Immunotherapy and SBRT Study in Borderline Resectable Pancreatic Cancer

This protocol attempts to treat pancreatic cancer using a naturally occurring barrier to
xenotransplantation in humans to increase the efficacy of immunizing subjects against their
pancreatic cancer. In this protocol, the transfer of the murine
alpha(1,3)galactosyltransferase [alpha(1,3)GT] gene to immunotherapy component cells results
in the cell surface expression of alpha(1,3)galactosyl-epitopes (alpha gal) epitopes on
membrane glycoproteins and glycolipids. These epitopes are the major target of the hyperacute
rejection response. This response occurs when organs are transplanted from lower animal donor
species into primates and results in rapid destruction of transplanted tissue and an
augmented response against transplant antigens, including antigens not related to the alpha
gal epitopes. Human hosts have pre-existing anti-alpha-gal antibodies that are thought to
result from chronic immunological stimulation due to exposure to alpha-gal epitopes that are
naturally expressed on normal gut flora and these antibodies may comprise up to 1% of serum
IgG. Opsonization and lysis of the immunotherapy component cells mediated by this antibody is
believed to increase the efficiency of antigen processing by targeting vaccine components to
antigen presenting cells via the Fc gamma receptor.

Inclusion Criteria:

- A histological diagnosis of adenocarcinoma of the pancreas confirmed by pathology.

- Patients must have borderline resectable pancreatic cancer with no metastatic spread
as determined by a baseline diagnostic CT scan with intravenous contrast (or MRI). CT
should be performed according to a defined pancreas protocol such as triphasic
cross-sectional imaging with thin slices. Optimal multi-phase technique including a
non-contrast phase plus arterial, pancreatic parenchymal and portal venous phase of
contrast enhancement with thin cuts (3mm) throughout the abdomen is preferred. Studies
must be evaluated by a radiologist and/or surgeon and deemed borderline resectable as
defined below:

1. Borderline resectable- Tumors considered borderline resectable are defined as
follows:

2. Venous involvement of the SMV/portal vein demonstrating tumor abutment with
impingement and narrowing of the lumen, encasement of the SMV/portal vein but
without encasement of the nearby arteries, or short-segment venous occlusion
resulting from either tumor thrombus or encasement but with suitable vessel
proximal and distal to the area of vessel involvement, allowing for safe
resection and reconstruction

3. Gastroduodenal artery encasement up to the hepatic artery with either short
segment encasement or direct abutment of the hepatic artery without extension to
the celiac axis.

4. Tumor abutment of the SMA not to exceed greater than 180 degrees of the
circumference of the vessel wall.

- Tumors considered to be unresectable due to local advancement include an absence of
distant metastases as well as:

1. Head: Greater than 180 degrees SMA encasement or any celiac abutment or
unreconstructible SMV/portal occlusion or aortic invasion or encasement.

2. Body: Greater than 180 degrees SMA or celiac encasement or unreconstructible
SMV/portal occlusion or aortic invasion.

3. Tail: SMA or celiac encasement greater than 180 degrees.

4. Nodal status: Involvement of lymph nodes beyond the field of resection should be
considered unresectable due to distant spread and therefore not eligible for this
protocol.

- Eastern Cooperative Oncology Group (ECOG) Performance Status ≤ 1.

- Serum albumin ≥ 2.0 gm/dL.

- Expected survival ≥ 6 months.

- Adequate organ function including:

1. Marrow: WBC ≥3000/mm^3 and platelets ≥100,000/mm^3.

2. Hepatic: serum total bilirubin ≤ 1.5 mg/dL, ALT (SGPT) and AST (SGOT) ≤3 x upper
limit of normal (ULN) at time of enrollment. If a patient has elevated liver
function tests at the time of initial presentation or develops them during
work-up and they are the result of a mechanical obstruction of biliary drainage
by tumor compression or invasion, a biliary drain may be placed as described in
NCCN Practice Guidelines in Oncology V2.2012. If drainage allows for the liver
function tests to come within inclusion criteria, the patient may be enrolled.

3. Renal: serum creatinine (sCr) ≤2.0 x ULN, or creatinine clearance (Ccr) ≥30
mL/min.

- Patients must have the ability to understand the study, its inherent risks, side
effects and potential benefits and be able to give written informed consent to
participate. Patients may not be consented by a durable power of attorney (DPA).

- All subjects of child producing potential must agree to use contraception or avoidance
of pregnancy measures while enrolled on study and receiving the experimental product,
and for one month after the last immunization.

Exclusion Criteria:

- Age <18-years-old.

- Active metastases.

- Other malignancy within five years, unless the probability of recurrence of the prior
malignancy is <5% as determined by the Principal Investigator based on available
information. Patient's curatively treated for squamous and basal cell carcinoma of the
skin or patients with a history of malignant tumor in the past that have been disease
free for at least five years are also eligible for this study.

- History of organ transplant.

- Current, active immunosuppressive therapy such as cyclosporine, tacrolimus, etc.

- Subjects taking chronic systemic corticosteroid therapy for any reason are not
eligible. Subjects may receive steroids as prophylactic anti-emetics per the
mFOLFIRINOX regimen. Subjects receiving inhaled or topical corticosteroids are
eligible. Subjects who require chronic systemic corticosteroids after beginning
treatment, will be removed from study.

- Significant or uncontrolled congestive heart failure (CHF), myocardial infarction or
significant ventricular arrhythmias within the last six months.

- Patient has active, uncontrolled bacterial, viral, or fungal infection(s) requiring
systemic therapy.

- Autoimmune disease (e.g., systemic lupus erythematosis (SLE), rheumatoid arthritis
(RA), etc.). Patients with a remote history of asthma or mild active asthma are
eligible.

- Other serious medical conditions that may be expected to limit life expectancy to less
than 2 years (e.g., active liver cirrhosis) or a serious illness in medical opinion of
the clinical investigator.

- Any condition, psychiatric or otherwise, that would preclude informed consent,
consistent follow-up or compliance with any aspect of the study (e.g., untreated
schizophrenia or other significant cognitive impairment, etc.).

- A known history of allergy or hypersensitivity to any of the study drugs or any of
their excipients.

- Pregnant or nursing women due to the unknown effects of immunization on the developing
fetus or newborn infant. (For patients with child bearing potential, a βHCG must be
completed within 14 days of first treatment).

- Known HIV positive.

- Prior treatment with chemotherapy or radiation for pancreatic cancer or prior
treatment with radiation for other diagnoses to expected pancreatic cancer treatment
fields.

- Current grade II or higher peripheral neuropathy.