Small intestinal neuroendocrine tumours: lines of therapy

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6 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	2

Screening, prevention and diagnosis

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	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.	Somatostatin receptor PET (68Ga/64Cu-DOTATATE)Gallium-68 DOTATATE (and Cu-64 DOTATATE)Neuroendocrine tumour grade (Ki-67) and WHO classificationChromogranin ACarcinoid syndrome and carcinoid heart disease	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	89

Early / localised

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	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.	Robotic & minimally invasive surgeryHepatectomy (liver resection)	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	40

Advanced, first line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	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).	Somatostatin analogues (octreotide, lanreotide)PROMIDCLARINETLutetium-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)	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 (NETTER-1); everolimus (RADIANT-4); cabozantinib (CABINET); liver-directed therapy for hepatic-dominant disease.	Lutetium-177 dotatateNETTER-1EverolimusRADIANT-3 and RADIANT-4CabozantinibCABINET (Alliance A021602)Transarterial chemoembolisation (TACE)Radioembolisation (TARE / SIRT, yttrium-90)Thermal ablation (RFA, microwave, cryo)Liver-directed therapy (TACE, TARE, HAI, ablation)	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	95

Other settings

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	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.	Somatostatin analogues (octreotide, lanreotide)Telotristat ethylCarcinoid syndrome and carcinoid heart disease	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	81
All comers	After radioligand therapy	Everolimus or cabozantinib; 177Lu-edotreotide if approved; alpha-emitting radioligands and retreatment in trials.	EverolimusCabozantinib177Lu-edotreotideCOMPETEActinium-225 DOTATATEACTION-1212Pb-DOTAMTATE	NCCN Guidelines: Neuroendocrine and Adrenal Tumors	95

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.