I began my fellowship at The University of Tennessee Health Science Center in Memphis in 2008 with the goal of pursuing an academic career. Like many first year fellows, I found myself trying to learn the new language of hematology/oncology while trying to find my academic calling. 

Toward the end of my first year, my program director, Raymond U. Osarogiagbon, MBBS, asked if I would be interested in writing an investigator initiated phase 2 clinical trial for a novel agent to be studied in non–small cell lung cancer. Of course, I jumped at the chance. After many revisions, the trial was ready to submit for approval.  

While writing a trial protocol, one must become an expert in the topic of the trial. Our research ended up not being funded because the drug was found not to be effective in other trials, but this led to my interest in lung cancer and I soon joined Dr. Osarogiagbon, who had since become my mentor, on his thoracic research team.

I’d found my calling—my “orange,” if you will. 

We stayed very busy. We met regularly with formal sessions that went well past dinnertime and held many impromptu gatherings during the day. All that hard work resulted in multiple abstracts and presentations at the American Society of Clinical Oncology Annual Meeting and the World Conference on Lung Cancer (WCLC). We submitted several manuscripts that ended up being published. By my third year, I had a dedicated continuity clinic seeing just patients with lung cancer and we had 11 abstracts presented at the WCLC. I was well on my way to becoming an academic thoracic oncologist.

During this time I met my wife, who was a physician doing her residency in internal medicine. She wanted to pursue a hematology/oncology fellowship and ended up matching at Tulane University in New Orleans, Louisiana. At the time, I was finishing my fellowship and had decided to stay on for a year to continue doing research but started searching for academic positions in New Orleans. My search led me to interview at Louisiana State University (LSU) Health Sciences Center where the program was still rebuilding after Hurricane Katrina but was ripe with opportunity. I did the required presentation for an academic job and discussed all the highlights of the thoracic research team I was leaving and what I could bring to LSU. I told them I was excited to join their team as a thoracic oncologist.

Their response was deflating: “We don’t need a thoracic oncologist. We need a neuroendocrine oncologist.”

I had read about neuroendocrine tumors (NETs) during fellowship but saw those diseases only a few times—usually on the boards and the treatment answer was always “octreotide.” We had a few patients on octreotide (Sandostatin LAR) and it seemed to be enough. How could someone, especially me, dedicate an entire practice to NETs? Could I switch from enjoying oranges and learn to enjoy this lemon?

The LSU group had a well-known NET team in collaboration with its community partner, Ochsner Health, which is known as the New Orleans Louisiana Neuroendocrine Tumor Specialists (NOLANETS). They attracted patients from throughout the United States and internationally. They were also quite productive from a research standpoint and well known among their peers in the handful of NET programs throughout the world.

One of the founding members of the group had left about a year prior and they were looking for a permanent replacement. They offered me the position and I accepted.

It turns out that NETs are not that uncommon. Although they still account for less than 1% of malignancies, the incidence is rising.

 The other factor that interested me was that about 25% of the carcinoid tumors originate in the lung, even though they account for only 2% of lung cancers.

My partners were more interested in gastrointestinal and pancreatic NETs—lung NETs would be my area to own. I learned as much as I could before I started and continued learning from my patients, partners, and peers every day. It was not long before I became immersed in the NET community. I was soon presenting research, publishing, and becoming involved in the North American Neuroendocrine Tumor Society, where I have since served on several committees. I have established research collaborations with many physicians around the country and have developed lifelong friendships with others in this small NET community.

I was with the NOLANETS team for almost 9 years before moving to Vanderbilt University Medical Center in Nashville, Tennessee, in 2021, where I am helping expand an established NET program. I am focusing more on general thoracic oncology but also thoracic NETs and continue to educate and mentor the next generation of NET oncologists. As a bonus, I am again working with Dr Osarogiagbon, who is director of the multidisciplinary thoracic oncology program at Baptist Cancer Center in Memphis and a research professor here at Vanderbilt.

I learned to want oranges during my fellowship. I studied hard and planned to make oranges my career. But life handed me lemons—and, it turns out, lemons are not so bad.

Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. 

. 2017;3(10):1335-1342. doi:10.1001/jamaoncol.2017.0589

Ramirez RA, Chauhan A, Gimenez J, Thomas KEH, Kokodis I, Voros BA. Management of pulmonary neuroendocrine tumors. 

. 2017;18(4):433-442. doi:10.1007/s11154-017-9429-9

Articles

Robert Ramirez, DO, FACP, details his path to clinical thoracic oncology after originally planning on entering the academic field early in his career.

Loving Lemons Even When You Wanted Oranges

Robert Ramirez, DO, FACP, Ochsner Medical Center, discusses treating patients with neuroendocrine tumors (NETs) of the lung.

Somatostatin analogs are an option for the treatment of patients with lung NETs, as there is retrospective data in the lung space that indicate they may be beneficial for these patients. Ramirez suggests that clinicians put their patients with lung NETs on clinical trials with somatostatin analogs.

One of these clinical trials is the SPINET trial, which is aiming to answer the question of the role of somatostatin analogs in NETs of the lung. Somatostatin analogs have previously shown benefit in NETs of the gastrointestinal tract and pancreas, but there is no definitive data on their impact in the lung. SPINET, which started in February 2016, is planned for an enrollment of 216 patients and is estimated to be completed by August 2019. To be eligible for enrollment, patients with a typical carcinoid tumor must have a mitotic index of <2 mitoses/2 mm2 and patients with an atypical carcinoid must have <10 mitoses/2 mm2 and/or foci of necrosis.

Additionally, there are data that suggests that the mTOR inhibitors everolimus (Afinitor) prolongs progression-free survival in patients with NETs of the lung. There are also emerging data that suggest peptide receptor radionuclide therapy (PRRT) is beneficial in lung NETs, and that liver-directed therapy and cytoreduction may have a role in treatment as well.

Videos

Robert Ramirez, DO, FACP, Ochsner Medical Center, discusses treating patients with neuroendocrine tumors (NETs) of the lung.
 

Robert Ramirez, DO, FACP

Articles

Loving Lemons Even When You Wanted Oranges

Dr. Ramirez Discusses Treating Patients With NETs of the Lung