Review Analysis of the REAL-LU Study: Effectiveness and Safety of Lutetium-177 DOTATATE in Italian Patients with GEP-NETs

This review of the analysis on Lutetium-177 DOTATATE in treating gastroenteropancreatic-neuroendocrine tumours (GEP-NETs), published as the Italian prospective observational (REAL-LU) study in the European Journal of Nuclear Medicine and Molecular Imaging, delves into the study’s rationale, design, and baseline characteristics. The review seeks to assess the study’s methodology and initial findings, offering insights into its relevance and prospective influence on clinical practice.

Introduction and Rationale

The REAL-LU study addresses a crucial gap in the existing literature by focusing on real-world data regarding the use of Lutetium-177 DOTATATE in Italian clinical practice. While the phase III NETTER-1 trial demonstrated the efficacy of this treatment in improving progression-free survival (PFS) and health-related quality of life (HRQoL) compared to high-dose somatostatin analogues, there is limited information on its application outside controlled clinical trials. The study’s primary objective is to evaluate the effectiveness of [177Lu]-DOTATATE in terms of PFS, with secondary objectives including safety, impact on HRQoL, and identification of prognostic factors. This focus on real-world data is essential for understanding how the treatment performs in routine clinical settings, which often involve more heterogeneous patient populations than those in clinical trials.

Study Design and Methodology

The REAL-LU study is a multicentre, long-term observational study conducted across 21 sites in Italy. It enrols patients with unresectable or metastatic GEP-NETs who have progressed on standard therapies. The study’s design is robust, with a comprehensive data collection approach that includes baseline characteristics, treatment details, and follow-up assessments. The inclusion of 161 evaluable patients provides a substantial sample size to derive meaningful insights.

However, observational studies inherently carry certain limitations, such as potential selection bias and the lack of a control group. These factors can impact the generalisability of the findings. Additionally, the study’s reliance on routine clinical visits for data collection may lead to variability in the quality and completeness of the data.

Baseline Characteristics and Interim Results

The interim analysis presents detailed baseline characteristics of the enrolled patients. The mean age was 64.7 years, with a high proportion (83.9%) having liver metastases and most patients (90.7%) presenting with stage IV disease. This demographic profile aligns closely with that of the NETTER-1 trial, although the REAL-LU cohort includes a higher proportion of patients with grade 2 tumours.

The findings indicate that [177Lu]-DOTATATE is primarily used as a second-line therapy (61.6%) and post-surgery (58.4%). HRQoL assessments revealed high levels of functioning and low levels of symptoms at baseline, with 50% of patients being symptom-free. These results suggest that the patient population in the REAL-LU study is well-matched to those in previous clinical trials, enhancing the relevance of the findings.

Discussion and Implications

The REAL-LU study provides valuable insights into the real-world application of [177Lu]-DOTATATE for GEP-NETs in Italy. The similarity in patient profiles between the REAL-LU and NETTER-1 studies suggests that the efficacy and safety observed in clinical trials may be replicable in routine practice. The inclusion of a higher proportion of grade 2 tumours in the REAL-LU study is noteworthy, as it may provide additional insights into the treatment’s effectiveness across different tumour grades.

One of the key strengths of the REAL-LU study is its focus on real-world data, which complements the controlled environment of clinical trials. This approach can provide a more comprehensive understanding of how treatments perform in diverse patient populations and settings. The study’s long-term follow-up will also offer insights into the durability of treatment benefits and potential late-onset side effects.

However, the study’s observational nature also presents challenges. The potential for selection bias and incomplete data collection must be carefully managed. The study’s findings will need to be interpreted in the context of these limitations, and further research may be required to confirm the results.


The REAL-LU study is a significant contribution to the field of nuclear medicine and the treatment of GEP-NETs. Focusing on real-world data addresses a critical gap in the literature and provides valuable insights into the effectiveness and safety of Lutetium-177 DOTATATE GEP-NETs in routine clinical practice. The preliminary findings are promising and suggest that the treatment’s benefits observed in clinical trials may extend to broader patient populations.

Further analysis of effectiveness, safety, and HRQoL outcomes will be essential as the study progresses. The identification of prognostic factors could also enhance patient selection and treatment optimization. Overall, the REAL-LU study represents an important step towards improving the management of GEP-NETs and advancing the use of peptide receptor radionuclide therapy in oncology.


Lastoria, S., Rodari, M., Sansovini, M. et al. Lutetium [177Lu]-DOTA-TATE in gastroenteropancreatic-neuroendocrine tumours: rationale, design and baseline characteristics of the Italian prospective observational (REAL-LU) study. Eur J Nucl Med Mol Imaging (2024).

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