Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors - CAM 60160

Description
Radiopharmaceuticals are composed of a radioisotope bond to an organic molecule and are used for diagnostic and therapeutic purposes. The organic molecule conveys the radioisotope to specific organs, tissues, or cells. Lutetium 177 (Lu 177) dotatate, classified as peptide receptor radionuclide therapy, is a radiolabeled-somatostatin analogue that binds to somatostatin receptor expressing cells, including malignant somatostatin receptor-positive tumors such as neuroendocrine tumors. It is then internalized and beta particle emission from Lu 177 induces cellular damage by formation of free radicals in somatostatin receptor-positive and neighboring cells. Similar to Lu 177, iobenguane I 131 is a radioactive therapeutic agent, which is similar in structure to norepinephrine. Due to its structural similarity with norepinephrine, iobenguane is taken up by the norepinephrine transporter where it accumulates in adrenergically innervated tissues including pheochromocytoma and paraganglioma cells. The beta and gamma radiation resulting from the radioactive decay causes an anti-tumor affect.

For individuals with a treatment-refractory gastroenteropancreatic neuroendocrine tumor including foregut, midgut, and hindgut tumors who receive Lu 177 dotatate, the evidence includes a randomized, open-labeled trial and a retrospective cohort study. The relevant outcomes are overall survival (OS), disease-specific survival, quality of life, and treatment-related mortality and morbidity. The randomized controlled trial results showed a consistent statistically significant and clinically meaningful effect on overall response rate, progression-free survival, and overall survival among patients treated with Lu 177 dotatate compared to those treated with long-acting octreotide. The results of the retrospective cohort study were consistent with the treatment effect observed in the randomized controlled trial and provide additional support for a clinical benefit of Lu 177 dotatate in patients with a gastroenteropancreatic neuroendocrine tumor. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with a treatment-refractory bronchopulmonary or thymus neuroendocrine tumors who receive Lu 177 dotatate, the evidence includes a retrospective cohort study. The relevant outcomes are OS, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The retrospective cohort study included a small number of patients with bronchopulmonary (n = 23) or thymus (n = 2) neuroendocrine tumors. Among the 23 patients with bronchopulmonary neuroendocrine tumor, the median progression-free survival was 20 months, the median time to progression was 25 months, and median overall survival was 52 months. Stratified results of two patients with thymus neuroendocrine tumors were not reported. The Food and Drug Administration in its review of the ERASMUS study for patients with gastroenteropancreatic neuroendocrine tumor concluded that time to event analyses such as time to progression, progression-free survival, and OS were not interpretable in the context of the single-arm ERASMUS study because of missing data at baseline, high dropout rates and open-label design of the study. Of note, despite the current evidence base, National Comprehensive Cancer Network guidelines give a category 2A recommendation for use of Lu 177 dotatate for the treatment of bronchopulmonary and thymic locoregional advanced or distant metastases neuroendocrine tumors if there are clinically significant tumor burden and low grade (typical) or evidence of progression or intermediate grade (atypical). The evidence is insufficient to determine the effects of technology on health outcomes.

For individuals with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy and who receive iobenguane I 131, the evidence includes a single-arm prospective cohort study. The relevant outcomes include OS, disease-specific survival, quality of life, treatment-related mortality and morbidity. The pivotal study reported that 25% of patients (95% confidence interval 16.2% to 36.5%) met the primary endpoint of reduction in antihypertensive medication of at least 50% for at least 6 months along with 22.1% of patients having a confirmed, centrally reviewed partial response (95% confidence interval: 13.6% to 32.7%). Of these, 53% of patients who responded to therapy maintained a duration of response for at least 6 months. The single-arm nature of the trial prevents adequate interpretation of the results of time to event endpoint of OS which was a secondary endpoint of the trial. Given the severity and rarity of the disease condition with an associated high degree of morbidity and mortality, especially in metastatic disease, these outcomes represents a clinically meaningful benefit for patients. As with all other radiopharmaceuticals, iobenguane I 131 is associated with an increased risk for secondary hematologic malignancy including myelodysplastic syndrome or acute leukemias. Due to the risk of serious adverse reactions, iobenguane I 131 is only indicated for patients with unresectable, locally advanced or metastatic paraganglioma who require systemic anticancer therapy and have no other known curative options. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.

Background
Neuroendocrine Tumors
Neuroendocrine tumors are a heterogeneous group of tumors that originate from the neuroendocrine cells in the diffuse neuroendocrine system anywhere in the body but more commonly in the gastrointestinal tract and the respiratory system. Approximately 61% of all neuroendocrine tumors originate from the gastrointestinal system or pancreas and are referred to as gastroenteropancreatic neuroendocrine tumors. Gastroenteropancreatic neuroendocrine tumors may further be characterized as functional or nonfunctional based on whether they secrete hormones that result in clinical symptoms particularly serotonin, which results in "carcinoid syndrome" that is characterized by flushing and diarrhea. Lung neuroendocrine tumors may also be referred to as pulmonary neuroendocrine tumors, pulmonary carcinoids, or bronchopulmonary neuroendocrine tumors. Bronchopulmonary neuroendocrine tumors comprise approximately 20% of all lung cancers and are classified into 4 subgroups: typical carcinoid tumor, atypical carcinoid tumor, large-cell neuroendocrine carcinoma, and small-cell lung carcinoma.¹ Less than 5% of bronchopulmonary neuroendocrine tumors exhibit hormonally-related symptoms such as carcinoid syndrome. Neuroendocrine tumors of the thymus account for only 5% of all tumors in the thymus and mediastinum.²

Neuroendocrine tumors are classified as orphan diseases by the U.S. Food and Drug Administration (FDA). Based on an analysis of Surveillance, Epidemiology, and End Results Program registry data from 1973 to 2012, the overall incidence of neuroendocrine tumors has been reported to be in the range of 6.98 per 100,000 people per year.³

Diagnosis
Neuroendocrine tumors are not easy to diagnose because of the rarity of the condition. Symptoms are often nonspecific or mimic other disorders such as irritable bowel syndrome (in the case of gastroenteropancreatic neuroendocrine tumors) or asthma (in the case of a lung neuroendocrine tumors) resulting in an average diagnosis delay of 5 to 7 years after symptom onset.⁴ In many cases, diagnosis is incidental to imaging for other unrelated causes. Most gastroenteropancreatic neuroendocrine tumors express somatostatin receptors that can be imaged using a radiolabeled form of the somatostatin analogue octreotide (e.g., 111In pentetreotide).

Treatment Approach
There is a general lack of prospective data to guide the treatment of neuroendocrine tumors. Gastroenteropancreatic neuroendocrine tumors are chemotherapy-responsive neoplasms, and platinum-based chemotherapy represents the backbone of treatment for both early and advanced-stage tumors.⁵ Surgery alone or followed by chemotherapy along with treatment of hormone-related symptoms may be the initial approach for localized disease. For asymptomatic patients with slow progression, observation with routine surveillance imaging is an option. The prognosis for patients with metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors is highly variable. The median overall survival (from diagnosis) for patients with metastatic pancreatic neuroendocrine tumors has been reported to range from 2 to 5.8 years,⁶ while the median overall survival for small bowel neuroendocrine tumors has been reported as 7.9 years.⁷

Pharmacologic Treatment
First-Line Treatment Options
Somatostatin Analogues (Octreotide and Lanreotide)
Somatostatin is a peptide that binds to somatostatin receptors that are expressed in a majority of carcinoid tumors and inhibits the secretion of a broad range of hormones. Somatostatin analogues (eg, octreotide, lanreotide) were initially developed to manage the hormonal symptoms related to neuroendocrine tumors; they were found to exert antiproliferative activity, and clinical studies have demonstrated prolonged progression-free survival (PFS) in patients with neuroendocrine tumors treated with somatostatin analogues.^8,9 However, the role of somatostatin analogues in patients with nonfunctioning neuroendocrine tumors is unclear.¹⁰

Commercially available long-acting release forms of octreotide and lanreotide (e.g., Sandostatin LAR, Somatuline Depot), which are administered intramuscularly on a monthly basis, have largely eliminated the need for daily self-injection of short-acting subcutaneous formulations.^11,12

Second-Line Treatment Options
Currently, there are no data to support a specific sequence of therapies and only streptozocin, everolimus, and sunitinib are FDA approved for the treatment of pancreatic neuroendocrine tumors.

Mechanistic Target of Rapamycin Inhibitors
The mechanistic target of rapamycin is an enzyme that regulates cell metabolism and proliferation in response to environmental stimuli. It is upregulated in a variety of malignancies in response to stimulation by growth factors and cytokines. Whole-exome genomic analysis has shown that approximately 15% of pancreatic neuroendocrine tumors are associated with somatic variants in genes associated with the mechanistic target of rapamycin pathway.¹³ Everolimus, an oral mechanistic target of rapamycin inhibitor, has been shown to significantly prolong PFS versus placebo in patients with pancreatic neuroendocrine tumors (RADIANT-3 trial),¹⁴ and lung and gastrointestinal neuroendocrine tumors nonfunctional (RADIANT-4 trial).¹⁵ Note that everolimus is approved by the FDA for adults with progressive neuroendocrine tumors of pancreatic origin and adults with progressive, well-differentiated, nonfunctional neuroendocrine tumors of gastrointestinal or lung origin that are unresectable, locally advanced or metastatic. The RADIANT-2 trial, conducted in patients with progressive advanced neuroendocrine tumors associated with carcinoid syndrome, failed to show a statistically significant improvement in the primary endpoint of PFS.¹⁶

Tyrosine Kinase Receptor Inhibitors
Neuroendocrine tumors frequently overexpress the vascular endothelial growth factor and receptor. Sunitinib is a multi-targeted tyrosine kinase inhibitor that targets multiple signaling pathways and growth factors and receptors including vascular endothelial growth factor and receptor 1, 2, and 3.¹³ It has been shown that daily sunitinib at a dose of 37.5 mg improves PFS, overall survival, and the overall response rate as compared with placebo among patients with advanced pancreatic neuroendocrine tumors.¹⁷ Note that sunitinib is FDA approved for the treatment of progressive, well-differentiated pancreatic neuroendocrine tumors in patients with unresectable locally advanced or metastatic disease.

Chemotherapy
Response to chemotherapy for advanced neuroendocrine tumors of the gastrointestinal tract and lung is highly variable and, at best, modest. Tumor response rates are generally low and no PFS benefit has been clearly demonstrated. Therefore, the careful selection of patients is critical to maximize the chance of response and avoid unnecessary toxicity. In advanced neuroendocrine tumors, platinum-based regimens are generally used. They include cisplatin and etoposide (most widely used), carboplatin and etoposide, 5-fluorouracil, capecitabine, dacarbazine, oxaliplatin, streptozocin, and temozolomide.¹⁸

Peptide Receptor Radionuclide Therapy: Lutetium 177 Dotatate
Lutetium 177 dotatate is a radiolabeled-somatostatin analogue that binds to somatostatin receptor expressing cells, including malignant somatostatin receptor-positive tumors. It is then internalized and beta particle emission from lutetium 177 induces cellular damage by formation of free radicals in somatostatin receptor-positive and neighboring cells.

Pheochromocytoma and Paraganglioma
Pheochromocytoma and paraganglioma are rare neuroendocrine tumors that originate from the chromaffin cells of the adrenal glands.¹⁹ Chromaffin cells produce catecholamine neurotransmitters, such as epinephrine, norepinephrine, and dopamine. Compared to the normal chromaffin cells, pheochromocytomas and paraganglioma express high levels of the norepinephrine transporter on their cell surfaces. The excess amount of norepinephrine causes the clinical signs and symptoms like hypertension, headache, sweating, tremor, and palpitation. While most pheochromocytoma and paraganglioma are non-malignant (non-metastatic), about 10% of pheochromocytoma are malignant and about 25% of paraganglioma are malignant (metastatic) which can spread to other parts of the body, such as the liver, lungs, bone, or distant lymph nodes.²⁰

The average age of diagnosis is 43 years old. The estimated annual incidence of pheochromocytoma and paraganglioma is approximately 1 in 300,000 population.²¹ The 5-year mortality rates for patients with metastatic pheochromocytoma and paraganglioma has been reported as 37% depending on the primary tumor site and sites of metastases.²² In addition, the medical overall and disease-specific survival were 24.6 and 33.7 years for pheochromocytoma and paraganglioma.²³

Diagnosis
The initial diagnosis of pheochromocytomas and paragangliomas includes biochemical testing, such as blood tests and urinalysis which measure the levels of metanephrine, a catecholamine metabolite in blood and urine. Imaging may be used to detect the location and size of tumors within the organs or tissues. Other advanced diagnostic procedures, such as 123I-metaiodobenzylguanidine (MIBG) scintigraphy, octreotide scan, and fluorodeoxyglucose-positron emission tomography scan are used to further determine whether the tumors are malignant and metastatic.¹⁹

Certain genetic disorders such as multiple endocrine neoplasia 2 syndrome, von Hippel-Lindau syndrome, Neurofibromatosis type 1, and hereditary paraganglioma syndrome²⁴ are considered risk factors for pheochromocytomas and paragangliomas and therefore genetic testing is recommended for all patients with pheochromocytoma or paraganglioma.¹⁹

Treatment Approach
Surgical resection is mostly reserved for benign tumors as curative surgical resection is nearly impossible in metastatic disease. For patients with local, unresectable disease, palliative external beam radiotherapy may be used with or without cytoreductive resection for patients with bone metastases.²⁵

Peptide Receptor Radionuclide Therapy: Iobenguane I 131
Prior to the approval of Iobenguane I 131, there were no FDA approved therapies for this indication. Radiotherapy options include off-label use of I 131-metaiodobenzylguanidine (131I-MIBG) for patients with MIBG-positive tumors.¹⁹131I-MIBG contains radioactive iodine and the compound is structurally similar to norepinephrine.²⁶ When 131I-MIBG is delivered to the target tissue, it gives off beta-radiation, killing neuroendocrine tumors. Due to the nature of the radiopharmaceutical mechanism of action, 131I-MIBG can cause toxicities including nausea, vomiting, anemia, leukocytopenia, and thrombocytopenia.²⁷ There is limited evidence for chemotherapy. In the case of unresectable progressive pheochromocytoma or paraganglioma, combination use of cyclophosphamide, dacarbazine, vincristine, doxorubicin, temozolomide, and thalidomide have been used.^28,29] Tyrosine kinase receptor inhibitors such as sunitinib have also been used.³⁰

Regulatory Status
On Jan. 26, 2018, Lutathera^® (lutetium 177 dotatate) was approved by the FDA for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors, including foregut, midgut, and hindgut neuroendocrine tumors in adults.

On July 30, 2018, AZEDRA (iobenguane I 131) injection was approved by the FDA for the treatment of adult and pediatric patient's age 12 years and older with iobenguane scan positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy.

Policy
Lutetium 177
Initial Treatment
Lutetium 177 (Lu 177) dotatate treatment is considered medically necessary when conditions 1 through 8 are met:

Patient is an adult (≥ 18 years of age).
Patient has documented low or intermediate grade (Ki-67 index ≤ 20%), locally advanced or metastatic, gastroenteropancreatic (including foregut, midgut, and hindgut) or bronchopulmonary or thymus neuroendocrine tumor.
Patient has documented somatostatin receptor expression of a neuroendocrine tumor as detected by somatostatin receptor-based imaging (⁶⁸Ga-dotate positron emission tomography or computed tomography, which is preferred) or somatostatin receptor scintigraphy.
Patient has documented disease progression while on octreotide long-acting release therapy.
Patient is not receiving long-acting somatostatin analogues for at least 4 weeks prior to initiating Lu 177 dotatate.
Patients does not have severe renal impairment (creatinine clearance, < 30 mL/min).
Patient has adequate bone marrow and hepatic function as determined by the treating physician.
Patient has documented Karnofsky Performance Status score of 60 or greater.

Continuation of Treatment
Continuation of Lu 177 dotatate is considered MEDICALLY NECESSARY when conditions 1 through 5 are met:

No recurrent grade 2, 3, or 4 thrombocytopenia (see Table PG1).
No recurrent grade 3 or 4 anemia and neutropenia (see Table PG1).
No recurrent hepatotoxicity (see definition of hepatotoxicity in the Policy Guidelines section).
No recurrent grade 3 or 4 nonhematologic toxicity (see Table PG1).
No renal toxicity requiring a treatment delay of 16 weeks or longer (see definition of renal toxicity in the Policy Guidelines section).

Lu 177 dotatate treatment is investigationaland/ or unproven therefore considered NOT MEDICALLY NECESSARY in all other situations in which the above criteria are not met.

Lu 177 dotatate treatment greater than a total of 4 doses as per the Food and Drug Administration-approved regimen is investigational and or/unproven therefore considered NOT MEDICALLY NECESSARY.

Iobenguane I 131
Iobenguane I 131 is considered MEDICALLY NECESSARY when conditions 1 through 5 are met:

Patient has documented iobenguane scan positive, locally advanced or metastatic pheochromocytoma and paraganglioma.
Patient is 12 years or older.
Patient has progressed on prior therapy for pheochromocytoma or paraganglioma OR is not a candidate for chemotherapy.
Patient does not have severe renal impairment (creatinine clearance < 30 mL/min).
Patient has platelet count greater than 80,000/mcL OR absolute neutrophil count greater than 1,200/mcL.

Iobenguane I 131 treatment is investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY for all other indications including neuroblastoma and gastroenteropancreatic neuroendocrine tumors.

Use of iobenguane I 131 not in accordance with FDA-approved dosing (first dosimetric dose followed by two therapeutic doses administered 90 days apart) is investigational and or/unproven and therefore considered NOT MEDICALLY NECESSARY. See policy guidelines below.

Policy Guidelines
Somatostatin Receptor-Based Imaging
Preferred somatostatin receptor (SSTR)-based imaging options to assess receptor status include SSTR-positron emission tomography (PET)/computed tomography (CT) or SSTR-PET/magnetic resonance imaging (MRI). Octreotide single-photon emission computed tomography (SPECT)/CT may be used only if SSTR-PET is not available, as it is much less sensitive for defining SSTR-positive disease. Appropriate SSTR-PET radiotracers include Gallium 68 (Ga 68) dotatate, Ga 68 dotatoc, or Copper 64 (Cu 64) dotatate. SSTR-positive status is confirmed when uptake in measurable lesions is greater than the liver.

Lutetium 177
The recommended dose of lutetium 177 (Lu 177) dotatate is 7.4 GBq (200 mCi) every 8 weeks for a total of 4 doses.

There are theoretical concerns regarding the competition between somatostatin analogues and Lu 177 dotatate for somatostatin receptor binding. Therefore, the following is recommended

Do not administer long-acting somatostatin analogues for 4 to 6 weeks prior to each Lu 177 dotatate treatment.
Stop short-acting somatostatin analogues 24 hours before each Lu 177 dotatate treatment.
Both long-acting and short-acting somatostatin analogues can be resumed 4 to 24 hours after each Lu 177 dotatate treatment.

Lu 177 dotatate is a radiopharmaceutical and should be used by or under the control of physicians who are qualified by specific training and experience in the safe use and handling of radiopharmaceuticals, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radiopharmaceuticals.

Lu 177 dotatate should be discontinued permanently if the patient develops hepatotoxicity defined as bilirubinemia greater than 3 times the upper limit of normal (grade 3 or 4), or hypoalbuminemia less than 30 g/L with a decreased prothrombin ratio less than 70%.

Lu 177 dotatate should be discontinued permanently if patient develops renal toxicity defined as a creatinine clearance of less than 40 mL/min calculated using Cockcroft-Gault equation with actual body weight, or 40% increase in baseline serum creatinine, or 40% decrease in baseline creatinine clearance calculated using Cockcroft-Gault equation with actual body weight.

Table PG1 describes the grading of severity used in the Common Toxicity Criteria for Adverse Events (version 4.03).

Table PG1. Common Toxicity Criteria for Adverse Events, Version 4.03

Grade	Description
1	Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated.
2	Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental activities of daily living and refer to preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc.
3	Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care activities of daily living and refer to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden.
4	Life-threatening consequences; urgent intervention indicated.
5	Death related to adverse event.

Iobenguane I 131

Iobenguane I 131 is administered intravenously as a dosimetric dose followed by 2 therapeutic doses administered 90 days apart.
- The recommended dosimetric dose is 185 to 222 MBq (5 to 6 mCi) in patients greater than 50 kg and 3.7 MBq/kg (0.1 mCi/kg) in patients 50 kg or less.
- The recommended therapeutic dose is 18,500 MBq (500 mCi) in patients greater than 62.5 kg and 296 MBq/kg (8 mCi/kg) in patients 62.5 kg or less.
Thyroid-blocking medications should be given prior to administration and after each dose.
Iobenguane I 131 is a radiopharmaceutical and should be used by or under the control of physicians who are qualified by specific training and experience in the safe use and handling of radiopharmaceuticals, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radiopharmaceuticals.
Iobenguane I 131 should be discontinued if:
- Platelet count is less than 80,000 mcL or absolute neutrophil count (ANC) is less than 1,200/mcL.
- Individual has liver dysfunction defined as aspartate aminotransferase or alanine aminotransferase ≥ 2.5 times the upper limit of normal or total bilirubin > 1.5 times the upper limit of normal or develops liver disease (including hepatitis and chronic alcohol abuse).
- Individual develops renal toxicity defined as a creatinine clearance of < 30 mL/min.

Coding
See the Codes table for details.

Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., Federal Employee Program) may dictate that certain U.S. Food and Drug Administration-approved devices, drugs, or biologics may not be considered investigational, and, thus, these devices may be assessed only by their medical necessity.

Rationale
Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function-including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Gastroenteropancreatic Neuroendocrine Tumors including Foregut, Midgut, and Hindgut Tumors
Clinical Context and Therapy Purpose
The purpose of lutetium 177 (Lu 177) dotatate in patients with locally advanced or metastatic somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumor who have progressed on first-line somatostatin analogues is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does Lu 177 dotatate improve the net health outcome in patients with treatment-refractory gastroenteropancreatic neuroendocrine tumors?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is patients with inoperable locally advanced or metastatic somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumor who have progressed on first-line somatostatin analogues.

Interventions
The therapy being considered is Lu 177 dotatate.

Comparators
The following practices (listed alphabetically with no preference) that are currently being used as second-line treatment options for patients who have progressed on first-line somatostatin analogues include: cytotoxic chemotherapy (e.g., 5-fluorouracil, capecitabine, dacarbazine, oxaliplatin, streptozocin, temozolomide), everolimus, hepatic-directed therapy (e.g., arterial embolization, hepatic chemoembolization, hepatic radioembolization, cytoreductive surgery/ablative therapies) for hepatic predominant disease, interferon alfa-2b, and radiotherapy.

Outcomes
The general outcomes of interest are overall survival (OS), median progression-free survival (PFS), and adverse events. In general, acute short-term safety outcomes occurring as a consequence of radiation include monitoring for lymphopenia, vomiting, nausea, increased aspartate aminotransferase, increased alanine aminotransferase, hyperglycemia, and hypokalemia; long-term chronic toxicities that require monitoring are amyelodysplastic syndrome, renal failure, and leukemia.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Randomized Controlled Trials
The evidence for use of Lu 177 dotatate for patients in midgut carcinoid tumors consists of the open-label NETTER-1 RCT (NCT01578239) and in patients with gastroenteropancreatic neuroendocrine tumors consists of the retrospective cohort ERASMUS study. Results of the NETTER-1 study were originally published by Strosberg et al. (2017).³² However, the U.S. Food and Drug Administration (FDA) reviewed updated results and therefore data for the NETTER-1 study reported herein are based on the FDA documents^33,34and not the published study.³² Similarly, results of the ERASMUS study were published by Kwekkeboom et al. (2008)³⁵ and by Brabander et al. (2017).³⁶ However, the 2017 published results included efficacy data for 443 patients with gastroenteropancreatic and bronchopulmonary and thymus neuroendocrine tumors. In its review, the FDA only assessed data for 360 patients with gastroenteropancreatic neuroendocrine tumors and therefore data for ERASMUS study reported herein are based on the FDA documents^33,34 and not the published studies.^36,35 Study characteristics and results are summarized in Tables 1 and 2.

In the NETTER-1 trial, patients with Ki-67 index of 20% or less (a grading parameter for neuroendocrine tumors index), Karnofsky Performance Status score of 60 or greater, confirmed presence of somatostatin receptors on all lesions (octreoscan uptake ≥ normal liver) and creatinine clearance of 50 mL/min or greater were included. Randomization was stratified by octreoscan tumor uptake score (grade 2, 3 or 4) and the length of time that patients had been on the most recent constant dose of octreotide prior to randomization (≤ 6 or > 6 months). The major efficacy outcome measure was PFS as determined by a blinded independent radiology committee per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 criteria. Additional efficacy outcome measures were overall response rate assessed by an independent review committee, duration of response, and OS. The result showed a consistent statistically significant and clinically meaningful effect on overall response rate, PFS, and OS among patients given Lu 177 dotatate compared with those given high-dose long-acting octreotide.

Table 1. Summary of Key RCT Characteristics

Trial	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
NETTER-1^33,³⁴	Belgium, France, Germany, Italy, Portugal, Spain, U.S.	41	2012 – 2016	Adults with metastasized or locally advanced, inoperable, histologically confirmed, progressive midgut NETs	116 patients given Lu 177 dotatate 7.4 GBq (200 mCi) every 8 wk for up to 4 administrations plus long-acting octreotide 30 mg 4 – 24 h after each Lu 177 dotatate dose and every 4 wk after completion of Lu 177 dotatate treatment until disease progression or week 76 of the trial	113 patients given long-acting octreotide (60 mg every 4 wk)

Lu 177: lutetium 177; NET: neuroendocrine tumor; RCT: randomized controlled trial.

Table 2. Summary of Key RCT Results

Trial	Median PFS (95% CI), months	Median OS (95% CI), months	ORR (95% CI), %	CR (95% CI), %	PR (95% CI), %	Median DOR (95% CI), months
NETTER-1^33,³⁴
N	229	229	229	229	229
Lu 177 dotatate	NR (NE)^a	NR (31.0 to NE)	13 (7 to 19)	1 (1%)	14 (12%)	NR (2.8 to NE)
Control	8.5 (5.8 to 9.1)	27.4 (22.2 to NE)	4 (0.1 to 7)	0	4 (4%)	1.9 (1.9 to NE)
HR (95% CI) or p	0.21 (0.13 to 0.32)	0.52 (0.32 to 0.84)^b	.015	Not reported	Not reported	Not reported

CI: confidence interval; CR: complete response; DOR: duration of response; HR: hazard ratio; Lu 177: lutetium 177; NE: not evaluable; NR: not reached; ORR: overall response rate; OS: overall survival; PFS: progression-free survival; PR: partial response; RCT: randomized controlled trial.
^a Median follow-up 10.5 mo at time of primary analysis of PFS (range, 0 – 29 mo).
^b Interim analysis of OS not statistically significant based on prespecified significance criteria.

The purpose of a limitations assessment is to identify notable limitations detected in each study. This information is synthesized as a summary of the body of evidence and provides the conclusions on the sufficiency of the evidence supporting the position statement. While this limitations analysis is not comprehensive, no notable limitations were identified for studies evaluated in this section.

Retrospective Studies
In the ERASMUS study, 1,214 patients with heterogeneous etiologies in terms of primary tumor site received Lu 177 dotatate as part of expanded access protocol at a single center in the Netherlands. Most patients had gastroenteropancreatic neuroendocrine tumors of the foregut, midgut, and hindgut, as well as the digestive tract, bronchus, and pancreatic neuroendocrine tumors. Other neuroendocrine tumors were also included in the trial, specifically medullary thyroid cancer, pheochromocytoma, paraganglioma, neuroblastoma, and Merkel cell carcinoma. Non-neuroendocrine somatostatin receptor-positive tumors including melanoma, nondifferentiated thyroid cancers, non-small-cell lung cancer, breast cancer, lymphoma, and malignant meningioma were also treated. From this heterogeneous cohort, 601 patients were assessed per RECIST criteria of whom 360 with foregut, midgut, or hindgut gastroenteropancreatic neuroendocrine tumors were retrospectively identified and analyzed. The major efficacy outcome was investigator-assessed overall response rate. Fifty-five percent of patients received a concomitant somatostatin analogue. Study characteristics and results are summarized in Tables 3 and 4.

In this cohort of 360 patients, the investigator-assessed overall response rate was 16% and the median duration of response was 35 months among 58 responders. The FDA did not view time to event analyses such as time to progression, PFS, and OS to be interpretable in the context of the single-arm ERASMUS study because of missing data at baseline, high dropout rates, and the open-label design of the study. However, the FDA considered that "these data provide statistically conservative estimates that were verifiable and are clinically meaningful for patients with gastroenteropancreatic neuroendocrine tumors. The results provide additional support for the indicated population that are consistent with the observed benefit in other populations of patients with the disease (ie, in NETTER-1), the biology of the disease itself, the mechanism of action of Lu 177 dotatate, and the limited treatment options available for these patients."

Table 3. Summary of Key Nonrandomized Trials Characteristics

Trial	Study Type	Country	Dates	Participants	Treatment	Follow-Up
ERASMUS Study^33,³⁴	Retrospective cohort	Netherlands	2000 – 2012	Patients with somatostatin-positive GEP-NETs with a life expectancy of > 12 wk and Karnofsky Performance Scale score ≥ 50	360 patients given Lu 177 dotatate 7.4 GBq (200 mCi) every 6 – 13 wk for up to 4 doses	34.8 months

GEP-NET: gastroenteropancreatic neuroendocrine tumor; Lu 177: lutetium 177.

Table 4. Summary of Key Nonrandomized Trial Results

Study	Median Duration of Response (95% CI), months	Overall Response Rate (95% CI), %
ERASMUS Study^33,³⁴
N	360	360
Lu 177 dotatate	35 (17 to 38)	16 (13 to 21)

CI: confidence interval; Lu 177: lutetium 177.

The purpose of the limitations tables (see Tables 5 and 6) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

Table 5. Study Relevance Limitations

Trial	Population^a	Intervention^b	Comparator^c	Outcomes^d	Follow-Up^e
ERASMUS Study^33,³⁴			2. This was a single cohort study. There was no comparator.	2.Investigator-assessed ORR not a validated surrogate outcome measure

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
ORR: overall response rate.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 6. Study Design and Conduct Limitations

Trial	Allocation^a	Blinding^b	Selective Reporting^c	Data Completeness ^d	Power^e	Statistical^f
NETTER-1^33,³⁴	1. Participants not randomly allocated because design was a retrospective single cohort study	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician		1. Baseline tumor assessments obtained for only 578/1,214 (48%) of patients	2. FDA noted that protocol along with a statistical analysis plan was retrospectively generated

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
FDA: U.S. Food and Drug Administration.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Section Summary: Gastroenteropancreatic Neuroendocrine Tumors Including Foregut, Midgut, and Hindgut Tumors
The evidence for use of Lu 177 dotatate consists of an open-labeled RCT and a retrospective cohort study. The RCT results showed a consistent statistically significant and clinically meaningful effect on overall response rate, PFS, and OS among patients treated with Lu 177 dotatate compared to those treated with long-acting octreotide. The results of the retrospective cohort study were consistent with the treatment effect observed in the RCT and provide additional support for a clinical benefit of Lu 177 dotatate in patients with gastroenteropancreatic neuroendocrine tumors.

Bronchopulmonary or Thymus Neuroendocrine Tumors
Clinical Context and Therapy Purpose
The purpose of Lu 177 dotatate in patients with a bronchopulmonary or thymus somatostatin receptor-positive neuroendocrine tumor who have progressed on first-line somatostatin analogues is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does Lu 177 dotatate improve the net health outcome in patients with treatment-refractory bronchopulmonary or thymus somatostatin receptor-positive neuroendocrine tumor?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is patients with locally advanced or metastatic somatostatin receptor-positive bronchopulmonary or thymus neuroendocrine tumor who have progressed on first-line somatostatin analogues. Bronchopulmonary neuroendocrine tumors comprise approximately 20% of all lung cancers.¹ Neuroendocrine tumors of the thymus account for only 5% of all tumors in the thymus and mediastinum.²

Interventions
The therapy being considered is Lu 177 dotatate.

Outcomes
The general outcomes of interest are OS, median PFS, and adverse events. In general, acute short-term safety outcomes occurring as a consequence of radiation include monitoring for lymphopenia, vomiting, nausea, increased aspartate aminotransferase, increased alanine aminotransferase, hyperglycemia, and hypokalemia; long-term chronic toxicities that require monitoring include myelodysplastic syndrome, renal failure, and leukemia.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Retrospective Studies
The evidence for use of Lu 177 dotatate in patients with bronchopulmonary or thymus neuroendocrine tumors consists of the retrospective ERASMUS cohort study and a bicenter, retrospective case series.^36,37 The ERASMUS study design and characteristics are described in the previous section. Unlike the previous indication, where the FDA considered a subset of 360 patients with gastroenteropancreatic neuroendocrine tumors as supportive evidence, the FDA identified multiple problems with ERASMUS data that precluded drawing conclusions about treatment efficacy in patients with bronchopulmonary or thymus neuroendocrine tumors. The FDA concluded that time to event analyses such as time to progression, PFS, and OS were not interpretable in the context of the single-arm ERASMUS study because of missing data at baseline, high dropout rates, and the open-label design of the study.

The ERASMUS study included 23 patients with bronchopulmonary and 2 patients with thymus neuroendocrine tumors.³⁶ Among the 23 patients with bronchopulmonary neuroendocrine tumor, the median PFS was 20 months, the median time to progression was 25 months, and median OS was 52 months. Stratified results of 2 patients with thymus neuroendocrine tumors were not reported.

Zidan et al. (2022) published data from a retrospective case series assessing the efficacy of Lu 177 dotatate in 48 patients with somatostatin receptor-positive lung neuroendocrine tumors treated between 2006 and 2019 at 2 centers in Australia and Israel.³⁷ Median patient age was 64 years. The series included 13 (27%) women and 43 (90%) atypical carcinoid tumors. The majority of patients (98%) were treated for radiographic disease progression, with 1 individual receiving treatment for uncontrolled symptoms. Of 40 patients with RECIST-measurable disease at 3 months, 8 (20%) had a partial response, 27 (68%) had stable disease, and 5 (12%) had disease progression. In 26 patients with RECIST-measurable stable disease, 10 patients were classified as partial response and 1 patient as progressive disease by Gallium 68 (Ga 68) dotatate positron emission tomography (PET)/computed tomography (CT). At a median follow-up of 42 months, the median PFS and OS were 23 months (95% confidence interval [CI], 18 to 28) and 59 months (95% CI, 50 to not reached), respectively.

The purpose of the limitations tables (see Tables 7 and 8) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

Table 7. Study Relevance Limitations

Trial	Population^a	Intervention^b	Comparator^c	Outcomes^d	Follow-Up^e
ERASMUS Study³⁶			2. This was a single cohort study without a comparator	2. Investigator-assessed ORR not a validated surrogate outcome measure
Zidan et al. (2022)³⁷		1. Patients received variable cycles of therapy, with or without radiosensitizing chemotherapy	2. This was a retrospective case series without a comparator	2. Investigator-assessed DCR not a validated surrogate outcome measure

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
DCR: disease control rate; ORR: overall response rate.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 8. Study Design and Conduct Limitations

Trial	Allocation^a	Blinding^b	Selective Reporting^c	Data Completeness ^d	Power^e	Statistical^f
ERASMUS Study³⁶	1. Participants not randomly allocated because design was a retrospective single cohort study	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician		1. Baseline tumor assessments obtained for only 578 (48%) of patients	2. FDA noted that protocol along with statistical analysis plan were retrospectively generated
Zidan et al. (2022)³⁷	1. Participants not randomly allocated because design was retrospective case series	1. Not blinded to treatment assignment 2. Not blinded outcome assessment 3. Outcome assessed by treating physician

Section Summary: Bronchopulmonary or Thymus Neuroendocrine Tumor
The evidence for use of Lu 177 dotatate consists of the retrospective ERASMUS cohort study and a bicenter, retrospective case series.The ERASMUS study included a small number of patients with bronchopulmonary (n = 23) and thymus (n = 2) neuroendocrine tumors. Results for the 2 patients with thymus neuroendocrine tumors were not reported separately. The case series evaluated 48 patients with predominantly atypical carcinoid bronchopulmonary tumors. Across studies, median PFS and OS ranged from 20 to 23 months and 52 to 59 months, respectively. No RCTs were identified.

Safety
In the safety analysis, exposure data from 922 patients who received at least 1 dose of Lu 177 dotatate treated in the NETTER-1 and ERASMUS studies were analyzed.³³ Drug exposure in NETTER-1 was a total of 600 mCi or more of Lu 177 dotatate in 79.3% of patients treated, and 26% of patients received cumulative doses of 800 mCi or more. Seventy-six percent of patients received all 4 planned doses. Dose reductions were reported in 6% of patients and drug discontinuation in 13% of patients. The most common adverse events observed in patients treated with Lu 177 dotatate were nausea (65%), vomiting (53%), fatigue (38%), diarrhea (26%), abdominal pain (26%), and decreased appetite (21%). The most common grade 3 and 4 adverse events with Lu 177 dotatate were lymphopenia (44%), increased gamma-glutamyl transferase (20%) vomiting (7%), nausea and elevated aspartate aminotransferase (5% each), as well as increased alanine aminotransferase, hyperglycemia, and hypokalemia (4% each). In the ERASMUS study, with a median follow-up of more than 4 years, the most serious chronic toxicities reported were myelodysplastic syndrome (2%), renal failure (2%), cardiac failure (2%), acute leukemia (1%), myocardial infarction (1%), and neuroendocrine hormonal crisis (1%).

Pheochromocytoma and Paraganglioma
Clinical Context and Therapy Purpose
The purpose of iobenguane I 131 or Lu 177 dotatate in patients with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does iobenguane I 131 or Lu 177 dotatate improve the net health outcome in patients with unresectable locally advanced or metastatic pheochromocytoma and paraganglioma?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is patients with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma.

Interventions
The therapies being considered are iobenguane I 131 (also known as I 131 MIBG) or Lu 177 dotatate injection. Iobenguane is also known as meta-iodobenzylguanidine (MIBG).

Comparators
The following practices are currently being used to treat unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma: external beam radiation therapy, ablation therapy, transarterial chemoembolization , and chemotherapeutic agents, including cyclophosphamide, dacarbazine, vincristine, doxorubicin, temozolomide, and thalidomide, and sunitinib.

Outcomes
The general outcomes of interest are OS, disease-specific survival, and adverse events. In general, acute short-term safety outcomes occurring as a consequence of radiation include monitoring for lymphopenia, vomiting, nausea, increased aspartate aminotransferase, increased alanine aminotransferase, hyperglycemia, and hypokalemia; long-term chronic toxicities that require monitoring are a myelodysplastic syndrome, renal failure, and leukemia.

Under a special protocol assessment, a new primary endpoint in oncology using reduction in the antihypertensive medication of at least 50% for at least 6 months was used in the iobenguane I 131 pivotal trial.³⁸ This endpoint was considered specifically to measure the antitumor activity of iobenguane I 131 in patients with pheochromocytoma or paraganglioma because hypertension is a key contributor to the disease-associated morbidity and is correlated with decreased tumor activity. Further, evidence that iobenguane I 131 demonstrated anti-tumor activity, and not a merely antihypertensive activity, the primary endpoint was supported by an evaluation of the overall response rate (ORR) by established response criteria (i.e., radiologic response by RECIST).

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Iobenguane I 131
Nonrandomized Studies
The evidence for use of iobenguane I 131 for patients with pheochromocytoma or paraganglioma consists of the multicenter, open-label, single-arm prospective MIP-IB12B (NCT00874614) study that included 74 intention-to-treat participants.³⁸ Study characteristics and results are summarized in Tables 9 and 10.

In the pivotal trial, patients age 12 years and old with a diagnosis of either pheochromocytoma or paraganglioma who were ineligible for curative therapy who failed a prior therapy were included. The primary efficacy outcome measure was the proportion of patients with 50% or greater reduction (including discontinuation) of all antihypertensive medication(s) lasting for at least 6 months after administering the last therapeutic dose of iobenguane I 131. Secondary efficacy outcome measures included best confirmed overall tumor response by RECIST 1.0 including complete response and partial response, changes from baseline in overall quality of life, and OS. A total of 74 patients received the dosimetric dose. Following dosimetry, 68 patients received at least 1 therapeutic dose, and 50 patients received 2 therapeutic doses administered at least 90 days apart. The study period consists of a 12-month efficacy phase and a 4-year long-term follow-up phase. In these heavily pre-treated patients with pheochromocytoma or paraganglioma, 25% of patients met the definition of the primary outcome measure and 22% achieved best overall response as per RECIST among patients given at least 1 therapeutic dose of iobenguane I 131.

Table 9. Summary of Key Nonrandomized Trials Characteristics

Trial	Study Type	Countries	Sites	Dates	Participants	Treatment	Follow-Up
MIP-IB12B [FDA review, Label]^38,³⁹	Single-arm prospective cohort	US	10	June 2009 to February 2021^a	Patients with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma	Iobenguane I 131 (n = 74)	1 year

FDA: U.S. Food and Drug Administration.
^a Estimated study completion date

Table 10. Summary of Key Nonrandomized Trial Results

Trial	Proportion of responders (95% CI)	Proportion with ORR (95% CI)^a	% Responders with duration of response ≥ 6 months
MIP-IB12B [FDA review, Label]^38,³⁹
N	68	68	15
Iobenguanen I 131	25% (16.2 to 37.5%)	22% (14 to 33%)	53%^b

CI: confidence interval; CR: complete response; FDA: U.S. Food and Drug Administration; ORR: overall response rate; PR: partial response.
^a Best confirmed overall tumor response: a response of CR or PR that was confirmed by repeat assessment performed no less than 4 weeks after the criteria for response were first met
^b Median duration of response was 6.5 months

The purpose of a study limitations assessment is to identify notable limitations detected in each study (See Table 11 and 12). This information is synthesized as a summary of the body of evidence and provides the conclusions on the sufficiency of the evidence supporting the position statement. While this study limitation analysis is not comprehensive, no notable limitations were identified for studies evaluated in this section.

Table 11. Study Relevance Limitations

Trial	Population^a	Intervention^b	Comparator^c	Outcomes^d	Follow-Up^e
MIP-IB12B [FDA review, Label]^38,³⁹					1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

FDA: U.S. Food and Drug Administration.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 12. Study Design and Conduct Limitations

Trial	Allocation^a	Blinding^b	Selective Reporting^c	Data Completeness ^d	Power^e	Statistical^f
MIP-IB12B [FDA review, Label]^38,³⁹	1. Participants not randomly allocated 4. Inadequate control for selection bias	1. Not blinded to treatment assignment

FDA: U.S. Food and Drug Administration.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Lu 177 Dotatate
The evidence for the use of Lu 177 dotatate in individuals with pheochromocytoma or paraganglioma consists of a systematic review of single-arm studies and a case series.

Systematic Reviews
Satapathy et al. (2019) published a systematic review and meta-analysis of peptide receptor radionuclide therapy with Lu 177 dotatate and/or Yttrium 90 (Y 90) dotatoc in patients with advanced pheochromocytoma and paraganglioma.⁴⁰ Eleven nonrandomized studies were evaluable for objective response rate and disease control rate, representing 179 patients and 151 patients, respectively. For Lu 177 dotatate, the pooled ORR was 26% (95% CI, 18% to 35%) with a disease control rate of 83% (95% CI, 75% to 90%). In contrast, the pooled ORR and disease control rate for Y 90 dotatoc was 24% (95% CI, 15% to 35%) and 85% (95% CI, 71% to 93%), respectively. Included studies varied in response criteria used and concomitant use of other treatment modalities, such as iobenguane I 131 or radiosensitizing chemotherapy.

Nonrandomized Studies
Severi et al. (2021) assessed the efficacy of Y 90 dotatoc (n = 12) or Lu 177 dotatate (n = 34) in consecutive patients with somatostatin receptor-positive progressive locally advanced or metastatic pheochromocytoma or paraganglioma enrolled across multiple study protocols at a single center in Italy from 2008 to 2018.41, Lu 177 dotatate was administered at dosages of 3.7 or 5.5 GBq/cycle, with lower dosages used in patients with risk factors for bone marrow or renal toxicity. Disease control rate, defined as the sum of partial responses and stable disease, was 82.4% with Lu 177 dotatate and 75% with Y 90 dotatoc after a median follow-up of 73 months. For Lu 177 dotatate, median PFS was not reached and and median OS was 143.5 months (95% CI, 103.1 to 146.2). For Y 90 dotatoc, median PFS was 74.5 months (95% CI, 8.4 to not reached) and median OS was 92.1 months (95% CI, 57.1 to 92.1). A disease control rate of 92% was achieved in patients receiving a full dosage of Lu 177 dotate, compared to 55% in those receiving a reduced dosage. Corresponding median PFS was not reached versus 27.5 months, respectively. Study relevance, design, and conduct limitations are summarized in Tables 13 and 14.

Kong et al. (2017) assessed the efficacy of 177 Lu dotatate in a retrospective analysis of 20 consecutive patients with unresectable paraganglioma or pheochromocytoma and high somatostatin receptor expression.⁴² Fourteen patients were treated for uncontrolled hypertension and 6 were treated for progressive or symptomatic metastatic disease or local recurrence. Nine patients received radiosensitizing chemotherapy. Of 16 patients who received iobenguane scans, 6 had concordant positive uptake, 6 had mild uptake, and 4 had negative scans. Overall, 5 patients had disease regression, with 4 partial RECIST responses and 1 minor morphologic regression observed on CT out of 14 evaluable patients. At 3 months post-treatment, 8/13 patients (62%) required reduced doses of antihypertensive medications compared with baseline. The remaining 5 patients had no change in medication dose but attained symptom control. During a median follow-up of 28 months (range, 5 to 74 months) median OS was not reached (5 deaths) and median PFS was 39 months. During follow-up, 2 patients had tumor progression, 5 patients had recurrence of hypertension, and 2 others were treated with further maintenance therapies for persistent disease with favorable response. The most common toxicity observed was grade 2 lymphopenia. One patient experienced catecholamine crisis following treatment and catecholamine crisis could not be excluded in 1 patient who died from cardiac arrest after a third cycle of treatment. The authors noted that given the favorable efficacy and potential logistic and radiation safety advantages of Lu 177 dotatate compared to iobenguane I 131, further prospective trials are warranted. Patient outcomes were not stratified by iobenguane uptake status. Study relevance, design, and conduct limitations are summarized in Tables 13 and 14.

Table 13. Study Relevance Limitations

Trial	Population^a	Intervention^b	Comparator^c	Outcomes^d	Follow-Up^e
Severi et al. (2021)⁴¹		1. Patients received variable doses of therapy and concomitant use of other treatment modalities was not standardized	2. This was a case series without planned direct comparison to other agents, including Y 90 dotatoc	2. Investigator-assessed DCR not a validated surrogate outcome measure
Kong et al. (2017)⁴²	1. Patients had variable degrees of iobenguane uptake	1. Patients received variable doses of therapy and concomitant use of other treatment modalities was not standardized	2. This was a retrospective study without a comparator	1. Patients outcomes were not stratified by iobenguane uptake status

DCR: disease control rate; Y 90: Yttrium 90.
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 14. Study Design and Conduct Limitations

Trial	Allocation^a	Blinding^b	Selective Reporting^c	Data Completeness^d	Power^e	Statistical^f
Severi et al. (2021)⁴¹	1. Participants not randomly allocated and evaluated across multiple study protocols 4. Inadequate control for selection bias	1. Not blinded to treatment assignment
Kong et al. (2017)⁴²	1. Participants not randomly allocated	1. Not blinded to treatment assignment		1. High loss to follow-up or missing data		3. Confidence intervals and/or p values not reported

^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Section Summary: Pheochromocytoma and Paraganglioma
The evidence for use of iobenguane I 131 consist of a single-arm prospective study in which the reported primary endpoint was achieved by 25% of patients (95% CI, 16.2% to 36.5%), and antitumor activity of Iobenguane I 131 was demonstrated with 22.1% of patients having a confirmed, centrally reviewed partial response (95% CI, 13.6% to 32.7%). Of these, 53% of patients who responded to therapy maintained a duration of response for at least 6 months. The single-arm nature of the trial prevents adequate interpretation of the results of time to the event endpoint of OS which was a secondary endpoint of the trial. Given the severity and rarity of the disease condition with an associated high degree of morbidity and mortality, especially in metastatic disease, these outcomes represent a clinically meaningful benefit for patients. Specifically, a decrease in the incidence and severity of hypertension represented by a 50% or greater decrease in antihypertensive medications for at least 6 months experienced by 25% of patients, in conjunction with an observed antitumor response of 22%, represents a clinically meaningful benefit for patients.

The evidence for the use of Lu 177 dotatate consists of a systematic review and meta-analysis of single-arm studies and 2 case series. The meta-analysis reported a pooled overall tumor response rate of 26% (95% CI, 18% to 35%). One retrospective case series reported that 8/13 patients were able to reduce dosages of antihypertensive treatment at 3 months. Disease regression was reported in 5/14 patients with available CT imaging. Out of 16 patients with available iobenguane scans, 10 patients had mild or negative uptake. However, patient outcomes were not stratified by iobenguane uptake status. No prospective studies directly comparing Lu 177 dotatate to iobenguane I 131 or assessing Lu 177 dotatate response in a fully non-iobenguane avid population were identified.

Summary of Evidence
For individuals with a treatment-refractory gastroenteropancreatic neuroendocrine tumor including foregut, midgut, and hindgut tumors who receive Lu 177 dotatate, the evidence includes a randomized, open-labeled trial and a retrospective cohort study. Relevant outcomes are OS, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The randomized controlled trial results showed a consistent statistically significant and clinically meaningful effect on overall response rate, progression-free survival, and overall survival among patients treated with Lu 177 dotatate compared to those treated with long-acting octreotide. The results of the retrospective cohort study were consistent with the treatment effect observed in the randomized controlled trial and provide additional support for a clinical benefit of Lu 177 dotatate in patients with a gastroenteropancreatic neuroendocrine tumor. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with treatment-refractory bronchopulmonary or thymus neuroendocrine tumors who receive Lu 177 dotatate, the evidence includes a retrospective cohort study and a bicenter, retrospective case series. Relevant outcomes are OS, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The retrospective cohort study included a small number of patients with bronchopulmonary (n = 23) or thymus (n = 2) neuroendocrine tumors. Among the 23 patients with bronchopulmonary neuroendocrine tumor, the median progression-free survival was 20 months, the median time to progression was 25 months, and median OS was 52 months. Stratified results of 2 patients with thymus neuroendocrine tumors were not reported. The U.S. Food and Drug Administration in its review of the ERASMUS study for patients with gastroenteropancreatic neuroendocrine tumor concluded that time to event analyses such as time to progression, progression-free survival, and OS were not interpretable in the context of the single-arm ERASMUS study because of missing data at baseline, high dropout rates and open-label design of the study. The case series evaluated 48 patients with predominantly atypical carcinoid bronchopulmonary tumors, finding a median progression-free survival and OS of 23 months and 59 months, respectively. Of note, despite the current evidence base, National Comprehensive Cancer Network guidelines give a category 2A recommendation for use of Lu 177 dotatate for the treatment of bronchopulmonary and thymic locoregional advanced or distant metastases neuroendocrine tumors if there are clinically significant tumor burden and low grade (typical) tumor or evidence of progression or intermediate grade (atypical) tumor. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy and who receive iobenguane I 131, the evidence includes a single-arm prospective cohort study. Relevant outcomes include OS, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The pivotal study reported that 25% of patients (95% CI, 16.2% to 36.5%) met the primary endpoint of reduction in antihypertensive medication of at least 50% for at least 6 months along with 22.1% of patients having a confirmed, centrally reviewed partial response (95% CI, 13.6% to 32.7%). Of these, 53% of patients who responded to therapy maintained a duration of response for at least 6 months. The single-arm nature of the trial prevents adequate interpretation of the results of time to event endpoint of OS, which was a secondary endpoint of the trial. Given the severity and rarity of the disease condition with an associated high degree of morbidity and mortality, especially in metastatic disease, these outcomes represent a clinically meaningful benefit for patients. As with all other radiopharmaceuticals, iobenguane I 131 is associated with an increased risk for secondary hematologic malignancy including myelodysplastic syndrome or acute leukemias. Due to the risk of serious adverse reactions, iobenguane I 131 is only indicated for patients with unresectable, locally advanced or metastatic paraganglioma who require systemic anticancer therapy and have no other known curative options. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy and who receive Lu 177 dotatate, the evidence includes a systematic review and meta-analysis of single-arm studies and 2 case series. Relevant outcomes include OS, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The meta-analysis reported a pooled overall tumor response rate of 26% (95% CI, 18% to 35%). One retrospective case series reported that 8/13 patients were able to reduce dosages of antihypertensive treatment at 3 months. Disease regression was reported in 5/14 patients with available CT imaging. Out of 16 patients with available iobenguane scans, 10 patients had mild or negative uptake. However, patient outcomes were not stratified by iobenguane uptake status. No prospective studies directly comparing Lu 177 dotatate to iobenguane I 131 or assessing Lu 177 dotatate response in a fully non-iobenguane avid population were identified. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in Supplemental Information if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

National Comprehensive Cancer Network Guidelines
The National Comprehensive Cancer Network (NCCN) guidelines (v.1.2022 ) for neuroendocrine and adrenal tumors have published key eligibility criteria for patients treated with lutetium 177 dotatate for neuroendocrine tumors. Eligibility criteria include low or intermediate grade neuroendocrine tumor (proliferation index Ki-67 < 20%), detection of somatostatin receptor expression using somatostatin-based receptor imaging, and adequate bone marrow, renal and hepatic function. Table 15 summarizes the NCCN guidelines for neuroendocrine and adrenal tumors.⁴³

Table 15. Recommendations for Use of Lutetium 177 Dotatate for Neuroendocrine Tumors

Treatment Category	Recommendation Category
Mid-gut locoregional advanced or distant metastases gastrointestinal neuroendocrine tumors after disease progression on somatostatin analogues	1
Bronchopulmonary/thymic distant metastases neuroendocrine tumors if there is clinically significant tumor burden and low grade (typical) tumor or evidence of progression or intermediate grade (atypical) tumor or symptomatic disease	2A
Locoregional advanced or distant metastases gastrointestinal neuroendocrine tumors after disease progression on somatostatin analogues	2A
Locoregional advanced or distant metastases pancreatic neuroendocrine tumors after disease progression on somatostatin analogues	2A

The NCCN guidelines also provide a category 2A recommendation to consider the use of lutetium 177 dotatate for treatment of patients with locally unresectable bronchopulmonary or thymus neuroendocrine tumors and locally unresectable or distant metastatic pheochromocytoma or paraganglioma. For pheochromocytoma and paraganglioma, the guidelines additionally note that data are limited for use in this setting.

The NCCN guidelines (v.1.2022) for neuroendocrine and adrenal tumors gives iobenguane I 131 category 2A recommendation for treatment of patients with locally unresectable or distant metastatic pheochromocytoma or paraganglioma with positive MIBG (iobenguane) scan.

U.S. Preventive Services Task Force Recommendations
Not applicable

Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 16.

Table 16. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT03206060	Lu-177-DOTATATE (Lutathera) in Therapy of Inoperable Pheochromocytoma/ Paraganglioma	90	Jan 2027
NCT04665739	Testing Lutetium Lu 177 Dotatate in Patients With Somatostatin Receptor Positive Advanced Bronchial Neuroendocrine Tumors	108	Jul 2024 (suspended)^b
NCT04086485	Lu-177-DOTATATE (Lutathera) in Combination With Olaparib in Inoperable Gastroenteropancreatico Neuroendocrine Tumors (GEP-NET)	37	Jan 2026
NCT03691064	Post-Authorization Long-Term Safety Study of Lutathera (SALUS)	900	Jun 2028
NCT04614766	A Clinical Trial Evaluating the Safety of Combining Lutathera and Azedra to Treat Mid-gut Neuroendocrine Tumors (SPORE-3)	50	Oct 2025
NCT03972488^a	A Phase III Multi-center, Randomized, Open-label Study to Evaluate the Efficacy and Safety of Lutathera in Patients With Grade 2 and Grade 3 Advanced GEP-NET (NETTER-2)	222	Oct 2027
NCT04954820	A Prospective Randomized Phase II Study Assess the Schema of Retreatment With Lutathera® ([177LU]LU-DOTA-TATE) in Patients With New Progression of Intestinal Well-differenciated Neuroendocrine Tumor (ReLUTH)	146	Sep 2029
NCT01876771	An Open-label Phase II Study of Lutetium-177 [DOTA0, Tyr3] Octreotate (Lu-DOTA-TATE) Treatment in Patients With Somatostatin Receptor Positive Tumours	500	Dec 2033

NCT: national clinical trial.
^a Denotes industry-sponsored or cosponsored trial.
^b Suspended due to drug supply issues.

References

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Coding Section

Codes	Number	Description
CPT		No Codes
HCPCS	A9513	Lutetium Lu 177, dotatate, therapeutic, 1 millicurie
	A9590	Iodine i-131, iobenguane, 1 millicurie
ICD-10-CM	C7A.00-C7A.8	Malignant neuroendocrine tumor code range
	C7B.00-C7B.09	Secondary neuroendocrine tumor code range
	C7B.8	Other secondary neuroendocrine tumors
ICD-10-PCS	No specific code
Type of service	Radiopharmaceuticals Oncology
Place of service	Outpatient

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

History From 2019 Forward

11/10/2022	Interim review after adoption of CAM 50143 Which addresses Lutetium in regards to prostate cancer. Updating title, background, guidelines, rationale, references and coding. No change to policy intent.
06/15/2022	Annual review, no change to policy intent.
06/07/2021	Annual review, no change to policy intent. UPdating ratonale and references.
06/01/2020	Annual review, adding medical necessity coverage for lobenguane I 131. Updating background, description, guidelines, regulatory status, rationale and references.
07/30/2019	Interim review, updating HCPCS coding. No other changes.
06/17/2019	New Policy, replacing CAM 203

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Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors - CAM 60160