Management lung carcinoid?
Surgery. No role for adjuvant tx. Lung carcinoid = well-differenciated neuro-endocrine tumour.
NOT neuroendocrine carcinoma (G3b) which can be either small or large cell.
When is adj tx indicated (and what) for large cell neuro-endocrine carcinoma?
ChatGPT
Adj Chemo indicated in stage II-III or N+
e.g. cis/etop x 4
High-risk pathological features, even if early stage:
Large tumour size
Lymphovascular invasion
Visceral pleural invasion
High proliferative index (high mitotic rate/Ki-67)
PCI
Little evidence but sometimes consider in N+ disease.
Grading neuro-endocrine tumours?
Ki-67 index of 2% or lower - TYPICAL
A Ki-67 index of 2% or lower means that fewer than 2 in every 100 cells (2%) are dividing. This is a grade 1 NET (well differentiated NET G1).
Ki-67 index between 3% and 20% - ATYPICAL - mets more likely so surgery is more extensive.
This means that between 3 and 20 cells in every 100 cells (3% and 20%) are dividing. This is a grade 2 NET (well differentiated NET G2).
Ki-67 index higher than 20%
A Ki-67 index of more than 20% means that more than 2 in every 10 cells (20%) are dividing. This is either a grade 3 NET (well differentiated NET G3a) or a neuroendocrine carcinoma (poorly differentiated NEC G3b).
NEC can be small or large cell.
Indications for adj RAI
dose
Prep for RAI#
RT protection
T1-T3N1a and no risk factors e.g. angioinvasion, poorly diffrrentiated. Can avoid RAI (ION trial)
1 or 3.7GBq (higher if N1b as weren’t many in HiLo trial)
Prep - low Iodine diet 7d, Recombinant TSH 48 and 24 hours before (0.9mg IM/dose).
Post - double flush toilet 1 week, no invasive procedures 1 month (or tell lab if need to send), avoid young kids/preg women for upto 3 weeks - 1-2 weeks = normal.
Metastatic thyroid cancer Mx?
Check RET, BRAF and NTRAK at diagnosis of metastatic disease.
Differentiated only = Upto 4 x RAI 5.5GBq
Iodine refractory (When mets grow within 6-12m or don’t take up iodine on scan)
DTC - progressive, locally advanced or metastatic DTC (papillary, follicular Hurthle cell) that is iodine refractory
1L - lenvatinib or sorafenib. Either first TKI or stopped taking another TKI within 3m of starting due to tox. (JW - RR much higher and less SE with lenvatinib so tend to go for this (no head to head with soraf).
2L Not Cabozantinib, NOT recommended (NICE 2023) - Improves PFS but not OS.
MTC - progressive MTC in adults with unresectable, locally advanced or metastatic disease.
Cabozantinib - Any line (caution risk of fistulae, caution in IBD or with hx of GI bleeding).
Not vandetanib - no longer recommended (NICE 2018)
Either group:
Selpercatinib - any line, if RET positive
Larotrectanib, entrectanib - solid tumour approval for NTRK positive if not other treatment options
Anaplastic thyroid cancer
40-50% are BRAF +
Dab/Tram via CDF. Even if PS2 still give.
Chemo options = a few including: carbo/taxol or doxorubicin
EBRT thyroid cancer indications.
Dose/#
Indications: Macroscopic disease post surgery or local disease or T4b inoperable
Almost never given I think
Thyroid cancer (Iodine refractory/dedifferentiated, anaplastic & medullary) 60Gy/30#with boost of 64Gy to macroscopic disease
Indications for Lutetium (177Lu) oxodotreotide?
Dose?
utetium (177Lu) oxodotreotide is recommended, within its marketing authorisation, as an option for treating unresectable or metastatic, progressive, well-differentiated (grade 1 or grade 2), somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumours (NETs) in adults.
