1. Unit of Gastrenterology Unit of Endocrinology THEAGENIO Hospital, Thessaloniki Metastatic neuroendocrine tumor of the jejunum-ileum

2. 54 year old male with symptoms of weight loss abdominal pain Past medical history: colitis? for the last 3 years No family history of note History

3. Biochemistry-Radiology Mildly raised LFT’s Abdominal computed tomography (CT) 3 cm mesenteric mass and liver lesion in segment IV

4. Surgical treatment (1) The patient was referred for surgical treatment and underwent (4/2008) laparotomy in which a 4 cm segment of small bowel was excised along with 2 para-aortic lymph nodes

5. Histology Carcinoid tumor of the small bowel, diameter 1.2 cm, invasive of all intestinal wall, with +2/2 lymph nodes (+) CgA, NSE Ki-67< 2% < 2 mitoses/10HPF G1 The patient was referred to the Gastroenterology Unit

6. Clinical examination-Initial assessment Weight: 55 kg, ΒΜΙ: 17 kg/m 2 BP 110/70 mm Hg Clinical examination: nil of note No symptoms of carcinoid syndrome CgA : 230 nmol/l (<4), 24-h urine 5 HIIA: 1 mg (<8) Heart echo- : normal Οctreoscan: normal distribution

7. Medical treatment Somatostatin analogues Chemotherapy (SZT + 5FU) from 6/2008 (5 cycles)

8. Reassesment Abdominal CT (12/2008) Multiple liver metastatic lesions 1-4 cm and a 4 cm mass in front of aorta Platinum based chemotherapy started 1/2009 (6 cycles) Somatostatin analogues continued During 2009 the disease remained radiologically stable, although CgA rose to 900 nmol/l

9. Initiation of mTOR inhibitors (2010) From January 2010 and for 16 months the patient was treated with Everolimus 10 mg daily Abdominal CT: Improvement of the large liver lesion by 20% CgA substantially reduced to 250 nmol/l The patient opted to stop treatment in May 2011

10. Οctreoscan (5/2011) Uptake in some liver mets and abdomen

11. At the beginning of 2012… The patient was admitted at the hospital with severe epigastric pain and vomiting Βarium follow-through Gastroscopy Stenosis of the 2nd part of duodenum

12. Abdominal CT (2/2012)

14. (Ki-67 40% from the hepatic metastasis) Surgical treatment (2) Gastro-entero-anastomosis (3/2012) Liver biopsy

15. 11 months later: The patient was admitted again with symptoms of ileus Cachexia, anemia, low albumin, increased PT Dysfunction of the gastro-entero-anastomosis

16. Surgical treatment (3) To the operating room for the 3 rd time (3/2013) A month later the patient succumbed to his disease

17. In summary This was a patient with midgut NET who developed LN, hepatic and mesenteric metastases, received treatment with Surgery (x 3) Somatostatin analogues Chemotherapy M-TOR inhibitors and died 5 years after the initial diagnosis

18. Points for discussion Extent of initial surgical treatment (extensive vs conservative) Repeated surgery (palliative) Use of chemotherapy Alternative therapeutic approaches