ΙΩΑΝΝΗΣ ΠΙΛΠΙΛΙΔΗΣ, MD, FEBGH

ΓΑΣΤΡΕΝΤΕΡΟΛΟΓΙΚΟ – ΟΓΚΟΛΟΓΙΚΟ ΤΜΗΜΑ

ΑΝΘ «ΘΕΑΓΕΝΕΙΟ»

ΝΕΤ MasterClass 2015

Dr ΧΑΡΑΛΑΜΠΟΣ ΑΝΔΡΕΑΔΗΣ

Γ’ ΤΜΗΜΑ ΚΛΙΝΙΚΗΣ ΟΓΚΟΛΟΓΙΑΣ

ΑΝΘ «ΘΕΑΓΕΝΕΙΟ»

Case Presentation

52 year-old man, good health

Dyspepsia (epigastric pain): 06/2012

Upper GI Endosccopy: Duodenal ulcer

Jaudice: 07/2012

Abdominal CT: tumor within the head of thepancreas (no mesenteric vessel involvement)

Question (1)

1.Biopsy

2.Surgery (pancreatectomy)

3.Stenting and biopsy

4.Stenting and surgery

5.Stenting and chemotherapy

7/11 G1 (64%) – 4 ασθενείς μεγαλύτερο G5/13 G2 (38%) – 8 ασθενείς μικρότερο G

Karoumpalis I, Salla Ch, Kontogeorgos G

Case Presentation

The patient underwent typical Whipple’s procedure(6-8-2012). R0 resection.

Pathology report: (well/poorly) differentiated NET, ki-67 about 20%. T3, N1, M1 (metastatic nodulesintraperitoneal?). CK, Chr A, synaptophysin (+), CD34 (+).

2nd consultation: (well/poorly) differentiated NEC(NET), ki-67 54%

Results• 31% of tumors were metastatic at diagnosis• Among GEP-NET: 57% were G1; 29% G2; and 14% G3

Conclusions• The relative distribution of NETs between GI and pulmonary

sites in French patients is comparable to that observed in other countries

Epidemiology of Neuroendocrine Tumors in France: The PRONET Study Scoazek J-Y , et al.

20% G3 WDNET

Case Presentation

RESTAGING on 2-10-2012:

Octreoscan: (-)

Abdominal MR imaging: (-)

Chromogranin A, NSE: (-)

Question (2)

1.Wait and watch – (PET-CT scan?)

2.Adjuvant chemotherapy (IA/ΙΒ)

3.“Adjuvant” somatostatin analogues (CLARINET)

4.“Adjuvant” everolimus (ΙΑ)

5.“Adjuvant” sunitinib (ΙΑ)

Case Presentation

The patient had received 4 cycleschemotherapy with the combination cisplatin+ etoposide, from 8/10/2012 – 13-12-2012.

Restaging on 10-1-2013: multiple secondaryliver lesions (>9)

Scintigraphy on 25-1-2013: Octreoscan: (-)

G1/G2

Question (3)

1.2nd line chemotherapy

2.Chemoembolization

3.RFAs (>9 lesions)

4.Surgery

5.PRRTs

6.Everolimus - Sunitinib

PET-CT scan?

PET-CT scan?

1.Liver only disease

2.Liver predominant disease

3.Liver predominantly progression of disease

Elias D, Goere D, Leroux G, et al. Eur J Surg Oncol 2009; 35: 1092–97.

10% infections, if enterobiliary anastomosisGillams A, Cassoni A, Conway G, Lees W, Abdom Imaging. 2005; 30: 435–41.

Question (4)

1.2nd line chemotherapy

2.PRRTs

3.Everolimus

71% disease-control

Case Presentation

Disease progression following 3 cycles ofchemotherapy with the combination(TEM + CAP + BEV).

Question (5)

1.3nd line chemotherapy

2.Everolimus

3.PRRTs (Octreoscan: -)

Case Presentation

131I-MIBG (on 11/4/2013): (+) uptake

On 26-4-2013: therapeutic dose (150 mCi 131IMIBG)

Addition of everolimus!!!

Clinical deterioration: 6/2013, CT scan +

7/2013: 68GA-Pet/CT scan: (-)

Case Presentation

5-8-2013: died because of liver failure.

Surgery: R0 resection

1st line chemo (cis-etoposide)

2nd line chemo (TEM – Cap – Bev)

PRRTs + Biologic (everolimus)

Case Presentation

1. Pathology report (preop biopsy)

2. Imaging (preoperatively)

3. MDT discussion (many options, many specialties)

4. Overtreatment!!!