What are the NCCN treatment guidelines for metastatic neuroendocrine tumors (NETs) of the GI tract?

Updated: Dec 23, 2018
  • Author: Evan S Ong, MD, MS; more...
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Answer

Answer

NCCN recommendations for the treatment of unresectable and/or metastatic carcinoid tumors of the GI tract include the following{ref6:

  • Somatostatin scintigraphy to assess sites of metastases and somatostatin receptor status if octreotide or lanreotide is being considered

  • Limited hepatic metastases: Complete resection of primary tumor and metastases with curative intent; noncurative debulking surgery in select cases

  • Unresectable hepatic progressive disease: Radiofrequency ablation or cryoablation or hepatic regional therapy (arterial embolization, chemoembolization, or radioembolization)

  • Palliative small bowel resection for patients with abdominal pain from bowel obstruction or ischemia related to the primary tumor

  • Octreotide or lanreotide to control tumor growth in patients with clinically significant tumor burden or progressive disease; everolimus can be considered for advanced tumors; for persistent diarrhea, telotristat 250 mg orally, three times daily, can be added; additional therapy may be used for any persistent symptoms (eg, flushing, diarrhea)

  • Consider capecitabine if no other options are feasible (category 3)

  • Consider interferon alfa-2b after octreotide or lanreotide failure (category 3)

  • Malignant carcinoid syndrome: Octreotide or lanreotide; cardiology consultation, and echocardiogram to assess for heart disease

  • Liver transplantation is investigational and not recommended as routine care

Note that the use of ablative techniques for hepatic disease is associated with increased infectious complications. Although the NCCN guidelines cite category 2b evidence for cryoablation and radiofrequency ablation, most centers use radiofrequency or microwave ablation. Cryoablation is generally used only in centers providing ablation for renal cell cancers, and it is associated with a small but definite risk of subsequent acute respiratory distress syndrome. [19]


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