Description:
Colorectal cancer patients with initially unresectable liver-only metastases may be cured
after downsizing of metastases by neoadjuvant systemic therapy. However, the optimal
neoadjuvant induction regimen has not been defined, and no consensus exist on criteria for
resectability.
In this study colorectal cancer patients with initially unresectable liver-only metastases,
as prospectively confirmed by an expert panel according to predefined criteria, will be
tested for RAS and BRAF tumor mutation status and selected by location of primary tumor.
Patients with RAS or BRAF mutant and/or right sided tumors will be randomised between doublet
chemotherapy (FOLFOX or FOLFIRI) plus bevacizumab (schedule 1), and triple chemotherapy
(FOLFOXIRI) plus bevacizumab (schedule 2). Patients with RAS AND BRAF wildtype AND left-sided
primary tumors will be randomized between doublet chemotherapy (FOLFOX or FOLFIRI) plus
either bevacizumab (schedule 1) or panitumumab (schedule 3). Patient imaging will be reviewed
for resectability by a central panel, consisting of at least one radiologist and three
surgeons every assessment. Central panel review will be performed prior to randomization as
well as during treatment, as described in the protocol.
Title
- Brief Title: Treatment Strategies in Colorectal Cancer Patients With Initially Unresectable Liver-only Metastases
- Official Title: Treatment Strategies in Colorectal Cancer Patients With Initially Unresectable Liver-only Metastases CAIRO5 a Randomized Phase 3 Study of the Dutch Colorectal Cancer Group (DCCG)
Clinical Trial IDs
- ORG STUDY ID:
CAIRO5
- SECONDARY ID:
2013-005435-24
- NCT ID:
NCT02162563
Conditions
- Colorectal Cancer
- Liver Metastases
Interventions
Drug | Synonyms | Arms |
---|
FOLFOX/ FOLFIRI with bevacizumab | - bevacizumab, - irinotecan, - leucovorin, - 5-fluorouracil, - oxaliplatin | Arm A: FOLFOX/FOLFIRI & bevacizumab |
FOLFOXIRI with bevacizumab | - bevacizumab, - irinotecan, - oxaliplatin, - leucovorin, - 5-fluorouracil | Arm B: FOLFOXIRI & bevacizumab |
FOLFOX/ FOLFIRI with panitumumab | - panitumumab, - irinotecan, - leucovorin, - 5-fluorouracil, - oxaliplatin | Arm D: FOLFOX/FOLFIRI & panitumumab |
Purpose
Colorectal cancer patients with initially unresectable liver-only metastases may be cured
after downsizing of metastases by neoadjuvant systemic therapy. However, the optimal
neoadjuvant induction regimen has not been defined, and no consensus exist on criteria for
resectability.
In this study colorectal cancer patients with initially unresectable liver-only metastases,
as prospectively confirmed by an expert panel according to predefined criteria, will be
tested for RAS and BRAF tumor mutation status and selected by location of primary tumor.
Patients with RAS or BRAF mutant and/or right sided tumors will be randomised between doublet
chemotherapy (FOLFOX or FOLFIRI) plus bevacizumab (schedule 1), and triple chemotherapy
(FOLFOXIRI) plus bevacizumab (schedule 2). Patients with RAS AND BRAF wildtype AND left-sided
primary tumors will be randomized between doublet chemotherapy (FOLFOX or FOLFIRI) plus
either bevacizumab (schedule 1) or panitumumab (schedule 3). Patient imaging will be reviewed
for resectability by a central panel, consisting of at least one radiologist and three
surgeons every assessment. Central panel review will be performed prior to randomization as
well as during treatment, as described in the protocol.
Detailed Description
Patients will be stratified for resectability of liver metastases (potentially resectable
versus permanently unresectable), serum lactate dehydrogenase (LDH) (normal versus abnormal),
BRAF mutation status (wildtype versus mutated), type of neoadjuvant chemotherapy (FOLFIRI
versus FOLFOX) and hospital of registration.
Patients with RAS and BRAF wildtype and left-sided primary tumors will be randomised between
FOLFOX or FOLFIRI plus either bevacizumab or panitumumab. The choice between FOLFOX or
FOLFIRI is to the discretion of the local investigator, however, the treatment is restricted
to regimens that are specified in the protocol. Patients with RAS or BRAF mutated and/or
right-sided primary tumors will be randomized between FOLFOX/ FOLFIRI (investigator choice)
plus bevacizumab or 5FU, irinotecan, oxaliplatin (FOLFOXIRI) plus bevacizumab.
Patients will be evaluated every 8 weeks by CT scan for disease status. The assigned systemic
treatment should be continued for at least 6 months or earlier in case of resectability,
progression of disease, unacceptable toxicity, or patient refusal. If after 6 months the
panel concludes that the patient is still not resectable, it is highly unlikely that
resectability will be achieved at all. Therefore the chemotherapy regimen may be reconsidered
after 6 months of treatment. These patients should continue with the targeted drug in
combination with chemotherapy, but the chemotherapy may be altered into a less toxic schedule
such as fluoropyrimidine monotherapy. The targeted drug should be continued until progression
or unacceptable toxicity. In patients who will become resectable and undergo secondary
surgery of liver metastases, the total duration of preoperative and postoperative treatment
together should be 6 months, with the chemotherapy schedule being administered according to
the assigned treatment arm. However in these patients the targeted drug (bevacizumab or
panitumumab) should not be continued after surgery.
Trial Arms
Name | Type | Description | Interventions |
---|
Arm B: FOLFOXIRI & bevacizumab | Experimental | Patients with RAS or BRAF mutated and/or right-sided tumors will receive 5FU, irinotecan, oxaliplatin (FOLFOXIRI) and bevacizumab.
Intervention: FOLFOXIRI with bevacizumab | - FOLFOXIRI with bevacizumab
|
Arm A: FOLFOX/FOLFIRI & bevacizumab | Active Comparator | Patients with RAS or BRAF mutated and/or right-sided tumors will receive doublet fluoropyrimidine-containing chemotherapy (FOLFOX or FOLFIRI), plus bevacizumab.
Intervention: FOLFOX/FOLFIRI with bevacizumab | - FOLFOX/ FOLFIRI with bevacizumab
|
Arm D: FOLFOX/FOLFIRI & panitumumab | Experimental | Patients with RAS and BRAF wildtype and left-sided tumors will receive doublet fluoropyrimidine-containing chemotherapy (FOLFOX or FOLFIRI), plus panitumumab.
Intervention: FOLFOX/FOLFIRI with panitumumab | - FOLFOX/ FOLFIRI with panitumumab
|
Arm C: FOLFOX/ FOLFIRI & bevacizumab | Active Comparator | Patients with RAS and BRAF wildtype and left-sided tumors will receive doublet fluoropyrimidine-containing chemotherapy (FOLFOX or FOLFIRI), plus bevacizumab.
Intervention: FOLFOX/FOLFIRI with bevacizumab | - FOLFOX/ FOLFIRI with bevacizumab
|
Eligibility Criteria
Inclusion Criteria:
- Histological proof of colorectal cancer
- Initially unresectable metastases confined to the liver according to CT scan, obtained
≤3 weeks prior to registration. Unresectability should be confirmed by the liver
expertpanel. Patients with small (≤ 1 cm) extrahepatic lesions that are not clearly
suspicious of metastases are eligible
- Known mutation status of RAS and BRAF
- WHO performance status 0-1 (Karnofsky performance status ≥ 70)
- Age ≥ 18 years
- No contraindications for liver surgery
- In case of primary tumor in situ: tumor should be resectable
- In case of resected primary tumor: adequate recovery from surgery
- Adequate organ functions, as determined by normal bone marrow function (Hb ≥ 6.0
mmol/L, absolute neutrophil count ≥ 1.5 x 109/L, platelets ≥ 100 x 109/L), renal
function (serum creatinine ≤ 1.5x ULN and creatinine clearance, Cockroft formula, ≥ 30
ml/min), liver function (serum bilirubin ≤ 2 x ULN, serum transaminases ≤ 5x ULN)
- Life expectancy > 12 weeks
- Expected adequacy of follow-up
- Written informed consent
Exclusion Criteria:
- Extrahepatic metastases, with the exception of small (≤ 1 cm) extrahepatic lesions
that are not clearly suspicious of metastases
- Unresectable primary tumor
- Serious comorbidity or any other condition preventing the safe administration of study
treatment (including both systemic treatment and surgery)
- Major cardiovascular events (myocardial infarction, severe/unstable angina, congestive
heart failure, CVA) within 12 months before randomisation
- Uncontrolled hypertension, or unsatisfactory blood pressure control with ≥3
antihypertensive drugs
- Previous systemic treatment for metastatic disease; previous adjuvant treatment is
allowed if completed ≥ 6 months prior to randomisation
- Previous surgery for metastatic disease
- Previous intolerance of study drugs in the adjuvant setting
- Pregnant or lactating women
- Second primary malignancy within the past 5 years with the exception of adequately
treated in situ carcinoma of any organ or basal cell carcinoma of the skin, or second
primary colorectal cancer.
- Any concomitant experimental treatment.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Progression-free survival (PFS) |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | Time from registration until progression or death whichever comes first |
Secondary Outcome Measures
Measure: | R0/1 secondary resection rate |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | R0/1 secondary resection rate in each of the 4 study arms upon neoadjuvant treatment with chemotherapy plus targeted therapy. |
Measure: | Median overall survival |
Time Frame: | 8 years after last patient in study |
Safety Issue: | |
Description: | From date of randomisation to death or last known to be alive |
Measure: | Response rate |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | Response according to RECIST 1.1 |
Measure: | Toxicity (AE) |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | Patients will be evaluated for Adverse Events at the start of each treatment cycle according to CTCAE version 4.0. |
Measure: | Pathological complete response rate (pCR) |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | Pathological complete response rate (pCR) of the resected lesions |
Measure: | Postoperative morbidity |
Time Frame: | After surgery during two months |
Safety Issue: | |
Description: | Patients will be evaluated for surgical morbidity during 2 months. Postoperative morbidity will be scored according 'Clavien Dindo Grade'. |
Measure: | Correlation of evaluation by the panel with outcome |
Time Frame: | 2 years after last patient in study |
Safety Issue: | |
Description: | CT-scans will be reviewed for liver resectability by expert panel before randomisation and during neo-adjuvant treatment (every 8 weeks). |
Details
Phase: | Phase 3 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | Dutch Colorectal Cancer Group |
Trial Keywords
- Colorectal cancer
- Chemotherapy
- Anti-EGFR
- Liver metastases
- R0 R1 liver resection
- Resectability of liver
- Liver expert panel
Last Updated
February 18, 2019