Testing Pump Chemotherapy in Addition to Standard of Care Chemotherapy Versus Standard of Care Chemotherapy Alone for Patients With Unresectable Colorectal Liver Metastases: The PUMP Trial

PRIMARY OBJECTIVE: I. To determine if patients with persistently unresectable colorectal liver metastases (CRLM) after treatment with first-line chemotherapy have improved overall survival (OS) with hepatic arterial infusion (HAI) and systemic chemotherapy versus systemic chemotherapy alone. SECONDARY OBJECTIVES: I. To determine whether there is a direct association between hepatic progression free survival (hPFS) and overall survival (OS) when patients are treated with HAI combined with systemic chemotherapy for unresectable CRLM. II To determine the impact on progression free survival (overall, hepatic and extrahepatic) for patients with unresectable CRLM treated with HAI in combination with systemic chemotherapy. III. To determine objective response rate (ORR) in the liver, defined as the proportion of patients achieving complete or partial response by Response Evaluation Criteria is Solid Tumors (RECIST) 1.1. IV. To determine the rate of conversion to resectable disease, defined as the proportion of patients who successfully convert from unresectable to resectable status and undergo R0/R1 resection/ablation. V. To determine the rate in which patients are intended to be treated with HAI but are deemed ineligible at the time of planned pump insertion due to detection of occult extrahepatic disease or unsuitable arterial anatomy (Intra-Operative Ineligibility, IOI). VI. To determine the extent to which patient and disease-specific factors correlate with short- and long-term risk of HAI-specific complications. OUTLINE: Patients are randomized to 1 of 2 arms. ARM A: Patients undergo surgery to place the HAI pump within 6 weeks of randomization, followed by single photon emission computed tomography/computed tomography (SPECT/CT) on study. Patients then receive floxuridine via the HAI pump within 12 weeks of randomization on study. Patients also receive one of the following standard chemotherapy regimens per the treating physician within 16 weeks of randomization: FOLFOX (fluorouracil intravenously \[IV\], oxaliplatin IV, and leucovorin IV), FOLFIRI (fluorouracil IV, irinotecan IV, and leucovorin IV), or OX/IRI (oxaliplatin IV and irinotecan IV) with or without cetuximab IV and/or panitumumab IV on days 1 and 15 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients may have leucovorin omitted from their regimen per institutional standards. Patients also undergo CT and/or magnetic resonance imaging (MRI) scans throughout the trial. ARM B: Patients receive one of the following standard chemotherapy regimens per the treating physician within 6 weeks of randomization: FOLFOXIRI (fluorouracil IV, oxaliplatin IV, irinotecan IV, and leucovorin IV), FOLFOX IV, FOLFIRI IV, or OX/IRI IV with or without cetuximab IV, panitumumab IV, and/or bevacizumab IV on days 1 and 15 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients may receive capecitabine orally (PO) in substitution for fluorouracil at the discretion of the investigator and may have leucovorin omitted from their regimen per institutional standards. Patients also undergo CT and/or MRI scans throughout the trial. After completion of treatment, patients follow up every 3 months for 2 years and then every 6 months for an additional 3 years.