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Neuroendocrine Tumours – Current Treatments

Neuroendocrine Tumours – Current Treatments. Mark WJ Strachan Metabolic Unit, Western General Hospital, Edinburgh. NETs Can Arise in Many Different Places. Spectrum of Malignancy. Benign. Malignant. Appendiceal carcinoids Insulinomas Gastric carcinoids. Non-functioning pancreatic NETs

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Neuroendocrine Tumours – Current Treatments

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  1. Neuroendocrine Tumours – Current Treatments Mark WJ Strachan Metabolic Unit, Western General Hospital, Edinburgh

  2. NETs Can Arise in Many Different Places

  3. Spectrum of Malignancy Benign Malignant Appendiceal carcinoids Insulinomas Gastric carcinoids Non-functioning pancreatic NETs Gastrinomas Glucagonomas Small bowel carcinoids Small cell lung cancer

  4. Hormone-Producing Glands

  5. Hormones Bind to Receptors

  6. NET hormones Carcinoids Serotonin Pancreatic NETs Gastrin Insulin Glucagon VIP

  7. Serotonin • Manufactured mainly in the bowel and the brain • Released in response to noxious foods • Causes diarrhoea and vomiting • Can improve mood and reduce appetite • Also is a growth factor for cells • Metabolised to 5-HIAA, which can be measured in a 24 hour urine sample

  8. Kallikrein • Vasoactive hormone • Helps reduce blood pressure by cause dilation of blood vessels • Causes flushing

  9. Clinical Features of Carcinoid Syndrome • Diarrhoea - Serotonin • Flushing - Kallikrein • Wheeze – probably Serotonin • Heart valve problems - Serotonin

  10. NET hormones • Chromogranin A and B • Small Bowel Carcinoids • Serotonin • Kallikrein • Pancreatic NETs • Most are non-functional • Gastrin • Insulin • Glucagon • VIP

  11. Treatment Options for NETs Observation Surgery Somatostatin analogue therapy (if Carcinoid syndrome) Chemotherapy Radiotherapy (Chemo) Embolisation procedure Radio-Frequency Ablation Targeted Radionuclide Therapy - MIBG/radio-labelled somatostatin analogue Interferon Sunitinib or Everolimus – pancreatic NETs

  12. Factors that Determine which Treatments We Use • Surgery • Can the tumour be removed completely – ‘cured’? • Is there a tumour mass causing a local problem that surgery will help? • (Does removal of the primary tumour slow the progression of secondary deposits?) • (Liver transplantation?)

  13. Factors that Determine which Treatments We Use • Hormones • Does the person have hormone-related symptoms? • Measure 5-HIAA in urine and pancreas hormones in blood

  14. Octreotide Scanning

  15. Factors that Determine which Treatments We Use • Hormones • Does the person have hormone-related symptoms • What is the extent of the cancer and how quickly is it growing? • Can get a clue from the biopsy specimen – number of cells dividing • Change over interval scans

  16. Treatment Options for NETs Observation Surgery Somatostatin analogue therapy (if Carcinoid syndrome) Chemotherapy Radiotherapy (Chemo) Embolisation procedure Radio-Frequency Ablation Targeted Radionuclide Therapy - MIBG/radio-labelled somatostatin analogue Interferon Sunitinib or Everolimus – pancreatic NETs

  17. Treatment Options for NETs Observation Surgery Somatostatin analogue therapy (if Carcinoid syndrome) Chemotherapy Radiotherapy (Chemo) Embolisation procedure Radio-Frequency Ablation Targeted Radionuclide Therapy - MIBG/radio-labelled somatostatin analogue Interferon Sunitinib or Everolimus – pancreatic NETs

  18. Conventional Chemotherapy ‘Crude’ therapy that targets cells which are multiplying rapidly Given over several cycles with close monitoring of tumour response

  19. Radiotherapy

  20. Treatment Options for NETs Observation Surgery Somatostatin analogue therapy (if Carcinoid syndrome) Chemotherapy Radiotherapy (Chemo) Embolisation procedure Radio-Frequency Ablation Targeted Radionuclide Therapy - MIBG/radio-labelled somatostatin analogue Interferon Sunitinib or Everolimus – pancreatic NETs

  21. Ablation and Embolisation • Can be given in most large centres • Only targets cancer deposits in the liver • Destructive therapy so potential for rapid release of hormones from the dying cells • This can cause major swings in blood pressure

  22. Radionuclide Therapy

  23. Peripheral Uptake of Radioactive Label

  24. Radiation Crossfire

  25. MIBG therapy – Glasgow, Dundee, Aberdeen DOTA-Octreotate – London Need for isolation Bone marrow toxicity can lower blood cell counts Can affect liver and kidney function Radionuclide Therapy

  26. Treatment Options for NETs Observation Surgery Somatostatin analogue therapy (if Carcinoid syndrome) Chemotherapy Radiotherapy (Chemo) Embolisation procedure Radio-Frequency Ablation Targeted Radionuclide Therapy - MIBG/radio-labelled somatostatin analogue Interferon Sunitinib or Everolimus – pancreatic NETs

  27. Summary • NETs are rare • Lots of different treatment options – which need to be tailored to the individual • More treatments are on the way…..

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