Would you ever consider treatment without tissue diagnosis for a gastrointestinal neuroendocrine metastatic tumor based on a positive DOTATATE scan alone?
What scenarios, if any, would you empirically treat a patient without a tissue diagnosis for a gastrointestinal neuroendocrine tumor based on a positive DOTATATE scan alone?
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Tissue would be ideal, but I would treat the above scenario with caveats.
The sensitivity and specificity of modern-day DOTA SSTR imaging approaches 90%.
The question I would have is whether the patient needs treatment in the first place, based on burden of disease seen?
Is disease behaving aggressively, where grade would be helpful to know?
Up to 90% of patients have liver involvement of their metastatic neuroendocrine tumor, so where is this patient's metastatic disease? Are they isolated asymptomatic bone lesions?
The approach here is individualized and nuanced, as is usually the case when we see patients.
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Based on oncologic principles, we should have a tissue diagnosis. However, if two biopsy attempts are non-diagnostic, I would consider treating based on a gallium dotatate scan. The sensitivity and specificity of this scan for NET are 91% and 94%, respectively, according to a recent meta-analysis of studies (Singh et al., PMID 30247209).
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