NALIRIFOX versus nab-paclitaxel and gemcitabine in treatment-naive patients with metastatic pancreatic ductal adenocarcinoma (NAPOLI 3): a randomised, open-label, phase 3 trial

Author(s): Zev A Wainberg, MD1; Davide Melisi, MD2; Teresa Macarulla, MD3; Roberto Pazo Cid, MD4; Sreenivasa R Chandana, MD5; Christelle De La Fouchardière, MD6; Andrew Dean, MD7; Igor Kiss, MD8; Woo Jin Lee, MD9; Thorsten O Goetze, MD10; Eric Van Cutsem, MD11; A Scott Paulson, MD12; Tanios Bekaii-Saab, MD13; Shubham Pant, MD14; Richard A Hubner, MD15; Zhimin Xiao, MD16; Huanyu Chen, PhD16; Fawzi Benzaghou, MD16; Eileen M O’Reilly, MD17
Source: DOI:
Maem Hussein MD

Dr. Maen Hussein's Thoughts

You may have enrolled a patient in this trial, but it seems we may have a new first line regimen. Surprisingly toxicity simar in both arms, but there was improvement in PFS and OS (17% reduction in death) although it wasn’t statistically significant in OS.
More diarrhea with nalirifox, but more neutropenia with gem abraxane.


Pancreatic ductal adenocarcinoma remains one of the most lethal malignancies, with few treatment options. NAPOLI 3 aimed to compare the efficacy and safety of NALIRIFOX versus nab-paclitaxel and gemcitabine as first-line therapy for metastatic pancreatic ductal adenocarcinoma (mPDAC).


NAPOLI 3 was a randomised, open-label, phase 3 study conducted at 187 community and academic sites in 18 countries worldwide across Europe, North America, South America, Asia, and Australia. Patients with mPDAC and Eastern Cooperative Oncology Group performance status score 0 or 1 were randomly assigned (1:1) to receive NALIRIFOX (liposomal irinotecan 50 mg/m2, oxaliplatin 60 mg/m2, leucovorin 400 mg/m2, and fluorouracil 2400 mg/m2, administered sequentially as a continuous intravenous infusion over 46 h) on days 1 and 15 of a 28-day cycle or nab-paclitaxel 125 mg/m2 and gemcitabine 1000 mg/m2, administered intravenously, on days 1, 8, and 15 of a 28-day cycle. Balanced block randomisation was stratified by geographical region, performance status, and liver metastases, managed through an interactive web response system. The primary endpoint was overall survival in the intention-to-treat population, evaluated when at least 543 events were observed across the two treatment groups. Safety was evaluated in all patients who received at least one dose of study treatment. This completed trial is registered with, NCT04083235.


Between Feb 19, 2020 and Aug 17, 2021, 770 patients were randomly assigned (NALIRIFOX, 383; nab-paclitaxel–gemcitabine, 387; median follow-up 16·1 months [IQR 13·4–19·1]). Median overall survival was 11·1 months (95% CI 10·0–12·1) with NALIRIFOX versus 9·2 months (8·3–10·6) with nab-paclitaxel–gemcitabine (hazard ratio 0·83; 95% CI 0·70–0·99; p=0·036). Grade 3 or higher treatment-emergent adverse events occurred in 322 (87%) of 370 patients receiving NALIRIFOX and 326 (86%) of 379 patients receiving nab-paclitaxel–gemcitabine; treatment-related deaths occurred in six (2%) patients in the NALIRIFOX group and eight (2%) patients in the nab-paclitaxel–gemcitabine group.


Our findings support use of the NALIRIFOX regimen as a possible reference regimen for first-line treatment of mPDAC.



Author Affiliations

1David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; 2Università degli studi di Verona and Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy; 3Vall d’Hebron University Hospital and Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain; 4Hospital Universitario Miguel Servet, Zaragoza, Spain; 5Cancer and Hematology Centers of Western Michigan, Grand Rapids, MI, USA; 6Centre Léon Bérard, Lyon, France; 7St John of God Subiaco Hospital, Subiaco, WA, Australia; 8Masaryk Memorial Cancer Institute, Brno, Czech Republic; 9National Cancer Center, Goyang, South Korea; 10Krankenhaus Nordwest, Frankfurt am Main, Germany; 11University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven, Belgium; 12Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, TX, USA; 13Mayo Clinic, Scottsdale, AZ, USA; 14MD Anderson Cancer Center, Houston, TX, USA; 15The Christie NHS Foundation Trust, and Division of Cancer Sciences, University of Manchester, Manchester, UK; 16Ipsen, Cambridge, MA, USA; 17Memorial Sloan Kettering Cancer Center, New York, NY, USA

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