Carcinoid Tumor, Metastatic Carcinoid Tumor, Neuroendocrine Neoplasm
Conditions
Brief summary
This phase II trial studies how well nintedanib works in treating patients with neuroendocrine tumors that have spread from where they started to nearby tissue or lymph nodes (locally advanced) or have spread from the primary site (place where they started) to other places in the body (metastatic). Nintedanib may stop the growth of tumor cells by slowing or stopping a certain type of receptor called vascular endothelial growth factor receptor (VEGFR) from attaching to its target. This may stop the growth of neuroendocrine tumors by blocking the growth of new blood vessels necessary for tumor growth.
Detailed description
PRIMARY OBJECTIVES: I. To assess progression free survival (PFS), defined as the time interval from initiation of therapy, to its cessation for documentation of progressive disease (PD) or death. SECONDARY OBJECTIVES: I. To assess the clinical response (complete response + partial response) in all patients with measurable disease (using standard Response Evaluation Criteria in Solid Tumors \[RECIST\] version \[v\]1.1 criteria). II. To assess overall survival (OS) in all patients. III. Assess changes in quality of life (QOL) throughout treatment using the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) - Gastrointestinal Neuroendocrine Tumors (NET) 21 (GI.NET21) questionnaire for carcinoid patients with gastrointestinal neuroendocrine tumors, in all patients who have filled out at least two QOL questionnaires and, will be reported by groups based on response (response, stable disease or progressive disease). IV. Steady-state pharmacokinetics (PK) of nintedanib, biomarkers, regulatory T cell (Treg) and cytokine expression and growth factors will be analyzed for all patients and reported in groups based on response. V. Gene mutations and copy number alterations analysis in the mammalian target of rapamycin (mTOR) pathway (will be performed only on the first 10 patients), protein expression of activation of protein kinase B (Akt) (as well as other downstream targets). VI. Toxicity (graded using the National Cancer Institute \[NCI\] Common Terminology Criteria for Adverse Events \[CTCAE\] version 4.0) will be closely monitored and all toxicities will be tabulated. OUTLINE: Patients receive nintedanib orally (PO) twice daily (BID) on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up at 30 days and then every 3 months for 2 years.
Interventions
OTHERLaboratory Biomarker Analysis
Correlative studies
DRUGNintedanib
Given PO
OTHERPharmacological Study
Correlative studies
OTHERQuality-of-Life Assessment
Ancillary studies
Sponsors
National Comprehensive Cancer Network
Roswell Park Cancer Institute
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient must be on a stable dose of octreotide (Sandostatin®) long-acting release (LAR) or lanreotide for 3 months prior to study enrollment * Patient must have histologically or cytologically confirmed well differentiated or moderately differentiated (low grade or intermediate grade) neuroendocrine tumor that is locally advanced or metastatic and not of pancreatic origin * Measurable disease determined by computed tomography (CT) or magnetic resonance imaging (MRI) * Have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 * Life expectancy greater than 3 months * Leukocytes \>= 3,000/uL * Absolute neutrophil count \>= 1,500/uL * Total bilirubin =\< 2 mg/dL * Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =\< 1.5 x upper limit of normal (ULN) and bilirubin =\< ULN for patients without liver metastases * AST/ALT =\< 2.5 x ULN and bilirubin =\< ULN for patients with liver metastases * Patients with Gilbert syndrome and bilirubin \< 2 x ULN and normal AST/ALT * Creatinine =\< 1.5 mg/dl * Prior treatment will be permitted including surgery (\>= 4 weeks), cytotoxic chemotherapy (maximum of 2 prior regimens); radiation, interferon, targeted growth factors (\>= 4 weeks); and prior treatment with octreotide, will be allowed * Ability to swallow and retain oral medication * Participants of child-bearing potential (both male and female) must agree to use adequate contraceptive methods (e.g., hormonal or barrier method of birth control; abstinence) prior to study entry; should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately * Participant or legal representative must understand the investigational nature of this study and sign an Independent Ethics Committee/Institutional Review Board approved written informed consent form prior to receiving any study related procedure * Archival tissue of carcinoid biopsy must be available
Exclusion criteria
* Uncontrolled hypertension, unstable angina, New York Heart Association grade II or greater congestive heart failure, unstable symptomatic arrhythmia requiring medication, or clinically significant peripheral vascular disease (grade II or greater) * Presence of brain metastases * Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to day 0, or anticipated need for major surgical procedure during the course of the study, or fine needle aspirations or core biopsies within 7 days prior to day 0 * Significant proteinuria at baseline (\>= 500 mg/24 hours \[h\]) * Serious non-healing wound, ulcer or bone fracture * Evidence of bleeding diathesis or coagulopathy * Recent (=\< 6 months) arterial thromboembolic events, including transient ischemic attack, cerebrovascular accident, unstable angina, or myocardial infarction * Poorly differentiated neuroendocrine carcinoma, high-grade neuroendocrine carcinoma, adenocarcinoid, goblet cell carcinoma, or small cell carcinoma * Hepatic artery embolization or ablation of hepatic metastasis within 3 months of enrollment, prior peptide receptor radionuclide therapy (PRRT) within 4 months or any other cancer therapy within 4 weeks (as long as all toxicities are resolved) * Intolerance or hypersensitivity to octreotide * Severe or uncontrolled medical conditions * Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements * Pregnant or nursing female participants * Unwilling or unable to follow protocol requirements * Any condition which in the investigator's opinion deems the participant an unsuitable candidate to receive study drug
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| PFS | Time interval from initiation of therapy, to its cessation for documentation of PD or death, assessed up to 2 years | Will be reported using standard Kaplan-Meier methods. Ninety percent confidence intervals for the median PFS will be calculated using Greenwood's formula. Additionally, a confidence interval for the 16-week PFS rate will be obtained using Jeffrey's prior method. The association between survival and quantified variables will be investigated using the Cox-proportional hazard model. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Quality of Life Score | Baseline to 30 days post-treatment | Quality of life will be investigated calculated by Subjects filing out EORTC Gastrointestinal Neuroendocrine Tumour 21 Questionnaire (QLQ-GI.NET21) A 21 question questionnaire that use a 4-point scale (1 = Not at all, 2 = A little, 3 = Quite a bit, 4 = Very much). The scores for different scales (i.e. endocrine, gastrointestinal, treatment, social function, disease Related, and global) are calculated by summing related questions from the questionnaire. The range of the subscale scores are from 0 to 100, with higher scores being worse. After the subscale scores being calculated, the Change in quality of life is calculated by subtracting baseline score from end of treatment |
| Plasma Concentrations at Steady State (Cpre,ss) of Nintedanib at Baseline and Week 8 | Baseline to week 8 | Sample collection will be obtained at baseline and week 8 |
| Clinical Response (Complete Response + Partial Response) Measured Using Standard RECISTv1.1 Criteria | Up to 2 years | Exact 90% confidence interval estimates using the Clopper-Pearson method will be given for the response rates. Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI, response rates are categorized 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. |
| Median OS | Up to 3 years (telephone contact is acceptable). | Will be reported using standard Kaplan-Meier methods. Ninety-five percent confidence intervals for the median OS will be calculated using Greenwood's formula. The association between survival and quantified variables will be investigated using the Cox-proportional hazard model. |
| Ratio of FGFR IIIb/IIIc and Ki-67 and Microvessel Density Scores | Baseline | Scores will be obtained to investigate association with PFS, clinical response, QOL and survival. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Change in Cytokine Expression | Baseline to 8 weeks | Will be analyzed for all patients and reported in groups based on response. Changes in pre- and post-treatment cytokine expression will be analyzed using permutation paired t-tests. |
| Change in Growth Factors | Baseline to 30 days post-treatment | Will be analyzed for all patients and reported in groups based on response. Changes in pre- and post-treatment growth factors will be analyzed using permutation paired t-tests. |
| Gene Mutations and Copy Number Alterations | Baseline | Gene mutations and copy number alterations in the several pathways particularly mTOR pathway will be evaluated. Will be analyzed for all patients and correlated with clinical outcomes. |
| Treg Levels | Baseline | Will be analyzed for all patients and reported in groups based on response. |
| Biomarker Levels | Baseline | Will be analyzed for all patients and reported in groups based on response. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Treatment (Nintedanib) Patients receive nintedanib PO BID on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.
Laboratory Biomarker Analysis: Correlative studies
Nintedanib: Given PO
Pharmacological Study: Correlative studies
Quality-of-Life Assessment: Ancillary studies | 32 |
| Total | 32 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | bowel obstruction (unrelated to dis-ease) | 1 |
| Overall Study | Withdrawal by Subject | 1 |
Baseline characteristics
| Characteristic | Treatment (Nintedanib) |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 16 Participants |
| Age, Categorical Between 18 and 65 years | 16 Participants |
| Age, Continuous | 65 years |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 16 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 16 Participants |
| Region of Enrollment United States | 32 participants |
| Sex: Female, Male Female | 15 Participants |
| Sex: Female, Male Male | 17 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 18 / 32 |
| other Total, other adverse events | 31 / 32 |
| serious Total, serious adverse events | 14 / 32 |
Outcome results
Primary
PFS
Will be reported using standard Kaplan-Meier methods. Ninety percent confidence intervals for the median PFS will be calculated using Greenwood's formula. Additionally, a confidence interval for the 16-week PFS rate will be obtained using Jeffrey's prior method. The association between survival and quantified variables will be investigated using the Cox-proportional hazard model.
Time frame: Time interval from initiation of therapy, to its cessation for documentation of PD or death, assessed up to 2 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nintedanib) | PFS | 11 months |
Secondary
Change in Quality of Life Score
Quality of life will be investigated calculated by Subjects filing out EORTC Gastrointestinal Neuroendocrine Tumour 21 Questionnaire (QLQ-GI.NET21) A 21 question questionnaire that use a 4-point scale (1 = Not at all, 2 = A little, 3 = Quite a bit, 4 = Very much). The scores for different scales (i.e. endocrine, gastrointestinal, treatment, social function, disease Related, and global) are calculated by summing related questions from the questionnaire. The range of the subscale scores are from 0 to 100, with higher scores being worse. After the subscale scores being calculated, the Change in quality of life is calculated by subtracting baseline score from end of treatment
Time frame: Baseline to 30 days post-treatment
Population: Patients completed at least 2 EORTC QLQ-GI.NET21 questionnaires are included for this outcome estimate
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in endocrine scale | 0 score on a scale |
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in gastrointestinal scale | 0 score on a scale |
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in treatment scale | 0 score on a scale |
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in social function scale | 0 score on a scale |
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in Disease Related Worry Scale | -6 score on a scale |
| Treatment (Nintedanib) | Change in Quality of Life Score | Change in Global scale | 1 score on a scale |
Secondary
Clinical Response (Complete Response + Partial Response) Measured Using Standard RECISTv1.1 Criteria
Exact 90% confidence interval estimates using the Clopper-Pearson method will be given for the response rates. Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI, response rates are categorized 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.
Time frame: Up to 2 years
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Treatment (Nintedanib) | Clinical Response (Complete Response + Partial Response) Measured Using Standard RECISTv1.1 Criteria | SD | 26 Participants |
| Treatment (Nintedanib) | Clinical Response (Complete Response + Partial Response) Measured Using Standard RECISTv1.1 Criteria | PD | 1 Participants |
| Treatment (Nintedanib) | Clinical Response (Complete Response + Partial Response) Measured Using Standard RECISTv1.1 Criteria | PR | 1 Participants |
Secondary
Median OS
Will be reported using standard Kaplan-Meier methods. Ninety-five percent confidence intervals for the median OS will be calculated using Greenwood's formula. The association between survival and quantified variables will be investigated using the Cox-proportional hazard model.
Time frame: Up to 3 years (telephone contact is acceptable).
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nintedanib) | Median OS | 32.7 months |
Secondary
Plasma Concentrations at Steady State (Cpre,ss) of Nintedanib at Baseline and Week 8
Sample collection will be obtained at baseline and week 8
Time frame: Baseline to week 8
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nintedanib) | Plasma Concentrations at Steady State (Cpre,ss) of Nintedanib at Baseline and Week 8 | 11.2 ng/mL |
Secondary
Ratio of FGFR IIIb/IIIc and Ki-67 and Microvessel Density Scores
Scores will be obtained to investigate association with PFS, clinical response, QOL and survival.
Time frame: Baseline
Population: The FGFR IIIb/IIIcm, Ki-67m and microvessel density scores were not measured (i.e. data not obtained) and analyses were not performed.
Other Pre-specified
Biomarker Levels
Will be analyzed for all patients and reported in groups based on response.
Time frame: Baseline
Population: The appropriate biomarkers were not measured (i.e. data not obtained) and analyses were not performed.
Other Pre-specified
Change in Cytokine Expression
Will be analyzed for all patients and reported in groups based on response. Changes in pre- and post-treatment cytokine expression will be analyzed using permutation paired t-tests.
Time frame: Baseline to 8 weeks
Population: The appropriate cytokine expressions were not measured (i.e. data not obtained) and analyses were not performed.
Other Pre-specified
Change in Growth Factors
Will be analyzed for all patients and reported in groups based on response. Changes in pre- and post-treatment growth factors will be analyzed using permutation paired t-tests.
Time frame: Baseline to 30 days post-treatment
Population: The appropriate growth factors were not measured (i.e. data not obtained) and analyses were not performed.
Other Pre-specified
Gene Mutations and Copy Number Alterations
Gene mutations and copy number alterations in the several pathways particularly mTOR pathway will be evaluated. Will be analyzed for all patients and correlated with clinical outcomes.
Time frame: Baseline
Population: Gene mutations and copy number alterations were not measured (i.e. data not obtained) and analyses were not performed.
Other Pre-specified
Treg Levels
Will be analyzed for all patients and reported in groups based on response.
Time frame: Baseline
Population: Treg levels were not measured and analyses were not performed.