Presently, surgical resection offers the only therapeutic means of cure. However only 15%-20%
of patients are found to have resectable disease at time of initial diagnosis. Of the
patients who undergo curative surgery, most will relapse and eventually succumb to the
disease. 5-year survival rates for node-negative and -positive disease at time of pancreatic
duodenectomy are 25%-30% and 10%, respectively.
Although early phase trials have not offered great success in the metastatic setting for
patients with pancreas adenocarcinoma (PDA), interim analysis of a multicenter, phase 1 trial
with durvalumab presented at European Society for Medical Oncology (ESMO) indicated a disease
control rate of 21%. As mentioned previously, PD-L1 expression correlates with poor prognosis
and decreased CD4+ and CD8+ T cell infiltration within the tumor. Targeting PD-L1 in the
micrometastatic setting (resectable disease), when robust mature immunosuppressive pathways
may not have yet formed, may be the optimum time to investigate anti-PD-L1 therapy. This arm
of the study aims to test if atezolizumab is able to modulate CD8+ T-cell infiltration
compared to historical matched controls. As a secondary endpoint we will also evaluate how
clinical outcomes compare to matched historical controls.
Neoplastic, immune, and stromal cells within PDA reside in a highly dense desmoplastic
environment composed of an extracellular matrix of which hyaluronidase (HA) is an abundant
component. HA is a linear glycosaminoglycan and an integral component of not only PDA tumors,
but has also been shown to accumulate in many solid tumors and is associated with a poor
prognosis and increased immunosuppression. In a preclinical autochthonous mouse model of PDA,
Sunil Hingorani's group demonstrated that the interstitial fluid pressures were unusually
high within tumors that exhibited a high HA content. Furthermore, high HA tumors contained
low vascularity, which compromised delivery of chemotherapeutic agents, such as gemcitabine.
Mice treated with hyaluronidase resulted in decreased HA content and microvasculature
re-expansion within tumors which led to a survival benefit. These preclinical studies led to
early phase clinical studies in metastatic PDA where addition of PEGPH20 to gemcitabine and
nab-paclitaxel (GA) in a randomized phase 2 study demonstrated a survival benefit in patients
with HA-high tumors. The objective response rate for patients who were treated with a
combination of PEGPH20 and GA compared to GA alone was 45% versus 31%, respectively, and the
median overall survival was 11.5 versus 8.5 months, respectively (hazard ratio (HR), 0.96;
95% Confidence Interval (CI), 0.57 to 1.61). A large phase 3 randomized clinical trial in the
high HA stage IV PDA population in the first line setting is ongoing.
PDA likely invokes multiple immune evading mechanisms which result in its aggressive
behavior; it is expected that multiple agents will likely be needed to develop effective
therapies. One such rationale is the combination of PEGPH20 and immune checkpoint blockade to
allow increased cytotoxic T-cell infiltration by increasing vascular permeability and
decreasing interstitial pressure. In a breast cancer preclinical model, PEGPH20 resulted in
an increase accumulation of CD8+ tumor-infiltrating lymphocytes (TIL) by 176% (p=0.0025) and
improved tumor growth inhibition by 38% relative to anti-PD-L1 alone (86% vs 62.4%,
p=0.0024). Other preclinical studies are also demonstrating increased CD8+ T-cell
infiltration with addition of PEGPH20 and improved tumor control in combination with immune
checkpoint blockade. These and other preclinical studies suggest that this combination is
worth pursuing in patients with resectable PDA. The combination is hoped to increase CD8+
T-cell infiltration within the primary tumor for improved immune mediated cytotoxicity and
decreased interstitial pressure to allow improved surgical resections. Hypothetically, the
combination should also be effective in foci of micrometastasis, where the tumor
microenvironment (TME) may not be as mature.
Identified risks for PEGPH20 include musculoskeletal events (MSEs), infusion-related
reactions (IRRs), and thromboembolic (TE) events.
Inclusion Criteria:
- Histological or pathological confirmation of pancreatic adenocarcinoma Cytologic or
histologic proof of PDA needs to be verified by the treating institution pathologist
either from the initial diagnostic biopsy, or from the required pre treatment biopsy
and prior to initiation of any study-related therapy
- Extent of disease. Stage 1 or 2 PDA and patient deemed a surgical candidate by the PI
in consultation with the designated site radiologist and surgeon at the treating
institution
- No prior surgical, systemic or radiotherapy for PDA.
- Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
- Minimum age of at least 18 years.
- Adequate hematological and end-organ function, defined by laboratory test results,
obtained within 14 days prior to initiation of study treatment:
- Tumor accessible for fresh biopsy
- Women of child-bearing potential must have a negative serum pregnancy test at
screening and must agree to use two forms of effective contraception from the time of
the negative pregnancy test and for a minimum of 5 months after the last dose of study
drug. Women will be considered not of child-bearing potential if amenorrheic at least
for one year or have undergone surgical sterilization.
- Fertile men must agree to use an effective method of birth control during the study
and for up to 5 months after the last dose of study drug.
- Willingness and ability to provide written informed consent prior to any study-related
procedures and to comply with all study requirements.
- Able to comply with the study protocol, in the investigator's judgment.
Exclusion Criteria:
- Prior treatment with T-cell co-stimulating or immune checkpoint blockade therapies,
including but not limited to anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic
antibodies.
- Patients who are receiving any other investigational agents concurrently.
- Concomitant treatment with other anti-neoplastic agents (hormonal therapy acceptable).
- Uncontrolled pleural effusion, pericardial effusion, or ascites.
- Patient receiving therapeutic doses of anticoagulation.
- Uncontrolled hypercalcemia or symptomatic hypercalcemia requiring continued use of
bisphosphonate therapy.
- Active or history of autoimmune disease or immune deficiency, including, but not
limited to, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus
erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid
antibody syndrome, Wegener granulomatosis, Sjögren's syndrome, Guillain-Barré
syndrome, or multiple sclerosis, with the following exceptions:
- Patients with a history of autoimmune-related hypothyroidism who are on thyroid
replacement hormone are eligible for the study.
- Patients with controlled Type 1 diabetes mellitus who are on a stable insulin regimen
are eligible for the study.
- Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with
dermatologic manifestations only (e.g., patients with psoriatic arthritis are
excluded) are eligible for the study provided all of following conditions are met:
- Rash must cover < 10% of body surface area.
- Disease is well controlled at baseline and requires only low-potency topical
corticosteroids.
- No occurrence of acute exacerbations of the underlying condition requiring psoralen
plus ultraviolet A radiation, methotrexate, retinoids, biologic agents, oral
calcineurin inhibitors, or high-potency or oral corticosteroids within the previous 12
months.
- History of idiopathic pulmonary fibrosis, interstitial lung disease, organizing
pneumonia (e.g., bronchiolitis obliterans), drug-induced pneumonitis, or idiopathic
pneumonitis, or evidence of active pneumonitis on screening chest CT scan
- History of radiation pneumonitis in the radiation field (fibrosis) is permitted
- Positive HIV test at screening or at any time prior to screening. Patients without a
prior positive HIV test result will undergo an HIV test at screening, unless not
permitted per local regulations.
- Active hepatitis B virus (HBV) infection (chronic or acute)
- Active hepatitis C virus (HCV) infection
- Known active tuberculosis.
- Severe infection within 4 weeks prior to initiation of study treatment
- Treatment with therapeutic oral or IV antibiotics within 2 weeks prior to initiation
of study treatment except for biliary tract infection due to bile duct obstruction
from the pancreas mass. Patients receiving prophylactic antibiotics (e.g., to prevent
a urinary tract infection or chronic obstructive pulmonary disease exacerbation) are
eligible for the study.
- Significant cardiovascular disease (such as New York Heart Association Class II or
greater cardiac disease, myocardial infarction, or cerebrovascular accident) within 12
months prior to initiation of study treatment, seizure disorder, uncontrolled
hypertension, or unstable arrhythmia or unstable angina within 3 months prior to
initiation of study treatment.
- Grade ≥3 hemorrhage or bleeding event within 28 days prior to initiation of study
treatment.
- Prior autologous stem cell, allogeneic stem cell, or solid organ transplantation.
- History of malignancy other than PDA within 2 years prior to screening, with the
exception of those with a negligible risk of metastasis or death (e.g., 5-year overall
survival of > 90%), such as adequately treated carcinoma in situ of the cervix,
nonmelanoma skin carcinoma, localized prostate cancer, ductal carcinoma in situ, or
Stage I uterine cancer. Patients with history of prior malignancies should have risk
of recurrence within 3 years after screening to be less than 90% (to be discussed with
the PI for final determination of eligibility).
- Treatment with a live, attenuated vaccine within 4 weeks prior to initiation of study
treatment, or anticipation of need for such a vaccine during treatment with
atezolizumab or within 5 months after the last dose of atezolizumab.
- History of severe allergic anaphylactic reactions to chimeric or humanized antibodies
or fusion proteins.
- Known hypersensitivity to Chinese hamster ovary cell products or recombinant human
antibodies.
- Known allergy or hypersensitivity to any of the study drugs or any of their
excipients.
- Treatment with systemic immunostimulatory agents (including, but not limited to,
interferon and interleukin 2) within 4 weeks or five half-lives of the drug (whichever
is longer) prior to initiation of study treatment.
- Treatment with systemic immunosuppressive medication (including, but not limited to,
corticosteroids, cyclophosphamide, azathioprine, methotrexate, thalidomide, and
anti-tumor necrosis factor alpha agents) within 2 weeks prior to initiation of study
treatment, or anticipation of need for systemic immunosuppressive medication during
the course of the study, with the following exceptions:
- Patients who received mineralocorticoids (e.g., fludrocortisone), corticosteroids for
chronic obstructive pulmonary disease or asthma, or low-dose corticosteroids for
orthostatic hypotension or adrenal insufficiency are eligible for the study if
receiving equivalent to less than 10mg of prednisone daily.
- Patients who received a one-time pulse dose of systemic immunosuppressant medication
are eligible for the study after approval from the PI has been obtained.
- Inability to swallow medication or malabsorption condition that would alter the
absorption of orally administered medications.
- Pregnant women are excluded from this study because there is an unknown but potential
risk for adverse events in nursing infants secondary to treatment of the mother with
these agents and breastfeeding should be discontinued.
- Major surgical procedure or significant traumatic injury within 14 days of initiating
study.
- Previous radiotherapy to 25% or more of the bone marrow.
- Any other disease, metabolic dysfunction, physical examination finding, or clinical
laboratory finding that contraindicates the use of an investigational drug, may affect
the interpretation of the results, or may render the patient at high risk from
treatment complications in the opinion of the treating investigator.
- Considered ineligible to receive full standard dose modified FOLFIRINOX therapy in the
adjuvant setting.
- Peripheral neuropathy > Grade 1
- History of allergy or hypersensitivity to oxaliplatin, irinotecan, leucovorin,
fluorouracil, pegfilgrastim, or any excipients.
- History of Gilbert's disease or known genotype UGT1A1 * 28/* 28.6.2.35 Inflammatory
disease of the colon or rectum, or severe uncontrolled diarrhea.
Exclusion Criteria for PEGPH20-Containing Arm Patients who meet any of the following
criteria will be excluded from the PEGPH20- containing arm:
- History of transient ischemic attack requiring intervention or treatment, carotid
artery disease requiring interventions or treatment, of cerebrovascular accident
- Evidence of deep vein thrombosis (DVT), pulmonary embolism, or other thromboembolic
event at screening, except:
- Superficial vein thrombosis
- Visceral or splanchnic vein thrombosis if the thrombosis is at a location near the
site of underlying pancreatic ductal adenocarcinoma (PDAC) which may contribute to the
etiology of the thrombus
- Treatment with megestrol acetate within 14 days prior to initiation of study treatment
- Unable to use low-molecular-weight heparin
Criteria to initiate chemotherapy
- Full recovery from surgery and subject able to receive chemotherapy.
- Subjects who have evidence of recurrent disease prior to initiation of chemotherapy
will need to undergo biopsy to prove disease recurrence if deemed safe.
- Hematological: laboratory test results within protocol defined safety limits
