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Therapeutic interventions for NETs

Management of a neuroendocrine tumor (NET) may depend on factors such as tumor size, grade, and location; extent of disease; tumor burden; and secretory status and potential associated symptoms.1,7 The key to optimal management is early detection and diagnosis.1

For patients with functional NETs, initial management primarily focuses on symptom palliation. Here, symptoms due to the oversecretion of hormones may need to be appropriately controlled before additional therapeutic measures can be taken against the tumor. In patients with advanced NETs where tumor bulk is not an immediate threat to the patient, management focuses on tumor control. For patients with high tumor volume, either in or on the verge of a visceral crisis, tumor debulking is the primary therapeutic goal.8,9

Surgical resection is the only potentially curative option for patients with localized disease.10

Surgery

Surgical resection is the only potentially curative option for patients with localized disease.10

Patients with advanced metastatic NETs may also benefit from a multidisciplinary combination of surgery and adjuvant interventions.11 In the setting of metastatic disease, surgery can play a role in achieving palliation in some patients.8

Chemotherapy

The usefulness of chemotherapy for NETs is limited in gastrointestinal NETs.12 However, the technique is considered a viable option for patients without other treatment options and for advanced pancreatic NETs and inoperable or poorly differentiated tumors, particularly where metastases and angioinvasion are present.13-15

Other systemic agents

Other cytotoxic agents may have application in NETs for symptom control and tumor reduction.9

Radiofrequency ablation (RFA)

When surgery is not an option, RFA may be an appropriate management modality. RFA can be effective in both relieving the symptoms of NET liver metastases and achieving local control of metastases. However, in most cases, a tumor >5 cm in diameter is considered unsuitable for this modality.15

Targeted radionuclide therapy

Iodine-131 metaiodobenzylguanidine (131I-MIBG) serves as a palliative option for certain patients with inoperable or metastatic tumors. Other forms of radionuclide therapy are currently under development or may be available in some countries.6

Peptide receptor radionuclide therapy (PRRT)

Using radiolabeled somatostatin analogs, PRRT can be an effective intervention for inoperable or metastatic NETs, particularly those expressing high numbers of somatostatin receptors. PRRT is currently available only in certain centers in Europe and is still investigational in the United States.13,17

Liver-directed therapy

When liver surgery is not an option, hepatic embolization may be a useful treatment modality. Selective hepatic transcatheter arterial embolization (TAE) or chemoembolization (TACE) with hepatic artery occlusion can be employed in the management of liver metastases in appropriate patients.16 The goal is to reduce tumor size and hormone output.6

Selective Internal Radiation Therapy (SIRT) is emerging as an effective modality for managing unresectable NET liver metastases. Studies show the technique may alleviate carcinoid syndrome symptoms, reduce levels of biochemical tumor markers (ie, 5-HIAA and CgA), and slow tumor progression in some patients.18

Clinical trials

Entering patients into formal trials of new agents, when feasible, should be considered.15,19 Visit www.clinicaltrials.gov to locate current, ongoing trials in NETs for your patients.

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