74 yo ECOG 0 diagnosed w/ well differentiated pancreatic neuoroendocrine neoplasm (KI 67 - 52%) who has progressed on cape/tem w/ new liver lesion and enlargement of the pancreatic mass. DOTATATE at diagnosis showed mild uptake in the pancreatic mass. Got 2 cycles of cape/tem with progression. I told him everolimus would likely be the next standard of care option. Lutathera less likely since the DOTATATE wasn't especially avid. I've had good anecdotal experience with FOLFIRINOX in some of these. His course has been complicated w/ recurrent pancreatitis which has resolved since placing a post pyloric feeding tube. Hoping to get a good objective response and advance his diet (which is why I favor FOLFIRINOX over everolimus).
I agree, everolimus would be reasonable SOC option. Now your suggestion and idea of FOLFIRINOX is not unreasonable. There are case reports 10.1007/s12029-015-9689-0 where FOLIRINOX is being used with response in higher grade pNETs and there was a clinical trial which closed due to slower accrual. Second line platinum based therapy (FOLFOX) is reasonable option, and thus FFX is also more aggressive but reasonable option. We have had a recent patient just like the one you highlighted, that has fairly aggressive biology, and did not respond to everolimus. Interesting they had high PD-L1 expression and IO was also tested, and we ultimately went to FOLFOX, thereafter.