Irinotecan plus cisplatin followed by octreotide long-acting release maintenance treatment in advanced gastroenteropancreatic neuroendocrine carcinoma: IPO-NEC study

From biology to clinical practice: antiproliferative effects of somatostatin analogs in neuroendocrine neoplasms

Somatostatin analogs (SSA), specifically octreotide and lanreotide, have demonstrated antiproliferative effects in patients with neuroendocrine tumors (NET), a group of rare malignancies of diverse origin and presentation. A prominent feature of NET cells is the expression of G protein-coupled receptors called somatostatin receptors (SSTR). Although these SSTR are not uniformly present in NET, they can be instrumental in the diagnosis and treatment of NET. Apart from their application in nuclear imaging and radionuclide therapy, SSA have proven invaluable in the treatment of hormonal syndromes associated with certain NET (antisecretory effects of SSA), but it took more than two decades to convincingly demonstrate the antiproliferative effects of SSA in metastatic NET with the two pivotal studies PROMID and CLARINET. The current review summarizes three decades of SSA treatment and provides an overview of the clinical trial landscape for SSA monotherapy and combination therapy, including clinical implications and quality of life aspects, as well as ongoing fields of research.

Potent molecular-targeted therapies for gastro-entero-pancreatic neuroendocrine carcinoma

Neuroendocrine neoplasms (NENs), which are characterized by neuroendocrine differentiation, can arise in various organs. NENs have been divided into well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs) based on morphological differentiation, each of which has a distinct etiology, molecular profile, and clinicopathological features. While the majority of NECs originate in the pulmonary organs, extrapulmonary NECs occur most predominantly in the gastro-entero-pancreatic (GEP) system. Although platinum-based chemotherapy is the main therapeutic option for recurrent or metastatic GEP-NEC patients, the clinical benefits are limited and associated with a poor prognosis, indicating the clinically urgent need for effective therapeutic agents. The clinical development of molecular-targeted therapies has been hampered due to the rarity of GEP-NECs and the paucity of knowledge on their biology. In this review, we summarize the biology, current treatments, and molecular profiles of GEP-NECs based on the findings of pivotal comprehensive molecular analyses; we also highlight potent therapeutic targets for future precision medicine based on the most recent results of clinical trials.

Expert Consensus Practice Recommendations of the North American Neuroendocrine Tumor Society for the management of high grade gastroenteropancreatic and gynecologic neuroendocrine neoplasms

High-grade neuroendocrine neoplasms are a rare disease entity and account for approximately 10% of all neuroendocrine neoplasms. Because of their rarity, there is an overall lack of prospectively collected data available to advise practitioners as to how best to manage these patients. As a result, best practices are largely based on expert opinion. Recently, a distinction was made between well-differentiated high-grade (G3) neuroendocrine tumors and poorly differentiated neuroendocrine carcinomas, and with this, pathologic details, appropriate imaging practices and treatment have become more complex. In an effort to provide practitioners with the best guidance for the management of patients with high-grade neuroendocrine neoplasms of the gastrointestinal tract, pancreas, and gynecologic system, the North American Neuroendocrine Tumor Society convened a panel of experts to develop a set of recommendations and a treatment algorithm that may be used by practitioners for the care of these patients. Here, we provide consensus recommendations from the panel on pathology, imaging practices, management of localized disease, management of metastatic disease and surveillance and draw key distinctions as to the approach that should be utilized in patients with well-differentiated G3 neuroendocrine tumors vs poorly differentiated neuroendocrine carcinomas.

Management of Large Cell Neuroendocrine Carcinoma

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive cancer with a dismal prognosis. The majority of cases occur in the lung and the gastrointestinal tract; however, it can occur throughout the body. Recently advances in the understanding of the molecular underpinnings of this disease have paved the way for additional novel promising therapies. This review will discuss the current best evidence for management of LCNEC and new directions in the classification and treatment of this rare disease.

METHODS

We performed a PubMed search for "Large cell neuroendocrine carcinoma" and "High grade neuroendocrine carcinoma." All titles were screened for relevance to the management of LCNEC. Papers were included based on relevance to the management of LCNEC.

RESULTS

Papers were included reviewing both pulmonary and extra pulmonary LCNEC. We summarized the data driven best practices for the management of both early and advanced stage LCNEC. We describe emerging therapies with promising potential.

DISCUSSION

LCNEC are rare and aggressive neoplasms. In advanced disease, the historical regimen of platinum based therapy in combination with etoposide or irinotecan remains among the commonly used first line therapies, however for extra thoracic LCNEC regimens like FOLFOX, FOLFOIRI and CAPTEM can also be used. Further effective and safe treatment options are desperately needed. Recently, new advances including a new understanding of the genetic subcategories of LCNEC and immunotherapy agents may guide further treatments.

Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma

OPINION STATEMENT

Treatment recommendations for advanced gastroenteropancreatic neuroendocrine carcinomas (GEP-NEC) are based on uncontrolled, mainly retrospective data. Chemotherapy can offer palliative relief, but long-lasting complete responses or cures are rare. The European Neuroendocrine Tumour Society (ENETS) and European Society for Medical Oncology (ESMO) recommend platinum-based chemotherapy as first-line treatment. This has been the golden standard since the late 1980s and has been evaluated in mostly retrospective clinical studies. However, progression is inevitable for most patients. Unfortunately, data on effective second-line treatment options are scant, and ENETS and ESMO recommendations propose fluorouracil- or temozolomide-based chemotherapy schedules. As such, there is a huge unmet need for improved care. Improved knowledge on GEP-NEC biology may provide a pathway towards more effective interventions including chemotherapy, targeted gene therapy, peptide receptor radionuclide therapy, as well as immune checkpoint inhibitors. The review summarises this current state of the art as well as the most promising developments for systemic therapy in GEP-NEC patients.

Etoposide and cisplatin versus irinotecan and cisplatin as the first-line therapy for patients with advanced, poorly differentiated gastroenteropancreatic neuroendocrine carcinoma: A randomized phase 2 study

Background

Platinum‐based chemotherapy is recommended for the treatment of advanced gastroenteropancreatic neuroendocrine carcinoma (GEP‐NEC). The objective of the current phase 2 study was to compare the efficacy and toxicity between etoposide and cisplatin (EP) and irinotecan and cisplatin (IP) as first‐line treatment in patients with advanced GEP‐NEC.

Methods

Patients with advanced, poorly differentiated GEP‐NEC randomly were assigned to receive EP or IP. The primary endpoint was the objective response rate (ORR). The secondary endpoints were progression‐free survival, overall survival, and toxicities.

Results

The planned size of the study population was 144 patients, but enrollment was terminated early at 66 patients because the premature analysis found similar responses in the 2 treatment arms. The ORRs of the EP and IP arms both were 42.4% (14 of 33 patients). The efficacy was similar for small cell NEC with EP or IP (63.2% and 61.5%, respectively; P = .61), whereas that of IP was slightly better in patients with non–small cell NEC (30% vs 14.3%; P = .42). The median progression‐free survival was 6.4 months and 5.8 months, respectively, for the EP and IP arms (P = .81), and the median overall survival was 11.3 months and 10.2 months, respectively, for the EP and IP arms (P = .37). The incidence of grade 3/4 neutropenia was significantly higher in the EP arm compared with the IP arm (45.4% vs 12.1%; P = .002). Nonhematological toxicity was relatively mild and more frequent in the IP arm compared with the EP arm (54.5% vs 18.2%; P = .001). No toxicity‐related deaths were reported.

Conclusions

The results of the current study demonstrated that IP is not inferior to EP, with comparable efficacy for poorly differentiated NEC of the digestive system. In addition, both regimens appear to be well tolerated with diverse toxicity profiles.

The current randomized, phase 2 study demonstrates that although the combinations of etoposide and cisplatin (EP) and irinotecan and cisplatin (IP) have comparable efficacy among patients with neuroendocrine carcinoma (NEC) of the digestive system, IP most likely has an advantage in patients with non–small cell NEC. In addition, both regimens are well tolerated despite their different toxicity profiles. The most common toxicities are myelosuppression in the EP arm and gastrointestinal toxicity in the IP arm.

Prognostic value of inflammation-based markers in advanced or metastatic neuroendocrine tumours

Background

The role of systemic inflammation-based markers remains uncertain in advanced or metastatic neuroendocrine tumours (nets).

Methods

Systemic inflammatory factors, such as levels of circulating white blood cells and other blood components, were combined to yield inflammation-based prognostic scores [high-sensitivity inflammation-based Glasgow prognostic score (hsgps), neutrophil:lymphocyte ratio (nlr), platelet:lymphocyte ratio (plr), high-sensitivity inflammation-based prognostic index (hspi), and prognostic nutritional index (pni)], whose individual values as prognostic markers were retrospectively determined. Univariate and multivariate analyses were used to examine the association of inflammatory markers with overall survival (os).

Results

The study included 135 patients. Univariate analysis revealed that elevated white blood cell count, elevated neutrophil count, low serum albumin, elevated high-sensitivity C-reactive protein, and elevated hspi, hsgps, and nlr scores were significantly associated with worse os. Multivariate analyses demonstrated that, apart from pathology grade and original site of the tumour, elevated hspi (p = 0.004) was an independent prognostic factor for worse os.

Conclusions

In the present study, elevated pretreatment hspi was observed to be an independent predictor of shorter os in patients with inoperable advanced or metastatic net. The hspi might thus provide additional guidance for therapeutic decision-making in such patients.

The efficacy of chemotherapy and operation in patients with colorectal neuroendocrine carcinoma

BACKGROUND

Colorectal neuroendocrine carcinoma (CRNEC) is a rare type of malignancy and is quite aggressive with dismal prognosis. Neither large-scale retrospective studies nor prospective studies have been performed to evaluate the prognostic value of adjuvant chemotherapy in patients with CRNEC.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database, 318 elderly patients who were diagnosed with high-grade colorectal neuroendocrine tumors were included. The survival benefit was evaluated using a Cox proportional hazards model and propensity score-matched techniques.

RESULTS

Among patients with stage I-III CRNEC, there was also no significant difference in cancer-specific survival (CSS) (P = 0.898) or overall survival (OS) (P = 0.539) between the 5-fluorouracil (5-FU) and the no chemotherapy groups. Meanwhile, the etoposide + platinum (EP) regimen showed no improved survival in patients with stage I-III CRNEC compared with the no chemotherapy group. For stage IV CRNEC, there was no significant difference between operation group and no operation group in CSS (P = 0.317) or OS (P = 0.385). Both 5-FU and EP regimens improved the CSS (for 5-FU, hazard ratio [HR] = 0.257, 95% confidence interval [CI] = 0.134-0.491, P < 0.001; for EP, HR = 0.348, 95% CI = 0.192-0.631, P = 0.001) and OS (for 5-FU, HR = 0.274, 95% CI = 0.149-0.502, P < 0.001; for EP, HR = 0.345, 95% CI = 0.194-0.612, P < 0.001) of patients in stage IV CRNEC.

CONCLUSIONS

Our findings demonstrated that neither the 5-FU based nor EP chemotherapy regimens improved the CSS or OS for patients with stage I-III CRNEC. And for stage IV CRNEC, chemotherapy is an independent prognostic factor for CSS and OS, while operation could not improve the CSS or OS for patients with stage IV CRNEC.