What is the best approach for a metastatic neuroendocrine tumor (NET) in the tail of the pancreas with liver metastasis?

From the Guidelines

The best approach for a metastatic neuroendocrine tumor in the tail of the pancreas with liver metastasis is a multidisciplinary treatment strategy, prioritizing long-acting somatostatin analogs, bland transarterial embolization (TAE), peptide receptor radionuclide therapy (PRRT), or transarterial chemoembolization (TACE) as comparable alternatives, as recommended by the most recent guidelines 1.

Key Considerations

• Initial management should include somatostatin analogs such as octreotide LAR 30mg intramuscularly every 4 weeks or lanreotide 120mg subcutaneously every 4 weeks to control hormone-related symptoms and potentially slow tumor growth.
• For liver metastases, consider liver-directed therapies including surgical resection if feasible, radiofrequency ablation, or transarterial chemoembolization (TACE).
• Systemic therapy options include everolimus 10mg daily or sunitinib 37.5mg daily for progressive disease.
• Peptide receptor radionuclide therapy (PRRT) with lutetium-177 dotatate should be considered if the tumor shows high somatostatin receptor expression on imaging, as supported by recent guidelines 1.

Treatment Options

• Long-acting somatostatin analogs: octreotide LAR or lanreotide
• Liver-directed therapies: surgical resection, radiofrequency ablation, TAE, TACE, or PRRT
• Systemic therapy: everolimus, sunitinib, or chemotherapy

Monitoring and Follow-up

• Regular monitoring with chromogranin A levels, cross-sectional imaging every 3-6 months, and symptom assessment is essential.
• Adjust treatment strategies based on disease progression, symptom control, and patient functional status.

Recent Guidelines

• The 2022 update of the ACR Appropriateness Criteria for management of liver cancer recommends long-acting somatostatin analogs, bland TAE, PRRT, or TACE as comparable alternatives for multifocal metastatic neuroendocrine tumor to the liver 1.
• The 2020 ESMO clinical practice guidelines for diagnosis, treatment, and follow-up of gastroenteropancreatic neuroendocrine neoplasms support the use of PRRT in SSTR-positive Pan-NETs, with consideration of earlier use in the treatment algorithm 1.

From the FDA Drug Label

1. 2 Gastroenteropancreatic Neuroendocrine Tumors Lanreotide Injection is 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.

2. 1 Recommended Dosage Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) The recommended dosage of Lanreotide Injection is 120 mg administered every 4 weeks by deep subcutaneous injection.

The best approach for a metastatic neuroendocrine tumor (NET) in the tail of the pancreas with liver metastasis is to use Lanreotide Injection at a dosage of 120 mg administered every 4 weeks by deep subcutaneous injection, as it is 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 2.

• Key points:
  • Dosage: 120 mg every 4 weeks
  • Administration: deep subcutaneous injection
  • Indication: metastatic GEP-NETs to improve progression-free survival

From the Research

Treatment Approaches for Metastatic Neuroendocrine Tumors (NETs) in the Pancreas with Liver Metastasis

• The management of neuroendocrine tumor liver metastases (NELMs) requires a multi-disciplinary approach 3.
• Primary tumor resection with resection of liver metastases is the treatment of choice for patients with NELMs 3.
• Liver-directed therapies, such as hepatic resection, radiofrequency ablation, chemoembolization, and transarterial embolization, can be considered for patients with unresectable liver metastases 4, 5.
• Systemic medical therapy is used for managing tumor burden and symptoms caused by NELMs 3.

Liver-Directed Therapies

• Hepatic resection is associated with highly favorable overall survival (OS) in patients with NELMs 4.
• Radiofrequency ablation (RFA) has been associated with symptomatic response rates of 71-95% for a mean duration of 8-10 months 5.
• Transarterial chemoembolization (TACE) has been associated with symptomatic response rates of 60-95% and a 5-year survival of between 50% and 65% 5.

Systemic Therapies

• Radiolabeled somatostatin analog therapy, such as 177Lu-DOTA-EB-TATE, has shown promise in the treatment of advanced metastatic NETs 6.
• This therapy has been associated with increased uptake and retention in NETs, as well as significantly increased accumulation in the kidneys and red marrow 6.

Prognostic Factors

• Age, small bowel primary site, hepatic resection, well-differentiated tumors, alkaline phosphatase within normal limit, and chromogranin A within normal limit are significant independent prognosticators for OS in patients with NELMs 4.