Summary

This phase II trial tests how well gemcitabine, cisplatin and nab-paclitaxel given before surgery (neoadjuvant) works in treating patients with pancreatic cancer that can be removed by surgery (resectable) or that is borderline resectable. The standard treatment for resectable and borderline resectable pancreatic cancer is a combination of surgery and chemotherapy. Neoadjuvant therapy has been shown to improve overall survival compared to patients receiving surgery first. Gemcitabine is a chemotherapy drug that blocks the cells from making DNA and may kill tumor cells. Cisplatin is in a class of medications known as platinum-containing compounds. It works by killing, stopping or slowing the growth of tumor cells. Nab-paclitaxel is an albumin-stabilized nanoparticle formulation of paclitaxel, an antimicrotubule agent that stops tumor cells from growing and dividing and may kill them. Nab-paclitaxel may have fewer side effects and work better than other forms of paclitaxel. Gemcitabine, cisplatin and nab-paclitaxel may be an effective neoadjuvant treatment option for patients with resectable or borderline resectable pancreatic cancer.

Objectives

PRIMARY OBJECTIVE:
I. Determine the major pathological response rate, feasibility and safety of biweekly gemcitabine, cisplatin and nab-paclitaxel (GCN) in the neoadjuvant setting for patients with resectable and borderline resectable pancreatic ductal adenocarcinoma.

SECONDARY OBJECTIVE:
I. Determine if neoadjuvant GCN increases tumoral infiltration of lymphocytes with local and systemic phenotypic features that assist in the antitumor immune response.

OUTLINE:

Patients receive nab-paclitaxel intravenously (IV) over 30 minutes, cisplatin IV over 60 minutes, and gemcitabine IV over 30 minutes on days 1 and 15 of each cycle. Treatment repeats every 28 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Patients with stable disease, partial or complete response undergo surgical resection per standard of care. Additionally, patients undergo biopsy at pre-study, computed tomography (CT) or magnetic resonance imaging (MRI) throughout the study and blood sample collection on study.

After completion of study treatment, patients are followed up every 3 months for up to 24 months.

Eligibility

1. Histologically or cytologically confirmed - resectable and borderline resectable pancreatic ductal adenocarcinoma * Resectability will be defined as per National Comprehensive Cancer Network (NCCN) guidelines using cross-sectional imaging (contrast-enhanced computed tomography or magnetic resonance imaging scans of the abdomen, and pelvis) * Decisions about resectability status will be made in consensus at multidisciplinary meetings/discussions Resectable disease will be defined as: * No interface of the tumor with celiac artery, common hepatic artery (CHA), or superior mesenteric arteries (SMA) (and, if present, variants) * Less than 180° interface between tumor and vessel wall of the portal or superior mesenteric veins (SMV) without vein contour irregularity * For tumors of the body and tail of the pancreas, interface with the splenic artery and splenic vein of any degree will be considered resectable disease Borderline resectable disease will be defined as: * To include at least one of the following: ** Tumor abutment < 180° of the superior mesenteric artery or celiac axis ** Solid tumor contact with CHA without extension to celiac artery (CA) or hepatic artery bifurcation allowing for safe and complete resection and reconstruction ** Solid tumor contact with variant arterial anatomy (ex: accessory right hepatic artery, replaced right hepatic artery, replaced CHA, and the origin of replaced or accessory artery) ** Tumor induced narrowing of SMV, portal vein (PV) or SMV-PV of > 180° of the diameter of the vessel ** Short segment occlusion of the SMV, PV or SMV-PV with a suitable PV above and SMV below, for reconstruction ** Solid tumor contact with inferior vena cava ** Biopsy proven N1 disease (regional lymph nodes involved) from pre-referral biopsy or endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA)
2. No distant extrapancreatic disease (M0)
3. Adults > 18 years of age
4. Able to give informed consent
5. Able to adhere to study visit schedule and other protocol requirements
6. Eastern Cooperative Oncology Group (ECOG) performance status of 0 - 1
7. Absolute neutrophil count (ANC) = 1,500 cells/ul
8. Platelet count = 100,000 cells/ul
9. Hemoglobin = 9 g/dL
10. Serum total bilirubin = 1.5 x institutional upper limit of normal (ULN)
11. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) = 2.5 x ULN
12. Albumin = 3 g/dl
13. Creatinine = 1.5 x ULN
14. Male, or a non-pregnant and non-lactating female
15. Women of child-bearing potential - defined as a sexually mature woman who has not undergone hysterectomy - the surgical removal of the uterus or bilateral oophorectomy - the surgical removal of both ovaries or has not been naturally postmenopausal for at least 24 consecutive months, i.e., has had menses at any time during the preceding 24 consecutive months, must commit to true abstinence from heterosexual contact, or agree to use, and be able to comply with, effective contraception without interruption for 28 days prior to starting gemcitabine/cisplatin/nab- paclitaxel (including dose interruptions) until treatment with gemcitabine/cisplatin/nab-paclitaxel is complete
16. Male subjects must practice true abstinence or agree to use a condom during sexual contact with a female of childbearing potential or a pregnant female while on treatment (including during dose interruptions) with gemcitabine/cisplatin/nab-paclitaxel and for 6 months following gemcitabine/cisplatin/nab- paclitaxel discontinuation, even if he has undergone a successful vasectomy