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Testing the Use of Chemotherapy after Surgery for High-Risk Pancreatic Neuroendocrine Tumors

Cancer Type
Neuroendocrine Tumor
Unknown Primary
Trial Phase
Phase II
18 Years and older, Male and Female
Study Type
Protocol IDs
S2104 (primary)
Study Sponsor


This phase II trial studies the effect of capecitabine and temozolomide after surgery in treating patients with high-risk well-differentiated pancreatic neuroendocrine tumors. Chemotherapy drugs, such as capecitabine and temozolomide, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving capecitabine and temozolomide after surgery could prevent or delay the return of cancer in patients with high-risk well-differentiated pancreatic neuroendocrine tumors.


I. To evaluate recurrence-free survival (RFS) in participants with resected pancreatic neuroendocrine tumors (pNETs) randomized to treatment with capecitabine + temozolomide (CAPTEM) compared to observation only.

I. To evaluate overall survival (OS) in participants randomized to treatment with CAPTEM compared to observation only.
II. To evaluate the safety and tolerability of CAPTEM compared to observation only.

I. To bank specimens for future correlative studies.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM I: Patients receive capecitabine orally (PO) twice daily (BID) on days 1-14 and temozolomide PO once daily (QD) on days 10-14. Treatment repeats every 28 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

ARM II: Patients undergo surveillance with no active treatment.

Patients also undergo computed tomography (CT) and/or magnetic resonance imaging (MRI) and may undergo blood sample collection while on study.

After completion of study treatment, patients are followed up every 6 months for 3 years and then annually until 5 years from randomization.


  1. Participants must have a histologic diagnosis of well-differentiated pancreatic neuroendocrine tumor (pNET) that was resected between 14 and 90 days prior to registration. Participants must have a scan within 90 days prior to registration without evidence of metastatic disease, unless liver oligo-metastatic disease was deemed to be resected/ablated at time of surgery. Acceptable scans are multiphase CT abdomen, MRI with intravenous (IV) contrast of the abdomen; Multiphasic CT of the abdomen should include arterial-phase imaging of the liver in addition to the portal venous phase
  2. Resection must have been an R0 or R1 per treating investigator’s assessment and/or pathology report
  3. Participants may have received resection/ablation of liver oligo-metastatic disease (up to 5 liver metastases) at the time of well-differentiated pNET resection
  4. Participants must have Ki-67 testing performed from the surgical specimen collection between 14 and 90 days prior to registration. The Ki-67 result must be >= 3% and =< 55%. NOTE: The Ki-67 testing, is considered standard of care in the pathology report. Treating investigators are encouraged to contact the S2104 Study Chairs and/or the study pathology chair with questions. If more than one Ki-67 is reported (e.g., primary tumor versus lymph node or metastatic site), the highest one should be considered for the study eligibility criteria
  5. Participants with localized resected pNETS must have a Zaidi score of >= 3 derived by the following factors and points: * 1 point; prior symptomatic tumor defined as at least one of the following: ** Gastrointestinal bleed ** Jaundice ** Gastrointestinal obstruction ** Pain from primary tumor prior to surgical resection ** Pancreatitis * 2 points; primary pancreas tumor size > 2 cm * 1 point; Ki-67 3% to 20% * 1 point; lymph node positivity = 1 * 6 points; Ki-67 21% to 55% The Zaidi score should be calculated after resection and prior to registration. The Zaidi score does not apply to the subset of participants with liver only metastatic disease; for the purpose of stratification, these participants will be assigned a score of 6.
  6. Participants must have recovered from effects of surgery as determined by the treating investigator
  7. Participants must be >= 18 years old
  8. Participants must have Zubrod performance status of 0-2
  9. Participants must have a complete medical history and physical exam within 28 days prior to registration
  10. Participants must have adequate organ and marrow function as defined below within 28 days prior to registration:
  11. Leukocytes >= 3 x 10^3/uL (within 28 days prior to registration)
  12. Absolute neutrophil count >= 1.5 x 10^3/uL (within 28 days prior to registration)
  13. Platelets >= 100 x 10^3/uL (within 28 days prior to registration)
  14. Total bilirubin =< institutional upper limit of normal (ULN) unless history of Gilbert’s disease. Participants with history of Gilbert’s disease must have total bilirubin =< 5 x institutional ULN (within 28 days prior to registration)
  15. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 3 x institutional ULN (within 28 days prior to registration)
  16. Serum creatinine =< 1.5 x institutional ULN (within 28 days prior to registration)
  17. Calculated creatinine clearance >= 50 ml/min (within 28 days prior to registration)
  18. Participants must be able to swallow pills
  19. Participants must be able to tolerate CT or MRI including contrast agents as required for their treatment and the protocol
  20. Participants must agree to have a hematoxylin and eosin (H&E) slide and an KI-67 immunohistochemistry (IHC) slide of the tumor submitted for central confirmatory quality review
  21. Participants must be offered the opportunity to participate in specimen banking. With participant consent, specimens must be collected and submitted via the SWOG Specimen Tracking System
  22. Participants must be informed of the investigational nature of this study and must sign and give informed consent in accordance with institutional and federal guidelines

Treatment Sites in Georgia

Emory Saint Joseph's Hospital

5665 Peachtree Dunwoody Road NE
Atlanta, GA 30342

Emory University Hospital - Midtown

550 Peachtree Street NE
Atlanta, GA 30308

Winship Cancer Institute of Emory University

1365 Clifton Road NE
Building C
Atlanta, GA 30322

**Clinical trials are research studies that involve people. These studies test new ways to prevent, detect, diagnose, or treat diseases. People who take part in cancer clinical trials have an opportunity to contribute to scientists’ knowledge about cancer and to help in the development of improved cancer treatments. They also receive state-of-the-art care from cancer experts... Click here to learn more about clinical trials.