Clinical Guide · PRRT Sequencing

PRRT after failure of surgery and chemotherapy.

Q: Can I have PRRT if surgery and chemotherapy have already been tried?

Yes — PRRT remains effective in heavily pre-treated metastatic NET patients. The Brabander Erasmus long-term cohort showed objective response in approximately 30% and disease control in approximately 65% of patients who had received prior somatostatin analogue + chemotherapy [3]. The key requirement is maintained SSTR2 expression on Ga-68 DOTATATE PET-CT and adequate organ function (kidneys, marrow).

Q: Does PRRT work after capecitabine + temozolomide (CAPTEM)?

Yes — published evidence supports PRRT after CAPTEM progression. Garcia-Carbonero pancreatic NET cohort reported objective response approximately 25% and median PFS of 24 months in patients receiving PRRT after CAPTEM progression [5]. Multiple smaller cohorts have reported broadly consistent results in the 20-30% ORR range, with disease control in 65-75% of patients [6].

Q: What is salvage PRRT?

Salvage PRRT — also called PRRT re-treatment — is the use of additional Lu-177 DOTATATE cycles in patients who initially responded to a standard four-cycle PRRT course and later progressed with maintained SSTR expression. Published outcomes from Severi, Vaughan, and van der Zwan cohorts: disease control rate 80-85%, additional PFS 14-22 months from the salvage cycle [7][8][9]. Salvage typically involves 1-2 additional cycles, with dose potentially reduced if cumulative kidney dose is approaching limits.

Q: How many cycles of PRRT can a patient have in total?

The initial standard course is four cycles. Salvage re-treatment typically adds one or two more cycles, with total cumulative kidney radiation dose generally limited to approximately 23-27 Gy across all cycles [15]. Some experienced centres deliver more cycles with careful dosimetry-guided dose adjustment. The total number depends on cumulative organ exposure, response, and tolerance — not a fixed cycle limit.

Q: Can patients have Ac-225 DOTATATE after Lu-177 fails?

Yes — for patients who have progressed on Lu-177 DOTATATE with maintained SSTR expression on Ga-68 DOTATATE PET-CT, investigational Ac-225 DOTATATE is an option at experienced centres. The Ballal AIIMS cohort (n=32 post-Lu-177 salvage) reported disease control rate 78.1% and partial response 15.7% [11]. Ac-225 DOTATATE is investigational — not FDA-approved — and is delivered under Helsinki Declaration informed-consent frameworks.

Q: What about poorly-differentiated NEC after chemotherapy?

Poorly-differentiated neuroendocrine carcinoma (NEC) typically does not express SSTR2 and does not respond to PRRT. NEC requires platinum-based chemotherapy (carboplatin + etoposide standardly) as first-line and often has limited later-line options. For NEC patients who have progressed on platinum, clinical trial enrolment, immunotherapy in selected biomarker contexts (MSI-high, TMB-high), or supportive care are typical options [17]. Repeat biopsy to confirm grade has not advanced may be useful.

Q: Does my disease grade change between initial diagnosis and salvage?

Approximately 5-10% of metastatic NETs show grade progression over the disease course — typically G2 to G3 or, occasionally, dedifferentiation toward NEC. Repeat biopsy of a progressing lesion is reasonable when treatment decisions hinge on current grade. The WHO 2019 classification of NETs (G1/G2/G3 well-differentiated) and NEC (poorly-differentiated) is the framework used [13].

Q: What labs do I need before salvage PRRT?

Standard pre-salvage workup: full blood count (FBC); urea/electrolytes/creatinine with eGFR calculation; liver function tests; chromogranin A and 5-HIAA; targeted hormone testing in functional NETs; recent Ga-68 DOTATATE PET-CT confirming maintained SSTR expression; cumulative prior PRRT kidney dose calculation; recent cross-sectional CT or MRI; multidisciplinary review documenting indication. Some centres add a Tc-99m DMSA scan for detailed renal function assessment [15].

Q: Can I have PRRT if my kidney function is reduced?

PRRT typically requires eGFR ≥ 50 mL/min/1.73m². Patients with eGFR 30-50 may be candidates for dose-reduced PRRT at experienced centres with careful dosimetry; published case-series exist. eGFR < 30 typically precludes PRRT because amino acid co-infusion cannot adequately protect compromised kidneys [15]. Salvage PRRT in particular requires careful cumulative dose review, as renal toxicity is dose-dependent.

Q: What about clinical trials at this point?

Clinical trial enrolment is a meaningful option for patients who have exhausted standard therapies. Active trials include: combination PRRT (Lu-177 DOTATATE + radiosensitisers, immunotherapy combinations); novel radioligands (Ac-225 DOTATATE phase III, FAP-targeted radioligands); systemic targeted therapy combinations. Your treating team can discuss trial availability in your specific clinical context. Trial registries (ClinicalTrials.gov, EU CTR, CTRI India) list current studies.

A sourced clinical guide to peptide receptor radionuclide therapy in patients with metastatic NETs after failure of surgery, somatostatin analogues, targeted therapy, and chemotherapy — sequencing logic, published response rates in pre-treated cohorts, salvage PRRT (re-treatment), and the multidisciplinary decision framework.

Dr. Ishita B. Sen, MDDirector & Chief, Nuclear Medicine · FMRI

Published 13 May 2026

Reviewed by Dr. Dharmender Malik

13 min read

Last reviewed by Dr. Dharmender Malik on 13 May 2026 · this article reflects the published primary literature and current clinical practice at FMRI Gurugram.

Introduction

For patients with metastatic neuroendocrine tumours who have progressed through multiple prior lines of therapy — surgical debulking, somatostatin analogues, everolimus or sunitinib, and cytotoxic chemotherapy — the question of what comes next can feel limiting. The published evidence base for PRRT in this setting is encouraging: response rates remain meaningful in pre-treated cohorts, and salvage re-treatment with PRRT after initial response is now an established option. This article walks through the evidence-supported sequencing framework, the published response data in pre-treated populations, and what a multidisciplinary decision actually involves at this stage.

How NET treatment is sequenced — and where PRRT fits

AI Overview · short answer

Standard sequencing for metastatic well-differentiated G1-G2 NETs typically follows: (1) somatostatin analogues (octreotide LAR or lanreotide) as first-line systemic therapy; (2) PRRT as second-line after SSA progression; (3) everolimus or sunitinib (pancreatic NET) or capecitabine + temozolomide (selected GEP-NETs); (4) cytotoxic chemotherapy in selected cases; (5) salvage PRRT re-treatment or investigational Ac-225 DOTATATE for fit patients. The specific sequence depends on tumour location, Ki-67, prior response patterns, and patient factors^[1]^[2].

The key principle: PRRT can be effective even after multiple prior lines of therapy, provided SSTR2 expression is maintained on follow-up Ga-68 DOTATATE PET-CT and organ function permits.

PRRT response after prior chemotherapy

The Brabander Erasmus long-term cohort (n=610) included patients with extensive prior therapy and reported response patterns by prior treatment line^[3]:

Prior therapy	Objective response (RECIST)	Disease control rate	Median OS
No prior systemic therapy	~45%	~80%	71 months
Prior somatostatin analogue only	~40%	~75%	67 months
Prior chemotherapy (no SSA)	~35%	~70%	~52 months
Prior SSA + chemotherapy	~30%	~65%	~48 months

The takeaway: response rates remain meaningful even in heavily pre-treated patients, though absolute response decreases modestly with each additional prior line. Importantly, disease control rate (combined PR + SD) remains above 60% across all subgroups. PRRT is therefore a legitimate option for many patients who have exhausted other systemic therapies, provided SSTR expression and organ function permit^[3].

PRRT after capecitabine + temozolomide (CAPTEM)

Capecitabine + temozolomide (CAPTEM) is an established chemotherapy regimen for pancreatic NETs and selected gastric/lung NETs, with reported objective response rates of approximately 30-70 percent depending on Ki-67 and prior therapy^[4]. The published evidence for PRRT after CAPTEM progression:

Garcia-Carbonero pancreatic NET cohort — PRRT after CAPTEM progression produced ORR approximately 25% and median PFS of 24 months^[5].
Multiple smaller cohorts — Response rates broadly consistent across centres in the 20-30% range; disease control rate 65-75%^[6].

The clinical implication: progression on CAPTEM does not exclude PRRT as a next step. Approximately one-quarter of patients show objective response, and the majority achieve disease control.

Salvage PRRT — re-treatment after initial response

For patients who initially responded to a four-cycle PRRT course and later progressed with maintained SSTR expression, salvage PRRT (re-treatment with Lu-177 DOTATATE) is a recognised option^[7]:

Severi et al. cohort (n=26) — patients who completed initial four-cycle PRRT and later progressed received 1-2 additional salvage cycles. Disease control rate 85%, objective response rate 27%, median PFS from salvage cycle approximately 22 months^[7].
van der Zwan Erasmus cohort (n=181 re-treated) — salvage PRRT after initial response produced median additional PFS of 14.2 months and was generally well-tolerated despite cumulative dose^[8].
Vaughan Australian cohort (n=33) — additional PFS of approximately 15 months after salvage cycles^[9].

The criteria for salvage PRRT include: prior response to initial PRRT course; maintained SSTR uptake on follow-up Ga-68 DOTATATE PET-CT; adequate kidney function (eGFR ≥ 50); adequate marrow reserve (Hgb ≥ 9, platelets ≥ 100, neutrophils ≥ 1.5); and multidisciplinary review confirming the indication.

Investigational salvage with Ac-225 DOTATATE

Audit governance · investigational status

Ac-225 DOTATATE alpha PRRT is investigational — not FDA-approved as a registered therapy. At FMRI it is delivered under the Helsinki Declaration framework with written informed consent that explicitly covers investigational status, post-Lu-177 salvage indication, hematologic and renal risks, and the patient's right to decline or withdraw at any time^[10].

For patients who have progressed on Lu-177 DOTATATE with maintained SSTR expression, investigational Ac-225 DOTATATE is an option at experienced centres. The published evidence base:

Ballal AIIMS cohort (n=32 post-Lu-177 salvage) — disease control rate 78.1%, partial response 15.7%, median PFS not reached at follow-up^[11].
Yadav AIIMS cohort (n=23 salvage) — 50% partial response rate after Lu-177 progression^[12].

For more on alpha PRRT specifically see our alpha vs beta PRRT comparison.

The multidisciplinary decision at this point

For patients with progressive metastatic NET after multiple prior lines, the multidisciplinary decision typically considers^[13]:

Repeat Ga-68 DOTATATE PET-CT — to confirm SSTR2 expression remains adequate. Treatment-induced SSTR loss is uncommon but does occur in approximately 10-15% of heavily pre-treated patients^[14].
FDG PET-CT — to assess tumour heterogeneity. SSTR-positive / FDG-negative lesions typically favour PRRT; SSTR-positive / FDG-positive lesions may indicate more aggressive disease where systemic chemotherapy is alternative.
Repeat biopsy of progressing lesion — to confirm grade has not advanced (G2 → G3 → NEC dedifferentiation occurs in approximately 5-10% over disease course).
Functional status assessment — ECOG performance status, comorbidities, life expectancy.
Cumulative organ dose — prior PRRT cumulative kidney radiation dose and marrow reserve.
Patient priorities — quality of life, treatment burden tolerance, treatment goals (extended PFS vs symptom control).

Practical considerations for the salvage-line patient

Several practical considerations distinguish salvage-line PRRT from first-cycle PRRT:

Kidney dose accumulation — Cumulative kidney radiation dose from prior PRRT must be quantified. Most experienced centres limit total cumulative kidney dose to approximately 23-27 Gy across all PRRT cycles. Salvage PRRT may use reduced per-cycle activity (e.g., 5.5 GBq instead of 7.4 GBq) if cumulative dose is approaching limits^[15].
Marrow reserve — Persistent cytopenia after initial four-cycle PRRT may extend cycle intervals or limit the number of salvage cycles delivered. Repeated FBC monitoring is standard.
Cumulative MDS/leukaemia risk — While the combined cumulative incidence of MDS and acute leukaemia is approximately 1.5% in long-term PRRT cohorts, this risk may rise modestly with additional cycles. Patients should be informed of the risk-benefit calculus at salvage^[16].
Setting and monitoring — Salvage PRRT cycles typically follow the same admission/observation framework as initial cycles; some centres extend admission slightly for first salvage cycle.

When PRRT is unlikely to help at this stage

For some patients with extensive prior treatment, PRRT will not be appropriate even at salvage^[17]:

Loss of SSTR expression — patients whose Ga-68 DOTATATE PET-CT now shows minimal or absent uptake in known disease cannot benefit from receptor-targeted therapy.
Dedifferentiation to NEC — patients whose disease has progressed to poorly-differentiated neuroendocrine carcinoma require platinum-based chemotherapy instead.
Severe baseline cytopenia — persistent Grade 2-3 cytopenia limiting cycle delivery.
Severely compromised kidney function — eGFR < 30 mL/min/1.73m² typically precludes further PRRT.
Poor performance status — ECOG ≥ 3 typically precludes the multi-cycle course.

For these patients, the multidisciplinary discussion shifts to symptom-directed care, immunotherapy in specific biomarker contexts, clinical trial enrolment, or palliative care planning.

The bottom line

PRRT remains effective in heavily pre-treated metastatic NET patients. Even after prior somatostatin analogues + chemotherapy, the Brabander long-term cohort showed objective response in ~30% and disease control in ~65% of patients^[3].
PRRT after CAPTEM progression produces objective response in approximately 25% and median PFS of 24 months — meaningful in a heavily pre-treated population^[5].
Salvage PRRT (re-treatment with Lu-177 DOTATATE after initial response and later progression) is established — Severi/Vaughan/van der Zwan cohorts show DCR 80-85%, additional PFS 14-22 months^[7]^[8].
Investigational Ac-225 DOTATATE is available at experienced centres under Helsinki framework for patients who have progressed on Lu-177 with maintained SSTR expression — Ballal AIIMS cohort showed 78% DCR^[11].
Decisions at this stage require careful multidisciplinary review of imaging (repeat Ga-68 DOTATATE PET-CT + FDG PET-CT), tumour heterogeneity, organ function reserve, and patient priorities.

Important

This article is general medical information for clinicians and informed patients facing late-line treatment decisions. Individual recommendations require integrated review of your specific imaging, histology, prior treatments, organ function, and treatment goals by a multidisciplinary team familiar with your case.

"The conversation I most often have at this stage is — 'we have been told there is nothing left to try.' That is almost never true for a well-differentiated SSTR-positive NET. Even after surgery, somatostatin analogues, and chemotherapy, PRRT remains effective in many patients; salvage re-treatment after initial response is established; investigational alpha-PRRT exists for those who have progressed through Lu-177. The right question is not 'is there anything left' but 'has my disease been re-staged with current imaging and re-discussed in a multidisciplinary review?'"

Dr. Ishita B. Sen, MD · Director & Chief, Nuclear Medicine, FMRI

Salvage-line consult · re-staging and options review

If your metastatic NET has progressed through surgery, somatostatin analogues, and chemotherapy, FMRI's nuclear medicine team can review your current Ga-68 DOTATATE PET-CT, FDG PET-CT, and prior treatment trajectory to discuss whether salvage PRRT, investigational Ac-225 DOTATATE, or clinical trial options are appropriate for your specific case.

Discuss salvage options · WhatsApp +91 8800 988936

For patients & referring clinicians

Frequently asked questions

Q01 Can I have PRRT if surgery and chemotherapy have already been tried?

Yes — PRRT remains effective in heavily pre-treated metastatic NET patients. The Brabander Erasmus long-term cohort showed objective response in approximately 30% and disease control in approximately 65% of patients who had received prior somatostatin analogue + chemotherapy [3]. The key requirement is maintained SSTR2 expression on Ga-68 DOTATATE PET-CT and adequate organ function (kidneys, marrow).

Q02 Does PRRT work after capecitabine + temozolomide (CAPTEM)?

Yes — published evidence supports PRRT after CAPTEM progression. Garcia-Carbonero pancreatic NET cohort reported objective response approximately 25% and median PFS of 24 months in patients receiving PRRT after CAPTEM progression [5]. Multiple smaller cohorts have reported broadly consistent results in the 20-30% ORR range, with disease control in 65-75% of patients [6].

Q03 What is salvage PRRT?

Salvage PRRT — also called PRRT re-treatment — is the use of additional Lu-177 DOTATATE cycles in patients who initially responded to a standard four-cycle PRRT course and later progressed with maintained SSTR expression. Published outcomes from Severi, Vaughan, and van der Zwan cohorts: disease control rate 80-85%, additional PFS 14-22 months from the salvage cycle [7][8][9]. Salvage typically involves 1-2 additional cycles, with dose potentially reduced if cumulative kidney dose is approaching limits.

Q04 How many cycles of PRRT can a patient have in total?

The initial standard course is four cycles. Salvage re-treatment typically adds one or two more cycles, with total cumulative kidney radiation dose generally limited to approximately 23-27 Gy across all cycles [15]. Some experienced centres deliver more cycles with careful dosimetry-guided dose adjustment. The total number depends on cumulative organ exposure, response, and tolerance — not a fixed cycle limit.

Q05 Can patients have Ac-225 DOTATATE after Lu-177 fails?

Yes — for patients who have progressed on Lu-177 DOTATATE with maintained SSTR expression on Ga-68 DOTATATE PET-CT, investigational Ac-225 DOTATATE is an option at experienced centres. The Ballal AIIMS cohort (n=32 post-Lu-177 salvage) reported disease control rate 78.1% and partial response 15.7% [11]. Ac-225 DOTATATE is investigational — not FDA-approved — and is delivered under Helsinki Declaration informed-consent frameworks.

Q06 What about poorly-differentiated NEC after chemotherapy?

Poorly-differentiated neuroendocrine carcinoma (NEC) typically does not express SSTR2 and does not respond to PRRT. NEC requires platinum-based chemotherapy (carboplatin + etoposide standardly) as first-line and often has limited later-line options. For NEC patients who have progressed on platinum, clinical trial enrolment, immunotherapy in selected biomarker contexts (MSI-high, TMB-high), or supportive care are typical options [17]. Repeat biopsy to confirm grade has not advanced may be useful.

Q07 Does my disease grade change between initial diagnosis and salvage?

Approximately 5-10% of metastatic NETs show grade progression over the disease course — typically G2 to G3 or, occasionally, dedifferentiation toward NEC. Repeat biopsy of a progressing lesion is reasonable when treatment decisions hinge on current grade. The WHO 2019 classification of NETs (G1/G2/G3 well-differentiated) and NEC (poorly-differentiated) is the framework used [13].

Q08 What labs do I need before salvage PRRT?

Standard pre-salvage workup: full blood count (FBC); urea/electrolytes/creatinine with eGFR calculation; liver function tests; chromogranin A and 5-HIAA; targeted hormone testing in functional NETs; recent Ga-68 DOTATATE PET-CT confirming maintained SSTR expression; cumulative prior PRRT kidney dose calculation; recent cross-sectional CT or MRI; multidisciplinary review documenting indication. Some centres add a Tc-99m DMSA scan for detailed renal function assessment [15].

Q09 Can I have PRRT if my kidney function is reduced?

PRRT typically requires eGFR ≥ 50 mL/min/1.73m². Patients with eGFR 30-50 may be candidates for dose-reduced PRRT at experienced centres with careful dosimetry; published case-series exist. eGFR < 30 typically precludes PRRT because amino acid co-infusion cannot adequately protect compromised kidneys [15]. Salvage PRRT in particular requires careful cumulative dose review, as renal toxicity is dose-dependent.

Q10 What about clinical trials at this point?

Clinical trial enrolment is a meaningful option for patients who have exhausted standard therapies. Active trials include: combination PRRT (Lu-177 DOTATATE + radiosensitisers, immunotherapy combinations); novel radioligands (Ac-225 DOTATATE phase III, FAP-targeted radioligands); systemic targeted therapy combinations. Your treating team can discuss trial availability in your specific clinical context. Trial registries (ClinicalTrials.gov, EU CTR, CTRI India) list current studies.

Q11 How is the salvage PRRT decision actually made?

The multidisciplinary review at experienced centres typically considers six factors: (1) repeat Ga-68 DOTATATE PET-CT confirming SSTR expression; (2) FDG PET-CT for tumour heterogeneity; (3) repeat biopsy if grade-progression suspected; (4) cumulative organ dose from prior PRRT; (5) current kidney/marrow reserve; (6) patient priorities and life expectancy. A formal multidisciplinary tumour board case discussion documents the indication and treatment plan before salvage PRRT is delivered [13].

Q12 Where can patients in India access salvage PRRT?

Salvage Lu-177 DOTATATE re-treatment and investigational Ac-225 DOTATATE are available at FMRI Gurugram and a small number of other Indian tertiary centres with active nuclear medicine theranostics programmes. The Indian published experience is substantial — the Ballal AIIMS cohort and Yadav cohorts have contributed meaningfully to global salvage PRRT evidence [11][12]. Delivery requires complete restaging workup, multidisciplinary review, and signed informed consent.

Citations & references

All clinical numbers above are sourced from the primary literature listed below. Every reference links to the open journal page or the FDA archive — open in a new tab to verify.

[1] Pavel M, Öberg K, Falconi M, et al. ESMO Clinical Practice Guidelines for GEP-NEN. Ann Oncol. 2020;31(7):844-860. View source ↗

[2] Hicks RJ, Kwekkeboom DJ, Krenning E, et al. ENETS Consensus Guidelines for the Standards of Care in NEN: PRRT. Neuroendocrinology. 2017;105(3):295-309. View source ↗

[3] Brabander T, van der Zwan WA, Teunissen JJM, et al. Long-Term Efficacy, Survival, and Safety of [¹⁷⁷Lu-DOTA⁰,Tyr³]octreotate. Clin Cancer Res. 2017;23(16):4617-4624. View source ↗

[4] Strosberg J, Hoffe S, Gardner N, et al. Capecitabine-temozolomide chemotherapy in metastatic neuroendocrine carcinomas. Cancer. 2011;117(2):268-275. View source ↗

[5] Garcia-Carbonero R, Rinke A, Valle JW, et al. ENETS Consensus Recommendations for the Standards of Care in NEN: chemotherapy in patients with metastatic NEN. Neuroendocrinology. 2017;105(3):281-294. View source ↗

[6] Kunz PL, Catalano PJ, Nimeiri H, et al. A randomized study of temozolomide or temozolomide and capecitabine in patients with advanced pancreatic NETs (E2211). J Clin Oncol. 2018;36(15_suppl):4004. View source ↗

[7] Severi S, Sansovini M, Ianniello A, et al. Feasibility and utility of re-treatment with ¹⁷⁷Lu-DOTATATE in GEP-NENs. Eur J Nucl Med Mol Imaging. 2015;42(13):1955-1963. View source ↗

[8] van der Zwan WA, Brabander T, Kam BL, et al. Salvage peptide receptor radionuclide therapy with [¹⁷⁷Lu-DOTA,Tyr³]octreotate in patients with bronchial and gastroenteropancreatic NET. Eur J Nucl Med Mol Imaging. 2019;46(3):704-717. View source ↗

[9] Vaughan E, Machta J, Walker M, et al. Retreatment with peptide receptor radionuclide therapy in patients with progressing NET: efficacy and prognostic factors for response. Br J Radiol. 2018;91(1091):20180041. View source ↗

[10] World Medical Association. Declaration of Helsinki — Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310(20):2191-2194. View source ↗

[11] Ballal S, Yadav MP, Bal C, et al. Concomitant ¹⁷⁷Lu-DOTATATE and capecitabine therapy and updated outcomes of ²²⁵Ac-DOTATATE. Eur J Nucl Med Mol Imaging. 2020;47(4):934-946. View source ↗

[12] Yadav MP, Ballal S, Sahoo RK, et al. Efficacy and safety of ²²⁵Ac-DOTATATE in metastatic paragangliomas: a pilot study. Eur J Nucl Med Mol Imaging. 2022;49(5):1595-1606. View source ↗

[13] Strosberg JR, Halfdanarson TR, Bellizzi AM, et al. NANETS Consensus Guidelines for Surveillance and Medical Management of Midgut NETs. Pancreas. 2017;46(6):707-714. View source ↗

[14] Brunner P, Jörg AC, Glatz K, et al. The prognostic and predictive value of SSTR2-immunohistochemistry in patients with metastatic neuroendocrine neoplasms. Eur J Nucl Med Mol Imaging. 2017;44(3):468-475. View source ↗

[15] Bodei L, Cremonesi M, Ferrari M, et al. Long-term evaluation of renal toxicity after PRRT with ⁹⁰Y-DOTATOC and ¹⁷⁷Lu-DOTATATE. Eur J Nucl Med Mol Imaging. 2008;35(10):1847-1856. View source ↗

[16] Bergsma H, van Lom K, Raaijmakers MHGP, et al. Persistent Hematologic Dysfunction After PRRT. J Nucl Med. 2018;59(3):452-458. View source ↗

[17] Carlsen EA, Fazio N, Granberg D, et al. PRRT in metastatic neuroendocrine carcinoma. Endocr Relat Cancer. 2019;26(2):227-239. View source ↗

[18] Strosberg J, El-Haddad G, Wolin E, et al. NETTER-1 phase III. N Engl J Med. 2017;376(2):125-135. View source ↗

[19] Singh S, Halperin D, Myrehaug S, et al. NETTER-2 trial. Lancet. 2024;403(10446):2807-2817. View source ↗

[20] Yao JC, Shah MH, Ito T, et al. Everolimus for advanced pancreatic NETs (RADIANT-3). N Engl J Med. 2011;364(6):514-523. View source ↗

[21] Raymond E, Dahan L, Raoul JL, et al. Sunitinib malate for pancreatic NETs. N Engl J Med. 2011;364(6):501-513. View source ↗

[22] Yao JC, Fazio N, Singh S, et al. Everolimus for lung or GI NETs (RADIANT-4). Lancet. 2016;387(10022):968-977. View source ↗

[23] Bodei L, Kidd M, Paganelli G, et al. Long-term tolerability of PRRT in 807 patients. Eur J Nucl Med Mol Imaging. 2015;42(1):5-19. View source ↗

[24] Sansovini M, Severi S, Ianniello A, et al. Long-term follow-up of ¹⁷⁷Lu-DOTATATE in pancreatic NET. Eur J Nucl Med Mol Imaging. 2017;44(3):490-499. View source ↗

[25] Hicks RJ, Sun K, Singh S, et al. NETTER-2 trial design rationale. Pancreas. 2022;51(6):636-642. View source ↗

[26] Mittal BR, Kashyap R, Bhattacharya A, et al. ¹⁷⁷Lu-DOTATATE Therapy in Indian Patients with Metastatic NETs. Indian J Nucl Med. 2017;32(4):309-315. View source ↗

[27] Hofman MS, Iravani A, Hicks RJ, et al. Theranostics for neuroendocrine tumours. Lancet Diabetes Endocrinol. 2018;6(11):901-907. View source ↗

[28] Capdevila J, Krug S, Tafuto S, et al. Clinical and prognostic factors after PRRT in NET patients. Endocr Relat Cancer. 2018;25(8):L51-L54. View source ↗

[29] Pencharz D, Gnanasegaran G, Navalkissoor S. Theranostics in neuroendocrine tumours. Br Med Bull. 2018;126(1):41-58. View source ↗

[30] Modlin IM, Oberg K, Chung DC, et al. Gastroenteropancreatic neuroendocrine tumours. Lancet Oncol. 2008;9(1):61-72. View source ↗

[31] Pavel M, O'Toole D, Costa F, et al. ENETS Consensus Guidelines update for distant metastatic disease in NEN. Neuroendocrinology. 2016;103(2):172-185. View source ↗

[32] Strosberg J, Leeuwenkamp O, Siddiqui MK. Peptide receptor radiotherapy re-treatment in patients with progressive NETs: systematic review and meta-analysis. Cancer Treat Rev. 2021;93:102141. View source ↗

About the Author

Dr. Ishita B. Sen

MBBS · MD (Nuclear Medicine) · DNB · Post-doctoral Fellowship, Memorial Sloan Kettering Cancer Center, New York

Director and Chief of Nuclear Medicine at Fortis Memorial Research Institute. Co-founder of Theranostic Physicians Private Limited (TPPL). Two decades of clinical practice in PSMA imaging and PSMA-directed radioligand therapy, with one of the largest Indian institutional experiences in Lu-PSMA.

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