A phase II/III randomized clinical trial of CisPlatin plUs Gemcitabine and Nabpaclitaxel (GAP) as pReoperative chemotherapy versus immediate resection in patIents with resecTable BiliarY Tract Cancers (BTC) at high risk for recurrence: PURITY study

BACKGROUND

Biliary tract cancers (BTCs) are rare and lethal cancers, with a 5-year survival inferior to 20%(1-3). The only potential curative treatment is surgical resection. However, despite complex surgical procedures that have a remarkable risk of postoperative morbidity and mortality, the 5-year survival rate after radical surgery (R0) is 20-40% and recurrence rates are up to ~ 75%(4-6). Up to ~ 40% of patients relapse within 12 months after resection, and half of these patient will recur systemically(4-6). There is no standard of care for neoadjuvant chemotherapy (NAC) in resectable BTC, but retrospective reports suggest its potential benefit (7, 8).

METHODS

PURITY is a no-profit, multicentre, randomized phase II/III trial aimed at evaluating the efficacy of the combination of gemcitabine, cisplatin and nabpaclitaxel (GAP) as neoadjuvant treatment in patients with resectable BTC at high risk for recurrence. Primary objective of this study is to evaluate the efficacy of neoadjuvant GAP followed by surgery as compared to upfront surgery, in terms of 12-month progression-free survival for the phase II part and of progression free survival (PFS) for the phase III study. Key Secondary objectives are event free survival (EFS), relapse-free survival, (RFS), overall survival (OS), R0/R1/R2 resection rate, quality of life (QoL), overall response rate (ORR), resectability. Safety analyses will include toxicity rate and perioperative morbidity and mortality rate. Exploratory studies including Next-Generation Sequencing (NGS) in archival tumor tissues and longitudinal ctDNA analysis are planned to identify potential biomarkers of primary resistance and prognosis.

DISCUSSION

Considering the poor prognosis of resected BTC experiencing early tumor recurrence and the negative prognostic impact of R1/R2 resections, PURITY study is based on the rationale that NAC may improve R0 resection rates and ultimately patients' outcomes. Furthermore, NAC should allow early eradication of microscopic distant metastases, undetectable by imaging but already present at the time of diagnosis and avoid mortality and morbidity associated with resection for patients with rapid progression or worsening general condition during neoadjuvant therapy. The randomized PURITY study will evaluate whether patients affected by BTC at high risk from recurrence benefit from a neoadjuvant therapy with GAP regimen as compared to immediate surgery.

TRIAL REGISTRATION

PURITY is registered at ClinicalTrials.gov (NCT06037980) and EuCT(2023-503295-25-00).

TRIPLETE: a randomised phase III study of modified FOLFOXIRI plus panitumumab versus mFOLFOX6 plus panitumumab as initial therapy for patients with unresectable RAS and BRAF wild-type metastatic colorectal cancer

Background

FOLFOXIRI plus bevacizumab is considered a standard option in the upfront treatment of clinically selected patients with metastatic colorectal cancer irrespective of RAS and BRAF molecular status. The randomised MACBETH and VOLFI studies showed that a modified FOLFOXIRI regimen in combination with cetuximab or panitumumab, respectively, achieved high therapeutic activity in RAS and BRAF wild-type patients with an acceptable toxicity profile. Drawing from these considerations, we designed TRIPLETE study aiming at comparing two different chemotherapy backbones (mFOLFOXIRI or mFOLFOX6) in combination with panitumumab in the first-line treatment of patients with RAS and BRAF wild-type metastatic colorectal cancer.

Methods

This is a prospective, open-label, multicentre phase III trial in which initially unresectable and previously untreated RAS and BRAF wild-type metastatic colorectal cancer patients are randomised to receive a standard treatment with mFOLFOX6 plus panitumumab or an experimental regimen with modified FOLFOXIRI (irinotecan 150 mg/m², oxaliplatin 85 mg/m², L-leucovorin 200 mg/m², 5-fluoruracil 2400 mg/m² 48-hour continuous infusion) plus panitumumab up to 12 cycles, followed by panitumumab plus 5-fluorouracil and L-leucovorin until disease progression. The primary endpoint is overall response rate according to RECIST 1.1 criteria.

Discussion

The relative benefit of chemotherapy intensification when using an anti-EGFR-based regimen in molecularly selected patients is unknown; TRIPLETE study aims at filling this gap of knowledge. The study is sponsored by the Gruppo Oncologico Nord Ovest Cooperative Group and is currently ongoing at 42 Italian centres.

Clinical trial information

NCT03231722.

A retrospective study of trifluridine/tipiracil in pretreated metastatic colorectal cancer patients in clinical practice

Aim: RECOURSE trial has shown a benefit for trifluridine/tipiracil (also known as TAS-102) over placebo in chemorefractory metastatic colorectal cancer (mCRC) patients. We evaluated efficacy and safety of patients treated with trifluridine/tipiracil in compassionate use. Patients & methods: RETROTAS is a retrospective study designed to evaluate efficacy and safety of trifluridine/tipiracil in mCRC patients previously exposed or not a candidate to all available drugs. Results: A total of 85 mCRC patients were included. Our data showed that 37.6% of patients achieved disease control. Median progression-free survival was 2.3 months; at 16 months follow-up, median overall survival was 9.2 months. Conclusion: This real-life experience confirms the safety and efficacy of trifluridine/tipiracil, resulting as a valid option in chemorefractory mCRC treatment scenario.

Circulating angiogenesis-related markers as predictors of benefit from regorafenib in metastatic colorectal cancer (mCRC) patients (pts)

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Background: Regorafenib is a treatment option for refractory mCRC pts. Considering its limited clinical benefit and the palliative setting, patients’ selection is essential to optimize the cost-effectiveness ratio. We aimed to describe the modulation of selected circulating angiogenic factors by regorafenib and to investigate their correlation with clinical outcome. Methods: IL-8, Ang-2, PDGF, bFGF, Tie-2, sVEGFR2, sVEGFR3, PlGF, VEGF-A, VEGF-B were assessed by ELISA on plasma samples collected at baseline (d1), after 15 days of treatment (d15), at the best RECIST response, at disease progression (PD) in mCRC pts treated with regorafenib, as per indication. Comparisons among concentrations of each marker at different timepoints were performed by Wilcoxon test. Markers showing significant changes were analyzed for correlation with outcome. Results: 105 pts were included. Median PFS and OS were 2.1 and 7.0 months (mos), respectively. As compared to d1, IL-8 and Ang-2 levels increased at PD. An early decrease at d15 was observed for PDGF, Tie-2, sVEGFR2 and sVEGFR3 levels, followed by an increase at PD. Conversely, PlGF levels increased at d15 and then decreased at PD. Baseline levels of Ang-2 and Tie-2 below the median value were associated with longer PFS (HR:0.61 [0.37-0.83] p = 0.006; HR:0.69 [0.43-0.95] p = 0.04, respectively) and OS (HR:0.45 [0.26-0.60] p < 0.0001; HR:0.68 [0.44-0.98] p = 0.04, respectively). With regard to Ang-2, 40 (45%) out of 89 pts with available plasma samples at d15 showed increased levels at d15 as compared to d1. Among them, 21 (53%) achieved disease control, as compared to 14 out of 49 (29%) pts with Ang-2 decreased levels (p = 0.03). Median PFS of pts with increased and decreased Ang-2 levels were 3.1 and 1.8 mos, respectively (HR:0.57 [0.33-0.78] p = 0.004). Conclusions: A dynamic modulation of plasma angiogenic factors occurs during the treatment with regorafenib. Low baseline Ang-2 and Tie-2 levels seem to be associated with good prognosis. The early modulation of Ang-2 levels may predict benefit from regorafenib. These results need validation in independent series.