Sequential Use of 90Y Microspheres Radioembolization and 177Lu-Dotatate in Pluri-Metastatic Neuroendocrine Tumors: A Case Report

Abstract

90 Y radioembolization and peptide-receptor radionuclide therapy (PRRT) with 177 Lu-DOTATATE are both effective treatments for patients with inoperable neuroendocrine metastatic tumors (NET). We report the case of a 72-year-old man with severe functional syndrome due to a metastatic NET. 68 Ga-DOTATOC positron-emission tomography (PET) revealed high somatostatin receptor expression in a gross liver metastasis, in one abdominal lymph node and in several s k e l e t a l l e s i o n s . T h e p a t i e n t u n d e r w e n t l i v e r radioembolization with 90 Y-resin microspheres followed by four cycles of PRRT with 177 Lu-DOTATATE. After 3 months, a complete remission of the functional syndrome was observed. 68 Ga-DOTATOC PET demonstrated a complete response for skeletal and lymph nodal lesions with a residual bulky mass in the liver. Therefore a further 90 Y radioembolization was performed as consolidation treatment for the hepatic lesion. Six months after these combined treatments, 68 Ga-DOTATOC PET demonstrated complete metabolic response in liver and stable extrahepatic lesions. No significant long-term adverse reactions were registered. To our knowledge, the sequential use of 90 Y radiembolization before and after PRRT in a liver-dominant advanced NET has not been reported in the literature and this case suggests that these combined treatments can be safe and effective.

Intra-arterial versus standard intravenous administration of lutetium-177-DOTA-octreotate in patients with NET liver metastases: study protocol for a multicenter, randomized controlled trial (LUTIA trial)

“…Even though the most recent ENETS guidelines suggest that loco-regional therapies can be applied in the absence of extrahepatic disease, more and more studies suggest that there is room for radioembolization even though extrahepatic disease is present [1,34,37,41]. When extrahepatic disease is present, a combined or sequential application of TARE with PRRT might be of added value in the future [42][43][44].…”

Additional hepatic 166Ho-radioembolization in patients with neuroendocrine tumours treated with 177Lu-DOTATATE; a single center, interventional, non-randomized, non-comparative, open label, phase II study (HEPAR PLUS trial)

“…Nonetheless, concerns arise when implementing RE shortly after PRRT, due to the cumulative radiation dose and the short interval, potentially provoking REILD [ 28 ]. On the other hand in a recent case report, Filippi et al described their treatment combination a patient with one hepatic metastasis, mesenteric metastasis and several bone metastases, diagnosed on a 68 Ga-DOTATATE-PET/CT [ 32 ]. The hepatic metastasis was downstaged with a lobar RE procedure, followed by 4 cycles of PRRT to treat extrahepatic lesions (a mesenteric metastasis and several bone metastases).…”

“…The hepatic metastasis was downstaged with a lobar RE procedure, followed by 4 cycles of PRRT to treat extrahepatic lesions (a mesenteric metastasis and several bone metastases). Restaging after 3 months with a 68 Ga-DOTATATE-PET/CT showed a nearly complete remission of the extrahepatic metastases and an incomplete remission of the hepatic metastasis, thus another additional lobar RE procedure was performed to treat the hepatic lesion, with success [ 32 ]. They reported no significant adverse events of the combined treatments, complete symptomatic control and a survival of 42 months [ 32 ].…”

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“…8 Radioembolization also seems to be an effective and safe procedure if associated with peptide receptor radionuclide therapy. 9 A liver resection after a liver transplant is technically feasible, but no data are available in the setting of NET. Additionally, chemotherapy can be given to NET patients who experience recurrence after liver transplant.…”