It is very important for patients with metastatic NETs, especially those with symptoms from significant tumor bulk and/or carcinoid syndrome, to be evaluated at high-volume centers that have expertise in the treatment of NETs. Multidisciplinary care is often needed for such patients, and it is quite beneficial for these individuals if each of the relevant disciplines has knowledge of NETs and the skills required to manage them.

Generally speaking, at our center, a medical oncologist will see the patient and review the history, antecedent workup, and findings. Gastroenterologists can, of course, be helpful in the assessment of gastroenteropancreatic NETs, of which the small bowel NETs are most commonly associated with carcinoid syndrome. And pathologists play a very important role as well, evaluating the morphology and classification, Ki-67 proliferative index, grading, and immunohistochemistry studies.

Expert radiological interpretation may come into play with deciphering some of the subtleties of the somatostatin receptor positron emission tomography/computed tomography (CT) imaging or ensuring that, when CT scans are done, hepatic, biphasic, contrast-enhanced CTs are used to highlight the NET liver metastases, which are often very subtle or are not at all clear on standard venous-enhanced CT scans. And nuclear medicine physicians with experience in peptide receptor radionuclide therapy can provide insights on both the pros and cons of this treatment, in view of the individual patient and their particular pattern, extent of disease, and organ involvement.

Likewise, I would say that patient care benefits from surgeons who not only have the ability to perform complicated surgeries but also have a good understanding of this unique disease and ample experience with performing the liver debulking surgeries that might be indicated, some of which can be especially complicated. The same is true for interventional radiology. Additionally, the surgery that is involved in repairing or replacing heart valves in the setting of carcinoid heart disease is also potentially difficult, and the referral to expert tertiary care centers with high-volume experience in carcinoid heart disease is often indicated. Anesthesia teams should have significant expertise in handling carcinoid crisis and other difficulties that can occur when some degree of right ventricular dysfunction is present.

I think that the ability to have evaluations from people across all of these specialties—as indicated, depending on the individual's disease features, manifestations, and comorbidities—all of whom have a lot of experience with this unique disease, is very beneficial for the patient with NETs.