Capecitabine, Temozolomide, And Bevacizumab For Metastatic Or Unresectable Pancreatic Neuroendocrine Tumors

Study Overview

Capecitabine, Temozolomide, and Bevacizumab for Metastatic or Unresectable Pancreatic Neuroendocrine Tumors

The purpose of this research is to evaluate the effectiveness and safety of a combination of capecitabine, temozolomide and bevacizumab in the treatment of advanced pancreatic neuroendocrine tumors.

PRIMARY OBJECTIVES: * Estimate if the combination of capecitabine and temozolomide with bevacizumab for metastatic or unresectable neuroendocrine tumors will improve response rate (RR) by 62% over historical controls (null RR of 40% to true RR 65%). * Assess the toxicities using Common Terminology Criteria for Adverse Events (CTCAE) v4.0. SECONDARY OBJECTIVES: * Evaluate progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier analysis. * Assess O6-methyl guanine-deoxyribonucleic acid (DNA) methyltransferase (MGMT) at baseline by central pathology (path) review. * Assess serum hormone marker levels. * Evaluate computed tomography (CT) Perfusion as a tool to predict early therapeutic response. (Optional) * Bank serum for future correlative analyses. OUTLINE: Patients receive bevacizumab intravenously (IV) over 30 to 90 minutes on days 1 and 15, capecitabine orally (PO) twice daily (BID) on days 1 to 14, and temozolomide PO once daily (QD) on days 10 to 14. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity, with assessment for treatment effect every 3 cycles. After completion of study treatment, patients are followed up patients are followed long-term for survival.

Gastrinoma
Glucagonoma
Insulinoma
Pancreatic Polypeptide Tumor
Recurrent Islet Cell Carcinoma
Recurrent Pancreatic Cancer
Somatostatinoma
Stage III Pancreatic Cancer
Stage IV Pancreatic Cancer

DRUG: Capecitabine
DRUG: Temozolomide
BIOLOGICAL: Bevacizumab

IRB-22412
NCI-2011-03497 (REGISTRY Identifier) (REGISTRY: CTRP (Clinical Trial Reporting Program))
SU-10282011-8571 (OTHER Identifier) (OTHER: Stanford University)
NET0012 (OTHER Identifier) (OTHER: OnCore)
END0012 (OTHER Identifier) (OTHER: superceded OnCore)
4593 (OTHER Identifier) (OTHER: superceded IRB number)

Study Record Dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Registration Dates	Results Reporting Dates	Study Record Updates
First Submitted 2012-01-10	Results First Submitted 2020-06-04	Last Update Submitted that met QC Criteria 2024-01-11
First Submitted that Met QC Criteria 2012-02-01	Results First Submitted that Met QC Criteria 2020-12-04	Last Update Posted (ACTUAL) 2024-02-06
First Posted (ACTUAL) 2012-02-02	Results First Posted 2020-12-30	Last Verified 2024-01

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

Design Details

Primary Purpose:
Treatment

Allocation:
Na

Interventional Model:
Single Group

Masking:
None

Arms and Interventions

Participant Group/Arm	Intervention/Treatment
EXPERIMENTAL: Bevacizumab + Capecitabine + Temozolomide Cycles repeat every 28 days until disease progression, unacceptable toxicity, or withdrawal.	DRUG: Capecitabine Capecitabine by mouth twice daily on Days 1 to 14 DRUG: Temozolomide Temozolomide by mouth daily on Days 10 to 14 BIOLOGICAL: Bevacizumab Bevacizumab IV over 30 to 90 minutes on Days 1 & 15

Participant Group/Arm

Intervention/Treatment

EXPERIMENTAL: Bevacizumab + Capecitabine + Temozolomide

Cycles repeat every 28 days until disease progression, unacceptable toxicity, or withdrawal.

DRUG: Capecitabine

Capecitabine by mouth twice daily on Days 1 to 14

DRUG: Temozolomide

Temozolomide by mouth daily on Days 10 to 14

BIOLOGICAL: Bevacizumab

Bevacizumab IV over 30 to 90 minutes on Days 1 & 15

Primary Outcome Measures	Measure Description	Time Frame
Radiographic Response (RR)	Tumor response to treatment with the combination of capecitabine & temozolomide plus bevacizumab in patients with metastatic or unresectable pancreatic neuroendocrine tumors was assessed per Response Evaluation Criteria in Solid Tumors Criteria (RECIST v1.1) for target lesions. Response is defined as: * Complete Response (CR) = Disappearance of all target lesions * Partial Response (PR) = ≥ 30% decrease in the sum of the longest diameter of target lesions * Overall Response (OR) = CR + PR * Progressive disease (PD) = 20% increase in the sum of the longest diameter of target lesions, and/or the appearance of one or more new lesion(s) * Stable disease (SD) = Small changes that do not meet any of the above criteria The outcome is reported as the number of participants who between 3 and 18 months after treatment initiation achieve CR, PR, or clinical response (PR + CR), each a number without dispersion.	18 months

Secondary Outcome Measures	Measure Description	Time Frame
Treatment-related Toxicity	Patients will be monitored for hematologic (blood and lymphatic), gastrointestinal (stomach and gut), renal (kidney), liver (metabolic), neurological, and systemic (constitutional) toxicities (treatment-related adverse events). Toxicity events occurring during treatment will be tabulated for each indicated organ system, and listed separated for serious and non-serious events, with the toxicity attribution indicated. The outcome is reported as the number of events, a number without dispersion.	18 months
Progression-free Survival (PFS)	Progression-free survival (PFS) means the length of time that participants survive without disease (tumor) progression, and was assessed using Kaplan-Meier analysis. The outcome is given as the mean in months with standard error of the mean.	82 months
Overall Survival (OS)	Time from the date of enrollment to the date of death due to any cause or the last date the patient was known to be alive (censored observation) at the date of data cutoff for the final analysis. The results will be reported as median in months The length of overall survival (OS) of participants was assessed by Kaplan-Meier analysis. The outcome is given as the median in months with full range.	82 mo
O6-methylguanine DNA Methyltransferase (MGMT) Status by Immunohistochemistry (IHC)	O6-alkylguanine DNA alkyltransferase is a protein that in humans is encoded by the gene "O6-methylguanine DNA methyltransferase" (MGMT). Deficiency of the gene product, ie, the protein, is refereed to as "MGMT deficiency," and is thought to be predictive of response to temozolomide and is more often associated with pancreatic NETs. MGMT status in pre-treatment biopsy specimens was to be assessed by immuno-histochemistry (IHC), and associated to best clinical response. The outcome is reported by the the number of patients that were IHC-positive (MGMT detected) or IHC-negative (MGMT not detected), and by best clinical response [ie, complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD)]. The outcome is reported as a number without dispersion.	18 months
O6-methylguanine DNA Methyltransferase (MGMT) by Promoter Methylation	O6-alkylguanine DNA alkyltransferase is a protein that in humans is encoded by the gene "O6-methylguanine DNA methyltransferase" (MGMT). Deficiency of the gene product, ie, the protein, is refered to as "MGMT deficiency," and is thought to be predictive of response to temozolomide and is more often associated with pancreatic NETs. MGMT status in pre-treatment biopsy specimens was to be assessed by extent of genetic promoter methylation (an analysis of DNA), and correlated to subject survival. MGMT status in pre-treatment biopsy specimens was to be assessed by promoter methylation assessment (PM), and associated to best clinical response. The outcome is reported by the the number of patients that were PM-positive (MGMT detected) or PM-negative (MGMT not detected), and by best clinical response [ie, complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD)]. The outcome is reported as a number without dispersion.	18 months

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person’s general health condition or prior treatments.

Ages Eligible for Study:
ALL

Sexes Eligible for Study:
18 Years

Accepts Healthy Volunteers:

Histologically-confirmed pancreatic neuroendocrine tumors that are moderately- or well-differentiated
Metastatic or unresectable disease
If prior surgical resection > 5 years before the development of metastatic disease, a separate (recent) histological or cytological confirmation of metastatic disease is required
If there is substantial clinical ambiguity regarding the nature or source of apparent metastases, clinicians should consider biopsy of lesions to establish diagnosis of metastatic disease
The site of previous radiotherapy, if the only site of disease, has evidence of progressive disease
If prior sunitinib and everolimus has been administered, a 2-week wash-out period is required prior to 1st dose on this study
If prior liver-directed therapies (ie, chemoembolization, radioembolization), target lesions in the liver have demonstrated growth since the liver-directed treatment
If prior peptide receptor radionuclide therapy (PRRT), target lesions in the liver have demonstrated growth since the liver-directed treatment
Low-dose aspirin (≤ 325 mg/d) may be continued in subjects at higher risk for arterial thromboembolic disease.
Primary or metastatic tumor lesion measurable in at least 1 dimension, within 4 weeks prior to entry of study.
Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2
≥ 18 years of age.
Laboratory values as follows, ≤ 2 weeks prior to randomization:
Absolute neutrophil count (ANC) ≥ 1.5 x 10e9/L (≥ 1500/mm³)
Platelets (PLT) ≥ 100 x 10e9/L (≥ 100,000/mm³)
Hemoglobin (Hgb) ≥ 9 g/dL
Serum creatinine ≤ 1.5 x upper limit of normal (ULN)
Serum bilirubin ≤ 1.5 x ULN
Aspartate aminotransferase (AST/SGOT), alanine aminotransferase (ALT/SGPT) ≤ 3.0 x ULN (≤ 5.0 x ULN if liver metastases present). Note: endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous stenting may be used to normalize the liver function tests
Urine dipstick or urinalysis for protein, value must be 0, trace, or 1+ protein to enroll. EXCEPTION: if ≥ 2+ must check 24-hour urine protein and must be < 1 g
Life expectancy ≥ 12 weeks
Ability to give written informed consent according to local guidelines
If any prior therapy-related toxicities, must have recovered from all

Prior bevacizumab; fluoropyrimidines (eg, capecitabine or 5-fluorouracil, 5FU); or temozolomide
Poorly-differentiated or high-grade pancreatic neuroendocrine tumors
Prior full field radiotherapy ≤ 4 weeks or limited field radiotherapy ≤ 2 weeks prior to enrollment
Diagnosis of another malignancy, unless > 3 years earlier and has been disease-free for > 6 months following the completion of curative intent therapy, specific eligibility exceptions as follows:
Curatively-resected non-melanomatous skin cancer
Curatively-treated cervical carcinoma in situ
Organ-confined prostate cancer with no evidence of recurrent or progressive disease based on prostate-specific antigen (PSA) values, if hormonal therapy has been initiated or a radical prostatectomy has been performed
Other primary solid tumor curatively treated with no known active disease present and no treatment administered for > 3 years
Concurrent use of other investigational agents and patients who have received investigational drugs ≤ 4 weeks prior to enrollment
Known hypersensitivity to capecitabine, temozolomide, or any component of the formulation
Known deficiency of dihydropyrimidine dehydrogenase Bevacizumab-specific Exclusions
Inadequately-controlled hypertension (defined as systolic blood pressure >150 mmHg and/or diastolic blood pressure > 100 mmHg)
Prior history of hypertensive crisis or hypertensive encephalopathy
New York Heart Association (NYHA) Grade II or greater congestive heart failure
History of myocardial infarction or unstable angina within 6 months prior to Day 1
History of stroke or transient ischemic attack within 6 months prior to Day 1
Known central nervous system (CNS) metastases
Significant vascular disease (eg, aortic aneurysm, requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to Day 1
History of hemoptysis (≥ ½ teaspoon of bright red blood per episode) within 1 month prior to Day 1
Evidence of bleeding diathesis or significant coagulopathy (in the absence of therapeutic anticoagulation)
Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to Day 1 or anticipation of need for major surgical procedure during the course of the study
Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to Day 1
History of abdominal fistula or gastrointestinal perforation within 6 months prior to Day 1
Serious, non-healing wound, active ulcer, or untreated bone fracture
Known hypersensitivity to any component of bevacizumab General Medical Exclusions
Inability to comply with study and/or follow-up procedures
Current, recent (within 4 weeks of the first infusion of this study), or planned participation in an experimental drug study
Pregnant or lactating/breast feeding
Lack of effective contraception men or women of child-bearing potential
Uncontrolled systemic fungal, bacterial, viral, or other infection (defined as exhibiting ongoing signs/symptoms related to the infection and without improvement, despite appropriate antibiotics or other treatment)
Known history of HIV, HBV, or HCV
Current, ongoing treatment with full-dose warfarin. However, patients may be on stable doses of a low-molecular weight heparin are allowed [eg, (enoxaparin (Lovenox)].

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

National Cancer Institute (NCI)

Investigators

PRINCIPAL_INVESTIGATOR: Shaheen Shagufta, MD, Stanford University

Publications

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

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Clinical Trial Record