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Goh KW, Yoshida H, Miura I, Miura C, Norita K, Ii T, Yamanami H, Kobayashi K. Multiple distant metastases arising from a single, low-grade rectal neuroendocrine tumor: an autopsy case report. J Med Case Rep 2023; 17:126. [PMID: 36973810 PMCID: PMC10044367 DOI: 10.1186/s13256-023-03854-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Rectal neuroendocrine neoplasms are rare epithelial neoplasms of the rectum. The incidence of these tumors has increased over the past decades. However, many questions remain unanswered regarding their clinicopathology, including the possible mechanisms in which these tumors may grow and metastasize. CASE PRESENTATION In this case report, we report the findings of an autopsy of a 65-year-old Japanese woman diagnosed with multiple liver metastases from a single, low-grade rectal neuroendocrine tumor. The diagnosis was made in late 2018 to early 2019, and subsequently the patient underwent several rounds of standard chemotherapy. However, due to unfavorable side effects, she opted for palliative care at our hospital instead from December 2020. The patient's condition was generally stable for the next 17 months, but in May 2022, she was hospitalized for increased abdominal pain. Despite enhanced pain control therapy, she eventually passed away. An autopsy was conducted to determine the exact cause of death. The primary rectal tumor was found to be small, but showed strong histological evidence of venous invasion. Metastases in the liver, pancreas, thyroid gland, adrenal glands, and vertebrae were also present. On the basis of the histological evidence obtained, we deduced that the tumor cells may have mutated and gained multiclonality as they spread vascularly to the liver, contributing to the distant metastases. CONCLUSIONS The results from this autopsy may provide an explanation for the possible mechanism by which small, low-grade rectal neuroendocrine tumors metastasize.
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Affiliation(s)
- Keng Wee Goh
- Junior Residency, Obihiro Daiichi Hospital, Obihiro, Japan.
| | - Hiroshi Yoshida
- Department of Palliative Care, Obihiro Daiichi Hospital, Obihiro, Japan
| | - Ichiro Miura
- Department of Clinical Laboratory, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
| | - Chisako Miura
- Department of Diagnostic Pathology, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
| | - Kazuaki Norita
- Department of Gastroenterology Medicine, Obihiro Daiichi Hospital, Obihiro, Japan
| | - Takayuki Ii
- Department of Surgery, Obihiro Daiichi Hospital, Obihiro, Japan
| | | | - Koju Kobayashi
- Department of Gastroenterology Medicine, Obihiro Daiichi Hospital, Obihiro, Japan
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Gebauer N, Ziehm M, Gebauer J, Riecke A, Meyhöfer S, Kulemann B, von Bubnoff N, Steinestel K, Bauer A, Witte HM. The Glasgow Prognostic Score Predicts Survival Outcomes in Neuroendocrine Neoplasms of the Gastro-Entero-Pancreatic (GEP-NEN) System. Cancers (Basel) 2022; 14:cancers14215465. [PMID: 36358883 PMCID: PMC9656405 DOI: 10.3390/cancers14215465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/10/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Across a variety of solid tumors, prognostic implications of nutritional and inflammation-based risk scores have been identified as a complementary resource of risk stratification. Methods: In this retrospective study, we performed a comparative analysis of several established risk scores and ratios, such as the Glasgow Prognostic Score (GPS), in neuroendocrine neoplasms of the gastro−entero−pancreatic (GEP-NEN) system with respect to their prognostic capabilities. Clinicopathological and treatment-related data for 102 GEP-NEN patients administered to the participating institutions between 2011 and 2021 were collected. Scores/ratios significantly associated with overall or progression-free survival (OS, PFS) upon univariate analysis were subsequently included in a Cox-proportional hazard model for the multivariate analysis. Results: The median age was 62 years (range 18−95 years) and the median follow-up period spanned 51 months. Pancreatic or intestinal localization at the initial diagnosis were present in 41 (40.2%) and 44 (43.1%) cases, respectively. In 17 patients (16.7%), the primary manifestation could not be ascertained (NNUP; neuroendocrine neoplasms of unknown primary). Histological grading (HG) revealed 24/102 (23.5%) NET/NEC (poorly differentiated; high grade G3) and 78/102 (76.5%) NET (highly or moderately differentiated; low−high grade G1−G2). In total, 53/102 (51.9%) patients presented with metastatic disease (UICC IV), 11/102 (10.7%) patients presented with multifocal disease, and 56/102 (54.9%) patients underwent a primary surgical or endoscopic approach, whereas 28 (27.5%) patients received systemic cytoreductive treatment. The univariate analysis revealed the GPS and PI (prognostic index), as well as UICC-stage IV, HG, and the Charlson comorbidity index (CCI) to predict both the PFS and OS in GEP-NEN patients. However, the calculation of the survival did not separate GPS subgroups at lower risk (GPS 0 versus GPS 1). Upon the subsequent multivariate analysis, GPS was the only independent predictor of both OS (p < 0.0001; HR = 3.459, 95% CI = 1.263−6.322) and PFS (p < 0.003; HR = 2.119, 95% CI = 0.944−4.265). Conclusion: In line with previous results for other entities, the present study revealed the GPS at baseline to be the only independent predictor of survival across all stages of GEP-NEN, and thus supports its clinical utility for risk stratification in this group of patients.
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Affiliation(s)
- Niklas Gebauer
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Maria Ziehm
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Judith Gebauer
- Department of Internal Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Armin Riecke
- Department of Hematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Sebastian Meyhöfer
- Department of Internal Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Birte Kulemann
- Department of Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Nikolas von Bubnoff
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Konrad Steinestel
- Institute for Pathology and Molecular Pathology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Arthur Bauer
- Department of Hematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Hanno M. Witte
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- Department of Hematology and Oncology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Institute for Pathology and Molecular Pathology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Correspondence:
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Sobash PT, Ullah A, Karim NA. Survival Benefit of Adjuvant Chemotherapy in Pulmonary Carcinoid Tumors. Cancers (Basel) 2022; 14:cancers14194730. [PMID: 36230651 PMCID: PMC9564155 DOI: 10.3390/cancers14194730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary carcinoid tumors are a rare subtype of neuroendocrine cell tumor found in approximately 1–2% of lung cancers. Management is primarily through surgical resection, with limited benefit of adjuvant therapy in the clinical setting. Genomic profiling is in the nascent stages to molecularly classify these tumors, but there are promising insights for future targeted therapy. A total of 80 abstracts were analyzed for further review with 11 included in our final analysis. Only 4 of the 11 reviewed in depth provided statistical analysis. We evaluated PFS, OS, 1- and 5-year survival as mentioned in the studies. Nodal and KI67 status were also analyzed. Based on the current literature, there is no definitive evidence that adjuvant chemotherapy after resection confers a survival benefit in typical or atypical carcinoids.
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Affiliation(s)
- Philip T. Sobash
- Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
| | - Asad Ullah
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Nagla Abdel Karim
- Inova Schar Cancer Institute, University of Virginia, Fairfax, VA 22031, USA
- Correspondence: or
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Khatami A, Sistani G, Sutherland DEK, DeBrabandere S, Reid RH, Laidley DT. Toxicity and Tolerability of 177Lu-DOTA-TATE PRRT with a Modified Administered Activity Protocol in NETs of Variable Origin - A Phase 2 Registry Study. Curr Radiopharm 2022; 15:123-133. [PMID: 35135467 PMCID: PMC9900697 DOI: 10.2174/1874471014666210810100435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Peptide receptor radionuclide therapy (PRRT) has been recently approved for advanced, metastatic, or progressive neuroendocrine tumors (NETs). OBJECTIVE This study reports the adverse events (AEs) observed with patient-tailored administered activity. METHODS Fifty-two PRRT naive patients were treated with 177Lu-DOTATATE. The administered activity ranges between 2.78 and 5.55 GBq/cycle using the patient's unique characteristics (age, symptoms, blood work, and biomarkers). RESULTS The protocol was well tolerated with the overwhelming majority of participants being forty- six (88%), completing all 4 induction therapy cycles. The median cumulative administered activity was 19.6 GBq (ranged 3.8-22.3 GBq). A total of 42/52 (81%) reported at least one symptom, and 43/52 (83%) had evidence of biochemical abnormality at enrollment that would meet grade 1 or 2 criteria for AEs. These symptoms only slightly increase with treatment to 50/52 (96%) and 51/52 (98%), respectively. The most common symptoms were mild fatigue (62%), shortness of breath (50%), nausea (44%), abdominal pain (38%), and musculoskeletal pain (37%). The most common biomarker abnormalities were mild anemia (81%), reduced estimated glomerular filtration rate (eGFR) (58%), increased alkaline phosphatase (ALP) (50%), and leukopenia (37%). Of critical importance, no 177Lu-DOTATATE related grade 3 or 4 AEs were observed. CONCLUSION Tailoring the administered activity of 177Lu-DOTATATE to the individual patient with a variety of NETs is both safe and well-tolerated. No patient developed severe grade 3 or 4 AEs. Most patients exhibit symptoms or biochemical abnormality before treatment and this only slightly worsens following induction therapy.
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Affiliation(s)
- Alireza Khatami
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; ,Address correspondence to this author at the Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; E-mail:
| | - Golmehr Sistani
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; ,Division of Radiology, Department of Medical Imaging, Western University, London, ON, Canada
| | - Duncan E. K. Sutherland
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - Sarah DeBrabandere
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - Robert H. Reid
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - David T. Laidley
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
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Lee L, Ramos-Alvarez I, Jensen RT. Predictive Factors for Resistant Disease with Medical/Radiologic/Liver-Directed Anti-Tumor Treatments in Patients with Advanced Pancreatic Neuroendocrine Neoplasms: Recent Advances and Controversies. Cancers (Basel) 2022; 14:cancers14051250. [PMID: 35267558 PMCID: PMC8909561 DOI: 10.3390/cancers14051250] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Tumor resistance, both primary and acquired, is leading to increased complexity in the nonsurgical treatment of patients with advanced panNENs, which would be greatly helped by reliable prognostic/predictive factors. The importance in identifying resistance is being contributed to by the increased array of possible treatments available for treating resistant advanced disease; the variable clinical course as well as response to any given treatment approach of patients within one staging or grading system, the advances in imaging which are providing increasing promising results/parameters that correlate with grading/outcome/resistance, the increased understanding of the molecular pathogenesis providing promising prognostic markers, all of which can contribute to selecting the best treatment to overcome resistance disease. Several factors have been identified that have prognostic/predictive value for identifying development resistant disease and affecting overall survival (OS)/PFS with various nonsurgical treatments of patients with advanced panNENs. Prognostic factors identified for patients with advanced panNENs for both OS/PFSs include various clinically-related factors (clinical, laboratory/biological markers, imaging, treatment-related factors), pathological factors (histological, classification, grading) and molecular factors. Particularly important prognostic factors for the different treatment modalities studies are the recent grading systems. Most prognostic factors for each treatment modality for OS/PFS are not specific for a given treatment option. These advances have generated several controversies and new unanswered questions, particularly those related to their possible role in predicting the possible sequence of different anti-tumor treatments in patients with different presentations. Each of these areas is reviewed in this paper. Abstract Purpose: Recent advances in the diagnosis, management and nonsurgical treatment of patients with advanced pancreatic neuroendocrine neoplasms (panNENs) have led to an emerging need for sensitive and useful prognostic factors for predicting responses/survival. Areas covered: The predictive value of a number of reported prognostic factors including clinically-related factors (clinical/laboratory/imaging/treatment-related factors), pathological factors (histological/classification/grading), and molecular factors, on therapeutic outcomes of anti-tumor medical therapies with molecular targeting agents (everolimus/sunitinib/somatostatin analogues), chemotherapy, radiological therapy with peptide receptor radionuclide therapy, or liver-directed therapies (embolization/chemoembolization/radio-embolization (SIRTs)) are reviewed. Recent findings in each of these areas, as well as remaining controversies and uncertainties, are discussed in detail, particularly from the viewpoint of treatment sequencing. Conclusions: The recent increase in the number of available therapeutic agents for the nonsurgical treatment of patients with advanced panNENs have raised the importance of prognostic factors predictive for therapeutic outcomes of each treatment option. The establishment of sensitive and useful prognostic markers will have a significant impact on optimal treatment selection, as well as in tailoring the therapeutic sequence, and for maximizing the survival benefit of each individual patient. In the paper, the progress in this area, as well as the controversies/uncertainties, are reviewed.
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Affiliation(s)
- Lingaku Lee
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
- National Kyushu Cancer Center, Department of Hepato-Biliary-Pancreatology, Fukuoka 811-1395, Japan
| | - Irene Ramos-Alvarez
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
| | - Robert T. Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
- Correspondence: ; Tel.: +1-301-496-4201
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Kim HJ, Lee KH, Shim HJ, Hwang EC, Choi YD, Bang H, Cho SH, Chung IJ, Hwang JE, Lee MA, Bae WK. Prognostic Significance of the Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Neuroendocrine Carcinoma. Chonnam Med J 2022; 58:29-36. [PMID: 35169557 PMCID: PMC8813653 DOI: 10.4068/cmj.2022.58.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022] Open
Abstract
Extra-pulmonary neuroendocrine carcinoma is a rare and aggressive cancer. Although several biological and histological markers have been suggested as prognostic factors for this cancer, the prognostic importance of systemic inflammatory markers, including the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio, is unclear. This study aimed to evaluate the association between systemic inflammatory markers and the prognosis of extra-pulmonary neuroendocrine carcinoma. We retrospectively analyzed the clinical data of 85 patients with unresectable or metastatic extra-pulmonary neuroendocrine carcinoma who received platinum-based chemotherapy as first-line chemotherapy from August 2007 to November 2019. We used time-dependent receiver operating characteristic curve analysis to determine the cut-off values. The cut-off values for the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were 3.0 and 158.5, respectively. There was no significant difference in the Eastern Cooperative Oncology Group performance status score, Ki-67 index, or response to chemotherapy between groups. The high neutrophil-lymphocyte ratio group showed significantly worse overall survival (high vs. low, median 11.1 vs. 21.0 months, log-rank p=0.004) and shorter median progression-free survival, but the latter was not statistically significant. The high platelet-lymphocyte ratio group also showed significantly worse progression-free survival and overall survival than the low platelet-lymphocyte ratio group (high vs. low: median 5.6 vs. 9.8 months, log-rank p=0.047 and median 13.8 vs. 21.0 months, log-rank p=0.013, respectively). In multivariable analysis, a high neutrophil-lymphocyte ratio was an independent prognostic factor for overall survival. The neutrophil-lymphocyte ratio is a potent and readily available prognostic factor for extra-pulmonary neuroendocrine carcinoma.
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Affiliation(s)
- Hyeon-Jong Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Kang Han Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Hyun Jeong Shim
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Yoo-Duk Choi
- Department of Pathology, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Hyunjin Bang
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Sang Hee Cho
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Ik-Joo Chung
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
- Immunotherapy Innovation Center, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Jun Eul Hwang
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, Cancer Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Woo Kyun Bae
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
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Espinosa-Olarte P, La Salvia A, Riesco-Martinez MC, Anton-Pascual B, Garcia-Carbonero R. Chemotherapy in NEN: still has a role? Rev Endocr Metab Disord 2021; 22:595-614. [PMID: 33843007 PMCID: PMC8346445 DOI: 10.1007/s11154-021-09638-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
Neuroendocrine neoplasms (NENs) comprise a broad spectrum of tumors with widely variable biological and clinical behavior. Primary tumor site, extent of disease, tumor differentiation and expression of so matostatin receptors, proliferation and growth rates are the major prognostic factors that determine the therapeutic strategy. Treatment options for advanced disease have considerably expanded in recent years, particularly for well differentiated tumors (NETs). Novel drugs approved over the past decade in this context include somatostatin analogues and 177Lu-oxodotreotide for somatostatin-receptor-positive gastroenteropancreatic (GEP) NETs, sunitinib for pancreatic NETs (P-NETs), and everolimus for P-NETs and non-functioning lung or gastrointestinal NETs. Nevertheless, chemotherapy remains an essential component of the treatment armamentarium of patients with NENs, particularly of patients with P-NETs or those with bulky, symptomatic or rapidly progressive tumors (generally G3 or high-G2 NENs). In this manuscript we will comprehensively review available evidence related to the use of chemotherapy in lung and GEP NENs and will critically discuss its role in the treatment algorithm of this family of neoplasms.
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Affiliation(s)
- Paula Espinosa-Olarte
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
| | - Anna La Salvia
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
| | | | - Beatriz Anton-Pascual
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
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Rinke A, Auernhammer CJ, Bodei L, Kidd M, Krug S, Lawlor R, Marinoni I, Perren A, Scarpa A, Sorbye H, Pavel ME, Weber MM, Modlin I, Gress TM. Treatment of advanced gastroenteropancreatic neuroendocrine neoplasia, are we on the way to personalised medicine? Gut 2021; 70:1768-1781. [PMID: 33692095 DOI: 10.1136/gutjnl-2020-321300] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Gastroenteropancreatic neuroendocrine neoplasia (GEPNEN) comprises clinically as well as prognostically diverse tumour entities often diagnosed at late stage. Current classification provides a uniform terminology and a Ki67-based grading system, thereby facilitating management. Advances in the study of genomic and epigenetic landscapes have amplified knowledge of tumour biology and enhanced identification of prognostic and potentially predictive treatment subgroups. Translation of this genomic and mechanistic biology into advanced GEPNEN management is limited. 'Targeted' treatments such as somatostatin analogues, peptide receptor radiotherapy, tyrosine kinase inhibitors and mammalian target of rapamycin inhibitors are treatment options but predictive tools are lacking. The inability to identify clonal heterogeneity and define critical oncoregulatory pathways prior to therapy, restrict therapeutic efficacy as does the inability to monitor disease status in real time. Chemotherapy in the poor prognosis NEN G3 group, though associated with acceptable response rates, only leads to short-term tumour control and their molecular biology requires delineation to provide new and more specific treatment options.The future requires an exploration of the NEN tumour genome, its microenvironment and an identification of critical oncologic checkpoints for precise drug targeting. In the advance to personalised medical treatment of patients with GEPNEN, clinical trials need to be based on mechanistic and multidimensional characterisation of each tumour in order to identify the therapeutic agent effective for the individual tumour.This review surveys advances in NEN research and delineates the current status of translation with a view to laying the basis for a genome-based personalised medicine management of advanced GEPNEN.
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Affiliation(s)
- Anja Rinke
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital Marburg and Philipps University, Marburg, Germany
| | - Christoph J Auernhammer
- Department of Internal Medicine IV and Interdisciplinary Center of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), Ludwig Maximilian University, LMU Klinikum, Munich, Germany
| | - Lisa Bodei
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark Kidd
- Wren Laboratories, Branford, Connecticut, USA
| | - Sebastian Krug
- Clinic for Internal Medicine I, Martin Luther University, Halle, Germany
| | - Rita Lawlor
- Applied Research on Cancer Centre, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Ilaria Marinoni
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Aldo Scarpa
- Applied Research on Cancer Centre, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Halfdan Sorbye
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Marianne Ellen Pavel
- Department of Internal Medicine I, Endocrinology, University of Erlangen, Erlangen, Germany
| | - Matthias M Weber
- Department of Internal Medicine I, Endocrinology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Irvin Modlin
- Gastroenterological and Endoscopic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital Marburg and Philipps University, Marburg, Germany
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Fazio N, Kulke M, Rosbrook B, Fernandez K, Raymond E. Updated Efficacy and Safety Outcomes for Patients with Well-Differentiated Pancreatic Neuroendocrine Tumors Treated with Sunitinib. Target Oncol 2021; 16:27-35. [PMID: 33411058 PMCID: PMC7810649 DOI: 10.1007/s11523-020-00784-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sunitinib prolonged progression-free survival (PFS) versus placebo in patients with metastatic pancreatic neuroendocrine tumors (panNETs) in a phase III trial. The efficacy and safety of sunitinib in patients with panNETs were confirmed in an open-label phase IV trial. OBJECTIVE To assess the clinical benefit with sunitinib using the combined data from these trials. PATIENTS AND METHODS An updated overall survival (OS) in patients with panNETs for the phase IV trial was provided, and an analysis of results from the sunitinib-treated combined cohort from the phase III and IV trials (combined cohort) was conducted to assess PFS, OS, and objective response rate (ORR). RESULTS The updated median OS for the phase IV trial was 54.1 months (95% CI 37.9-not reached). Investigator-assessed median PFS for the combined cohort (n = 102) was 12.9 months (95% CI 7.4-16.7) with a significant benefit versus placebo in the phase III trial (n = 35) (HR 0.429; 95% CI 0.245-0.752; p = 0.001). Median OS could not be calculated for the combined cohort or placebo group due to the high number of patients censored; however, the estimated HR of 0.303 (CI 0.100-0.921; p = 0.013) favored sunitinib. ORR for the combined cohort was 16.7% (95% CI 10.0-25.3). Sunitinib was well tolerated in both trials with a safety profile similar to previously seen in other studies. CONCLUSIONS The combined analysis of these studies confirms the objective tumor responses and improvements in PFS observed in the initial phase III trial, providing further support for the clinical benefit of sunitinib in patients with advanced panNETs. CLINICALTRIALS. GOV IDENTIFIERS NCT00428597 and NCT01525550.
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Affiliation(s)
- Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IEO, IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
| | - Matthew Kulke
- Boston University and Boston Medical Center, Boston, MA, USA
| | | | | | - Eric Raymond
- Department of Medical Oncology, Paris Saint-Joseph Hospital Group, Paris, France
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10
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Wang W, Zhang Y, Peng Y, Jin KZ, Li YL, Liang Y, Tan HY, Yu XJ, Zhou ZW, Chen J. A Ki-67 Index to Predict Treatment Response to the Capecitabine/Temozolomide Regimen in Neuroendocrine Neoplasms: A Retrospective Multicenter Study. Neuroendocrinology 2021; 111:752-763. [PMID: 32668427 DOI: 10.1159/000510159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The efficacy of the capecitabine/temozolomide (CAPTEM) regimen has been demonstrated in metastatic neuroendocrine neoplasms (NENs), but because of varying response rates among the patients, biomarkers to predict its response are greatly needed. Here, we investigated the clinical utility of a Ki-67 index to predict the CAPTEM regimen objective responses and select patients who could benefit from this regimen. METHODS Metastatic NENs patients treated with the CAPTEM regimen from 4 high-volume medical centers were selected and grouped in a training and validation cohort. The classification and regression tree (CART) was generated to identify the optimal threshold of Ki-67 for stratifying the patients into different Ki-67 range groups based on their response to the CAPTEM regimen. RESULTS AND CONCLUSIONS The overall response rate (ORR) and disease control rate of the entire cohort (N = 151) were 26.5 and 76.2%, respectively, with a median progression-free survival (PFS) of 12.0 months. CART analysis showed that patients in the Ki-67 range group 10-40% demonstrated a significantly higher ORR than those in Ki-67 >40 and <10% groups (p < 0.001 in the training cohort and p = 0.036 in the validation cohort). Response to the CAPTEM regimen was not influenced by the expression of O6-methylguanine-DNA methyltransferase or primary tumor location. Multivariate analysis identified the Ki-67 index as the only independent prognostic factor for overall survival (p = 0.031) and PFS (p = 0.006). The proposed Ki-67 index was externally validated and could be used to clinically identify suitable metastatic NENs patients who could achieve an optimal cytoreduction using the CAPTEM regimen.
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Affiliation(s)
- Wei Wang
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Peng
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Kai-Zhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yuan-Liang Li
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Yao Liang
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huang-Ying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhi-Wei Zhou
- Department of Gastric Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jie Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,
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11
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Owens R, Gilmore E, Bingham V, Cardwell C, McBride H, McQuaid S, Humphries M, Kelly P. Comparison of different anti-Ki67 antibody clones and hot-spot sizes for assessing proliferative index and grading in pancreatic neuroendocrine tumours using manual and image analysis. Histopathology 2020; 77:646-658. [PMID: 32617996 DOI: 10.1111/his.14200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 01/06/2023]
Abstract
AIMS Ki67 proliferative index (PI) is essential for grading gastroenteric and pancreatic neuroendocrine tumours (GEP NETs). Analytical and preanalytical variables can affect Ki67 PI. In contrast to counting methodology, until now little attention has focused on the question of clone equivalence and the effect of hot-spot size on Ki67 PI in GEP NETs. Using manual counting and image analysis, this study compared the Ki67 PI achieved using MM1, K2 and 30-9 to MIB1, a clone which has been validated for, and is referenced in, guidelines relating to assessment of Ki67 PI in GEP NETs. METHODS AND RESULTS Forty-two pancreatic NETs were each immunohistochemically stained for the anti-Ki67 clones MIB1, MM1, K2 and 30-9. Ki67 PI was calculated manually and by image analysis, the latter using three different hot-spot sizes. In manual comparisons using single hot-spot high-power fields, non-MIB1 clones overestimated Ki67 PI compared to MIB1, resulting in grading discordances. Image analysis shows good agreement with manual Ki67 PI but a tendency to overestimate absolute Ki67 PI. Increasing the size of tumour hot-spot from 500 to 2000 cells resulted in a decrease in Ki67 PI. CONCLUSION Different anti-Ki67 clones do not produce equivalent PIs in GEP NETs, and clone selection may therefore affect patient care. Increasing the hot-spot size decreases the Ki67 PI. Greater standardisation in terms of antibody clone selection and hot-spot size is required for grading GEP NETs. Image analysis is an effective tool for assisting Ki67 assessment and allows easier standardisation of the size of the tumour hot-spot.
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Affiliation(s)
- Roisin Owens
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Elaine Gilmore
- Precision Medicine Centre of Excellence, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Victoria Bingham
- Precision Medicine Centre of Excellence, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Christopher Cardwell
- Centre for Public Health, Institute of Clinical Sciences, Queen's University, Belfast, Northern Ireland, UK
| | - Hilary McBride
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Stephen McQuaid
- Precision Medicine Centre of Excellence, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Matthew Humphries
- Precision Medicine Centre of Excellence, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Paul Kelly
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
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12
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Ramírez-Rentería C, Ferreira-Hermosillo A, Marrero-Rodríguez D, Taniguchi-Ponciano K, Melgar-Manzanilla V, Mercado M. An Update on Gastroenteropancreatic Neuroendocrine Neoplasms: From Mysteries to Paradigm Shifts. Arch Med Res 2020; 51:765-776. [PMID: 32654882 DOI: 10.1016/j.arcmed.2020.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
Although neuroendocrine neoplasms (NEN) were once thought to be rare and mostly "benign" diseases, they are now being redefined in light of recently discovered molecular information. NENs constitute a spectrum of variably differentiated neoplasms, ranging from well-differentiated tumors with a protracted course over many years to very aggressive neuroendocrine carcinomas. Although the majority of NEN are non-functional lesions, some of these tumors, do produce a hormonal hypersecretion syndrome. Their reappraisal has led scientist to unveil previously unknown oncogenic pathways and connections that resulted in a new category in the International Classification of Diseases (ICD-11) and a revised version of the World Health Organization Classification (WHO 2018). Complex diseases like NEN require a multidisciplinary approach that includes the perspectives of endocrinologists, medical and surgical oncologists, radiation oncologists, imaging specialists and pathologists. There are currently virtually thousands of ongoing trials evaluating the efficacy and safety of several molecular targeted therapies. The purpose of this review was to critically evaluate recent information regarding the pathogenesis, diagnosis and treatment of NEN.
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Affiliation(s)
- Claudia Ramírez-Rentería
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Aldo Ferreira-Hermosillo
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Daniel Marrero-Rodríguez
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Keiko Taniguchi-Ponciano
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Virgilio Melgar-Manzanilla
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Moisés Mercado
- Unidad de Investigación Médica en Enfermedades Endocrinas. Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
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13
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Cives M, Pelle’ E, Quaresmini D, Mandriani B, Tucci M, Silvestris F. The Role of Cytotoxic Chemotherapy in Well-Differentiated Gastroenteropancreatic and Lung Neuroendocrine Tumors. Curr Treat Options Oncol 2019; 20:72. [DOI: 10.1007/s11864-019-0669-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Zhai H, Li D, Feng Q, Qian X, Li L, Yao J. Pancreatic neuroendocrine tumours: Grade is superior to T, N, or M status in predicting outcome and selecting patients for chemotherapy:A retrospective cohort study in the SEER database. Int J Surg 2019; 66:103-109. [PMID: 30872175 DOI: 10.1016/j.ijsu.2019.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/19/2019] [Accepted: 03/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumours (pNETs) are a rare and heterogeneous group of tumours with an increasing incidence. Current staging criteria for pNETs remain limited and controversial. Meanwhile, the impact of chemotherapy on overall survival has not been fully defined. OBJECTIVES The current study aimed to explore epidemiologic trends of pancreatic neuroendocrine tumours (pNETs). To determine feasible improvements to staging criteria and investigate the relationship between chemotherapy and survival. METHODS A retrospective cohort study design was used to analyse annual cancer incidence rates, patient demographics, tumour site and stage, and treatment of pNETs. Data were obtained from the National Cancer Institute's SEER registry for all patients diagnosed with pNETs between January 1973 and December 2015. RESULTS Patients diagnosed after 2010 were more likely to present with age greater than 45 years, T0, T1 status, N0 status, M0 status, and well differentiation. Current AJCC staging criteria was applicable to patients with well differentiation, but not other differentiation. The revised system, defined by Grade, T, N, and M status, could robustly discriminate between survival curves. Chemotherapy was associated with significantly improved survival for patients with poorly differentiated and undifferentiated tumour grading. CONCLUSIONS Grade is superior to 'T', 'N', or 'M' status in predicting outcomes and selecting patients for chemotherapy. It is necessary and feasible to combine grade into current staging criteria.
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Affiliation(s)
- Huamin Zhai
- Yangzhou University Medical College, Yangzhou, Jiangsu, 225001, China
| | - Duguang Li
- The Second Clinical College of Dalian Medical University, Dalian, Liaoning, 116044, China
| | - Qingbo Feng
- The Second Clinical College of Dalian Medical University, Dalian, Liaoning, 116044, China
| | - Xiaowei Qian
- Yangzhou University Medical College, Yangzhou, Jiangsu, 225001, China
| | - Ling Li
- The Second Clinical College of Dalian Medical University, Dalian, Liaoning, 116044, China
| | - Jie Yao
- Department of Hepatobiliary and Pancreatic Surgery, Northern Jiangsu People's Hospital, Clinic Medical College of Yangzhou University, Yangzhou, Jiangsu, 225001, China.
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Daskalakis K, Norlén O, Hellman P, Stålberg P. Applying the use of novel biomarkers for neuroendocrine tumors in the clinic: where are we now? INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2019. [DOI: 10.2217/ije-2017-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kosmas Daskalakis
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
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16
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Zhang H, Shen G, Zhang S, Du F, Cao Y, Jiang J, Zheng F, Ma X, Wang Z, Ren D, Ahmad R, Zhao F, Zhao J. Novel fluoropyrimidine-based chemotherapy for advanced well-differentiated neuroendocrine tumors: a clinical update. Expert Opin Pharmacother 2018; 19:795-807. [PMID: 29693454 DOI: 10.1080/14656566.2018.1465928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patients with advanced well-differentiated neuroendocrine tumors (NETs) who have bulky and/or symptomatic and/or rapidly progressive disease require chemotherapy treatment. AREAS COVERED This review summarizes the accumulating evidence for treatment with fluorouracil-based chemotherapy in well-differentiated NETs. The main clinical studies, toxicity and predictors of fluorouracil- based chemotherapy regimens in well-differentiated NETs are discussed, along with the current issues, future research directions and therapeutic prospects. EXPERT OPINION Somatostatin analogs may control symptoms of hormone excess and tumor growth in patients with well-differentiated metastatic NETs, and biological therapies may improve progression-free survival for these patients. However, chemotherapy leads to higher objective response rates and symptom control by reducing tumor bulk. The low response rate and significant toxicities of conventional chemotherapy regimens limit their widespread use. Fortunately, some novel fluoropyrimidine-based treatment including fluorouracil, capecitabine, or S-1 based chemotherapy with or without antiangiogenic agents have been investigated in recent years. These treatments showed significant efficacy and less toxicity in pancreatic and non-pancreatic metastatic well-differentiated NETs. Additionally, non-pancreatic well-differentiated NETs have also achieved similar tumor response or survival comparable to pancreatic NETs. Moreover, some predictors of response to these treatment regimens have been evaluated.
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Affiliation(s)
- Heling Zhang
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Guoshuang Shen
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Shuisheng Zhang
- b Department of Medical Oncology , National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Feng Du
- c Peking University Cancer Hospital and Institute , Beijing , China
| | - Yang Cao
- d The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou , China
| | - Jun Jiang
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Fangchao Zheng
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Xinfu Ma
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Ziyi Wang
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Dengfen Ren
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Raees Ahmad
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Fuxin Zhao
- a Affiliated Hospital of Qinghai University , Xining , China
| | - Jiuda Zhao
- a Affiliated Hospital of Qinghai University , Xining , China
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Abstract
The majority of neuroendocrine tumours (NETs) are well-differentiated tumours that follow an indolent course, in contrast to a minority of poorly differentiated neuroendocrine carcinomas (NECs) which exhibit an aggressive course and assocaited with an overall short survival. Although surgery is the only curative treatment for NETs it is not always feasible,necessitating the application of other therapies including chemotherapy. Streptozotocin (STZ)-based regimens have long been used for advanced or metastatic well-to-moderately differentiated (G1-G2) NETs, especially those originating from the pancreas (pNETs). In poorly differentiated grade 3 (G3) tumours, platinum-based chemotherapy is recommended as first-line therapy, albeit without durable responses. Although data for temozolomide (TMZ)-based chemotherapy are still evolving, this treatment may replace STZ-based regimens in pNETs due to its better tolerability and side effect profile. In addition, there is evidence that TMZ could also be used in the subgroup of well-differentiated G3 NETs. There is less clear-cut evidence of a benefit for chemotherapy in intestinal NETs, but still evolving data suggest that TMZ may be efficacious in particular patients. In lung and thymic carcinoids, chemotherapy is reserved for patients with progressive metastatic disease in whom other treatment options are unavailable. Overall, chemotherapy is indicated in patients who have progressed on first-line treatment with somatostatin analogues, have extensive tumour load or exhibit rapid growth following a period of follow-up, and/or have a high proliferative rate; it may occasionally can be used in a neo-adjuvant setting. Prospective randomised studies are awaited to substantiate the role of chemotherapy in the therapeutic algorithm of NETs along with other evolving treatments.
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Affiliation(s)
- Anna Angelousi
- Department of Pathophysiology, Endocrine Oncology Unit, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Gregory Kaltsas
- Department of Pathophysiology, Endocrine Oncology Unit, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Endocrinology, University of Warwick Medical School, Coventry, UK
| | - Anna Koumarianou
- Hematology- Oncology Unit, Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Attikon Hospital, Athens, Greece
| | - Martin O Weickert
- Department of Endocrinology, University of Warwick Medical School, Coventry, UK
| | - Ashley Grossman
- Neuroendocrine Tumour Centre, Royal Free Hospital, London, UK
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18
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Sampathirao N, Basu S. MIB-1 Index-Stratified Assessment of Dual-Tracer PET/CT with 68Ga-DOTATATE and 18F-FDG and Multimodality Anatomic Imaging in Metastatic Neuroendocrine Tumors of Unknown Primary in a PRRT Workup Setting. J Nucl Med Technol 2017; 45:34-41. [PMID: 28154019 DOI: 10.2967/jnmt.116.185777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 11/30/2016] [Indexed: 01/08/2023] Open
Abstract
Our aim was to comparatively assess dual-tracer PET/CT (68Ga-DOTATATE and 18F-FDG) and multimodality anatomic imaging in studying metastatic neuroendocrine tumors (NETs) of unknown primary (CUP-NETs) scheduled for peptide receptor radionuclide therapy for divergence of tracer uptake on dual-tracer PET/CT, detection of primary, and overall lesion detection vis-a-vis tumor proliferation index (MIB-1/Ki-67). Methods: Fifty-one patients with CUP-NETs (25 men, 26 women; age, 22-74 y), histopathologically proven and thoroughly investigated with conventional imaging modalities (ultrasonography, CT/contrast-enhanced CT, MRI, and endoscopic ultrasound, wherever applicable), were retrospectively analyzed. Patients were primarily referred for deciding on feasibility of peptide receptor radionuclide therapy (except 2 patients), and all had undergone 68Ga-DOTATATE and 18F-FDG PET/CT as part of pretreatment workup. The sites of metastases included liver, lung/mediastinum, skeleton, abdominal nodes, and other soft-tissue sites. Patients were divided into 5 groups on the basis of MIB-1/Ki-67 index on a 5-point scale: group I (1%-5%) (n = 35), group II (6%-10%) (n = 8), group III (11%-15%) (n = 4), group IV (16%-20%) (n = 2), and group V (>20%) (n = 2). Semiquantitative analysis of tracer uptake was undertaken by SUVmax of metastatic lesions and the primary (when detected). The SUVmax values were studied over increasing MIB-1/Ki-67 index. The detection sensitivity of 68Ga-DOTATATE for primary and metastatic lesions was assessed and compared with other imaging modalities including 18F-FDG PET/CT. Results: Unknown primary was detected on 68Ga-DOTATATE in 31 of 51 patients, resulting in sensitivity of 60.78% whereas overall lesion detection sensitivity was 96.87%. The overall lesion detection sensitivities (individual groupwise from group I to group V) were 97.75%, 87.5%, 100%, 100%, and 66.67%, respectively. As MIB-1/Ki-67 index increased, 68Ga-DOTATATE uptake decreased in metastatic and primary lesions (mean SUVmax, 43.5 and 22.68 g/dL in group I to 22.54 and 16.83 g/dL in group V, respectively), whereas 18F-FDG uptake showed a gradual rise (mean SUVmax, 3.66 and 2.86 g/dL in group I to 7.53 and 9.58 g/dL in group V, respectively). There was a corresponding decrease in the 68Ga-DOTATATE-to-18F-FDG uptake ratio with increasing MIB-1/Ki-67 index (from 11.89 in group I to 2.99 in group V). Conclusion: In CUP-NETs, the pattern of uptake on dual-tracer PET (68Ga-DOTATATE and 18F-FDG) correlates well with tumor proliferation index with a few outliers; combined dual-tracer PET/CT with MIB-1/Ki-67 index would aid in better whole-body assessment of tumor biology in CUP-NETs.
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Affiliation(s)
- Nikita Sampathirao
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai
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Lamarca A, Barriuso J, McNamara MG, Hubner RA, Valle JW. Telotristat ethyl: a new option for the management of carcinoid syndrome. Expert Opin Pharmacother 2016; 17:2487-2498. [PMID: 27817224 DOI: 10.1080/14656566.2016.1254191] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Many patients with neuroendocrine tumour-related carcinoid syndrome treated with somatostatin analogues (SSA) won't achieve adequate symptom relief with the SSA alone; new treatment options are required. Telotristat ethyl is a tryptophan hydroxylase inhibitor, developed for the treatment of carcinoid syndrome. Areas covered: This review summarises the evidence supporting the role of telotristat ethyl in the management of carcinoid syndrome. Rationale, pharmacodynamics, pharmacokinetics, metabolism, clinical experience, efficacy and toxicity profiles are covered. Expert opinion: The efficacy of telotristat ethyl in producing a statistically-significant and clinically-meaningful reduction in daily bowel movements has been confirmed in phase III clinical trials. Two pivotal trials, TELESTAR and TELECAST, explored the role of telotristat ethyl in the management of patients with carcinoid syndrome refractory to SSAs focusing on patients with ≥4 and <4 daily bowel movements, respectively. In addition, benefit was confirmed in patient-reported outcomes. Based on activity and safe toxicity profile, telotristat ethyl is pending regulatory agencies evaluation and is likely to add to the armamentarium used to treat carcinoid syndrome. Long-term safety and efficacy data will be available from the ongoing TELEPATH study. The impact on carcinoid heart disease, mesenteric fibrosis and other long-term complications of carcinoid syndrome as well as its role earlier in patients' pathways remain investigational.
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Affiliation(s)
- Angela Lamarca
- a Department of Medical Oncology , The Christie NHS Foundation Trust , Manchester , UK
| | - Jorge Barriuso
- a Department of Medical Oncology , The Christie NHS Foundation Trust , Manchester , UK.,b Faculty of Medical, Biological and Human Sciences , University of Manchester , Manchester , UK
| | - Mairéad G McNamara
- a Department of Medical Oncology , The Christie NHS Foundation Trust , Manchester , UK.,c Institute of Cancer Sciences , University of Manchester , Manchester , UK
| | - Richard A Hubner
- a Department of Medical Oncology , The Christie NHS Foundation Trust , Manchester , UK
| | - Juan W Valle
- a Department of Medical Oncology , The Christie NHS Foundation Trust , Manchester , UK.,c Institute of Cancer Sciences , University of Manchester , Manchester , UK
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20
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Pavel ME, Sers C. WOMEN IN CANCER THEMATIC REVIEW: Systemic therapies in neuroendocrine tumors and novel approaches toward personalized medicine. Endocr Relat Cancer 2016; 23:T135-T154. [PMID: 27649723 DOI: 10.1530/erc-16-0370] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 12/19/2022]
Abstract
Neuroendocrine tumors (NETs) are a group of heterogenous neoplasms. Evidence-based treatment options for antiproliferative therapy include somatostatin analogues, the mTOR inhibitor everolimus, the multiple tyrosine kinase inhibitor sunitinib and peptide receptor radionuclide therapy with 177-Lu-octreotate. In the absence of definite predictive markers, therapeutic decision making follows clinical and pathological criteria. As objective response rates with targeted drugs are rather low, and response duration is limited in most patients, numerous combination therapies targeting multiple pathways have been explored in the field. Upfront combination of drugs, however, is associated with increasing toxicity and has shown little benefit. Major advancements in the molecular understanding of NET based on genomic, epigenomic and transcriptomic analysis have been achieved with prognostic and therapeutic impact. New insight into molecular alterations has paved the way to biomarker-driven clinical trials and may facilitate treatment stratification toward personalized medicine in the near future. However, an improved understanding of the complexity of pathway interactions is required for successful treatment. A systems biology approach is one of the tools that may help to achieve this endeavor.
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Affiliation(s)
- Marianne E Pavel
- Medical DepartmentDivision of Hepatology and Gastroenterology including Metabolic Diseases, Campus Virchow Klinikum, Charité University Medicine, Berlin, Germany
| | - Christine Sers
- Institute of PathologyCharité University Medicine, Berlin, Germany
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