ΝΕΤ MasterClass 2015 ΙΩΑΝΝΗΣ ΠΙΛΠΙΛΙΔΗΣ, MD, FEBGH ΓΑΣΤΡΕΝΤΕΡΟΛΟΓΙΚΟ – ΟΓΚΟΛΟΓΙΚΟ ΤΜΗΜΑ ΑΝΘ «ΘΕΑΓΕΝΕΙΟ» 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 the pancreas (no mesenteric vessel involvement)

Question (1) Biopsy Surgery (pancreatectomy) Stenting and biopsy Stenting and surgery Stenting and chemotherapy

7/11 G1 (64%) – 4 ασθενείς μεγαλύτερο G Karoumpalis I, Salla Ch, Kontogeorgos G 7/11 G1 (64%) – 4 ασθενείς μεγαλύτερο G 5/13 G2 (38%) – 8 ασθενείς μικρότερο 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 nodules intraperitoneal?). CK, Chr A, synaptophysin (+), CD34 (+). 2nd consultation: (well/poorly) differentiated NEC (NET), ki-67 54%

Epidemiology of Neuroendocrine Tumors in France: The PRONET Study Scoazek J-Y , et al. 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 20% G3 WDNET

Case Presentation RESTAGING on 2-10-2012: Octreoscan: (-) Abdominal MR imaging: (-) Chromogranin A, NSE: (-)

Question (2) Wait and watch – (PET-CT scan?) Adjuvant chemotherapy (IA/ΙΒ) “Adjuvant” somatostatin analogues (CLARINET) “Adjuvant” everolimus (ΙΑ) “Adjuvant” sunitinib (ΙΑ)

Case Presentation The patient had received 4 cycles chemotherapy with the combination cisplatin + etoposide, from 8/10/2012 – 13-12-2012. Restaging on 10-1-2013: multiple secondary liver lesions (>9) Scintigraphy on 25-1-2013: Octreoscan: (-)

G1/G2

Question (3) PET-CT scan? 2nd line chemotherapy Chemoembolization RFAs (>9 lesions) Surgery PRRTs Everolimus - Sunitinib PET-CT scan?

Elias D, Goere D, Leroux G, et al. Eur J Surg Oncol 2009; 35: 1092–97. PET-CT scan? Liver only disease Liver predominant disease 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 anastomosis Gillams A, Cassoni A, Conway G, Lees W, Abdom Imaging. 2005; 30: 435–41.

Question (4) 2nd line chemotherapy PRRTs Everolimus

71% disease-control

Case Presentation Disease progression following 3 cycles of chemotherapy with the combination (TEM + CAP + BEV).

Question (5) 3nd line chemotherapy Everolimus PRRTs (Octreoscan: -)

Case Presentation 131I-MIBG (on 11/4/2013): (+) uptake On 26-4-2013: therapeutic dose (150 mCi 131I MIBG) 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 Pathology report (preop biopsy) Imaging (preoperatively) MDT discussion (many options, many specialties) Overtreatment!!!