A comprehensive strategy for the diagnosis and treatment of neuroendocrine tumors, and the advantages of multiple disciplines complement each other to overcome diagnostic problems!

*Only for medical professionals to read and refer to the diagnosis, classification and treatment principles of neuroendocrine tumors, a detailed explanation! Neuroendocrine tumors (NEN) are a special group of heterogeneous tumors, and their clinical manifestations and malignant degrees are also different due to different locations
.

NEN originates from neuroendocrine cells, and neuroendocrine cells are distributed throughout the body, so NEN can occur anywhere in the body, but the most common is the digestive system NEN such as the stomach, intestines, and pancreas
.

In order to clarify the diagnosis, classification and treatment principles of NEN, the "medical community" invites Professor Xu Jianming, Director of the Department of Digestive Oncology, the Fifth Medical Center of the PLA General Hospital, Professor Li Jie, Director of the Department of Oncology, Peking University Cancer Hospital, and Department of Oncology, Jiangsu Cancer Hospital Professor Sun Xiaofeng, Director, Professor Sun Yu, Director of the Department of Pathology, Peking University Cancer Hospital, and Professor Yu Jiangyuan from the Department of Nuclear Medicine, Peking University Cancer Hospital, discussed NEN related issues
.

The onset of NEN has various symptoms and is easy to be missed.
Imaging + pathology breaks the diagnosis problem.
The clinical symptoms of NEN are atypical and the clinical features are complex, so the diagnosis is also difficult.
At this time, the doctor's rich experience determines whether it can be targeted.
Carry out the corresponding inspections accordingly
.

Professor Xu Jianming shared: “If the patient often has late-onset diarrhea, the possibility of NEN needs to be considered if the conventional treatment fails
.
The
patient often has high blood pressure.
After the essential hypertension is ruled out through routine examinations, It is necessary to consider the occurrence of NEN in the pancreas or a certain part
.

In addition, including hypoglycemia or hyperglycemia, the appearance of skin migratory erythema, etc.
, are relatively rare symptoms of NEN.
At this time, the accuracy of diagnosis depends on the doctor's knowledge of NEN.
Is it rich
?
If the doctor is aware of the disease, follow-up examinations will be smoother
.

In addition to conventional CT, NMR, B-ultrasound, and gastrointestinal endoscopy, whole-body radionuclide scans are also required, such as F18-FDG PET/CT or Ga68-PET/CT, but in the end, a'gold standard' pathological biopsy is needed for further Confirmed
.

In fact, no matter at home or abroad, many patients often have reached stage IV after showing obvious symptoms
.

In addition, the pathological classification of NEN is relatively complicated.
With the vigorous popularization of science and education in China in recent years, most pathology departments of hospitals above the tertiary level have a clear understanding of the classification and differentiation of NEN.
Reports are becoming more and more standardized
.

In general, NEN is generally divided into three types, G1, G2, and G3
.
There will be some differences in the actual treatment of these three types of patients .

"Professor Sun Xiaofeng mentioned: "The heterogeneity of NEN makes early diagnosis more difficult.
For tumors with carcinoid syndrome, about 40% of patients will have some hormone secretion problems, which can lead to intractable hypertension.
, Stubborn digestive ulcers, hypoglycemia, hyperglycemia, etc.
These situations require attention
.

For most tumors without carcinoid syndrome, it is necessary to rely on some routine physical examinations to find these tumors, such as imaging examinations, including B-ultrasound and digestive endoscopy
.

If the patient has some symptoms of tumor compression or obstruction, more sophisticated examination methods can be selected at this time
.

For example, the NEN of the small intestine can be examined with advanced capsule endoscopy, or PET/CT, Ga68-PET/CT, through these examinations, NEN can be detected early, and early detection can help determine how to treat it.
In addition, the'gold standard' for NEN diagnosis is still a pathological examination
.

"NEN system diagnosis and treatment still needs individualized and dynamic evaluation.
Professor Li Jie shared: "Some patients feel that their biological behavior is better at the beginning and the tumor grows more slowly during the treatment process, but they will find that in the course of the disease.
The malignancy and biological behavior of tumors are also changing
.

There are some patients whose tumors will grow faster and faster.
Clinically, they will also encounter relatively low Ki-67 index at the beginning, but the progress of liver metastasis or progress in other parts occurs during the course of treatment.
When pathological biopsy is performed, it is found The Ki-67 index is also changing, and even the expression profile of genetic testing has also changed
.

Of course, this type of population is relatively small, but this also means that with this systemic treatment, there are dynamic changes in evaluation as the condition changes
.

At the same time, the specific conditions of the patient, such as age, physical condition, tumor location, and symptoms caused by the tumor, should be taken into consideration before formulating a treatment plan
.

"How to distinguish between NEC and NET? A comprehensive understanding to avoid misdiagnosis! Professor Sun Yu said: "NEN is very heterogeneous, including better differentiated neuroendocrine tumors (NET), and poorly differentiated neuroendocrine carcinoma (NEC).
)
.

Therefore, there are many difficulties in pathological diagnosis.
The most important and prominent difficulty is the differential diagnosis of G3 NET and NEC
.

NEC and NET have different treatment modes.
The biological behavior of tumors is completely different, and the process of occurrence and development is also different
.

Therefore, accurate pathological diagnosis is very important
.

The second difficulty is that with the improvement of the understanding of this type of tumor, pathologists have paid more attention to this type of tumor in the past ten years.
Therefore, when the morphological characteristics of this aspect appear, they will further detect neuroendocrine markers
.

After the positive result of the marker is detected, some non-NEN patients are often misdiagnosed as NEN, which greatly misleads the choice of later treatment
.

Therefore, to avoid misdiagnosis and misdiagnosis, to a certain extent, pathologists need to have a very comprehensive understanding and understanding of NEN tumors
.

Diagnosis should not only pay attention to the morphology, but also the biological characteristics.
It is necessary to comprehensively judge the patient's medical history, the entire diagnosis and treatment process, and the changes in molecular markers during the development of the disease, and make an accurate diagnosis to provide later treatment.
Basis
.

"In view of the pathological classification of NEN and the characteristics of different types of tumors, Professor Sun Yu shared: "NET, NEC, and mixed NEN, how to observe and distinguish the characteristics of these three types of NEN? The well-differentiated NET has better biological behavior, and the morphological characteristics observed pathologically are characterized by the characteristic organ-like arrangement, and the size and morphology of tumor cells are highly consistent
.

Differentiated tumor cells have many similarities with normal tissues in their biological behavior
.

The poorly differentiated NEC is observed under the microscope, in other words, to look at its appearance
.
If the tumor cells are too ugly, it is the performance of NEC .

Secondly, the general shape can be observed.
For example, the general shape of NET is often a polyp with a small gastrointestinal volume, but the gastrointestinal area of ​​NEC will form a larger ulcerative change
.

The mixed NEN may have a variety of mixtures, including NET, adenocarcinoma, and squamous cell carcinoma
.

All in all, the types of NEN are complex and need to be fully understood
.

"Ki-67+ functional imaging, complementary advantages, precise guidance of NEN diagnosis and treatment, Professor Yu Jiang Yuan said: "Functional imaging, molecular imaging and pathology are closely related, pathology has an index that is very important in tumors-Ki-67 index, exponential High and low determine the grade and degree of differentiation, prognosis and treatment options of the tumor
.

Pathological examination also has limitations, it does not represent the full picture of the tumor
.

As the disease progresses, there is also heterogeneity between lesions, so pathological examination alone cannot fully reflect the overall biological information of the tumor
.

Functional imaging is hoped to be an effective supplement to pathological biopsy, reflecting the degree of tumor differentiation
.

Somatostatin receptor imaging and Ki-67 index are negatively correlated.
The better the differentiation of tumors, the higher the positive rate of somatostatin receptor imaging and the higher the uptake value
.

FDG imaging is positively correlated with Ki-67 index.
The more poorly differentiated and malignant tumors, the higher the metabolic value of FDG
.

Therefore, one is from the degree of expression of somatostatin receptor, and the other is from the degree of FDG metabolism, dual imaging, bidirectional assessment of the biological characteristics of the whole body, can be used as a useful supplement for pathological grading and prognosis
.

In addition, we can use somatostatin receptor type II immunohistochemistry to reflect the expression level of the receptor from the histological level
.

There is a good correlation between nuclear medicine and pathology, and there is also a correlation between nuclear medicine and immunohistochemistry.
In turn, immunohistochemistry will also optimize the application of imaging, complement each other's advantages, and play a role in predicting and controlling clinical treatment.
Guiding significance
.

"Expert Profile Professor Jianming Xu, Director of the Department of Digestive Oncology, First Medical Center, PLA General Hospital, Professor, Ph.
D.
Supervisor, Deputy Chairman, Chinese Biomedical Engineering Association, Committee on Molecular Targeted Drug Therapy, Chinese Research Hospitals, Vice Chairman, Chinese Research Hospital Oncology Committee, China Professor Sun Xiaofeng, Member of the Standing Committee of the Gastrointestinal Pancreatic Neuroendocrine Tumor Professional Committee of the Clinical Oncology Society, Chief Physician, Department of Oncology, Jiangsu Cancer Hospital Member of the Academic Steering Committee of the Chinese Anti-Cancer Association Rehabilitation Association Member of the Oncology Professional Committee of the Chinese Medical Doctor Association Member of the Chinese Medical Doctor Association Gastrointestinal Stromal Tumor Member of the Professional Committee Member of the Gastrointestinal Stromal Tumor Professional Committee of the Chinese Anti-Cancer Association Member of the Academic Committee Member of the Pancreatic Disease Professional Committee of the Jiangsu Medical Association Professor Xiang Lijie, Chief Physician, Department of Digestive Oncology, Peking University Cancer Hospital, Member of the Executive Committee of the Geriatric Oncology Committee of the Chinese Society of Gerontology, Member of the Executive Committee of the Geriatric Oncology Committee of the Chinese Society of Gerontology, Member of the Gastrointestinal Subcommittee of the Chinese Society of Gerontology, Member of the Standing Committee of the Clinical Oncology Committee of the Chinese Association of Women Physicians, China Member of the Gastrointestinal Neuroendocrine Tumor Expert Committee of the Clinical Oncology Society Member of the Pancreatic Neuroendocrine Tumor Professional Committee of the Pancreatology Committee of the Chinese Medical Doctor Association Vice Chairman of the Medical Ethics Committee of the Chinese Anti-Cancer Association Member of the Beijing Medical Ethics Expert Committee, Shenzhen Member of the Biomedical Ethics Advisory Committee Member of the Medical Ethics Professional Committee of the Beijing Medical Association comprehensive medical treatment, particularly gastric cancer, colorectal cancer, pancreatic cancer, gastrointestinal stromal tumors, neuroendocrine tumors of gastrointestinal medical treatment
.

was a visiting scholar in the United States during the University of Pennsylvania Abramson cancer Center, and worked in Barcelona, Spain Receive short-term related professional training with UCLA in the United States
.

Professor Sun Yu, Chief Physician and Associate Professor of the Department of Pathology, Peking University Cancer Hospital, and Deputy Director of the Department of Pathology, a Master's Supervisor, Sub-specialty: Pathological diagnosis and research of gastric, hepatobiliary and pancreatic tumors, Beijing Cancer Prevention and Treatment Society, Vice Chairman, Gastric Cancer Prevention and Treatment Committee, Beijing Cancer Society Member of the Pathology Professional Committee Member of the Beijing Cancer Pathology Precision Diagnosis Research Association Member of the Basic and Pathology Group of the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association Member of the Gastrointestinal Cooperation Group of the Chinese Anti-Cancer Association Tumor Pathology Professional Committee Member, Standing Committee of the Youth Group of the Pancreatic Disease Branch of the China Association for the Promotion of International Health Care Professor Yuan, Peking University Cancer Hospital, Associate Chief Physician, Department of Nuclear Medicine, Peking University Cancer Hospital, visited JohnsHopkins Hospital for one year in 2017, and studied at Zentralklinik Bad BerkaPRRT Center in Germany in 2019.
The main research direction is multimodal neuroendocrine tumor imaging and radionuclide CSCO Nuclear Medicine Professional Committee Member, Clinical Committee Member, Chinese Women Physicians Association, Committee Member, Neuroendocrine Oncology Group, Pancreatic Cancer Professional Committee, China Anti-Cancer Association Scientific information provided by medical professionals does not represent the views of this platform