ESMO 2017: Some reflections on the meeting

The new and  now annual ESMO convention met at the Feria in Madrid between 8 and 12 September 2017. This was very well attended with over 20,000 delegates and we were blessed with wall-to-wall sunshine and on Sunday some people were able to witness the climax of La Vuelta cycle race around the city centre. Having attended ESMO quite a few times over the past 20 years it has been remarkable how neuroendocrine tumours have really established themselves as a distinct and separate entity and this was reflected in the number of sessions devoted to NETs. This really is quite a remarkable achievement for the specialty and the organisers should be complimented.

It is always difficult trying to cater for such a diverse audience which included a number of Europe and North America’s key opinion leaders in the field. Nevertheless I think the balance was generally very good and even the experts may well have picked up a few new tips and those new to the specialty wanting to learn about NETs will have found this a very valuable experience and opportunity.

The opening NET session was on how to treat patients who are progressing on somatostatin analogues and this was led by Strosberg who gave a good overview of the role of targeted agents, interferons, other newer agents, telotristat and PRRT. The challenge is how to integrate all these into clinical practice and to determine what is the optimal scheduling. A further useful review was on the topic of hepatic artery embolisation. There are different levels of enthusiasm about embolisation but when used in the appropriate patient and carried out by a team familiar with the process it is very safe and effective.

On the Sunday afternoon was a very useful overview session which covered adrenocortical carcinomas, recent advances in medullary thyroid cancer management and a review of paragangliomas and pheochromocytomas. Personally I found the PGL presentation by Crona from Upsala to be one of the most informative and valuable sessions in the whole meeting particularly with his review of some of the new molecular pathways. Alfredo Berutti gave an excellent overview of the current management of adrenocortical cancers and Jamie Capdevila covered the updates in medullary thyroid cancers very thoroughly.

To date immunotherapy has made minimal impact in neuroendocrine tumours but the presentation on the Pembro-Keynote 28 study included a number of carcinoid and pancreatic neuroendocrine tumours showing modest activity and giving a hint that these drugs will become more widely used in the future. Another paper from Dingemans discussed some of the issues with bronchial neuroendocrine tumours at the more aggressive end of the spectrum and reviewed some of the more recently identified molecular pathways. There still remains much heated discussion about whether small cell lung cancer regimes like platinum and etoposide are better than other schedules used in non-small cell lung cancer such as gemcitabine and paclitaxel. There are some hints that we may need to review our treatment options for this different tumours as we learn more about them. The reader is also referred to the abstract book for the oral presentations which were discussed by Ian Chau.

Martyn Caplin and Marianne Pavel led a very useful overview of the management of bronchopulmonary neuroendocrine tumours and this was followed on by the discussion of the posters . The first 3 focused on BRAF and kRas in thyroid cancer molecular pathways alterations. An interesting poster looked at notch signalling expression in a variety of tumours including G3 neuroendocrine carcinomas. There was an update on the quality of life in the NETTER01 study and a similar update on the TELSTAR study of telotristat. A very valuable poster highlighted the experience more than 1000 patients treated in Bad-Berka with PRRT highlighting the relatively low risk of myelodysplasia and leukaemia which cumulatively occurred in around 2.1% of the patient’s treated. I personally found this reassuring as some of the early reports indicated that the risks of haematological sequela might be much higher. There appeared to be no obvious predictive factors for those who developed the severe haematological consequences. Finally an interesting paper came from the Commonwealth group looking at guidelines for follow-up which always causes discussion and debate this could be a further useful addition to the literature on the topic.

Finally from bench to bedside late on Monday afternoon lead off with Anne Couvelard from Paris telling us what is new in the pathology of pancreatic NETs and what has changed. There are some important changes particularly with the inclusion of the well differentiated neuroendocrine tumours with grade 3 with the Ki-67 index between 20 and 50%. She discussed some of the issues and pitfalls in distinguishing between NET G3 and NEC G3. In addition there are important developments with next generation sequencing and new molecular pathways which will help with treatment planning. Lisa Bodei gave an authoritative overview of radionuclide imaging and treatment covering some of the new developments with SSTR antagonists and some other newer PET radionuclides. The use of PRRT is now well established and just waiting for NICE to make its for recommendation and hopefully to become available in the UK for the treatment of our patients with advance NETs.

So I came away having had some excellent science and updates in neuroendocrine tumours. One is never too old to stop learning. In addition we had some wonderful warm sunshine and some excellent hospitality confirming how good Spanish cuisine is. If this is the direction in which ESMO is travelling it is very reassuring to see that neuroendocrine tumours are being given such a prominent role. Here’s to Munich 2018 which amusingly will take place during the Oktober Bierfest. I think most of us will drink to that!!  Let us hope we get an invite.

Prof. Nick Reed