Assessment of the Efficacy of Bevacizumab in Combination With Folfiri as Second-line Treatment in Patients Suffering From an Advanced Inoperable Poorly Differentiated Neuroendocrine Carcinoma of an Unknown or Gastroentero-pancreatic Primary Cancer

Prior treatment

• Relating to the tumor, the patient, and previous treatment:
  • Well differentiated neuroendocrine tumor
  • Mixed tumor, except if the NEC component is \> 70%, the patient is eligible,
  • First-line chemotherapy other than cisplatin (or carboplatin) and etoposide,
  • All malignant disease in the three years before randomization, with the exception of basal cell carcinoma or in situ cancer treated for curative purposes,
  • A pregnant or breastfeeding woman,
  • Lack of efficient contraception (for men or women of reproductive age),
  • All medical, geographical, social, and psychological conditions or a legal situation that will not allow the patient to finish the study or sign an informed consent form,

Lab values

• Relating to the chemotherapy (Folfiri):
  • Any of the following uncontrolled progressive diseases in the 6 months before randomization: liver failure, renal insufficiency, respiratory distress, congestive heart failure (NYHA III-IV), unstable angina, myocardial infarction, significant arrhythmia,
  • Known deficiency in dihydropyrimidine dehydrogenase,
  • Known Gilbert's syndrome,
  • Total bilirubin level \>1.5x the upper limit of normal (ULN); AST (Aspartate transaminase) and/or ALT (Alanine transaminase) \>5x ULN; TP \<50%;
  • Neutrophils \<1.5x109/l, platelets \<100x109/l, hemoglobin \<9 g/dl,
  • Chronic uncontrolled diarrhea, unresolved intestinal occlusion or subocclusion,
  • History of anaphylactic reaction or known intolerance to atropine (sulfate) or to loperamide or to antiemetics administered in association with Folfiri,
  • All treatment with concomitant anticonvulsive agents, CYP3A4 inducers (phenytoin, phenobarbital, carbamazepine), discontinued for at least 7 days,
• Relating to bevacizumab:
  • Uncontrolled brain metastases (by local treatment),
  • All uncontrolled progressive disease within 1 month prior to randomization: grade 3-4 gastrointestinal bleeding (peptic ulcer, erosive esophagitis or gastritis), infectious disease or intestinal inflammation, diverticulitis, pulmonary embolism or other uncontrolled thromboembolic event,
  • Uncontrolled high blood pressure defined as a systolic blood pressure \>140 mmHg or diastolic pressure \>90 mmHg,
  • Patients receiving anticoagulant treatment with an unstable dose of a vitamin K antagonist treatment, and/or having an abnormal INR (\>3) in the four weeks before the randomization,
  • Verified proteinuria above or equal to 1g/24 hours measured from 24 hours of urine if the urinary protein dipstick control is above or equal to 2+,
  • Creatinine clearance (MDRD) \<50 ml/min.
  • Hypersensitivity to the active substance or to any of the excipients.
  • Hypersensitivity to Chinese Hamster Ovary (CHO) cell products or other recombinant human or humanised antibodies.

• Man or woman aged ≥ 18 years old,
• Poorly differentiated neuroendocrine carcinoma (NEC) from a gastrointestinal tract (from esophagus to anal canal) and biliopancreatic primary or an unknown primary cancer, locally advanced and/or metastatic,
• Centralized review of the diagnostic by a consulting pathologist specializing in NET (TENPATH network),
• Recommendation of a second-line chemotherapy after progression, documented using the RECIST criteria v.1.1, and after a first-line chemotherapy treatment by cisplatin (or carboplatin) + etoposide or in the event of progression in the 6 months following the discontinuation of this first-line treatment,
• Recommendation of a second-line chemotherapy for the refractory patient or contraindicated for platinum-etoposide chemotherapy
• Patients presenting at least one measurable target lesion according to the RECIST criteria v.1.1, in an area not previously irradiated,
• General condition ≤ 2 (WHO),
• Patient of child bearing age accepting to use an effective contraception during treatment and until 6 months after the last administration,
• Patient who signed the informed consent form.