Sandbox:Hannan1

Neuroendocrine tumor		Clinical manifestations		Dianosis						Gold standard	Other features
		Symptoms	Signs	Blood & Urine	Gross	Histology	Immunohistochemistry	Imaging	Others
Medullary thyroid carcinoma		Dysphagia Hoarseness Respiratory difficulty Flushing Diarrhea Weight loss	Palpable neck mass Signs of Cushing syndrome	↑ Calcitonin ↑ Serum calcium ↑ or - Cortisol ↑ CEA level	White or gray in color Firm to palpation	Nests of uniform cells Deposition of stromal amyloid Granular chromatin C-cell hyperplasia	Calcitonin Chromogranin A Carcinoembryonic antigen (CEA)	Solid thyroid nodule (US) CT scan/MRI and PET scan for metastatis	Genetic testing	FNA cytology with immunohisto- chemistry and calcitonin levels	Associated with MEN 2A and 2B Familial association with RET mutations May present as Cushing syndrome
Pheochromocytoma		Headaches Palpitations Excessive sweating Anxiety Pallor Pain in chest/abdomen Weakness, fatigue Nausea/vomiting Dizziness Paresthesias Constipation (rarely diarrhea) Visual disturbance	Hypertension Postural hypotension Tachycardia or reflex bradycardia Tremulousness Pallor Flushing (rare) Weight loss Fasting hyperglycaemia Decreased GI motility Pallor ↑ Respiratory rate Psychosis	↑ Plasma and urine catecholamines ↑ Plasma and urine metanephrines ↑ Chromogranin A ↑ Plasma methoxytyramine	N/A	Loosely cohesive clusters Scattered tumor cells with prominent anisokaryosis, abundant eosinophilic granular cytoplasm and indistinct cell borders Occasional binucleate cells	Chromogranin A (CGA) Protein gene product (PGP) 9.5 Synaptophysin (SYN) CD56 (also known as neural cell adhesion molecule or N-CAM) Glial fibrillary acidic protein (GFAP)	Heterogeneous appearance, often with some cystic areas. Calcifications or hemorrhage may also be present (CT) T2-bright lesions, with/without cystic or necrotic components (MRI) Cystic or solid with necrotic areas or hemorrhages (U/S)	Genetic testing Provacative glucagon test Clonidine suppression test Metaiodobenzyl-guanidine scintigraphy PET scan Octereoscan	Plasma and urine catecholamines & metanephrines combined with clinical findings	May mimic panic attack May be associated with Von Hippel-Lindau disease, MEN type 2 and Neurofibromatosis type 1. Arise from the chromaffin cells
Merkel cell carcinoma		Asymptomatic red-to-violet nodules	Violaceous nodule Ulcerated Nodule Lympadenopathy	Seropositivity for Merkel cell polyomavirus Anti-ST antibodies	Dermal and subcutaneous nodule	Monomorphic cells with 3 main types — small-cell, trabecular and intermediate May show necrosis & pleomorphism Epidermotropism	Chromogranin-A Synaptophysin Cytokeratin 20 (CK20) Merkel cell polyomavirus (MCPyV) large T antigen	U/S, CT scan, MRI and PET scan for metastasis	N/A	Biopsy with immunohisto-chemistry	Higher mortality than melanoma ↑ Risk in immun-compromised
Parathyroid adenoma		Depression Memory loss Fatigue Sleep problems Bone or muscle pains GERD ↓ concentration Renal colic Constipation	Nephrolithiasis Nephrocalcinosis osteopenia osteoporosis	↑ Serum and urinary Calcium ↑ or N/L PTH	Enlarged smooth Soft Reddish brown in color	Discrete with thin fibrous capsule May be multinodular and irregular Proliferation of a single cell type with solid to pseudo-glandular, follicular, and acinar structure	Chromogranin Parathyroid hormone	Enlarged gland on U/S and 99mTc-sestamibi scintigraphy Single photon emission computed tomography	Staining for bcl-1 Ki67 p27 parafibromin	Biopsy	Associated with MEN Associated with HPRT
Paraganglioma		Headaches Palpitations Tinnitus Decreased hearing Localized pain GI & intracranial hemorrhage Cardiomyopathy Generalized weakness	Pallor Hypertension Localized mass Orthostasis Incidentalomas Cranial nerve palsies	↑ Plasma and urine catecholamines ↑ Plasma and urine metanephrines ↑ Chromogranin A ↑ Plasma methoxytyramine	Clear margins Encapsulated	Honeycomb or nests patterns separated by broad bands of fibrous tissue Prominent vascularization Argyrophilic fibers	Chromogranin A Synaptophysin CD56 S-100 Cytokeratin	Mass with an un-enhanced density Internal Hemorrhage Cystic changes Necrosis Internal calcifications	Genetic testing Provacative glucagon test Clonidine suppression test Metaiodobenzyl-guanidine scintigraphy PET scan Octereoscan	N/A	Paragangliomas are similar to pheochromo-cytomas but arise outside adrenal medulla
Pituitary gland tumors
Neuroendocrine tumors of the testicles		Painless scrotal mass & swelling Scrotal pain Carcinoid syndrome	Firm painless or painful scrotal mass & swelling Flushing Hydrocele	↑ Serum NSE ↑ Serum vanillylmandelic acid ↑ Serum serotonin and serotonin metabolites	Well-defined Non-capsulated Calcified cyst Hemorrhage & necrosis	Presence of argentaffin and argyrophilic cells Monomorphous polygonal cells Eosinophilic cytoplasm Finely dispersed chromatin	Cytokeratin Chromogranin Synaptophysin Serotonin NSE Vimentin	Well-defined solid hypoechoic mass (U/S) Dense punctate calcifications (U/S)	For metastasis and grading: CT scan Octreotide scintigraphy Pan GI endoscopy	Scrotal U/S with immunohisto-chemistry	May be associated with testicular teratoma Normal serum levels of testicular tumor markers
Neuroendocrine tumors of the ovaries		Lower abdominal pain & swelling Carcinoid syndrome	Abdominal and/or pelvic mass Ascites Flushing	↑ Urinary 5-hydroxyindole-acetic acid ↑ Chromogranin A ↑ or - CA 125	Well-defined Smooth Solid with cystic areas	Insular pattern with nested areas Cells in groups and trabeculae arrangement Mild to moderate nuclear pleomorphism	CD 56 Synaptophysin Chromogranin	Solid ovarian mass with significant enhancement (MRI) Ovarian solid mass (U/S)	For metastasis and grading: CT scan Octreotide scintigraphy Pan GI endoscopy	N/A	CDX2 may distinguish primary ovarian NET from metastatic NET from GI tract
Thymic neuroendocrine cancer		Chest pain Cough Respiratory distress Cushing’s syndrome Carcinoid syndrome (rare)	↓ Breath sounds Flushing Cushing’s syndrome Hypercalcemia	Usually normal May see ↑ Serum calcium & ACTH ↑ Serum serotonin and its metabolites	Solid mass Hemorrhage & necrosis Calcification Gross invasion	Small cells with scant cytoplasm Trabeculae Solid nests Vascular invasion Fine granular or vesicular chromatin	Keratins (AE1/AE3, CAM5.2) Synaptophysin Chromogranin NSE CD 56	Mediastinal mass Necrotic areas Unclear margins Adjacent compression	For metastasis and grading: PET scan Endoscopy	H & E morphology	May co-exist with thymoma Associated with MEN-1
Jejuno-Ileal neuroendocrine tumors
Appendix neuroendocrine tumors
Colon neuroendocrine tumors
Rectum neuroendocrine tumors
Gastric neuroendocrine tumors	Type I GNET
	Type II GNET
	Type III GNET
	Type IV GNET
Duodenal neuroendocrine tumors	Gastrinoma	Atypical PUD Abdominal pain and/or cramps Esophagitis GERD Upper GI blee Secretory diarrhea	Abdominal tenderness Hypercalcemia	↑ Gastrin or gastrin precursors ↑ Serum calcium ↑ Chromogranin A	N/A	Trabeculae Solid nests Presence of argentaffin and argyrophilic cells	Chromogranin A Neuron-specific enolase Synaptophysin Gastrin	Diffuse erosive esophagitis, gastric and duodenal ulcer (Endoscopic gastroduo-denoscopy) Enhancing lobulated lesion (CT)	Gastrin levels Pancreatic polypeptide levels Insulin levels Glucagon levels VIP levels PET with gallium 68–labeled octreotide	Provocative secretin test & biopsy	Associated with MEN-1
	Somatostatinomas	Abdominal pain Jaundice Gastrointestinal bleeding Diarrhea Weight loss Hypoglycemia related	Jaundice Diabetes mellitus Gallstones Hypochlorhydria Hypoglycemia related	↑ Somatostatin Anemia Hyper or hypoglycemia	N/A	Acinar structures Trabeculae Psammoma body Abundant fine granular cytoplasm Salt and pepper chromatin	Chromogranin A Neuron-specific enolase Synaptophysin Leu-7	Isodense Hypervascular lesion Dual phase CT MRI Endoscopic ultrasonography	68Ga-DOTATATE Octreoscan Gastrin levels Pancreatic polypeptide levels Insulin levels Glucagon levels	N/A	Associated with NF-1
	Gangliocytic paraganglionomas
	Nonfunctioning NET
	neuroendocrine carcinomas
Pancreatic neuroendocrine tumours	Gastrinoma	Atypical PUD Abdominal pain and/or cramps Esophagitis GERD Upper GI blee Secretory diarrhea	Abdominal tenderness Hypercalcemia	↑ Gastrin or gastrin precursors ↑ Serum calcium ↑ Chromogranin A	N/A	Trabeculae Solid nests Presence of argentaffin and argyrophilic cells	Chromogranin A Neuron-specific enolase Synaptophysin Pancreastatin Gastrin	Diffuse erosive esophagitis, gastric and duodenal ulcer (Endoscopic gastroduo-denoscopy) Enhancing lobulated lesion (CT)	Gastrin levels Insulin levels Glucagon levels VIP levels PET with gallium 68–labeled octreotide Indium-labelled octreotide (111In-octreotide)	Provocative secretin test & biopsy	Associated with MEN-1
	Insulinoma
	Glucagonoma
	Somatostatinoma	Abdominal pain Jaundice Gastrointestinal bleeding Diarrhea Weight loss Hypoglycemia related	Jaundice Diabetes mellitus Gallstones Hypochlorhydria Hypoglycemia related	↑ Somatostatin Anemia Hyper or hypoglycemia	N/A	Acinar structures Trabeculae Psammoma body Abundant fine granular cytoplasm Salt and pepper chromatin	Chromogranin A Neuron-specific enolase Synaptophysin Leu-7	Isodense Hypervascular lesion Dual phase CT MRI Endoscopic ultrasonography	68Ga-DOTATATE Octreoscan Gastrin levels Pancreatic polypeptide levels Insulin levels Glucagon levels	N/A	Associated with MEN-1
	VIPoma
	ACTHoma
Lung neuroendocrine tumors	Typical carcinoid tumours	Asymptomatic Constitutional Cough Hemoptysis Recurrent pneumonia Seizures	↓ Breath sounds Fever Weight loss Carcinoid syndrome related Cushing's syndrome related	↑ Urinary 5-hydroxyindole-acetic acid ↑ Chromogranin A	Central Polypoid Usually well defined Smooth No necrosis	Organized structure <2 mitoses/2 mm2 No necroses Nesting and/or trabecular pattern	Synaptophysin Chromogranin A CD56/NCAM TTF1 Estrogen receptor	N/L Coin lesion Enlarged lymph nodes Mass (rare)	Bronchoscopy (Gold standard for tumor visualization) Endoscopic biopsy	N/A	5‐year survival rate >90% 12% metastasis at presentation
	Atypical carcinoid tumours	Asymptomatic Constitutional Cough Hemoptysis Recurrent pneumonia Seizures	↓ Breath sounds Fever Weight loss Carcinoid syndrome related Cushing's syndrome related	↑ Urinary 5-hydroxyindole-acetic acid ↑ Chromogranin A	Peripheral Polypoid Irregular margins Smooth Necrosis	More pleomorphism 2–10 mitoses/2 mm2 Necroses Nesting and/or trabecular pattern	Synaptophysin Chromogranin A CD56/NCAM TTF1 Estrogen receptor	N/L Coin lesion Enlarged lymph nodes Mass (rare)	Bronchoscopy (Gold standard for tumor visualization) Endoscopic biopsy	N/A	5‐year survival rate 40-75% 50% metastasis at presentation
	Large cell lung neuroendocrine carcinomas	Asymptomatic Cough Hemoptysis Recurrent infections Seizures	↓ Breath sounds Fever Carcinoid syndrome related (rare) Cushing's syndrome related (rare)	↑ Urinary 5-hydroxyindole-acetic acid (rare) ↑ Serum ACTH (rare) ↑ Chromogranin A	Less differentiated Grey-white Invasive Hemorrhage/necrosis	Organoid or trabecular pattern Rosette-like structures Cells are ×3 the diameter of resting lymphocytes Necrosis	Chromogranin Neuron-specific enolase Synaptophysin Somatostatin CD56	Peripheral lesion Expansively growing Irregular margins Mediastinal lymph node enlargement	Bronchoscopy (Gold standard for tumor visualization) SSTR (somatostatin receptors ) scintigraphy	Biopsy with immunohisto-chemistry	Associated Smoking Humoral hypercalcemia of malignancy SIADH Hypoglycemia Acromegaly Carcinoid syndrome Neurological syndromes Gynecomastia Hyperthyroidism
	Small cell lung neuroendocrine carcinomas	Asymptomatic Cough Hemoptysis Recurrent infections Seizures	↓ Breath sounds Fever Carcinoid syndrome related (rare) Cushing's syndrome related (rare)	↑ Urinary 5-hydroxyindole-acetic acid (rare) ↑ Serum ACTH (rare) ↑ Chromogranin A	Less differentiated Grey-white Invasive Hemorrhage/necrosis	Diffuse sheets No prominent neucleoli Cells < size of three small resting lymphocytes The mitotic rate averages over 60 mitoses/2 mm2 Extensive necrosis	Chromogranin Neuron-specific enolase Synaptophysin Somatostatin CD56	Homogeneous or noncontiguous parenchymal mass, or peripheral nodule Adjacent compression Atelectasis Pleural effusion . Intratumoral calcification Lymphadenopathy	PET scan Bronchoscopy Scintigraphy	Biopsy with immunohisto-chemistry	Associated Smoking Humoral hypercalcemia of malignancy SIADH Hypoglycemia Acromegaly Neurological syndromes Gynecomastia Hyperthyroidism