Pembrolizumab after Neoadjuvant Chemotherapy followed by Surgery for the Treatment of Patients with Localized, Resectable Pancreatic Cancer

Inclusion Criteria

• Patient is >= 18 years of age and has histologically or cytologically confirmed localized adenocarcinoma of the pancreas that is potentially resectable. Patients with islet cell or other neuroendocrine neoplasms are excluded
• Definition of localized, potentially resectable disease: * Staging by intravenous contrast-enhanced thin section helical abdominal computed tomography (2.5 mm cuts or less) or magnetic resonance imaging (MRI) (for patients with an IV contrast allergy) using pancreatic protocol. Endoscopic ultrasound is required for tissue acquisition and staging confirmation * No extension to superior mesenteric artery (SMA) and hepatic artery. Patent superior mesenteric vein/portal vein (SMV/PV) with < 180-degree abutment and no evidence of invasion * Clear fat plane between the SMA and celiac axis * No extension to celiac axis and hepatic artery * Patent superior mesenteric vein and portal vein * No evidence of distant disease by additional imaging of the chest (computed tomography [CT] with or without contrast or positron emission tomography [PET]/CT) and pelvis (CT with contrast, PET/CT, or MRI with contrast) * No other evidence of distant disease
• If a female patient is of childbearing potential, she must have a negative serum pregnancy test (beta human chorionic gonadotropin [beta hCG]) documented within 72 hours of the first administration of study drug
• Fertile participants must use contraception considered adequate and appropriate as stated
• A male participant must agree to use contraception as detailed during the treatment period and for at least 220 days after the last dose of study treatment and refrain from donating sperm during this period
• Patient must not have received prior chemotherapy or radiation for pancreatic cancer
• Patient has an Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-1
• Patient has been informed about the nature of the study, and has agreed to participate in the study, and signed the informed consent form before participation in any study-related activities
• A female participant is eligible to participate if: * Not a woman of childbearing potential (WOCBP) OR * A WOCBP who is not pregnant, not breastfeeding, and agreeing to use proper contraception for at least 160 days after the last dose of study treatment
• Absolute neutrophil count (ANC) >= 1500/uL (within 10 days before the start of study intervention)
• Platelets >= 100,000/uL (within 10 days before the start of study intervention)
• Hemoglobin >= 9.0 g/dL or >= 5.6 mmol/L (within 10 days before the start of study intervention) * Criteria must be met without erythropoietin dependency and without packed red blood cell (pRBC) transfusion within the last 2 weeks
• Creatinine =< 1.5 x upper limit of normal (ULN) OR measured or calculated creatinine clearance >= 30 mL/min for the participant with creatinine levels > 1.5 x institutional ULN (glomerular filtration rate [GFR] can also be used in place of creatinine or creatinine clearance [CrCl]) (within 10 days before the start of study intervention) * Creatinine clearance (CrCl) should be calculated per institutional standard
• Total bilirubin =< 1.5 x ULN OR direct bilirubin =< ULN for participants with total bilirubin levels > 1.5 x ULN (within 10 days before the start of study intervention)
• Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 x ULN (=< 5 x ULN for participants with liver metastases) (within 10 days before the start of study intervention)
• International normalized ratio (INR) OR prothrombin time (PT) =< 1.5 x ULN unless the participant is receiving anticoagulant therapy as long as PT or activated partial thromboplastin time (aPTT) is within the therapeutic range of intended use of anticoagulants (within 10 days before the start of study intervention)
• Activated partial thromboplastin time (aPTT) =< 1.5 x ULN unless the participant is receiving anticoagulant therapy as long as PT or aPTT is within the therapeutic range of intended use of anticoagulants (within 10 days before the start of study intervention)

Exclusion Criteria

• Patient has borderline resectable, locally advanced unresectable, or advanced metastatic disease. Patients with neuroendocrine tumors, adenosquamous cancer, lymphoma of the pancreas, or ampullary cancer are also ineligible
• Patient has active, uncontrolled bacterial, viral, or fungal infection(s) requiring systemic therapy
• Patient has known infection with human immunodeficiency virus (HIV)
• Patient has undergone major surgery, other than diagnostic surgery (— e.g. diagnostic laparoscopy or placement of a central venous catheter), within 4 weeks before day 1 of treatment in this study
• Patient has a history of allergy or hypersensitivity to the study drugs
• Patient has serious medical risk factors involving any of the major organ systems such that the investigator considers it unsafe for the patient to receive chemotherapy and/or radiation therapy
• Has a known additional malignancy that is progressing or has required active treatment within the past 2 years. Participants with basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or carcinoma in situ (eg, breast carcinoma, cervical cancer in situ) that have undergone potentially curative therapy are not excluded
• Patient has had clinically significant cardiovascular disease (including myocardial infarction, unstable angina, symptomatic congestive heart failure, serious uncontrolled cardiac arrhythmia) =< 1 year before registration
• Patient is unwilling or unable to comply with study procedures
• Patient is enrolled in any other therapeutic clinical protocol or investigational trial
• Patients aged >= 80 are not excluded. However, candidates in this age group should be thoroughly evaluated before enrollment in the study, to ensure they are fit to receive chemotherapy, and to potentially undergo pancreaticoduodenectomy. In addition to meeting all of the baseline patient selection criteria, clinical judgment on their susceptibility to infection and expected stability of their performance status and suitability to receive intensive chemotherapy cycles, should be paid special attention to. Patients should not be enrolled in the study should there be any hesitation on any of these considerations. Baseline criteria for all patients enrolled in the study must be carefully evaluated and all criteria followed appropriately
• Patient has evidence of peripheral neuropathy grade 2 or higher
• A WOCBP who has a positive urine pregnancy test within 72 hours prior to allocation. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required. In the event that 72 hours have elapsed between the screening pregnancy test and the first dose of study treatment, another pregnancy test (urine or serum) must be performed and must be negative in order for the subject to start receiving study medication
• Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent or with an agent directed to another stimulatory or co-inhibitory T-cell receptor (eg, CTLA-4, OX-40, CD137)
• Has received a live vaccine or live-attenuated vaccine within 30 days prior to the first dose of study drug
• Is currently participating in or has participated in a study of an investigational agent or has used an investigational device within 4 weeks prior to the first dose of study intervention
• Has a diagnosis of immunodeficiency or is receiving chronic systemic steroid therapy (in dosing exceeding 10 mg daily of prednisone equivalent) or any other form of immunosuppressive therapy within 7 days prior to the first dose of study drug
• Has active autoimmune disease that has required systemic treatment in the past 2 years (i.e. with use of disease-modifying agents, corticosteroids, or immunosuppressive drugs). Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment and is allowed
• Has a history of (non-infectious) pneumonitis/interstitial lung disease that required steroids or has current pneumonitis/interstitial lung disease
• Has a known history of hepatitis B (defined as hepatitis B surface antigen [HBsAg] reactive) or known active hepatitis C virus (defined as detectable hepatitis C virus [HCV] by ribonucleic acid [RNA]) infection. Note: no testing for hepatitis B and hepatitis C is required unless mandated by local health authorities
• Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the study, interfere with the participant’s participation for the full duration of the study, or is not in the best interest of the participant to participate, in the opinion of the treating investigator
• Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial
• Has had an allogenic tissue/solid organ transplant