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Lower Gastrointestinal NET
Clinical case
One patient and how many doctors ?
Dimitrios Dimitroulopoulos MD, PhD
Consultant
Gastroenterology Dpt.
“Agios Savvas” Cancer Hospital of Athens
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.
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.
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).
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.
Initial therapeutic approach
2009
Administration 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).
Nuclear medicine treatment continue…
2010
90Y-DOTATOC
• MRI scans reported progressive metastatic liver disease.
• The attendant (surgeon) decided a new nuclear medicine treatment with 90YDOTATOC.
• The patient underwent three cycles with 90Y-DOTATOC administration in the state
cancer hospital of Salonika.
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.
Nuclear medicine treatment continue…
2012
90Y-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.
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.
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
... and now
what ?
(…and how many doctors ?)