Preop Chemoradiation Resectable Pancreas
Preop Chemoradiation Resectable Pancreas
Primary Objective:

 1. To assess resectability rate in patients undergoing gemcitabine plus Avastin-based
 chemoradiation followed by pancreaticoduodenectomy for adenocarcinoma of the pancreas.

 Secondary Objectives:

 1. To assess disease free survival and overall survival

 2. To assess margin resection rate (R0 vs. R1) in these patients

 3. To assess patterns of failure
Gemcitabine is designed to disrupt the growth of the cancer cells, which causes the cancer
 cells to start to die.

 Avastin is designed to prevent or slow down the growth of tumors by its damaging effects on
 blood vessel growth in tumors.

 Before treatment starts, you will have a complete physical exam. Blood (about 2 tablespoons)
 will be drawn for tests, and a urine test will be performed. Chest x-rays and computed
 tomography (CT) scans of the abdomen will be done. Women who are able to have children must
 have a negative blood (1-2 tablespoons) pregnancy test.

 If you are found to be eligible to take part in this study, you will receive gemcitabine once
 a week, Avastin once every 2 weeks, and radiation 5 times a week. Gemcitabine and Avastin
 will be given on Saturdays, and the radiation will be given Monday through Friday of each
 week. You will receive this treatment as an outpatient for 6 weeks.

 You will receive gemcitabine through a needle in a vein on Days 1, 8, 15, 22, 29, and 36 (+/-
 2 days). You will receive Avastin through a needle in a vein every 2 weeks on Days 1, 15, and
 29 (+/- 2 days). On the days you receive both drugs, you will receive Avastin over 30-90
 minutes and gemcitabine over 40 minutes.

 The first dose of Avastin will be given over about 90 minutes. If you do not have a reaction
 (such as fever/chills), the next dose will be given over about 60 minutes, and if again no
 reaction occurs, each dose after that will be given over about 30 minutes. If you experience
 a reaction to the Avastin infusion, you may be given acetaminophen (such as Tylenol) by mouth
 and/or diphenhydramine (Benadryl) by vein over 30 minutes before each dose to decrease the
 risk of further reactions.

 Radiation will be given Monday through Friday for 5 1/2 weeks. Each day of treatment, you
 will lie on a treatment table. The radiation therapist will help position your body so that
 the radiation goes to the right place. A machine will deliver the radiation. It will take
 about 15-20 minutes to receive the radiation treatment each day.

 If any days of radiation are missed, these days will be made up at the end of your treatment
 (at the end of 28 days) so that you receive the full amount of radiation.

 During the study, you will have physical exams weekly while you are receiving chemoradiation,
 every other week while you are receiving chemotherapy after surgery, and every 4 months
 during the follow-up period. You will have blood drawn (1-2 tablespoons each time) for
 routine tests on a weekly basis while you are receiving chemoradiation, every other week
 while you are taking Avastin after surgery for 3 months, and every 4 months during the
 follow-up period. The possible development of side effects will be closely monitored and
 could require extra blood and/or urine samples. You may also have physical exams, blood and
 urine tests, x-rays, and scans after completing the chemoradiation part of the study,
 depending upon what is medically needed for evaluation of ongoing therapy.

 The overall effect of treatment will be evaluated at least 8 weeks (+/- 2 days) after the
 completion of chemoradiation. A chest x-ray and CT scans of the chest, abdomen, and pelvis
 will then be performed, and blood (about 2 tablespoons) will be drawn for routine tests. Some
 participants will have surgery to remove part of the pancreas, if needed. The reason to wait
 at least 8 weeks is to allow a safe period of time to pass after the last dose of Avastin to
 prevent bleeding during surgery. It may also help decrease the risk of postoperative
 complications, including bleeding and poor wound healing.

 This research study allows participants to receive up to 3 infusions of Avastin during the
 chemoradiation part of the study. If the treatment is shown to benefit you, your doctor may
 continue to give additional infusions of Avastin every 2 weeks (+/- 2 days) for 3 months
 after surgery. After the Avastin treatment, you will have a chest x-ray, abdominal CT scan,
 and blood (about 2 tablespoons) will be drawn for routine tests every 4 months after surgery
 for 2 years to check the status of the tumor.

 This is an investigational study. The study drugs are commercially available and FDA
 approved, but their use together with radiation is experimental. Avastin is FDA approved for
 colon and lung cancers but has not been evaluated by the FDA for pancreatic cancer.
 Gemcitabine is FDA approved for pancreatic cancer. Avastin will be provided free of charge
 during the study, however the cost of the infusion of the drug will be the responsibility of
 you and/or your insurance company. The costs of gemcitabine and radiation are considered
 standard of care, and will be the responsibility of you and/or your insurance company. Up to
 31 patients will take part in this study. All will be enrolled at M. D. Anderson.
Inclusion Criteria:

 1. Cytologic or histologic proof of adenocarcinoma of the pancreatic head or uncinate
 process is required prior to treatment. Islet cell tumors are not eligible.

 2. Patients must be staged with a physical exam, CXR, and contrast-enhanced CT. Only
 potentially resectable patients are eligible. Potentially resectable defined as: a) no
 extra pancreatic disease, b) no evidence (on CT) of tumor extension to the celiac axis
 or SMA, and c) no evidence (CT or angiogram) of occlusion of the SMV or SMPV
 confluence. Visceral angiography is optional. Laparoscopic staging is not part of the
 pretreatment evaluation for this study. Laparoscopy may be performed prior to planned
 laparotomy at surgeon's discretion. Staging needs to be done within 28 days of
 enrollment.

 3. Patients cannot have known hepatic or peritoneal metastases detected by ultrasound
 (US), CT scan, or laparotomy prior to chemoradiation.

 4. There will be no upper age restriction; patients with Karnofsky performance status
 greater than 70 are eligible.

 5. Adequate renal, and bone marrow function: Leukocytes greater than or equal to
 3,000/uL; Absolute neutrophil count greater than or equal to 1,500/uL; Platelets
 greater than or equal to 100,000/U1; Serum creatinine less than or equal to 2.0-mg/dL
 and urine protein: creatinine ratio less than or equal to 1.0 at screening

 6. Hepatic function (endoscopic or percutaneous drainage as needed) Total bilirubin less
 than or equal to 2 X institutional upper limits of normal (ULN); AST (SGOT)/ALT (SGPT)
 less than or equal to 5 X institutional ULN

 7. Patients must have no fever or evidence of infection or other coexisting medical
 condition that would preclude protocol therapy.

 8. Pregnant women with a positive (blood B-HCG) pregnancy test are excluded from this
 study; women of childbearing potential (defined as those who have not undergone a
 hysterectomy or who have not been postmenopausal for at least 24 consecutive months)
 must agree to practice adequate contraception and to refrain from breast feeding, as
 specified in the informed consent.

 9. Patients must sign a study-specific consent form.

 Exclusion Criteria:

 1. Tumors in the body or tail of the pancreas (to the left of the portal -SMV confluence)
 are not eligible.

 2. Patients with uncontrolled hypertension, baseline blood pressure of greater than
 150/100 mmHg

 3. Unstable angina or New York Heart Association (NYHA) Grade II or greater congestive
 heart failure.

 4. History of myocardial infarction, stroke, DVT, or pulmonary embolism within 6 months
 of the study

 5. Clinically significant peripheral vascular disease.

 6. Known history of bleeding diathesis coagulopathy. If patient has prior documented PT,
 INR then INR should be less than 2.0 (patients on anticoagulation for atrial
 fibrillation, other cardiac disorders, and for remote history of thrombosis are not
 excluded). Lab results should be within 2 weeks of patient enrollment.

 7. Known presence of central nervous system or brain metastases.

 8. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days
 prior to Day 0, anticipation of need for major surgical procedure during the course of
 the study

 9. Minor surgical procedures such as fine needle aspirations or core biopsies within 7
 days prior to Day 0

 10. Urine protein: creatinine ratio greater than 1.0 at screening; a 24 hour urine protein
 should be obtained and the level must be less than 1gm/24 hours in order for the
 patient to be eligible.

 11. History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess
 within 6 months prior to Day 0

 12. Serious, non-healing wound, ulcer, or bone fracture

 13. Evidence of duodenal invasion

 14. Inability to comply with study and/or follow-up procedures

 15. Patients less than 18 years of age.