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Rationale: Multiple endocrine neoplasia type 1 (MEN1) syndrome is a rare and complicated disease that is associated with several endocrine tumors. Here, we report a case of MEN1 associated with insulinoma, parathyroid, and pituitary tumors by 68Ga-DOTATATE positron emission tomography/computed tomography (PET/CT). Patient concerns: A 49-year-old woman presented with intermittent hypoglycemia for more than a year and developed indistinct consciousness without an apparent trigger. Diagnoses: Biochemical results showed abnormally high serum insulin and parathyroid hormone levels. She underwent an Abdominal magnetic resonance imaging revealed a small nodule in the uncinate process of the pancreas, but it did not clarify the nature of the small nodule. Pituitary magnetic resonance imaging scan revealed a micropituitary tumor, and parathyroid imaging showed no abnormalities. 18F-FDG PET/CT showed no apparent abnormal 18F-FDG uptake in the whole body. In contrast, 68Ga-DOTATATE PET/CT imaging showed pathological radiotracer uptake in the pancreatic uncinate process, accompanied by mild radiotracer uptake in the pituitary gland, and no apparent abnormal radiotracer uptake in the parathyroid area. Interventions: The patient underwent echoendoscopy for pancreatic uncinate process lesions and surgical resection. Outcomes: Histological analysis was suggested of insulinoma of pancreatic neuroendocrine tumor, the Ki-67 index was low (only 1% being positive). Lessons: This case demonstrates that 68Ga-DOTATATE can be used for the detection of MEN1-related tumors and preoperative localization of small and low-grade insulinomas by PET/CT.

6095 Background: In the multicenter, double-blind, randomized, phase 3 REALITY study, apatinib significantly improved clinical benefits in terms of progression-free survival (PFS), overall survival (OS) and objective response rate (ORR) compared to placebo with a tolerable safety profile in patients with progressive locally advanced or metastatic radioactive iodine-refractory, differentiated thyroid cancer (RAIR-DTC). Here, we investigate the association between baseline characteristics and survival endpoints. Methods: Post-hoc analyses of PFS and OS were done in patients treated with apatinib according to the following subgroups: ECOG performance status (PS) (0 vs 1-2), thyroglobulin (Tg) ( < 223 vs ≥ 223 ng/mL), and tumor target lesions diameter ( < 33.2 vs ≥ 33.2 cm). Results: Among 92 patients with RAIR-DTC included in the study, 46 patients received apatinib. As of December 3, 2021, median PFS was 25.77 (95% CI 11.14-not reached [NR]) vs 11.08 months (95% CI 7.17-NR) for ECOG PS 0 / 1-2, though no statistical significance (HR 0.454, 95% CI 0.161-1.285, p = 0.1373). The median OS was significant prolonged in patients with ECOG PS of 0 compared with those ECOG 1-2 (not reached vs 29.42 months, 95% CI 18.87-NR; HR 0.199, 95% CI 0.054-0.733, p = 0.0152). In subgroups by Tg, median PFS was 25.77 (95% CI 9.11-NR) vs 11.08 (95% CI 5.65-NR) months for Tg < 223 / ≥ 223 ng/mL. A trend towards improved PFS was observed (HR 0.444, 95% CI 0.145-1.361, p = 0.1556). The median OS was significantly improved in patients with Tg < 223 in contrast to those Tg ≥ 223 ng/mL (NR vs 25.87 months, 95% CI 13.58-NR; HR 0.151, 95% CI 0.033-0.689, p = 0. 0147). The median PFS for tumor target lesions diameter < 33.2 cm was significantly improved relative to those ≥33.2 cm (25.77, 95% CI 11.14-NR vs 9.11 months, 95% CI 5.65-NR) with a significant difference (HR 0.289, 95% CI 0.097- 0.859, p = 0.0255); OS data in two subgroups were not mature (NR, 95% CI 29.42-NR vs NR, 95% CI 17.95-NR; HR 0.364, 95% CI 0.112-1.184, p = 0.0932). Conclusions: Post-hoc analysis indicated that among patients receiving apatinib, longer OS benefits were associated with better ECOG PS, lower Tg levels; longer PFS benefits were associated with smaller tumor diameter. These results suggest a better prognosis for early initiation of apatinib treatment in patients with RAIR-DTC. Clinical trial information: NCT03048877.