Phase I Trial of Consolidative Radiotherapy with Concurrent Bevacizumab, Erlotinib and Capecitabine for Unresectable Pancreatic Cancer
Phase I Trial of Consolidative Radiotherapy with Concurrent Bevacizumab, Erlotinib and Capecitabine for Unresectable Pancreatic Cancer
Awalpreet S. Chadha 0
Heath D. Skinner 0
Jillian R. Gunther 0
Mark F. Munsell
Prajnan Das 0
Bruce D. Minsky 0
Marc E. Delclos 0
Marilyn Clemons 0
Geena George 0
Pankaj K. Singh 0
Matthew H. Katz
Jason B. Fleming
Milind M. Javle 1
Robert A. Wolff 1
Gauri R. Varadhachary 1
Christopher H. Crane 0
Sunil Krishnan 0
Gregory Lesinski, The Ohio State University,
0 Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston , Texas, United States of America, 2 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston , Texas, United States of America, 3 Department of Pathology, The University of Texas MD Anderson Cancer Center , Houston , Texas, United States of America, 4 Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , United States of America
1 Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , United States of America
Data Availability Statement: All relevant data are
within the paper and its Supporting Information files.
Funding: Genentech, Inc. funded SK. The funder
approved the phase I concept but had no role in data
collection and analysis, decision to publish, or
preparation of the manuscript. This work was
supported in part by Cancer Center Support (Core)
Grant P30 CA16672 to The University of Texas MD
Anderson Cancer Center for use of the Clinical Trials
Support Resource and the John E. and Dorothy J.
Harris Endowed Professorship to SK.
able pancreatic cancer.
To determine the safety, tolerability and maximum tolerated dose (MTD) of addition of erlotinib to bevacizumab and capecitabine-based definitive chemoradiation (CRT) in unresect
Seventeen patients with CT-staged, biopsy-proven unresectable pancreatic cancer were
enrolled between 3/2008 and 10/2010. Prior chemotherapy was permitted. Two patients
each were enrolled at dose levels (DLs) 1–4 and 9 patients at DL 5. All patients received
50.4 Gy (GTV only) in 28 fractions with concurrent capecitabine, bevacizumab and erlotinib.
Dose of each drug was escalated in 5 DLs using the continual reassessment method. Beva
cizumab was escalated from 5mg/Kg q2weeks (DLs 1–4) to 10mg/Kg q2weeks (DL 5); daily
erlotinib from 100mg/day (DLs 1–2) to 150 mg/Kg (DLs 3–5); and capecitabine from 400mg/
m2 twice daily on days of radiation (DL 1) to 650mg/m2 (DLs 2–3) to 825 mg/m2 (DLs 4–5).
Reassessment for potential resection was performed 6–8 weeks later.
Competing Interests: PD an SK received funding
from Genentech, Inc. for this trial and a concurrent
trial for rectal cancer. This does not alter the authors'
adherence to PLOS ONE policies on sharing data
Sixteen patients received gemcitabine-based chemotherapy prior to CRT. With a median
clinical follow-up of 10 months, no grade 3 toxicities were observed in DLs 1–4. Three
(33%) patients at DL 5 developed a grade 3 acute toxicity (2 diarrhea, 1 rash). No grade 4 or
5 toxicities were seen. DL 4 was selected as the MTD; therefore, the recommended doses
in combination with radiation are: bevacizumab, 5mg/Kg q2weeks; erlotinib, 150 mg/Kg
daily; and capecitabine, 825mg/m2 BID. Median survival was 17.4 months. Of the five
patients who underwent resection, 4 were originally deemed locally advanced and 1 was
borderline resectable. Three patients had excellent pathological response (2 complete
response and 20% viable tumor) at surgery, and the 2 patients with complete response are
still alive at 61 and 67 months of follow up with no local or distant failures.
This chemoradiation regimen at the recommended dose levels is safe and tolerable for patients with unresectable pancreatic cancer and merits further evaluation.
Pancreatic cancer is the third most common gastrointestinal (GI) malignancy and has a 5 year
overall survival (OS) rate of less than 5%.[
] Unfortunately, the absence of validated
screening biomarkers and/or imaging tools coupled with the inherent aggressiveness of the tumor
prevent detection at an early stage, and at least half of all patients have radiographically
detectable metastatic disease at diagnosis. Margin-negative surgical resection is the only
potentially curative treatment for prima facie non-metastatic patients, and even they have a 5 year
OS rate of only 15–25%,[
] with high rates of both local and distant progression. Patients with
unresectable disease are generally treated with chemotherapy followed by chemoradiation
therapy; treatment outcomes are universally poor with a 5 year OS rate of less than 10%. In contrast
to the commonly held belief that pancreatic cancers rapidly disseminate via hematogenous
metastases to the liver or intra-abdominal spread along the peritoneal lining, a recent autopsy
series suggested that close to one-third of patients with pancreatic cancer die due to locally
destructive disease rather than distant metastasis. Thus, improving local control is critical to
improve overall treatment outcomes for patients with unresectable pancreatic cancer. [
The role of radiation therapy in optimization of local control is even more important in the
current setting, where advances in combination cytotoxic chemotherapy have improved distant
In recent years, there have been advances in our understanding of the genetic, biochemical
and cellular makeup of pancreatic cancer. Pancreatic cancers overexpress epidermal growth
factor (EGFR), and the presence of this receptor has been shown to correlate with negative
] After ligand activation, members of the EGFR family dimerize,
trans-autophosphorylate each other, and subsequently activate a wide variety of downstream signals
controlling cell proliferation, resistance to apoptosis, invasion, angiogenesis and metastasis.
] Erlotinib is an orally administered human EGFR tyrosine kinase inhibitor which prevents
autophosphorylation of the receptor dimer and activation of downstream targets. The utility of
this agent has been proven in the setting of locally advanced, unresectable or metastatic
pancreatic cancer with a large randomized phase III trial of 569 patients that showed a modest overall
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survival benefit (6.24 vs. 5.91 months, p = 0.04) with the addition of erlotinib to gemcitabine.
Increased levels of vascular endothelial growth factor (VEGF) expression in tumors has
been correlated with increased rates of recurrence and metastasis.[
] Bevacizumab, a
humanized anti-VEGF monoclonal antibody has been studied extensively for possible use as
an anti-angiogenic agent in pancreatic cancers patients. Our group has previously
demonstrated that addition of bevacizumab to concurrent capecitabine-based radiation is safe in a
phase I trial of locally advanced pancreatic cancer (LAPC) patients.[
] Inhibition of VEGF
signaling in combination with radiation is believed to enhance both the endothelial cell and
tumor cell toxicity.[
] However, there is evidence to suggest that, in the context of VEGF
blockade, angiogenic signaling can be mediated by other tyrosine kinase signaling cascades,
] We hypothesized that simultaneous targeting of VEGF and EGFR
pathways, in combination with chemoradiation, would lead to increased response rates in patients
with pancreatic cancer.
Therefore, we designed a phase I trial to assess the safety and tolerability of adding erlotinib
and bevacizumab to capecitabine-based definitive chemoradiation for patients with
unresectable pancreatic cancer.
This protocol was approved and monitored by the University of Texas MD Anderson Cancer
Center institutional review board. A total of 17 patients with unresectable pancreatic cancer
(borderline and locally advanced) treated at our institution were enrolled in this study from
March 10, 2008 to October 25, 2010. Inclusion criteria are shown in Table 1 and exclusion
criteria are shown in Table 2. A tumor was deemed locally advanced if it extended to the celiac
axis, the superior mesenteric artery (SMA) (>180 degrees encasement) or the aorta or occluded
the superior mesenteric -portal venous (SMV-PV) confluence, based on review of imaging. For
borderline pancreatic cancer (BRPC), we used the MD Anderson Cancer Center (MDACC)
definition of BRPC which included tumors with segmental occlusion of the SMV/PV
confluence, < 180° abutment of the SMA and celiac axis and abutment or short segment encasement
of the common hepatic artery, typically at the origin of the gastroduodenal artery.
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The primary endpoint of the study was the safety and tolerability of erlotinib and bevacizumab
in combination with capecitabine-based definitive chemoradiation in the study patient
population. Secondary endpoints included radiographic and pathologic response rates, rate of
margin-negative resection in patients deemed unresectable at initiation of treatment, disease-free
survival, and OS.
A quality of life questionnaire was administered at baseline and weekly throughout
Systemic therapy treatment plan
Patients were sequentially treated with 5 escalating dose levels (table 3), in cohorts of size 2
starting at the lowest dose. The maximum tolerated dose (MTD) was determined from these 5
dose combinations using the continual reassessment method.[
] Capecitabine was given
orally twice a day on the days of radiation, with the dose increased from 400 mg/m2 in dose
level 1, to 825 mg/m2 in dose level 5. Erlotinib was given orally once a day throughout the
course of chemoradiation. The dose was increased from 100 mg in dose levels 1–2 to 150 mg
in dose levels 3–5. Bevacizumab was administered intravenously every 2 weeks at 5mg/kg
(dose levels 1–4) or 10mg/kg (dose level 5) for a total of 3 doses, starting on the first day of
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Bevacizumab (mg/Kg q2w)
Radiation therapy technique
Patients were treated over a period of 5–6 weeks to a total dose of 50.4 Gy in 28 fractions. The
primary tumor and any clinically enlarged lymph nodes were targeted using either a 3-D
conformal radiation therapy or intensity modulated radiation therapy (IMRT). For 3-D conformal
planning, a 2–4 field technique was used (margin from tumor to block edge 2 cm radial, 3 cm
cranial/caudal), and the total dose was prescribed to the 95% isodose line. Only one patient was
treated with an IMRT boost; for this, a multiple beam technique was used to ensure 95% dose
coverage to the GTV.
Dose modifications for toxicity
Toxicities were evaluated using the National Cancer Institute Common Terminology
Criteria for Adverse Events, version 3.0. Capecitabine was withheld in patients who developed
grade 2 or greater neutropenia, hand-foot syndrome, mucositis or gastrointestinal (GI)
toxicities unresponsive to medical management and was restarted following recovery to grade 1.
The dose was adjusted based on the number of episodes of grade 2 or higher events: dose was
reduced to 75% and 50% of starting dose after the first or second occurrence, respectively,
and discontinued after the third occurrence. Once doses were reduced they were never
increased at a later time. Bevacizumab infusion was interrupted for any grade 3 or greater
toxicity suspected to be related to the drug; treatment was withheld until the toxicity resolved
to grade 1 and then continued without dose adjustment. Erlotinib was withheld if the
patients developed grade 3 diarrhea or GI bleeding, an intolerable rash or a pulmonary event
possibly related to the drug (pending further evaluation) and was restarted at a reduced dose
following recovering to grade 2 or lower toxicity. Dose re-escalation was allowed for
intolerable rash but not for grade 3 diarrhea. Erlotinib was permanently discontinued if a patient
developed grade 4 diarrhea, rash or if the pulmonary event was determined to be related to
Restaging using pancreatic protocol CT, chest X-ray and CA19-9 along with surgical evaluation
was performed 5–6 weeks after completion of chemoradiation. All patients with stable or
responding disease were offered the option of either surgical resection (if technically resectable)
with maintenance therapy or maintenance bevacizumab and erlotinib (at the same dose-level
as used during chemoradiation) until disease progression. Further follow-up was scheduled
every 2 months. Locoregional recurrence was defined as any recurrence at or adjacent to the
initial primary site or in the regional lymph nodes as determined by abdominal-pelvic CT
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Smad4 immunostaining of diagnostic specimens
Out of the 17 specimens examined, only 11 contained adequate tumor cellularity for analysis,
six of these were pre-treatment fine needle aspirates. Immunohistochemical staining for
SMAD4 was performed either on 5-μm unstained sections from biopsy FFPE blocks or
cytology smears from fine needle aspiration specimens. Following deparaffinization, antigen
retrieval was performed on the tissue sections at 100°C in a steamer containing 10 mmol
TrisEDTA buffer for 35 min. The sections were then washed and immersed in anti-SMAD4
antibody (Clone B-8, 1:100 dilution, Santa Cruz Biotechnology) at 35°C for 15 min. Subsequently,
the sections were immersed in 3.0% hydrogen peroxidase at 35°C for 5 min to block the
endogenous peroxidase activity. A polymer enhancer solution was then applied to the slides and
incubated at 35°C for 8 minutes. The sections were then incubated with secondary Poly-HRP
anti-mouse/anti-rabbit immunoglobulin at 35°C for 8 min. Diaminobenzidine (DAB) was
used as a chromogen and DAB enhancer was applied, and hematoxylin was used for
counterstaining. Each specimen slide was scored as either Smad4 (Dpc4) positive or Smad4 (Dpc4)
negative by a cytopathologist.
Standard response criteria were used to assess tumor response. OS and disease-free survival
were estimated using the Kaplan-Meier method. OS was calculated from the start of
chemoradiation to the time of death or last follow-up on record if death was not observed. Disease-free
survival was calculated from the start of chemoradiation to the date of documented disease
progression (locoregional or distant). If no progression was observed, patients were censored at
the date of last follow-up. Advancement of dose levels was determined based on the continual
reassessment method where the maximum acceptable DLT rate was 25%.[
] The a priori
DLT probabilities for the 5 dose levels were assumed to be 0.03, 0.05, 0.10, 0.15, and 0.20. An
added measure of safety was employed such that if there was more than a 0.95 probability that
the DLT rate of the first dose exceeded 25% the study would be stopped.
Patient and tumor characteristics are shown in Table 4 and Fig 1 details patient progression
through the trial. Most patients had locally advanced tumors at the time of protocol entry
(76.4%), with two patients (11.8%) having borderline resectable tumors due to venous
involvement, one patient (5.9%) unable to undergo surgery secondary to comorbidity, and
one patient (5.9%) with gross residual disease following an R1 resection. The majority
(94.1%) of patients were treated with gemcitabine-based chemotherapy prior to
chemoradiation, with a median of 4 cycles (range 3–10). After chemoradiation, unresectable patients
were treated with maintenance therapies including erlotinib and bevacizumab (2 patients);
gemcitabine and cisplatin (2 patients); FOLFOX (2 patients; of these, one was treated with
palliative intent due to hepatic metastasis); capecitabine and erlotinib (1 patient);
capecitabine and oxaliplatin (1 patient); single agent erlotinib (1 patient); palliative surgery (1
patient); and single agent 5-FU (1 patient). For the patients who underwent surgery (5
patients), maintenance therapies included single agent capecitabine (1 patient), gemcitabine
and cisplatin (2 patients), and observation (2 patients). The median clinical and radiological
follow up times from completion of chemoradiation were 10 months (range, 1–69 months)
and 9 months (range, 1–69 months) respectively.
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Toxicities separated by dose level (DL) are shown in Table 5. No grade 3 toxicities were
observed in dose levels 1–4, while three patients in group 5 had grade 3 toxicity. One patient
developed an acneiform rash that covered >30% of his body after 10 fractions of radiation. The
patient was prescribed oral antibiotics and erlotinib was stopped for five days. The rash
improved and the patient resumed erlotinib at fraction 15. Two patients developed grade 3
diarrhea. Neither patient required hospitalization. One patient required discontinuation of
capecitabine two days prior to therapy completion and a dose reduction in erlotinib; this
patient also experienced grade 2 HFS. The second patient had capecitabine discontinued after
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fraction 23 and erlotinib discontinued after fraction 25. For both patients, the diarrhea resolved
by the end of radiation. For patients with GI toxicity (three patients with grade 2 diarrhea and
four patients with grade 2 nausea), the dose of capecitabine was reduced only in one patient
with grade 2 nausea; in others dose reduction was not required as the nausea and diarrhea was
responsive to medical management (as specified per methods). Based on these results, DL 4,
with a posterior probability of DLT of 0.122, was selected as the maximum tolerated dose. DL5
had a posterior probability of 0.263 which was slightly greater than the pre-defined maximum
acceptable limit of 0.25. Toxicities separated by type are shown in Table 6. The most common
toxicities overall included: grade 1 anorexia (94.1%), nausea (88.2%), fatigue (76.5%), diarrhea
and rash (70.6% each). Quality of life metrics were compared for patients in DL1-4 and DL5
and were non-significant.
All seventeen patients had stable disease based on RECIST criteria, and no correlation with
dose levels was observed.
Surgical resection and pathologic response
Five patients (29.4%) were felt to be surgically resectable following radiotherapy based on
radiographic evidence of sufficient disease response. At time of diagnosis, only one was deemed
borderline resectable; the remaining patients were locally advanced. Four of these patients
received dose level 5, and one patient received dose level 2. Of the patients who were able to
undergo resection, two patients had a complete pathologic response, one patient had <20%
viable tumor, one patient had 90% viable tumor and one patient had a resection at an outside
facility (unknown response to therapy). All patients had negative resection margins. Of the 2
patients with a complete pathological response, there have been no disease recurrences or
deaths at follow-up of 61 and 67 months after completion of chemoradiation. The remaining
three resected patients developed distant metastases at 5, 12 and 38 months.
Survival outcomes and patterns of progression
Median survival from start of chemoradiation was 17.4 months (95% CI, 7.5 to 26.7 months)
with a 1 year overall survival of 59% (Fig 2a). Thirteen (76%) patients had progressive disease.
The median progression-free survival was 8.1 months (95% confidence interval, CI, 3.3 to 23.5
months). The first site of progression was locoregional in three (18%) patients, distant in seven
(41%) patients, and synchronous locoregional and distant sites in three (18%) patients. The
Fig 2. Kaplan-Meier estimates of (a) overall survival, (b) distant progression-free survival and (c) local progression-free survival
from start of chemoradiation therapy.
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other four patients (23%) did not have any evidence of locoregional or distant disease
progression at the time of last follow-up. Median time to distant failure was 12.1 months (95% CI, 3.7
to 38.9 months), with a 1 year freedom from metastasis rate of 55%. The median distant
progression-free survival was 8.1 months (95% CI, 3.7 to 26.6 months) (Fig 2b). The most
common initial site for distant metastasis was the liver (7 patients, 41%). Other initial sites of
distant metastasis included: lung and peritoneal carcinomatosis (2 patients each, 12%) and
non-regional lymphadenopathy (1 patient, 6%). Median time to locoregional progression was
21.6 months (95% CI, 8.8 to 16.9 months) with a 1 year freedom from progression rate of 77%.
The median local progression-free survival was 16.9 months (95% CI, 7.2 to 23.5 months) (Fig
2c). All sites of locoregional progression were within the treatment field.
SMAD-4 expression and survival outcomes
The pretreatment Smad4 (Dpc4) status was available for six patients, of which, two were scored
as Smad4 (Dpc4) intact (immunohistochemically positive). Of these two patients, one had a
complete pathological response following surgical resection and the other had synchronous
loco-regional and distant progression. Among the 4 patients with loss of Smad4, one
progressed distantly as their first site of failure, two progressed loco-regionally, and one had no
evidence of loco-regional or distant failure at last follow-up. In our study, Smad4 expression
was not associated with a particular pattern of disease progression. Intact Smad4 expression
was, surprisingly, associated with a trend towards poor overall survival (9 vs. 21.7 months,
p = 0.82) and progression free survival (3.3 vs. 8.8 months, p = 0.93). However, the sample size
is too small to draw any definitive conclusions. Smad4 status of patients enrolled on the current
RTOG 1201 protocol will provide additional information on the prognostic value of this
marker. Furthermore, where possible, the use of core biopsies instead of fine needle aspirates
may overcome some of the challenges with staining sparse tissue in cytology blocks remaining
after processing for clinical assessment.
The advances in our understanding of the molecular mechanisms responsible for
transformation and progression of pancreatic cancer have led to renewed interest in the development of
novel, rationally-designed, molecularly-targeted therapies. These have been evaluated in
several clinical trials in combination with standard chemoradiation regimens.[
12, 16, 21–24
phase I study demonstrates the safety and tolerability of combining erlotinib and bevacizumab
with capecitabine-based chemoradiotherapy for patients with unresectable pancreatic cancer.
Treatment was tolerated well with no unexpected increases in the frequency or severity of
toxicities. The maximum tolerated dose was determined as erlotinib 150mg/day and bevacizumab
5mg/Kg every two weeks when given with capecitabine-based chemoradiation therapy.
Therefore, the recommended doses in combination with radiation are bevacizumab: 5mg/Kg
q2weeks, erlotinib: 150 mg/Kg daily, and capecitabine 650mg/m2 BID. The median survival
was 17.4 months from the start of chemoradiation therapy (19.4 months from the date of
diagnosis) which is comparable to some of the better survival outcomes reported in literature.
Remarkably, four of the five patients who were able to undergo surgery following
chemoradiation were locally advanced at time of diagnosis; of these, two had a complete pathological
response and one patient had <20% viable tumor cells. Despite these promising outcomes, the
significance of improving CRT outcomes by adding molecular targeted agents remains unclear
when viewed within the context of recent evidence from the LAP07 trial which showed no
benefit from the addition of CRT following induction chemotherapy (chemotherapy alone vs.
chemotherapy followed by CRT, 16.5 vs. 15.3 months, p = 0.83) or of the addition erlotinib to
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gemcitabine (gemcitabine vs. gemcitabine plus erlotinib, 13.6 vs. 11.9 months, p = 0.09).
Consequently, any benefit from addition of molecular agents would be limited to subsets of
patients, if they are readily defined, who benefit from consolidative CRT in the first place.
Our group previously investigated the combination of bevacizumab with concurrent
capecitabine and radiation therapy in a phase I trial and reported no additional grade 3 or higher
] This approach was further tested in a multi-institutional phase II
trial, RTOG 0411. Although bevacizumab-related adverse events were uncommon, there was
no improvement in the 1-year overall survival rate.[
] The addition of erlotinib to
conventional chemoradiation regimen for resectable pancreatic cancer was subsequently tested in a
phase II study by Herman et al. This study showed that the combination of erlotinib (100mg/
day) with capecitabine and radiation was relatively well-tolerated with overall grade 3 and 4
toxicity rates of 31% and 2% respectively.[
] Similarly, Duffy et al. in a phase I trial showed
that the combination of erlotinib with gemcitabine and radiation in LAPC was relatively
welltolerated with grade 3 rash seen in 2 (14%) patients and grade 3 GI toxicity in 3 (21%) patients.
] The MTD of erlotinib reported in this study was 100mg/day. Patients had a median
survival of 18.7 months. There are phase I and II clinical data supporting the combination of
bevacizumab and erlotinib alone or in combination with cytotoxic chemotherapy in a variety of
other disease sites like rectal cancer and non-small cell lung cancer.[
] The present trial,
to our knowledge, is the first to simultaneously evaluate the safety of adding two targeted
agents, erlotinib and bevacizumab, to capecitabine-based chemoradiation in unresectable
Pancreatic cancer cells overexpress a variety of growth factors and cytokines which confer a
survival advantage by supporting self-sufficiency in nutritional and proliferative signals,
evasion of apoptosis, and promotion of angiogenesis, invasion and dissemination. It has been
proposed that blockade of a single pathway may not be capable of sufficiently deterring tumor
growth, as acquired resistance mechanisms utilize redundant pathways. Thus, simultaneous
treatment with bevacizumab and erlotinib, two agents working through different pathways
involved in tumor growth, should, in theory, improve outcomes. Preclinical studies in
xenograft models have supported this hypothesis, demonstrating that the combination of
bevacizumab and erlotinib results in greater efficacy than either agent alone.[
] Moreover, the
antiangiogenic action of bevacizumab has been shown to stabilize tumor vasculature and
enhance radiation response through improved tumor oxygenation.[
because there is little to no overlap in toxicity profile between the two agents, the combination
appears to be well-tolerated and may provide a substantial benefit to patients who are unable
to receive traditional cytotoxic therapy.
Our study was successful in determination of the MTD and recommended dose levels of
erlotinib and bevacizumab when combined with capecitabine-based chemoradiation therapy.
Only two patients (22%) treated at DL5 developed grade 3 diarrhea requiring dose adjustment
or discontinuation of erlotinib and capecitabine. This is comparable to the results of RTOG
0411 (22%) study.[
] None of our patients developed grade 4 or 5 toxicity and overall only
18% had grade 3 toxicity at DL5. The 1 year overall survival rate of 59% is also comparable to
the previously reported rates in RTOG 0411 (47%) and RTOG 9812 (43%) trials.[
results provide encouraging evidence that bevacizumab and erlotinib may be safely combined
with capecitabine and radiation. Five (29%) patients were successfully able to undergo surgical
resection following chemoradiation. The two patients who had a complete pathological
response had no recurrences at 5 years of follow-up, a finding similar to other studies showing
improved survival in patients with complete response after chemoradiation. Interestingly,
the Smad4 expression in our study did not correlate with the pattern of disease progression.
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However, given the small number of patients evaluated and few patients with disease
progression at time of evaluation, it is difficult to draw definitive conclusions from this cohort.
In summary, at the recommended dose levels, the addition of erlotinib and bevacizumab to
capecitabine-based chemoradiotherapy is safe and tolerable in patients with unresectable
pancreatic cancer. The rate of acute toxicity was minimal and similar to those observed in previous
trials. In addition, the promising survival outcomes and high rate of conversion to resectability
at the higher dose levels suggest that this strategy of dual inhibition of growth factor receptor
pathways during chemoradiotherapy warrants continued evaluation in a larger study.
S1 File. Trend Statement Checklist.
S2 File. Informed Consent Document.
S3 File. Protocol Page.
Conceived and designed the experiments: MFM GRV CHC SK. Performed the experiments:
HDS MFM PD BDM MED DC HW MHK JBF MMJ RAW GRV CHC SK. Analyzed the data:
ASC HDS JRG MFM SK. Contributed reagents/materials/analysis tools: MFM DC HW MC
GG PKS SK. Wrote the paper: ASC HDS JRG MFM PD BDM MED DC HW MC GG PKS
MHK JBF MMJ RAW GRV CHC SK.
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