Narayanan et al.

BMC Cancer (2021) 21:785

https://doi.org/10.1186/s12885-021-08474-4

STUDY PROTOCOL Open Access

Multicenter randomized controlled trial and

registry study to assess the safety and
efficacy of the NanoKnife® system for the
ablation of stage 3 pancreatic
adenocarcinoma: overview of study
protocols
Govindarajan Narayanan1*, Malcolm M. Bilimoria2, Peter J. Hosein3, Zhaohui Su4, Kathleen M. Mortimer4 and
Robert C. G. Martin II5

Abstract
Background: Irreversible electroporation (IRE) is a local ablation technique utilizing high voltage, low energy direct
current to create nanopores in cell membrane which disrupt homeostasis and leads to cell death. Previous reports
have suggested IRE may have a role in treating borderline resectable and unresectable Stage 3 pancreatic tumors.
Methods: Patients with Stage 3 pancreatic ductal adenocarcinoma (PDAC) will be enrolled in either a randomized,
controlled, multicenter trial (RCT) or a multicenter registry study. Subjects enrolled in the RCT must have no
evidence of disease progression after 3 months of modified FOLFIRINOX (mFOLFIRINOX) treatment prior to being
randomization to either a control or IRE arm. Post-induction and post-IRE treatment for the control and IRE arms,
respectively, will be left to the discretion of the treating physician. The RCT will enroll 528 subjects with 264 per
arm and include up to 15 sites. All subjects will be followed for at least 24 months or until death. The registry study
will include two cohorts of patients with Stage 3 PDAC, patients who received institutional standard of care (SOC)
alone and those treated with IRE in addition to SOC. Both cohorts will be required to have undergone at least 3
months of SOC without progression prior to enrollment. The registry study will enroll 532 patients with 266 patients
in each arm. All patients will be followed for at least 24 months or until death. The primary efficacy endpoint for
both studies will be overall survival (OS). Co-primary safety endpoints will be 1) time from randomization or
enrollment in the registry to death or new onset of Grade 4 adverse event (AE), and (2 high-grade complications
defined as any AE or serious AE (SAE) with a CTCAE v5.0 grade of 3 or higher. Secondary endpoints will include
progression-free survival, cancer-related pain, quality of life, and procedure-related pain for the IRE arm only.

* Correspondence: [email protected]
1
Interventional Oncology, Miami Cancer Institute, Baptist Health of South
Florida, Miami, FL, USA
Full list of author information is available at the end of the article

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Narayanan et al. BMC Cancer (2021) 21:785 Page 2 of 10

Discussion: These studies are intended to provide Level 1 clinical evidence and real-world data demonstrating the
clinical utility and safety of the use of IRE in combination with chemotherapy in patients with Stage 3 PDAC.
Trial registration: Clinicaltrials.gov NCT03899636 and NCT03899649. Registered April 2, 2019. Food and Drug
Administration (FDA) Investigational Device Exemption (IDE) trial G180278 approved on May 3, 2019.
Keywords: Pancreatic ductal adenocarcinoma, Locally advanced pancreatic cancer, Irreversible electroporation,
NanoKnife system, Ablation, Modified FOLFIRINOX

Background chemoradiation therapy or continue chemotherapy.

The incidence of pancreatic cancer has risen consistently There was no difference in the primary endpoint of OS
from 1992 to 2020, while the number of deaths due to although there was decreased local tumor progression in
pancreatic cancer in the United States has also risen the chemoradiation arm. One major limitation of this
proportionately [1]. There will be an estimated 57,600 trial is that the induction chemotherapy used was not
patients initially diagnosed pancreatic cancer in 2020, consistent with the current standard of using multiagent
representing 3.2% of all new cancer cases. A total of 47, combination chemotherapy and it is possible that a more
050 deaths due to pancreatic cancer are projected to effective systemic induction regimen like mFOLFIRI-
occur in the U.S. in 2020 representing 7.8% of all cancer NOX may set the stage for benefit from a local interven-
deaths [1]. Median overall 5-year survival for patients tion like radiation or ablation.
with Stage 1 and 2 pancreatic cancer has been reported The poor outcomes among patients with pancreatic
to be 24.4 months while locally advanced pancreatic cancer has led to the pursuit of new treatment options.
Stage 3 cancer (LAPC) has a median survival of less 1 Irreversible electroporation or IRE (NanoKnife System,
year [2, 3]. Patients with Stage 3 pancreatic ductal AngioDynamics, Inc., Latham, New York) is a non-
adenocarcinoma (PDAC) represent 39.2% of the nonme- thermal based method for local ablation which causes
tastatic patient population with an associated 5-year sur- increased permeabilization of the cell membrane
vival of 10.8% [2]. The probability of survival is inversely through exposure of the cell to electric pulses [9]. Elec-
proportional to tumor size and the number of positive trodes are placed in a pattern which enables the tumor
lymph nodes [4]. to be encompassed by the electrical field produced, with
The current standard of care (SOC) for stage 3 PDAC electric pulses irreversibly permeating the membranes
includes systemic chemotherapy. FOLFIRINOX (com- resulting in cell death. IRE may lead to better preserva-
bination chemotherapy using 5-fluorouracil [5-FU], leu- tion of vessels, nerves, and extracellular matrix within or
covorin [folinic acid], irinotecan, and oxaliplatin) has close to the ablated area compared to thermal ablation
demonstrated improved overall survival to 11.1 months techniques [10–13].
for FOLFIRINOX versus 6.4 months for gemcitabine in A growing body of evidence exists on the use of the
metastatic pancreatic cancer, but at the cost of greater NanoKnife System to treat pancreatic tumors, including
toxicity [5]. More recently, a modified form of FOLFIRI- both borderline resectable and unresectable tumors
NOX (without the bolus 5-FU and with a reduced dose [14–16]. Studies have reported a median OS from diag-
of irinotecan) has been shown to have an acceptable nosis ranging from 14 to 27 months [17–27] and a me-
safety profile while maintaining comparable efficacy of dian OS from IRE treatment ranging from 10 to 27
FOLFIRINOX in metastatic pancreatic cancer [6]. The months [28–30]. The largest of these studies, a 200-
National Cooperative Cancer Network (NCCN) has re- patient, multicenter registry of patients with stage 3
cently added modified FOLFIRINOX (mFOLFIRINOX) pancreatic cancer treated with IRE via an open surgical
as a preferred regimen for Stage 3 pancreatic cancer pa- approach, reported a median OS of 24.9 months and a
tients with a good performance status (ECOG 0–1) [7]. median local progression free interval of 10.7 months
Although radiation therapy is frequently utilized in the [21]. Holland et al. recently reported results from a
United States for patients with Stage 3 pancreatic cancer, multicenter registry which included 152 patients with
there currently exists a dearth of level 1 evidence dem- LAPC treated with IRE via an open approach at 6 dif-
onstrating benefit for radiation or any other local ther- ferent institutions [31]. Median OS from diagnosis,
apy modality. One of the pivotal studies for radiation progression-free survival (PFS), and time to progression
therapy in this population was the LAP07 prospective (TTP), all from diagnosis were 30.7 months, 22.8
randomized trial [8]. In this trial, patients received months, and 27.3 months, respectively.
induction chemotherapy with gemcitabine with or Narayanan et al. reported a retrospective review of 50
without erlotinib and were then randomized to receive patients with LAPC treated with percutaneous IRE (26).
Narayanan et al. BMC Cancer (2021) 21:785 Page 3 of 10

Median OS was 27 months (95% confidence interval treatment in patients with Stage 3 PDAC, with the goal
[CI], 22.7–32.5 months from the time of diagnosis) and of establishing level 1 clinical evidence via a RCT and
14.2 months (95% CI, 9.7–16.2 months) from the time of the collection of real-world data via a parallel registry
IRE. Multivariate analysis demonstrated patients with study that facilitates the enrollment of a similar, yet
tumors ≤3 cm had significantly longer median OS than broader, patient population.
patients with tumors > 3 cm (33.8 vs. 22.7 months from
time of diagnosis; p = 0.002, and 16.2 vs. 9.9 months Methods
from time of IRE; p = 0.031). More recently, Ruarus et al. Randomized controlled trial (RCT)
reported the results of the Phase II multicenter PANF The randomized, controlled, 2-arm, unblinded multicen-
IRE II study which prospectively enrolled 50 patients ter trial will be conducted at up to 15 sites. After subjects
treated with CT-guided percutaneous IRE [25]. This in- have been treated with 3 months of mFOLFIRINOX and
cluded 40 patients with LAPC and 10 patients with local there is no evidence of disease progression, they will be
recurring pancreatic cancer following resection. The me- randomized to either a control arm or a treatment arm of
dian OS from diagnosis for patients with LAPC was 17 IRE with the NanoKnife System using either an open or a
months. For patients with local recurrence, the median percutaneous approach. Randomization will be conducted
OS was 16 months from the diagnosis of recurrence and centrally with subjects randomized in a 1:1 ratio after as-
9 months from IRE treatment. He et al. retrospectively sessment using a study specified imaging protocol. (Fig. 1).
compared 36 patients treated with IRE and 40 patients Post-induction treatment in the control arm and post IRE
receiving radiotherapy with both groups receiving 4 treatment for the IRE arm will be left to the discretion of
months of induction chemotherapy prior to treatment the treating physician. The mFOLFIRINOX regimen will
[32]. Following a Propensity Score Matching (PSM) ana- consist of oxaliplatin at 85 mg/m2, leucovorin at 400 mg/
lysis, patients in the IRE group had longer median OS m2, irinotecan at 150 mg/m2 all on day 1, plus 5-FU at
than patients receiving radiotherapy (21.6 months vs. 2.4 g/m2 starting on day 1 for 46 h. This regimen will be
10.6 months) with significantly greater 1-year (71.4% vs. repeated every 14 days. The minimum period of follow-up
41.3%) and 2 year (53.5% vs. 20.7%) OS rates (p = 0.011). for each subject will be for 24 months or until death.
Major complications (grade 3 or higher) have been re- Study accrual is estimated to require 36 months to
ported in approximately 21 to 34% of patients treated complete with each subject followed until 24 months after
with IRE [16, 25]. This includes the development of por- enrollment of the last subject, or death.
tal vein thrombosis, pancreatic fistulae, pancreatitis and
hematomas [15]. Registry study
The above studies have paved the way for conducting The multicenter, observational registry study will include
two U.S. Food and Drug Administration (FDA) approved patients with Stage 3 PDAC who received SOC alone
Investigational Device Exemption (IDE) studies to and those treated with IRE in addition to SOC (Fig. 2).
prospectively investigate the safety and efficacy of IRE Both cohorts will be required to undergo at least 3

Fig. 1 Study Design: Randomized Controlled

Narayanan et al. BMC Cancer (2021) 21:785 Page 4 of 10

Fig. 2 Study design: Registry

months of SOC without progression prior to enrollment study will have broader inclusion/exclusion criteria
in the registry. The accrual time for the registry study is allowing for evaluation of real-world evidence regarding
24 months, and each patient will be followed-up for at the safety and effectiveness of NanoKnife IRE. Patients
least 3 months after the study enrolls 266 patients in who have received a wide variety of prior treatments
each cohort. The Registry study will enroll both control (chemotherapy, chemoradiation or other procedures) as
and IRE patients from sites where patients are routinely well as those who choose to receive the IRE treatment
treated with ablation using the NanoKnife System. Add- rather than get randomized are eligible to participate in
itional control patients will also be enrolled from sites the registry study. Subjects must have no evidence of
that do not offer treatment with the NanoKnife System. disease progression after completion of the 3 months of
The non-NanoKnife sites will be selected to be compar- induction therapy in order to participate in the RCT and
able to the NanoKnife sites with respect to type of cen- registry. Response Evaluation Criteria In Solid Tumours
ter, geography, size, volume of patients with pancreatic 1.1 (RECIST 1.1) and pancreatic cancer specific second-
cancer, volume of pancreatic cancer surgeries, type of ary endpoints may be used to assess radiologic and clin-
chemotherapy, and duration of chemotherapy. ical outcomes associated with disease progression.
Blinded reads of imaging will be performed in a central
Study objectives location by external blinded readers for both the ran-
The primary objectives for both the RCT and registry domized controlled trial and the registry study.
study are to test the hypothesis that IRE with the Nano-
Knife System improves OS in subjects with Stage 3 Study endpoints and assessments
PDAC and to assess the safety of IRE compared to the The primary efficacy endpoint for both the RCT and the
control arm for the RCT or SOC cohort for the registry registry study will be OS defined as the time (in months)
study. Secondary objectives include comparing PFS, from randomization or enrollment in the registry to the
cancer-related pain and quality of life (QOL) for subjects date of death for any reason. Co-primary safety end-
in the control arm versus the IRE arm and to assess points include time (in months) from randomization or
procedure-related pain in subjects in the IRE arm. enrollment in the registry to death or new onset of
Grade 4 AE, and the development of high-grade compli-
Key eligibility criteria cations defined as any AE or SAE with a CTCAE v5.0
The RCT will be limited to subjects with cytologically or grade of 3 or higher.
pathologically confirmed pancreatic adenocarcinoma Secondary endpoints for both studies include a) PFS
that are unresectable and who meet the study’s inclu- defined as the time (in months) from randomization or
sion/exclusion criteria (Table 1). As compared to the enrollment in the registry to the date of first observed
stringent eligibility requirements of the RCT, the registry disease progression (per clinical and radiologic criteria),
Narayanan et al. BMC Cancer (2021) 21:785 Page 5 of 10

Table 1 Patient Inclusion and Exclusion Criteria

Key Inclusion Criteria
Randomized Controlled Multicenter Study Multicenter Registry
● Signed and dated informed consent form. ● Signed and dated informed consent form
● 18 years of age and older. ● 18 years of age and older
● Diagnosis of unresectable Stage 3 pancreatic adenocarcinoma cancer ● Diagnosis of Stage 3 PC cytologically or pathologically confirmed per
cytologically or pathologically confirmed per American Joint American Joint Committee on Cancer (AJCC) staging criteria.
Committee on Cancer (AJCC) staging criteria. ● Tumor evaluated as Stage 3 according to National Comprehensive
● Tumor evaluated as Stage 3 according to National Comprehensive Cancer Network (NCCN) guidelines, based on radiographic imaging or
Cancer Network (NCCN) guidelines, based on radiographic imaging or exploratory surgery
exploratory surgery. ● Maximum axial and anterior to posterior tumor dimension of ≤3.5 cm
● Maximum axial and anterior to posterior tumor dimension of ≤3.5 cm, after standard of care.
after receiving three months of treatment with the mFOLFIRINOX ● Has received 3 months of standard of care per each participating
regimen. institution’s guidelines
● Has received 3 months of treatment with the mFOLFIRINOX regimen. ● Has an Eastern Cooperative Oncology Group (ECOG) performance
● Has an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
status of 0 or 1. ● Has an American Society of Anesthesiologists (ASA) classification of
● Has an American Society of Anesthesiologists (ASA) classification of physical health status of 1, 2, 3 or 4.
physical health status of 1, 2, 3 or 4. ● Are at an IRE site and are deemed eligible for IRE and receive ablation
using the NanoKnife System.
● Shows no evidence of disease progression based on NCCN guidelines
after completing 3 months of standard of care.
Key Exclusion Criteria
Randomized Controlled Multicenter Study Multicenter Registry
● Subjects who are or may be pregnant as determined by a positive ● Participating in an interventional trial for pancreatic cancer during the
pregnancy test or breastfeeding or male or female patients of study data collection period.
reproductive potential who are not willing to employ highly effective ● Pregnant or lactating patients or male or female patients of
birth control from screening to 6 months after the last dose of reproductive potential who are not willing to employ highly effective
chemotherapy. birth control from screening to 6 months after the last dose of
● Unable to tolerate general anesthetic with full skeletal muscle blockade. chemotherapy
● Is actively bleeding, anticoagulated, coagulopathy, or has any of the ● Unable to tolerate general anesthetic with full skeletal muscle
following hematology results: hemoglobin less than10 g/dL without blockade.
the support of growth factors or transfusions; absolute neutrophil ● Has an implanted cardiac pacemaker, defibrillator, electronic device(s)
count less than 1500 cells/mL; or platelet count less than 100,000. or implanted device(s) with metal parts in the thoracic cavity at the
● Has an implanted cardiac pacemaker, defibrillator, electronic device(s) time of IRE.
or implanted device(s) with metal parts in the thoracic cavity at the
time of IRE.
● Has a history of epilepsy or other neurological diseases.
● Has renal, cardiac, liver, or hematological abnormalities of concern to
the investigator.
● Has Stage 3, 4, or 5 chronic kidney disease.
● Is receiving IRE for margin accentuation.
● Has evidence of disease progression at 3 months after FOLFIRINOX
treatment.
● Participating in an interventional trial for pancreatic cancer during the
study data collection period.
● Did not meet study defined criteria for adequacy of induction
treatment at the end of the 3 months.

or death from any cause, if death occurs without docu- from date of enrollment, and identification of risk
mented disease progression, b) procedure-related pain in factors and biomarkers associated with outcomes.
subjects in the IRE arm, as measured by the Brief Pain Additional QOL exploratory endpoints which will be
Inventory (BPI-SHORT FORM) on the day of the pro- collected include rates of avoidable events associate with
cedure and post-procedure days 1, 7, 14 and 30, c) chemotherapy in the IRE arm during chemotherapy free
cancer-related pain assessed in the control and IRE arms days compared to the control arm, unplanned readmis-
using the BPI-SHORT FORM at baseline, 3 months, 6 sions within 30 days following discharge, and in-hospital
months and at 6-month intervals thereafter, and d) QOL mortality.
assessed in the control and IRE arms using the EQ-5D
questionnaire at baseline, 3 months, 6 months and then Sample size and statistical considerations
at 6-month intervals for the duration of the study.
The registry study will also assess several exploratory Randomized controlled trial
endpoints including chemotherapy-free days (after 3 Randomization will be conducted centrally. Concurrent
months of SOC), the need for opioids for cancer-related randomization to either the IRE or control arm will take
pain, OS from date of pancreatic cancer diagnosis, PFS place at the completion of 3-month modified FOLFIRINOX
Narayanan et al. BMC Cancer (2021) 21:785 Page 6 of 10

administration, at participating sites, and be stratified by the (regardless of actual treatment received); 2) a Modified
response following 3 months of treatment with mFOLFIRI- Intent-to-treat population (mITT) which includes random-
NOX (responder vs. stable disease), planned type of ized subjects in the control arm who did not receive IRE
IRE procedure (open or percutaneous) and planned procedures, and those in the IRE arm who have undergone
post-procedure treatment (chemotherapy versus radio- the IRE procedure, excluding subjects with major protocol
therapy/ chemotherapy versus observation). A total of deviations. Treatment assignment will be based on the ran-
444 Intent-to-treat population (ITT) subjects (with domized treatment. For subjects who are randomized to
222 subjects in each arm) are required for at least control arm but later received IRE treatment, the study data
80% power for the primary efficacy endpoint (OS), only up to the date of IRE will be considered in this analysis
with the expectation that there will be a total of 380 population. Those subjects randomized to the IRE arm but
events in both arms. With the consideration of up to did not receive IRE procedures will be excluded from this
16% attrition rate in both arms, and assuming a me- analysis population; and 3) a Safety Population consisting of
dian survival of 12 months and exponential survival, all randomized subjects. If subjects randomized to the con-
up to 528 subjects (with 264 subjects per arm) will trol arm receive IRE treatment with NanoKnife, they will
need to be randomized. be included in the IRE safety population. Similarly, if sub-
The sample size consideration for the primary end- jects randomized to the IRE arm did not receive IRE treat-
point OS was based on the assumptions that 1) there ment, they will be included in the control safety population.
will be a 1:1 randomization scheme, 2) median survival For the primary efficacy endpoint, the null hypothesis
will be 12 months and 16 months in the control and the for OS is stated as H0: Scontrol = SIRE and the alternative
IRE arm, respectively, i.e., a hazard ratio of 0.75 for IRE hypothesis is H1: Scontrol ≠ SIRE, where Scontrol is the me-
versus control 3) there will be a 5% 2-sided type I error, dian OS time for the control arm, and SIRE is the median
4) there will be an accrual period of 36 months and OS time for the IRE treatment arm.
follow-up period of 24 months after the study is fully en- The null hypothesis states that there is no difference
rolled. In addition, based on an assumption that median in median OS time post randomization between the IRE
times to PFS will be 6 months and 8 months in the con- arm and the control arm, while the alternative hypoth-
trol and IRE arm, respectively, the study has at least 80% esis states there is. The trial is powered to show the
power for analysis of the difference in the secondary superiority of OS of 4 months in the IRE arm over the
endpoint of time to PFS between the IRE and control control arm. The above null hypothesis will be tested by
arms. a 2-sided log rank test at 0.05 significance level in the
final analysis. If the null hypothesis is rejected by the
Registry study two-sided test and the observed median OS time in the
The registry study will enroll 266 patients in the IRE IRE is greater than in the control arm, the alternative
cohort and 266 patients in the SOC cohort in order to hypothesis will be established and the superiority of OS
achieve 90% power for analyzing both the OS and PFS in the IRE arm will be statistically proven.
endpoints. The power calculation assumes that it will For the secondary efficacy analysis, the null hypothesis
take 24 months for accrual, and all 532 patients will be for PFS is H0: μcontrol = μIRE with the alternative hypoth-
followed for at least 3 months after completion of ac- esis being H1: μcontrol ≠ μIRE,where μcontrol is the median
crual. The sample size consideration was based on the PFS time for the control arm, and μIRE is the median
assumptions that the median OS time will be 12 months PFS time for the IRE arm. This study is powered to show
for SOC cohort and 18 months for the IRE cohort and the superiority of PFS of 2 months in the IRE arm over
there will be a 0.05 Alpha level (Type I error rate). For the control arm. The above null hypothesis will be tested
the secondary effectiveness endpoint of PFS, 210 patients by a 2-sided log rank test at 0.05 significance level only
will be needed per cohort for 90% statistical power as- if the result of testing the primary efficacy endpoint is
suming a median PFS of 8 months and 12 months for statistically significant. If the above null hypothesis is
the SOC and IRE cohorts, respectively, or 116 patients rejected by the two-sided test and the observed median
per cohort if the median PFS survival is 8 months for the PFS time in the IRE is greater than in the control arm,
SOC cohort and 14 months for the IRE cohort. the alternative hypothesis will be established and the su-
periority of the PFS in the IRE arm will be statistically
Statistical analysis proven.
Analysis of the primary efficacy endpoint and key sec-
Randomized controlled trial ondary endpoints will also be performed for the mITT
There will be three analysis populations: 1) an Intent-to- population as supportive analyses. Safety analysis will be
treat population (ITT) which includes all subjects random- performed on the Safety population. To control the
ized with treatment assignment based on randomization overall type I error rate for testing efficacy endpoints, a
Narayanan et al. BMC Cancer (2021) 21:785 Page 7 of 10

fixed-sequence testing procedure will be used to test the Subjects who do not have disease progression and
primary and secondary efficacy endpoints in a prede- have not died, will be censored at the date of last tumor
fined order. The test will be performed in sequence and assessment. Subjects with a single missing radiologic or
significance of OS endpoint is required in order to clinical assessment immediately prior to a visit with doc-
proceed to the testing of PFS endpoint. All statistical umented disease progression (or death) will be analyzed
tests will be at the two-sided 0.05 significance level and as a PFS event at the time of the clinical or radiologic as-
the corresponding p-values and 95% confidence intervals sessment that shows progression. Subjects with two or
(CIs) will be reported. Subjects alive or lost to follow-up more consecutive missing radiologic or clinical assess-
at the time of analysis will be censored at their last date ments immediately prior to an assessment without docu-
of follow-up. In the final analysis, OS will be compared mented progression (or death) will be censored at the
between the randomized treatment arms using a two-sided date of last assessment when the subject was docu-
log-rank test at a type I error rate of 0.05. ITT analysis will mented as progression-free prior to the first of the two
be the primary analytic methods, supported with mITT or more missing assessments. PFS will be analyzed using
and Cox proportional hazards analysis. Kaplan-Meier similar statistical methods as that for the OS endpoint.
methods will be used to summarize survival distribution of Pain Severity Scores and average Pain Interference
OS and median OS time for each treatment arm. The rela- Score will be derived for each subject from BPI-SHORT
tive treatment effect between the IRE arm and the control FORM questionnaire. QOL measures will be derived for
arm with respect to OS will be estimated by the hazard ra- each subject from the EQ-5D questionnaire, including
tio (HR) and the associated two-sided 95% CIs using the the EQ Visual Analogue Scale (VAS) and EQ-5D sum-
Cox proportional hazards model. mary index. Both absolute change and percent change
There will be one planned interim analysis with an from baseline will be analyzed by treatment arm and by
early stopping rule for adverse events and for superiority study visit for all of the above.
associated with the primary efficacy endpoint. Stopping For the primary safety endpoints, a log-rank test will
rules for adverse events will include (but will not be lim- be used to compare the time (in months) from
ited to) two IRE related ventricular arrhythmias during randomization to death or new onset of Grade 4 AEs for
the IRE procedure that require synchronized cardiover- the two treatment arms, with data censored at the time
sion or defibrillation or one death determined by the in- of loss to follow up or study discontinuation. The num-
vestigator and the Data Monitoring Committee (DMC) ber and proportion of subjects with a high-grade compli-
to be related to IRE. cation defined as any AEs or SAEs with a CTCAEv5.0
There will be a single OS-based threshold for stopping grade of 3 or higher will be summarized by treatment
the trial for superiority using a pre-specified Haybittle- arm and CTCAE grade.
Peto boundary with an alpha level of 0.001. If the IRE
arm demonstrates superiority over the control arm with Registry study
P-value< 0.001 following the interim analysis, the study There will be two analysis populations including 1) an
may be terminated early, depending on the safety profile. Effectiveness Population which consists of all enrolled
Since the study will be powered based on an OS primary patients who will be matched by propensity score quin-
endpoint, there will not be an adverse events related tiles, all of whom have received at least 3 months of
threshold for stopping the trial for superiority. therapy per SOC without evidence of disease progres-
The interim analysis will not be used to lead to early sion, and 2) a Safety Population which consists of all en-
termination of the study because of futility (e.g., the IRE rolled patients with the cohort assignment based on the
arm does not demonstrate superiority over the control actual treatment received.
arm). The DMC will have the ability to make recom- For the primary efficacy endpoint, the null hypothesis
mendations after reviewing the results of the interim for OS is stated as H0: Ssoc = SIRE and the alternative hy-
analysis or through safety monitoring, and in conjunc- pothesis is H1: Ssoc ≠ SIRE, where Ssoc is the median OS
tion with the study sponsor, can decide to continue or time for the SOC cohort, and SIRE is the median overall
terminate the study to save resources. survival time for the IRE cohort. For the secondary effi-
The interim analysis will be conducted when approxi- cacy analysis, the null hypothesis for PFS is H0: μsoc =
mately 251 (66% of the total 380) deaths have been ob- μIRE with the alternative hypothesis being H1: μsoc ≠ μIRE,
served in the overall ITT population. As part of the where μsoc is the median PFS time for the SOC cohort,
interim analysis, the assumptions about the sample size and μIRE is the median PFS time for the IRE arm. The
estimation will also be evaluated. The final analyses of null hypothesis for each state that there is no difference
OS will be conducted at the 5% level of significance in median OS or PFS time post the initial 3 months of
when approximately 380 death events occurred. Interim therapy between the IRE cohort and the SOC cohort,
data will be evaluated by the independent DMC. while the alternative hypothesis states there is. This
Narayanan et al. BMC Cancer (2021) 21:785 Page 8 of 10

study is powered to show the superiority of OS and PFS These two studies will be run in parallel to collect
in the IRE cohort over the SOC cohort. The above null both level 1 clinical evidence and real-world data. This
hypotheses will be tested by a 2-sided log rank test will be accomplished via multicenter studies using both
stratified by propensity score quintiles at the 0.05 signifi- a randomized, controlled trial design with more strin-
cance level. The PFS endpoint will be tested only if the gent inclusion/exclusion criteria and an observational
result of testing the primary effectiveness endpoint is registry enrolling of individuals which are more reflect-
statistically significant. Exploratory subgroup analyses ive of the broader population of patients with Stage 3
will include patient’s sex (male or female), and other PDAC. This dual study approach will be useful towards
factors to be determined after the study team reviews addressing the inherent limitations associated with using
the final analyses of primary and secondary endpoints. either of these study designs for assessing the treatment
There will be one planned interim analysis for the of cancer patients [32, 33]. For randomized, controlled
registry study, to be conducted when 50% of 266 pa- trials, a typical limitation is the inability to generalize the
tients in either cohort die, or per the recommenda- results to a larger patient population since the study
tion of the DMC. The purpose of the interim analysis subjects may not be representative of all cancer patients.
is to examine accrual rate and check the assumptions While registry studies can provide insights on clinical
about the median survival times (i.e., 12 months for outcomes associated with newer therapies, they have in-
SOC cohort and 18 months for the IRE cohort), to herent weaknesses that impact the ability to make com-
ensure that the study will have sufficient power for parisons between nonrandomized patient cohorts.
planned analyses. The present studies are designed to contribute to the
Exploratory analyses for the registry study will include comprehensive information and clinical evidence re-
OS from date of diagnosis, PFS from date of diagnosis, ported to date supporting the safety and efficacy associ-
chemotherapy-free days per 100 person-months of ated with IRE treatment in patients with Stage 3 PDAC.
follow-up after enrollment, proportion of patients Positive results from the study in terms of clinical effi-
treated with opioids for cancer-related pain at 3, 6, 12, cacy with an acceptable safety profile would support the
18 and 24 months after enrollment, mean Morphine standard use of IRE in patients with Stage 3 PDAC.
Milligram Equivalent (MME)/Day among patients using
opioids in each cohort at these time points, rates of Abbreviations
avoidable events associated with chemotherapy in the AE: Adverse Event; AJCC: American Joint Committee on Cancer;
IRE arm during chemotherapy free days compared to ASA: American Society of Anesthesiologists; BPI: Brief Pain Inventory;
CRF: case Report Form; CTCAE: Common Terminology Criteria for Adverse
the control arm, 30-day unplanned readmissions, in- Events; DMC: Data Monitoring Committee; ECOG: Eastern Cooperative
hospital mortality and identification of risk factors and Oncology Group; FOLFIRINOX: Regimen of leucovorin, fluorouracil, irinotecan,
biomarkers associated with outcomes. These exploratory oxaliplatin; IRB: Institutional Review Board; IRE: Irreversible Electroporation;
ITT: Intention-to-Treat; mITT: Modified Intent-to-treat; NCCN: National
analyses will be descriptive and, as deemed necessary, Comprehensive Cancer Network; NCI: National Cancer Institute; OS: Overall
will be stratified by propensity score quintiles, or includ- Survival; PDAC: Pancreatic Ductal Adenocarcinoma; PET: Positron Emission
ing propensity scores as a covariate. Unless explicitly Tomography; PFS: Progression-Free Survival; QOL: Quality of Life; RECI
ST: Response Evaluation Criteria In Solid Tumours; SAE: Serious Adverse
stated otherwise in the analysis plan, the exploratory Event; SD: Standard Deviation; SOC: Standard of Care; TTP: Time to
analyses will be based on the Effectiveness population. Progression
The analysis method for OS from date of diagnosis and
PFS from date of diagnosis will be the same as for OS Acknowledgements
from date of enrollment. Poisson regression model will We thank the patients, their families, and all the institutions and investigators
who are participating in this study. Medical writing assistance was provided
be used for analyzing chemotherapy-free days, and logis- by Larry Yost from The Atticus Group, LLC (Portsmouth, New Hampshire,
tic regression model will be used for analyzing other bin- USA) who reports being a paid consultant to AngioDynamics, Inc.
ary endpoints.
Authors’ contributions
Discussion GN, MMB, PJH, ZS, KMM, and RCGM made substantial contributions to the
A diagnosis of Stage 3 PDAC is associated with poor design of both studies referenced in the present work. GN, MMB, PJH, and
RCGM are involved conduction of the studies. GN drafted the manuscript. All
outcomes and a low 5-year survival rate. The present authors were involved with revising the manuscript draft and approved the
studies are designed to test the hypothesis that IRE final manuscript.
treatment with the NanoKnife System when combined
with a standard chemotherapy regimen improves overall Funding
survival with an acceptable safety profile. Additional Both studies referenced are funded by AngioDynamics, Inc. (Latham, New
goals of the study are to also provide evidence that IRE York, USA). The funding company participated in the design of the study
and will assist with the collection, analysis, and interpretation of data. The
treatment can also improve PFS, reduce cancer-related company provide compensation to an independent medical writer to assist
pain and improve QOL. with the development of the manuscript.
Narayanan et al. BMC Cancer (2021) 21:785 Page 9 of 10

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