Date:
Patient:
Reason for Visit:
Initial evaluation for suspected small bowel NET
Follow-up for established small bowel NET
Assessment of treatment response or disease progression
Management plan discussion
History:
Presenting Illness: (For initial evaluation)
Onset and duration of symptoms (abdominal pain, diarrhea, flushing, wheezing – if carcinoid syndrome), weight loss
Presence of any hormone-related symptoms (e.g., diarrhea, flushing, skin rash) suggestive of carcinoid syndrome
Risk factors (e.g., family history of MEN 1 syndrome)
Past Medical History (PMH):
Comorbid conditions (e.g., diabetes, heart disease)
Previous surgeries or procedures (relevant to GI tract)
Medications (including medications for potential carcinoid syndrome)
Social History:
Smoking history
Alcohol use
Family history of cancer (especially GI cancers or MEN 1 syndrome)
Physical Exam:
General: Assess vital signs (temperature, heart rate, blood pressure, weight loss).
Abdominal: Evaluate for abdominal distention, tenderness, masses.
Skin: Look for signs of flushing or rashes suggestive of carcinoid syndrome.
Diagnostic Tests (may be ordered depending on clinical suspicion):
Laboratory Tests:
Complete blood count (CBC) – may show anemia
Chromogranin A (CgA) and urine 5-HIAA levels – elevated levels suggestive of NETs, but not specific for diagnosis.
Other hormone tests (depending on suspected hormone production) – e.g., gastrin, serotonin
Liver function tests (LFTs) – may be abnormal with advanced disease
Imaging Studies:
Abdominal CT scan with enteric contrast – most common imaging modality for diagnosis and localization.
MRI scan (may be used in some cases)
Octreotide scan (may be helpful for identifying well-differentiated NETs)
PET scan (may be used for staging or evaluating for recurrence)
Endoscopy (may be performed):
Upper endoscopy (esophagogastroduodenoscopy, EGD) or colonoscopy – to visualize the upper and lower GI tract and potentially obtain tissue samples.
Capsule endoscopy – for visualizing the entire small intestine if other modalities are inconclusive.
Biopsy: Tissue sample obtained during endoscopy, surgery, or percutaneous needle biopsy for definitive diagnosis.
Assessment:
Clinical suspicion of small bowel NET: Based on history, physical exam findings, and initial laboratory tests.
Confirmation of diagnosis: Requires histopathological examination of a biopsy specimen, including grading (well-differentiated, poorly differentiated) and assessment of hormone production.
Staging (if diagnosis confirmed): Determines the extent of cancer spread (localized, regional, or distant metastasis). Staging is crucial for treatment planning and prognosis.
Differential diagnosis: Consider other causes of small bowel symptoms (e.g., inflammatory bowel disease, carcinoid syndrome from other sources).
Plan:
Treatment approach depends on several factors:
Stage and grade of the tumor
Patient’s overall health and performance status
Presence of carcinoid syndrome symptoms
Surgical options:
Surgical resection (primary treatment for localized disease) with removal of the affected portion of the small intestine and possibly involved lymph nodes.
Cytoreductive surgery with or without HIPEC (heated intraperitoneal chemotherapy) may be considered for advanced disease with extensive peritoneal involvement.
Other treatment modalities:
Somatostatin analogs (octreotide, lanreotide) to control hormone-related symptoms and potentially slow tumor growth.
Targeted therapies (e.g., everolimus) for advanced, progressive NETs.
Liver-directed therapies (e.g., embolization, ablation) for controlling liver metastases.
Palliative care (to manage symptoms and improve quality of life in advanced stages)
Nutritional support: May be needed before, during, and after treatment to address malnutrition or weight loss.
Follow-up (if diagnosis confirmed):
Regular follow-up appointments to monitor for recurrence and manage any side effects of treatment.
Imaging studies (CT scans) and hormone level monitoring to assess for disease progression.
Additional treatment decisions based on follow-up findings.
Patient education: Provide information about small bowel NETs, their diagnosis, treatment options, and potential side effects.