The correct answer is the second option, as octreotide and lanreotide can worsen hypoglycemia in the absence of insulinoma somatostatin receptors by suppressing counter-regulatory hormones. In the trial called the Controlled Study of Lanreotide Antiproliferative Response in Neuroendocrine Tumors (CLARINET), 204 patients with unresectable locally advanced or metastatic pancreatic or intestinal neuroendocrine tumors were randomized to receive either 2 years of lanreotide or placebo. The only functional tumors allowed were gastrinomas controlled with a proton pump inhibitor for at least 4 months, not insulinomas. Although the primary endpoint was met, with lanreotide resulting in significantly improved progression-free survival (Hazard Ratio 0.47; 95% Confidence Interval, 0.30 – 0.73; P < .001), this patient population was different from “patient 1″. Lanreotide is a monthly deep subcutaneous injection and is therefore more easily administered than octreotide which is a monthly intramuscular injection. Lanreotide and octreotide are similar in efficacy.
Clinical management of our patient in case one: As enucleation was not possible due to the deep location of the tumor and proximity to vasculature, the patient underwent a pancreaticoduodenectomy. Pathology showed a 1.7cm tumor confined to the head of the pancreas. One of seven lymph nodes were involved with disease.
Based on AJCC 8th, PNET pathology (p)T stage is based on the tumor size (<2 cm pT1, 2-4 cm: pT2 and >4 cm pT3). Tumor invasion of the duodenum or common bile duct also qualifies as pT3, and tumor invasion of the adjacent organs (colon, stomach, spleen, adrenal gland) or the wall of large vessels (SMA or celiac axis) is pT4. Presence of any lymph node metastasis, irrespective of the number, is pN1. Distant metastasis to liver is M1a, to the other organs is M1b and to both liver and extra-hepatic organ(s) is M1c, making case 1 T1N1M0, overall Stage III.