expert roundtables

Metastatic Neuroendocrine Tumors With Carcinoid Syndrome: Individualized Care

by Lowell B. Anthony, MD, FACP; Timothy J. Hobday, MD; and Jonathan R. Strosberg, MD

Overview

For patients with metastatic neuroendocrine tumors (NETs) and carcinoid syndrome, individualized care may involve the consideration of the disease biology, symptom burden, tumor bulk, and sites and patterns of tumor involvement.

Q:

How do you individualize care for patients with lower-grade, metastatic, small bowel NETs with carcinoid syndrome? Does baseline tumor grade influence your approach?

Jonathan R. Strosberg, MD

Professor of Gastrointestinal Oncology
Section Head, Neuroendocrine Tumor Division
Chair, Gastrointestinal Department Research Program
Moffitt Cancer Center
Tampa, FL

“The factors that ultimately determine treatment include how the disease develops and manifests over time, not necessarily the patient’s baseline grade, which reflects just one biopsy or one surgical specimen at a particular point in time.”

Jonathan R. Strosberg, MD

Recommendations for treatment do not differ greatly based on whether a patient has grade 1 or grade 2 disease. If a patient has a Ki-67 proliferative index of greater than 10%, you might want to increase your monitoring frequency. The factors that ultimately determine treatment include how the disease develops and manifests over time, not necessarily the patient’s baseline grade, which reflects just one biopsy or one surgical specimen at a particular point in time. The stability of the patient’s tumor in the recent past is likely a better guide than the tumor grade of 1 vs 2 when it comes to determining the best monitoring frequency. For example, if the tumor has been stable for more than 6 months, you can consider gradually increasing the monitoring interval. 

One of the first questions that relate to individualization is whether the patient is a candidate for surgery. Resection of the primary tumor may be advisable in certain scenarios, and sometimes resections are performed prophylactically. For instance, resection of the primary tumor is certainly indicated if it is causing the patient to be symptomatic. Debulking may be possible, and decisions about debulking depend on how much disease is in the liver, the pattern of liver involvement, and how much disease is outside of the liver. There can be a very large tumor involving an entire hepatic lobe. By removing that lobe, you can achieve significant debulking. In contrast, in a patient with a similar hepatic tumor burden but a more scattered pattern of involvement (ie, many small tumors in both lobes), surgical debulking becomes much less feasible. 

The standard treatment for metastatic unresectable NETs with carcinoid syndrome is a somatostatin analogue (SSA), for both control of the syndrome and stabilization of tumor growth. For patients who progress, you can try increasing the dosage or dosing frequency of the SSA for better control. 

The standard second-line therapy for progressive, metastatic, small bowel NETs consists of peptide receptor radionuclide therapy (PRRT) in patients with somatostatin receptor–expressing tumors. However, we still recommend liver embolization as an alternative second-line therapy in patients with liver-dominant disease if they progress on an SSA. 

Timothy J. Hobday, MD

Associate Professor of Oncology
Education Chair, Division of Medical Oncology
Program Director, Hematology/Oncology Fellowship
Mayo Clinic College of Medicine and Science
Rochester, MN

Once you have a patient whose disease starts to tell its own story and the track record of their disease starts to unfold, then I am a little less concerned about what grade they were assigned at diagnosis.”

Timothy J. Hobday, MD

The difference between a grade 1 and a grade 2 well-differentiated NET may be an artificial distinction in some respects. That is, if one were to biopsy a couple of different sites in the same patient, the Ki-67 proliferative index might be 2% in one sample and 6% in the other, meaning that the same patient might receive a classification of grade 1 or grade 2, depending on the site sampled. I personally review the patient’s symptoms and the disease burden, and I do not know that a Ki-67 of 2% or 6% would make a big difference in how I assess and treat that individual patient. Once you have a patient whose disease starts to tell its own story and the track record of their disease starts to unfold, then I am a little less concerned about what grade they were assigned at diagnosis.

At the population level, however, grade 1, grade 2, and well-differentiated grade 3 NETs are associated with different long-term prognoses. Additionally, the Ki-67 proliferative index can change over time. As the Ki-67s get higher (eg, 10%, 15%, or 20%), that may influence what we anticipate for the future, and I might follow that patient more closely (if I am following them) or treat them more aggressively (if I am treating them).

Regarding surgery/embolic therapy vs PRRT, I would consider trying PRRT in a patient who had symptoms and a significant extrahepatic metastatic disease burden, outside of their primary and regional tumor. Surgical or embolic techniques are likely more reliable for trying to improve difficult symptomatic situations if they are due to the locoregional disease or significant liver involvement.

Lowell B. Anthony, MD, FACP

Professor and Chief

Division of Medical Oncology

Department of Medicine

Member, UK Markey Cancer Center

University of Kentucky

Lexington, KY

“ . . . baseline tumor grade is a single factor out of many that should be considered. The patient's care is individualized according to their biology, symptomatology, disease sites, and disease bulk.”

Lowell B. Anthony, MD, FACP

I agree with my colleagues that baseline tumor grade is a single factor out of many that should be considered. The patient's care is individualized according to their biology, symptomatology, disease sites, and disease bulk. If you were going to try to match a monitoring frequency to their biology, for grade 1, you might scan them twice per year. For grade 2, you might consider scans every 3 or 4 months. For patients with grade 2 NETs, depending on how things are unfolding, we may start them on a treatment earlier rather than waiting for disease progression.

A small group of patients might de-differentiate into a more aggressive phenotype, and then we would have to adjust their treatment accordingly. The role of chemotherapy has not been well described for patients with grade 3 disease. There are some data to support the use of capecitabine. If the tumor is grade 3 and the patient is not syndromic, we may still use an SSA or we might go straight to chemotherapy. For grades 1 and 2, we would never go straight to chemotherapy; we would only use chemotherapy if the tumor de-differentiated. I have seen a few patients who have poorly differentiated NETs that are nonetheless functional. It is not common, but it does occur.

Normally, for grades 1, 2, and 3, if they are well differentiated, you would generally expect them to express somatostatin receptors, and the DOTATATE positron emission tomography/computed tomography would show uptake. PRRT would be useful for patients with significant tumor bulk and significant bone involvement, along with lymph node and, potentially, liver involvement.

References

Bodei L, Ćwikla JB, Kidd M, Modlin IM. The role of peptide receptor radionuclide therapy in advanced/metastatic thoracic neuroendocrine tumors. J Thorac Dis. 2017;9(suppl 15):S1511-S1523. doi:10.21037/jtd.2017.09.82

Lamarca A, Cives M, de Mestier L, et al. Advanced small-bowel well-differentiated neuroendocrine tumours: an international survey of practice on 3rd-line treatment. World J Gastroenterol. 2021;27(10):976-989. doi:10.3748/wjg.v27.i10.976

Lee MS, O'Neil BH. Summary of emerging personalized medicine in neuroendocrine tumors: are we on track? J Gastrointest Oncol. 2016;7(5):804-818. doi:10.21037/jgo.2016.08.05

Nadler A, Cukier M, Rowsell C, et al. Ki-67 is a reliable pathological grading marker for neuroendocrine tumors. Virchows Arch. 2013;462(5):501-505. doi:10.1007/s00428-013-1410-8

Ramirez RA, Beyer DT, Chauhan A, Boudreaux JP, Wang Y-Z, Woltering EA. The role of capecitabine/temozolomide in metastatic neuroendocrine tumors. Oncologist. 2016;21(6):671-675. doi:10.1634/theoncologist.2015-0470

Tsoli M, Chatzellis E, Koumarianou A, Kolomodi D, Kaltsas G. Current best practice in the management of neuroendocrine tumors. Ther Adv Endocrinol Metab. 2018;10:2042018818804698. doi:10.1177/2042018818804698

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