1. Lower Gastrointestinal NET Clinical case One patient and how many doctors ? Dimitrios Dimitroulopoulos MD, PhD Consultant Gastroenterology Dpt. “Agios Savvas” Cancer Hospital of Athens NET Masterclass

2. The first contact 2007 The 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. Diagnosis 2008 The 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” 2008 Visiting 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” 2009 Visiting 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 scintigraphy etc) Octreoscan revealed intraperitoneal metastatic lymph nodes.

6. Initial therapeutic approach 2009 Administration of radiolabeled In 111 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… 2010 90 Y-DOTATOC MRI scans reported progressive metastatic liver disease. The attendant (surgeon) decided a new nuclear medicine treatment with 90 Y- DOTATOC. The patient underwent three cycles with 90 Y-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… 2012 90 Y-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 90 Y-DOTATOC (3 cycles). Six months after, stable disease.

10. Administration of somatostatin analogue 2013 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. Progression 2014 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 ?)