Small intestinal neuroendocrine tumours: the decisions you may face
6 treatment settings, 5 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Diagnosis and staging
Biopsy with Ki-67 grading, somatostatin receptor PET, cross-sectional imaging of the liver, chromogranin A and urinary 5-HIAA, echocardiography if carcinoid syndrome is present.
A PET scan using a radioactive hormone mimic that lights up neuroendocrine tumours and shows whether the matching radioactive treatment will work.
- Whole-body receptor map
- Theranostic gatekeeper for 177Lu-DOTATATE
- Changes management in ~40% of patients versus conventional imaging
The PET scan for neuroendocrine tumours that finds far more disease than older scans and confirms eligibility for lutetium radioligand therapy (the theranostic pair).
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Physiologic uptake in pancreas uncinate, spleen, pituitary
- Poor sensitivity in SSTR-negative high-grade disease
- 68Ga generator supply and short half-life
- Between Somatostatin receptor PET (68Ga/64Cu-DOTATATE) and Gallium-68 DOTATATE (and Cu-64 DOTATATE), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (diagnosis and staging), which of the standard options do you recommend and why?Why: Guideline options include: Biopsy with Ki-67 grading, somatostatin receptor PET, cross-sectional imaging of the liver, chromogranin A and urinary 5-HIAA, echocardiography if carcinoid syndrome is present.
- Am I a candidate for Gallium-68 DOTATATE (and Cu-64 DOTATATE), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
Localised or resectable disease
Segmental small bowel resection with mesenteric lymphadenectomy, inspecting the whole small bowel for further primaries; the primary is often removed even when liver metastases are present.
Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.
- Precision, shorter stay
- Enables complex minimally invasive resections
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Cost
- Loss of haptic feedback
- Not superior for every indication
- Is Robotic & minimally invasive surgery the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (localised or resectable disease), which of the standard options do you recommend and why?Why: Guideline options include: Segmental small bowel resection with mesenteric lymphadenectomy, inspecting the whole small bowel for further primaries; the primary is often removed even when liver metastases are present.
Add these to your appointment list, or take the full question set for this cancer.
Advanced, first line
Octreotide LAR or lanreotide (PROMID, CLARINET); lutetium-177 dotatate first line for grade 2 to 3 tumours with a Ki-67 of 10 percent or more (NETTER-2).
Monthly injections of a synthetic hormone that both quiets tumour hormone symptoms and slows tumour growth, the first treatment for most neuroendocrine tumours.
Lutetium-177 dotatate was the first modern radioligand therapy (2018), for neuroendocrine tumours, and is now used in first line.
A radioactive version of the hormone mimic used for the scan; it homes to neuroendocrine tumour cells and irradiates them from inside.
- Systemic, receptor-targeted
- Response and quality-of-life benefit
- Imaging selects and monitors
- Treatment-naive metastatic midgut NETs: octreotide LAR vs placebo
TTP 14.3 vs 6.0 months, HR 0.34.
Time to tumour progression (months): Octreotide LAR 14.3 (n=42) vs Placebo 6 (n=43) · HR 0.34 · source - Non-functioning enteropancreatic NETs, grade 1-2: lanreotide 120 mg vs placebo
PFS HR 0.47.
- Study to Evaluate the Efficacy and Safety of Lutathera in Patients With Grade 2 and Grade 3 Advanced GEP-NETPhase 3NCT03972488226 peopleevidence 47Tests Lutetium-177 dotatateA Phase III Multi-center, Randomized, Open-label Study to Evaluate the Efficacy and Safety of Lutathera in Patients With Grade 2 and Grade 3 Advanced GEP-NET
No headline result recorded yet.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Lymphopenia · NETTER-1; grade 3-4 rates | - | 44% |
| GGT increased · NETTER-1; grade 3-4 rates | - | 20% |
| Vomiting · NETTER-1; grade 3-4 rates | - | 7% |
| Nausea · NETTER-1; grade 3-4 rates | - | 5% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Myelosuppression, rare MDS/AML (~2-3%)
- Renal dose
- Not curative; retreatment data limited
- Between Somatostatin analogues (octreotide, lanreotide), Lutetium-177 dotatate and Peptide receptor radionuclide therapy (PRRT), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in PROMID and CLARINET, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Lutetium-177 dotatate are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (advanced, first line), which of the standard options do you recommend and why?Why: Guideline options include: Octreotide LAR or lanreotide (PROMID, CLARINET); lutetium-177 dotatate first line for grade 2 to 3 tumours with a Ki-67 of 10 percent or more (NETTER-2).
- Am I a candidate for Somatostatin analogues (octreotide, lanreotide), Lutetium-177 dotatate, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PROMID and CLARINET apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Progression on a somatostatin analogue
Lutetium-177 dotatate (NETTER-1); everolimus (RADIANT-4); cabozantinib (CABINET); liver-directed therapy for hepatic-dominant disease.
Lutetium-177 dotatate was the first modern radioligand therapy (2018), for neuroendocrine tumours, and is now used in first line.
An mTOR-blocking pill that doubled progression-free time with exemestane in 2012 and is now paired with the oral SERD giredestrant.
A pill that blocks both blood-vessel growth and the MET escape pathway, used in kidney, liver, thyroid and, since 2025, neuroendocrine cancers.
A catheter threaded into the artery feeding a liver tumour delivers chemotherapy and then blocks the vessel, starving the tumour from inside.
- Liver-directed with limited systemic toxicity
- Decades of evidence and universal availability
- Bridges patients to transplant
Millions of tiny radioactive glass or resin beads are injected into the liver artery, lodging in the tumour and irradiating it from within.
- Outpatient, single session
- Effective in portal vein thrombosis where TACE is contraindicated
- Radiation segmentectomy can be curative for small tumours
Thermal ablation kills a tumour with heat or cold delivered through a needle, with no incision required.
- Outpatient, repeatable
- Preserves organ function
- Tests Lutetium-177 dotatateInoperable, progressive midgut neuroendocrine tumours: 177Lu-Dotatate plus octreotide versus high-dose octreotide LAR
PFS at 20 months 65.2% vs 10.8% (HR 0.21); ORR 18% vs 3%.
Progression-free survival at 20 months (%): 177Lu-Dotatate + octreotide 65.2 (n=116) vs High-dose octreotide LAR 10.8 (n=113) · HR 0.21 · source - Tests EverolimusProgressive pancreatic NETs (RADIANT-3, n=410) and lung/GI NETs (RADIANT-4, n=302): everolimus vs placebo
PFS HR 0.35 (pNET) and 0.48 (lung/GI).
Progression-free survival (RADIANT-3) (months): Everolimus 11 (n=207) vs Placebo 4.6 (n=203) · HR 0.35 · source - Tests CabozantinibPreviously treated advanced pancreatic (n=95) and extra-pancreatic (n=203) NETs: cabozantinib vs placebo
PFS HR 0.23 (pNET), 0.38 (epNET).
Progression-free survival (pancreatic NET) (months): Cabozantinib 13.8 vs Placebo 4.4 · HR 0.23 · source
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Lymphopenia · NETTER-1; grade 3-4 rates | - | 44% |
| GGT increased · NETTER-1; grade 3-4 rates | - | 20% |
| Vomiting · NETTER-1; grade 3-4 rates | - | 7% |
| Nausea · NETTER-1; grade 3-4 rates | - | 5% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Avoid grapefruit. Live vaccines are contraindicated.
- 7.5 mg (mild), 5 mg (moderate), 2.5 mg (severe).
- Tablets: take on an empty stomach (no food 2 hours before or 1 hour after). Avoid grapefruit.
- Reduce to 40 mg daily in moderate impairment; avoid in severe.
- Post-embolisation syndrome; hepatic decompensation in poor liver function
- Rarely curative; repeat sessions
- OS benefit of combinations with systemic therapy not yet shown
- Radioembolisation-induced liver disease
- Failed to beat sorafenib on OS in advanced disease
- Lung shunting excludes some patients
- Size limit ~3 cm
- Heat-sink near vessels
- Between Lutetium-177 dotatate, Everolimus, Cabozantinib and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in NETTER-1 and RADIANT-3 and RADIANT-4, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Lutetium-177 dotatate are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (progression on a somatostatin analogue), which of the standard options do you recommend and why?Why: Guideline options include: Lutetium-177 dotatate (NETTER-1); everolimus (RADIANT-4); cabozantinib (CABINET); liver-directed therapy for hepatic-dominant disease.
- Am I a candidate for Lutetium-177 dotatate, Everolimus, Cabozantinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of NETTER-1 and RADIANT-3 and RADIANT-4 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Carcinoid syndrome
Somatostatin analogue dose escalation, telotristat ethyl for refractory diarrhoea, octreotide infusion around procedures to prevent carcinoid crisis, valve surgery for carcinoid heart disease.
Monthly injections of a synthetic hormone that both quiets tumour hormone symptoms and slows tumour growth, the first treatment for most neuroendocrine tumours.
Telotristat ethyl (Xermelo) is a tablet that cuts the serotonin that neuroendocrine tumours pour out, easing the relentless diarrhoea of carcinoid syndrome when somatostatin analogue injections are not enough.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.
- Between Somatostatin analogues (octreotide, lanreotide) and Telotristat ethyl, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (carcinoid syndrome), which of the standard options do you recommend and why?Why: Guideline options include: Somatostatin analogue dose escalation, telotristat ethyl for refractory diarrhoea, octreotide infusion around procedures to prevent carcinoid crisis, valve surgery for carcinoid heart disease.
- Am I a candidate for Somatostatin analogues (octreotide, lanreotide), Telotristat ethyl, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
After radioligand therapy
Everolimus or cabozantinib; 177Lu-edotreotide if approved; alpha-emitting radioligands and retreatment in trials.
An mTOR-blocking pill that doubled progression-free time with exemestane in 2012 and is now paired with the oral SERD giredestrant.
A pill that blocks both blood-vessel growth and the MET escape pathway, used in kidney, liver, thyroid and, since 2025, neuroendocrine cancers.
A second lutetium radioligand for neuroendocrine tumours that beat the standard pill everolimus in a head-to-head trial and is awaiting an FDA decision.
An alpha-particle version of Lutathera for neuroendocrine tumours that have stopped responding to the beta version.
An alpha-particle version of neuroendocrine radioligand therapy that produced responses in over half of patients who had never had PRRT, with FDA Breakthrough designation.
- Tests Everolimus, 177Lu-edotreotideProgressive grade 1-2 SSTR-positive GEP-NETs: 177Lu-edotreotide vs everolimus
PFS 23.9 vs 14.1 months, HR 0.67.
Progression-free survival (months): 177Lu-edotreotide 23.9 (n=207) vs Everolimus 14.1 (n=102) · HR 0.67 · source - Tests Actinium-225 DOTATATESSTR-positive GEP-NETs progressing after 177Lu somatostatin-analogue therapy: 225Ac-DOTATATE (RYZ101) vs investigator's choice
No headline result recorded yet.
- Avoid grapefruit. Live vaccines are contraindicated.
- 7.5 mg (mild), 5 mg (moderate), 2.5 mg (severe).
- Tablets: take on an empty stomach (no food 2 hours before or 1 hour after). Avoid grapefruit.
- Reduce to 40 mg daily in moderate impairment; avoid in severe.
- Between Everolimus, Cabozantinib, 177Lu-edotreotide and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in COMPETE and ACTION-1, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Neuroendocrine and Adrenal Tumors), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (after radioligand therapy), which of the standard options do you recommend and why?Why: Guideline options include: Everolimus or cabozantinib; 177Lu-edotreotide if approved; alpha-emitting radioligands and retreatment in trials.
- Am I a candidate for Everolimus, Cabozantinib, 177Lu-edotreotide or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of COMPETE and ACTION-1 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.