Designing Future Trials and Functional Imaging

Faculty discuss how future trials should be designed to address unmet needs in lung and thymic neuroendocrine tumors. Several propose randomized studies evaluating cabozantinib before everolimus, with stratification by typical versus atypical histology, and note an ongoing randomized trial comparing a tyrosine kinase inhibitor with everolimus that includes lung patients. The panel emphasizes incorporating functional imaging into trial assessments, weighing FDG versus dotatate PET to guide therapy, while acknowledging variability in somatostatin receptor uptake and scan interpretation. Faculty caution against somatostatin analog and radioligand therapy in lung tumors given heterogeneous receptor expression, stressing the need for experienced nuclear medicine and central radiology review. They highlight enrollment challenges in this rare population, calling for large multicenter and international collaboration, and reference an ongoing radioligand trial struggling to accrue. The discussion also explores borrowing receptor-targeting strategies from other tumor types and using clinical judgment alongside imaging to avoid missing progression.