Herein, we present the case of a 48yo Caucasian male diagnosed with a well differentiated (WD) pancreatic NET. At primary resection in 2014 pathological staging was pT3N1M0 R0 with Ki67 4%. 5 years later he developed recurrence in local lymph nodes and started on lanreotide followed by IRE on subsequent progression. In 2020, there was strongly DPET-avid metastases in mesenteric nodes and liver, so he was enrolled onto the COMPETE trial1. There was sequential progressive disease in the liver after PRRT (PFS 34.2 months) and 5 cycles of everolimus (PFS 7.8 months). He had further widespread disease progression on both DPET and FDG PET in 2023. Capecitabinetemozolamide (CAPTEM) and zometa was commenced and a liver biopsy showed a WD NET with Ki67 19%. He deteriorated clinically after 3 cycles so did not receive any further systemic treatment (OS 9.5 years).
Conclusions: Scheduling of treatment in WD G2 NET represents a challenging landscape. Though CAPTEM is an established first-line treatment with prospective data2, would an earlier biopsy prompted us to use 5FU based treatment3,4 given the rapid rate of progression. Positive FDG PET is significantly associated with reduced overall survival5, thus this may help to guide treatment choice.
References: 1. Pavel, M. E., Rinke, A., & Baum, R. P. (2018). COMPETE trial: Peptide receptor radionuclide therapy (PRRT) with 177Lu-edotreotide vs. everolimus in progressive GEPNET. Annals of Oncology, 29, viii478. https://doi.org/10.1093/annonc/mdy293.028. 2. Zappi, A., Persano, I., Galvani, L., Parlagreco, E., Andrini, E., Campana, D., Brizzi, M. P., Lamberti, G., & La Salvia, A. (2023). Chemotherapy in well differentiated neuroendocrine tumors (NET) G1, G2, and G3: A narrative review. Journal of Clinical Medicine, 12(2), 717. https://doi.org/10.3390/jcm12020717. 3. Dilz, L.-M., Denecke, T., Steffen, I. G., Prasad, V., von Weikersthal, L. F., Pape, U.-F., Wiedenmann, B., & Pavel, M. (2015). Streptozocin/5-fluorouracil chemotherapy is associated with durable response in patients with advanced pancreatic neuroendocrine tumours. European Journal of Cancer (Oxford, England: 1990), 51(10), 12531262. https://doi.org/10.1016/j.ejca.2015.04.005. 4. Pavel, M., Öberg, K., Falconi, M., Krenning, E. P., Sundin, A., Perren, A., & Berruti, A. (2020). Gastroenteropancreatic neuroendocrine neoplasms: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 31(7), 844860. https://doi.org/10.1016/j.annonc.2020.03.304. 5. Solar Vasconcelos, J. P., Zhou, M., Ravi, P., Allan, H., Saprunoff, H., Bloise, I., Harsini, S., Wilson, D., Benard, F., Martineau, P., & Loree, J. M. (2023). Prospective evaluation of the utility of concurrent 18F-FDG PET/CT and 68Ga-DOTA-TOC imaging in gastroenteropancreatic neuroendocrine neoplasms (GEPNENs): The PETNET study. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 41(16_suppl), 40224022. https://doi.org/10.1200/jco.2023.41.16_suppl.4022