DR PHILIP: 52-year-old lady, full-time employment, who has a stressful job. Comes to us with left-sided abdominal pain. Actually, she comes as – after she had previous treatment elsewhere. And she did have a mass, which was in the tail of the pancreas, hypervascular, and she underwent a — this is still a pancreatectomy, but also they removed the spleen, part of the colonic flexure and, also, the left adrenal gland, well-differentiated neuroendocrine tumor, 2 out of 8 lymph nodes involved. And the people who treated her gave her adjuvant radiation therapy at the time. Completed radiation in February of 2012. And soon after that, they did a scan to see what’s going on and she had at least 6 liver metastases, bilobar. That was kept under watchful waiting until more recently, when she started to have progression.

They gave – she underwent radioembolization, both lobes of the liver, stable disease for a number of months, and then she started to develop disease progression, remains asymptomatic. She was given the options of chemotherapy, as you mentioned, everolimus or sunitinib, and she chose to go on everolimus, 10 milligrams a day.

DR LOVE: So, I wanted to get your take in terms of these choices. When you went through this with her, what – how did you present it to her in terms of risk and benefits of these 3 major options? And why was the decision made to use everolimus?

DR PHILIP: I mean, for a patient like this, who was completely asymptomatic, she wanted to continue to work. The cape/temozolomide appeared to be, to her, the one which will give her the most in terms of side effects, although we agreed that it’s a relatively well-tolerated treatment. And the issue of the sunitinib, again, she was concerned about the hypertension and some of the other side effects. And she realizes that it’s going to be a sequential treatment. And she only chose to start with everolimus as her first leg of the treatment for her metastatic disease.

DR LOVE: And how is she doing in terms of —

DR PHILIP: She’s doing well. We haven’t done the next scan yet. I like to do the scan not less than 3 months, because in this type of disease, which inherently it’s not a rapidly progressive disease, she’s asymptomatic, so I chose to do the scan 3 months after starting the treatment.

DR LOVE: And what about side effects — mucositis or, obviously, everolimus now is part of breast cancer treatment. It’s been around for renal cell cancer. What happened with her?

DR PHILIP: She’s had some fatigue, I would say Grade I, but otherwise she has continued to work thus far.

DR LOVE: So Charlie, how do you approach this decision about initial systemic therapy?

DR FUCHS: I think that the data for everolimus and sunitinib in pancreatic neuroendocrine tumors are both compelling. The tolerability, in my mind, for everolimus is a little better. That is to say, I think the constitutional symptoms associated with sunitinib may be greater. And so my preference would be, if I’m contemplating one of those 2 agents, is to use everolimus. But invariably, they’ll wind up on both.

DR LOVE: And what have you seen in terms of tolerability? Again, mucositis is a question a lot of people have.

DR FUCHS: For the everolimus? Yes. You definitely see it. But I think it’s quite manageable. And people are on it for extended periods, given the nature of the disease.

I’ve also used temozolomide quite a bit in pancreatic neuroendocrine tumor, and I agree with Randy. It’s an interesting drug. And there’s actually a biology to explain why it’s —

DR HECHT: Why it doesn’t work in carcinoid.

DR FUCHS: — more active.

DR HECHT: Yes.

DR FUCHS: Right, because pancreatic neuroendocrine tumors more commonly lose MGMT compared to carcinoids and probably explains the better effect.

DR HECHT: Yes. But what he was saying was that when they looked at it in carcinoids, there was virtually no benefit. So you have this one group that has great benefit.

Colorectal cancer

Gastric cancer

Pancreatic cancer

Hepatocellular carcinoma

Gastrointestinal neuroendocrine tumors

Gastrointestinal stromal tumors