What considerations drive your decision between bland embolization, TACE, and radioembolization in managing neuroendocrine tumors? In this BackTable episode, Dr. Daniel DePietro, interventional radiologist at the University of Pennsylvania joins host Dr. Kavi Krishnasamy for an in-depth discussion on the interventional management of neuroendocrine tumors.

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SYNPOSIS

The physicians start by discussing the intricacies of primary and metastatic neuroendocrine tumors, focusing on how treatment decisions are shaped by factors such as symptom burden, extent of disease requiring debulking, and symptom progression despite systemic therapy. Dr. DePietro shares insights from his clinical experience and emphasizes the critical role of interdisciplinary collaboration in optimizing patient outcomes.

Dr. DePietro then shares his approach to using Y90 radioembolization in patients with biliary contraindications to TACE or bland embolization—such as those with prior Whipple surgery, sphincterotomy, or biliary stents—where the risk of hepatic abscess with ischemia-based therapies is higher. He also notes that patients who derive less than a year of benefit from prior TACE or bland embolization may be good candidates for radioembolization.

The conversation also covers the role of thermal ablation in select patients with solitary lesions, and also touches on several key trials, including the ongoing CapTemY90 study.

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00:00 - Introduction
02:09 - Specialization in Neuroendocrine Tumors
06:32 - Patient Selection and Treatment Criteria
10:40 - Grading and Treatment of Neuroendocrine Tumors
16:09 - Systemic Therapy Options
22:22 - Rebiopsy and Its Importance
28:01 - Technical Aspects of Local Regional Therapies
39:14 - Radioembolization: When and How
43:33 - Segmentectomy and Multimodal Approaches
45:22 - CapTemY90 Trial and Promising Results
49:52 - Hormone Release During Local Regional Therapies
53:12 - Combining Radioembolization with PRT
56:12 - Thermal Ablation in Neuroendocrine Tumor Patients
58:06 - Follow-Up Imaging and Tumor Markers
01:02:40 - Updates from Nanets Conference
01:05:08 - Collaborating Across Specialties
01:07:56 - Managing High Tumor Burden Patients
01:13:59 - Treating Carcinoid Heart Disease
01:19:37 - Closing Remarks and Acknowledgments

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RESOURCES

NETTER-1 Trial
https://www.nejm.org/doi/full/10.1056/NEJMoa1607427

REMINET Trial
https://ascopubs.org/doi/10.1200/JCO.2016.34.15_suppl.TPS4148

CapTemY90 Trial
https://www.clinicaltrials.gov/study/NCT04339036#contacts-and-locations