OVERVIEW OF THE DIAGNOSIS AND TREATMENT OF GI NETS

OVERVIEW OF THE DIAGNOSIS AND TREATMENT OF GI NETS Dr Christos G. Toumpanakis MD PhD FRCP FEBGH Consultant in Gastroenterology/Neuroendocrine Tumours Hon. Senior Lecturer University College of London Neuroendocrine Tumour Unit - ENETS Centre of Excellence ROYAL FREE HOSPITAL, London, UK

NEUROENDOCRINE CELLS Peptide hormone-producing cells that share a neural-endocrine phenotype Cells that form glands - Adenohypophysis - Parathyroids - Paraganglia - Adrenal medulla Cell Type Localisation Products D cells GI tract Somatostatin Enterochromaffin GI tract Serotonin, Substance P Enterochromaffin-like GI Tract Histamine G cells Stomach and duodenum Gastrin VIP cells GI Tract VIP A cells Pancreas Glucagon B cells Pancreas Insulin Chromaffin Adrenals Catecholamines C cells Thyroid Calcitonin Cells that are diffusely distributed - Skin - Thyroid - Lung - Thymus - Genitourinary tract - GI tract - Pancreas Image from: http://www.brown.edu/courses/digital_path/systemic_path/index.html

Rare May secrete hormones NETs Usually Slow growing May have somatostatin receptors Usually can be treated with more than one options

INCIDENCE OF NEUROENDOCRINE TUMOURS (NETS) OVER TIME, BY SITE AND BY DISEASE STAGE Reproduced with permission from Dasari A, et al. JAMA Oncol 2017;3(10):1335 42. Copyright 2017 American Medical Association. All rights reserved.

HISTOPATHOLOGICAL ASSESSMENT OF NETS Cell morphology Immunohistochemistry General markers Chromogranin, synaptophysin, cytokeratin Peptide hormones (serotonin) Receptors Ki67 (to assess tumour grading) (marker of proliferation, showing how many cells are in cycle) Courtesy of the Royal Free Hospital, London, Histopathology Lab database. Klöppel G. Best Pract Res Clin Endocr Metabol 2007;21:15 31.

HISTOPATHOLOGICAL CLASSIFICATION OF NETS WHO 2017 CLASSIFICATION 1. Well-differentiated neuroendocrine tumours of G1 grade (Ki67 <2%) 2. Well-differentiated neuroendocrine tumours of G2 grade (Ki67 3-20%) 3a. Neuroendocrine tumours of G3 grade (Ki67 >20%): well differentiated 3b. Neuroendocrine carcinoma, NEC (Ki67 >20%): poorly differentiated (small or large cell) + TNM staging SilverScreen / Alamy Stock Photo World Health Organization 2017.

NET HETEROGENEITY Intra-tumoural phenotypic heterogeneity is frequently observed in GEP-NETs Most primary small bowel NETs are G1 tumours (Ki67<2%) However, when these tumours metastasize to the liver, they may become highly proliferative More than two-thirds of the patients who had G1 primary tumour developed G2 or G3 liver metastases Shi C, et al. Am J Clin Pathol 2015; 143(3): 398 404, by permission of the American Society for Clinical Pathology.

CLINICAL CLASSIFICATION OF NETS Pancreatic neuroendocrine tumours Gastrointestinal neuroendocrine tumours Carcinoids foregut midgut hindgut Up to 10% associated with adenocarcinoma Functional or Non-functional Functional or Non-functional Solcia E, et al. WHO 2002.

TYPES OF GASTRIC NETS Type I Type ΙΙ Type ΙΙΙ Relative frequency 70 80% 5 6% 14 25% Features Usually multiple (<10mm) Usually multiple (<10mm) Usually solitary (> 20mm) Ass. diseases Atrophic gastritis ΜΕΝ-1/ Gastrinoma No Histology G1 G1 G2 / G3 Serum Gastrin Raised Raised Normal Gastric p H Alkaline Hyperacid Normal Metastases < 5 % 10 30% 50 100% Tumour related deaths - < 10% 25 30%

DUODENAL NEUROENDOCRINE TUMOURS 1 3 % of all duodenal neoplasms Five types: Non-functional d-nens (positive immunohistochemistry for serotonin and calcitonin) Duodenal gastrinomas Somatostatinomas Duodenal gangliocytic paragangliomas High-grade poorly differentiated neuroendocrine carcinomas 90% are located in D1 and D2 >75% are measuring <2 cm Lymph nodal metastases are noted: 20 60% 20% are located in peri-ampullary region (18% are associated with von-reckinhausen s disease) Copyright Sato Y, et al. Published by Baishideng Publishing Group Inc. All rights reserved. Distributed under the terms of the Creative Commons Attribution-Noncommercial (CC BY-NC 4.0) License (https://creativecommons.org/licenses/by-nc/4.0/) Image from Dermatology Oasis. Available at: http://dermatologyoasis.net/. Accessed February 2018 Delle Fave G, et al. ENETS Consensus Guidelines for the management of patients with gastroduodenal neoplasms. Neuroendocrinology 2012;95(2):74 87. Reproduced with permission from S. Karger AG, Basel. Sato Y, et al. World J Gastroenterol 2016;22(30):6817-28.

DIAGNOSIS OF NETS History and clinical examination Biochemical tests Imaging studies (for localisation of primary and metastatic lesions) Histology - gold standard

CLINICAL PRESENTATION (1) SPECIFIC SYMPTOMS MIDGUT NETs (in 5% of bronchial NETs and 1% of pancreatic NETs) Image courtesy of Dr. Christos G. Toumpanakis Carcinoid syndrome Flushing, diarrhoea, bronchospasm, carcinoid heart disease 20 30 % of patients with liver metastases 5% of patients with carcinoid syndrome do not have liver metastases Carcinoid crisis Severe symptoms of carcinoid syndrome + hypotension during procedures that involve GA, as well as in TAE, and when the patient is on inotropes

CARCINOID HEART DISEASE May develop in 20 50% of patients, with carcinoid syndrome Main cause of death in 40 50% of patients Involves mainly the right valves of the heart May be present even in asymptomatic patients Valve replacement in a selected group of patients Image courtesy of Dr. Christos G. Toumpanakis Battacharyya S, Toumpanakis CG, et al. Am J Cardiol 2008;101(3):378-81.

CLINICAL PRESENTATION (2) NON-SPECIFIC SYMPTOMS Dyspepsia Chronic abdominal pain Weight loss Symptoms compatible with IBS Etc, etc.. So Tumours are diagnosed incidentally: a. During surgery b. During endoscopy c. On imaging studies and guided biopsy of tumour lesions

BIOCHEMICAL TESTS (BIOMARKERS): NON-SPECIFIC - CHROMOGRANIN-A (CGA) Sensitivity: 60-90%, Specificity: 68 100% Correlate with tumour burden Independent factor of survival in midgut NETs Not raised in: May be raised in non-nets situations: Rectal NETs Poorly differentiated NECs Chronic PPI use Atrophic gastritis IBD Renal failure Cirrhosis Other cancers Modlin IM, et al. Ann Surg Oncol 2010.

BIOCHEMICAL TESTS (BIOMARKERS): SPECIFIC a) 24 hour urinary 5-HIAA (metastatic midgut NETs) Please note that certain foods like banana, avocado, aubergine, pineapple, plum, walnut and some drugs like paracetamol, fluorouracil, methysergide, naproxen and caffeine, may cause false positive results, whilst other drugs like levodopa or phenothiazines may cause false negative results. b) Role of Gastrin in differentiation of types of Gastric NETs

USEFULNESS OF N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE AS A BIOMARKER OF THE PRESENCE OF CARCINOID HEART DISEASE 200 patients with midgut NETs underwent cardiac ECHO and estimation of N-terminal pro-brain natriuretic peptide 19.5% had ECHO findings consistent with CHD NT pro-bnp levels were significantly higher (p<0.001) in patients with carcinoid heart disease Sensitivity and specificity for cut-off level of 260pg/ml was 92% and 91%. NT pro-bnp levels had positive correlation with CHD score (r: 0.81, p<0.001) and NYHA scale (p<0.001) Reprinted from Am J Cardiol, 102(7), Bhattacharyya S, et al. Usefulness of N-terminal Pro Brain Natriuretic Peptide as a Biomarker of the Presence of Carcinoid Heart Disease, 938-42. Copyright 2008, with permission from Elsevier.

NOVEL BIOMARKERS

CIRCULATING TUMOUR CELLS (CTCS) AS PROGNOSTIC MARKERS IN NEUROENDOCRINE TUMOURS Presence of CTCs was associated with increased burden, increased tumour grade, and elevated serum chromogranin A The presence of one CTC was associated with worse PFS and overall survival Within tumour grades, presence of CTCs was able to define a poor prognostic subgroup CTCs are a promising prognostic marker for patients with NETs and should be assessed in the context of clinical trials with defined tumour subtypes and therapy Different types of NETs (midgut, pancreatic) with same cut-off (one CTC) as predicting a worse outcome applied, whilst evidence from other cancers suggested the correct cut-off varied depending on tumour type. Khan MS, et al. J Clin Oncol, 31(3), 2013:365 72. Reprinted with permission. 2013 American Society of Clinical Oncology. All rights reserved.

EARLY CHANGES IN CIRCULATING TUMOUR CELLS Are associated with response and survival following treatment of metastatic neuroendocrine neoplasms 138 patients with metastatic NENs (G1/G2) commencing therapy were prospectively recruited First post-treatment time point (PT1): 3 5 weeks Group A: 0 CTCs at baseline and PT1 Group B: >50% reduction from baseline Group C: <50% reduction or increase 0 CTCs at PT1: only 4% progressed >8 CTCs at PT1: 65% progressed CTCs No Median Survival mo 0 Not reached at 54 1-8 31.2 >8 10.8 Early post-treatment CTC change is associated with radiologic response and survival, presenting an opportunity to explore biomarker-led sequencing studies in patients with NENs Reprinted from Clin Cancer Research 2015, 22(1) 365-72, Khan MS, et al. Early Changes in Circulating Tumor Cells Are Associated with Response and Survival Following Treatment of Metastatic Neuroendocrine Neoplasms. with permission from AACR.

MAAA PCR-BASED TEST (NETEST) Multianalyte with Algorithm Analysis Assay Using gene microarray-based approaches of both malignant NET tissue and blood, a PCR-based 51 marker signature (multigene test) was developed High sensitivity (85 98%) and specificity (93 97%) for the detection of intestinal and p NETs in circulating blood Not affected by age, gender, ethnicity, fasting or PPIs A NET score (0 8) is derived from the PCR data Values ranged from 0 to 8; a value of >2 is a positive tumour score Reprinted by permission from Springer Customer Service Centre GmbH: Springer Nature, Am J Gastroenterol, The Clinical Utility of a Novel Blood-Based Multi- Transcriptome Assay for the Diagnosis of Neuroendocrine Tumors of the Gastrointestinal Tract, Modlin IM, et al. Copyright 2015.

NETEST POTENTIAL CLINICAL APPLICATIONS Can it define the effectiveness of operative resection and loco-regional [TA(C)E, RFA] treatments? 35 patients with GEP-NET (mainly G1 & G2) were included Surgery was performed in 27 (1) to remove primary tumour, including loco-regional lymph nodes (n = 21); (2) for debulking (n = 4); and (3) for suspicion of NET 8 subjects had loco-regional treatments (TAE = 3, TACE: 3, RFA = 3) for hepatic metastases The NETest was scaled as minimal activity risk <14%, low activity risk 14 47%, and high activity risk >47%. Surgery significantly reduced scores in each of these groups 4 (27%) developed disease recurrence locoregionally at 6 months identified by imaging ( 68 Gasomatostatin receptor-based PET). At 1 month after surgery, all 4 patients exhibited increased NETest scores (median, 30%; range 13-87%) For group III, the pre-ablation NETest scores were elevated (76.2 ± 4.4%) and reduced after treatment Reprinted from Surgery 159(1), Modlin IM, et al. Blood measurement of neuroendocrine gene transcripts defines the effectiveness of operative resection and ablation strategies, 336 47. Copyright 2016, with permission from Elsevier.

CONVENTIONAL IMAGING IN NETS Images courtesy of Dr Christos G.Toumpanakis Image from Paulsen RD, et al. Spiral CT and MRI: can reveal the primary site in ~30 70% and distal metastases in 90% of patients CT enterography: can detect the primary small bowel NET with sensitivity 85% and specificity 97% Ricke J, et al. European J Radiol 2001;37(1):8-17. Paulsen SR, et al. Radiographics 2006;26(3):641 57. Copyright 2006 Radiological Society of North America

ENDOSCOPIC ULTRASOUND & WIRELESS SMALL BOWEL CAPSULE ENDOSCOPY Endoscopic ultrasound Can assess depth of invasion of stomach, duodenal, rectal wall Wireless small bowel capsule endoscopy May have a role for detection of occult small bowel NETs Jensen RT, Neuroendocrinology 2004;80 Suppl 1:23 7; Tucker ON, et al. Br J Surg 2006;93(3):264 75 Rondonotti E, et al. Endoscopy 2008;40(6):488 9

SOMATOSTATIN RECEPTORS IN NETS Carcinoid tumours: sst2>sst5>sst1>sst3&4 Gastrinomas: sst2>sst5=sst1>sst3>sst4 Insulinomas: sst5>sst3>sst2>sst4>sst1 NFPETS: sst2>sst3>sst1>sst5>sst4 Glucagonomas/MCT/phaeo: sst2>sst1>sst5=sst4>ssst3 From N Engl J Med, Lamberts SW, et al. Octreotide, 334:246 54. Copyright 1996 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

ΟCTREOSCAN Reveals the primary in 50-80% and the metastases 95% of patients Can predict the response with somatostatin analogues Low sensitivity in poorly-differentiated NETs, small duodenal gastrinomas and insulinomas Ant Post Images courtesy of Dr. Christos G. Toumpanakis Warner RR. Gastroenterology 2005;128(6):1668 84

THE ROLE OF 18F-FDG-PET IN NETS 18 F- FDG PET is useful for evaluation of extent of disease: a) In poorly differentiated G3 tumours b) In tumours with high Ki67 10%,and no Octreoscan uptake It seems that intense 18F- FDG uptake by tumour lesions predicts survival (one study) Image courtesy of Dr. Christos G. Toumpanakis Eriksson B, et al. Ann N Y Acad Sci 2002;970:159 69 Binderup T, et al. Clin Cancer Res 2010;16(3):978 85 Abgral R, et al. J Clin Endocrinol Metab 2011;96(3):665 71

PET SCANS SPECIFIC FOR NETS PET with 68 Ga-somatostatin analogues 68 Ga DOTATATE 68 Ga DOTATOC 68 Ga DOTANOC Better sensitivity than OCTREOSCAN, CT More expertise is needed in interpretation of its results, in view of its physiological uptake 18 F-DOPA PET 11 C 5-HTP PET Image from: Toumpanakis CG, et al. Neuroendocrinology 2014;99:63 74. Copyright 2014, Karger Publishers, Basel, Switzerland For GI-NETs, 18F-DOPA PET was found to be more sensitive than 11C-5-HTP PET (98% vs. 89%), whilst just the opposite was noted in patients with pnets A cyclotron is required Sensitivity seems to be inferior to 68Ga PET studies Sundin A, et al. Neuroendocrinology 2007; Gabriel M, et al. J Nucl Medicine 2007; Frilling A, et al. Ann Surg 2010.

HEPATIC METASTASES IN THE SAME PATIENT Hepatic metastases from NET (68Ga-octreotate PET, left) Colorectal cancer (FDG-PET, right) in the same patient Image courtesy of Dr. Christos G. Toumpanakis Use of molecular imaging to differentiate liver metastasis of colorectal cancer metastasis from neuroendocrine tumour origin Desai AP, et al. J Clin Gastroenterol. 2011;45(1):e8-11.

COMBINATION OF PETS FOR NET HETEROGENEITY Ga68 Ga68 FDG FDG Images courtesy of Dr. Christos G. Toumpanakis

NOVEL MOLECULAR IMAGING

IMAGING WITH SOMATOSTATIN RECEPTOR ANTAGONISTS Comparison of 111In-DTPA-octreotide scintigraphy (SSTR2 agonist), 111In-DOTA-BASS scintigraphy (SSTR2 antagonist), and 111In-DOTA-JR11 scintigraphy (SSTR2 antagonist) in a patient with NET of unknown origin (G2). Reprinted from Best Pract Res Clin Endocrinol Metab, 30(1), Baumann T, et al. Gastroenteropancreatic neuroendocrine tumours (GEP-NET) Imaging and staging, 45 57. Copyright 2016, with permission from Elsevier.

Image courtesy of Dr. Christos G. Toumpanakis with consent Image courtesy of Dr. Christos G. Toumpanakis

AS REQUIRED IMAGING MODALITIES Parathyroid scan MRI spine, most sensitive technique for demonstrating bone metastases MRI pituitary Images courtesy of Dr. Christos G. Toumpanakis. Kos-Kudla B, et al. Neuroendocrinology 2010;91(4):341 50.

DIAGNOSTIC ALGORITHM History clinical examination Chromogranin-A 5-HIAA NT-pro BNP Cardiac ECHO FDG-PET scan High-grade tumours Suspected tumour heterogeneity Suspected second malignancy Triple phase CT c/a/p Or MRI Somatostatin Receptor Scintigraphy (Ga-68 PET OctreoScan) Tissue diagnosis MRI liver MRI spine CT/MRI enterography S.B capsule endoscopy EUS Commencement of treatment Clinical, biochemical and radiological follow-up

TREATMENT OF NETS A. Medical control of patient s symptoms B. Resection of tumour primary and if possible, metastatic lesions C. Control of tumour growth in cases of advanced disease D. Improvement and maintenance of patient s quality of life.

SOMATOSTATIN ANALOGUES Octreotide LAR https://www.hcp.novartis.com/products/sandostatin-lar-depot/carcinoid-syndrome/dosing-administration/. Accessed May 2018 Lanreotide autogel

SOMATOSTATIN ANALOGUES IN CARCINOID SYNDROME First and best choice medications 1,2 Reduce flushing >70% 1,2 Reduce diarrhoea >60% 1,2 Biochemical response ~50% 1,2 Prospective cross over analysis of 33 patients 3 No differences between octreotide and lanreotide in symptom control or biochemical response 3 SST Inhibition of hormone secretion by the tumour SST 1. Shah T & Caplin M, Best Pract Res Clin Gastroenterol. 2005; 2. Plockinger U & Wiedenmann B, Best Pract Res Clin End Metab 2007; 3. O Toole D, et al. Cancer 2000.

INTERFERON-ALPHA FOR CARCINOID SYNDROME SYMPTOMS CONTROL RFH Interferon Data 2 24 pts, in combination with SSTA Diarrhoea improved 45% Flushing improved in 54% No statistically significant decrease of 5-HIAA levels Of the 19 patients given alpha-interferon in combination with octreotide, 72% showed significant reduction in urinary 5-HIAA for a median of 10 months 1 27% of patients discontinued treatment at 3 months, due to AE A symptomatic improvement was seen in 49% 1 The combination was well tolerated 1 1. Janson ET & Oberg K, Acta Oncol 1993; 2. Mirvis E, et al. Anticancer Research 2015.

PASIREOTIDE (SOM230) Pasireotide is a novel multireceptor-targeted somatostatin analogue with high binding affinity for somatostatin receptor subtypes 1, 2, 3 and 5 1 Preclinical models have shown that pasireotide can influence tumour cell growth via effects on apoptosis and angiogenesis 1 Hormone Ca 2+ Ca 2+ Ca 2+ - Ca 2+ Voltage Ca 2+ camp Secretion (frequently) K + K + K + K + channel channel Adenyl cyclase - - + PTPase SHP-1 SHP-2 PTPᶯ Caspase 8 Wt P53 ERK1/2 Bax ph i Endonuclease Apoptosis Somatostatin G Gβ GƔ + SSTR + ERK1/2 P27 Kip1 + - PLCβ/IP 3 Cell growth + ER Ca 2+ Secretion (infrequently) Ca 2+ channel Hormone 1. Feelders RA, et al. Drugs Today (Barc) 2013;49:89 103

PHASE III STUDY OF PASIREOTIDE LAR VS. OCTREOTIDE LAR IN PATIENTS WITH METASTATIC MIDGUT NET Blinded treatment period of 6 months NET patients with carcinoid syndrome symptoms inadequately controlled by maximum doses of currently available SSAs 1:1 randomisation Pasireotide LAR 60 mg IM every 28 days x 6 months with dose to 40 mg for tolerability (n=53) Octreotide LAR 40 mg IM every 28 days x 6 months with dose to 30 mg for tolerability (n=57) Primary endpoint: symptom control (month 6) Secondary endpoints: tumour response, PFS, safety Trial was terminated early based on interim analysis demonstrating futility for primary endpoint (symptom response at month 6) Wolin EM, et al. J Clin Oncol 2013;31:(suppl; abstr 4031); http://clinicaltrials.gov identifier NCT00690430.

ΙN ADDITION TO SSA, TELOTRISTAT ETIPRATE INHIBITS SEROTONIN PRODUCTION AND ALLEVIATES SYMPTOMS Serotonin Hormonal syndrome flushing, diarrhoea... 5-HIAA Urine 5-HIAA: 5-hydroxyindole acetic acid SSA somatostatin analogue SSTR somatostatin receptor Serotonin Tryptophan- Hydroxylase Tryptophan 5-Hydroxytryptophan (5-HTP) Serotonin (5-HT) NET-Cell Telotristat etiprate SSTR SSA

TELESTAR PHASE 3 STUDY DESIGN 3- to 4-week run-in (n=135) Run in: Evaluation of bowel movement (BM) frequency 1:1:1 R Placebo TID (n=45) Telotristat etiprate 250 mg TID (n=45) Telotristat etiprate 500 mg TID* (n=45) Telotristat etiprate 500 mg TID Evaluation of primary endpoint: Reduction in number of daily BMs from baseline (averaged over 12-week double-blind treatment phase) All patients required to be on SSA at enrollment and continue SSA therapy throughout study period Kulke M, et al. J Clin Oncol 2017;35(1):14 23

TELESTAR RESULTS: REDUCTION IN MEAN DAILY BOWEL MOVEMENT FREQUENCY AT BASELINE AND WEEK 12 17% 28% 36% Mild nausea: 15% Mild depression: 15 20% Kulke M, et al. J Clin Oncol 35(1), 2017:14 23. Reprinted with permission 2017, American Society of Clinical Oncology. All rights reserved.

SURVIVAL OF PATIENTS With bowel bypass (12) versus failed resection (17) versus no resection (80) versus resection (210) Study supported by UKI-NETS 5 UKI NET centres 360 patients RP NR ByP FR Median survival 9.92 years 4.68 years 5.61 years 6.74 years Deaths due to fibrosisrelated cachexia RP 4.78% NR,ByP, FR 12.72% Republished with permission of Society for Endocrinology from Endocr Relat Cancer, Ahmed A, et al. 16(7), 2009; permission conveyed through Copyright Clearance Center, Inc

MESENTERIC FIBROSIS IN MIDGUT NETS Episodes of sub-acute bowel obstruction Diet modification Hydronephrosis Ureteric stents Malnutrition Nutritional supplements, enteral feeding, TPN? Small bowel bacterial overgrowth Antibiotics Recurrent ascites, ectopic varices SMV stenting? Images courtesy of Dr. Christos G. Toumpanakis Toumpanakis CG, et al. BSG 2006; Naik et al. ENETS 2014.

CONTROL OF TUMOUR GROWTH FOR ADVANCED INOPERABLE GASTRO-INTESTINAL NETS Medical therapy Somatostatin analogues (SSAs) Interferon-α Molecular targeted therapies mtor inhibitors Systemic chemotherapy Loco-regional therapy Radiofrequency ablation (RFA) Embolization/chemoembolization/ radioembolization Nuclear medicine and radiation Tumour-targeted, radioactive therapy: PRRT using: 177 Lu DOTATATE External radiation (for bone/brain metastases)

OCTREOTIDE LAR IN PATIENTS WITH METASTATIC NEUROENDOCRINE MIDGUT TUMOURS PROMID placebo-controlled, double-blind, randomized study Median time to progression: 14.3 months in LAR group vs. 6 months in placebo After 6 m of treatment: Stable disease in 66.7% of LAR vs. 37.2% of placebo Most favorable effect in patients with low-hepatic tumour load and resected primary tumour Rinke A, et al. J Clin Oncol 27, 2009:4656 63. Reprinted with permission. 2009 American Society of Clinical Oncology. All rights reserved.

PRIMARY ENDPOINT: PFS PFS and tumour growth with Lanreotide Autogel in patients with enteropancreatic NETs: Results from CLARINET, a randomised, double-blind, placebo-controlled study 62% 22% Time (months) (ITT, N=204) P-value derived from stratified log-rank test; HR derived from Cox proportional hazard model. HR, hazard ratio; ITT, intention-to-treat. From N Engl J Med, Caplin ME, et al. Lanreotide in Metastatic Enteropancreatic Neuroendocrine Tumors, 371(3):224 33. Copyright 2014 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

RESULTS OF PHASE III STUDY OF PASIREOTIDE LAR VS. OCTREOTIDE LAR In patients with metastatic midgut NET There was no difference in symptoms control between the two arms Overall there was no difference in disease control (CR+PR+SD) between the two arms Pasireotide LAR demonstrated a benefit in tumour shrinkage Prolongation of PFS by 5 months was observed in patients treated with pasireotide LAR (11.8 vs. 6.8 months) Wolin EM, et al. Drug Des Dev Ther 2015;9:5075 86. Licensed under Creative Commons Attribution Non Commercial (unported, v3.0) available at http://creativecommons.org/licenses/by-nc/3.0/.

COMBINATION OF SOMATOSTATIN ANALOGUES WITH INTERFERON Study No of pts Primary Combination SD % PR / CR % Frank M, et al. 21 Pancreatic / midgut OCT + INF-α 62 5 Fjällskog ML, et al. 16 pancreatic OCT + INF-α >80 Kölby L, et al. 68 Midgut OCT + INF-α Faiss S, et al. 80 Foregut/ midgut / hindgut Arnold R, et al. 105 Pancreatic Midgut LAN or INF-α or LAN+ INF-α OCT or OCT + INF-α Reduced risk in tumour progression No benefit in survival No benefit of the combination More adverse effects No superior to monotherapy In PFS & OS Frank M, et al. Am J Gastroenterol 1999; Fjällskog ML, et al. Med Oncol 2002; Kölby L, et al. Br J Surg 2003; Faiss S, et al. J Clin Oncol 2003; Arnold R, et al. Clin Gastroenterol Hepatol 2005

SYSTEMIC CHEMOTHERAPY Platinum-based chemotherapy is the treatment of first choice in GEP-NECs with good RR but short PFS A 55% cut-off level of Ki67 seems promising predictive factor of response in NECs Streptozocin-based regimens induce responses ONLY in 15% of small bowel NETs Ki67 by itself cannot predict response in well-diff NETs Chemotherapy could be an option to be the preferred option in type III gastric NETs with rapid symptomatic and radiological progression; however, prospective studies are needed Kouvaraki MA, et al. J Clin Oncol 22(23), 2004:4762 71. Reprinted with permission 2004. American Society of Clinical Oncology. All rights reserved. Toumpanakis CG, et al. Best Pract Res Clin End Metab 2007; Sorbye et al. the NORDIC NEC study, Ann Oncol 2013.

Sunitinib Everolimus Reprinted from Gastroenterology, 135(5), Metz D, Jensen R. Gastrointestinal Neuroendocrine Tumors: Pancreatic Endocrine Tumors, 1469 92. Copyright 2008, with permission from Elsevier.

RADIANT-4 STUDY DESIGN Patients with well-differentiated (G1/G2), advanced, progressive, nonfunctional NET of lung or GI origin (N = 302) Absence of active or any history of carcinoid syndrome Pathologically confirmed advanced disease Enrolled within 6 months from radiologic progression R A N D O M I S E 2:1 Everolimus 10 mg/day N = 205 Placebo N = 97 Treated until PD, intolerable AE, or consent withdrawal Endpoints: Primary: PFS (central) Key Secondary: OS Secondary: ORR, DCR, safety, HRQoL (FACT-G), WHO PS, NSE/CgA, PK Stratified by: Prior SSA treatment (yes vs. no) Tumour origin (stratum A vs. B)* WHO PS (0 vs. 1) *Based on prognostic level, grouped as: Stratum A (better prognosis) appendix, caecum, jejunum, ileum, duodenum, and NET of unknown primary. Stratum B (worse prognosis) lung, stomach, rectum, and colon except caecum. Crossover to open label everolimus after progression in the placebo arm was not allowed prior to the primary analysis. Yao JC, et al. Lancet 2016;387(10022):968 77

PRIMARY ENDPOINT: PFS BY CENTRAL REVIEW 52% reduction in the relative risk of progression or death with everolimus vs. placebo HR=0.48 (95% CI, 0.35-0.67); P<0.00001 P-value is obtained from the stratified one-sided log-rank test; Hazard ratio is obtained from stratified Cox model. Reprinted from The Lancet, 387(10022), Yao JC, et al. Everolimus for the treatment of advanced, non-functional neuroendocrine tumours of the lung or gastrointestinal tract (RADIANT-4): a randomised, placebo-controlled, phase 3 study, 968 77. Copyright 2016, with permission from Elsevier.

TRANSARTERIAL HEPATIC EMBOLIZATION AND CHEMOEMBOLIZATION Symptomatic benefit (40 80%) 1,2 Partial response: ~50% 1,2 Survival benefit? 1,2 Morbidity (carcinoid crisis, fever, pain, hepatic failure, intestinal ischaemia) 2 Mortality 3 IV octreotide infusion pre- and posttherapy in midgut carcinoids 3 Careful selection of patients 3 Images courtesy of Dr. Christos G. Toumpanakis 1. Brown KT, et al. J Vasc Interv Radiol 1999;10(4):397-403; 2. Chamberlain et al. J Am Coll Surg 2000;190:432-445; 3. Toumpanakis CG, et al. Best Pract Res Clin End Metab 2007.

OTHER ABLATION THERAPIES Radio-frequency ablation Laser-induced thermotherapy Cryotherapy Ethanol ablation Reprinted from Gastroenterology, 134(6), El-Serag HB, et al. Diagnosis and Treatment of Hepatocellular Carcinoma, 1752 1763. Copyright 2008 with permission from Elsevier Brachytherapy

SST ANALOGUE TARGETED RADIOTHERAPY Mechanism of action Isotope + Sst analogue Somatostatin receptor Tumour cell Tumour cell The β-emitter labelled somatostatin analogue delivers a lethal radiation dose to the tumour cell

NETTER-1 STUDY OBJECTIVES AND DESIGN Aim Evaluate the efficacy and safety of LUTATHERA + SSAs (symptoms control) compared to Octreotide LAR 60mg (off-label use) in patients with inoperable, somatostatin receptor positive, midgut NET, progressive under Octreotide LAR 30mg (label use) Design International, multicentre, randomised, comparator-controlled, parallel-group n = 116 n = 113 Treatment and assessments Progression-free survival (RECIST criteria) every 12 weeks 4 administrations of 7.4 GBq of LUTATHERA every 8 weeks + SSAs (symptom control) Octreotide LAR (high dose 60mg every 4 weeks) 5 Years follow up Baseline progression according to RECIST 1.1 criteria The median time between the oldest pre-baseline and the baseline scans (used to determine the progression at enrolment) was 11.4 months for patients in the LUTATHERA arm and 11.7 months for the control arm Strosberg J, et al. N Engl J Med 2017;376(2):125 35.

PFS, OS AND SUBGROUP ANALYSIS IN NETTER-1 Adverse effects Nausea: 59% Vomiting: 47% Anaemia:14% Neutropenia: 6% Thrombocytopenia: 25% NO RENAL TOXICITY From N Engl J Med, 376(2), Strosberg J, et al. Phase 3 Trial of 177Lu-Dotatate for Midgut Neuroendocrine Tumors, 125 35. Copyright 2017 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

OBJECTIVE RESPONSE IN NETTER-1 Response category 177 Lu-dotatate group (n=101) Complete response, n (%) 1 (1) 0 Partial response, n (%) 17 (17) 3 (3) Objective response Objective Tumor Response* No. with response 18 3 Control group (n=100) P-value Rate, % (95% CI) 18 18 (10 25) 3 (0 6) <0.001 Learning point from NETTER-1 trial PRRT with 177 Lu-dotatate can control tumour growth in G1/G2 advanced and progressive midgut NETs with quite good objective response rates *The objective response rate was defined as the percentage of patients who had a response according to Response Evaluation Criteria in Solid Tumors (RECIST) #(sum of partial responses and complete responses). Patients for whom no post-baseline computed tomography (CT) or magnetic resonance imaging (MRI) scans or central response data were available (15 patients in the 177Lu-Dotatate group and 13 patients in the control group) were excluded from this analysis (trial is still ongoing). P-value calculated using Fisher s exact text. Strosberg J, et al. NEJM 2017;376:125 35

LONG-TERM EFFICACY OF LU-177 DOTATATE IN GEP-NETS Tumour type N CR PR SD ORR DoR (months) n % n % N % n % 95% CI Median 95% CI All* 360 11 3% 151 42% 183 51% 162 45% 40% 50% 16.3 12.2 17.8 Bronchial 19 0 0% 7 37% 11 58% 7 37% 16% 62% 23.9 1.7 30.0 Pancreatic 133 7 5% 74 56% 47 35% 81 61% 52% 69% 16.3 12.1 21.8 Foregut** 12 1 8% 6 50% 4 33% 7 58% 28% 85% 22.3 0.0 38.0 Midgut 183 3 2% 58 32% 115 63% 61 33% 27% 41% 15.3 10.5 17.7 Hindgut 13 0 0% 6 46% 6 46% 6 46% 19% 75% 17.8 6.2 29.9 Tumour type N PFS Time (months) OS Time (months) Median 95% CI Median 95% CI All* 360 28.5 24.8 31.4 61.2 54.8 67.4 Bronchial 19 18.4 10.4 25.5 50.6 31.3 85.4 Pancreatic 133 30.3 24.3 36.3 66.4 57.2 80.9 Foregut** 12 43.9 10.9 21.3 Midgut 183 28.5 23.9 33.3 54.9 47.5 63.2 Hindgut 13 29.4 18.9 35.0 CR: Complete Response PR: Partial Response SD: Stable Disease ORR: Overall Radiological Response PFS: Progression Free Survival OS: Overall Survival Brabander T, et al. Clin Cancer Res. 2017

EARLY EFFICACY OF AND TOXICITY FROM LU-177 DOTATATE TREATMENT In patients with progressive metastatic GEP-NET Kaplan-Meier chart of PFS for the whole cohort Objective response: 13% Disease stabilization: 64% Estimated median PFS was 28 months, 95% CI: 23 33 months Pencharz D, et al. Early efficacy of and toxicity from lutetium-177-dotatate treatment in patients with progressive metastatic NET Nucl Med Commun 2017;38(7):593 600. Available at: https://journals.lww.com/nuclearmedicinecomm/abstract/2017/07000/early_efficacy_of_and_toxicity_from.4.aspx.

COMBINATION OF SOMATOSTATIN ANALOGUES WITH OTHER AGENTS IN MIDGUT NETS CARCINOIDS Octreotide LAR + bevacizumab Octreotide LAR + PEG - INF No of pts SD % PR/CR % PFS % (18 w) 22 77 18 95 21 68 68 CARCINOIDS Octreotide LAR + placebo Octreotide LAR + everolimus PFS 11.3 months 16.4 months RADIANT-2 trial No difference in partial response No difference in disease stabilization More adverse effects in combination group Yao JC, et al. J Clin Oncol 2008;26(8):1316-23; Reprinted from The Lancet, 378 (9808), Pavel ME, et al. Everolimus plus octreotide long-acting repeatable for the treatment of advanced neuroendocrine tumours associated with carcinoid syndrome (RADIANT-2): a randomised, placebo-controlled, phase 3 study, 2005-12, Copyright 2011, with permission from Elsevier.

WHICH TREATMENT AND FOR WHOM Patient s clinical status, comorbidities and preferences Tumour histology Location of primary Positive uptake in Octreoscan or Ga-68 PET Tumour burden Tumour status Presence of carcinoid heart disease and/or mesenteric fibrosis Predictive molecular markers? Cost??

G3 GEP-NETS Patient s performance status 0-2 Systemic chemotherapy Platinum-based chemotherapy [Temozolomide-based chemotherapy (if Ki67 < 55%)] Disease progression 2 nd Line Systemic Chemotherapy (FOLFOX, FOLFIRI) Well differentiated G3 GEP-NETs PRRT? Molecular targeted? Sorbye H, et al. Cancer 2014; ENETS Guidelines 2016.

Biopsies of surrounding mucosa Serum gastrin No atrophic gastritis Normal serum gastrin ΤYPE III Atrophic gastritis Hypergastrinaemia ΤYPE I No atrophic gastritis Hypergastrinaemia ΤYPE II In localised disease Surgical resection In advanced disease Systemic treatment Management algorithm of gastric NETs >2 cm Invasion beyond Submucosa Lymph nodes? Local resection +/- antrectomy or +/- somatostatin analogues 1-2 cm No vascular invasion No deep invasion G1 Endoscopic resection <1 cm >1 cm Resection, if symptomatic or Somatostatin analogues Annual endoscopic surveillance Delle Fave G, et al. Neuroendocrinology. 2016;103(2):119-24.

ENETS 2016 CONSENSUS GUIDELINES FOR DUODENAL NETS Delle Fave G, et al. ENETS Consensus Guidelines Update for Gastroduodenal Neuroendocrine Neoplasms. Neuroendocrinology. 2016;103(2):119-24. With permission from S. Karger AG, Basel.

ENETS 2016 CONSENSUS GUIDELINES FOR INTESTINAL NETS Pavel M, et al. ENETS Consensus Guidelines Update for the Management of Distant Metastatic Disease of Intestinal, Pancreatic, Bronchial Neuroendocrine Neoplasms (NEN) and NEN of Unknown Primary Site. Neuroendocrinology 2016;103(2):172-85. With permission from S. Karger AG, Basel.

Dieticians Hepatobiliary & GI surgery Specialist NET Nurses Endocrinology NET patient Pathology Genetics Cardiology Oncology Radiology & Nuclear Medicine Gastroenterology Palliative care & Pain control

MULTI-DISCIPLINARY TEAM (MDT) APPROACH FOR NETS Accurate diagnosis & staging Evaluation of performance status & quality of life Consensus agreement on treatment plan Continuous reassessment, discussion and peer review of the individualised treatment plan

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