How would you manage liver-metastatic pancreatic neuroendocrine tumor after progression on a somatostatin analogue, chemotherapy, immune checkpoint blockade, and embolization?

The optimal sequencing of systemic therapy beyond somatostatin analogs (SSAs) in patients with pancreatic NETs (pNETs) remains to be determined. Assuming that regional therapy is not feasible, there are several options such as capecitabine/temozolomide (CAPTEM), everolimus, sunitinib, and PRRT. The 2020 NANETS guidelines on medical management of pNETs do address the question of post-SSA progression to some extent.

Assuming the patient in question received CAPTEM as the chemotherapy and is not a candidate for further liver-directed therapy such as HAE/TACE/SIRT/SBRT, we have PRRT, sunitinib, and everolimus as reasonable options. While prospective, phase III level data is not available for PRRT (as it is for everolimus and sunitinib), PRRT is ...