![]() ![]() And ideally, especially with the high-grade tumors, you would want the pathologist to also comment on differentiation. Strosberg, MD: Mitotic rate and Ki 67 should be measured in all patients, leading to tumor grade that is low, intermediate, and high. Strosberg, MD: These days, a pathology report that says simply neuroendocrine tumor or carcinoid tumor is inadequate. When you see a pathology report, what are those key features that you look for to make a neuroendocrine diagnosis and to start planning treatment? What do you look for? There are a lot of features on the pathology. One thing I do want to mention is the importance of pathology and having a good pathological impact, in terms of when we do diagnose a NET. I think it can cause a lot of anxiety, not only for clinicians but for patients as well. So I think we have to be very cautious about using chromogranin A as a diagnostic tool. I do think we need to realize that there are a lot of reasons for false elevation of chromogranin A-things like proton pump inhibitor use, hypertension, a lot of other medications, and even diet. Simron Singh, MD: I think chromogranin A is probably the best biomarker that we have right now. There’s a lot of controversy about nonspecific tumor markers like chromogranin. Recognizing the important hormonal syndrome is an important part of the work-up. Patients with pancreatic neuroendocrine tumors can present with symptoms such as heartburn, diarrhea, hypoglycemia, and weight loss. For example, in patients with diarrhea and flushing, you should obtain a urine 5-HIAA, or serum serotonin, or even a blood 5-HIAA. So the gallium 68 DOTATATE scan has really become an important part of the initial patient work-up.Īnd then, of course, it is important to recognize hormonal syndromes and order the appropriate hormonal tests. It often has the ability to detect a primary site. These days, gallium 68 DOTATATE has really improved the sensitivity and the resolution ability to detect small lesions. Somatostatin receptor imaging, of course, is an example. When it comes to working up patients, once you’ve established the pathological diagnosis of a NET, there are certain things that are unique to neuroendocrine tumors. You can see them in retrospect, but they’re often missed, leading to a delay in diagnosis. Either the CT scans are not done or the mesenteric masses are not recognized. One thing we see quite frequently is patients with small-bowel NETs with mesenteric disease presenting with recurrent bowel obstructions year after year. Often the symptoms are just not specific enough. So I think something we need to work on is improving the diagnosis. Unfortunately, we probably miss the diagnosis, as a community, quite a bit, and that leads to a delayed diagnosis. The number of patients who present with what we are classically taught in medical school to be carcinoid syndrome-the flushing, wheezing, bronchospasm-is actually a minority. ![]() Most patients present with things like bloating or abdominal pain. Not only is this due to the uncommon nature, but most of the symptoms are nonspecific. Simron Singh, MD: Jon, as you know, the diagnosis of NETs is challenging. Strosberg, MD: Simron, can you talk a little about what kinds of symptoms patients sometimes present with? And what are the unique challenges of working up patients with NETs ? ![]()
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