Randomized Embolization Trial for NeuroEndocrine Tumor Metastases To The Liver (RETNET): A Phase 3 Randomized Multicenter Trial to Compare Hepatic Progression-Free Survival Following Bland Embolization, Lipiodol Chemoembolization, and Drug-Eluting Bead Chemoembolization of Neuroendocrine Liver Metastases
The purpose of this study is 1) to determine if one or more of three techniques provide longer-lasting control of tumors in the liver, and 2) to see if outcomes for participants treated with the three techniques show that there are differences in quality of life, side effects, or safety.
To estimate the duration of hepatic progression-free survival (HPFS) in participants treated with bland embolization (BE), transcatheter arterial Lipiodol chemoembolization (TACE), and embolization by drug-eluting beads (DEB). The primary hypothesis is that chemoembolization will be nearly twice as durable as bland embolization.
Measurable metastasis to liver with at least one dimension ≥ 1.0 cm.
Tumor burden dominant in the liver AND liver tumor burden less than or equal to 70%.
Not a candidate for surgical resection based on unresectability, anatomy, anesthesia risk, patient preference.
Age 18 years or older
Symptoms uncontrolled by somatostatin analogues OR morphologically progressive tumor by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria in the liver OR baseline tumor burden >25% of the liver volume.
There must be no plans for the patient to receive other concomitant therapy while on this protocol treatment (other than somatostatin analog or bone-strengthening agents)
Performance status 0-2 on Zubrod/ECOG Performance Scale
Serum creatinine > Serum bilirubin ≤ 2.0 mg/dL
Serum albumin ≥ 3.0 g/dL
Platelet count > 50 thousands/uL (corrected if needed)
International Normalized Ratio (INR) ≤ 1.5 (corrected if needed)
Pregnant or lactating women may not participate due to the embryotoxic effects of protocol treatment. Women/men of reproductive potential may not participate unless they have agreed to use an effective contraceptive method.
Prior hepatic arterial therapy or hepatic radiation therapy. Prior surgical resection or ablation of liver metastases is acceptable. Patients must be at least one month beyond prior radiotherapy or surgery, and 6 months beyond chemotherapy and have recovered from all therapy-associated toxicities.
Extensive extrahepatic tumor (not just confined to lymph nodes/bone metastases)
Active infection (Symptomatic bacterial and fungal infection - newly diagnosed and/or requiring treatment);
Choledochoenteric anastomosis; transpapillary biliary stent, or sphincterotomy of duodenal papilla
Absolute contraindication to intravenous iodinated contrast (Hx of significant previous contrast reaction, not mitigated by appropriate pre-medication).
Contraindications to arteriography and selective visceral catheterization: 1.) severe allergy or intolerance to contrast media, narcotics, sedatives, or atropine; 2.) bleeding diathesis not correctable by usual forms of therapy; 3.) severe peripheral vascular disease precluding catheterization.
Contraindications to hepatic artery embolization: 1.) high risk of hepatic failure, indicated by the constellation of greater than 50% liver replacement by tumor, LDH>425 mU/ml, SGOT(AST)>100mU/ml. and bilirubin >2 mg./dl; 2.) portal vein occlusion without hepatopedal collateral flow demonstrated by angiography; or portal hypertension with hepatofugal flow; 3.) hepatic encephalopathy.
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