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  • Review Article
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Neuroendocrine tumours: the role of imaging for diagnosis and therapy

Nature Reviews Endocrinology volume 10, pages 102–114 (2014)Cite this article

Subjects

Key Points

  • When assessing neuroendocrine tumours (NETs), which comprise a wide variety of tumours with different imaging characteristics, morphological imaging (mostly CT or MRI) and nuclear medicine techniques are complementary

  • CT and MRI are typically used to evaluate a patient's response to therapy; however, a role for nuclear medicine techniques, aside from establishing progressive disease by visualizing new lesions, has yet to be defined

  • Somatostatin receptor imaging with radiolabelled somatostatin analogues is mandatory to determine whether patients are eligible for peptide receptor radionuclide therapy

  • 111In-pentetreotide scintigraphy is currently the most widely used method to assess somatostatin receptor expression, but 68Ga-DOTA-somatostatin analogue PET–CT could become the nuclear medicine test of choice for staging of patients with well-differentiated NETs

  • PET–CT with 18F-dihydroxy-L-phenylalanine and 11C-hydroxy-L-tryptophan might potentially be used in the future for therapy response evaluation

  • 18F-FDG-PET is only recommended in patients with grade 3 neuroendocrine cancers but shows potential for other indications, for example, to predict prognosis and determine treatment schedule

Abstract

In patients with neuroendocrine tumours (NETs), a combination of morphological imaging and nuclear medicine techniques is mandatory for primary tumour visualization, staging and evaluation of somatostatin receptor status. CT and MRI are well-suited for discerning small lesions that might escape detection by single photon emission tomography (SPECT) or PET, as well as for assessing the local invasiveness of the tumour or the response to therapy. Somatostatin receptor imaging, by 111In-pentetreotide scintigraphy or PET with 68Ga-labelled somatostatin analogues, frequently identifies additional lesions that are not visible on CT or MRI scans. Currently, somatostatin receptor scintigraphy with 111In-pentetreotide is the more frequently available of the two techniques to determine somatostatin receptor expression and is needed to select patients for peptide receptor radionuclide therapy. In the future, because of its higher sensitivity, PET with 68Ga-labelled somatostatin analogues is expected to replace somatostatin receptor scintigraphy. Whereas 18F-FDG-PET is only used in high-grade neuroendocrine cancers, PET–CT with 18F-dihydroxy-L-phenylalanine or 11C-5-hydroxy-L-tryptophan is a useful problem-solving tool and could be considered for the evaluation of therapy response in the future. This article reviews the role of imaging for the diagnosis and management of intestinal and pancreatic NETs. Response evaluation and controversies in NET imaging will also be discussed.

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Figure 1: Transversal CT image of a large hypervascular nonfunctioning pancreatic NET.
Figure 2: Transversal CT image of a typical small-bowel neuroendocrine tumour mesenteric metastasis (arrow).
Figure 3: Transversal CT image of a small hypervascular pancreatic neuroendocrine tumour in the pancreatic head (arrow).
Figure 4: T2-weighted transversal MRI of a high-signalling pancreatic neuroendocrine tumour.
Figure 5: Normal somatostatin receptor scintigram.
Figure 6: Comparison of neuroendocrine tumour imaging results with varying imaging modalities.
Figure 7: Suggested imaging procedures for patients with neuroendocrine tumours.
Figure 8: 68Ga-DOTA-TOC-PET–CT images of a patient with a small-bowel neuroendocrine tumour.
Figure 9: Diagnostic, therapeutic and follow-up imaging in a patient with metastasized pancreatic neuroendocrine tumour.

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Authors and Affiliations

  1. Department of Nuclear Medicine, Erasmus MC, 's Gravendijkwal 230, Rotterdam, 3015, GD, Netherlands

    Martijn van Essen, Eric P. Krenning & Dik J. Kwekkeboom

  2. Department of Radiology, Karolinska University Hospital, Stockholm, 17176, Stockholm, Sweden

    Anders Sundin

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  1. Martijn van Essen
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  2. Anders Sundin
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  3. Eric P. Krenning
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  4. Dik J. Kwekkeboom
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The authors contributed equally to all aspects of the article.

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Correspondence to Eric P. Krenning.

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Competing interests

E.P. Krenning and D.J. Kwekkeboom are stockholders in Advanced Accelerator Applications (AAA). The other authors declare no competing interests.

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van Essen, M., Sundin, A., Krenning, E. et al. Neuroendocrine tumours: the role of imaging for diagnosis and therapy. Nat Rev Endocrinol 10, 102–114 (2014). https://doi.org/10.1038/nrendo.2013.246

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