foregut (bronchial, gastric, duodenal, pancreatic)
midgut (ileal, jejunal, caecal)
hindgut (distal colonic, rectal).3
Pancreatic NET
1. Typically are well differentiated
2. FDA approved treatment: somatostatin analogs, everolimus, sunitinib, and peptide receptor radionuclide therapy
3. Contrast enhanced EUS differentiates pan NETs from pancreatic adenocarcinoma
4. 68Ga-dotatate PET/CT had the highest detection rate for pancreatic lesions (95% CI, 89.4 to 98.1). Standard first line imaging. 68Ga-dotatate PET/CT has become the first-line modality of choice for detecting SSTR ( somatostatin receptor) expression in PanNETs.
5. 5 types of F-Pan NET- insulinoma, glucagonoma, Gastrinoma, VIPoma, somatostatinoma
6. NF Pan NET < 2 cm observe, > 2 cm resect ( non functional)
7. F-Pan NET ( functional)- resect at any size if resection feasible.
8. In advanced pan-NET, resection is controversial.
9. Poorly differentiated pan-NET treated with chemo- temodar or streptozocin ( +5FU or doxorubicin, the latter preferred)
However temodar is preferred- CAPTEM
CAPTEM resulted in median OS of 24 months (95% CI, 17.1% to 30.8%) as well as a 2-year OS of 42%
10. Everolimus in grade1/2 pan-NET- RADIANT III trial
median PFS with everolimus treatment (11 months v 4.6 months; HR, 0.35)
AE-stomatitis, rash, diarrhea, and fatigue
11. Sunitinib in advanced pan-NET-median PFS of 13.2 months and an overall response rate of 24.5% in patients given sunitinib treatment. AE neutropenia, diarrhea, erythrodysesthesia, hypertension, and thrombocytopenia
12. PRRT- 2 trials ERASMUS ( GEP) and NETTER ( mid gut NET).
177Lu had an overall response rate of 16% and a median duration of response of 35 months.40 However, approximately 1%-2% of patients reported acute leukemia and myelodysplastic syndrome.
13. Cabozantinib after sunitinib or everolimus in phase II:
A phase II study of cabozantinib demonstrated a 15% response rate and a median PFS of 21.8 months in patients with grade 1 and 2 PanNETs who had a treatment history of everolimus or sunitinib.44 An ongoing phase III CABINET trial
Liver directed therapy
Liver mets are important in prognosis.
40% 5 yr survival in liver mets versus 100% OS in non liver mets
Liver debulking if > 70% hepatic mets resection or tumor clearance. Threshold lowered from previously used cut off of 90%.
Radiofrequency ablation- 5 yr OS 48%, median OS 4 yr. Improves survival for tumors < 3 cm ideally but can be done up to 5 cm.
HAE- transarterial embolization, TACE, Transarterial radioembolization ( TARE).
TARE has 89% disease control in the short term but concern for long term toxicity.
CLARINET Trial- metastatic foregut -lanreotide versus placebo
PROMID trial- metastatic mid gut- octreotide vs placebo
No comments:
Post a Comment