NET Cancer Questions with Jonathan Strosberg, MD

NET Cancer Questions with Jonathan Strosberg, MD


You know, patients come in with all
sorts of different levels
of experience and knowledge. Some have read about it. For others, it may be new. I mean, yeah. It’s hard to, hard to
generalize that particular situation. But you know, if patients are coming in with
the notion that, you know, well, many patients come in with
the notion that, you know, I’m going to die in the next six months
because they have a stage four cancer and that’s obviously not necessarily
the case with this disease. So in many cases there’s a
reassurance that, you know, the situation may not be as bad as
it has seemed at the outset. But, you know, it varies quite a bit. I mean, there are patients with disease who do
have a poor prognosis, unfortunately. So everyone’s very
different. And, you know, it’s hard to overestimate how
heterogeneous neuroendocrine tumors are. Stage, grade, differentiation,
hormone production. I mean, it’s not one cancer, it’s
a huge family of cancers. So I’m not a nuclear medicine doctor. But, you know, my understanding is that each scan is somewhat variable as
far as what the individual scan, individual scan is. And so it actually is hard to translate
a precise SUV from one PET scan to another. Although, you know,
the range is probably not huge. You know, it’s actually useful
to compare to the normal liver. So usually the normal liver just ballpark
would be an SUV range of say four to 10, meaning that twice the normal liver
would be somewhere from, you know, 10 to 20. These are just ballpark numbers. So carcinoid tumors can produce symptoms
either by just by virtue of the tumors themselves which can cause bowel
obstruction, can cause pain, weight loss, nausea depending on
location. And then, you know, they produce hormones in many
cases like serotonin. And, so the carcinoid syndrome
primarily consists of flushing, which means redness of the
face, upper abdomen warmth, and diarrhea. Those are the main symptoms. Patients eventually can develop
carcinoid heart disease, which gives you shortness of breath,
leg swelling, things like that. That’s a, that’s a tough one. So it sounds like someone who’s
going to have debulking surgery. Debulking surgery rarely
takes up all the NETs. Usually once you have metastatic disease, there is at least microscopic disease
left behind, although if you’re lucky, I think and they can remove
all gross visible disease, then that’s, that’s obviously
a good thing. Yeah, if all visible disease is removed
and you have carcinoid syndrome, likely you will no longer have
carcinoid syndrome after surgery, at least for a period of time. So I would say that immunotherapy as a
whole has been relatively disappointing for neuroendocrine tumors. Certainly with single-agent PD-1 or
PD-L1 inhibitors like pembrolizumab. You know, there’s, there was very preliminary
data from a study, the so called DART study, that looked at the combination
of the ipilimumab and nivolumab. So a combination of two
immunotherapy drugs in poorly differentiated high grade
neuroendocrine carcinomas showing a high response rate. But, you know,
there’s a lot of caveats. It was a tiny number of patients. It
wasn’t a preplan subgroup analysis. Um, it was an interim analysis. So
we’re still waiting for the final data. In the end, you know, it’ll probably turn out that the
overall response rate is lower, but there is some activity. And in a disease like especially poorly
differentiated neuroendocrine cancers where there are very few
treatment options, you know, this, there will be some patients who have
longterm remission and so it’s probably worth trying, but the response rates are going
to be quite low, I think.

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