Inclusion Criteria:

PRE-REGISTRATION:

• Well- or moderately-differentiated neuroendocrine tumor(s) of bronchial origin (i.e., carcinoid) as assessed by local pathology.
• The pathology report must state ONE of the following:
  • Well- or moderately-differentiated neuroendocrine tumor;
  • Low- or intermediate-grade neuroendocrine tumor.
• Carcinoid tumor (including typical or atypical carcinoid tumors): 
  • Documentation of histology from a primary or metastatic site is allowed.
• Functional (evidence of peptide hormones and/or bioactive substances associated with a clinical hormone syndrome such as carcinoid syndrome or Cushing's syndrome) or nonfunctional tumors are allowed.
• Patients with poorly-differentiated or high-grade neuroendocrine carcinoma (i.e., large cell neuroendocrine carcinoma of lung, small cell lung cancer) or mixed tumors (i.e., adenocarcinoid tumor) are not eligible.
• Recurrent or locally-advanced/unresectable or metastatic disease.
• Neuroendocrine tumor of bronchial (i.e., lung) primary site.
• Lesions must have shown radiological evidence of disease progression in the 12 months prior to pre-registration.
• Tumor must have shown somatostatin receptor (SSTR) positivity on 68Ga-DOTATATE PET or other SSTR-PET scan in the 12 months prior to pre-registration; however, documentation of SSTR positivity in the 6 months prior to pre-registration is preferred. SSTR positivity is defined as uptake greater than background liver in all measurable lesions.
• Patients must have measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1 by computer tomography (CT) scan or magnetic imaging (MRI). Any lesions which have undergone percutaneous therapies or radiotherapy should not be considered measurable unless the lesion has clearly progressed since the procedure.
• Lesions must be accurately measured in at least one dimension (longest diameter to be recorded) as ≥ 1 cm with CT or MRI (or ≥ 1.5 cm for lymph nodes). Non-measurable disease includes disease smaller than these dimensions or lesions considered truly non-measurable including: leptomeningeal disease, bone metastases, ascites, pleural or pericardial effusion, lymphangitic involvement of skin or lung.

REGISTRATION:

• Confirmation of SSTR positivity by Alliance Imaging Core Lab (ICL) at Imaging and Radiation Oncology Core (IROC) Ohio central radiographic review.
• Patients with treatment-naive or previously-treated disease are allowed. Patients with previously-treated disease must have demonstrated radiographic disease progression on the prior therapy.
• No prior treatment with peptide receptor radionuclide therapy (PRRT) (e.g. < lutetium Lu 177 dotatate).
• No prior treatment with mammalian target of rapamycin (mTOR) inhibitors (e.g., deforolimus, everolimus, sirolimus, temsirolimus, etc.).
• Prior treatment with hepatic artery embolization (including bland embolization, chemoembolization, and selective radioembolization) or ablative therapies (i.e., cryoablation, radiofrequency ablation, etc.) is allowed if measurable disease remains outside of the treated area or if there is documented disease progression in a treated site. Prior liver-directed or other ablative treatment must be completed at least 28 days prior to registration.
• Prior treatment with 90-Yttrium radioembolization must be completed at least 6 months prior to registration.
• Radiation therapy (conventional fractionated or stereotactic ablative) to the lung and/or mediastinum must be completed at least 28 days prior to registration.
• Prior treatment with systemic anticancer therapy must be completed at least 28 days prior to registration (except for somatostatin analogs in patients with functional tumors). Continuation of treatment with somatostatin analogs while on protocol therapy is allowed provided that the patient:
  • Has functional tumors (evidence of peptide hormones and/or bioactive substances associated with a clinical hormone syndrome such as carcinoid syndrome or Cushing's syndrome);
  • Has been on a stable dose of somatostatin analog therapy for at least three months;
  • Has previously demonstrated radiographic disease progression while on somatostatin analog therapy.
• Patients must have completed any major surgery at least 28 days prior to registration. Complete wound healing from major surgery should occur prior to registration.
• Patients should have improvement of any toxic effects of prior therapy (except alopecia, fatigue, and other non-reversible toxic effects such as neuropathy from cisplatin) to National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), version 5.0, grade 1 or less.
• Not pregnant and not nursing, because this study involves:
  • An investigational agent whose genotoxic, mutagenic, and teratogenic effects on the developing fetus and newborn are unknown;
  • An agent that has known genotoxic, mutagenic, and teratogenic effects.
  • Therefore, for women of childbearing potential only, a negative pregnancy test done ≤ 14 days prior to registration is required.
• Age ≥ 18 years.
• Eastern Cooperative Oncology Group (ECOG) performance status 0-2.
• Hemoglobin ≥ 8.0 g/dL.
• Platelet count ≥ 75,000/mm^3.
• Absolute neutrophil count (ANC) ≥ 1,500/mm^3.
• Creatinine ≤ 1.5 x upper limit of normal (ULN) OR calculated creatinine clearance ≥ 40 mL/min.
• Calculated by the Cockcroft-Gault equation -ION:
• Total bilirubin ≤ 2.0 x ULN.
• In patients with Gilbert's syndrome, if total bilirubin is > 2.0 x ULN, then direct bilirubin must be =< 2.0 x ULN.
• Albumin ≥ 2.8 g/dL.
• Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 3.0 x ULN.
• No known central nervous system metastases unless adequately treated, stable, and off steroid support for at least 14 days prior to registration.
• No other currently active malignancy that requires therapy or is expected to require therapy during the study (excluding non-melanoma skin cancers or in situ carcinomas, such as breast or cervical).
• No uncontrolled diabetes mellitus, defined as fasting glucose > 200 mg/dL, despite optimal medical therapy.
• No known uncontrolled hypercholesterolemia (defined as fasting cholesterol > 300 mg/dL OR > 7.75 mmol/L) or hypertriglyceridemia (defined as fasting triglycerides > 2.5 x ULN), despite optimal medical therapy -
• No known active hepatitis B (defined as hepatitis B surface antigen [HbsAg] reactive) or known active hepatitis C virus (defined as hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] is detected) Patients with human immunodeficiency virus (HIV) positivity are allowed if CD4 count > 500 cells/uL.
• No known active or uncontrolled infections requiring ongoing antifungals or antibiotics in the 3 days prior to registration.
• No receipt of live attenuated vaccines in the 7 days prior to registration.
• No known liver cirrhosis.
• No known prior drug-induced pneumonitis that was symptomatic or required treatment
• No known medical condition causing an inability to swallow and no known impairment of gastrointestinal function that may significantly alter the absorption of an oral agent.
• No known hypersensitivity to everolimus or other rapamycin analogs (e.g., sirolimus, temsirolimus, etc.).
• Concurrent somatostatin analog use while on protocol therapy is allowed provided that the patient:
  • has a functional tumor (evidence of peptide hormones and/or bioactive substances associated with a clinical hormone syndrome such as carcinoid syndrome or Cushing's syndrome);
  • has been on a stable dose of somatostatin analog therapy for at least three months;
  • has previously demonstrated radiographic disease progression while on somatostatin analog therapy. For subjects receiving lutetium Lu 177 dotatate, there should be a minimum of 14 days between long-acting somatostatin analogue and lutetium Lu 177 dotatate dosing. Short-acting somatostatin analogs should not be administered within 24 hours of lutetium Lu 177 dotatate dosing. Following lutetium Lu 177 dotatate dosing, long-acting somatostatin analogs may be administered between 4 and 24 hours after each dose.
• Chronic concomitant treatment with strong inhibitors or inducers of CYP3A4 is not allowed on this study. Patients on strong inhibitors or inducers of CYP3A4 must discontinue the drug(s) 7 days prior to registration.
• Chronic concomitant treatment with strong inhibitors or inducers of P-glycoprotein (PgP) is not allowed on this study. Patients on strong inhibitors or inducers of PgP must discontinue the drug(s) 7 days prior to registration.

RE-REGISTRATION:

• Confirmation of disease progression by RECIST v1.1 by real-time Alliance ICL at IROC Ohio central radiographic review.
• Not pregnant and not nursing.
• Therefore, for women of childbearing potential only, a negative pregnancy test done ≤ 14 days prior to re-registration is required.
• ECOG performance status 0-2.
• Hemoglobin ≥ 8.0 g/dL.
• Platelet count ≥ 75,000/mm^3.
• Absolute neutrophil count (ANC) ≥ 1,500/mm^3.
• Creatinine ≤ 1.5 x upper limit of normal (ULN) OR calculated creatinine clearance ≥ 40 mL/min.
• Calculated by the Cockcroft-Gault equation.
• Total bilirubin ≤ 2.0 x ULN.
• In patients with Gilbert's syndrome, if total bilirubin is > 2.0 x ULN, then direct bilirubin must be ≤ 2.0 x ULN.
• Albumin ≥ 2.8 g/dL.
• AST/ALT ≤ 3.0 x ULN.

Eligibility last updated 1/17/22. Questions regarding updates should be directed to the study team contact.