Prior Resection of the Primary Tumor Prolongs Survival After Peptide Receptor Radionuclide Therapy of Advanced Neuroendocrine Neoplasms

Abstract

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The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors

“…A recent study from the group at Bad Berka compared patients with stage IV NETs who had their primary tumors removed before PRRT (486/889 patients, 55%) with those who had PRRT without primary tumor resection (402 patients, 45%). 219 Of these, 38% had PNETs and 32% had small bowel NETs, with a mean of 4 cycles of PRRT given ( 177 Lu-or 90 Y-DOTATATE or TOC, or combination of both in 52% of patients). Of the PNET patients, 148/335 (44.2%) presented after resection of their primary tumors (two-thirds were pancreatic head resections, less than one-third distal pancreatectomies) and 55.8% had PRRT only.…”

“…220 Recommendations: Even though many studies have suggested a potential benefit to resecting primary PNETs in patients with metastatic disease, all are flawed by virtue of their retrospective nature and the high likelihood of selection bias. Recent studies reporting excellent results with primary resection and PRRT 219 further highlight the need for prospective, randomized trials. No consensus was reached on this question, but the majority felt that resection of the primary may be beneficial under select circumstances.…”

“…211 Kammerer et al reported that in their series of 889 patients with stage IV NETs (38% of which were PNETs), that 71.6% of patients had extrahepatic disease, yet they still derived significant survival benefit from resecting the primary tumor and having PRRT relative to having PRRT alone. 219 None of these studies addressed whether patients with extrahepatic disease had a diminished survival benefit of resecting the primary tumor.…”

“…Two studies have examined whether primary resection improves the response to PRRT in metastatic PNETs, but Bertani et al specifically excluded patients having resection of the primary tumor and cytoreduction, 207 while Kaemmerer et al did not report on results or frequency of cytoreductive procedures. 219 Previous studies have suggested that lower tumor burdens result in improved responses with PRRT, 232,233 which may explain why survival benefits were seen after resecting primary tumors then giving PRRT. Performing hepatic cytoreduction prior to PRRT could hypothetically improve the delivery of the isotope to other metastatic sites.…”

Endokrine und neuroendokrine Tumoren

“…Neben der chirurgischen Resektion des Primarius, die in vielen Fällen auch bei kleinen Tumoren im metastasierten Stadium mit der Intention, lokale Komplikationen durch Tumorwachstum zu vermeiden, und zur Kontrollehormonbedingter Symptome indiziert ist, gibt es eine Vielzahl an weiteren Therapieoptionen bei fortgeschrittenen NETs, und die Molekularpathologie hat auch hier einen wichtigen Stellenwert. Bei fortgeschrittenen NEC G3 ist die Chirurgie nur Ausnahmsweise Bestandteil einer multimodalen Therapie [8,12]. Somatostatinanaloga (SSA; Octreotid, Lanreotid) binden in unterschiedlicher Affinität an die SSTR und hemmen einerseits die Hormonausschüttung, andererseits haben sie eine antiproliferative Wirkung.…”