Neuroendocrine treatment options
If possible, surgery is performed with the intention of removing the tumour in the hope of a cure. Sometimes "debulking" surgery is performed in order to remove as much tumour as possible so that other treatments have less tumour to treat.
Somatostatin analogues such as daily octreotide injections or long-acting preparations such as Sandostatin LAR or Lanreotide Autogel given monthly are very useful for controlling the symptoms of hormone release by carcinoid or pancreatic NETs. They may have an anti-tumour effect at high dose in a small number of people
The NET Patient Foundation is conducting a survey to find out the experiences of patients prescribed somatostatin analogues injections. Take the survey.
Chemotherapy is usually reserved for bronchial carcinoids or pancreatic neuroendocrine tumours. It would also be the treatment of choice for "poorly differentiated" tumours (on biopsy).Chemotherapy is less helpful for "midgut" and "hindgut" carcinoid tumours and therefore other treatments are considered in these patients.
Interferon stimulates the immune system to fight cancer and may be effective, especially in combination with somatostatin analogues.
Radionuclide therapy may be of benefit in patients who have positive scans, ie patients who have positive I-123 mIBG scans may benefit from therapeutic I-131 mIBG therapy. Similarly, patients who have positive Octreotide scans or Ga68 Octreotate PET scans may benefit from agents such as Yttrium-90 DOTA Octreotide / octreotate Lutetium-177 DOTA octreotate.
In the NHS PRRT with Lutetium-177 has recently been approved by NICE for treatment of gastroenteropancreatic (GEP) NETs. For those non-GEP NETs outside of the funded NHSE agreement for PRRT we have only been able to treat such non-GEP NET patients (i.e. bronchial NETs, paraganglioma, phaeochromocytoma, medullary thyroid cancer and those requiring retreatment, which are not funded by NHSE) within a limited prospective audit and registry of such patients. At present further inclusion of such patients beyond those currently agreed is on hold. Future treatment for such patients has yet to be defined, however if it becomes possible, it will remain limited and within the need for prospective audit the decision for PRRT if it becomes available for non-GEP NET patients will be via the Royal Free NET MDT.
Liver embolization, that is, cutting off the blood supply to tumours in the liver with or without the addition of chemotherapy (chemoembolization), is useful for patients who have predominantly liver disease.
Thermal ablation such as radio-frequency ablation, ie probes that "burn" away the tumours, may be useful in patients who have a small number of liver tumours.
Rarely, liver transplantation is considered in patients who have disease confined to the liver and have had investigations to fully exclude disease outside the liver. Even so, other criteria will need to be met and the concern is of recurrence of disease after liver transplant.
The treatment of patients with NETs is a rapidly advancing field and new treatments are being developed all the time. Many patients will be involved in clinical trials. The ongoing clinical trials include: NET-01 chemotherapy study for pancreatic NETs, RAD 001 for advanced midgut NETs and Lanreotide Autogel study for non-functional NETs.