Preoperative Nutrition With Immune Enhancing Nutritional Supplement (Immunomodulation)

Study Objectives: The primary objective of this study is to determine the optimal effective
dose for preoperative nutritional supplementation with immunomodulators on immune function
and perioperative outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.

Primary Endpoints:

The primary endpoints will be effect on immunological profile (circulating Myeloid derived
suppressor cells, circulating B cells, NK cells, CD4 and CD8 cells), serum arginine levels,
immunological milieu of the tumor (tumor infiltrating lymphocytes), overall morbidity rate
and infectious complication rates.

Secondary Endpoints:

- Monitor Safety and Tolerability

- Hospital Length of Stay

- Readmission rate

- One-year event free survival

- Effect on nutritional parameters (serum total protein, prealbumin, albumin and
transferrin)

- Effect on acute phase reactants (CRP, IL6, TNF alpha)

Study Design: This is a 1:1:1:1 four-arm single center prospective randomized feasibility
study to compare preoperative nutritional supplementation with an enhanced formula
containing immune-modulating agents (IMPACT AR) for 5 days with 1,2 or 3 cans versus 5 days
of 3 cans of comparable iso-caloric iso-nitrogenous supplementation (Boost) for patients
with resectable pancreatic adenocarcinoma.

Number of Patients 20 (5 in each arm) Eligibility Criteria: Patients over 18 years of age,
who have histologic and/or radiologic evidence of pancreatic adenocarcinoma in the head of
the pancreas, who have been deemed resectable, and who are able to give informed consent,
will be eligible Exclusion criteria would include Active uncontrolled bacterial, viral or
fungal infection within 21 days of study entry OR Inability to take oral, nasojejunal or
jejunostomy tube nutritional supplements OR patients on chronic steroid therapy (i.e.
greater than 3 months)

Nutritional Supplement interventions:

Patients randomized to the TEST intervention will receive Impact Advanced Recovery™ formula,
which is a commercially available oral nutrition supplement drink that is supplied in 237mL
containers. Each serving provides 1.4 kcal/mL (340 kcal/serving) of which 22% of the kcal
are derived from protein (18.1 gm protein/serving), in addition to their regular diet.
Patients randomized to CONTROL Boost® High Protein Drink will consume their regular diet and
4 cans of Boost per day for 5 days preoperatively (to maintain equivalent supplementation in
terms of calories and protein with the group receiving the highest dose of Impact AR).

Study procedure:

Screening/baseline assessments will performed prior to the first treatment within
approximately four weeks of the treatment and will include a detailed medical history and
physical examination,standard of Care Laboratory tests (CBC, CMP), tumor markers: as
indicated: CEA and CA19-9; and coagulation (baseline and as clinically indicated): INR, PTT,
PT. Imaging to confirm respectability would include a high quality tri-phasic CT scan with
0.7mm cuts or Dynamic MRI with contrast to confirm the absence of metastatic disease Study
specific tests include pre-treatment and post treatment (Office visit/ pre-anesthesia visit,
Morning of surgery, postop day 5)

- Nutritional parameters and acute phase reactants: serum prealbumin, albumin,
transferrin, CRP, IL6, TNF alpha

- Serum arginine,

- MSDC (myeloid derived suppressor cell) assay of fresh blood and Arginase I expression
Study procedure at the time of surgery: Semi-quantitative assay of Tumor infiltrating
lymphocytes from tissue block of tumor obtained at time of surgery. Tumor tissue will
also be banked for post hoc tests if needed.

During follow up visits history and physical examination, performance Status evaluation and
Standard of care Laboratory Tests (CBC, CMP, and Tumor Marker Assessment as clinically
indicated per the discretion of the investigator would be done approximately every three
months). Imaging during follow up include a CT/MRI for disease status (approximately every
three months during follow-up) Adverse Event Monitoring and Concomitant Medication
monitoring will be done out to 90 days

Inclusion Criteria:

- Over 18 years of age, of any race or sex, with histologic and/or radiologic proof of
pancreatic adenocarcinoma (PDAC)

- PDAC that is deemed resectable by the operating surgeon

- Non-pregnant with an acceptable contraception method in premenopausal women

- Signed, written informed consent

Exclusion Criteria:

- Active bacterial, viral or fungal infection within 21 days of study entry

- Women who are pregnant or breast feeding

- Evidence of metastatic disease

- Presence of another malignancy with the exception of cervical carcinoma in situ and
stage I basal or squamous cell carcinoma of the skin

- Inability to take oral or nasojejunal nutritional supplements

- Patients with immunodeficiency conditions

- Patients on chronic steroid therapy

- Patients with know sensitivity to arginine, omega-3 fatty acids or glutamine