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Lu-177-DOTATATE (Lutathera) in Therapy of Inoperable Pheochromocytoma/ Paraganglioma

Primary Purpose

Pheochromocytoma, Paraganglioma, Neuroendocrine Tumors

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Lu-177-DOTATATE
Ga-68-DOTATATE
F-18-FDG
Amino Acid solution
Sponsored by
National Cancer Institute (NCI)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Pheochromocytoma focused on measuring Hypertension, Catecholamine, Familial Syndromes, Somatostatin Receptors, Ionizing Radiation

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

-INCLUSION CRITERIA:

  1. Surgically inoperable participants with clinical diagnosis of PHEO/PGL who also have demonstrated disease histologically consistent with pheochromocytoma or paraganglioma (preferably confirmed by research site pathology review if initial pathology was done outside of research site, but not mandatory).
  2. Progressive disease by RECIST with or without symptoms within the last 12 months. NOTE: Untreated participants with existing histologic diagnoses are eligible if progression can be demonstrated.
  3. PHEO/PGL that is not associated with any known susceptibility genetic mutations for PHEO/PGL except SDHx mutation (a.k.a. "apparent sporadic"), based on documented genetic testing results obtained prior to study enrollment. PHEO/PGL that is associated with non-SDHx mutations such as VHL, NF1, and RET will not be eligible for this study.
  4. Patient is or will be enrolled on protocol 00-CH-0093, Diagnosis, Pathophysiology, and Molecular Biology of Pheochromocytoma and Paraganglioma (NIH only).
  5. Both metastatic and inoperable primary-only participants are eligible.
  6. Must have presence of SSTR+ disease as documented by positive Ga-68-DOTATATE PET scan within 12 weeks of anticipated treatment.

    NOTE:

    • Positivity of Ga-68-DOTATATE PET scan defined as having at least one lesion that is greater than or equal to 10 mm in diameter with uptake that is higher than or equal to liver and is qualitatively higher and distinguishable from background activity.
    • Measurable disease as defined by RECIST 1.1
  7. Age greater than or equal to 18
  8. Karnofsky Performance Score greater than or equal to 60 or ECOG Performance Status of 2 or better.
  9. Able to understand and willings to sign informed consent
  10. Ability and willingness to obtain all required scans per study schedule.
  11. Negative serum pregnancy test for women of child bearing potential or NOTE: A female is not of childbearing potential if a prior history of hysterectomy with bilateral oophorectomy or other procedure has render the participant surgically sterile, or >2 years since last menstruation.
  12. Female participants of childbearing potential and male participants who are not surgically sterile or with female partners of childbearing potential must agree to use effective, non-hormonal means of contraception (intrauterine contraceptive device, barrier method of contraception in conjunction with spermicidal gel) prior to study entry, for the duration of study participation and for 6 months (10 half-lives of Lu-177) after the last dose of Lu-177- DOTATATE.
  13. Must have outside endocrinologist/medical oncologist who can follow the participant after receiving PRRT (NIH only requirement).
  14. Patients with secreting tumors must be receiving adequate pharmacologic catecholamine blockade as determined by the treating physician.
  15. Ineligible, unable to or unwilling to receive standard first line therapy for PHEO/PGL.

EXCLUSION CRITERIA:

  1. Creatinine clearance <50 mL/min calculated by the MDRD method, eventually confirmed by measured creatinine clearance (or measured glomerular filtration rate (GFR) using plasma clearance methods.
  2. Serum albumin less than or equal to 3.0 g/dL unless prothrombin time is within the normal range.
  3. Liver dysfunction as evidenced by Child s Class C Liver Disease or worse Alternatively, AST or ALT > 2.5 times institutional upper limit of normal (ULN) unless liver metastases are present, in which case up to 5 times ULN would be allowed.
  4. Hb < 8.0 g/dL; WBC < 2.0 x 10^9/L (or Absolute Neutrophil Count < 1000); Platelets < 100 x 10^9/L
  5. In participants with symptoms of congestive heart failure, New York Heart Association (NYHA) classification of grade III or IV
  6. Pregnancy or lactation.
  7. Prior anti-tumoral radionuclide therapy with unsealed sources. Prior therapy with sealed radioactive sources such as brachytherapy will be allowed.
  8. Prior local radiation therapy would be allowed as long as there is at least one non-irradiated index lesions.
  9. Known brain metastases, unless these metastases have been treated and stabilized for at least 24 weeks, prior to enrollment in the study. Patients with a history of brain metastases must have a head CT or MRI scan with contrast to document stable disease for at least 24 weeks prior to enrolment in the study.
  10. Other known co-existing malignancies except non-melanoma skin cancer and carcinoma in situ of the uterine cervix, unless definitively treated and proven no evidence of recurrence for 5 years.
  11. Patients who participated in any therapeutic clinical study with an investigational agent within the last 30 days.
  12. Patients may be on somatostatin analogue therapy (e.g. but not only limited to sandostatin or lanreotide therapy). However, therapy with somatostatin analogues should not be initiated or altered within 3 months of study enrolment. Patients on short term octreotide may have dose held for 24 hours prior to Lu-177-DOTATATE therapy. Those on long acting octreotide therapy will receive treatment at 1 to 5 days prior to their next cold octreotide dose, in order to prevent competition for the receptor.
  13. Patient weight > 400 lbs (table limit for PET scanner) or per local institutional standard for non-NIH sites.
  14. Uncontrolled inter-current illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, hypertension (>180/110), arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
  15. Inability to tolerate at least one modality of diagnostic anatomic imaging, such as CT or MRI.

Sites / Locations

  • National Institutes of Health Clinical CenterRecruiting

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

1/Lu-177-DOTATATE

Arm Description

Lu-177-DOTATATE is administered IV every 8 (+/- 2) weeks, for a total of 4 administrations. A Ga-68-DOTATATE PET and F-18-FDG-PET, as well as CT/ MRI for RECIST monitoring, will be obtained post 2 administrations and post 4 administrations. Concomitant administration of an IV infusion of an amino acid (AA) solution will also be done for renal protection. Concomitant administration of an IV infusion of an amino acid (AA) solution will also be done for renal protection.

Outcomes

Primary Outcome Measures

progression-free survival
Median amount of time subject survives without disease progression after treatment

Secondary Outcome Measures

Time to tumor progression
Median amount of time subject survives without disease progression after treatment
Safety and tolerability profile
List of adverse event frequency
Overall survival
Median amount of time subject survives after therapy
Objective response rate
Proportion of patients whose tumors shrunk after therapy
Evaluate Quality of Life
Proportion of patients with increased Quality of Life (QoL)
Determine changes in plasma biochemical markers
changes in plasma biochemical markers
Determine ability to decrease anti-hypertensive medication
Proportion of patients using decreased amount of anti-hypertensive medication

Full Information

First Posted
June 30, 2017
Last Updated
September 26, 2023
Sponsor
National Cancer Institute (NCI)
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1. Study Identification

Unique Protocol Identification Number
NCT03206060
Brief Title
Lu-177-DOTATATE (Lutathera) in Therapy of Inoperable Pheochromocytoma/ Paraganglioma
Official Title
Lu-177-DOTATATE (Lutathera) in Therapy of Inoperable Pheochromocytoma/ Paraganglioma
Study Type
Interventional

2. Study Status

Record Verification Date
September 25, 2023
Overall Recruitment Status
Recruiting
Study Start Date
October 10, 2017 (Actual)
Primary Completion Date
January 1, 2026 (Anticipated)
Study Completion Date
January 1, 2027 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
National Cancer Institute (NCI)

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No

5. Study Description

Brief Summary
Background: Pheochromocytoma and paraganglioma are rare tumors. They usually form inside and near the adrenal gland or in the neck region. Not all these tumors can be removed with surgery, and there are no good treatments if the disease has spread. Researchers think a new drug may be able to help. Objective: To learn the safety and tolerability of Lu-177-DOTATATE. Also, to see if it improves the length of time it takes for the cancer to return. Eligibility: Adults who have an inoperable tumor of the study cancer that can be detected with Ga-68-DOTATATE PET/CT imaging Design: Participants will be screened with a medical history, physical exam, and blood tests. Eligible participants will be admitted to the NIH Clinical Center. Participants will get the study drug in an intravenous infusion. They will get 4 doses, given about 8 weeks apart. Between 4 and 24 hours after each study drug dose, participants will have scans taken. They will lie on their back on a scanner table. Participants will have vital signs taken. They will give blood and urine samples. During the study, participants will have other scans taken. Some scans will use a radioactive tracer. Participants will complete quality of life questionnaires. Participants will be contacted by phone 1-3 days after they leave the Clinical Center. They will then be followed every 3 to 6 months for 3 years or until their disease gets worse.
Detailed Description
Background: Pheochromocytomas/paragangliomas (PHEOs/PGLs) are rare tumors arising from neural crest tissue that can develop in sympathetic and parasympathetic paraganglia throughout the body. Those arising in the adrenal gland are called PHEOs while those located extraadrenally are called PGLs. While benign and uni-focal, PHEO/PGL can be effectively treated with surgical resection, participants with metastatic PHEO/PGL often times have few effective and efficient treatment options with current treatments aimed more at palliation and symptom control. Furthermore, some benign head and neck PGLs may be inoperable because of their size and location. Somatostatin receptors (SSTR), especially type 2, have been shown to be over-expressed in a number of human tumors, including gastroenteropancreatic (GEP), carcinoids, neuroblastoma, prostate cancer, and PHEO/PGL among many others. Ionizing radiation such as the beta particles emitted by Lu-177 cause DNA damage to target cells through both direct and indirect mechanisms. In addition, ionizing radiation has also been shown to induce cell death through what is known as the bystander effect, a phenomenon where cellular signaling from irradiated cells towards non-irradiated cells induces cellular damage and eventually death in nearby surrounding cells. Lu-177-DOTATATE is a somatostatin analog that predominantly recognizes SSTR2. This reagent has been used extensively and its well-tolerated safety profile and efficacy has been shown in a variety of neuroendocrine tumors. Primary Objective: To assess the safety and to evaluate the ability of Lu-177-DOTATATE to improve upon progression-free survival (PFS) at 6 months in participants with inoperable, SSTR positive PHEO/PGL by comparing PFS of participants treated with Lu-177-DOTATATE to historical controls from existing literature. Eligibility: Histologically-proven, surgically inoperable, PHEO/PGL participants (both newly diagnosed or participants with existing diagnoses are eligible) Must have presence of SSTR+ disease as documented by positive Ga-68-DOTATATE PET scan Positivity of Ga-68-DOTATATE PET scan defined as having at least one lesion that is greater than or equal to 10 mm in diameter with uptake that is higher than or equal to liver and is qualitatively higher and distinguishable from background activity. Measurable disease as defined by RECIST 1.1 Age: greater than or equal to 18 Karnofsky Performance Score greater than or equal to 60 or, ECOG Performance Status of 2 or better Able to understand and willing to sign informed consent Design: Open-label, single-arm, multi-center, phase 2 study evaluating efficacy and safety of Lu- 177-DOTATATE in the selected participant population divided into two cohorts: 1) SDHx cohort will include participants with the succinate dehydrogenase mutation, which is the most common and most aggressive genetic sub-group of participants with PHEO/PGL, and 2) apparent sporadic cohort which will include participants without a clear genetic mutation. Patients who have met the primary endpoint of having achieved a PFS of at least 6 months after the initial treatment course, may be eligible to receive further cycles of Lu- 177-DOTATATE at the time of progression. Simon 2-stage optimal design will be applied to each cohort independently. For each cohort, if 11/18 participants are progression-free at 6 months, accrual will proceed to the second stage, where an additional 23 participants will be accrued, for a total of 41 participants per cohort. Assuming a loss-to-follow-up rate of 10%, a total of 45 participants will be accrued to each cohort, with a total accrual ceiling of 90 participants.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Pheochromocytoma, Paraganglioma, Neuroendocrine Tumors, Neuroendocrine Neoplasms
Keywords
Hypertension, Catecholamine, Familial Syndromes, Somatostatin Receptors, Ionizing Radiation

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
90 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
1/Lu-177-DOTATATE
Arm Type
Experimental
Arm Description
Lu-177-DOTATATE is administered IV every 8 (+/- 2) weeks, for a total of 4 administrations. A Ga-68-DOTATATE PET and F-18-FDG-PET, as well as CT/ MRI for RECIST monitoring, will be obtained post 2 administrations and post 4 administrations. Concomitant administration of an IV infusion of an amino acid (AA) solution will also be done for renal protection. Concomitant administration of an IV infusion of an amino acid (AA) solution will also be done for renal protection.
Intervention Type
Drug
Intervention Name(s)
Lu-177-DOTATATE
Intervention Description
Lu-177-DOTATATE IV at weeks 1, 8, 16 and 24.
Intervention Type
Drug
Intervention Name(s)
Ga-68-DOTATATE
Intervention Description
Ga-68-DOTATATE PET/CT at weeks 15 and 31, every 24 weeks during 3 years follow up period.
Intervention Type
Drug
Intervention Name(s)
F-18-FDG
Intervention Description
F-18-FDG PET/CT at weeks 15 and 31, every 24 weeks during 3 years follow up period.
Intervention Type
Drug
Intervention Name(s)
Amino Acid solution
Intervention Description
AA solution will be administered 60 minutes prior to each Lu-177-DOTATATE infusion.
Primary Outcome Measure Information:
Title
progression-free survival
Description
Median amount of time subject survives without disease progression after treatment
Time Frame
6 months
Secondary Outcome Measure Information:
Title
Time to tumor progression
Description
Median amount of time subject survives without disease progression after treatment
Time Frame
at disease progression
Title
Safety and tolerability profile
Description
List of adverse event frequency
Time Frame
30 days after the last dose of study drug
Title
Overall survival
Description
Median amount of time subject survives after therapy
Time Frame
at death
Title
Objective response rate
Description
Proportion of patients whose tumors shrunk after therapy
Time Frame
at disease progression
Title
Evaluate Quality of Life
Description
Proportion of patients with increased Quality of Life (QoL)
Time Frame
3 years
Title
Determine changes in plasma biochemical markers
Description
changes in plasma biochemical markers
Time Frame
3 years
Title
Determine ability to decrease anti-hypertensive medication
Description
Proportion of patients using decreased amount of anti-hypertensive medication
Time Frame
3 years

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
-INCLUSION CRITERIA: Surgically inoperable participants with clinical diagnosis of PHEO/PGL who also have demonstrated disease histologically consistent with pheochromocytoma or paraganglioma (preferably confirmed by research site pathology review if initial pathology was done outside of research site, but not mandatory). Progressive disease by RECIST with or without symptoms within the last 12 months. NOTE: Untreated participants with existing histologic diagnoses are eligible if progression can be demonstrated. PHEO/PGL that is not associated with any known susceptibility genetic mutations for PHEO/PGL except SDHx mutation (a.k.a. "apparent sporadic"), based on documented genetic testing results obtained prior to study enrollment. PHEO/PGL that is associated with non-SDHx mutations such as VHL, NF1, and RET will not be eligible for this study. Patient is or will be enrolled on protocol 00-CH-0093, Diagnosis, Pathophysiology, and Molecular Biology of Pheochromocytoma and Paraganglioma (NIH only). Both metastatic and inoperable primary-only participants are eligible. Must have presence of SSTR+ disease as documented by positive Ga-68-DOTATATE PET scan within 12 weeks of anticipated treatment. NOTE: Positivity of Ga-68-DOTATATE PET scan defined as having at least one lesion that is greater than or equal to 10 mm in diameter with uptake that is higher than or equal to liver and is qualitatively higher and distinguishable from background activity. Measurable disease as defined by RECIST 1.1 Age greater than or equal to 18 Karnofsky Performance Score greater than or equal to 60 or ECOG Performance Status of 2 or better. Able to understand and willings to sign informed consent Ability and willingness to obtain all required scans per study schedule. Negative serum pregnancy test for women of child bearing potential or NOTE: A female is not of childbearing potential if a prior history of hysterectomy with bilateral oophorectomy or other procedure has render the participant surgically sterile, or >2 years since last menstruation. Female participants of childbearing potential and male participants who are not surgically sterile or with female partners of childbearing potential must agree to use effective, non-hormonal means of contraception (intrauterine contraceptive device, barrier method of contraception in conjunction with spermicidal gel) prior to study entry, for the duration of study participation and for 6 months (10 half-lives of Lu-177) after the last dose of Lu-177- DOTATATE. Must have outside endocrinologist/medical oncologist who can follow the participant after receiving PRRT (NIH only requirement). Patients with secreting tumors must be receiving adequate pharmacologic catecholamine blockade as determined by the treating physician. Ineligible, unable to or unwilling to receive standard first line therapy for PHEO/PGL. EXCLUSION CRITERIA: Creatinine clearance <50 mL/min calculated by the MDRD method, eventually confirmed by measured creatinine clearance (or measured glomerular filtration rate (GFR) using plasma clearance methods. Serum albumin less than or equal to 3.0 g/dL unless prothrombin time is within the normal range. Liver dysfunction as evidenced by Child s Class C Liver Disease or worse Alternatively, AST or ALT > 2.5 times institutional upper limit of normal (ULN) unless liver metastases are present, in which case up to 5 times ULN would be allowed. Hb < 8.0 g/dL; WBC < 2.0 x 10^9/L (or Absolute Neutrophil Count < 1000); Platelets < 100 x 10^9/L In participants with symptoms of congestive heart failure, New York Heart Association (NYHA) classification of grade III or IV Pregnancy or lactation. Prior anti-tumoral radionuclide therapy with unsealed sources. Prior therapy with sealed radioactive sources such as brachytherapy will be allowed. Prior local radiation therapy would be allowed as long as there is at least one non-irradiated index lesions. Known brain metastases, unless these metastases have been treated and stabilized for at least 24 weeks, prior to enrollment in the study. Patients with a history of brain metastases must have a head CT or MRI scan with contrast to document stable disease for at least 24 weeks prior to enrolment in the study. Other known co-existing malignancies except non-melanoma skin cancer and carcinoma in situ of the uterine cervix, unless definitively treated and proven no evidence of recurrence for 5 years. Patients who participated in any therapeutic clinical study with an investigational agent within the last 30 days. Patients may be on somatostatin analogue therapy (e.g. but not only limited to sandostatin or lanreotide therapy). However, therapy with somatostatin analogues should not be initiated or altered within 3 months of study enrolment. Patients on short term octreotide may have dose held for 24 hours prior to Lu-177-DOTATATE therapy. Those on long acting octreotide therapy will receive treatment at 1 to 5 days prior to their next cold octreotide dose, in order to prevent competition for the receptor. Patient weight > 400 lbs (table limit for PET scanner) or per local institutional standard for non-NIH sites. Uncontrolled inter-current illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, hypertension (>180/110), arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. Inability to tolerate at least one modality of diagnostic anatomic imaging, such as CT or MRI.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Joy Zou, R.N.
Phone
(240) 760-6153
Email
joy.zou@nih.gov
First Name & Middle Initial & Last Name or Official Title & Degree
Frank I Lin, M.D.
Phone
(240) 760-6166
Email
frank.lin2@nih.gov
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Frank I Lin, M.D.
Organizational Affiliation
National Cancer Institute (NCI)
Official's Role
Principal Investigator
Facility Information:
Facility Name
National Institutes of Health Clinical Center
City
Bethesda
State/Province
Maryland
ZIP/Postal Code
20892
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
For more information at the NIH Clinical Center contact National Cancer Institute Referral Office
Phone
888-624-1937

12. IPD Sharing Statement

Plan to Share IPD
Yes
IPD Sharing Plan Description
.All IPD recorded in the medical record will be shared with intramural investigators upon request.
IPD Sharing Time Frame
Clinical data available during the study and indefinitely.
IPD Sharing Access Criteria
Clinical data will be made available via subscription to BTRIS and with the permission of the study PI.
Citations:
PubMed Identifier
26253273
Citation
Kim SJ, Pak K, Koo PJ, Kwak JJ, Chang S. The efficacy of (177)Lu-labelled peptide receptor radionuclide therapy in patients with neuroendocrine tumours: a meta-analysis. Eur J Nucl Med Mol Imaging. 2015 Dec;42(13):1964-70. doi: 10.1007/s00259-015-3155-x. Epub 2015 Aug 9.
Results Reference
background
PubMed Identifier
24893135
Citation
Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, Naruse M, Pacak K, Young WF Jr; Endocrine Society. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014 Jun;99(6):1915-42. doi: 10.1210/jc.2014-1498. Erratum In: J Clin Endocrinol Metab. 2023 Apr 13;108(5):e200.
Results Reference
background
PubMed Identifier
22526961
Citation
Maurice JB, Troke R, Win Z, Ramachandran R, Al-Nahhas A, Naji M, Dhillo W, Meeran K, Goldstone AP, Martin NM, Todd JF, Palazzo F, Tan T. A comparison of the performance of (6)(8)Ga-DOTATATE PET/CT and (1)(2)(3)I-MIBG SPECT in the diagnosis and follow-up of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging. 2012 Aug;39(8):1266-70. doi: 10.1007/s00259-012-2119-7. Epub 2012 Apr 20.
Results Reference
background
PubMed Identifier
33551992
Citation
Gubbi S, Al-Jundi M, Del Rivero J, Jha A, Knue M, Zou J, Turkbey B, Carrasquillo JA, Lin E, Pacak K, Klubo-Gwiezdzinska J, Lin FI. Case Report: Primary Hypothyroidism Associated With Lutetium 177-DOTATATE Therapy for Metastatic Paraganglioma. Front Endocrinol (Lausanne). 2021 Jan 21;11:587065. doi: 10.3389/fendo.2020.587065. eCollection 2020.
Results Reference
derived
Links:
URL
https://clinicalstudies.info.nih.gov/cgi/detail.cgi?A_2017-C-0087.html
Description
NIH Clinical Center Detailed Web Page

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Lu-177-DOTATATE (Lutathera) in Therapy of Inoperable Pheochromocytoma/ Paraganglioma

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