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

INCLUSION CRITERIA

• 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 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 nee