miguel navarro. salamanca - bases biológicas del cáncer ... · salamanca . introduction to...
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TUMORES NEUROENDOCRINOS
Miguel Navarro. Salamanca
Introduction to Neuroendocrine Tumours (NETs)
• NETs are relatively RARE
• At least 40 different entities are described arising in different organs.
• Different terminologies
have also caused confusion.
Most NETs 70% are non functional
Diagnostic challenges in NET
Wide variety of clinical presentations – Late presentation
• Over 60% of NETs are advanced at the time of diagnosis
• The median survival for patients with advanced NET is 33 months
Incidence Trends of NETs
Dasari A et al. JAMA Oncol. April 2017
NETs Are Second Most Prevalent Gastrointestinal Tumor
Median survival • Localized 203 months • Regional 114 months • Distant 39 months
Confusion Caused by the Term “Carcinoid”
• Oberndorfer coined the term “karzinoide” in 1907 .
• This term implies that these tumours are benign; this is an unfortunate misnomer for the majority of NET.
• NET have malignant potential and metastasize, generally to the liver.
Histologic classification
Treatment challenges in NET
One Treatment Does Not Fit All
Treatment challenges in NET
Somatostatin Analogues AAS
Telotristat. A Tryptophan Hydroxylase (TPH) Inhibitor
to treat carcinoid syndrome diarrhea
Indicated for carcinoid syndrome diarrhea in combination with somatostatin analog (SSA) therapy in adults inadequately controlled by SSA therapy
Telotristat
Patients who received telotristat etiprate also experienced a lower frequency of flushing episodes and less intense abdominal pain compared to placebo, though these differences did not reach statistical significance.
Where does telotristat fit in?
• Active in controlling diarrhea from carcinoid syndrome.
• Does it have QOL benefits beyond diarrhea control? Flushing? Abdominal pain?
• Is there a role in prevention of carcinoid heart disease?
New options in NETs
Treatment challenges in NET
WATCHFUL WAITING
“cancers in slow motion”
Somatostatin Analogues AAS
PROMID Trial
CLARINET Trial
Somatostatin Analogues AAS
• Previous restrictions on the
use of AAS in non functioning tumors are no longer justified.
• Favorable side effects profile.
• Appropriate 1st line agents in most well-differenciated NETs.
• Early antitumor therapy
Indications for cytotoxic chemotherapy
QT en NETS
Newer chemotherapy regimens have demonstrated acceptable toxicity in advanced NET
Cap/Tem Example of response Baseline Maximal response
Targeting NETs
Targeting NETs
Targeting NETs
• AAS
Targeting NETS
There are several biological agents being evaluated.
• Pazopanib (Votrient)
• Cabozantinib (Cabometyx) • Axitinib (Inlyta)
• Lenvatinib (Lenvima)
Targeting NETS
Radionuclide Therapy
Theranostics-Diagnosis and Therapy
n engl j med 376;2 nejm.org January 12, 2017
Number of deaths: LU-Dotate: 14 Control: 26 Estimated risk of death 60% lower
n engl j med 376;2 nejm.org January 12, 2017
Case Report 58 yo m. Large cell Neuroendocrine carcinoma.
Surgery. Stage Ib Cisplatin-Vp16 (Ady)
2009-2015 Liver- Bone Mtx Carboplatin-Vp16, Lanreotide, Everolimus,Pazopanib,TMZ-Cap Topotecan ECOG -2. Oxycontin 60 mg/12 h plus oxinorm
2016-2017 ECOG-0, weight gain 20 KG, no opioids
PRRT
Case Report 2
• 2018 Progression
• If patient had responded to the first few rounds of Lutathera and then the tumors start to grow again, it can be given safely for a second time?
• 5 round of Lutathera May/18
Where does PRRT fit in?
• Phase 3 randomized data only in midgut NETs. – Early phase data suggesting higher response rates in non-midgut NETs
– COMPETE trial.
• Somatostatin-receptor (SSTR) expression is strong predictive marker.
• Consider as 2nd line therapy in patients with strong SSTR expression.
• Advantages: Limited treatment course (4x), exceptionally long-PFS, low toxicity
• Are there long-term risks to consider?
Inmunotherapy
• NETs do not have many mutations.
• Merkel cell carcinoma (MCC).
– Rare and aggressive neuroendocrine tumor of the skin.
– MCC incidence is higher in immunocompromised populations.
– Tumour oncogenesis is linked to Merkel cell polyomavirus integration and ultraviolet-radiation-induced mutations, providing rationale for treatment with immunotherapy antibodies that target the PD-L1/PD-1 pathway.
CarboVp16 –Rt - Avelumab
Ongoing clinical trials
Take Home Messages
Nets are not rare.
Consider patient and tumor characteristic.
Increasing number of treatment options
Octeotride / Lanreotide
Telotristat
Sunitinib / Everolimus
Temozolomide.
PPRT
Exciting Decade in Neuroendocrine Tumor Treatment
