Expert oncologist Robert Ramirez, DO, FACP, provides his perspective on the recent advances in identifying and managing neuroendocrine tumors that have improved the overall treatment of this complex disease.
PUBLISHED May 14, 2018
Robert Ramirez, DO, FACP: There have been several advances in neuroendocrine tumor treatment and diagnostics over the last several years. One of the biggest ones is the approval of the Gallium-68 PET/CT scan. This has really changed how we manage our patients. When we look at an octreotide scan, it is somewhat of a cumbersome scan, but it was the best that we had for a number of years. What a physician does for the octreotide scan is bring in a patient, inject them with an octreotide-labeled solution, and then say, “All right, after your injection, be back here in 4 hours to do your scan.” So, they’ve got to wait and come back. And then they do their scan, they get off the table, and the physician says, “All right, well, come back tomorrow to do the second part of your scan.” Depending on where you’re at, sometimes they say to come back another day as well. It’s a very cumbersome type of scan. And then, when we get the images, we get these fuzzy images. Sometimes we say, “Oh, yeah, there may be something here.” It’s by no means the most precise scan.
About a year-and-a-half ago, the Gallium-68 PET/CT scan was approved in the United States. This is a 1-day test. We inject the patient and an hour later we scan them. It gives us very, very precise images. We know exactly where things are and what their uptake is as far as how hot their tumor is on the scan. What we have noticed as well is that it picks up things that the octreotide scan misses. Many times, patients will come in who have had an octreotide scan for a number of years and then all of a sudden, they get their first Gallium-68 scan.
What happens is that more things pop up on the Gallium-68 scan, and patients can be pretty devastated that way. They say, “Oh no, my tumor has really become active and I’m getting more and more tumors.” I have to take a step back and say, “Well, maybe it’s not that. Maybe these tumors were there in the past, but we just didn’t see them, and this is going to be your new baseline.” If they’re otherwise feeling well and tumor markers and other scans look like things are stable, then I’ll say, “All right, we don’t need to make any changes right now. We’re going to repeat this in another 3 or 6 months, however, depending on what’s going on.” That’s what we’re seeing now with that scan. So, that’s one of the big advances in imaging.
One of the other things that has come along is everolimus, which was used primarily in patients with pancreatic neuroendocrine tumors. There was a clinical trial recently completed that showed that not only does this work in pancreatic neuroendocrine tumors, but that it also works in neuroendocrine tumors in the lung and GI [gastrointestinal] tract. We knew this was the case, but it’s nice to have a trial that confirms this. Now, the treatment of lung carcinoids has really differed. When we look at treatment of lung carcinoids, we look at surgical resection; that’s one of the big things. But everolimus, when that came around, was one of the first things to really be approved for treatment of lung carcinoids. Now, there’s a clinical trial looking at the use of lanreotide in patients who have uptake on their octreotide scan or Gallium-68 scan with unresectable lung carcinoids. So, we’re eagerly awaiting these results as well and that may add another tool to our tool chest to help treat some of the lung carcinoids.
Finally, one of the biggest things we’ve been looking forward to is being able to use PRRT [peptide receptor radionuclide therapy]. This was recently FDA approved. We have a clinical trial up and running at our center, and there are several other expanded access protocols. But this will be coming soon, and it is really going to change the way that we manage patients.
We’re excited for the future of neuroendocrine tumor research. We have lots of clinical trials that may help patients, and we’re hopeful that more things will be coming down the pipeline shortly. Thank you for joining us for this CURE® Expert Connections series, and a special thanks to Sylvia and Francisca for joining us and sharing their stories.