Neuroendocrine tumor

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14 regimens on this page 20 variants on this page

Adrenal gland tumors, adrenocortical carcinoma - adjuvant therapy

Mitotane (Lysodren)

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There is limited and controversial clinical trial information about adjuvant mitotane use. See the references for additional case series and expert recommendation articles.

Regimen #1

Study	Evidence
Wängberg et al. 2010	Phase II

Patients started on adjuvant mitotane within 4 weeks of their surgical resection.

Chemotherapy

• Mitotane (Lysodren) 2000 mg PO per day (frequency not specified, such as whether the total daily dose was divided into a few doses throughout the day); within the first 2 to 3 months, dose was adjusted to achieve a target therapeutic drug level of 14 to 20 mg/L

2 to 3-year course

Regimen #2

Study	Evidence
Haak et al. 1994	Phase II

Haak et al. 1994 concluded that "mitotane treatment in adrenocortical carcinoma is effective only when high serum levels [trough of at least 14 mg/L] can be achieved."

Chemotherapy

• Mitotane (Lysodren) 1000 to 2000 mg PO QID (total dose per day: 4000 to 8000 mg), with target mitotane trough of above 14 mg/L

Supportive medications

• Hydrocortisone (Cortef) 30 to 120 mg per day or Fludrocortisone (Florinef) 0.1 to 0.4 mg per day
• Metoclopramide (Reglan) prn "gastrointestinal side-effects"
• Loperamide (Imodium) prn "gastrointestinal side-effects"

2-year course "if resection was judged to be complete or for 1 year after apparent disappearance of the tumour"

References

1. Vassilopoulou-Sellin R, Guinee VF, Klein MJ, Taylor SH, Hess KR, Schultz PN, Samaan NA. Impact of adjuvant mitotane on the clinical course of patients with adrenocortical cancer. Cancer. 1993 May 15;71(10):3119-23. link to original article PubMed
2. Haak HR, Hermans J, van de Velde CJ, Lentjes EG, Goslings BM, Fleuren GJ, Krans HM. Optimal treatment of adrenocortical carcinoma with mitotane: results in a consecutive series of 96 patients. Br J Cancer. 1994 May;69(5):947-51. link to PMC article contains verified protocol PubMed content property of HemOnc.org
3. Terzolo M, Angeli A, Fassnacht M, Daffara F, Tauchmanova L, Conton PA, Rossetto R, Buci L, Sperone P, Grossrubatscher E, Reimondo G, Bollito E, Papotti M, Saeger W, Hahner S, Koschker AC, Arvat E, Ambrosi B, Loli P, Lombardi G, Mannelli M, Bruzzi P, Mantero F, Allolio B, Dogliotti L, Berruti A. Adjuvant mitotane treatment for adrenocortical carcinoma. N Engl J Med. 2007 Jun 7;356(23):2372-80. link to original article PubMed
4. Veytsman I, Nieman L, Fojo T. Management of endocrine manifestations and the use of mitotane as a chemotherapeutic agent for adrenocortical carcinoma. J Clin Oncol. 2009 Sep 20;27(27):4619-29. Epub 2009 Aug 10. link to original article PubMed
5. Wängberg B, Khorram-Manesh A, Jansson S, Nilsson B, Nilsson O, Jakobsson CE, Lindstedt S, Odén A, Ahlman H. The long-term survival in adrenocortical carcinoma with active surgical management and use of monitored mitotane. Endocr Relat Cancer. 2010 Feb 18;17(1):265-72. Print 2010 Mar. link to original article contains verified protocol PubMed

Mitotane & Streptozocin

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Regimen

Study	Evidence
Khan et al. 2010	Phase II

Induction course

• Streptozocin (Zanosar) 1000 mg IV once per day on days 1 to 5

5-day course, followed by main regimen

Main regimen

• Mitotane (Lysodren) 1000 to 4000 mg/day PO; daily dose is taken in 2 to 3 divided doses per day
• Streptozocin (Zanosar) 2000 mg IV once per day on days 1 to 5

Supportive medications

• 5-HT3 antagonists prior to streptozocin
• Hydrocortisone (Cortef) 25 to 100 mg/day

21-day cycles; duration of therapy not clearly specified

References

1. Khan TS, Imam H, Juhlin C, Skogseid B, Gröndal S, Tibblin S, Wilander E, Oberg K, Eriksson B. Streptozocin and o,p'DDD in the treatment of adrenocortical cancer patients: long-term survival in its adjuvant use. Ann Oncol. 2000 Oct;11(10):1281-7. link to original article contains verified protocol PubMed

Adrenal gland tumors, adrenocortical carcinoma - recurrent, locally advanced, or metastatic disease

Mitotane (Lysodren)

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Regimen

Study	Evidence
Veytsman et al. 2009	Review

Chemotherapy

• Mitotane (Lysodren) 1000 to 2000 mg PO per day (frequency not specified, such as whether the total daily dose was divided into a few doses throughout the day); then increase daily dose of Mitotane (Lysodren) by 1000 to 2000 mg every 1 to 2 weeks to the maximum tolerated dose, not to exceed 6000 mg ("never > 6 to 10 g/d"). Target mitotane drug level is 10 to 14 mg/L.

References

1. Review: Veytsman I, Nieman L, Fojo T. Management of endocrine manifestations and the use of mitotane as a chemotherapeutic agent for adrenocortical carcinoma. J Clin Oncol. 2009 Sep 20;27(27):4619-29. Epub 2009 Aug 10. link to original article contains verified protocol PubMed

Mitotane & EDP

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EDP: Etoposide, Doxorubicin, Platinol (Cisplatin)

Regimen #1

Study	Evidence	Comparator	Efficacy
Fassnacht et al. 2012 (FIRM-ACT)	Phase III	Mitotane & Streptozocin	Superior PFS

Mitotane is started at least 1 week before the other chemotherapy; the rest of the therapy is as described below.

Chemotherapy

• Mitotane (Lysodren) on days 1 to 28, with target mitotane trough of 14 to 20 mg/L (initial dose and frequency not specified)
• Etoposide (Vepesid) 100 mg/m² IV once per day on days 2 to 4
• Doxorubicin (Adriamycin) 40 mg/m² IV once on day 1
• Cisplatin (Platinol) 40 mg/m² IV once per day on days 3 & 4

Supportive medications

• Glucocorticoid replacement was recommended in all patients except those with persistent Cushing's syndrome.

28-day cycles

Regimen #2

Study	Evidence
Berruti et al. 2005	Phase II

Chemotherapy

• Mitotane (Lysodren) 1000 mg PO per day (frequency not specified, such as whether the total daily dose was divided into a few doses throughout the day) on days 1 to 28; then dose is increased as tolerated up to 4000 mg/day or maximum tolerated dose
• Etoposide (Vepesid) 100 mg/m² IV once per day on days 5 to 7
• Doxorubicin (Adriamycin) 20 mg/m² IV once per day on days 1 & 8
• Cisplatin (Platinol) 40 mg/m² IV once per day on days 2 & 9

28-day cycle for up to 6 cycles, given until progression of disease, unacceptable toxicity, or patient refusal

References

1. Berruti A, Terzolo M, Sperone P, Pia A, Della Casa S, Gross DJ, Carnaghi C, Casali P, Porpiglia F, Mantero F, Reimondo G, Angeli A, Dogliotti L. Etoposide, doxorubicin and cisplatin plus mitotane in the treatment of advanced adrenocortical carcinoma: a large prospective phase II trial. Endocr Relat Cancer. 2005 Sep;12(3):657-66. link to original article contains verified protocol PubMed
2. Fassnacht M, Terzolo M, Allolio B, Baudin E, Haak H, Berruti A, Welin S, Schade-Brittinger C, Lacroix A, Jarzab B, Sorbye H, Torpy DJ, Stepan V, Schteingart DE, Arlt W, Kroiss M, Leboulleux S, Sperone P, Sundin A, Hermsen I, Hahner S, Willenberg HS, Tabarin A, Quinkler M, de la Fouchardière C, Schlumberger M, Mantero F, Weismann D, Beuschlein F, Gelderblom H, Wilmink H, Sender M, Edgerly M, Kenn W, Fojo T, Müller HH, Skogseid B; FIRM-ACT Study Group. Combination chemotherapy in advanced adrenocortical carcinoma. N Engl J Med. 2012 Jun 7;366(23):2189-97. Epub 2012 May 2. link to original article contains verified protocol PubMed

Mitotane & Streptozocin

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Regimen

Study	Evidence	Comparator	Efficacy
Fassnacht et al. 2012 (FIRM-ACT)	Phase III	Mitotane & EDP	Inferior PFS

Mitotane is started at least 1 week before the other chemotherapy; the rest of the therapy is as described below.

Chemotherapy

• Mitotane (Lysodren) on days 1 to 21, with target mitotane trough of 14 to 20 mg/L (initial dose and frequency not specified)
• Streptozocin (Zanosar) 1000 mg IV once per day on days 1 to 5 of cycle 1; then Streptozocin (Zanosar) 2000 mg IV once on day 1 of cycles 2 and on

Supportive medications

• Glucocorticoid replacement was recommended in all patients except those with persistent Cushing's syndrome.

21-day cycles

References

1. Fassnacht M, Terzolo M, Allolio B, Baudin E, Haak H, Berruti A, Welin S, Schade-Brittinger C, Lacroix A, Jarzab B, Sorbye H, Torpy DJ, Stepan V, Schteingart DE, Arlt W, Kroiss M, Leboulleux S, Sperone P, Sundin A, Hermsen I, Hahner S, Willenberg HS, Tabarin A, Quinkler M, de la Fouchardière C, Schlumberger M, Mantero F, Weismann D, Beuschlein F, Gelderblom H, Wilmink H, Sender M, Edgerly M, Kenn W, Fojo T, Müller HH, Skogseid B; FIRM-ACT Study Group. Combination chemotherapy in advanced adrenocortical carcinoma. N Engl J Med. 2012 Jun 7;366(23):2189-97. Epub 2012 May 2. link to original article contains verified protocol PubMed

Carcinoid tumors

Interferon alfa-2b (Intron-A)

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Regimen

Study	Evidence	Comparator	Efficacy
Faiss et al. 2003	Phase III	Lanreotide	Seems not superior
		Lanreotide & Interferon alfa-2b	Seems not superior

Immunotherapy

• Interferon alfa-2b (Intron-A) 5 million units SC given once per day, 3 times per week

Given until progression of disease

Patients who progressed on monotherapy then received combination lanreotide & interferon alfa.

References

1. Faiss S, Pape UF, Böhmig M, Dörffel Y, Mansmann U, Golder W, Riecken EO, Wiedenmann B; International Lanreotide and Interferon Alfa Study Group. Prospective, randomized, multicenter trial on the antiproliferative effect of lanreotide, interferon alfa, and their combination for therapy of metastatic neuroendocrine gastroenteropancreatic tumors--the International Lanreotide and Interferon Alfa Study Group. J Clin Oncol. 2003 Jul 15;21(14):2689-96. link to original article contains verified protocol PubMed

Lanreotide (Somatuline)

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Regimen

Study	Evidence	Comparator	Efficacy
Faiss et al. 2003	Phase III	Interferon alfa-2b	Seems not superior
		Lanreotide & Interferon alfa-2b	Seems not superior

Endocrine therapy

• Lanreotide (Somatuline) 1 mg SC TID

Given until progression of disease

Patients who progressed on monotherapy then received combination lanreotide & interferon alfa.

References

1. Faiss S, Pape UF, Böhmig M, Dörffel Y, Mansmann U, Golder W, Riecken EO, Wiedenmann B; International Lanreotide and Interferon Alfa Study Group. Prospective, randomized, multicenter trial on the antiproliferative effect of lanreotide, interferon alfa, and their combination for therapy of metastatic neuroendocrine gastroenteropancreatic tumors--the International Lanreotide and Interferon Alfa Study Group. J Clin Oncol. 2003 Jul 15;21(14):2689-96. link to original article contains verified protocol PubMed

Lanreotide & Interferon alfa-2b

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Regimen

Study	Evidence	Comparator	Efficacy
Faiss et al. 2003	Phase III	Interferon alfa-2b	Seems not superior
		Lanreotide	Seems not superior

Endocrine & Immunotherapy

• Lanreotide (Somatuline) 1 mg SC TID
• Interferon alfa-2b (Intron-A) 5 million units SC given once per day, 3 times per week

References

1. Faiss S, Pape UF, Böhmig M, Dörffel Y, Mansmann U, Golder W, Riecken EO, Wiedenmann B; International Lanreotide and Interferon Alfa Study Group. Prospective, randomized, multicenter trial on the antiproliferative effect of lanreotide, interferon alfa, and their combination for therapy of metastatic neuroendocrine gastroenteropancreatic tumors--the International Lanreotide and Interferon Alfa Study Group. J Clin Oncol. 2003 Jul 15;21(14):2689-96. link to original article contains verified protocol PubMed

Octreotide (Sandostatin)

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Regimen #1

Study	Evidence
Oberg et al. 2004	Consensus guideline

Endocrine therapy

• Octreotide (Sandostatin) 0.1 to 0.5 mg SC given 2 to 4 times per day, with dose increased by doubling the dose every 3 to 4 days as needed to control symptoms
  • "A reasonable starting dose is" Octreotide (Sandostatin) 0.15 mg SC TID

Treatment continued indefinitely unless patients have unmanageable side-effects or insufficient control of symptoms

Regimen #2

Study	Evidence
Kvols et al. 1986	Phase II

Endocrine therapy

• Octreotide (Sandostatin) 0.15 mg SC BID on days 1 & 2, then 0.15 mg TID on days 3 and on

"Treatment was continued for as long as a clinical improvement was maintained"

Regimen #3

Study	Evidence	Comparator	Efficacy
Kölby et al. 2003	Randomized Phase II	Octreotide & Interferon alfa	Inferior TTP

Endocrine therapy

• Octreotide (Sandostatin) 0.1 mg SC BID; patients with persistent carcinoid symptoms could receive increased doses up to 0.2 mg SC TID

References

1. Kvols LK, Moertel CG, O'Connell MJ, Schutt AJ, Rubin J, Hahn RG. Treatment of the malignant carcinoid syndrome. Evaluation of a long-acting somatostatin analogue. N Engl J Med. 1986 Sep 11;315(11):663-6. link to original article contains verified protocol PubMed
2. Janson ET, Oberg K. Long-term management of the carcinoid syndrome. Treatment with octreotide alone and in combination with alpha-interferon. Acta Oncol. 1993;32(2):225-9. link to original article PubMed
3. Brentjens R, Saltz L. Islet cell tumors of the pancreas: the medical oncologist's perspective. Surg Clin North Am. 2001 Jun;81(3):527-42. link to original article PubMed
4. Kölby L, Persson G, Franzén S, Ahrén B. Randomized clinical trial of the effect of interferon alpha on survival in patients with disseminated midgut carcinoid tumours. Br J Surg. 2003 Jun;90(6):687-93. link to original article contains verified protocol PubMed
5. Review: Oberg K, Kvols L, Caplin M, Delle Fave G, de Herder W, Rindi G, Ruszniewski P, Woltering EA, Wiedenmann B. Consensus report on the use of somatostatin analogs for the management of neuroendocrine tumors of the gastroenteropancreatic system. Ann Oncol. 2004 Jun;15(6):966-73. link to original article contains verified protocol PubMed

Octreotide LAR (Sandostatin LAR)

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Regimen #1

Study	Evidence	Comparator	Efficacy
Rinke et al. 2009 (PROMID)	Phase III	Placebo	Superior TTP
Pavel et al. 2011 (RADIANT-2)	Phase III	Octreotide LAR & Everolimus	Seems to have inferior PFS

Endocrine therapy

• Octreotide LAR (Sandostatin LAR) 30 mg IM once on day 1, with potentially higher doses if needed for symptom control

28-day cycles, given until progression of disease

Regimen #2

Study	Evidence
Oberg et al. 2004	Consensus guideline

Endocrine therapy

• Octreotide LAR (Sandostatin LAR) 20 to 30 mg IM once on day 1, with potentially higher doses if needed for symptom control
  • "As a general rule, if the total [octreotide] IR dose is 200 to 600 µg/day [0.2 to 0.6 mg/day], LAR 20 mg should be tried, and if total IR dose is 750 to 1500 µg/day [0.75 to 1.5 mg/day], LAR 30 mg should be tried."
• Octreotide (Sandostatin) (dose not specified) SC as needed for additional symptom control

28-day cycles; treatment continued indefinitely unless patients have unmanageable side-effects or insufficient control of symptoms

References

1. Review: Oberg K, Kvols L, Caplin M, Delle Fave G, de Herder W, Rindi G, Ruszniewski P, Woltering EA, Wiedenmann B. Consensus report on the use of somatostatin analogs for the management of neuroendocrine tumors of the gastroenteropancreatic system. Ann Oncol. 2004 Jun;15(6):966-73. link to original article contains verified protocol PubMed
2. Rinke A, Müller HH, Schade-Brittinger C, Klose KJ, Barth P, Wied M, Mayer C, Aminossadati B, Pape UF, Bläker M, Harder J, Arnold C, Gress T, Arnold R; PROMID Study Group. Placebo-controlled, double-blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors: a report from the PROMID Study Group. J Clin Oncol. 2009 Oct 1;27(28):4656-63. Epub 2009 Aug 24. link to original article contains verified protocol PubMed
3. Pavel ME, Hainsworth JD, Baudin E, Peeters M, Hörsch D, Winkler RE, Klimovsky J, Lebwohl D, Jehl V, Wolin EM, Oberg K, Van Cutsem E, Yao JC; RADIANT-2 Study Group. Everolimus plus octreotide long-acting repeatable for the treatment of advanced neuroendocrine tumours associated with carcinoid syndrome (RADIANT-2): a randomised, placebo-controlled, phase 3 study. Lancet. 2011 Dec 10;378(9808):2005-12. Epub 2011 Nov 25. link to original article contains verified protocol PubMed

Octreotide & Everolimus

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Regimen #1

Study	Evidence	Comparator	Efficacy
Pavel et al. 2011 (RADIANT-2)	Phase III	Octreotide LAR	Seems to have superior PFS

Endocrine & Chemotherapy

• Octreotide LAR (Sandostatin LAR) 30 mg IM once every 28 days
• Everolimus (Afinitor) 10 mg PO once per day

Given until progression of disease or unacceptable toxicity

Regimen #2

Study	Evidence
Yao et al. 2008	Phase II

Note: Everolimus "dose of 10 mg was associated with superior PFS...however, the study was not prospectively powered for these comparisons. These analyses should be considered exploratory."

Endocrine & Chemotherapy

• Octreotide LAR (Sandostatin LAR) 30 mg IM once on day 1
• Everolimus (Afinitor) 5 or 10 mg PO once per day on days 1 to 28

28-day cycle for up to 12 cycles or until progression of disease, though treatment could be continued beyond this period if thought by the treating physician to be beneficial

References

1. Yao JC, Phan AT, Chang DZ, Wolff RA, Hess K, Gupta S, Jacobs C, Mares JE, Landgraf AN, Rashid A, Meric-Bernstam F. Efficacy of RAD001 (everolimus) and octreotide LAR in advanced low- to intermediate-grade neuroendocrine tumors: results of a phase II study. J Clin Oncol. 2008 Sep 10;26(26):4311-8. link to original article contains verified protocol PubMed
2. Pavel ME, Hainsworth JD, Baudin E, Peeters M, Hörsch D, Winkler RE, Klimovsky J, Lebwohl D, Jehl V, Wolin EM, Oberg K, Van Cutsem E, Yao JC; RADIANT-2 Study Group. Everolimus plus octreotide long-acting repeatable for the treatment of advanced neuroendocrine tumours associated with carcinoid syndrome (RADIANT-2): a randomised, placebo-controlled, phase 3 study. Lancet. 2011 Dec 10;378(9808):2005-12. Epub 2011 Nov 25. link to original article contains verified protocol PubMed

Octreotide & Interferon alfa

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Regimen

Study	Evidence	Comparator	Efficacy
Kölby et al. 2003	Randomized Phase II	Octreotide LAR	Superior TTP

Kölby et al. 2003 did not specifically say whether Interferon alfa-2b (Intron-A) or Interferon alfa-2a (Roferon-A) was used.

Endocrine & Immunotherapy

• Octreotide (Sandostatin) 0.1 mg SC BID; patients with persistent carcinoid symptoms could receive increased doses up to Octreotide (Sandostatin) 0.2 mg SC TID
• Interferon alfa-2b (Intron-A) 3 million units (route not specified) given once per day, 3 days per week; increased as needed based on symptoms up to Interferon alfa-2b (Intron-A) 5 million units (route not specified) given once per day, 5 days per week

References

1. Janson ET, Oberg K. Long-term management of the carcinoid syndrome. Treatment with octreotide alone and in combination with alpha-interferon. Acta Oncol. 1993;32(2):225-9. link to original article PubMed
2. Kölby L, Persson G, Franzén S, Ahrén B. Randomized clinical trial of the effect of interferon alpha on survival in patients with disseminated midgut carcinoid tumours. Br J Surg. 2003 Jun;90(6):687-93. link to original article contains verified protocol PubMed

Placebo

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Regimen

Study	Evidence	Comparator	Efficacy
Rinke et al. 2009 (PROMID)	Phase III	Octreotide LAR	Inferior TTP

No active antineoplastic treatment. Used as a comparator arm and here for reference purposes only.

References

1. Rinke A, Müller HH, Schade-Brittinger C, Klose KJ, Barth P, Wied M, Mayer C, Aminossadati B, Pape UF, Bläker M, Harder J, Arnold C, Gress T, Arnold R; PROMID Study Group. Placebo-controlled, double-blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors: a report from the PROMID Study Group. J Clin Oncol. 2009 Oct 1;27(28):4656-63. Epub 2009 Aug 24. link to original article contains verified protocol PubMed

Temozolomide (Temodar)

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Regimen

Study	Evidence
Ekeblad et al. 2007	Phase II

Chemotherapy

• Temozolomide (Temodar) as follows:
  • Cycle 1: 100 or 150 mg/m² PO once per day on days 1 to 5
  • Cycle 2 onwards: increased as tolerated up to 200 mg/m² PO once per day on days 1 to 5

Supportive medications

• Tropisetron (Navoban) (dose/route/schedule not specified) routinely used as an antiemetic

28-day cycles, given until progression of disease or unacceptable toxicity

References

1. Ekeblad S, Sundin A, Janson ET, Welin S, Granberg D, Kindmark H, Dunder K, Kozlovacki G, Orlefors H, Sigurd M, Oberg K, Eriksson B, Skogseid B. Temozolomide as monotherapy is effective in treatment of advanced malignant neuroendocrine tumors. Clin Cancer Res. 2007 May 15;13(10):2986-91. link to original article contains verified protocol PubMed

Neuroendocrine tumors of unknown primary, poorly differentiated (high-grade) neuroendocrine tumors

The NCCN Guidelines, Neuroendocrine tumors version 1.2013, suggests that these are treated with a small cell lung cancer regimen.

Pancreatic neuroendocrine islet cell tumors

Everolimus (Afinitor)

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Regimen

Study	Evidence	Comparator	Efficacy
Yao et al. 2010	Phase II
Yao et al. 2011 (RADIANT-3)	Phase III	Placebo	Superior PFS

Chemotherapy

• Everolimus (Afinitor) 10 mg PO once per day

Given until progression of disease, unacceptable toxicity, drug interruption of 3 weeks or longer, or withdrawal of consent

References

1. Yao JC, Lombard-Bohas C, Baudin E, Kvols LK, Rougier P, Ruszniewski P, Hoosen S, St Peter J, Haas T, Lebwohl D, Van Cutsem E, Kulke MH, Hobday TJ, O'Dorisio TM, Shah MH, Cadiot G, Luppi G, Posey JA, Wiedenmann B. Daily oral everolimus activity in patients with metastatic pancreatic neuroendocrine tumors after failure of cytotoxic chemotherapy: a phase II trial. J Clin Oncol. 2010 Jan 1;28(1):69-76. Epub 2009 Nov 23. link to original article contains verified protocol PubMed
2. Yao JC, Shah MH, Ito T, Bohas CL, Wolin EM, Van Cutsem E, Hobday TJ, Okusaka T, Capdevila J, de Vries EG, Tomassetti P, Pavel ME, Hoosen S, Haas T, Lincy J, Lebwohl D, Öberg K; RAD001 in Advanced Neuroendocrine Tumors, Third Trial (RADIANT-3) Study Group. Everolimus for advanced pancreatic neuroendocrine tumors. N Engl J Med. 2011 Feb 10;364(6):514-23. link to original article contains verified protocol PubMed
3. Review: Yao JC, Phan AT, Jehl V, Shah G, Meric-Bernstam F. Everolimus in advanced pancreatic neuroendocrine tumors: the clinical experience. Cancer Res. 2013 Mar 1;73(5):1449-53. Epub 2013 Feb 22. link to original article PubMed

Lanreotide (Somatuline) Depot/Autogel

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Regimen

Study	Evidence	Comparator	Efficacy
Caplin et al. 2014 (CLARINET)	Phase III	Placebo	Superior PFS

Endocrine therapy

• Lanreotide (Somatuline) Depot/Autogel 120 mg deep subcutaneous injection once on day 1

4-week cycle for 96 weeks (CLARINET), until progression of disease, or unacceptable toxicity

Patients in NET729 (unpublished) could be treated for up to 8 years.

References

1. Caplin ME, Pavel M, Cwikla JB, Phan AT, Raderer M, Sedlácková E, Cadiot G, Wolin EM, Capdevila J, Wall L, Rindi G, Langley A, Martinez S, Blumberg J, Ruszniewski P; CLARINET Investigators. Lanreotide in metastatic enteropancreatic neuroendocrine tumors. N Engl J Med. 2014 Jul 17;371(3):224-33. link to original article contains verified protocol PubMed
2. Lanreotide (Somatuline) package insert
3. NIHR (National Institute for Health Research) Horizon Scanning Centre, School of Health & Population Sciences, University of Birmingham. Lanreotide for unresectable, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumours – first line
4. ClinicalTrials.gov: Study of Lanreotide Autogel 120mg in Patients With Non-functioning Entero- Pancreatic Endocrine Tumour (NET729)

Lanreotide & Interferon alfa

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Regimen

Study	Evidence
Fjällskog et al. 2002	Pilot, <20 pts

Fjällskog et al. 2002 contained case reports of several patients treated with lanreotide & interferon alfa. Each patient received individualized therapy rather than a standard regimen.

Endocrine & Immunotherapy

• Lanreotide (Somatuline) 3 mg SC BID
• Interferon alfa-2b (Intron-A) 3 to 5 million units SC given once per day, 3 to 7 days per week (total of 9 to 25 million units per week)

References

1. Fjällskog ML, Sundin A, Westlin JE, Oberg K, Janson ET, Eriksson B. Treatment of malignant endocrine pancreatic tumors with a combination of alpha-interferon and somatostatin analogs. Med Oncol. 2002;19(1):35-42. link to original article PubMed

Octreotide (Sandostatin)

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Regimen

Study	Evidence
Oberg et al. 2004	Consensus guideline

Endocrine therapy

• Octreotide (Sandostatin) 0.1 to 0.5 mg SC given 2 to 4 times per day, with dose increased by doubling the dose every 3 to 4 days as needed to control symptoms
  • "A reasonable starting dose is" Octreotide (Sandostatin) 0.15 mg SC TID

Treatment continued indefinitely unless patients have unmanageable side-effects or insufficient control of symptoms

References

1. Brentjens R, Saltz L. Islet cell tumors of the pancreas: the medical oncologist's perspective. Surg Clin North Am. 2001 Jun;81(3):527-42. link to original article PubMed
2. Review: Oberg K, Kvols L, Caplin M, Delle Fave G, de Herder W, Rindi G, Ruszniewski P, Woltering EA, Wiedenmann B. Consensus report on the use of somatostatin analogs for the management of neuroendocrine tumors of the gastroenteropancreatic system. Ann Oncol. 2004 Jun;15(6):966-73. link to original article contains verified protocol PubMed

Octreotide LAR (Sandostatin LAR)

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Regimen #1

Study	Evidence
Oberg et al. 2004	Consensus guideline

Endocrine therapy

• Octreotide LAR (Sandostatin LAR) 20 to 30 mg IM once on day 1, with potentially higher doses if needed for symptom control
  • "As a general rule, if the total [octreotide] IR dose is 200–600 µg/day, LAR 20 mg should be tried, and if total IR dose is 750–1500 µg/day, LAR 30 mg should be tried."
• Octreotide (Sandostatin) (dose not specified) SC as needed for additional symptom control

28-day cycles; treatment continued indefinitely unless patients have unmanageable side-effects or insufficient control of symptoms

Regimen #2

Study	Evidence	Comparator	Efficacy
Rinke et al. 2009 (PROMID)	Phase III	Placebo	Superior TTP

Endocrine therapy

• Octreotide LAR (Sandostatin LAR) 30 mg IM once on day 1, with potentially higher doses if needed for symptom control

28-day cycles, given until progression of disease

References

1. Review: Oberg K, Kvols L, Caplin M, Delle Fave G, de Herder W, Rindi G, Ruszniewski P, Woltering EA, Wiedenmann B. Consensus report on the use of somatostatin analogs for the management of neuroendocrine tumors of the gastroenteropancreatic system. Ann Oncol. 2004 Jun;15(6):966-73. link to original article contains verified protocol PubMed
2. Rinke A, Müller HH, Schade-Brittinger C, Klose KJ, Barth P, Wied M, Mayer C, Aminossadati B, Pape UF, Bläker M, Harder J, Arnold C, Gress T, Arnold R; PROMID Study Group. Placebo-controlled, double-blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors: a report from the PROMID Study Group. J Clin Oncol. 2009 Oct 1;27(28):4656-63. Epub 2009 Aug 24. link to original article contains verified protocol PubMed

Octreotide & Everolimus

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Regimen #1

Study	Evidence
Yao et al. 2010	Phase II

Patients in Yao et al. 2010 who received this regimen had already been receiving octreotide LAR for at least 3 months before participating in the study.

Endocrine & Chemotherapy

• Octreotide LAR (Sandostatin LAR) ≤30 mg (whatever their prestudy dose was) IM once every 28 days
• Everolimus (Afinitor) 10 mg PO once per day

Given until progression of disease, unacceptable toxicity, drug interruption of 3 weeks or longer, or withdrawal of consent

Regimen #2

Study	Evidence
Yao et al. 2008	Phase II

Note: Everolimus "dose of 10 mg was associated with superior PFS...however, the study was not prospectively powered for these comparisons. These analyses should be considered exploratory."

Endocrine & Chemotherapy

• Octreotide LAR (Sandostatin LAR) 30 mg IM once on day 1
• Everolimus (Afinitor) 5 or 10 mg PO once per day on days 1 to 28

28-day cycle for up to 12 cycles or until progression of disease, though treatment could be continued beyond this period if thought by the treating physician to be beneficial

References

1. Yao JC, Phan AT, Chang DZ, Wolff RA, Hess K, Gupta S, Jacobs C, Mares JE, Landgraf AN, Rashid A, Meric-Bernstam F. Efficacy of RAD001 (everolimus) and octreotide LAR in advanced low- to intermediate-grade neuroendocrine tumors: results of a phase II study. J Clin Oncol. 2008 Sep 10;26(26):4311-8. link to original article contains verified protocol PubMed
2. Yao JC, Lombard-Bohas C, Baudin E, Kvols LK, Rougier P, Ruszniewski P, Hoosen S, St Peter J, Haas T, Lebwohl D, Van Cutsem E, Kulke MH, Hobday TJ, O'Dorisio TM, Shah MH, Cadiot G, Luppi G, Posey JA, Wiedenmann B. Daily oral everolimus activity in patients with metastatic pancreatic neuroendocrine tumors after failure of cytotoxic chemotherapy: a phase II trial. J Clin Oncol. 2010 Jan 1;28(1):69-76. Epub 2009 Nov 23. link to original article contains verified protocol PubMed

Octreotide & Interferon alfa

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Regimen

Study	Evidence
Fjällskog et al. 2002	Pilot, <20 pts

Fjällskog et al. 2002 contained case reports of several patients treated with octreotide & interferon alfa. Each patient received individualized therapy rather than a standard regimen.

Endocrine & Immunotherapy

• Octreotide (Sandostatin) 0.05 to 0.5 mg SC given 2 to 3 times per day
• Interferon alfa-2b (Intron-A) 3 to 5 million units SC given once per day, 3 to 7 days per week (total of 9 to 25 million units per week)

References

1. Janson ET, Oberg K. Long-term management of the carcinoid syndrome. Treatment with octreotide alone and in combination with alpha-interferon. Acta Oncol. 1993;32(2):225-9. link to original article PubMed
2. Fjällskog ML, Sundin A, Westlin JE, Oberg K, Janson ET, Eriksson B. Treatment of malignant endocrine pancreatic tumors with a combination of alpha-interferon and somatostatin analogs. Med Oncol. 2002;19(1):35-42. link to original article PubMed
3. Fazio N, de Braud F, Delle Fave G, Oberg K. Interferon-alpha and somatostatin analog in patients with gastroenteropancreatic neuroendocrine carcinoma: single agent or combination? Ann Oncol. 2007 Jan;18(1):13-9. Epub 2006 Jun 23. link to original article PubMed

Placebo

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Regimen

Study	Evidence	Comparator	Efficacy
Rinke et al. 2009 (PROMID)	Phase III	Octreotide LAR	Inferior TTP
Raymond et al. 2011	Phase III	Sunitinib	Seems to have inferior OS
Yao et al. 2011 (RADIANT-3)	Phase III	Everolimus	Inferior PFS
Caplin et al. 2014 (CLARINET)	Phase III	Lanreotide	Inferior PFS

No active antineoplastic treatment. Used as a comparator arm and here for reference purposes only.

References

1. Rinke A, Müller HH, Schade-Brittinger C, Klose KJ, Barth P, Wied M, Mayer C, Aminossadati B, Pape UF, Bläker M, Harder J, Arnold C, Gress T, Arnold R; PROMID Study Group. Placebo-controlled, double-blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors: a report from the PROMID Study Group. J Clin Oncol. 2009 Oct 1;27(28):4656-63. Epub 2009 Aug 24. link to original article contains verified protocol PubMed
2. Raymond E, Dahan L, Raoul JL, Bang YJ, Borbath I, Lombard-Bohas C, Valle J, Metrakos P, Smith D, Vinik A, Chen JS, Hörsch D, Hammel P, Wiedenmann B, Van Cutsem E, Patyna S, Lu DR, Blanckmeister C, Chao R, Ruszniewski P. Sunitinib malate for the treatment of pancreatic neuroendocrine tumors. N Engl J Med. 2011 Feb 10;364(6):501-13. link to original article contains verified protocol PubMed
3. Yao JC, Shah MH, Ito T, Bohas CL, Wolin EM, Van Cutsem E, Hobday TJ, Okusaka T, Capdevila J, de Vries EG, Tomassetti P, Pavel ME, Hoosen S, Haas T, Lincy J, Lebwohl D, Öberg K; RAD001 in Advanced Neuroendocrine Tumors, Third Trial (RADIANT-3) Study Group. Everolimus for advanced pancreatic neuroendocrine tumors. N Engl J Med. 2011 Feb 10;364(6):514-23. link to original article contains verified protocol PubMed
4. Caplin ME, Pavel M, Cwikla JB, Phan AT, Raderer M, Sedlácková E, Cadiot G, Wolin EM, Capdevila J, Wall L, Rindi G, Langley A, Martinez S, Blumberg J, Ruszniewski P; CLARINET Investigators. Lanreotide in metastatic enteropancreatic neuroendocrine tumors. N Engl J Med. 2014 Jul 17;371(3):224-33. link to original article contains verified protocol PubMed

Streptozocin & Doxorubicin

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Regimen

Study	Evidence	Comparator	Efficacy
Moertel et al. 1992	Phase III	Chlorozotocin	Superior OS
		Streptozocin & Fluorouracil	Superior OS

Chemotherapy

• Streptozocin (Zanosar) 500 mg/m² IV once per day on days 1 to 5
• Doxorubicin (Adriamycin) 50 mg/m² IV once per day on days 1 & 22

6-week cycles, given until progression of disease

References

1. Moertel CG, Lefkopoulo M, Lipsitz S, Hahn RG, Klaassen D. Streptozocin-doxorubicin, streptozocin-fluorouracil or chlorozotocin in the treatment of advanced islet-cell carcinoma. N Engl J Med. 1992 Feb 20;326(8):519-23. link to original article contains verified protocol PubMed

Streptozocin, Doxorubicin, Fluorouracil (FAS)

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FAS: Fluorouracil, Adriamycin (Doxorubicin), Streptozocin

Regimen

Study	Evidence
Kouvaraki et al. 2004	Retrospective

Chemotherapy

• Fluorouracil (5-FU) 400 mg/m² IV bolus once per day on days 1 to 5
• Doxorubicin (Adriamycin) 40 mg/m² IV bolus once on day 1
• Streptozocin (Zanosar) 400 mg/m² IV bolus once per day on days 1 to 5

28-day cycles, given until progression of disease, unacceptable toxicity, or patient intolerance

References

1. Retrospective: Kouvaraki MA, Ajani JA, Hoff P, Wolff R, Evans DB, Lozano R, Yao JC. Fluorouracil, doxorubicin, and streptozocin in the treatment of patients with locally advanced and metastatic pancreatic endocrine carcinomas. J Clin Oncol. 2004 Dec 1;22(23):4762-71. link to original article contains verified protocol PubMed

Streptozocin & Fluorouracil

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Regimen

Study	Evidence	Comparator	Efficacy
Moertel et al. 1992	Phase III	Chlorozotocin	Seems not superior
		Streptozocin & Doxorubicin	Inferior OS

Chemotherapy

• Streptozocin (Zanosar) 500 mg/m² IV once per day on days 1 to 5
• Fluorouracil (5-FU) 400 mg/m² IV bolus once per day on days 1 to 5

6-week cycles, given until progression of disease

References

1. Moertel CG, Lefkopoulo M, Lipsitz S, Hahn RG, Klaassen D. Streptozocin-doxorubicin, streptozocin-fluorouracil or chlorozotocin in the treatment of advanced islet-cell carcinoma. N Engl J Med. 1992 Feb 20;326(8):519-23. link to original article contains verified protocol PubMed

Sunitinib (Sutent)

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Regimen

Study	Evidence	Comparator	Efficacy
Raymond et al. 2011	Phase III	Placebo	Seems to have superior OS

Chemotherapy

• Sunitinib (Sutent) 37.5 mg PO once per day

Given until progression of disease, unacceptable toxicity, or patient death

References

1. Raymond E, Dahan L, Raoul JL, Bang YJ, Borbath I, Lombard-Bohas C, Valle J, Metrakos P, Smith D, Vinik A, Chen JS, Hörsch D, Hammel P, Wiedenmann B, Van Cutsem E, Patyna S, Lu DR, Blanckmeister C, Chao R, Ruszniewski P. Sunitinib malate for the treatment of pancreatic neuroendocrine tumors. N Engl J Med. 2011 Feb 10;364(6):501-13. link to original article contains verified protocol PubMed

Temozolomide (Temodar)

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Regimen

Study	Evidence
Ekeblad et al. 2007	Phase II

Chemotherapy

• Temozolomide (Temodar) as follows:
  • Cycle 1: 100 or 150 mg/m² PO once per day on days 1 to 5
  • Cycle 2 onwards: increased as tolerated up to 200 mg/m² PO once per day on days 1 to 5

Supportive medications

• Tropisetron (Navoban) (dose/route/schedule not specified) routinely used as an antiemetic

28-day cycles, given until progression of disease or unacceptable toxicity

References

1. Ekeblad S, Sundin A, Janson ET, Welin S, Granberg D, Kindmark H, Dunder K, Kozlovacki G, Orlefors H, Sigurd M, Oberg K, Eriksson B, Skogseid B. Temozolomide as monotherapy is effective in treatment of advanced malignant neuroendocrine tumors. Clin Cancer Res. 2007 May 15;13(10):2986-91. link to original article contains verified protocol PubMed

Temozolomide & Bevacizumab

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Regimen

Study	Evidence
Chan et al. 2012	Phase II

Chemotherapy

• Temozolomide (Temodar) 150 mg/m² PO once per day on days 1 to 7, 15 to 21
• Bevacizumab (Avastin) 5 mg/kg IV once per day on days 1 & 15

Supportive medications

• Trimethoprim/Sulfamethoxazole (Bactrim DS) 160/800 mg PO once every Monday, Wednesday, and Friday; allergic patients received alternate Pneumocystis carinii (PCP) prophylaxis
• Acyclovir (Zovirax) 400 mg PO TID as prophylaxis against varicella zoster

28-day cycles, given until progression of disease or unacceptable toxicity

References

1. Chan JA, Stuart K, Earle CC, Clark JW, Bhargava P, Miksad R, Blaszkowsky L, Enzinger PC, Meyerhardt JA, Zheng H, Fuchs CS, Kulke MH. Prospective study of bevacizumab plus temozolomide in patients with advanced neuroendocrine tumors. J Clin Oncol. 2012 Aug 20;30(24):2963-8. Epub 2012 Jul 9. link to original article contains verified protocol PubMed

Temozolomide & Capecitabine

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Regimen

Study	Evidence
Strosberg et al. 2011	Retrospective

Chemotherapy

• Temozolomide (Temodar) 200 mg/m² PO once per day at bedtime on days 10 to 14
• Capecitabine (Xeloda) 750 mg/m² PO BID on days 1 to 14

Supportive medications

• Ondansetron (Zofran) 8 mg (route not specified) prior to each dose of Temozolomide (Temodar)

28-day cycles

References

1. Retrospective: Strosberg JR, Fine RL, Choi J, Nasir A, Coppola D, Chen DT, Helm J, Kvols L. First-line chemotherapy with capecitabine and temozolomide in patients with metastatic pancreatic endocrine carcinomas. Cancer. 2011 Jan 15;117(2):268-75. Epub 2010 Sep 7. link to original article contains verified protocol PubMed

Temozolomide & Thalidomide

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Regimen

Study	Evidence
Kulke et al. 2006	Phase II

Chemotherapy

• Temozolomide (Temodar) 150 mg/m² PO once per day on days 1 to 7, 15 to 21
• Thalidomide (Thalomid) 200 mg PO once per day

28-day cycles, given until progression of disease or unacceptable toxicity

References

1. Kulke MH, Stuart K, Enzinger PC, Ryan DP, Clark JW, Muzikansky A, Vincitore M, Michelini A, Fuchs CS. Phase II study of temozolomide and thalidomide in patients with metastatic neuroendocrine tumors. J Clin Oncol. 2006 Jan 20;24(3):401-6. link to original article contains verified protocol PubMed

Pheochromocytoma

Cyclophosphamide, Vincristine, Dacarbazine (CVD)

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CVD: Cyclophosphamide, Vincristine, Dacarbazine

Regimen

Study	Evidence
Averbuch et al. 1988	Pilot, <20 pts

Chemotherapy

• Cyclophosphamide (Cytoxan) 750 mg/m² IV once on day 1
• Vincristine (Oncovin) 1.4 mg/m² IV once on day 1
• Dacarbazine (DTIC) 600 mg/m² IV once per day on days 1 & 2

21-day cycles

References

1. Averbuch SD, Steakley CS, Young RC, Gelmann EP, Goldstein DS, Stull R, Keiser HR. Malignant pheochromocytoma: effective treatment with a combination of cyclophosphamide, vincristine, and dacarbazine. Ann Intern Med. 1988 Aug 15;109(4):267-73. link to original article contains protocol PubMed

¹³¹I-Metaiodobenzylguanidine (¹³¹I-MIBG)

Also known as m-[131I]iodobenzylguanidine ([131I]MIBG).

Regimen #1

Study	Evidence
Rose et al. 2003	Pilot, <20 pts

Patients underwent stem cell harvest prior to treatment in case autologous stem cell infusion was needed.

Radiotherapy

• ¹³¹I-Metaiodobenzylguanidine (¹³¹I-MIBG) 12 to 18 mCi/kg (maximum single dose of 850 mCi) IV over 2 hours once on day 1

Supportive medications

• Intravenous fluids started 12 hours before 131I-MIBG administration.
• Potassium iodide (KI) 6 mg/kg PO once at least 2 hours prior to 131I-MIBG, then potassium iodide (KI) 0.88 mg/kg PO Q4H x 7 days, then potassium iodide (KI) 1 mg/kg PO (frequency not specified) "for 45 days after the infusion."
• Potassium perchlorate 8 mg/kg once at least 2 hours prior to 131I-MIBG, then potassium perchlorate 2 mg/kg PO Q6H x 5 days.

"Repeat 131I-MIBG treatments were administered on a case-by-case basis in an effort to improve the overall response"

Regimen #2

Study	Evidence
Krempf et al. 1991	Pilot, <20 pts

Radiotherapy

• m-[131I]iodobenzylguanidine ([131I]MIBG) 740 megabequerel/mg every 3 months

References

1. Krempf M, Lumbroso J, Mornex R, Brendel AJ, Wemeau JL, Delisle MJ, Aubert B, Carpentier P, Fleury-Goyon MC, Gibold C et al. Use of m-[131I]iodobenzylguanidine in the treatment of malignant pheochromocytoma. J Clin Endocrinol Metab. 1991 Feb;72(2):455-61. link to original article contains protocol PubMed
2. Rose B, Matthay KK, Price D, Huberty J, Klencke B, Norton JA, Fitzgerald PA. High-dose 131I-metaiodobenzylguanidine therapy for 12 patients with malignant pheochromocytoma. Cancer. 2003 Jul 15;98(2):239-48. link to original article contains verified protocol PubMed