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In this episode of the Oncology Brothers podcast, we dived deep into the evolving treatment strategies for neuroendocrine tumors (NETs), focusing specifically on Peptide Receptor Radionuclide Therapy (PRRT). We were joined by two experts: Dr. Heloisa Soares, a medical oncologist specializing in NETs, and Prof. Ken Herrmann, a nuclear medicine physician with extensive experience in Europe. Together, they broke down the role of PRRT in treatment sequencing, discussed practical patient management pearls, and highlighted the importance of multidisciplinary collaboration in achieving the best outcomes for NET patients.
The discussion began by outlining the current landscape of therapies for NETs. Functional tumors are managed with somatostatin analogues, while newer systemic agents—such as cabozantinib and everolimus—have added to the arsenal. For high-grade NETs, regimens borrowed from small cell lung cancer are still commonly used. But the true game-changer lies in PRRT using radionuclide therapies such as 177Lutetium-Dotatate.
From imaging standpoint, Dr. Soares explained the shift from Octreoscan toward newer high-sensitivity tracers like Gallium-68 and Copper-64 DOTATATE PET, which can achieve sensitivities up to 90%. Both isotopes are highly effective and largely interchangeable, with the choice depending on institutional availability. Importantly, these scans are used not only to characterize disease but also to confirm somatostatin receptor positivity—a prerequisite for PRRT.
Where PRRT fits in the treatment sequence was a central theme. Most patients receive PRRT in the second-line setting, especially midgut NETs, where it has consistently shown superiority to high-dose octreotide or everolimus in clinical trials such as NETTER-1 and COMPETE. The experts noted that while promising data supports the use of PRRT in certain first-line scenarios, widespread adoption will require more mature overall survival data. In practice, careful sequencing is critical, especially in high-grade or more aggressive disease patterns.
Toxicity management was another important component. From the patient’s perspective, nausea is the most common complaint—largely due to kidney-protecting amino acids rather than the radiation itself. Regulators remain most concerned about renal safety. Clinicians, however, pay close attention to bone marrow suppression and the small but proven risk of secondary malignancies such as MDS and leukemia. Rates are typically in the 2–3% range but may climb higher in patients who also receive alkylating chemotherapy. This makes careful sequencing and counseling essential, especially in pancreatic NETs where temozolomide is widely used.
Monitoring after PRRT involves cross-sectional imaging with CT or MRI, usually performed 3 months after completing therapy. DOTATATE PET is excellent for baseline staging but not routinely required for treatment surveillance. Chromogranin A, once a staple biomarker, has little utility while on treatment.
Throughout the discussion, both experts underscored the importance of the multidisciplinary team (MDT). From radiology and nuclear medicine to surgery, medical oncology, and supportive care, NET management thrives on collaboration. Tailored treatment decisions, patient education on expectations, and balancing disease biology with individual patient goals form the backbone of good outcomes.
COR2ED: https://cor2ed.com/net-connect/programmes/targeted-radiopharmaceutical-treatment-nets/