1. Use the following CASE to answer questions 1 through 9.
SS is a 66-year-old African American male from rural Ohio with a 6-month history of red skin and periodic diarrhea. He reports feeling like he has a "fever," and he has also been complaining of severe abdominal pain. He reports a life-long battle with alcohol abuse and a family history of liver carcinoma (mother). He is not married and has no children.

Based on current population data, which characteristic of SS's history is the most significant risk factor for developing gastroenteropancreatic neuroendocrine tumors (GEP-NETs)?

2. A full work-up is requested to better understand SS's symptoms, and initial imaging and lab work is requested. Considering SS's presentation, what would be the initial imaging modality requested if assessment of the full pancreas with tissue contrast imaging is required?

3. Considering SS's presentation, what is the most sensitive lab test to consider for assessing the diffuse hormonal symptoms (e.g., flushing, diarrhea) indicative of carcinoid syndrome (CS)?

4. Upon review of SS's initial presentation and with knowledge of the pending tests, the medical team decides to do initial genetic testing to rule out other possible causes of his symptoms. Which biomarker is being studied for pancreatic involvement of GEP-NETS?

5. Based on SS's symptoms, positive PAX8 test, and high 5-HIAA level, the medical team is concerned about the potential oncologic picture. The MRI shows 3 nodular-appearing lesions on the body of the stomach. Biopsy is completed: The hematoxylin and eosin (H&E) stain reveals an organoid pattern and it is difficult to find mitotic activity. The pathology report reveals the lesions have a Ki-67 level of 3% and a mitotic index of 4/10 HPF. SS's diagnosis aligns with which World Health Organization (WHO) neuroendocrine tumor classification?

6. Which treatment option will offer SS the best overall survival?

7. In SS's case, CS would be considered according to the functional appearance of the neoplasm prior to surgery for tumor resection. What would be the appropriate dose of a somatostatin analog?

8. Two years after complete resection, SS presents to clinic with flushing and hypertension. MRI reveals additional tumor burden. Which therapy would you recommend for SS at this point in his GEP-NET management?

9. When preparing for SS's therapy selection, you notice that he is reporting income less than $14,000 annually. (The 2019 United States Federal Poverty Guidelines gross annual income for a family size of 1 is $12,490.) The manufacturer's income requirement for the assistance program for the selected therapy is a gross annual income less than 125% of the 2019 Federal Poverty Guidelines. With this in mind, medication provided by the manufacturer at a discounted cost or no cost to the patient is commonly referred to by what acronym?

10. Use the following CASE to answer question 10.
HT is a 56-year-old female with G2 gastroenteropancreatic neuroendocrine tumors (GEP-NETs) with new liver metastases on the most recent restaging evaluation. The interdisciplinary team opts to initiate everolimus and would like someone to provide education to HT regarding side effects and the importance of taking each dose. It is clear that HT needs financial assistance with the product and that she has insurance questions due to the requirement to use a specialty pharmacy to receive her medications.

Which medical professional is most suited to offer these services to HT?

« Return to Activity