Locally Advanced Pancreatic Cancer: The LAPACT Trial

John Marshall, MD:A new study has just been done—it’s now published—taking patients with locally advanced pancreas cancer, and instead of using the sort of biased FOLFIRINOX frontline, it’s using gemcitabine/nab-paclitaxel with traditional dosing and the like. About 100 patients was the number. In fact, they were able to show not only responses in these patients but also a decent percentage of patients who were in fact converted to being resectable. This opens up, really, a new option for us. We can hold off the 3-drug regimen in the right patient by using the 2-drug regimen in locally advanced pancreas cancer, now with prospective data saying that that 2-drug regimen will convert some patients to being resectable.

Specifically, this study enrolled a little over 100 patients in the trial. Everybody had locally advanced pancreas cancer as defined by traditional imaging measures. They were treated with gemcitabine/nab-paclitaxel using traditional doses. Traditional side effects were observed in the study, with no new signals there. But I think the really important part of this study is not the disease control rate. We’re expecting all of that. It’s that 15% of patients were able to undergo surgical resection. I think what this gives us is a new appropriate option for some patients: maybe those who can’t tolerate FOLFIRINOX, maybe more than that. But this is an appropriate choice in locally advanced pancreas cancer as a preoperative strategy in order to try to get some patients to surgery.

This is not something that’s new to us. They’re data that support what we’ve been doing anyway. There are a lot of patients who present with this kind of problem who would never be candidates for FOLFIRINOX, where it’s too spicy, too complicated, or there’s not enough support at home to manage a FOLFIRINOX regimen. Gemcitabine/nab-paclitaxel is a pretty easy regimen to give, particularly in the older population. We have seen patients with nice responses in this space who then become candidates for surgery.

Transcript edited for clarity.

May 2017

• A 64-year-old female was diagnosed with locally advanced pancreatic adenocarcinoma and referred for consultation at a high-volume center
• CT with contrast showed a 2.8-cm mass in the pancreatic body, invading the common hepatic, celiac, and splenic arteries, with abutment more than 180° to the superior mesenteric artery (SMA) but no encasement
• Staging laparoscopy showed no distant metastasis; peritoneal washing cytology showed no malignant cells
• She received FOLFIRINOX followed by capecitabine and concurrent RT

December 2017

• Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and abutment to the main artery was diminished but still detectable
• She underwent distal pancreatectomy with celiac artery resection
• Histopathology showed fibrous changes around the celiac artery; Evans grade IIb
• No evidence of residual tumor at the periphery; R0