![]() 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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