Short-Course Radiotherapy, Nal-IRI, Capecitabine, and Camrelizumab for Locally Advanced MSS Rectal Cancer

Official title

Short-Course Radiotherapy Followed by Liposomal Irinotecan, Capecitabine, and Camrelizumab as Neoadjuvant Therapy for Locally Advanced pMMR/MSS Low Rectal Cancer: A Prospective Single-Arm Phase II Trial Protocol

Overview

This study is for adults with locally advanced rectal cancer that has not spread to distant organs, and is classified as pMMR or MSS (which means it typically does not respond well to immunotherapy alone). The purpose is to see if a new combination of treatments given before surgery (neoadjuvant therapy) can more effectively shrink the tumor and increase the chance of curing the cancer or avoiding surgical removal of the rectum. The main things you will do in this study are: 1. Receive a Short Course of Radiation Therapy (5 treatments over 1 week). 2. After a 1-week break, receive a combination of three drugs: 1）Nal-IRI (a special form of the chemotherapy drug Irinotecan, designed to have fewer side effects) 2）Capecitabine (a chemotherapy pill) 3）Camrelizumab (an immunotherapy drug) 3. This drug combination is given in 8 cycles, with each cycle lasting 3 weeks. 4. After finishing all cycles, the doctors will carefully check how the tumor responded. The most important goal of this research is to see how many patients achieve a "Complete Response," which means: 1. No sign of cancer cells in the surgically removed tissue (Pathological Complete Response, pCR), or 2. No sign of cancer can be found through clinical exams, scans, and scopes, allowing the patient to avoid immediate surgery under a "Watch and Wait" strategy (Clinical Complete Response, cCR). Researchers will also monitor: 1. The safety of the treatment and its side effects. 2. How well the cancer is controlled over time (e.g., 3-year survival without cancer recurrence). 3. The rate of successful tumor removal and the rate of preserving the anus.

Interventions

• Radiation Short-Course Radiotherapy
  Short-course radiotherapy is a radiation therapy regimen delivered over a condensed period. In this study, patients will receive a total dose of 25 Gray (Gy), administered in 5 fractions (5 Gy per fraction), delivered once daily over five consecutive days. This intervention constitutes the initial phase of the neoadjuvant treatment protocol.
• Drug Liposomal Irinotecan (nal-IRI)
  Liposomal irinotecan is a nanoliposomal formulation of the chemotherapeutic agent irinotecan, designed to enhance tumor drug delivery and reduce systemic toxicity. In this study, it will be administered intravenously at a dose of 60 mg/m² on Day 1 of each 21-day cycle, for a total of 8 cycles, following the completion of short-course radiotherapy.
• Drug Capecitabine
  Capecitabine is an oral fluoropyrimidine carbamate prodrug that is converted to 5-fluorouracil in the body. In this study, it will be administered orally at a dose of 1000 mg/m² twice daily (BID) from Days 1 to 14 of each 21-day cycle, for a total of 8 cycles, in combination with liposomal irinotecan and camrelizumab.
• Drug Camrelizumab
  Camrelizumab is a humanized monoclonal antibody that targets the programmed cell death-1 (PD-1) receptor on immune cells, functioning as an immune checkpoint inhibitor. In this study, it will be administered intravenously at a fixed dose of 200 mg on Day 1 of each 21-day cycle, for a total of 8 cycles, in combination with liposomal irinotecan and capecitabine.

Primary outcome measures

• Complete Response Rate [Time frame: From the start of treatment until approximately 2 weeks after the completion of all neoadjuvant therapy, assessed over a period of approximately 24-26 weeks.]

Secondary outcome measures (7)

• 3 year Disease-Free Survival [Time frame: 3 years from the start of treatment.]
• 3 year Overall Survival [Time frame: 3 years from the start of treatment.]
• Objective Response Rate [Time frame: From the start of treatment until approximately 2 weeks after the completion of all neoadjuvant therapy, assessed over a period of approximately 24-26 weeks.]
• R0 Resection Rate [Time frame: Assessed at the time of surgery following neoadjuvant therapy, over a period of approximately 24-30 weeks from the start of treatment.]
• Tumor Regression Grade [Time frame: Assessed during pathological evaluation after surgery, over a period of approximately 24-30 weeks from the start of treatment.]
• Sphincter Preservation Rate [Time frame: Confirmed immediately after surgery, over a period of approximately 24-30 weeks from the start of treatment.]
• Incidence of Treatment-Related Adverse Events [Time frame: From the time of informed consent until 30 days after the last dose of study treatment, assessed over a period of approximately 28-31 weeks.]

Eligibility criteria

Inclusion criteria

• Aged 18 to 75 years, male or female.
• Histologically confirmed diagnosis of rectal adenocarcinoma.
• Confirmed mismatch repair proficient (pMMR) or microsatellite stable (MSS) status by immunohistochemistry or PCR methods.
• Locally advanced disease assessed by pelvic MRI, classified as cT3-4aN0M0 or any T stage with node-positive (N+) disease, without distant metastasis (M0), according to the AJCC 8th edition staging system.
• The lower edge of the tumor is located within 10 cm from the anal verge (defined as low/mid rectal cancer).
• Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
• Adequate bone marrow, hepatic, and renal function, defined as: Absolute Neutrophil Count (ANC) ≥ 1.5 x 10⁹/L，Platelet count ≥ 100 x 10⁹/L，Hemoglobin ≥ 90 g/L，Total Bilirubin ≤ 1.5 times the Upper Limit of Normal (ULN)，Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) ≤ 2.5 x ULN，Serum creatinine ≤ 1.5 x ULN or Creatinine Clearance ≥ 50 mL/min (calculated by Cockcroft-Gault formula)
• Voluntarily participates in the study, signs the informed consent form, demonstrates good compliance, and is able to cooperate with follow-up procedures.

Exclusion criteria

• Evidence of distant metastasis (M1 disease) on baseline imaging.
• Previous radiotherapy to the pelvis, or any prior systemic chemotherapy, targeted therapy, or immunotherapy for colorectal cancer.
• History of other active malignancies within the past 5 years, except for adequately treated carcinoma in situ of the cervix, basal cell carcinoma of the skin, or other localized tumors considered cured by local treatment.
• Any of the following uncontrolled conditions or comorbidities:

1）Severe active infection requiring systemic therapy. 2）Unstable angina, myocardial infarction, or congestive heart failure (NYHA Class II-IV) within the last 6 months.

3）Uncontrolled epilepsy, central nervous system disorders, or psychiatric disorders that would compromise the ability to provide informed consent or comply with study procedures.

5\. Known history of severe immunodeficiency or active autoimmune disease requiring systemic immunosuppressive therapy (e.g., corticosteroids at doses > 10mg/day prednisone equivalent) within the past 2 years.

6\. Known history of hypersensitivity to any component of the study drugs (Liposomal Irinotecan, Capecitabine, Camrelizumab) or history of severe hypersensitivity reactions to other monoclonal antibodies.

7\. Pregnant or lactating women, or subjects of childbearing potential who are unwilling to use highly effective contraception during the study period and for at least 6 months after the last dose of study treatment.

8\. Any other condition or circumstance that, in the opinion of the investigator, would compromise the patient's safety or adherence to the protocol (e.g., inability to swallow oral medications, active gastrointestinal bleeding, intestinal obstruction).

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

N/A

Model

Single group

Masking

Open label

Primary purpose

Treatment

Study locations

China · 1 center

• Guangdong Provincial People's Hospital — Guangzhou

Publications

• Yang Y, Pang K, Lin G, Liu X, Gao J, Zhou J, Xu L, Gao Z, Wu Y, Li A, Han J, Wu G, Wang X, Li F, Ye Y, Zhang J, Chen G, Wang H, Kong Y, Wu A, Xiao Y, Yao H, Zhang Z. Neoadjuvant chemoradiation with or without PD-1 blockade in locally advanced rectal cancer: a randomized phase 2 trial. Nat Med. 2025 Feb;31(2):449-456. doi: 10.1038/s41591-024-03360-5. Epub 2025 Jan 6. PMID 39762418
• Rahma OE, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Colangelo LH, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, O'Rourke MA, Faller BA, Valicenti RK, Schefter TE, George S, Kainthla R, Stella PJ, Sigurdson E, Wolmark N, George TJ. Use of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Initial Results From the Pembrolizumab Arm of a Phase 2 Randomized Cli PMID 34196693
• Wang-Gillam A, Li CP, Bodoky G, Dean A, Shan YS, Jameson G, Macarulla T, Lee KH, Cunningham D, Blanc JF, Hubner RA, Chiu CF, Schwartsmann G, Siveke JT, Braiteh F, Moyo V, Belanger B, Dhindsa N, Bayever E, Von Hoff DD, Chen LT; NAPOLI-1 Study Group. Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1): a glob PMID 26615328
• Cercek A, Lumish M, Sinopoli J, Weiss J, Shia J, Lamendola-Essel M, El Dika IH, Segal N, Shcherba M, Sugarman R, Stadler Z, Yaeger R, Smith JJ, Rousseau B, Argiles G, Patel M, Desai A, Saltz LB, Widmar M, Iyer K, Zhang J, Gianino N, Crane C, Romesser PB, Pappou EP, Paty P, Garcia-Aguilar J, Gonen M, Gollub M, Weiser MR, Schalper KA, Diaz LA Jr. PD-1 Blockade in Mismatch Repair-Deficient, Locally A PMID 35660797
• Cui J, Qin S, Zhou Y, Zhang S, Sun X, Zhang M, Cui J, Fang W, Gu K, Li Z, Wang J, Chen X, Yao J, Zhou J, Wang G, Bai Y, Xiao J, Qiu W, Wang B, Xia T, Wang C, Kong L, Yin J, Zhang T, Shen X, Fu D, Gao C, Wang H, Wang Q, Wang L. Irinotecan hydrochloride liposome HR070803 in combination with 5-fluorouracil and leucovorin in locally advanced or metastatic pancreatic ductal adenocarcinoma following pri PMID 39300077
• Lee YM, Chen YH, Ou DL, Hsu CL, Liu JH, Ko JY, Hu MC, Tan CT. SN-38, an active metabolite of irinotecan, enhances anti-PD-1 treatment efficacy in head and neck squamous cell carcinoma. J Pathol. 2023 Apr;259(4):428-440. doi: 10.1002/path.6055. Epub 2023 Feb 24. PMID 36641765
• Chung YM, Khan PP, Wang H, Tsai WB, Qiao Y, Yu B, Larrick JW, Hu MC. Sensitizing tumors to anti-PD-1 therapy by promoting NK and CD8+ T cells via pharmacological activation of FOXO3. J Immunother Cancer. 2021 Dec;9(12):e002772. doi: 10.1136/jitc-2021-002772. PMID 34887262
• Zhu J, Liu A, Sun X, Liu L, Zhu Y, Zhang T, Jia J, Tan S, Wu J, Wang X, Zhou J, Yang J, Zhang C, Zhang H, Zhao Y, Cai G, Zhang W, Xia F, Wan J, Zhang H, Shen L, Cai S, Zhang Z. Multicenter, Randomized, Phase III Trial of Neoadjuvant Chemoradiation With Capecitabine and Irinotecan Guided by UGT1A1 Status in Patients With Locally Advanced Rectal Cancer. J Clin Oncol. 2020 Dec 20;38(36):4231-4239. do PMID 33119477

Identifiers

NCT: NCT07521605 · neoNRCC

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗