European Multidisciplinary Conference in Thoracic Oncology (EMCTO 2011) 24—26th February 2011, Lugano

Treatment options for low grade neuroendocrine lung carcinoma

Dr Martin Frueh (Kantonsspital, St Gallen, Switzerland)

Now, Martin Frueh, you are here to talk about advances in systemic therapy for neuroendocrine tumours affecting the lung. What have you got to say to us here at the Lugano Conference?

Well, actually I was giving quite a difficult topic. The low grade neuroendocrine carcinomas, the metastatic ones, for sure are quite a rare disease so there is not a lot of data out there and what I did in my work was actually review the data about chemotherapy and also targeted therapy that is available in these very rare clinical situations of patients with low grade carcinoids of the lung.

First of all then, what should doctors be looking out for as this is rare?

Well I think most of the studies have been performed in neuroendocrine tumours in general, regardless of the origin of the cancer, and it is really hard for the oncologist to get an overview where exactly are these neuroendocrine tumours from the lung hiding. So it is quite difficult to extrapolate the data that is generated in neuroendocrine tumours in general to the lung carcinoid tumours.

So these tumours, many of them are low grade, so what are the consequences?

Well, as I said, I did look at the low grade carcinoids of the lung and there are some really small series that looked at it and there seems to be a differential efficacy of chemotherapy in this really small segment of patients. So the bottom line is that we really need to do more studies and when we do studies in carcinoids in general we should analyse the lung carcinoids separately to gain more information here.

And neuroendocrine tumours of the lung include small cell lung cancer.

Right, it is a continuum of low grade neuroendocrine tumours and intermediate grade neuroendocrine tumours also called typical carcinoids and atypical carcinoids and within the high grade neuroendocrine tumours of course those are the ones which are more frequent. You have small cell lung cancer and, as a smaller entity, also the large cell neuroendocrine carcinomas.

Now what light have you been able to throw in your work and the discussions you’ve had on diagnosis and management and how to optimise these and, indeed, individualise them?

Well there is actually quite a lot going on in low grade neuroendocrine carcinomas but of course very much going on in small cell lung cancer. However if you compare it to non-small cell lung cancer you really have to say that we are lagging behind with progress in small cell lung cancer. So there are lots of targeted approaches being followed in small cell lung cancer but so far no treatment has led to any major success.

And what are the big lessons that you need doctors to take out of all the knowledge you’ve gained?

Well in small cell lung cancer I think that we need to have a better understanding of the complex biology and also identify predictive molecular markers to make real progress in this field and we are working on it but we are not quite there at the moment. For the low grade neuroendocrine tumours, as I said, it is very important to identify this group of patients as a separate entity, not mix them up with, for example, pancreatic neuroendocrine carcinomas which seem to fare differently than tumours with their origin in the lung. So these studies also have to be made.

What about the use of novel agents and molecularly targeted agents? Where are those appropriate?

Those are mainly ... the best thing would be to employ those in study protocols but it is currently of interest in both low grade end small cell lung cancer, actually the anti-angiogenic approach, since those are very well vascularised tumours one would appreciate that we would get some success here. Then there are of course other pathways that are looked at: PCL2 inhibition, HDAC or histone deacetylase inhibition, so there are very, very interesting approaches currently followed but none of them are ready for prime time.

But what are the big areas of progress, though, that doctors need to keep in mind?

Well, as I said, there is really not that much of progress as far as clinical implementation at that point but there is really a broad field of research being performed in all different kinds of targeted approaches which lead to the hope that finally one of these approaches will come to fruition and improve results for our patients.

How do you think busy doctors should be thinking about this whole issue? They have a patient who has a neuroendocrine tumour, what should be the priorities?

The priority is not to hasten things, often times those are very slow growing tumours so the first thing would be really to think does this particular patient need therapy, because once it is metastasised there is actually no cure for the disease, so the primary goal would be not to make harm. And that is the number one question - do you really have to jump in with therapy or can you observe what is the natural course of the disease and then decide upon when to initiate any kind of treatment.

And if you go for therapy, systemic therapy is preferred?

Systemic therapy is often preferred. There are other options, there are localised therapy options like surgery, also chemoembolisation if you have one mass that is causing problems but actually in most of the cases you need chemo or chemo/octreotides, it’s a somatostatin receptor target therapy for the patient.

But watchful waiting is a possible option?

Correct.

So what bottom line message should doctors take away from your talk here today in Lugano?

I think in my talk I focused on these low grade neuroendocrine carcinomas as this is really a rare situation and a lot of doctors maybe do not encounter this situation at all because it is so rare. So in this kind of patients I would draw the attention towards the fact that the published data out there, most of it is about gastropancreatic cancers, cannot necessarily be directly extrapolated to carcinoids of the lung. So that’s an important point.

And how might the multidisciplinary approach help?

That’s always very important of course to have a multidisciplinary discussion also for, as we discussed, the potential role of local treatments in these patients.

So to conclude, is there a consensus here in Lugano about neuroendocrine tumours and the therapy for them, do you think?

I think what we can say is that we really need to make better studies to really document the response of these very rare patients to the new treatments, and hopefully this will eventually then evolve into a new standard. But at the moment we do really not have sufficient data to suggest one agent over the other or give general recommendation in this very rare sub-group of patients.

Martin Frueh, thank you very much for joining ecancer.tv.

Thank you for the interview.