A multi-institutional, single arm pilot study of antibiotics and pembrolizumab, following chemotherapy for the treatment of surgically resectable pancreatic cancer.
Phase: Pilot Study Objectives Primary Objectives: • To determine the change in immune activation in pancreatic tumor tissue following treatment with antibiotics, pembrolizumab. Secondary Objectives: * To establish the safety and feasibility of pre-operative antibiotics in combination with pembrolizumab following chemotherapy * To describe the preliminary anti-tumor activity of pre-operative therapy with antibiotics, pembrolizumab, and chemotherapy in subjects with resectable pancreatic cancer Exploratory Objectives: * To determine immunophenotypic changes in the pancreatic tumor microenvironment following depletion of the microbiome using antibiotics and inhibition of PD-1 with pembrolizumab and to correlate these changes with tumor response as measured by histologic regression. * To determine changes in systemic immunogenicity as measured in PBMCs harvested from blood following depletion of the microbiome using antibiotics and inhibition of PD-1 with pembrolizumab and to correlate these changes with tumor response as measured by histologic regression. * To determine changes in the microbiome as measured in tumor and stool following treatment with chemotherapy, antibiotics, and pembrolizumab and to correlate these changes with tumor response as measured by histologic regression. * To correlate changes in immune activation with changes in microbiome abundance and composition. Methodology: Multi-center, open label, single arm pilot study Endpoint Primary endpoint: • Achievement of immune response, defined as activation of one or more of the following T cell markers: HLA-DR, CD38, CD25, KI67, and CD69; activation is defined as an increase of 20% or more over baseline in percentage of T cells expressing the marker. Secondary Endpoints: * Adverse events graded according to the NCI's Common Terminology Criteria for Adverse Events (CTCAE v5.0). * R0 resection rate and histologic regression score * Histologic regression score * Overall response rate (ORR) * Overall survival rate (OS) Exploratory Endpoints: * Immune changes within blood and tissue following treatment and correlate with clinical endpoints * Microbiome changes in tissue and stool following treatment and correlate with clinical and immunologic endpoints Study Duration 5 years Participant Duration 6 months Enrollment Period 2 years Duration of IP administration 1 week Study Centers/Sites Multicenter: 1. Mount Sinai Health System, Tisch Cancer Institute 2. TBD 3. TBD Number of participants: 25 participants with 11 accrued at Mount Sinai Health over 2 years Description of Study Agent/Procedure: Ciprofloxacin 500 mg PO BID days 63-84. Metronidazole 500 mg PO TID days 63-84. Pembrolizumab 200 mg IV day 70. 5-Fluorouracil 2400 mg/m2 IV 46-48 hours infusion days 1, 15, 28, 42, 56. Leucovorin 400 mg/m2IV days 1, 15, 28, 42, 56. Irinotecan 150 mg/m2IV days 1, 15, 28, 42, 56. Oxaliplatin 85mg/m2IV days 1, 15, 28, 42, 56. Key Procedures: Tumor biopsy, surgical resection, blood draws, and stool collection. Statistical Analysis: The primary efficacy endpoint is the achievement of immune response, defined as activation of one or more of the following markers: HLA-DR, CD38, CD25, KI67, and CD69; activation is defined as an increase of 20% or more over baseline in percentage of cells expressing the marker. With 25 patients, a 95% exact confidence interval around the immune response rate will be no more than 0.46 units wide.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
25
Pre-treatment tumor biopsy
Patients will receive FOLFIRINOX chemotherapy every 2 weeks for 5 cycles. One cycle of mFOLFIRINOX = 14 days. Cycles of mFOLFIRINOX are delivered as follows\*: * Oxaliplatin: 85 mg/m2 IV over 2 hours on Day 1, followed by, * Irinotecan: 150 mg/m2 IV over 90 minutes on Day 1, followed by, * Leucovorin\*\*: 400 mg/m2 IV over 2 hours on Day 1, followed by, * 5FU: 2400 mg/m2 IV over 46-48 hours on Days 1-3
Ciprofloxacin and metronidazole will be initiated 7 days following 5th dose of FOLFIRINOX. Subjects will self-administer ciprofloxacin 500mg PO BID on days 1-21. Participants will be instructed to take the antibiotics with food to minimize stomach upset and to administer at the same time each day. Treatment with antibiotics will continue for 21 days unless there is unacceptable toxicity or disease progression. Subjects will record date, time and number of tablets they take on provided drug diaries.
Icahn School of Medicine at Mount Sinai
New York, New York, United States
RECRUITINGAchievement of overall immune response
Achievement of overall immune response, defined as activation of one or more of the following T cell markers: HLA-DR, CD38, CD25, KI67, and CD69; activation is defined as an increase of 20% or more over baseline in percentage of T cells expressing the marker. Comparison to be made between tissue biopsy taken following chemotherapy (and prior to antibiotics and pembrolizumab) and definitive surgical specimen.
Time frame: at day 43
Achievement of overall immune response
Achievement of overall immune response, defined as activation of one or more of the following T cell markers: HLA-DR, CD38, CD25, KI67, and CD69; activation is defined as an increase of 20% or more over baseline in percentage of T cells expressing the marker. Comparison to be made between tissue biopsy taken following chemotherapy (and prior to antibiotics and pembrolizumab) and definitive surgical specimen.
Time frame: day 102
Adverse event incidence rate
Adverse events will be graded according to the NCI's Common Terminology Criteria for Adverse Events (CTCAE v5.0)
Time frame: at 6 months
R0 resection rate
The R0 Resection Rate (percent) is defined as the percentage of resected specimen that have lateral and deep margins that are free of neoplasia under microscopic visualization.
Time frame: at 3-4 months
Proportion of participants with histologic regression score 0, 1, or 2
The histologic regression score is defined as the proportion of patients with Grade 0, 1 or 2 histologic tumor response (Grade 0: no viable tumor; Grade 1: \<5% viable tumor cells; Grade 2: ≥5% viable tumor cells)
Time frame: at 3-4 months
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Ciprofloxacin and metronidazole will be initiated 7 days following 5th dose of FOLFIRINOX. Subjects will self-administer metronidazole 500mg PO every 8 hours on days 1-21. Participants will be instructed to take the antibiotics with food to minimize stomach upset and to administer at the same time each day. Treatment with antibiotics will continue for 21 days unless there is unacceptable toxicity or disease progression. Subjects will record date, time and number of tablets they take on provided drug diaries.
Pembrolizumab will be initiated 7 days post initiation of antibiotics. Subjects will receive a flat dose of pembrolizumab 200mg IV over 30 minutes.
Following completion of 21 days of antibiotics, participant will undergo repeat imaging studies. If there is no progressive disease which renders participant surgically unresectable (based on NCCN guidelines 2.2021), subject will undergo definitive surgical resection.
Overall response rate (ORR)
The overall response rate (ORR) is defined as the proportion of patients who achieve complete response (CR) or partial response (PR) as per the RECIST 1.1 criteria.
Time frame: at 3-4 months
Overall survival rate (OS)
Overall survival rate (OS) is defined as the duration of time from initial pembrolizumab administration to the date of death from any cause. Subjects who are alive or lost to follow-up as of the data analysis cutoff date will be censored for OS. The censoring date will be determined from the subject's date of last examination or data analysis cutoff date, whichever event occurs first.
Time frame: at 5 years