Case report of a patient with initially inoperable well-differentiated midgut neuroendocrine tumor (WDNT) — PRRT and long-acting somatostatin analogs as the neoadjuvant therapy

Anna Sowa-Staszczak, Dorota Pach, Agnieszka Stefańska, Piotr Szybiński, Jan Kulig, Romana Tomaszewska, Robert Chrzan, Alicja Hubalewska-Dydejczyk

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Abstract

A 43-year-old man was admitted to Surgery Department because
of abdominal pain, vomiting, weight loss and flushes. Computed
tomography (CT) examination revealed upper and middle abdomen
tumor of about 110 × 110 mm. Histopathological analysis of
the tissues obtained during the exploratory laparotomy confirmed
WDNT (well-differentiated neuroendocrine tumor according to
the WHO classification 2000). The patient received 5 doses of
chemotherapy without any response. A positive result of 99mTc-
[EDDA/Hynic] Octreotate scintigraphy (SRS) gave the possibility of PRRT (peptide receptor radionuclide therapy). The patient
was treated with the total dose of 400 mCi of 90Y-DOTA-TATE.
CT performed after the PRRT revealed regression of the tumor
size to 72 × 94 mm. A decrease of CgA level and release of
symptoms were also observed. Aiming at the removal of the
considerable diminished tumor the patient was qualified for the
second laparotomy. “Cytoreduction” surgery with partial excision
of the tumor was performed. Additionally tumor-affected appendix
was removed. The second focus of WDNT (according to the WHO
classification 2000) with Ki67 < 1% was found in the appendix. Pathologists
confirmed the above-mentioned lesions as independent
(an extremely rare clinical situation). The following treatment with
long-acting somatostatin analogs and 300 mCi of 90Y-DOTA-TATE
resulted in further regression of the tumor size to 25 × 35 mm.
Consecutive laparotomy is considered. If complete tumor removal
might be achieved is an open question. The above case report
shows the efficacy of combined therapy with the use of “hot” and
“cold” somatostatin analogs not only in controlling the symptoms
of the disease but also in obtaining tumor size regression
making surgical intervention possible. Such a neoadjuvant therapy
seems to be a promising tool in the management of patients with
initially inoperable neuroendocrine tumors.

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