Lower Gastrointestinal NET C linical case One patient and how many doctors ?

1. NET Masterclass Lower Gastrointestinal NETClinical caseOne patient andhow many doctors? Dimitrios Dimitroulopoulos MD, PhD Consultant Gastroenterology Dpt. “AgiosSavvas” Cancer Hospital of Athens

2. The first contact2007The family doctor • Female,50 years old, without previous history of serious illness and without family history of cancer, underwent some routine blood tests and radiology examinations ordered by their GP, due to thoracic pain. • CT scans revealed focal liver lesions and a wall thickness in the lower sigmoid colon area.

3. Diagnosis2008The initial hospital contact • Hospitalization in Athens hospital for further investigation. • Endoscopic examination of the lower digestive tract revealed at 35 cm from the anal canal a large lesion. • Pathology report : Neuroendocrine tumor of colon. • NO treatment decision.

4. Searching for a “solution”2008Visiting several surgeons • The patient was consulted by three surgeons in different private hospitals. • Two of them proposed surgery and chemotherapy and the third surgery and chemoembolization for the focal liver lesions, and if this was not adequate, RF. • The patient in this period was without symptoms and in good performance status. • CEA 14.9 ng/ml (UNL 7,00).

5. Searching for a “solution”2009Visiting a surgeon in a cancer hospital • The patient was consulted by a surgeon in a cancer hospital of Athens. • Patient’s decision : “This is the perfect doctor for me”. • Doctor’s decision : Due to good performance status and the “fear of massive intraoperative hemorrhage during the operation” the doctor decided re-staging • Hospitalization in surgery department . • Imaging and laboratory tests focused to the disease (hormones, somatostatine receptors scintigraphyetc) • Octreoscan revealed intraperitoneal metastatic lymph nodes.

6. Initial therapeutic approach2009Administration of radiolabeled In111 • Four doses of Octreoscan In-111 80mCi (09/2009 – 02/2010) were administered. • Three months later, control examinations reported “stability and maybe a small remission of the disease” (according to the report of the responsible nuclear medicine doctor).

7. Nuclear medicine treatment continue…201090Y-DOTATOC • MRI scans reported progressive metastatic liver disease. • The attendant (surgeon) decided a new nuclear medicine treatment with 90Y-DOTATOC. • The patient underwent three cycles with 90Y-DOTATOC administration in the state cancer hospital of Salonika.

8. Nuclear medicine treatment continue…2010 - 2012 • Dead of attendant doctor. • The follow up and the management is made now by the gastroenterology Dpt. of the state cancer hospital of Salonika. • Re-staging : Stable disease. • No other therapeutic approach.

9. Nuclear medicine treatment continue…201290Y-DOTATOC • CT and MRI scans revealed progression of the disease in the liver. • The patient decided to entrust herself to another doctor • Decision for re-treatment with 90Y-DOTATOC (3 cycles). • Six months after, stable disease.

10. Administration of somatostatin analogue2013 • JAN 2013 : Administration of a somatostatin analogue (every 28 days). • APR 2013 : According to a new Octreoscan report “the patient present’s significant scintigraphic improvement in comparison with an examination of JUL 2013”. Laboratory, imaging and endoscopic examination without any changes. • CEA 8,6 (UNL 4,7 ng/ml). • Good performance status.

11. Progression2014 • MAR 2014 : Loss of weight (12 Kg in 4 months). • Laboratory examinations : Diabetes mellitus, CEA 52,1 ng/ml (UNL 4,7), NSE 89 ng/ml (UNL 16,3), ALP 400 U/l, γ-GT 187, LDH 310. • Imaging examinations : Disease progression. • Octreoscan and endoscopy pending

12. ... and now what? (…and how many doctors ?)