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 To introduce the Interdisciplinary Neuroendocrine care team
model at London Health Sciences Centre/London Regional
Cancer Program
 To highlight the decision making process, treatment
recommendations and referral process for patients diagnosed
with neuroendocrine tumor
 To increase the understanding of treatment options available
in London
Dr. W. Kocha, Medical Oncologist
Dr. R. Reid, Nuclear Medicine
Dr. D. Gray, General Surgeon
Dr. D. Quan, Hepatobillary Surgeon
Dr. J. Elliott, Interventional Radiologist
Dr. A. Mujoomdar, Interventional Radiologist
Dr. B. Dias, Cardiologist
Dr. M. Lock, Radiation Oncologist
Dr. C. Howlett, Pathologist
Dr. S. Van Uum, Endocrinologist St. Joseph’s Hospital
Catherine Bond-Mills, Pharmacist
James Mulligan, Registered Dietician
Heather Shaddick, Social Worker
Helen Battler, Spiritual Care Specialist
Rosemary Davidson, Primary Nurse
Dr. Kocha, Medical Oncologist
Specialist on antineoplastic therapy. Utilizes targeted therapies,
clinical trials, somatostatin analogs that best treat neuroendocrine
tumours. Also a hematologist therefore familiar with hematological
abnormalities that can result from therapies.
Dr. Reid, Nuclear Medicine
Expertise evaluating isotope scans, obtaining/administration of
radiopharmaceutical therapy. I 131 MIBG, In111 Octreotide and
Lutetium 177 Octreotate. Samarium offered for wide spread bone
metastases.
Dr. Gray, General Surgeon
Recommends surgery which can span the spectrum of complete
resection to debulking of tumour to preventing life threatening
complications from tumour invasion.
Dr. Quan, Hepatobillary Surgeon
Specialty ranges from liver transplant, resection or debulking of liver
tumours. Debulking if able to remove 80% of metastatic liver disease.
Extremely important for patients who have functional tumours.
Dr. Elliott & Dr. Mujoomdar, Interventional Radiologists
Expertise in performing embolizations/RFA procedures for metastatic
liver tumors. Perform liver biopsies, angiograms, place billary stents,
nephrostomy tubes. Evaluate patients to determine who would benefit
from embolizations or RFA procedures.
Dr. Dias, Cardiologist
Evaluates echocardiograms to determine the intervention/treatment of
carcinoid related heart disease. Provides surgeons with cardiac risk factor
and patients ability to undergo general anesthetic.
Dr. Lock, Radiation Oncologist
Expertise in the application of external beam radiation therapy for
metastatic bone lesions and will treat metastatic liver tumours if
applicable.
Dr. Howlett, Pathologist
Reports and reviews pathologies of neuroendocrine tumours. Determines
the Ki-67% and # of mitosis/high powered field which differentiates the
low to high grade NET’s. Pathology directs treatment.
Dr. VanUum, Endocrinologist
Expertise in the management of hormone imbalances that accompany
many of the MEN I/II NET’s and pNET’s. Prescribes, adjusts medication
required for thyroid abnormalities, diabetes, pituitary tumors.
Catherine Bond-Mills, Pharmacist
Collaborates with inpatient pharmacy. Referral point for patients who
require assistance for medication coverage, patient assistant programs.
Reinforces education on oral chemotherapy, targeted therapies.
Supportive Care Team
James Mulligan, Registered Dietician
Heather Shaddick, Social Worker
Helen Battler, Spiritual Care Specialist
Rosemary Davidson, Primary Nurse
Collaborates with MDT members, coordinates treatment, procedures,
referrals, admissions. Provide patient education re: treatment options
& recommendation. Develops education material. Provides emotional
support. Contact point for patients and health care professionals in
Canada.
Intake clerk/secretary from any MDT physicians accepts referral.
Information required per MDT Guidelines:
 Operative note/Pathology with Ki-67 & #of mitoses/hpf
 Radiology/Nuclear Medicine scans done within 6 weeks of
referral to LRCP/LHSC
 Lab values, 24 hour urinary 5-HIAA or urinary catecholamines
 Clinical notes, previous chemotherapy, radiation therapy,
targeted therapies, embolizations, somatostatin analogue therapy
WORKING TOGETHER
 Core group of physicians on the Neuroendocrine
Team discuss all new patients referred to LRCP or
LHSC at the multidisciplinary tumour board
rounds
 At MDT rounds, treatment options and plan of
care is the focus
 The goal of the team is to enhance the quality of
life for each patient by sharing their expertise in
the management/recommendations of NET’s
PATIENTS OUTSIDE THE LIN: It is important to maintain
contact with your local team…We WANT TO SHARE your care!
Tumour board note/letter is dictated with recommendations to the
referring physician. The letter requests the referring physician
review the MDT recommendations with their patient
 If surgery is an option, patients often prefer this be preformed
close to home rather than in London
 If radioisotope therapy offered, treatment must be in London
BUT care is shared with referring oncologist
 If chemotherapy is the recommendation, this can be done at the
local cancer centre
WORKING TOGETHER
PATIENTS INSIDE THE LIN:
Intake clerk schedules patient for a consultation with
Dr. Kocha and Dr. Reid. Treatment recommendations
discussed and referral made to appropriated MDT
physician
 Surgery…..Referral to Dr. Gray or Dr. Quan
 Radioisotope therapy…..Referral to Dr. Reid/Dr. Kocha
 Chemotherapy…..Referral to Dr. Kocha
 External beam radiation therapy…..Referral to Dr. Lock
LET’S TALK ABOUT
NEUROENDOCRINE
TUMOURS
NEUROENDOCRINE TUMOURS
 NET’s are derived from cells of
the nervous & endocrine
system.
 NET cells are located in the
endocrine glands, adrenals,
pancreas, thyroid, pituitary
 Can start at the respiratory
system and end at the rectum.
 NET cells also found in the
ovaries and testes
 Total of 24 types of NET’s
FUNCTIONING NET’S
 Most common functioning NET’s are Carcinoids (50%
in the GI tract). Pheochromocytoma & Paraganglioma
are functional tumours
 Four common functional pNET’s, each named after
the hormone they secrete
 Symptoms of hormone production can make a person
very ill. This can lead to early diagnosis which results
in resection
 Most common hormone secreted is serotonin, this
causes carcinoid syndrome
TUMOURS & THEIR HORMONES
TUMOUR
HORMONE
SYNDROME
Carcinoid
Serotonin, histamine,
bradykinin, kallikrein,
etc
Flushing, diarrhea,
cramps, wheezing,
palpitations, Rt. heart
changes, heart failure
Insulinoma
Insulin
Hypoglycemia, very high
insulin levels, low
glucose levels
Glucogonoma
Glucagon
High glucagon levels,
diarrhea, weight loss,
thromboembolic disease,
rash “necrolytic
migratory erythema”
VIPoma
Vasoactive intestinal
peptide
Profuse watery diarrhea,
hypokalemia,
hypochlorhydria,
anemia, dehydration
TUMOURS & THEIR HORMONES
TUMOUR
Gastrinoma
Pheochromocytoma
Paraganglioma
HORMONE
SYNDROME
Gastrin
Recurrent multiple
peptic ulcers,
diarrhea,
hyperacidity,
abdominal pain
Epinephrine &
Norepinephrine
Hypertension,
tachycardia,
palpitations, sweats,
pallor, nausea,
feelings of
impending death
Hypocalcemia,
osteoporosis
Medullary thyroid Calcitonin
NON-FUNCTIONING NET’s
 May be found incidentally at surgery, can be large but due
to lack of hormone production the individual does not
feel ill
 Presenting symptom may be intermittent SBO due to
mesenteric fibrosis
 25 to 50% of carcinoid tumours are non-functioning
 33 to 50% of pNET’s are non-functioning
 Carcinoid or pNET’s can evolve into a functioning tumour
PATHOLOGY ...... SO IMPORTANT
Dr. Howlett, the pathologist on the NET team, reviews pathology at
tumour board rounds. If incomplete, he will request the actual
slides be sent to him for review.
Ki-67 is regarded as a prognostic factor for survival and directs
treatment.
NET’s are divided into low, intermediate and high grade
classifications. Grade determines treatment/prognosis
Low and intermediate grade tumours are well differentiated and
have a more favourable prognosis (G1 and G2 disease)
High grade tumours are poorly differentiated, more aggressive and
have a less favourable prognosis (G3 disease)
Tumours that demonstrate a significant increase in growth on
imaging need to be biopsied and pathology reviewed
It is not uncommon for tumours to transform and develop more
aggressive features on pathology
WHO classification if NET’s was updated 2010
Criteria based on:
 proliferative activity(how fast the cells grow)
 tumour pathology, well or poorly differentiated
 tumour size and involved nodes
 metastases
TREATMENT OPTIONS
SURGERY….. EVEN IF METASTATIC !
Dr. Gray and Dr. Quan evaluate the role of surgery at MDT rounds
 RESECT the primary tumour = CURE
 RESECT or debulk liver tumours if able to remove 80%
 REDUCE tumour size. Debulking can improve overall survival
(NET’S are usually slow growing), reduce symptoms from
hormone producing NET’s, and improve efficacy of
radiopharmaceutical therapy
 REDUCE symptoms caused by tumour. Mesenteric fibrotic
changes caused by primary tumours in the GI tract can lead to
partial or complete bowel obstruction. Resection or bypass
surgery will reduce or eliminate this complication
RADIOPHARACEUTICAL THERAPY
Dr. Reid, Nuclear Medicine physician secures all three isotopes, In
111 Octreotide, I 131 MIBG and Lutetuim 177 Octreotate. He
administers the isotope in the patients room.
All isotopes are requested by special access therefore follow up is
ongoing even after completion of therapy.
In 111 Octreotide and I 131 MIBG scan are required at LHSC to
determine avidity to the isotope.
In 111 Octreotide and/or I 131 MIBG therapy is offered pending
avidity. Often carcinoid and pheochromocytoma have avidity for
both isotopes. pNET’s are only avid for In 111 Octreotide
Lutetium 177 therapy. Tumour must be octreotide avid. Highest
energy isotope given in Canada
IN 111 OCTREOTIDE THERAPY
In 111 Octreotide therapy planned q 6 weeks x 3
Admit 3 days to a private room. Body secretions radioactive (esp.
urine)
5FU or Xeloda given 7 days before and 7 days after each isotope
therapy. Four hours post isotope Epirubicin & Carboplatin are
administered. Chemotherapy acts as a radiosensitizer.
Weekly blood work at local lab while on therapy and x 8 weeks
after final therapy.
CT/MRI 3-4 months after last Octreotide therapy
Pending response, maintenance therapy q 6 months x 2 years.
Goal to achieve tumour stability
I-131 MIBG THERAPY
MIBG therapy planned q 9 weeks x 3 based on blood work values
Admit 5 days to a private room. Body secretions urine, stool and
blood are radioactive
5FU or Xeloda given 7 days before and for 7 days after each isotope
therapy. Four hours post isotope Epirubicin & Carboplatin are
administered . Chemotherapy acts as a radiosensitizer.
Thyrosafe (Potassium Iodide) x 10 days to protect the thyroid.
Weekly blood work at local lab while on therapy and x 8 weeks
after final therapy.
CT/MRI 3-4 months after last MIBG therapy. Pending response
maintenance therapy q 6 months x 2 years. Goal to achieve tumour
stability
ALTERNATING ISOTOPE THERAPY
Offered if avidity for both In 111 Octreotide and I 131 MIBG.
Receive 2 treatments of each isotope
Chemotherapy is administered with each isotope therapy
MIBG - 9 week recovery – Octreotide - 6 week recovery –
MIBG - 9week recovery then final treatment with Octreotide
Weekly blood work at local lab while on therapy and x 8
weeks after final therapy
CT/MRI 3-4 months after last therapy. Pending response
maintenance therapy q 6 months x 2 years. Goal to achieve
tumour stability
LUTETIUM 177 OCTREOTATE
If avid for Octreotide, total of 3 therapies q 10 to 16 weeks
CT scan, Octreotide and Renal scan including GFR pre L-177 tx
Admit 3 days to a private room. Body secretions urine, stool and
blood radioactive
Chemotherapy not administer with Lutetium, higher radiation
Weekly blood work at local lab while on therapy and x 8 weeks
after final therapy
 CT/MRI 3-4 months after final therapy. Regular follow up
appointments to monitor tumour response
TRANSARTERIAL CHEMOEMBOLIZATION
TACE is preformed by Dr. Mujoomdar or Dr. Elliott
Interventional Radiologists
Localized palliative therapy for liver only metastases from
neuroendocrine tumours. There can be no disease outside the liver
for this therapy
Most tumours receive blood supply from the hepatic artery,
embolization interrupts this blood supply, thus delays tumour
growth
Contraindicated if portal vein occlusion, dilated billiary ducts,
previous Whipple’s procedure, ascites
TRANSARTERIAL CHEMOEMBOLIZATION
A thin catheter is thread up into the tumour by the physician. The
catheter entry point is the groin
In London doxorubicin and cisplatin powder are mixed with
lipiodol and injected into the tumour. Chemotherapy increases
tumour necrosis
Review of 122 patients treated with TACE, 82% had tumour
regression and 92% reported improvement of symptoms
TACE can be done to reduce tumour volume prior to radioisotope
therapy. Less tumour volume=more concentrated isotope therapy
COURSE IN HOSPITAL
 IV antibiotics, foley catheter and pain pump started pre
embolization
Post embolization oral antibiotics for 10 days. Ondansetron,
decadron while in hospital( 3 day admission)
Common side effects are bloating, decreased appetite and
increased fatigue that can last x 4-6 weeks
Functional tumours
Sandostatin 60 mg IM 14 days prior to embolization
Sandostatin 500 mcg. s/c 1 hr pre embolization
If carcinoid syndrome during procedure Sandostatin IV
TREATMENTS AVAILABLE AT YOUR LOCAL
CANCER CENTRE
TREATMENTS AVAILABLE AT YOUR LOCAL
CANCER CENTRE
CHEMOTHERPAY
G3 Disease: Etoposide/Cisplatinum
5Flurouracil infusion x 14 days/Dacarbazine infusion
for last 5 days of the cycle
Streptozocin/Adriamycin or 5FU (only for pNET’s)
Asses response after every 2 cycles, treat to maximum response
G2 Disease: Same chemotherapy as for G3 disease, image after
every 2 cycles and treat to maximum response. Your Oncologist
then can advise Dr. Kocha of response. Next step is to perform the
In 111 Octreotide and/or MIBG scan, if avid offer appropriate
isotope therapy
SOMATOSTATIN ANALOGUES (SSA’s)
 Bind to somatostatin receptors to decrease production of
hormones. Serotonin from carcinoids, insulin, glucogon,
gastrin and vasoactive polypeptide(VIP) from pancreatic
neuroendocrine tumours.
 Recommend as primary treatment for symptomatic NET’s and
asymptomatic NET’s with progressive disease to stabilize
tumour. Evidence of tumour stability in 35-70% of patients on
LAR (PROMID trial)
TARGETED THERAPIES
 Interfere and block various pathways that are needed for cancer
cells to grow. They can prevent the formation of blood vessels,
cut off the blood and oxygen supply to the cells .
End result, inhibits tumour growth
The complexities of a Neuroendocrine tumour require the
collaboration of a TEAM of health care professionals
The MDT at LRCP/LHSC are committed to provide the very best
care, management and follow up for this unique patient population
Our team strives to educate Health Care Professionals across
Canada about the complexities of NET’s and treatment options
available in London
It is the collaboration and dedication of this team that will offer
you the most current treatment options and best quality of life
YOUR QUESTIONS PLEASE
THANK YOU FOR YOUR TIME