LUTETIUM IN THE TREATMENT OF METASTATIC NEUROENDOCRINE TUMOUR IN A PATIENT ON MAINTENANCE HEMODIALYSIS - A CASE REPORT

Introduction:

Neuroendocrine tumours (NET) arise from neuroendocrine cells with an incidence of 2 per 1,00,000 general population (0.5% of all malignancies).  Radio ligand therapy (aka Peptide Receptor Radionuclide Therapy) with 177Lutetium-dotatate is a documented safe and effective treatment in metastatic NET. Bone marrow suppression and renal impairment are the dose limiting adverse effects. 

Methods:

A 38 year old female, a case of lupus nephritis end stage kidney disease on twice weekly hemodialysis with a dialysis vintage of 4 years was incidentally diagnosed to have multiple liver masses in ultrasound. Percutaneous liver biopsy showed infiltration by well differentiated grade II neuroendocrine tumour (Ki 67- 8-10%). 68Ga Dotatate PET CT scan showed SSTR (somatostatin receptor) expressing lesions in the liver and jejunum (NETPET grade P2b). In view of poor tolerance to octreotide she was treated with 3 cycles of 177Lu-dotatate over 15 months with serial PET CT scan monitoring. Following each cycle, dialysis was performed within 24 hours. She was also given an extra dialysis session in the same week of each cycle to facilitate elimination. Serial planar whole body scans were performed after administration of 177Lu-dotatate therapy using gamma camera. First scan was performed immediately after administration of 177Lu-dotatate and then every 24-48 hours post dialysis sessions and radio activity was monitored. Hemodialysis sessions were performed in an isolated room that was 2 metres away from nursing station and other patients with necessary radio protective measures. Complete hemogram was monitored weekly for 6-8 weeks after every cycle. The nadir hemoglobin was 6.9g/dL, nadir leukocyte count was 1670 cells/µL and nadir platelet count was 15000 cells/ µL after first cycle of 177Lu-dotatate. She required packed cells and platelet transfusion. She was continued on higher doses of erythropoietin stimulating agents and given thrombopoeitin analogue to improve her cell counts. Repeat PET CT scan done after 14 months of diagnosis showed interval resolution of the previously seen SSTR expressing ill defined lesion in the jejunum and further decrease in size and SSTR expression of the liver lesions suggestive of partial response.

Results:

Our patient had a partial response with 3 cycles of 177Lu-dotatate (Total dosage 180mCi+100mCi+100mCi- Total 380mCi). With lower drug dose, blood transfusion and bone marrow stimulating agents we were able to minimize the bone marrow toxicity. Hemoglobin, leukocyte and platelet counts after each cycle of 177Lu-dotatate is depicted.

Patient is now asymptomatic on regular maintenance hemodialysis and on regular follow up with six monthly ultrasound scans and yearly dotatate PET CT scans.

Conclusions:

Lutetium is not tolerated in patients with neuroendocrine tumour having renal impairment owing to nephrotoxicity and bone marrow suppression. In patients on maintenance hemodialysis it can be used at a lower dose and at less frequent cycles with close monitoring and supportive therapy with blood transfusion and bone marrow stimulating agents.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.