Randomized phase III multi-institutional study of TNFerade biologic with fluorouracil and radiotherapy for locally advanced pancreatic cancer: final results

Abstract

Purpose: TNFerade biologic is a novel means of delivering tumor necrosis factor alpha to tumor cells by gene transfer. We herein report final results of the largest randomized phase III trial performed to date among patients with locally advanced pancreatic cancer (LAPC) and the first to test gene transfer against this malignancy.

Patients and methods: In all, 304 patients were randomly assigned 2:1 to standard of care plus TNFerade (SOC + TNFerade) versus standard of care alone (SOC). SOC consisted of 50.4 Gy in 28 fractions with concurrent fluorouracil (200 mg/m(2) per day continuous infusion). TNFerade was injected intratumorally before the first fraction of radiotherapy each week at a dose of 4 × 10(11) particle units by using either a percutaneous transabdominal or an endoscopic ultrasound approach. Four weeks after chemoradiotherapy, patients began gemcitabine (1,000 mg/m(2) intravenously) with or without erlotinib (100 to 150 mg per day orally) until progression or toxicity.

Results: The analysis included 187 patients randomly assigned to SOC + TNFerade and 90 to SOC by using a modified intention-to-treat approach. Median follow-up was 9.1 months (range, 0.1 to 50.5 months). Median survival was 10.0 months for patients in both the SOC + TNFerade and SOC arms (hazard ratio [HR], 0.90; 95% CI, 0.66 to 1.22; P = .26). Median progression-free survival (PFS) was 6.8 months for SOC + TNFerade versus 7.0 months for SOC (HR, 0.96; 95% CI, 0.69 to 1.32; P = .51). Among patients treated on the SOC + TNFerade arm, multivariate analysis showed that TNFerade injection by an endoscopic ultrasound-guided transgastric/transduodenal approach rather than a percutaneous transabdominal approach was a risk factor for inferior PFS (HR, 2.08; 95% CI, 1.06 to 4.06; P = .032). The patients in the SOC + TNFerade arm experienced more grade 1 to 2 fever and chills than those in the SOC arm (P < .001) but both arms had similar rates of grade 3 to 4 toxicities (all P > .05).

Conclusion: SOC + TNFerade is safe but not effective for prolonging survival in patients with LAPC.

Trial registration: ClinicalTrials.gov NCT00051467.

Fig 1.

CONSORT diagram; enrollment and outcomes. SOC, standard of care; TNF, TNFerade.

Fig 2.

Kaplan-Meier curves depicting (A) overall survival, (B) progression-free survival, and (C) time to radiologic progression by modified intention-to-treat groups. P values given in each panel represent the significance level obtained when groups were compared by univariate analysis. SOC, standard of care; TNF, TNFerade.

Fig 3.

Kaplan-Meier curves depicting (A) overall survival, (B) progression-free survival, (C) time to any radiologic progression, (D) time to distant radiologic progression, and (E) time to local radiologic progression by TNFerade delivery method among patients treated on the standard of care + TNFerade arm. P values given in each panel represent the significance level obtained when groups were compared by univariate analysis. EUS, endoscopic ultrasound guided (transgastric/transduodenal approach); PTA, percutaneous transabdominal approach.