Thor Halfdanarson
@OncoThor
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🇮🇸Medical Oncologist/Educator, NET/GI/CUP enthusiast. Husband/dadx4 (bad dad jokes). Cyclist. Avant gardener. Professor of Oncology, Mayo Clinic. Tweets mine.
Rochester, Minnesota
Joined December 2016
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Can one distill systemic therapy of gastroenteropancreatic NETs down to one slide...? Preparing for AHPBA next week. I have 8 min to cover systemic therapy of NETs. The final slide works better in presentation mode but here it is. Anything missing...?
#neuroendocrinetumors
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A true story: in the NET clinic today. Clinical dilemma. I’m stumped (that happens sometimes). I emailed 5 incredibly experienced NET colleagues, 4 in Europe and one in the US. Every single one got back within 6 hours. I absolutely love the academic NET community 😍 So thankful.
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Dear friends, sincerest thanks for the trust and thanks to
@PamelaKunzMD
for model leadership. I could not have had a better mentor for this role. Very much looking forward to a bright
@NANETS1
future in an organization packed with incredible individuals. Onwards and upwards!
Congratulations Mr President
@OncoThor
!
And thanks
@PamelaKunzMD
for your leadership over the last year and taking the society to the next level.
Can’t wait to see what’s next for
@NANETS1
✨
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Saw a patient with resected panc NET last month. 6 month postop chromogranin A >50 times upper limit of normal (>5000). Stopped PPI, CgA normalized. Beware, not all elevated CgA is from NETs... Highest CgA elevation I’ve seen from PPI thus far
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A very important trial showing impressive PFS difference favoring PRRT.
Read after me: NETs are NOT rare anymore (the second most prevalent GI cancer according to some studies) and we can very successfully conduct phase III trials in this population.
NETTER-2 reports significantly improved PFS in Ki67 10-55% GEP-NETS with first-line
#Lutathera
vs ⬆️ dose SSA, HR 0.27. Similar benefit in subgroups.
#GI24
@LACNETS
@CarcinoidNETs
@OncoThor
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Minnesota! When you are nice, you can be really, really nice…
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Another outstanding study led by
@HallberaG
of
@MayoSurgery
. More than 500 NET pts who underwent liver resection. Symptom relief in 96% of pts w/ functional NETs w/ durable symptom control. 122 month OS (!!) with 90-day mortality of 1.6%.
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Repeat after me: "Grade 3 NETs and G3 NECs are not the same malignancy"... All too often, these are lumped together in studies. Different outcomes and genetics. Up to a quarter will have the dx changed on expert review! Well done
@RachelRiechelm2
and team!
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Another fantastic presentation, this time by
@PamelaKunzMD
, president of
@NANETS1
. Some trials to watch, including trials led by junior investigators. Very exciting times for NENs.
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How is that for a Twitter headline: “An oncologist eats a delicious platter of suspected carcinogens and thoroughly enjoys it…”? Gotta enjoy ENETS and beautiful and delicious Barcelona. You don’t get this stuff in Minnesota.
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How should we follow non-operatively managed patients with nonfunctional pancreatic G1/G2 NETs...? I hope most/all of us have accepted that surveillance is an acceptable (preferred) approach for most patients. Here is an attempt to summarize follow-up. Would love to hear comments
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How was your morning commute…? Mine was exciting, and a little challenging…
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It’s out! The results of NETTER-2. Upfront PRRT for G2 (Ki67 10 or more) and G3 NETs. Much higher ORR than in the lower grade NETTER-1 siNET population and much longer PFS than on the control arm of high dose octreotide LAR.
📢It's out - NETTER 2 in
@TheLancet
!
☢️ PRRT 🆚💉SSA
RCT for 1st line in G2/3 advanced GEP-NETs
⤴️PFS by >12 months median
👉🏻HR 0.28 (0.18–0.42)
Across all sub-groups
💥Unprecedented response 43%
Congrats to all co-investigators!👏🏻
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Repeat after me: "I will not order another monophasic (venous phase) CT to evaluate NET liver mets"
This is an excellent example why we need arterial phase imaging when evaluating NET liver mets. They are sneaky little bastards...
Dual phase CT all the way!
Or an MRI... :)
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On the inpatient oncology service with brand new interns… The future of medicine is bright! So much fun to work with trainees at all levels.
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What a way to start the day. Driving to work w/ my teenage daughter, listening to Shine on You Crazy Diamond with Pink Floyd and we saw sun dogs (-20C out). Then we saw a bald eagle. It’s gonna be a good day!
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Someone used the word "hypermetabolic" in a DOTATATE PET CT report...
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Hey you medical journals! How about always attaching the supplementary materials to the downloaded article PDF? I am tired of clicking various links to find valuable information.... There is enough mouse clicking as is in my life now (Epic, are you listening...?)
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An attempt to explain the concept of grade 3 NENs and the overlap of G3 NETs and NECs. The highest Ki67 I have seen in a well diff G3 NET is 93% and the lowest Ki67 in a NEC was 28%. Thanks to Halfdan Sorbye, Aurel Perren & Eric Baudin for the inspiration
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A giant in the field, a tireless advocate for patients and a class A human being, Dr. Thomas O'Dorisio, has passed. One of the kindest, most generous, smartest and funniest person I have met in my career. My sincerest condolences to his family and friends.
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Are you a GI oncologist but also interested in gravel riding…? If so, we have 2 open GI onc positions. World class gravel riding here. If you are a GI oncologist with no interest in gravel riding, we still have 2 open positions…🙂 Feel free to PM me for more info.
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Capturing the current status of systemic therapy for pNETs in one slide is not easy... Need a summary slide for a talk. One slide cannot capture all the variables such as regimens, comorbidities, trials, sequences etc. Here is the first stab at it. Ideas/suggestions welcomed...
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Important and much awaited study! No indication for right hemicolectomy for appendiceal NETs 1-2%. Simple appendectomy seems sufficient. Nodal mets occur in 20% but seem irrelevant. After 13 yr median follow-up, no pt developed mets. Is surveillance even needed...?
"Right-sided hemicolectomy is not indicated after complete appendicectomy in 1-2cm appendiceal NETs."
Conclusion of the biggest european cohort with 278 cases from 40 institutions.
👇🏻👇🏻👇🏻
🦓🦓🦓
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Finally, the NANETS guidelines on medical management and surveillance of pancreatic NETs are out. Hopefully a useful resource for clinicians and patients. Thanks to NANETS and the outstanding authors for getting this done!
@NANETS1
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Here is a paper I have very eagerly been waiting for. New ENETS guidelines on neuroendocrine carcinoma (NEC). Such a challenging disease. And if you wait a little longer,
@NANETS1
might have a similar paper out soon. Well done
@drenriquegrande
& team!
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Trying to capture the use of chemo (CAPTEM as we don't do the STZ thing anymore) in the management of pNETs. Works best when presented step by step but I know I am leaving stuff out and not all decisions are based by solid data. PRRT may also become an option neoadj (
@spartelli
)
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Trial Alert!
ACTION-1 is now open at all three Mayo Clinic sites.
Phase III trial of alpha particle PRRT w/ Ac-225 DOTATATE vs. provider's choice of SOC therapy for pts w/ progressive G1/G2 GEPNETs and prior Lu-177 PRRT.
Very simplified schema below
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7 AM tumor board, full day of clinic, the Alliance GI Group meeting and capping off the day with local gravel ride. I call that a good day…
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You have a NET patient in need of PRRT but with high-volume liver, peritoneal or bone mets and not sure how to proceed? Impaired renal function - not sure what to do? This excellent review may have some answers for you. Good stuff from Royal Free Hospital
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Not that you needed a reminder but here is an example that PRRT with Lu-177 DOTATATE can be very effective. G2 NET of unknown primary, progressing on lanreotide. 1 year after last and 4th cycle. Excellent and durable response.
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Treatment-related myeloid neoplasia (t-MN) following PRRT and CAPTEM appears more common than previously thought. Can we identify patients at risk ahead of time? Is CHIP the key? Outstanding presentation
@altoubaht
!
#enets2022
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Exciting times for those interested in clinical trials for neuroendocrine neoplasms (NENs). And these are just the NCI-sponsored trials. Lots of other studies out there, either accruing or coming down the pike. Outstanding presentation by Dr. Elise Kohn at NCI.
@NANETS1
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Those are my principles, and if you don't like them... well, I have others. (Groucho Marx)
That got messy pretty quickly... That's what happens in the near RCT-free zone. We can debate this back and forth and I will go sleep on this now. At 10:30 PM it kinda made sense to me...
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The unstoppable Mayo Surgery team is at it again...! Resection of NET liver mets of unknown primary yields similar results as in small bowel NETs and better than panc NETs. Are UP-NETLM occult sbNET primaries...? Either way, resection seems to help!
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Two outstanding young oncologists (
@KLeventakos
and
@hfuentesbayne
), an excellent fellow and some random old dude in a 3 piece suit with a stethoscope. I must admit I am extremely lucky with my colleagues.
@MayoHemeOnc
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All quiet on the Eastern Front outside of the Mayo Methodist Hospital… Covering the inpatient service this weekend with stellar residents and NPs.
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The 100K Rift gravel race in the highlands of Iceland is in the books and I survived…
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Why both FDG and SSTR PET? Because they both provide very important info. Heard about the NETPET score? If no (or if yes), please read on. NETPET score predicts OS and PFS after adjusting for grade and other predictors. Well done
@DrDavidLChan
& team!
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Cabozantinib (and presumably other MKIs) work for very high proliferative index well diff panc NETs. 5th line therapy for progressive pNET, Ki67 75%. TMB >200 m/Mb post TMZ (blew through pembro - so much for TMB as a marker...). Excellent and durable response to off-label cabo
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PRRT for NETs - not just tumor control but also effective for control of carcinoid syndrome symptoms. Excellent work by
@w_zandee
et al. Clinically meaningful reduction in symptom burden. Definitely the kind of data we clinicians love to see.
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Is it just me or has the manuscript reviewing process turned into a messy soup of similarly looking websites, all with different usernames and passwords...? I am trying to be a good citizen in the academic community but it is hard. And ORCID is not solving my problem...
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First gravel ride after getting COVID19 11 days ago. Despite quadruple vaxxed, it was nasty (would prob have been sicker w/o vaxx). Definitely not up to speed yet but better than expected. I give this COVID thing a 1-star review. It sucks. Skip it if you can and get your shots.
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Not that I was ever a believer in primary tumor resection in metastatic CRC... But it helps to have data from a RCT. Would love to see more RCTs answering surgical questions, especially in NETs where data are scant and beliefs are strong...
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Grade 3 neuroendocrine neoplasms (G3 NENs) are NOT a homogeneous entity. G3 NETs are very different from G3 NECs. An excellent paper from the outstanding NET pathology team in Munich. Time to routinely use Rb1 and p53 staining?
@IHC_guy
@rondell_graham
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PRRT in NET patients with extensive liver involvement...? Safe...? Should we do it...? This study suggests it is safe, even in patients with > 75% liver involvement. Excellent work led by
@drjasonstarr
and team including
@sonbol_bassam
and
@TubaKendi
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Looking for a trial of PRRT for well differentiated G2/G3 NETs? If so, this one may be opening at a center near you. COMPOSE - Lu-177 Edotreotide vs. best standard of care. Please keep it in mind for suitable patients as it opens.
@DianeReidyLagun
@NVijayvergiaMD
@
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Post-clinic, SE Minnesota gravel riding to de-stress. Some chill bovines. Picture shamelessly oversaturated (but it was still damn pretty…). We even saw a zebra out there.
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Been waiting for this one since ENETS... More info on G3 NETs. They're NOT NECs! But clearly worse than G1/G2 NETs. CAPTEM seems to work and there seems to be SSA activity too. Platinum/etoposide w/ little activity. Well done
@GillSharlene
@jonathanloree
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And this, my friends (and P2P folks on the other end of the line), is one of the reasons why we cannot use PET to measure tumor size... And yes, I DO NEED BOTH a PET and a contrast-enhanced cross-sectional imaging study for this patient.
(tiny pNET with a big PET presence...)
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@oncologician
I must disagree with this and I have worked at several academic institutions with countless excellent surgeons, many who were quite well versed in medical oncology. Oncology is a team sport as someone said (although I like the word "activity" better than "sport" in this context).
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How often do I have to tell you…? Somatostatin PET scans are NOT signed out as having hypermetabolic lesions!
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While I do applaud the researchers who do this important work, there comes a time when we should do more than just measure the problem and actually act on fixing it... I have been to many more talks describing burnout than meetings trying to actually do somehting about it...
Oof. 😓 Burnout among oncologists has increased from 34% to 59% over the past 10 years. 22% likely to reduce clinical hours in the next year (up from 16%).
#ASCOQLTY23
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This is an excellent paper on appendiceal NETs (aNETs), the best guidance/review you will find. There is one notable omission though, the surveillance of ≤ 2cm G1/G2 aNETs resected w/ appendectomy. The risk of LN mets is 10-15%. Surveillance or not?
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Repeat after me: NETs are not rare! Although the incidence may be low, the prevalence is high. For small bowel NETs, the prevalence (regardless of disease status) is almost 20x the incidence. No surprises but nicely done by the Oslo University team. Clinically relevant info.
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A full session dedicated to high grade neuroendocrine neoplasms. A disease desperately in need for more trials and better understanding of biology and genetics. Excellent opening of the session by Dr. Nitya Raj from MSKCC.
#enets2022
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Should we add ICIs to platinum/etoposide chemo in extrapulmonary NECs? My answer is NO, not outside of a trial. This retrospective study led by
@jennifer_gile
did not report benefit. Please, please keep SWOG S2012 in mind and enroll whenever possible!!
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Now that folks are posting travel pics, I might as well join the party. Last weeks scenery…
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Therapy-related heme malignancies (including t-MN) and clonal cytopenia after PRRT. Among 346 pts who had at least 1 PRRT, 4% had a therapy-related neoplasm or clonal cytopenia - 2.3 % with t-MN.
@MrinalPatnaik
@sonbol_bassam
@TubaKendi
@a_mangaonkar
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As of today, the COMPOSE phase III RCT is open at Mayo Clinic in Rochester! PRRT with Lu-177 edotreotide (DOTATOC) vs. CAPTEM, FOLFOX or everolimus for 1st or 2nd line therapy for advanced high-risk G2 NETs (Ki67 15-20%) or well diff G3 NETs ≤ 55%.
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Were you ever told that radiation did not work in well diff NETs...? We beg to differ. RT can be very activite and is a very valuable tool for palliation in patients with NETs as this case shows. Too bad I can't tag Chris Hallemeier and Brianne Mansfield.
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Everything is groovy at me. How about you? Should I write a groovy piece for this respected journal?
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10% risk of treatment-related myeloid neoplasia (t-MN - AML or MDS) after sequential therapy with CAPTEM and PRRT. Small study but concerning numbers.
@altoubaht
is crushing it at
#NANETS2022
with 2 oral presentations in the same session. Super impressive!!
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Fantastic overview by
@PamelaKunzMD
of advances and ongoing trials and studies in neuroendocrine neoplasms. Onwards and upwards for NET care and research! I encourage all interested in NETs to join NANETS…
#NANETS2022
@NANETS1
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The perks of having ENETS in Vienna… A healthy dose of arts and architecture…
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What drug is this patient on...?
A patient with intrahepatic cholangiocarcinoma with FGFR2 fusion. Responding nicely to pemigatinib, an FDA-approved FGFR inhibitor. Tumor calcifications are sometimes seen and here is an example of that. Remember, sequence ALL biliary cancers!!!
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Next up, no other than
@Ja_Capdevila
discussing novel TKIs for GEPNETs. More than just sunitinib… Making sense of all the “ibs” in the management of patients with GEPNETs and what to expect of future studies.
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Pancreatic exocrine insufficiency (PEI) is very common among patients with NETs who are on SSAs and/or have had pancreatic resections. This small study (not in NET pts) suggests we do a poor job discussing PEI with our patients and PEI is undertreated.
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Temozolomide in grade 3 neuroendocrine neoplasms (G3 NENs). Does it work? Not surprisingly, ORR and TTF higher in pancreatic primaries and in 1st line. There is activity in well diff G3 NETs but not so much in poorly diff NECs (TTF 2 mos),
@PatrickMcGarrah
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Maintaining and promoting a healthy lifestyle (well, a selfie at 20 mph may not be wise…) and repping my wonderful institution at the same time. Keep the moving parts moving. If you have not bicycled in the Midwest during the warm summer nights, you are missing out…
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Quadruple vaxxed!
And I need to report hyperacute, hair-related side effects…
Well, never-mind, I take that back. Actually, I normally look like that…
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Underwhelming efficacy of dual ICI in NECs. No responses in pts on PD1/PDL1 monotherapy and 13% ORR with dual ICI therapy with short PFS. How can we select responders? Excellent work,
@jennifer_gile
,
@PatrickMcGarrah
,
@sonbol_bassam
,
@drjasonstarr
& others
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A twist in the management of small (1.1 to 2 cm) nonfunctional panc NETs or not...? This NCDB study suggested a survival benefit of resection after adjusting for various pre-op factors. I still support observation of NF pNETs ≤2 cm. What do others think?
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Combined new book day (almost as exciting as new CD day - yes, I still buy CDs) and nerd alert. A brand new Harrison in da house. I have not had one of those since med school. Once an internist, always an internist…
And who is that Fauci author? The name sounds very familiar…
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Dual PET (FDG+DOTA) for all NETs, at least at some point in the course? Maybe. FDG avidity predicts worse outcomes (no surprise) and also shorter response to PRRT (not this paper). Can we get insurance carriers to understand that not all PETs are the same
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Another example on the importance of quality anatomic imaging with SSTR PET. As seen below, the PET exaggerates the tumor size substantially. Also, changes in avidity/intensity over time are common. Yes, SSTR PET is great but coupled w/ contrast CT or MRI it can be excellent
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Exciting times for NET therapy and NET patients! The first Lu-177 PRRT (Lutathera) treatment outside of clinical trial at was done at Mayo today. The Mayo PRRT program has gone live! Thanks to the incredible NET team at Mayo, in particular Nuclear Medicine.
#carcinoid
#NETcancer
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Introducing the new Mayo Clinic website for nuclear medicine therapy. Thrilled to be a part of such an amazing and dedicated team. Nuclear Medicine is a crucial component of the multidisciplinary and comprehensive NET service provided at Mayo Clinic
@MayoCancerCare
#NeuroendocrineTumors
can occur anywhere in the body, and
#NucMedTherapy
like
#PRRT
can target the tumor cells with minimal effect to surrounding tissue.
#NucMed
#MolRad
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Good night y’all. Today was a good clinic day. I really like clinical practice. 🙂
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Wondering when and how to apply FDG-PET imaging in the management of NETs? If so, this consensus report from ENETS may help you. Perhaps (I'm being optimistic here), this will come in handy next time you need to have a talk with insurance companies...
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Confused about the sequencing of therapies targeting the somatostatin receptor...? Worry not,
@altoubaht
@lisabodei
@DianeReidyLagun
and Dr's. El-Haddad and Strosberg (who are not on Twitter to my knowledge) have you covered.
Excellent piece!
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GI oncologist spotted ingesting carcinogens at his first DDW conference… I will probably not be invited again…
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Somatostatin analogs (SSAs) after PRRT? Do they help? Amazingly, in 2022, we don't know. While this trial does not answer the question, it suggests lack of benefit. SSAs are not cheap and if no added value, why use post-PRRT for nonfunctional NETs...?
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The course director of the
@NANETS1
Regional Conference in Cleveland, Dr. Amr Mohamed educating us on the emerging therapies for GEPNETs. We need to bring more NET education to the oncology community. NETs are now the 10th most prevalent cancer in the UK. We can’t ignore them…
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Elderly patient with recurrent esophageal NEC. Resection and adj chemo 4 years prior. Oligometastatic bone disease, treated w/ RT for a year. Then, explosive disease. Carbo/eto w/ no response. ECOG PS 3 - hospice vs. ipi/nivo. Coming off therapy after 2 years in CR.
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NET liver mets (NELM) - to transplant or not? An excellent multicenter retrospective study suggests better outcomes over liver resection but of course, in highly selected patients. With more effective systemic therapy, will the difference disappear...?
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FDG PET for all locally advanced/borderline resectable pancreatic adenocarcinomas? I'd say yes... Serial PETs showing metabolic response strongly correlate with path response and OS, better than CA 19-9. Should FDG PET be routine?
@MayoCancerCare
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It is on! The 2022 Mayo Clinic Oncology Review in Minneapolis, my favorite oncology course (as a course director, I may be biased). On the podium now is
@rleonferre
educating us on advances in the management of HER2+ and triple negative breast cancer. Many great talks ahead.
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Last ENETS in Vienna, Kraków next year… Get your abstracts ready…
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Good news for NET patients! Mayo Clinic Laboratories (
@mayocliniclabs
) is now offering plasma 5-HIAA measurements. Much more convenient than 24-hr urine collection (overnight fast) and as accurate. Turnaround time only 3-6 days! More information below.
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