What is the best approach for a metastatic neuroendocrine tumor (NET) in the tail of the pancreas with liver metastasis, in a physically fit patient with mild symptoms, normal liver function tests (LFTs), and multiple liver nodules?

From the Guidelines

The best approach for a metastatic neuroendocrine tumor in the tail of the pancreas with liver metastasis, in a physically fit patient with mild symptoms, normal liver function tests (LFTs), and multiple liver nodules is a multidisciplinary treatment strategy that includes long-acting somatostatin analogs, peptide receptor radionuclide therapy, and liver-directed therapies such as transarterial embolization or radiofrequency ablation. Initial management should include somatostatin analogs such as octreotide LAR 30mg intramuscularly every 4 weeks or lanreotide 120mg subcutaneously every 4 weeks to control symptoms and potentially slow tumor growth, as recommended by recent guidelines 1. For this specific presentation with multiple liver nodules but otherwise good performance status, systemic therapy options include targeted agents like everolimus (10mg daily) or sunitinib (37.5mg daily), which have shown efficacy in pancreatic neuroendocrine tumors. Peptide receptor radionuclide therapy (PRRT) with lutetium-177 dotatate should be considered if the tumor shows high somatostatin receptor expression on imaging, as it has been shown to be effective in controlling symptoms and potentially slowing tumor growth 1. Liver-directed therapies such as transarterial embolization or radiofrequency ablation may provide additional benefit for controlling liver metastases, as they have been shown to be effective in reducing tumor burden and alleviating symptoms 1. Surgical resection of both the primary tumor and liver metastases could be considered if technically feasible and if the metastatic burden is limited. This comprehensive approach is recommended because pancreatic neuroendocrine tumors often have an indolent course, and patients with preserved liver function and good performance status can benefit from multiple lines of therapy aimed at both controlling symptoms and extending survival. Key considerations in the management of these patients include:

• The use of somatostatin analogs as first-line therapy to control symptoms and potentially slow tumor growth
• The consideration of peptide receptor radionuclide therapy for patients with high somatostatin receptor expression on imaging
• The use of liver-directed therapies such as transarterial embolization or radiofrequency ablation to control liver metastases
• The potential for surgical resection of both the primary tumor and liver metastases in selected patients.

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.

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 recommended 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, 2, 2.

From the Research

Treatment Approaches for Metastatic Neuroendocrine Tumors (NETs)

• For a physically fit patient with mild symptoms, normal liver function tests (LFTs), and multiple liver nodules, a multidisciplinary approach is recommended 3, 4, 5.
• The treatment of choice for patients with resectable liver metastases is primary tumor resection with resection of liver metastases 4.
• For patients with unresectable liver metastases, liver-directed therapies such as cytoreductive surgery, thermal ablation, and embolization can be considered 3, 5.
• Systemic medical therapy, including somatostatin analogues, cytotoxic chemotherapy, and targeted therapies, can be used to manage tumor burden and symptoms caused by NETs 3, 5.
• Resection of the primary pancreatic neuroendocrine tumor may be beneficial in terms of survival, even in patients with unresectable liver metastases, and should be discussed within a multidisciplinary team 6.

Key Considerations

• A multidisciplinary approach, including medical oncologists, surgeons, interventional radiologists, and radiation oncologists, is essential for the management of NETs with liver metastases 3, 4, 5.
• The treatment plan should be personalized according to the tumor's features and prognostic factors, with the goal of preserving a satisfactory quality of life for the patient 3.
• The timing and indication for resection of the primary tumor should be discussed within a multidisciplinary team, taking into account factors such as age, Ki-67 index, and liver tumor burden 6.