The Miami "EMPIRE" Trial - Eradication of Metastatic Pancreatic Cancer With Immuno-Radiation

Eligibility Criteria

• 1. ≥18 years old
• 2. Histologically or cytologically confirmed diagnosis of pancreatic ductal adenocarcinoma.
• 3. Microsatellite stable (MSS) disease by pathologic assessment.
• 4. Patients must have measurable disease as defined by RECIST 1.1.
• 5. Progression on ≥1 line of systemic therapy.
• 6. No concomitant therapy with any of the following: interleukin (IL)-2, interferon, non study immunotherapy regimens, cytotoxic chemotherapy, immunosuppressive agents, other investigational therapies, and/or chronic use of systemic corticosteroids.
• 7. No known infection with human immunodeficiency virus (HIV) or active infection with Hepatitis B.
• 8. Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1.
• 9. Life expectancy ≥3 months.
• 10. Patients must have the following lab values obtained \<4 weeks prior to starting protocol treatment:
• 1. absolute neutrophil count (ANC) ≥1,000 cells/μL
• 2. white blood count (WBC) ≥2,000 cells/μL
• 3. platelets ≥75,000 per μL
• 4. hemoglobin ≥8.0 g/dL
• 5. creatinine clearance ≥40 mL/min)
• 6. serum total bilirubin ≤ 1.5 times the upper limit of normal (ULN)
• 7. aspartate aminotransferase (AST) and alanine transaminase (ALT) ≤3 × ULN (or ≤5 × ULN in patients with liver metastases)
• 8. international normalized ratio or prothrombin time ≤1.5 × ULN
• 9. activated partial thromboplastin time ≤2.5 × ULN
• 10. absolute lymphocyte count (ALC) ≥1000 cells/μL at baseline
• 11. At least 1 previously unirradiated lesion amenable to pre-treatment biopsy.
• 12. No limit on overall numbers of lesions, but liver tumor burden ≤25% of total liver volume.
• 13. Women of childbearing potential (WOCBP): negative serum pregnancy test (within 7 days prior to Day 1 of protocol therapy)
• 14. Male and female patients of reproductive potential must use effective methods of contraception or abstain from sexual activity for the course of the study through at least 6 months after the last dose of balstilimab and/or botensilimab. See Section 4.11, Contraception.
• 1. Liver tumor burden exceeding 25% of total liver volume.
• 2. Active, untreated central nervous system (CNS) metastases.
• 3. Active autoimmune disease or history of autoimmune disease that required systemic treatment within 2 years of the start of study treatment (i.e., with use of disease-modifying agents or immunosuppressive drugs).
• 4. Participants with a condition requiring systemic treatment with either corticosteroids (\> 10 mg daily prednisone equivalent) within 14 days or another immunosuppressive medication within 30 days of randomization. Inhaled or topical steroids, and adrenal replacement steroid doses (≤ 10 mg daily prednisone equivalent) are permitted in the absence of active autoimmune disease.
• 5. Previous external beam radiation therapy to the liver or radioisotope therapy directed to the liver or any liver embolization.
• 6. Clinically significant ascites requiring a paracentesis in the last 4 weeks, or clinically significant history of liver failure defined as any prior episode of hepatic encephalopathy and/or any prior history of an elevated serum ammonia level.
• 7. Partial or complete bowel obstruction within the last 3 months prior to study enrollment, signs/symptoms of bowel obstruction, or known radiologic evidence of impending obstruction.
• 8. Clinically significant (i.e., active) cardiovascular disease: cerebral vascular accident/stroke or myocardial infarction within 6 months of study enrollment, unstable angina, congestive heart failure (New York Heart Association class ≥ III), or serious uncontrolled cardiac arrhythmia requiring medication.
• 9. Prior allogeneic organ transplantation.
• 10. Treatment with chemotherapy or targeted therapy within 2 weeks prior to initiating EMPIRE treatment.
• 11. Persistent grade ≥2 adverse events (aEs) from prior therapy (except neuropathy).
• 12. Known additional malignancy requiring active treatment.
• 13. History of non-infectious pneumonitis.
• 14. Active infection requiring antibiotic.
• 15. Live vaccine within 30 days of protocol treatment.
• 16. Severe acute respiratory syndrome (SARS) coronavirus 2 (CoV 2) (SARS-CoV-2) vaccine or booster \< 7 days before Cycle 1 Day 1 (C1D1). For vaccines requiring more than 1 dose, the full series should be completed prior to C1D1, when feasible. Booster shot not required but also must be administered \> 7 days from C1D1 or \> 7 days from future cycle on study.
• 17. History of severe hypersensitivity reaction to monoclonal antibody.
• 18. Participants with impaired decision-making capacity.