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Sedlack AJH, Varghese DG, Naimian A, Yazdian Anari P, Bodei L, Hallet J, Riechelmann RP, Halfdanarson T, Capdevilla J, Del Rivero J. Update in the management of gastroenteropancreatic neuroendocrine tumors. Cancer 2024. [PMID: 39012928 DOI: 10.1002/cncr.35463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 07/18/2024]
Abstract
Neuroendocrine neoplasms are a diverse group of neoplasms that can occur in various areas throughout the body. Well-differentiated neuroendocrine tumors (NETs) most often arise in the gastrointestinal tract, termed gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Although GEP-NETs are still uncommon, their incidence and prevalence have been steadily increasing over the past decades. The primary treatment for GEP-NETs is surgery, which offers the best chance for a cure. However, because GEP-NETs are often slow-growing and do not cause symptoms until they have spread widely, curative surgery is not always an option. Significant advances have been made in systemic and locoregional treatment options in recent years, including peptide-receptor radionuclide therapy with α and β emitters, somatostatin analogs, chemotherapy, and targeted molecular therapies.
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Affiliation(s)
- Andrew J H Sedlack
- Medical Scientist Training Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Diana Grace Varghese
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Amirkia Naimian
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Pouria Yazdian Anari
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Bodei
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Julie Hallet
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, East York, Ontario, Canada
| | | | | | | | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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Kusne Y, Lasho T, Finke C, Elsabbagh Z, McCue S, Hobday T, Starr J, Bekaii-Saab T, Halfdanarson TR, Patnaik MM, Ou FS, Sonbol MB. Clonal Hematopoiesis in Patients With Neuroendocrine Tumor Treated With Lutetium-177 and the Risk of Thrombocytopenia: A Prospective Study. JCO Precis Oncol 2024; 8:e2400143. [PMID: 38976813 DOI: 10.1200/po.24.00143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 07/10/2024] Open
Abstract
PURPOSE Thrombocytopenia is a relatively common dose-limiting toxicity during peptide receptor radionuclide therapy (PRRT) in patients with NET. Although uncommon, some patients develop persistent cytopenia and eventually therapy-related myeloid neoplasm (t-MN), which has a dismal prognosis. As the indications for PRRT are expanding, it is important to investigate factors that may predict cytopenias during/after PRRT. We prospectively evaluated the prevalence of clonal hematopoiesis (CH) and cytopenia in patients with NET undergoing PRRT. MATERIALS AND METHODS Patients with metastatic NET with plan to receive four cycles of lutetium-177 were enrolled. CH was evaluated before PRRT using a panel of 220 genes with a targeted depth of ≥1,000×. Patients were followed during PRRT and every 3 months thereafter. RESULTS Of 37 patients enrolled, the median age was 68 years and 51.4% were male. Previous treatment exposures included alkylating agents in 30%, platinum agents in 8%, and external radiation in 13%. CH was detected in 35.1% using a variant allele frequency (VAF) cutoff of ≥2% and 45.9% with a VAF of ≥1%. The most common mutations were in age-related genes (DNMT3A, TET2). CH was not associated with anemia or neutropenia; however, it was associated with lower platelet count at baseline and more time spent in a thrombocytopenic state during/after PRRT. Five patients had bone marrow biopsies (BMBs) because of sustained hematologic dysfunction post-PRRT, and of those, diagnoses included clonal cytopenia of undetermined significance (CCUS) in three and idiopathic cytopenia of undetermined significance (ICUS) in two. CONCLUSION CH is present in 35.1% of patients with NET and is associated with thrombocytopenia risk during PRRT. Future studies with long-term follow-up will delineate whether CH might be a predictor for higher risk of t-MN after PRRT.
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Affiliation(s)
- Yael Kusne
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | - Terra Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Christy Finke
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Zaid Elsabbagh
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | - Shaylene McCue
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Timothy Hobday
- Division of Medical Oncology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jason Starr
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | | | | | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Fang-Shu Ou
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
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Sukrithan V, Armbruster H, Rogers S, Vogt SM, Grenade C, Verschraegen C, Zhou Y, Goyal A, Natwa M, Hussein A, Barr H, Konate D, Batdorf R, Brown A, Williams B, Zhao S, Wei L, Xu M, Shah MH, Konda B. Safety and efficacy of peptide receptor radionuclide therapy in neuroendocrine tumors: A single center experience. PLoS One 2024; 19:e0298824. [PMID: 38748739 PMCID: PMC11095666 DOI: 10.1371/journal.pone.0298824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/30/2024] [Indexed: 05/19/2024] Open
Abstract
Peptide receptor radionucleotide therapy (PRRT) with 177Lu-dotatate is widely used for the treatment of patients with neuroendocrine tumors (NETs). We analyzed data from 104 patients with NETs treated with 177Lu -dotatate at a US academic center between December 2017 and October 2020 to better understand patterns of long-term efficacy, safety, and toxicity in the real-world setting. 177Lu-dotatate (200 mCi) was administered every eight weeks for four doses. The most common sites of primary disease were small intestine NETs (n = 49, 47%), pancreatic NETs (n = 32, 31%), and lung NETs (n = 7, 7%). Twenty-seven percent had Ki-67 <3%, 49% had Ki-67 between 3-20%, and 13.5% had Ki-67 >20%. The cohort had been pretreated with a median of two prior lines of treatment. Forty percent had received prior liver-directed treatment. Seventy-four percent of patients completed all four doses of treatment. The objective response rate was 18%. The median time-to-treatment failure/death was significantly longer for small-bowel NETs when compared to pancreatic NETs (37.3 months vs. 13.2 months, p = 0.001). In a multivariate model, Ki-67, primary site, and liver tumor burden ≥50% were found to independently predict time-to-treatment failure/death. Around 40% of patients experienced adverse events of ≥grade 3 severity. Treatment-related adverse events leading to discontinuation of therapy happened in 10% of patients. Preexisting mesenteric/peritoneal disease was present in 33 patients; seven of these patients developed bowel-related toxicities including two grade 5 events. We also report two cases of delayed-onset minimal change nephrotic syndrome, which occurred 14 and 27 months after the last dose of PRRT. Lastly, we describe six patients who developed rapid tumor progression in the liver leading to terminal liver failure within 7.3 months from the start of PRRT, and identify potential risk factors associated with this occurrence, which will need further study.
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Affiliation(s)
- Vineeth Sukrithan
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Heather Armbruster
- Department of Pharmacy, The Ohio State University, Columbus, Ohio, United States of America
| | - Sherise Rogers
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Sherry Mori Vogt
- Division of Pharmacy, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Cassandra Grenade
- Division of Hematology Oncology, Department of Medicine, Ohio Health, Delaware, OH, United States of America
| | - Claire Verschraegen
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Ye Zhou
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Ashima Goyal
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Mona Natwa
- Department of Radiology, The Ohio State University, Columbus, Ohio, United States of America
| | - Akram Hussein
- Department of Nuclear Medicine Pharmacy, The Ohio State University, Columbus, Ohio, United States of America
| | - Hallie Barr
- Department of Pharmacy, The Ohio State University, Columbus, Ohio, United States of America
| | - Dramane Konate
- Department of Environmental Health and Safety, The Ohio State University, Columbus, Ohio, United States of America
| | - Rochelle Batdorf
- Department of Environmental Health and Safety, The Ohio State University, Columbus, Ohio, United States of America
| | - Andrew Brown
- Cardinal Health, Dublin, Ohio, United States of America
| | - Bonnie Williams
- Department of Radiology, The Ohio State University, Columbus, Ohio, United States of America
| | - Songzhu Zhao
- Department of Biostatistics, The Ohio State University, Columbus, Ohio, United States of America
| | - Lai Wei
- Department of Biostatistics, The Ohio State University, Columbus, Ohio, United States of America
| | - Menglin Xu
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Manisha H. Shah
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
| | - Bhavana Konda
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, United States of America
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Lee H, Kipnis ST, Niman R, O’Brien SR, Eads JR, Katona BW, Pryma DA. Prediction of 177Lu-DOTATATE Therapy Outcomes in Neuroendocrine Tumor Patients Using Semi-Automatic Tumor Delineation on 68Ga-DOTATATE PET/CT. Cancers (Basel) 2023; 16:200. [PMID: 38201627 PMCID: PMC10778298 DOI: 10.3390/cancers16010200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Treatment of metastatic neuroendocrine tumors (NET) with 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) results in favorable response only in a subset of patients. We investigated the prognostic value of quantitative pre-treatment semi-automatic 68Ga-DOTATATE PET/CT analysis in NET patients treated with PRRT. METHODS The medical records of 94 NET patients who received at least one cycle of PRRT at a single institution were retrospectively reviewed. On each pre-treatment 68Ga-DOTATATE PET/CT, the total tumor volume (TTV), maximum tumor standardized uptake value for the patient (SUVmax), and average uptake in the lesion with the lowest radiotracer uptake (SUVmin) were determined with a semi-automatic tumor delineation method. Progression-free survival (PFS) and overall survival (OS) among the patients were compared based on optimal cutoff values for the imaging parameters. RESULTS On Kaplan-Meier analysis and univariate Cox regression, significantly shorter PFS was observed in patients with lower SUVmax, lower SUVmin, and higher TTV. On multivariate Cox regression, lower SUVmin and higher TTV remained predictive of shorter PFS. Only higher TTV was found to be predictive of shorter OS on Kaplan-Meier and Cox regression analyses. In a post hoc Kaplan-Meier analysis, patients with at least one high-risk feature (low SUVmin or high TTV) showed shorter PFS and OS, which may be the most convenient parameter to measure in clinical practice. CONCLUSIONS The tumor volume and lowest lesion uptake on 68Ga-DOTATATE PET/CT can predict disease progression following PRRT in NET patients, with the former also predictive of overall survival. NET patients at risk for poor outcomes following PRRT can be identified with semi-automated quantitative analysis of 68Ga-DOTATATE PET/CT.
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Affiliation(s)
- Hwan Lee
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Sarit T. Kipnis
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- Department of Medicine, Georgetown University, Washington, DC 20007, USA
| | - Remy Niman
- MIM Software Inc., Cleveland, OH 44122, USA
| | - Sophia R. O’Brien
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jennifer R. Eads
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Bryson W. Katona
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Daniel A. Pryma
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
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Wheless M, Das S. Systemic Therapy for Pancreatic Neuroendocrine Tumors. Clin Colorectal Cancer 2023; 22:34-44. [PMID: 36114085 DOI: 10.1016/j.clcc.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/21/2022] [Accepted: 08/02/2022] [Indexed: 11/03/2022]
Abstract
Patients with metastatic or advanced pancreatic neuroendocrine tumors (NETs) carry poorer prognoses relative to patients with other NETs due to bulkier and often, more proliferative baseline disease. Patients with these tumors also possess more approved treatment options relative to patients with other NETs, making therapeutic sequencing nuanced. As such, defining optimal therapeutic sequencing and developing more potent cytoreductive treatments for patients are significant areas of research need in the field. Herein this review, we discuss the current systemic therapy landscape, our approach to therapeutic sequencing in the clinic and ongoing studies seeking to define optimal sequencing of systemic therapies, and novel therapeutics in development, for patients with pancreatic NETs. We limit the scope of this latter topic to agents with preclinical or clinical rationale over the last 8 years to provide a contemporary view of the drug development landscape and focus primarily on new types of peptide receptor radionuclide therapy, anti-vascular endothelial growth factor receptor tyrosine kinase inhibitors and anti-vascular endothelial growth receptor tyrosine kinase inhibitor plus immunotherapy combinations.
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Affiliation(s)
- Margaret Wheless
- Vanderbilt University Medical Center, Department of Medicine, Nashville, TN
| | - Satya Das
- Vanderbilt University Medical Center, Department of Medicine, Division of Hematology and Oncology, Nashville, TN.
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Perrier M, Scoazec JY, Walter T. A practical proposal on treatment sequencing of metastatic well-differentiated neuroendocrine tumours. Ther Adv Med Oncol 2023; 15:17588359231171041. [PMID: 37152421 PMCID: PMC10155015 DOI: 10.1177/17588359231171041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
According to the neuroendocrine tumour (NET) characteristics, 3 to 7 different treatment options are available, corresponding to 6 to 5,040 theoretical different sequences. Even though each patient is unique and despite a large heterogeneity in NET characteristics, the present review aims to discuss the main sequences and addresses how one can propose the best sequence to treat metastatic NET (mNET) on a case-by-case basis. Each treatment must be discussed during dedicated multi-disciplinary meetings, and inclusions in clinical trials should be favoured. After a thorough characterization of patients and their mNET, and taking into account the availability of drugs, the first-line treatment should be chosen according to the treatment aim. The latter is determined based on three main topics (efficacy, safety, and patient preferences) that do not necessarily converge and must be defined a priori. At baseline, physicians should design an a priori full therapeutic sequence, which may evolve at each step depending on the response to previous treatment, the occurrence of chronic toxicities, and the patients' perception of the prior treatment. To improve knowledge in terms of effectiveness and risk of cumulative toxicities regarding the different sequences, real-world data using long follow-up durations are necessary; such issues will not be resolved by randomized clinical trials.
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Affiliation(s)
- Marine Perrier
- Université Reims Champagne-Ardenne, Department
of Gastroenterology and Digestive Oncology, Reims University Hospital,
Reims, France
| | - Jean-Yves Scoazec
- Department of Surgical and Molecular Pathology,
Gustave Roussy, Villejuif, France
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Ramirez RA, Cass AS, Das S, Low SW, Mehrad M, Rickman OB, Scherer PM, Thomas KE, Gillaspie EA. A multidisciplinary approach to the work up and management of pulmonary carcinoid tumors and DIPNECH: a narrative review. Transl Lung Cancer Res 2022; 11:2567-2587. [PMID: 36636417 PMCID: PMC9830261 DOI: 10.21037/tlcr-22-415] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/06/2022] [Indexed: 12/12/2022]
Abstract
Background and Objective Low and intermediate grade neuroendocrine tumors of the lung are uncommon malignancies representing 2% of all lung cancers. These are termed typical and atypical pulmonary carcinoid tumors. These can arise in the setting of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH). The presentation, workup, management and outcomes of patients with these tumors can overlap with more common lung cancers but differ in that many of these patients have a prolonged clinical course. The objective of this narrative review is to summarize the literature and provide evidence and expert-based algorithms for work up and treatment of pulmonary carcinoids and DIPNECH. Methods A search of PubMed and Web of Science databases ending April 15, 2022, with the following keywords "lung carcinoid", "DIPNECH", "lung neuroendocrine," and "bronchopulmonary carcinoid". Key Content and Findings Pulmonary carcinoid tumors benefit from a multidisciplinary approach. Pre-treatment imaging with contrast-enhanced computed tomography, and DOTATATE positron emission tomography is required. Surgical resection is the gold standard for curative intent, and possibly including sublobar resections. Patients can recur or develop new primaries thus emphasizing the importance of surveillance; national guidelines recommend at least a 10-year follow up. A growing body of literature support the use of endobronchial therapy, with long responses documented. Systemic therapy consists of everolimus, somatostatin analogs, peptide receptor radionuclide therapy, and chemotherapy. Diffuse idiopathic pulmonary neuroendocrine tumor cell hyperplasia is rare, but series suggest somatostatin analogs may confer clinical benefit. Conclusions Pulmonary carcinoid tumors and DIPNECH are rare. Despite lack of regulatory approvals for advanced disease, multiple options are available but should be sequenced according to the clinical status and disease biology. Each patient should be discussed in a multidisciplinary setting and clinical trials should be considered if available.
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Affiliation(s)
- Robert A. Ramirez
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S. Cass
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Satya Das
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - See-Wei Low
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mitra Mehrad
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Otis B. Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip M. Scherer
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katharine E. Thomas
- Division of Hematology and Oncology, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Erin A. Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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