Advancing Surgical Techniques in Neuroendocrine Tumors

During the 2024 Annual Oncology Clinical Practice and Research Summit, CancerNetwork^® spoke with Brett L. Ecker, MD, regarding the current standard-of-care therapy for neuroendocrine tumors, and how it is set to evolve.¹

Ecker is a surgical oncologist and assistant professor in the Department of Surgery, Division of Surgical Oncology, and Section of Gastrointestinal Oncology at the Rutgers Robert Wood Johnson Medical School. Throughout the discussion, he focused on ways to de-escalate or escalate care when appropriate and highlighted specific studies that focused on these strategies.

While he spoke about the use of surgery, he also mentioned the use of adjuvant therapy, and how that could be useful in the treatment of patients with neuroendocrine tumors.

Transcript:

For patients with localized disease, the standard of care is currently surgery. There’s increasing momentum, though, for de-escalation of therapy, particularly for smaller tumors. Some of the data I’ll be covering [at the conference] involves pancreatic neuroendocrine tumors that are less than 2 cm in size. We now don’t just have retrospective data suggesting that it’s safe to observe these patients, but we now have the interim results of 2 prospective studies, both from Europe, that have nearly 500 patients together. From those 2 studies, we only observed 1 patient who had metastatic progression in the course of surveillance, meaning that the number needed to treat is about 1 in 500. Altogether, [the data] suggest that observation is a safe strategy for selected patients with small, less than 2 cm neuroendocrine tumors of the pancreas.

The standard of care has been surgery, and I was just describing, there is one way that we’re trying to de-escalate care. There’s another cohort of patients where we’re trying to escalate care. Traditionally, we have not had therapies that we can use as adjuvant agents, because the standard treatments of neuroendocrine tumors, mostly somatostatin analogs, and subsequent treatments tend to be cytostatic and not cytotoxic. When you start thinking about what treatments you want to use to eradicate micrometastatic disease, you’re looking for therapies that are going to be cytotoxic. We now have that based on our recently presented ECOG study, at least in the metastatic setting, using CAPTEM [capecitabine (Xeloda) and temozolomide (Temodar)], showing that it improves progression-free survival.

Now that we have our cytotoxic agent, there’s an ongoing phase 2 SWOG S2104 study [NCT05040360] that is looking at the use of CAPTEM as an adjuvant strategy for patients at high risk for recurrence. This took some data that was published by an author, Zaidi, and generated the Zaidi score.² Shishir Maithel was the senior author of that work, and it was multi-institutional and collaborative. But it demonstrated that you could identify patients who were low-, moderate-, and high-risk after a section of pancreatic neuroendocrine tumors. And then in patients with moderate- or high-risk features, they have a significant risk of recurrence well over for moderate risk; it was [approximately] 20% at 5 years. For the high-risk [population], it was [approximately] 100% at 3 years. This is a high-risk cohort where we need to escalate therapy to improve oncologic outcomes. The ongoing SWOG study is looking at using CAPTEM to try to improve outcomes for those patients.

References

1. Deek M, Ecker B. Neuroendocrine tumors: state-of-the-art care in 2024. Presented at the 2024 Annual Oncology Clinical Practice and Research Summit; November 15-16, 2024; New Brunswick, NJ.
2. Zaidi MY, Lopez-Aguiar AG, Switchenko JM, et al. A novel validated recurrence risk score to guide a pragmatic surveillance strategy after resection of pancreatic neuroendocrine tumors: an international study of 1006 patients. Ann Surg. 2019;270(3):422-433. doi:10.1097/SLA.0000000000003461