Cancer Therapy AdvisorEpisode 3: Tumors and Logistical Challenges When Referring Advanced GEP-NET Patients for Radioligand Therapy

Navigating the Complexities of Radioligand Therapy in Neuroendocrine Tumors: Insights from Oncology Experts

Three medical oncologists specializing in neuroendocrine tumors (NETs) discuss the challenges and considerations in treating pheochromocytomas, paragangliomas, and gastroenteropancreatic NETs (GEP-NETs) with radioligand therapy (RLT). They emphasize the importance of multidisciplinary care, patient selection, and logistical considerations in administering these treatments.

Key Points:

• Pheochromocytomas and paragangliomas are increasingly falling under the domain of NET specialists
• Collaboration with endocrinologists is crucial for managing these patients to avoid catecholamine crisis
• Somatic and germline testing is essential for proper patient categorization
• RLT plays a growing role in treating paragangliomas and pheochromocytomas
• Two RLTs are available: Azedra® (MIBG-based) and Lutathera® (off-label use)
• Azedra® was approved for improving blood pressure control in functional tumors
• PRRT (Lutathera®) is being studied for paragangliomas and pheochromocytomas with promising results
• Surgery remains the first-line treatment for localized disease
• 10%+ of patients have multifocal or metastatic disease requiring systemic therapy
• Appropriate workup includes serum metanephrines and urine catecholamines
• Medical therapy prior to systemic treatment or surgery is essential to prevent complications
• Logistical challenges in RLT administration include:
  • Coordinating care between referring oncologists and specialist centers
  • Managing patients between treatments
  • Organizing octreotide LAR injections
  • Monitoring hematologic and renal function
  • Communicating effectively among all care team members
• Patient selection considerations for PRRT:
  • Contraindications include large mesenteric masses and extensive peritoneal disease
  • Risk of bowel obstruction in patients with significant peritoneal involvement
  • Baseline bone marrow function assessment
• Emerging therapies include alpha emitters, which are being studied in clinical trials
• Wait times for starting PRRT can be an issue due to high patient volume

“I never thought I would have to take care of paragangliomas or pheochromocytomas, but now they are more and more falling under our domain. I think the key issue, especially for those at multidisciplinary centers, is to get an endocrinologist involved.”
– Andrew Hendifar, MD, Cedars-Sinai Medical Center

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