FRANKLY SPEAKING ABOUT CANCER:

NEUROENDOCRINE & CARCINOID

TUMORS (NETS)

Joseph Dillon, MDNeuroendocrine Tumor Clinic

University of Iowa Hospitals & Clinics

Gilda’s Club Quad Cities

November 5th, 2018

Diffuse (Neuro)Endocrine System

Thymus

Skin (Merkel)

Cervix/Uterus/Ovary

Stomach

(modified)

Neuroendocrine Cell

¼” = 1,000,000 cells

Neuroendocrine Cell

¼” = 1,000,000 cells

Neuroendocrine Cell

¼” = 1,000,000 cells

Neuroendocrine

Hormones

Neuroendocrine Cell

¼” = 1,000,000 cells

Somatostatin

Receptor

Neuroendocrine

Hormones

= Primary

(% occurrence)

= Metastasis

Liver>Lung>Bone

- Skin / Merkel

- Thymus(modified)

Neuroendocrine (“Carcinoid”) Tumors (NET)

~1.35 million

new cancer

How many people get a new diagnosis

of any cancer per year?

Modified from Dasari, A. JAMA Oncol. 2017;3:1335

~22,000

new NET

1.6% of all

new cancers

How many people get a new diagnosis

of NET per year?

Modified from Dasari, A. JAMA Oncol. 2017;3:1335

Modified from Dasari, A. JAMA Oncol. 2017;3:1335

0.05

0.04

0.03

0.02

0.01

0

2012200720021997

Year

Pre

vale

nce,

%~150,000 living

with NET

How many people are living with

NET?

Yao, JC. J Clin Oncol 2008

How many people are living with NET

compared to other cancers?

Important information about your tumor:

-Site of origin

-Size

-Stage (extent of spread; Radiologist)

-Grade (how quickly the tumor is growing; Pathologist)

-Differentiation (how abnormal looking are tumor cells; Pathologist)

-Hormone production (functional vs nonfunctional; blood / urine tests)

-Genetic changes* (blood test or tumor biopsy)

Classification of NETs

Liver

Metastasis Mesenteric

nodes

Staging of NETs: CT Scan

Pancreas

NET

Liver

Metastases

Staging of NETs: Gallium-68

DOTATATE PET (NETSPOT®) scan

Important information about your tumor:

-Site of origin

-Size

-Stage (extent of spread; Radiologist)

-Grade (how quickly the tumor is growing; Pathologist)

-Differentiation (how abnormal looking are tumor cells; Pathologist)

-Hormone production (functional vs nonfunctional; blood / urine tests)

-Genetic changes* (blood test or tumor biopsy)

Classification of NETs

Ki-67 stains cells that are dividing

<3% Grade 1

3-20% Grade 2

>20% Grade 3

Ki67 staining

Grading of NETs

Important information about your tumor:

-Site of origin

-Size

-Stage (extent of spread; Radiologist)

-Grade (how quickly the tumor is growing; Pathologist)

-Differentiation (how abnormal looking are tumor cells; Pathologist)

-Hormone production (functional vs nonfunctional; blood / urine tests)

-Genetic changes* (blood test or tumor biopsy)

Classification of NETs

No Symptoms

Tumor mass: Pain, Bowel obstruction, Bleeding

Tumor secretions: Carcinoid Syndrome (~20%):

(Diarrhea, Flushing, Wheezing, Palpitations)

Other: Changes in BP, blood sugar

What are the symptoms of a NET?

How do we diagnose NET?

Symptoms: Diarrhea, Flushing, Wheeze, Palpitations

Local Symptoms: e.g., Abdominal Pain

Fluid Retention / Heart Failure

Imaging: CT, MRI, Ga68 DOTA-PET (Diagnosis & Staging)

Lab Tests*: Serotonin, CGA, pancreastatin, etc

Biopsy: Diagnosis & Grading

*(Tumor markers, Biomarkers)

Imaging (STAGE)CT, MRI, Gallium-

DOTATATE PET (Netspot®)

Somatostatin Analog

Sandostatin®,Somatuline®

(Serotonin Inhibitor Xermelo®)

Hepatic Artery

Embolization

Bland, Chemo-, Radio-

Peptide Receptor Radio-

nuclide Therapy (P.R.R.T.)

(LUTATHERA®, Clinical

Trials)

Patient

Pathology (GRADE): Ki67 / differentiation

Somatostatin Receptor

Surgery ?

Primary tumor,

lymph nodes, liver

resection / ablation

Drug Therapy

‘Targeted’: Affinitor, Sutent

‘Conventional’: CAP-TEM,

other

Clinical Trials: Immune Inhibitor

*

Treatment Protocol for patients with NET

• For localized metastatic liver disease

• Bland-, Chemo-, or Radio-Embolization

• Rapidly reverses carcinoid syndrome

• Can precipitate acute carcinoid syndrome

Hepatic artery embolization for NET

Cause of Diarrhea Treatment

Surgical Small Bowel removal Cholestyramine, Colestipol

Cholecystectomy Cholestyramine, Colestipol

Small Intestine Bacterial

OvergrowthAntibiotics

Carcinoid TumorOctreotide*, Xermelo,

Other NET therapy

Sandostatin /Lanreotide side effect Pancreas enzymes

Not all diarrhea is carcinoid syndrome

University of Iowa Neuroendocrine

Tumor Group

Thomas M O’Dorisio, MD, Director

Internal Medicine

Thomas O’Dorisio, MD

Joseph Dillon, MD

C. Chandrasekharan, MD

Daniel Berg, MD

Muhammad Furqan, MD

Nuclear Medicine

David Bushnell, MD

Yusuf Menda, MD

Michael Schultz, PhD

Michael Graham, MD

Surgery

James Howe, MD

Kal Parehk, MD

Joel Shilyansky, MD

Interventional Radiology

Schilang Sun, MD

Sandeep Laroia, MD

Pediatrics

Sue O’Dorisio, MD, PhD

PI Neuroendocrine SPORE

Nursing/Research

& Clinic Staff

Kimberly Miller, RN (Clinic)

Mary Schall, RN (Clin Res)

Kristen Varner, RN (Clin Res)

Kellie Bodeker (Clin Res)

Melissa Thompson (Clinic)

Molly Becker (Clinic)

Megan Peterson (Res)

Veronica Howsare(Res)

➢Neuroendocrine Tumor Center of Excellence (ENETS)

➢Neuroendocrine Cancer SPORE(Specialized Program of Research Excellence, NIH)