Case 1 - JK a 42 year old gentleman diagnosed with Grade 3 (Ki67 – 30-40%), metastatic, Pancreatic Nueroendocrine Tumor (NET) in 2015, when he presented with painful obstructive jaundice. He unfortunately had progressive metastatic disease despite being treated with multiple chemotherapy ( 6 cycles of Carboplatin/Etoposide followed by CAB chemotherapy ).

In view of progressive disease, despite chemotherapy, Ga-68-DOTATATE scan was performed with uptake in the primary pancreatic and regional nodes higher than the liver, but lower than the spleen (Krenning score - 3). On this basis, Lutate therapy was offered and post cycle 1, the Lutate uptake in the primary pancreatic malignancy and the nodes seems to be higher than that seen on DOTATATE scan.

Discussion – Indication of Somatostatin receptor scan and Lutate therapy in Grade 3 NET and difference in radiotracer uptake in the theranostic pair.

Case 2 – BM, a 69 year old gentleman with new diagnosis of Grade 2 Pancreatic NET (Ki67 - 2.5%, Mitoses – 3/HPF) underwent FDG and Ga-68-DOTATATE PET-CT. The known primary pancreatic malignancy and the liver metastases were not avid on the DOTATATE scan but avid on FDG PET.

Discussion – DOTATATE negative, FDG positive low grade NET –prognostic implication.

Case 3 – CJ, a 62 year old female with Multiendocrine Neoplasia (MEN1) and primary pancreatic NET presented in 2011 with abdominal and liver metastases. Patient had progressive metastatic disease noted on multiple scans, despite being on Sandostatin. She was treated with 4 cycles of Lutate, completed in 2013.

3 month post-therapy scan in January 2014 showed significant disease progression. Patient died in February 2014.

Discussion – Progressive disease in NET with germ line mutation and when to start treatment.