Pancreatic neuroendocrine tumours: lines of therapy

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7 standard-of-care settings across 5 lines and 1 biomarker subgroup. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

Line	All comers
Screening, prevention and diagnosis	1
Early / localised	1
Advanced, first line	1
Second line	1
Other settings	3

Screening, prevention and diagnosis

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Diagnosis and staging	Contrast CT or MRI, somatostatin receptor PET, biopsy with Ki-67 grading, chromogranin A, hormone assays where a syndrome is suspected, and germline testing.	Somatostatin receptor PET (68Ga/64Cu-DOTATATE)Gallium-68 DOTATATE (and Cu-64 DOTATATE)Neuroendocrine tumour grade (Ki-67) and WHO classificationChromogranin AGermline (hereditary) testingMEN1 and hereditary neuroendocrine syndromes	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	94

Early / localised

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Localised, resectable	Enucleation or distal pancreatectomy for small tumours, Whipple procedure for tumours in the head, lymphadenectomy for tumours over two centimetres; surveillance for small non-functioning tumours.	Whipple procedure (pancreaticoduodenectomy)Robotic & minimally invasive surgery	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	40

Advanced, first line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Advanced, first line	Lanreotide or octreotide (CLARINET); lutetium-177 dotatate first line for grade 2 to 3 tumours with a Ki-67 of 10 percent or more (NETTER-2); CAPTEM when shrinkage is needed.	Somatostatin analogues (octreotide, lanreotide)CLARINETLutetium-177 dotatateStudy to Evaluate the Efficacy and Safety of Lutathera in Patients With Grade 2 and Grade 3 Advanced GEP-NETPeptide receptor radionuclide therapy (PRRT)Capecitabine + temozolomide (CAPTEM)	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	89

Second line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Progression on a somatostatin analogue	Lutetium-177 dotatate; everolimus (RADIANT-3); sunitinib; cabozantinib (CABINET); CAPTEM or streptozocin-based chemotherapy.	Lutetium-177 dotatateEverolimusRADIANT-3 and RADIANT-4SunitinibCabozantinibCABINET (Alliance A021602)Capecitabine + temozolomide (CAPTEM)Streptozocin	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	95

Other settings

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Functioning syndromes	Surgery for insulinoma with diazoxide or everolimus to control hypoglycaemia beforehand; high-dose proton-pump inhibitors and resection for gastrinoma; somatostatin analogues for glucagonoma and VIPoma.	Somatostatin analogues (octreotide, lanreotide)EverolimusMEN1 and hereditary neuroendocrine syndromes	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	91
All comers	Liver-dominant disease	Resection, thermal ablation, chemoembolisation or radioembolisation, alongside systemic therapy.	Hepatectomy (liver resection)Thermal ablation (RFA, microwave, cryo)Transarterial chemoembolisation (TACE)Radioembolisation (TARE / SIRT, yttrium-90)Liver-directed therapy (TACE, TARE, HAI, ablation)	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	59
All comers	VHL-associated pancreatic NET	Belzutifan for tumours not requiring immediate surgery (approved 2021).	BelzutifanBelzutifan/MK-6482 for the Treatment of Advanced Pheochromocytoma/Paraganglioma (PPGL), Pancreatic Neuroendocrine Tumor (pNET), Von Hippel-Lindau (VHLMEN1 and hereditary neuroendocrine syndromes	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	92

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.