Coordinating the Timing of Interventions in NETs

Simron Singh, MD, MPH, of Sunnybrook Odette Cancer Centre, explains how a multidisciplinary team sequences surgery, interventional radiology, nuclear medicine, and systemic therapy for patients with neuroendocrine tumors (NETs), in conversation with moderator Daniel M. Halperin, MD, of Winship Cancer Institute of Emory University. Timing depends on whether the tumor produces hormones, which may move localized ablative therapy earlier, and on disease biology, which dictates how aggressive treatment needs to be. He illustrates the process with a recent patient who had a small bowel NET with widespread metastases, high serotonin levels, and cardiac valve damage. Although surgeons felt they could debulk the disease, the team decided to replace the valves first because her cardiac situation was too precarious. Medical oncology then controlled her hormones medically as a bridge until definitive liver-directed therapy, likely a combination of surgery and embolization, became feasible. Halperin notes that this debate recurs constantly and depends on everyone being on the same page.