Surgical oncologists are refining treatment approaches for neuroendocrine tumors (NETs), introducing both de-escalation and escalation strategies based on patient risk factors and tumor characteristics.
Dr. Brett L. Ecker, surgical oncologist at Rutgers Robert Wood Johnson Medical School, highlighted significant developments in NET treatment during the 2024 Annual Oncology Clinical Practice and Research Summit. These advances are reshaping the traditional surgery-first approach with more nuanced, risk-stratified treatment protocols.
De-escalation Strategy for Small Tumors
For pancreatic neuroendocrine tumors smaller than 2 cm, emerging evidence supports a surveillance-first approach. Recent interim results from two European prospective studies, encompassing nearly 500 patients, revealed that only one patient developed metastatic progression during observation. This remarkably low progression rate suggests that careful monitoring, rather than immediate surgery, may be appropriate for select patients with small pancreatic NETs.
Advanced Treatment for High-Risk Patients
While some patients benefit from less aggressive approaches, others require intensified treatment. The traditional limitations of cytostatic treatments like somatostatin analogs are being addressed with new cytotoxic options. CAPTEM, combining capecitabine (Xeloda) and temozolomide (Temodar), has shown promising results in improving progression-free survival in metastatic settings.
Risk Stratification and Adjuvant Therapy
The Zaidi scoring system, developed through multi-institutional collaboration, has emerged as a valuable tool for risk stratification. This system identifies patients as low-, moderate-, or high-risk following pancreatic NET resection. The data reveals concerning recurrence rates:
- Moderate-risk patients: approximately 20% recurrence at 5 years
- High-risk patients: nearly 100% recurrence at 3 years
SWOG S2104 Trial: A New Direction
The ongoing phase 2 SWOG S2104 trial is investigating CAPTEM's potential as adjuvant therapy for high-risk patients. This study represents a critical step toward improving outcomes for patients with significant recurrence risk, potentially establishing a new standard of care for aggressive disease management.
