancérologie de Lorraine
  • Villejuif, France, 94804
    • Hopital Paul Brousse

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• ECOG performance status 0 or 1
• Adult patients ≥ 18 years and ≤ 75 years of age
• Histologic or cytologic proven adenocarcinoma of the pancreas (histologic confirmation of diagnosis is preferred)
• Confirmation by independent multidisciplinary expert review of borderline resectable status, according to NCCN-Clinical Practice Guidelines in Oncology "pancreatic adenocarcinoma", version 1.2015.
• Adequate hematologic function, as follows:
• absolute neutrophil count (ANC) ≥ > 2000/mm3
• platelet count ≥ 100 000/mm3
• haemoglobin ≥ 10 g/dL

• Adequate renal, hepatic and bone marrow function, defined as:

  • Calculated creatinine clearance ≥ 50 mL/min according to MDRD formula
  • Serum total bilirubin ≤ 1.5 times the institutional upper limit of normal. Patients with a biliary short metal stent due to cancer obstruction may be included provided that high-quality imaging is performed before stenting and bilirubin level after stent insertion decreased to ≤ 20 mg/L (≤ 34 µmol/l), and there is no cholangitis.

• Male and female subjects who agree to use highly effective methods of birth control (e.g., condoms, combined oral contraceptives, some intrauterine devices [IUDs], sexual abstinence, or sterilized partner)

  • for male subject: during the treatment and for up to 6 months after the last dose of oxaliplatin or up to 3 months after the last dose of irinotcan.
  • for female subject: during the treatment and for up to 4 months after the last dose of oxaliplatin or up to 3 months after the last dose of irinotcan.
• Ability to provide written informed consent before the start of any study specific procedures
• Patient's legal capacity to consent to study participation and to understand and comply with the requirements of the study.

Exclusion Criteria:

• Any previous treatment of the pancreatic cancer except biliary short metal stenting (chemotherapy, targeted tumor therapy, local ablative therapy, previous irradiation within the actual fields of planned radiotherapy)
• Evidence of distant metastases including ascites
• Evidence of extent of pancreatic cancer beyond that defined as "borderline resectable" : suspicious lymphadenopathy outside of the standard field of resection (i.e., aortocaval nodes, distant abdominal nodes)
• Contraindication for pancreas resection
• Pregnant or breast feeding females
• Patients with known Gilbert's Syndrome or homozygosity for UGT1A1*28 polymorphism
• Uracilemia ≥ 16ng/mL either a partial or complete deficiency in dihydropyrimidine dehydrogenase (DPD)
• Participation in any other clinical trial or treatment with any experimental drug within 28 days before enrolment to the study or during study participation until the end of treatment visit that can be interfering with the objectives of the study
• Previous or concurrent malignant tumor disease other than underlying tumor disease (with the exception of cervical cancer in situ, adequately treated non-melanoma skin cancers, superficial bladder tumors (Ta, Tis, and T1) or any curatively treated without chemotherapy and favourable prognosis tumors without evidence of disease for > 3 years prior to enrolment)

• Any severe and/or uncontrolled medical conditions including but not limited to:

  • Clinically significant cardiovascular or vascular disease : angina pectoris (even controlled), previous myocardial infarction, serious uncontrolled cardiac arrhythmia, chronic heart failure, acute or chronic infectious disease requiring general treatment)
  • Acute and chronic, active infectious disorders that requires systemic treatment
  • Peripheral polyneuropathy > grade 1
  • Any previous inflammatory disease of colon or rectum
  • Any other severe concomitant disease or disorder, which could influence patient's ability to participate in the study and his/her safety during the study e.g. severe hepatic, renal, pulmonary, metabolic, or psychiatric disorders
• Uncorrected disturbed electrolyte balance, in particular hypokalemia or hypocalcemia
• Hypersensitivity against any of the study drugs (gemcitabine, oxaliplatin, irinotecan, 5-fluorouracil, folinic acid), or the ingredients of these drugs (e.g. fructose).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm B; Neoadjuvant chemotherapy with mFolfirinox regimen + concomitant chemoradiotherapy + surgery + adjuvant chemotherapy	Drug: mFolfirinox; oxaliplatin folinic acid irinotecan 5FU oxaliplatin; Radiation: Chemoradiotherapy; conformational external irradiation (50.4 Gy) + capecitabine; Procedure: surgery; 1 to 4 weeks after neoadjuvant treatment according to tumour response; Drug: Adjuvant chemotherapy; Gemcitabine or modified LV5FU (folinic acid+-bolus fluorouracil+ infusional fluorouracil)
Active Comparator: Arm A; Neoadjuvant chemotherapy with mFolfirinox regimen + surgery + adjuvant chemotherapy	Drug: mFolfirinox; oxaliplatin folinic acid irinotecan 5FU oxaliplatin; Procedure: surgery; 1 to 4 weeks after neoadjuvant treatment according to tumour response; Drug: Adjuvant chemotherapy; Gemcitabine or modified LV5FU (folinic acid+-bolus fluorouracil+ infusional fluorouracil)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
To assess the efficacy of two neoadjuvant therapies in patients with borderline resectable pancreatic carcinoma evaluated on histological R0 resection margin rate	up to 7.5 months

Secondary Outcome Measures

Outcome Measure	Time Frame
Evaluate the toxicities associated with chemotherapy and chemoradiotherapy	up to 7 years
Evaluate the proportion of resected patients	up to 7.5 months
Evaluate the response rate to chemotherapy and chemoradiotherapy	up to 7.5 months
Evaluate the histological complete response rate in resected patients.	up to 7.5 months
Evaluate the perioperative mortality rate	up to 8.5 months
Evaluate the perioperative morbidity rate	up to 8.5 months
Evaluate the overall survival	up to 7 years
Evaluate the quality of life	up to 7.5 months
Evaluate the loco-regional relapse-free survival	7 years
Evaluate the metastatic Progression Free Survival	7 years
Evaluate the progression-free survival	7 years

Collaborators and Investigators

• Sponsor: Institut de Cancérologie de Lorraine
• Investigators: Principal Investigator: Thierry CONROY, Pr, Institut de Cancérologie de Lorraine; Study Chair: Jean-Baptiste BACHET, Pr, Groupe Hospitalier Pitie-Salpetriere; Study Chair: Pascal HAMMEL, Pr, Hôpital Paul Brousse - Hôpitaux de Paris (AP-HP)

Study record dates

Study Major Dates

• Study Start (Actual): October 13, 2016
• Primary Completion (Estimated): June 1, 2024
• Study Completion (Estimated): October 1, 2027

Study Registration Dates

• First Submitted: February 3, 2016
• First Submitted That Met QC Criteria: February 3, 2016
• First Posted (Estimated): February 8, 2016

Study Record Updates

• Last Update Posted (Actual): September 28, 2023
• Last Update Submitted That Met QC Criteria: September 26, 2023
• Last Verified: September 1, 2023

More Information

Terms related to this study

• Keywords: Chemoradiotherapy; Neoadjuvant treatment; Borderline; mFolfirinox
• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms by Histologic Type; Neoplasms; Neoplasms by Site; Neoplasms, Glandular and Epithelial; Endocrine System Diseases; Digestive System Neoplasms; Endocrine Gland Neoplasms; Pancreatic Diseases; Carcinoma; Pancreatic Neoplasms
• Other Study ID Numbers: 2014-005681-29

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO