Preoperative PRRT Versus Surgical Cytoreduction in Metastatic Pancreatic Neuroendocrine Tumors to the Liver

Inclusion Criteria:

* Metastatic Pancreatic neuroendocrine tumors (PanNET) to the liver
* Well- or moderately differentiated (grade 1 or grade 2, Ki-
* Ability to aim for equal or greater than 90% hepatic cytoreduction surgically
* Proof of SSTR2 expression by uptake of tumor on 68Ga DOTATATE PET CT (Krenning Score on all or a majority of lesions
* Age older than 18 years
* No Somatostatin Analogues (SSA) or other systemic therapy for 4 weeks prior to starting PRRT, if randomized to arm 2.

Exclusion Criteria:

* Patient with G3 or poorly differentiated NET (grade 3, Ki-67 \>20%)
* Previous liver-directed therapy with Yttrium-90 (TACE/TAE allowed if performed more than 12 months prior to enrollment)
* Systemic therapy with Capecitabine and/or Temozolamide within 12 months of enrollment.
* No tumor uptake on 68Ga DOTATATE PET CT
* Liver tumor burden \> 50% (as defined by CT or MRI)
* Signs of early liver failure (T-Bilirubin \>3, INR \> 1.5, Albumin \<3.0 g/dL unless prothrombin time is within the normal range) or cirrhosis or ascites
* calculated by the Cockroft Gault method, eventually confirmed by measured creatinine clearance
* (or measured glomerular filtration rate (GFR) using plasma clearance methods, not gamma
* camera-based) \<50 mL/min (the measured creatinine clearance / GFR is required only as - confirmatory exam).
* 2\. Hb concentration \<5.0 mmol/L (\<8.0 g/dL); WBC \<2x109/L (2000/mm3); platelets \<75x109/L - (75x103/mm3).
* Known brain metastases, unless these metastases have been treated and stabilized.
* Uncontrolled congestive heart failure (NYHA II, III, IV).
* Uncontrolled diabetes mellitus as defined by a fasting blood glucose \>2 ULN.
* Pregnancy or lactation.
* For female patients of childbearing potential (defined as \< 2 years after last menstruation and not surgically sterile) and male patients, who are not surgically sterile or with female partners of childbearing potential: absence of effective, non-hormonal means of contraception (intrauterine contraceptive device, barrier method of contraception in conjunction with spermicidal gel). - Prior external beam radiation therapy to more than 25% of the bone marrow.
* Current spontaneous urinary incontinence making impossible the safe administration of the radioactive IMP.
* Other known co-existing malignancies except non-melanoma skin cancer and carcinoma in situ of the uterine cervix, unless definitively treated and with no evidence of recurrence.
* Patients who have not provided a signed informed consent form to accept this treatment.
* Poor renal function
* Quality Unit language added
* editorial changes