Successful neoadjuvant peptide receptor radionuclide therapy for an inoperable pancreatic neuroendocrine tumour

Abstract

SummaryNon-functional pancreatic neuroendocrine tumours (NETs) can present with advanced local or distant (metastatic) disease limiting the possibility of surgical cure. Several treatment options have been used in experimental neoadjuvant settings to improve the outcomes in such cases. Peptide receptor radionuclide therapy (PPRT) using beta emitting radiolabelled somatostatin analogues has been used in progressive pancreatic NETs. We report a 55-year-old female patient with a 12.8 cm pancreatic NET with significant local stomach and superior mesenteric vein compression and liver metastases. The patient underwent treatment with [177Lutetium-DOTA0,Tyr3]octreotate (177Lu-octreotate) for the treatment of local and metastatic symptomatic disease. Six months after 4 cycles of 177lutetium-octreotate, resolution of the abdominal complaints was associated with a significant reduction in tumour size and the tumour was rendered operable. Histology of the tumour showed a 90% necrotic tumour with abundant hyalinized fibrosis and haemorrhage compatible with PPRT-induced radiation effects on tumour cells. This report supports that PPRT has a role in unresectable and metastatic pancreatic NET.Learning points:PRRT with 177Lu-octreotate can be considered a useful therapy for symptomatic somatostatin receptor-positive pancreatic NET.The clinical benefits of PRRT with 177Lu-octreotate can be seen in the first months while tumour reduction can be seen up to a year after treatment.PRRT with 177Lu-octreotate was clinically well tolerated and did not interfere with the subsequent surgical procedure.PRRT with 177Lu-octreotate can result in significant tumour reduction and may improve surgical outcomes. As such, this therapy can be considered as a neoadjuvant therapy.

Somatostatin Analogues in the Treatment of Neuroendocrine Tumors: Past, Present and Future

“…The PRRT is becoming increasingly important in a neoadjuvant setting [99]. In patients with inoperable P-NET and distant (metastatic) disease, PRRT was associated with a significant reduction in tumor size, and the tumor was rendered operable [100]. In such cases, complete response can be achieved.…”

Systemic Treatment Selection for Patients with Advanced Pancreatic Neuroendocrine Tumours (PanNETs)

“…Neoadjvant approach in locally advanced or even metastatic PanNETs with surgical treatment in responders to first line systemic therapy is a potential strategy [ 130 ]. In the recent years, some studies report good results and R0 resections after neoadjuvant PPRT [ 131 , 132 , 133 , 134 ]; however, this should be validated in larger studies and patient selection has to be improved.…”

“…The power of the study cannot be assessed, as the study was not randomised-controlled (which makes it difficult to clarify if the prolonged PFS is due to PRRT or due to patient selection) and did not provide a sample size calculation [ 80 ]. The use of radioisotope treatment in the neoadjuvant [ 131 , 132 , 133 , 134 ] or adjuvant setting [ 41 , 154 ], alone or in combinations with other therapeutics [ 130 ], is being investigated. However, future prospective randomised trials exploring PRRT usage need to provide clarity regarding patient selection, including predictive biomarkers of treatment response (beyond SSTR expression).…”

Neuroendocrine Tumor Therapy with Lutetium-177: A Literature Review

“…Different radiopeptides have also been used in combination with success but definitive proof requires prospective randomized trials. PRRT has proven efficacy as a neoadjuvant treatment for NETs [24]. Its combination with other drugs needs further research.…”