Lutetium-DOTA TATE Treatment of inoperable GEP NETs

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1 Logo 177 Lutetium-DOTA TATE Treatment of inoperable GEP NETs Dr. Augusto Llamas-Olier. Nuclear medicine department. Dr. Maria Cristina Martínez*, Dr. Alfonso Lozano** and Dr. Augusto Llamas-Olier*. *Nuclear Medicine and **Diagnostic Imaging Departments. Instituto Nacional de Cancerologia. Bogota, Colombia Nuclear medicine department. Instituto Nacional de Cancerologia. Bogota, Colombia. Instituto Nacional de Cancerologia. Bogota, Colombia.

2 Patient: 50-year old female Clinical history: the patient was diagnosed with a well-differentiated neuroendocrine carcinoma of the pancreas with liver metastases and extensive tumor involvement of mediastinal and retroperitoneal lymph nodes.

3 Logo A Subcarinal (A) and retrocrural (B) lymph node involment B

4 Logo C Retroperitoneal (C) lymph node involvement and tumor mass (D) in head of pancreas D

5 Digitized MIP images obtained from a hard copy provided by the patient. The study was performed in an external institution. Baseline somatostatin receptor scintigraphy Indium-111 DTPA- Phe 1 -octreotide Activitiy: 5 mci There is extensive abnormal uptake in intrathoracic and retroperitoneal lymph nodes.

6 The tumor was considered inoperable by the board of neuroendocrine tumors treatment and palliative treatment was approved with 600 mci of Lu-177 DOTA TATE divided in 200- mci cycles every 6-10 weeks. Logo

7 Aug/09 Dosimetry 3,4 mci ANT 48 h Oct/09 Dec/09 Feb/10 Post therapy scan Post therapy scan Post therapy scan 150 mci 200 mci 200 mci ANT 24 h ANT 24 h ANT 24 h A B C D Interval response to therapy. Baseline dosimetry scan (A) obtained with a low dose of the radioligand. There is significant interval change between the first (B) and second (C) post therapy scans obtained with a 3-mo difference. Further response is noticed in the final post therapy scan, obtained almost 6 months after the start of treatment.

8 99m Tc-Hynic-Tyr 3 -octreotide. Selected coronal and sagital half-body SPECT images obtained at 4 hours post injection. End of treatment. After three therapy doses of 177 Lu-DOTA TATE there is residual focal uptake in the head of the pancreas. Significance reduction of uptake in retroperitoneal lymph nodes is noted.

9 Baseline 6 mo. after last dose CT follow up. The baseline lesion in the head of the pancreas is no longer evident at 6 months post therapy. Residual retroperitoneal lymph nodes are less than 1 cm.

10 Comparison between end of treatment (Feb/09) and 13 mo. follow up MRI. Interval disappearance of retroperitoneal lymph nodes is noted

11 Results A significant response to treatment was evident after only two cycles of 177 Lu-DOTA TATE. At the end of treatment the final response was deemed partial by RECIST standards, as there were residual paraaortic lymph nodes and a 3-cm mass in the head of the pancreas. 6 months after the last treatment cycle the mass at the head of the pancreas had disappeared and significant reduction in retroperitoneal lymph node involvement was noted.

12 Teaching Points Therapy with 177Lutetium DOTA TATE can be useful for inoperable, metastatic GEP NETs. The rate of complete responses obtained by Kwekkeboom et al was only 2% in patients treated with 177 Lu-DOTA TATE. They reported partial responses, minor responses, stable disease and progressive disease, respectively, in 26%, 19%, 35% and 15% of their patients. Treatment tolerance was good, significant reduction of symptoms was obtained and 2-yr survival rate was 76 ± 16%. Predictors of good response include: high uptake of lesions in somatostatin receptor scintigraphy and Karnofky s performance status > 70%. Predictors of poor prognosis include: massive liver involvement, bone metastases and Karnofky s index < 70%. 12

13 References Radiolabeled Somatostatin Analog [177Lu-DOTA0,Tyr3]Octreotate in Patients With Endocrine Gastroenteropancreatic Tumors. Kwekkeboom DJ, Teunissen JJ, Bakker WH, Kooij PP, De Herder WW, Feelders RA, et al. J Clin Oncol 2005;23: Treatment With the Radiolabeled Somatostatin Analog [177Lu- DOTA0,Tyr3] Octreotate: Toxicity, Efficacy, and Survival. Kwekkeboom DJ, De Herder WW, Kam BL, Van Eijck CH, van Essen M, Kooij PP, et al. J Clin Oncol 2008;26:

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