1. Ki 67% : low-grade if they had a Ki67 index of 0 to 2%, intermediate-grade if they had a Ki67 index of 3 to 20%, or high-grade if they had a Ki67 index of greater than 20%
Differentiate between grade 3 well differentiated NET and poorly differentiated NEC: both have mitotic rate > 20, Ki 67% > 20%, but high grade NEC large and small cell can have Ki 67> 50%
If Ki 67% greater than 55% treat neuroendocrine carcinomas( NEC) similar to small cell. Unless primary is from the lung, no data to support use of IO. Use carbo etoposide alone.
2. Location of primary:
- Midgut: jejunum, ileum, proximal colon ( before splenic flexure)
- Pancreatic NET is different from extra pancreatic NET different diseases
- Lung neuroendocrine
NETTER 2 link: all GI neuroendocrine whereas NETTER 1 was for small bowel NET
How is Lu 177 given?
- Start arginine lysine infusion 30 min before start of Lu 117 infusion. Total 4 hr infusion.
- Lu 177 runs for 30 mins.
- At the end of arginine lysine infusion for 4 hr, give IM octreotide 30 mg .
- Lu 117 q 8 weeks times 4 doses+ octreotide LAR 30 mg q 4 weeks.
Reference: NEJM 2017 NETTER 1
CABINET Study: Cabozantinib
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