From the Guidelines
Surgical resection offers the best chance for long-term survival in patients with liver metastases from pancreatic neuroendocrine tumors (PNETs) when metastases are limited and complete removal is possible. Treatment options for liver metastases from PNETs include both local and systemic approaches based on disease extent and patient factors.
Local Approaches
- Surgical resection of both the primary tumor and liver metastases can be performed in a staged or synchronous fashion, with hepatectomy considered before pancreatic resection to reduce the risk of perihepatic sepsis 1.
- Liver-directed therapies include radiofrequency ablation, microwave ablation, transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and stereotactic body radiation therapy (SBRT).
Systemic Approaches
- Systemic treatments include somatostatin analogs like octreotide LAR (20-30 mg every 4 weeks) or lanreotide (120 mg every 4 weeks), which control symptoms and slow tumor growth 1.
- For progressive disease, targeted therapies such as everolimus (10 mg daily) or sunitinib (37.5 mg daily) may be used.
- Peptide receptor radionuclide therapy (PRRT) with lutetium-177 dotatate (200 mCi every 8 weeks for 4 cycles) is effective for somatostatin receptor-positive tumors 1.
- Cytotoxic chemotherapy with temozolomide-based regimens (e.g., temozolomide 150-200 mg/m² days 1-5 with capecitabine 750 mg/m² twice daily days 1-14, every 28 days) is used for aggressive tumors. Treatment selection depends on tumor burden, growth rate, symptoms, and patient performance status, with multidisciplinary evaluation recommended to determine the optimal approach for each patient 1.
From the FDA Drug Label
LANREOTIDE injection, for subcutaneous use ... INDICATIONS AND USAGE Lanreotide Injection is a somatostatin analog indicated for: ... the treatment of adult patients with unresectable, well- or moderately- differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to improve progression-free survival. (1.2)
The treatment options for liver metastases from a pancreatic neuroendocrine tumor (PNET) include lanreotide.
- Lanreotide is a somatostatin analog that can be used to improve progression-free survival in adult patients with unresectable, well- or moderately-differentiated, locally advanced or metastatic GEP-NETs, which includes PNETs with liver metastases.
- The recommended dosage of lanreotide for GEP-NETs is 120 mg every 4 weeks 2.
- Another option is sunitinib, which is indicated for the treatment of progressive, well-differentiated pancreatic neuroendocrine tumors (pNET) in adult patients with unresectable locally advanced or metastatic disease 3.
- The recommended dosage of sunitinib for pNET is 37.5 mg orally once daily 3.
From the Research
Treatment Options for Liver Metastases from PNET
The treatment options for liver metastases from pancreatic neuroendocrine tumors (PNETs) include:
- Surgical treatment: Surgery remains the only potentially curative therapeutic option in patients with PNETs and resectable liver metastases, even if relapse rates are high 4.
- Loco-regional therapies: Several techniques for loco-regional control of metastases are available, including chemo- or radioembolization 4, 5, 6.
- Pharmacological treatment: Efficacy of medical treatment has increased with advances in targeted therapies, such as everolimus and sunitinib, and the introduction of radiolabeled somatostatin analogs 4, 7, 6, 8.
- Peptide receptor radionuclide therapy: This is a novel method of treatment in patients with metastatic neuroendocrine tumors (NETs), with preliminary results showing partial response and minimal response to treatment in 28% and 3% of patients, respectively 7.
- Hepatic cytoreduction: This can palliate progressive symptoms associated with liver metastases from intractable neuroendocrine tumors, and postoperative adjuvant therapy with octreotide LAR can prolong symptom-free survival 8.
Considerations for Treatment
When considering treatment options, it is essential to take into account the individual patient's and tumor's features, as well as the burden of liver disease 4, 5. A multidisciplinary approach is recommended to determine the best course of treatment 4, 5.
Available Therapies
Several liver-directed therapies are available for patients who are not surgical candidates, including:
- Transarterial embolization
- Chemoembolization
- Radioembolization 5, 6 These therapies can assist with locoregional control, extend progression-free survival (PFS), and improve symptoms of carcinoid syndrome 5.
Systemic Therapy Options
Multiple systemic therapy options exist for patients with metastatic PNET, which are often prioritized for those patients with advanced or progressive disease 5.