REVIEW

Biochemical Testing for Neuroendocrine Tumors

Aaron I. Vinik, MD, PhD,* Maria P. Silva, MD,* Gene Woltering, MD,Þ Vay Liang W. Go, MD,þ
Richard Warner, MD,§ and Martyn Caplin, MD||

in the real incidence of the disease, but we still need more

Abstract: In this review, we focus on the use of biochemical markers accurate and precise biochemical methods for trying to diagnose
for the diagnosis of neuroendocrine tumors and exclusion of conditions the presence of a NET as accounting for a symptom complex.
that masquerade as neuroendocrine tumors. In addition, we outline the The natural history of this disease is invariably attended by
use of biochemical markers for follow-up, response to intervention, and a long history of vague abdominal symptoms, a series of visits to
determination of prognosis. Previous publications have focused only on a primary care practitioner, and referral to a gastroenterologist,
markers specific to certain tumor types, but the uniqueness of this often with a misdiagnosis of irritable bowel syndrome (Fig. 1).
chapter is that it presents a new approach ranging from biochemical These symptoms persist with a median latency to correct diag-
markers that relate to symptoms to the use of markers that facilitate nosis of 9.2 years, by which time the tumor has metastasized,
decision making with regard to optimizing the choices of therapy from causing symptoms like flushing and diarrhea and progressing on
the complex arrays of intervention, The sequence of presentation in this its slow but relentless course until the patient dies. Clearly, a
chapter is first to provide the usual view, that is, biochemical markers of greater index of suspicion and a carcinoid tumor profile screen
each tumor type and thereafter the diagnosis of the underlying condition are warranted for all patients presenting with traditional irritable
or exclusion thereof and finally the algorithm for their use from the bowel syndrome symptoms. The diagnosis of metastases to the
clinical presentation to the suspected diagnosis and the biochemical liver is generally more obvious but often still takes place only
markers to monitor progression and therapeutic choice. There is also a after a delay of many years. Even then, an incorrect diagno-
specific description of the properties of the most important biochemical sis is not uncommon. Unless biopsy material is examined for
markers and 2 complications, bone metastasis and carcinoid heart dis- the secretory peptides chromogranin (Cg), synaptophysin, or
ease, from the biochemical point of view. neuron-specific enolase (NSE), tumors may be labeled errone-
Key Words: biochemical tests, chromogranin A, pancreastatin, ously as adenocarcinoma, with a negative impact on physicians’
neurokinin, Ki-67 attitudes regarding management and underestimation of pro-
spects for survival.5
(Pancreas 2009;38: 876Y889)

SPECIFIC BIOCHEMICAL MARKERS FOR EACH

TUMOR TYPE
N euroendocrine tumors (NETs) are rare, usually slow-
growing, neoplasms characterized by the ability to store
and secrete different peptides and neuroamines.1 Some of these
Each tumor, depending on the site of origin will be more
prone to produce one or another hormone or peptide. In rare
substances cause a specific clinical syndrome.2 It is important cases when the tumor is localized before the symptoms occur,
to be able to recognize from the clinical presentation the most then these biochemical markers (Table 1) will be useful to con-
useful markers to reduce time and costs and that way facilitate firm the diagnosis, follow the progression or treatment response,
the diagnosis and make wise use of resources. Unfortunately, and may even have prognostic value.
there is no Bideal neuroendocrine tumor marker,3[ but according The historic classification of NETs into foregut, midgut,
to the presentation, the sensitivity and specificity of each marker and hindgut carcinoid tumors (see later) still has some virtue
vary and it is generally possible to choose those of greatest value even in the era of the recent World Health Organization clas-
for each patient. In addition, it is important to recognize the sification of endocrine tumors.7 Less than 10% of NETs are
contribution of each marker to diagnosis, follow-up of treatment functional, that is, hormone secreting with an associated syn-
response, or prognosis. drome. Most NETs are nonfunctional, that is, no associated
The biochemical markers are those hormones or amines hormonal secretion.
secreted by the enterochromaffin (EC) cells from which these In general, poorly differentiated NETs are nonfunctional
tumors are derived. Some of these are nonspecific to any tumor and act as would an aggressive adenocarcinoma often presenting
but, in contrast, are produced and secreted by most NETs; other with advanced disease.
biochemical markers are more specific to the type of tumor.
The incidence of NETs has risen to 40 to 50 cases per Foregut Carcinoid Tumors
million, perhaps largely caused by better diagnosis than a change Foregut carcinoid tumors occur in the thymus, bronchus,
stomach, first portion of the duodenum, pancreas, and ovaries.
These tumors produce less serotonin when compared with car-
From the *Eastern Virginia Medical School, Strelitz Diabetes Research cinoid tumors in the midgut and secrete the serotonin precursor
Center and Neuroendocrine Unit, Norfolk, VA; †Louisiana State University 5-hydroxytryptophan (5-HTP). This is caused by a deficiency
Health Sciences Center, Department of Surgery, New Orleans, LA; ‡David in dopa-decarboxylase, an enzyme that catalyzes the conversion
Geffen School of Medicine of University of CaliforniaYLos Angeles, Los
Angeles, CA; §Center for Carcinoid and Neuroendocrine Tumors, Mount
of 5-HTP to serotonin (Fig. 2). However, after secretion, a small
Sinai School of Medicine, New York, NY; and ||Gastroenterology and Hepa- amount of 5-HTP is converted to 5-hydroxyindoleacetic acid
tobiliary Medicine, Royal Free Hospital, London, UK. (5-HIAA) and serotonin, so modest elevation of these metabo-
Received for publication May 27, 2009; accepted August 12, 2009. lites can be found with foregut tumors. When all these me-
Reprints: Aaron I. Vinik, MD, PhD, Eastern Virginia Medical School,
Strelitz Diabetes Research Center and Neuroendocrine Unit, Norfolk,
tabolites are measured together, the sensitivity increases to 84%.
VA 23510 (e-mail: [email protected]). Other products of foregut carcinoids are histamine, substance
Copyright * 2009 by Lippincott Williams & Wilkins P (SP), neuropeptide K, pancreatic polypeptide (PP), and CgA5

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

FIGURE 1. The natural history of NETs. Vague symptoms such as abdominal pain precede the diagnosis by a median of 9.2 years,
and flushing and diarrhea, the major manifestations of carcinoid NETs, occur after the tumor has metastasized. On the right, the
figure shows the relationship between tumor size and when the biochemical markers are positive when measured in blood, usually,
after the tumor reaches a diameter of approximately 3 mm and contains about 1 million cells.4

(Fig. 3). A further point of interest is that a sex variation kinins, prostaglandins, and SP.5 Both functional and nonfunc-
is present when a NET coexists with multiple endocrine neo- tional midgut NETs produce CgA.
plasia type 1 (MEN-I) syndrome; more than two thirds of the
Hindgut Carcinoid
time, the tumor is in the thymus in males, whereas in females,
more than 75% of the time, it is in the lung.5 Hindgut carcinoid tumors include those tumors of the trans-
verse colon, descending colon, and rectum. They are argentaffin
negative, rarely contain serotonin, rarely secrete 5-HTP or other
Midgut Carcinoid
peptides, and usually are silent in their presentation. Plasma CgA
These tumors occur in the second portion of the duodenum, is usually elevated as may acid phosphatase.
jejunum, ileum, and ascending colon. They are argentaffin pos-
itive on cytochemical staining. They produce huge amounts of Bronchus
serotonin, but the serotonin precursor 5-HTP is rarely produced. Bronchopulmonary NETs comprise 20% of all lung cancers
These tumors also secrete other vasoactive compounds such as and up to 30% of all NETs.9 The biochemical findings are

TABLE 1. Specific Biochemical Markers for Each Tumor Type6

Site Tumor Type Marker Specificity

All CgA and CgB High
PP, NSE, neurokinin, neurotensin Intermediate
HCG-> and HCG-A Low
Thymus Foregut carcinoid ACTH Intermediate
Bronchus Foregut carcinoid, small-cell lung ACTH, ADH, serotonin, 5-HIAA, Intermediate
carcinoma Histamine, GRP, GHRH, VIP, PTHrp Low
Stomach Foregut carcinoid, gastrinoma, Histamine, gastrin Intermediate
ghrelinoma Ghrelin Low
Pancreas Gastrinoma, insulinoma, Gastrin, insulin, proinsulin, High
glucagonoma glucagon, somatostatin
Somatostatinoma, PPoma, VIPoma C-peptide, neurotensin, VIP, PTHrp, Low
calcitonin
Duodenum Gastrinoma, somatostatinoma Somatostatin, gastrin High
Ileum Midgut carcinoid Serotonin, 5-HIAA High
NKA, neuropeptide K, SP Intermediate
Colon and rectum Hindgut carcinoid Peptide YY, somatostatin Intermediate
Bone Metastasis bAP, N-telopeptide High (blastic lesions), modest
(lytic lesions)
Vitamin D25, 1:25-OHD Universal vitamin D
deficiency
PTH, PTHrp Intermediate
Cardiac involvement Carcinoid BNP Intermediate
Shows the specific biochemical markers used for each tumor and their specificity.
1:25-OHD indicates 25-hydroxyvitamin D; ADH, antidiuretic hormone; GRP, gastrin-releasing peptide; HCG, human chorionic gonadotropin.

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Vinik et al Pancreas & Volume 38, Number 8, November 2009

Thus, there are 3 different biochemical markers useful for

gastric NETs: (1) fasting serum gastrin (FSG) levels, which will
be elevated in types 1 and 2 gastric NETs. Of great importance is
to stop the use of proton pump inhibitors (PPIs), if possible, 7
days before the test to avoid false-positive results (patients may
still need acid suppression with, eg, histamine type 2 receptor
antagonists).5 Histamine, the main secretory product of the ECL
cells, and ghrelin have been shown to be of limited value as
serum markers. Plasma CgA is often significantly elevated par-
ticularly in patients with types II and III gastric carcinoid.
Pancreas
Neuroendocrine tumors of the pancreas are frequently
(40%Y50%) nonfunctioning or secrete peptides with low bio-
logical impact such as PP or neurotensin. The functioning
tumors are named according to their secretory product: insu-
linoma, gastrinoma (nb. most gastrinomas are found in the duo-
denum), VIPoma, glucagonoma, and somatostatinoma. The first
2 (insulinomas and gastrinomas) are the most frequent func-
tioning pancreatic NETs.1
FIGURE 2. Synthesis of 5-HIAA. MAO indicates monoamine
oxidase. Insulinomas
There are 6 criteria for the diagnosis of insulinomas: doc-
umented blood glucose levels less than or equal to 2.2 mmol/L
dependent on the histological type of bronchial NET. The typical (e40 mg/dL), concomitant insulin levels greater than or equal
carcinoid may present with increased plasma levels of CgA. When to 6 KU/mL (Q36 pmol/L, Q3 KU/mL by immunochemilumino-
hormone-related symptoms are rarely present, plasma adrenocor- metric assay), C-peptide levels greater than or equal to 200
ticotropic hormone (ACTH), growth hormoneYreleasing hormone pmol/L, proinsulin levels greater than or equal to 5 pmol/L,
(GHRH), insulin-like growth factor I (IGF-I), urine cortisol, urine A-hydroxybutyrate levels less than or equal to 2.7 mmol/L, and
5-HIAA, or histamine metabolites (U-methylimidazole acetic absence of sulfonylurea (metabolites) in the plasma and/or
acid) may be elevated.10 urine. Further controlled testing includes the 72-hour fast, which
Thymus is the criterion standard for establishing the diagnosis of in-
sulinoma.14 Actually, 98% of patients with insulinomas will de-
The overall age-adjusted incidence of thymic carcinoids is
velop symptomatic hypoglycemia within 72 hours.1 When the
0.01 per 100,000 per year. These tumors might be part of the
patient develops symptoms and the blood glucose levels are
MEN-I syndrome. These tumors may be similar to bronchial
less than or equal to 2.2 mmol/L (e40 mg/dL), blood should also
carcinoids in their biochemical profile.10
be drawn for C-peptide, proinsulin, and insulin. Failure of ap-
Stomach propriate insulin suppression in the presence of hypoglycemia
There are different neuroendocrine cells in the stomach: G substantiates an autonomously secreting insulinoma.14 It has
cells (antrum), D cells (corpus and antrum), EC-like (ECL) cells been proposed that the sensitivity of the 48-hour fasting test
(corpus and fundus), D1 cells, EC cells, parietal cells, and X is between 94.5% and 95.7% and should be enough for diag-
cells, which have different products and are prone to tumor nosis of insulinoma instead of the 72-hour fast test.15,16 In a case
formation. The gastric NETs are most likely to derive from ECL of suspected insulinoma, it is important to keep in mind the
cells. They constitute up to 30% to 40% of the neuroendocrine possible differential diagnoses: nesidioblastosis, noninsulinoma
cells of the stomach and release histamine.11 Gastric NETs are pancreatogenous hypoglycemia syndrome (see discussion later),
divided into: type 1 (multiple, small, relatively nonaggressive and multiple adenomas.
tumors, associated with achlorhydria often in the presence of
pernicious anemia, and high gastrin levels); type 2 (associated
with high levels of gastric acid and gastrin [Zollinger-Ellison
syndrome {ZES}], they are larger and more prone to metastasize
than type 1 tumors); and type 3 tumors (the largest gastric NET
with the highest metastasis rate, are sporadic, and usually
present with normal gastric acid and gastrin levels).5 Prolonged
increased gastrin levels can produce ECL cell hyperplasia and
subsequently the development of a gastric NET.5
With the discovery of the orexigenic gastric hormone,
ghrelin, it has been known that its circulating levels rise be-
fore and decrease after a meal.12 The physiological functions
of this new gut hormone are being elucidated and a role in
NETs is anticipated. Despite the frequent occurrence of ghrelin-
immunoreactive cells in both the neoplastic parenchyma and the
oxyntic mucosa, plasma total ghrelin concentrations do not
increase above the reference range and therefore cannot be used
as a clinical marker to identify ghrelin-expressing ECL cells, FIGURE 3. Percentage of patients with carcinoid tumors with
NETs, or ghrelin cell hyperplasia.13 elevated 5-HIAA.8

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

Gastrinomas tastases are not to be expected until the tumor extends beyond
For gastrinomas (ZES), 2 measurements are critical: FSG the submucosa.
and basal gastric acid output. Fasting serum gastrin alone is not Duodenal Gangliocytic Paragangliomas
enough because of its lack of specificity, making it impossible to
distinguish hypergastrinemia caused by a gastrinoma from that Duodenal gangliocytic paragangliomas occur in the vicin-
caused by achlorhydric states. For these measures, a washout ity of the papilla of Vater. Although the tumors are often greater
than 2 cm and infiltrate into the muscularis propria, they gen-
period from PPI treatment of 1 to 4 weeks is recommended.17
If the FSG is greater than or equal to 1000 ng/L (pg/mL) and erally follow a benign course.20 Thus, the most common prod-
the gastric pH is less than 2.5, the diagnosis is established1 if ucts of duodenal NETs are gastrin and somatostatin, and these
the patient is normocalcemic, free of pyloric obstruction, and are the markers considered for diagnosis.
has a normal renal function.18 The 2006 European Neuroendo- Poorly Differentiated Duodenal Carcinomas
crine Tumor Society guidelines had cutoff values of greater than
Poorly differentiated duodenal carcinomas occur primarily
10-fold elevation for FSG and gastric pH less than or equal to
in the region of the papilla of Vater. They are hormonally in-
2.17 In case that the FSG values are not high enough to make
active. At the time of diagnosis, advanced metastasis into the
a definitive diagnosis, then a provocative test should be done.
regional lymph nodes and the liver has usually occurred.
Following administration of secretin after an overnight fast,
serum for estimation of gastrin levels are collected during fast- Small Bowel
ing and 2, 5, 10, 15, and 30 minutes after the secretin bolus. In These are the most frequent gastrointestinal (GI) tract NETs,
healthy people, the increase in gastrin is not higher than 50% especially appendiceal tumors. Most are well differentiated and
over the baseline level; in the presence of a gastrinoma, the grow slowly. Rarely, they are less differentiated with fast growth
increase is greater than 100 ng/L above the baseline levels, and poor prognosis. Symptoms are atypical; diagnosis is often
which will also distinguish patients with hypergastrinemia from accidental. In 4% to 10% of patients, typical symptoms of
achlorhydric states (ie, type 1 gastric NETs, use of PPIs, per- carcinoid syndrome are present. The biochemical markers that
nicious anemia, atrophic gastritis), who do not respond to the should be measured in these patients are CgA and urinary ex-
administration of secretin, unlike patients with a gastrinoma.5 cretion of 5-HIAA, which is used for the diagnosis and mon-
itoring of the disease.21 Some clinicians also measure blood
Miscellaneous Pancreatic NETs serotonin, which occasionally may be the only elevated marker.
For VIPomas, glucagonomas, somatostatinomas, and Colon and Rectum
PPomas, the biochemical markers are vasoactive intestinal peptide
Most of the tumors from the distal colon and rectum are
(VIP), glucagon, somatostatin, and PP, respectively.1 For every
nonfunctioning hindgut carcinoids. It is possible to measure
pancreatic NET, always screen for MEN-I syndrome, measuring
peptide YY (PYY), which is a naturally occurring gut hormone
ionized calcium, serum parathyroid hormone (PTH), and pro-
with mostly inhibitory actions on multiple tissue targets, which
lactin.19 Biochemical screening for pancreatic NETs, in the pres-
has been identified in several carcinoid tumors; a decreased
ence of suspected MEN 1 syndrome, should include gastrin,
expression of PYY may be relevant to the development and
insulin/proinsulin, PP, glucagon, and CgA, which together have
progression of colon adenocarcinoma.22
a sensitivity of approximately 70% that can be increased if >-
and A-hCG subunits, VIP, postprandial gastrin, and PP measure- Pheochromocytoma
ments are added.18 Pheochromocytoma is a rare catecholamine-producing
tumor usually localized in the adrenal gland that arises from
Duodenum neuroendocrine chromaffin cells of the adrenal medulla. Guller
Five types of duodenal NETs can currently be distinguished. et al23 published in 2006 that the tests of choice to establish the
diagnosis of pheochromocytomas are urinary normetanephrine
Duodenal Gastrinomas and platelet norepinephrine, with sensitivities of 96.9% and
Duodenal gastrinomas are either sporadic or associated 93.8%, respectively. In a study conducted in Switzerland by
with MEN-1 and are combined with a ZES. In both situations, Giovanella et al24 in 2006, plasma metanephrines and CgA
these gastrinomas are usually not bigger than 1 cm and are showed 95% sensitivity with comparable high specificity and
located predominantly in the upper part of the duodenum. If diagnostic accuracy (96% and 96% for CgA, 94% and 95% for
associated with MEN-1, they are usually multiple, in contrast to metanephrine, respectively). If both were used, then sensitivity
sporadic gastrinomas. increases to 100%. The difference found between these 2
markers is that only CgA was correlated with tumor mass.24 In
Duodenal Somatostatin-Producing Tumors 2008, Bilek et al25 also studied the use of CgA for pheochro-
Duodenal somatostatin-producing tumors account for ap- mocytoma and found that it is a great marker for following
proximately 15% of all duodenal NETs. Their preferential lo- response to treatment and that the levels of CgA were correlated
calization is in the region of the papilla of Vater or periampullary. with the size and the malignancy of the tumor.
They are not associated with any hormonal syndrome but often Paragangliomas
occur in patients with neurofibromatosis type 1. In this situation, Paragangliomas are NETs that arise from the paravertebral
a bilateral pheochromocytoma may simultaneously occur. axis. Sympathetic paragangliomas usually hypersecrete cate-
cholamines and are localized in the thorax, abdomen, or pelvis.
Nonfunctioning Duodenal NETs Parasympathetic paragangliomas are nonsecretory tumors usu-
Nonfunctioning duodenal NETs usually consist of serotonin- ally localized in the head and neck area.26
producing cells. Occasionally, there are also tumors with gastrin- Diagnosis of paragangliomas is similar to that of pheo-
or calcitonin-positive cells. The prognosis of this group of non- chromocytomas because these 2 entities only differ in their
functioning tumors is much more favorable than ZES-associated places of origin, extraadrenal versus adrenal, respectively.
gastrinomas or ampullary somatostatin-producing tumors. Me- Algeciras-Schimnich et al27 suggested that when plasma

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Vinik et al Pancreas & Volume 38, Number 8, November 2009

fractionated metanephrines are measured and values are not The PG test is used to distinguish MCT from CCH because
4-fold above upper normal limit, then serum or plasma CgA it is thought that the response to this stimulus is typical of
and urine fractionated metanephrines should be measured pathological thyroid C cells. The cutoff value of calcitonin
to confirm the diagnosis. After surgery, the biochemical follow- response between patients with MCT and CCH remains to be
up should be done 1 to 2 weeks later with 24-hour urine established.35 Pentagastrin stimulation test is no longer available
fractionated catecholamines and metanephrines; if normal, in the United States, but it consists of the intravenous injection of
complete resection is claimed, but if it is persistently elevated, 0.5 Kg/kg body weight of PG and measurements of calcitonin at
a second primary or occult metastasis should be suspected and 0, 1, 2, 5, and 10 minutes after the injection; healthy people do
investigated. Young 28 also proposed an annual biochemical test- not experience an increase in calcitonin greater than 200 pg/mL
ing follow-up for life, with 24-hour urinary excretion of after the administration of PG.5 Instead, a stimulation test can
fractionated catecholamines and metanephrines or plasma frac- also be done with intravenous calcium infusion.
tionated metanephrines; and only in the case of elevated levels,
C-Cell Hyperplasia
imaging follow-up is then considered.
All patients with paragangliomas should be considered This entity has been proposed to be a precancerous lesion
for genetic testing with VHL, RET, NF1, SDHD, SDHB, and that eventually transforms into MCT. Schley, Shin, Perry, and
SDHC genes.26 If positive, then genetic testing of first-degree Vinik submitted a study where 3 cases are reported in which
relatives should be suggested and genetic counseling should be patients presented with flushing, abdominal pain, diarrhea, and fa-
offered. First-degree relatives should always undergo biochem- cial telangiectasia, resembling carcinoid syndrome, but the only
ical testing with 24-hour urine fractionated metanephrines and biochemical abnormalities were elevated calcitonin levels and
catecholamines.28 positive PG and calcium infusion tests. Venous sampling was
performed, and it localized the overproduction of calcitonin to the
Medullary Carcinoma of the Thyroid thyroid and histology showed CCH. After thyroidectomy, symp-
Medullary carcinomas of the thyroid (MCT) originate from toms resolved and calcitonin levels returned to normal. They pro-
the parafollicular cells of the thyroid, which secrete calcitonin. posed that the condition might be a gene mutation, but so far, the
These represent 4% to 10% of all thyroid neoplasms.29 The site has not been identified, considering that RET proto-oncogene
MCT can present as 2 different forms, sporadic (75%) or in- was negative in the 3 patients. These findings (Schley et al, un-
herited (25%), and the last can be either isolated or part of the published data, 2009) suggest that every case of flushing and di-
MEN-2 syndrome.30 A germline autosomal-dominant mutation arrhea should have a calcitonin measurement, considering CCH
in the RET proto-oncogene, which encodes for a transmembrane or MCT in the differential diagnosis.
tyrosine kinase receptor, predisposes individuals to develop MEN Syndromes
MCT. Screening for RET germline mutations has allowed for This entity is classified as either MEN-1 or MEN-2. They
early and accurate diagnosis of patients at risk for developing are both inherited in an autosomal-dominant pattern. Mutations
MCT.31,32 on the MEN-1 tumor suppressor gene (inactivated) or the RET
The most common clinical presentation of MCT is a thyroid proto-oncogene (activated) are found in MEN-1 and MEN-2,
nodule, either singly or as a multinodular goiter. Usually, no respectively.37
other manifestations are present unless the tumor is already in
stage IV (metastatic disease), when diarrhea and/or flushing can Multiple Endocrine Neoplasia Type 1
present.33 Multiple endocrine neoplasia type 1 is characterized by
The calcitonin-secreting nature of these tumors and the fact hyperplasia and/or neoplasm of the parathyroid glands, enter-
that calcitonin is almost exclusively secreted by C cells explain opancreatic NETs, and pituitary adenomas. Some patients do not
why this hormone is the preferred biochemical marker for the present with all these tumors, so it has been agreed upon that
diagnosis and follow-up of this disease. Besides, it has been diagnosis is made when a patient presents with 2 of these con-
shown that calcitonin measurement is more sensitive than fine- comitantly. To diagnose familial MEN-1 syndrome, a first-degree
needle aspiration for the diagnosis of MCT.33 A 10-year survival relative has to present at least one of the tumors previously men-
of only 50% for MCT patients is reported in several series. The tioned.38 Hyperparathyroidism occurs in about 90% of patients;
only possible means to improve the cure and survival rate of endocrine pancreatic tumors in 60% of patients, usually they are
these patients consists of early diagnosis and early surgical small and nonfunctional, and the most common hormonally
treatment while the MCT is still intrathyroid.33 Costante et al29 active ones are insulinomas or gastrinomas. Pituitary adenomas
reported in 2007 that the positive predictive value of basal are present in 40% of patients, and in 60% of the patients, skin
calcitonin levels greater than 100 pg/mL is 100% for MCT, and manifestations can also be present.38,39 Genetic studies are avail-
if pentagastrin (PG) stimulation test is used, calcitonin levels able for MEN-1 syndrome; MEN-1 germline mutations are found
greater than 100 pg/mL had a positive predictive value of 40%, in these patients, but their presence does not prompt any im-
but below this cutoff value, the false-positive results increase mediate intervention.40 Piecha et al38 proposed a recommendation
until the positive predictive value of basal calcitonin levels for carriers of MEN-1 mutation to be screened biochemically
greater than 20 pg/mL is less than 25%. Cohen et al30 found that every 1 to 3 years for hyperparathyroidism, prolactinoma, gastri-
calcitonin levels are not only useful as a diagnostic marker, but noma, insulinoma, and other enteropancreatic tumors.
they are also correlated with tumor size and metastasis, which
gives some prognostic value to this hormone. When levels Multiple Endocrine Neoplasia Type 2
are less than 50 pg/mL preoperatively, the normalization of This syndrome is subclassified into type 2A, 2B, and fa-
calcitonin levels postoperatively is found in 97.8% of the pa- milial MCT, all sharing the presence of MCT; and they are all
tients.30 Scheuba et al34 recently published that values of basal characterized by an activating germline mutation in the RET
calcitonin greater than 64 pg/mL or stimulated calcitonin levels proto-oncogene, specific for each type and which can be iden-
greater than 560 pg/mL had a sensitivity of 100% for MCT. tified in almost 100% of the patients with genetic testing. Once
Increased calcitonin levels can be observed also in parafollicular the genetic test demonstrates the mutation, a total thyroidec-
C-cell hyperplasia (CCH) and other extrathyroidal conditions. tomy is mandatory either prophylactically in carriers or as

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

TABLE 2. The Clinical Presentations, Syndromes, Tumor Types, Sites, and Hormones5

Clinical Presentation Syndrome Tumor Type Sites Hormones

Flushing Carcinoid Carcinoid Midgut/foregut Serotonin, NKA, TCT, PP
Adrenal medulla GCRP, VIP
Gastric SP
Diarrhea Carcinoid, WDHHA, Carcinoid, VIPoma, As above, pancreas, As above, VIP, gastrin,
ZES, PP, MCT gastrinoma, PPoma, MCT mast cells, thyroid PP, calcitonin
Diarrhea/steatorrhea Somatostatin Somatostatinoma, Pancreas Somatostatin
Bleeding GI tract neurofibromatosis Duodenum
Wheezing Carcinoid Carcinoid Gut/pancreas/lung SP, CGRP, serotonin
Ulcer/dyspepsia ZES Gastrinoma Pancreas/duodenum Gastrin
Hypoglycemia Whipple triad Insulinoma, sarcoma, Pancreas, Insulin, IGF-1, IGF-11
hepatoma retroperitoneal
Liver
Dermatitis Sweet syndrome Glucagonoma Pancreas Glucagon
Pellagra Carcinoid Midgut Serotonin
Dementia Sweet syndrome Glucagonoma Pancreas Glucagon
Diabetes Glucagonoma Glucagonoma Pancreas Glucagon
Somatostatin Somatostatinoma Pancreas Somatostatin
DVT, steatorrhea, cholelithiasis Somatostatin Somatostatinoma Pancreas Somatostatin
Neurofibromatosis Duodenum
Silent, liver mets Silent PPoma Pancreas PP
Acromegaly Acromegaly, NET Pancreas GHRH
gigantism
Cushing Cushing NET Pancreas CRH, ACTH
Pigmentation Pigmentation NET Pancreas MSH
Anorexia, nausea, vomiting, Hypercalcemia NET Pancreas PTHrp
abdominal pain
Summarizes our approach based upon the clinical presentation, the tumor type, their sites of origin and the possible means of diagnosis, and the
biochemical markers that should be measured.
CRH indicates corticotropin-releasing hormone; MSH, melanocyte-stimulating hormone; WDHHA, watery diarrhea, hypokalemia, hyperchlorhydria,
and acidosis.

treatment in patients who already present with manifestations of Midgut

the syndrome.41 Multiple endocrine neoplasia type 2A presents A midgut tumor is faint pink to red and involves the face and
with MCT, bilateral pheochromocytomas, and primary hyper- upper trunk as far as the nipple line. The flush is initially provoked
parathyroidism; lately, it has been published that Hirschsprung by exercise, alcohol, and food containing tyramines (eg, blue
disease could also be a manifestation of this syndrome, and
genetic screening for RET proto-oncogene mutation is recom-
mended in this patients42; MEN type 2B is an association of
MCT, pheochromocytomas, and mucosal neuromas43; these
patients usually present with a marfanoid phenotype.
The biochemical studies recommended for these syndromes
are the same as previously proposed for each tumor type, de-
pending on the clinical syndrome; and in the case when MEN
syndrome is suspected, genetic testing should also be performed
in the patient, and if positive, first-degree relatives should also
be tested.

SPECIFIC BIOCHEMICAL MARKERS FOR EACH

CLINICAL SYNDROME
Flushing
Foregut
The flushing in foregut carcinoid tumors is dry, long
lasting, intense, and purplish or violet in contrast to the common
red/pink seen in other neuroendocrine-related flushing. It is
related to telangiectasia and skin hypertrophy mostly in the face
and upper neck but can also involve the limbs, and it can lead to FIGURE 4. Biochemical markers for flushing. TCT indicates
a leonine appearance after repeated episodes (Table 2; Fig. 4). thyrocalcitonin.

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Vinik et al Pancreas & Volume 38, Number 8, November 2009

cheese, chocolate, red sausage, and red wine). With time, the flush patients. All patients with PG-induced GI symptoms demon-
may occur spontaneously and without provocation. It usually is strated elevated serotonin levels in peripheral blood. Adminis-
ephemeral, lasting only a few minutes, and may occur many times tration of a serotonin receptor antagonist had no effect on
per day. However, over many years, patients may develop a per- serotonin release but completely aborted the GI symptoms. The
sistent flush with a purpuric malar and nasal hue. authors emphasized the improved reliability of PG compared
Differential diagnosis of flushing includes the postmen- with calcium infusion, another provocative test popularized by
opausal state, simultaneous ingestion of chlorpropamide and Kaplan et al,48 and pointed out that PG provocation occasionally
alcohol, panic attacks, MCT, autonomic epilepsy, autonomic can be falsely negative in patients with subclinical disease.
neuropathy, and mastocytosis.44 A pseudocarcinoid syndrome Our own experience is that PG uniformly induced flushing in
with flushing and increased 5-HIAA has been described in patients with gastric carcinoid tumors that was associated with
men with hypogonadism, which responds to testosterone treat- a rise in circulating levels of SP in 80%. Thus, SP is one neu-
ment.45 To differentiate all those causes from a carcinoid tu- rohumor that may be involved in the flushing of carcinoid
mor, besides knowing the differences in the characteristics of syndrome.
the flushing, it is also necessary to know what is producing the Substance P has been found in tumor extracts and plasma
flushing (Table 3). from patients with carcinoid tumors and, in 1 reported case, was
Flushing in carcinoid syndrome has been ascribed to pros- useful for tumor localization. Neurokinin A (NKA), its amino-
taglandins, kinins, and serotonin (5-HT). With the advent of terminally extended form, neuropeptide K, and SP are a group of
sophisticated radioimmunoassay methods and region-specific peptides (ie, tachykinins) with common biological properties.
antisera, a number of neurohumors now are thought to be se- Norheim et al49 measured peptide responses to PG or ingestion of
creted by carcinoid tumors, including serotonin, dopamine, food or alcohol in 16 patients with metastatic carcinoid tumors and
histamine, and 5-HIAA, kallikrein, SP, neurotensin, motilin, so- demonstrated 2-fold or greater increases in NKA and neuropeptide
matotropin releaseYinhibiting factor, VIP, prostaglandins, neu- K in 75% of patients, as well as variable increases in SP in
ropeptide K, and gastrin-releasing peptide. approximately 20% of patients.
Feldman and O’Dorisio46 have previously reported the inci- Conlon50 used region-specific antisera to SP and NKA to
dence of elevated levels of plasma neuropeptide concentrations. measure circulating tachykinins during a meal-induced flush in
Despite the elevated basal concentrations of SP and neurotensin, 10 patients with metastatic carcinoid tumors. Five patients had
these authors were able to document further increases in these undetectable levels of NKA and SP after stimulation, thus sug-
neuropeptides during ethanol-induced facial flushing. We sup- gesting that elevated tachykinin concentrations are not a constant
port this contention and hasten to add that neuropeptide ab- feature of such patients. The authors also studied the effect of a
normalities frequently occur in patients with other forms of somatostatin-analogue administration on meal-induced tachyki-
flushing and may be of pathogenetic significance. nin responses in 3 patients with carcinoid tumors. Flushing was
Several provocative tests have been developed to identify aborted in 2 patients, but tachykinin levels were only partially
the cause of flushing in carcinoid syndrome. These tests are suppressed, indicating that these peptides cannot be solely
based upon the need to distinguish the flushing from that found responsible for the carcinoid flush. When the diagnosis of the
in a host of other conditions, particularly in panic syndrome, in underlying cause of flushing has been established, pathogenesis-
which the associated anxiety and phobias usually establish the oriented treatment can be very helpful.44
cause but frequently the physician and patient need reassurance Cunningham et al51 also performed a study in which they
that there is no underlying malignancy. used patients with metastasizing ileocecal serotonin-producing
Ahlman et al47 reported the results of PG provocation in carcinoid tumors and looked for the relationship of flushing
16 patients with midgut carcinoid tumors and hepatic metas- totachykinin production. They concluded that metastasizing ileo-
tases. All patients tested had elevated urinary 5-HIAA levels, cecal serotonin-producing carcinoid tumors produce many bio-
and 12 had profuse diarrhea requiring medication. Pentagastrin logically active substances with partially overlapping biological
uniformly induced facial flushing and GI symptoms in patients functions. The biological processes underlying the specific symp-
with liver metastases, but it had no effect in healthy control toms of the carcinoid syndrome are probably multifactorial. They

TABLE 3. Differential Diagnosis of Flushing and Recommended Tests

Clinical Condition Tests

Carcinoid Serotonin, 5-HIAA, NKA, TCT, PP, CGRP, VIP, SP, PGD2, PGE1, PGF2
MCT Calcitonin, Ca2+ infusion, RET proto-oncogene
Pheochromocytoma CgA, plasma free metanephrines, urine metanephrines, VMA, Epi, Norepi,
glucagon stimulation, MIBG
Diabetic autonomic neuropathy HRV, 2 hs PP glucose
Menopause FSH
Epilepsy EEG
Panic attack PG, ACTH
Mastocytosis Plasma histamine, urine tryptase
Hypomastia and mitral valve prolapse Cardiac echo
Male hypogonadism Testosterone
EEG indicates electroencephalography; Epi, epinephrine; FSH, follicle-stimulating hormone; HRV, heart rate variability; MIBG,
metaiodobenzylguanidine; Norepi, norepinephrine; PGD2, prostaglandin D2; PGE1, prostaglandin E1; PGF2, prostaglandin F2; TCT, thyrocalcitonin;
VMA, vanillylmandelic acid.

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

confirmed results from earlier studies showing that tachykinins

and 5-HIAA levels are elevated in patients with daily episodes
of flushing. The hormone effects were not mutually independent.
It is possible that the development of flushing is the result of
multihormonal stimulation. Other biologically active substances,
such as kallikrein, and prostaglandins, may also contribute.51
Diarrhea
Secretory diarrhea is characteristic of NETs (Fig. 5), caus-
ing large volume stools, persists with fasting, and there is no
osmotic gap between serum and stool. There are several causes
of secretory diarrhea that need to be taken into consideration in
the differential diagnosis: watery diarrhea, hypokalemia, hyper-
chlorhydria, and acidosis syndrome, the ZES, carcinoid tumors,
MCT, secreting villous adenoma of the rectum, surreptitious
laxative abuse, and idiopathic.
Neuroendocrine tumors can produce diarrhea by different FIGURE 6. Gastrinoma triangle.
mechanisms depending on their secretory products. Gastrin can
increase the acid secretion by the stomach, which in turn inacti-
vates lipase, amylase, and trypsin, and damages the mucosa of the show a prolonged forced expiratory volume in the first second.
small bowel, leading to decreased absorption and impaired di- Differential diagnoses are asthma and chronic obstructive
gestion in the small bowel, exceeding the absorptive capacity of pulmonary disease. In the carcinoid syndrome, the cause of
the colon, what gives an increased fecal volume and malabsorp- bronchoconstriction is usually SP, histamine, or serotonin that
tive syndromes and sometimes steatorrhea. On the other hand, should be measured in patients who present with this symptom.5
carcinoid or other NETs can produce other substances such as Dyspepsia or Peptic Ulcer
VIP, PP, SP, calcitonin geneYrelated peptide (CGRP), and/or thy- The ZES is characterized by peptic ulcers and diarrhea that
rocalcitonin (TCT), all of which will act on the small bowel in- respond to therapy with proton pump inhibitors (PPIs) in the
creasing the secretion of fluids and ions, which in turn will also setting of hypergastrinemia and low gastric pH. Gastrinomas are
exceed the colonic absorptive capacity producing an increased localized 90% of the time in the Bgastrinoma triangle[ (Fig. 6). As
fecal volume as well as great losses of potassium and bicarbonate. discussed in the previous section, the measurements that should
A disturbing cause that may be very difficult to differentiate be drawn for these tumors are FSG and gastric acid output.
is laxative abuse, and in all circumstances, a KOH stool prepa-
ration to detect laxatives is mandatory. Measurement of intestinal Hypoglycemia
secretion by passing a multilumen tube and quantifying elec- The Whipple triad (symptoms of hypoglycemia, blood
trolytes and water transport, in addition to the measurement of glucose levels less than 40 mg/dL, and relief of symptoms with
stool electrolytes, which should account for the total osmolarity, glucose) is the clinical presentation of insulinomas, but other
will help to exclude laxative abuse, but is rarely performed. causes should be ruled out.
It is important to mention that Cunningham et al51 found in Patients with noninsulinoma pancreatogenous hypogly-
their study of tachykinins and NETs that there is an associa- cemia present with postprandial neuroglycopenia symptoms
tion between the elevation of tachykinins and the severity of the (within 4 hours of meal ingestion); have negative 72-hour fast-
diarrhea. They concluded that all biochemical marker concen- ing test; negative tumor localization studies; and on histological
trations were elevated in patients with daily episodes of diarrhea, diagnosis, hypertrophy or nesidioblastosis rather than an in-
although the association between increased plasma tachykinins sulinoma is found.18,52 Other possible causes that should be
and the severity of diarrhea was independent of both CgA and thought of are fasting, autoimmune (insulin antibodies), counter-
5-HIAA concentrations.51 regulatory hormone deficiency, drug-induced, and factitious hy-
poglycemia. To exclude all the other causes, clinical suspicion
Bronchoconstriction together with measurement of hormones or peptides should be
Wheezing caused by bronchospasm occurs in up to one used (Fig. 7).
third of patients with carcinoid syndrome. Lung function tests

FIGURE 5. Biochemical markers for diarrhea. FIGURE 7. Differential diagnosis of hypoglycemia.

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Vinik et al Pancreas & Volume 38, Number 8, November 2009

In case of hypoglycemia, the recommended biochemical tolerance test also measures lipids and insulin, which should
markers are insulin, IGF-2, C-peptide, glucagon-like peptide type also be suppressed. Other pituitary and hypothalamic hormones
1 (GLP-1), glucose-dependent insulinotropic peptide, sulfonyl- should also be measured, such as prolactin, the > and A subunits
urea, ACTH, GH, insulin antibodies, and liver enzymes.5 of gonadotropins, and thyroid-stimulating hormone.5
Dumping Syndrome Cushing Syndrome
This manifestation occurs after surgery when the pylorus A pituitary tumor, small cell carcinoma of the lung (known
has been resected or inactivated. It can be early, when symptoms to produce ACTH), or an ACTH-secreting NET will present
resemble shock, or late, which presents as hypoglycemia. For the clinically as the Cushing syndrome from oversecretion of cor-
diagnosis of this syndrome, a provocative test is done, giving the tisol, adrenal androgens, and 11-deoxycorticosterone. To reach
patient a high-calorie carbohydrate-rich breakfast with 750 kcal the diagnosis, several steps should be followed. New guidelines
(21 g protein, 30 g fat, and 99 g carbohydrate) that should be for the diagnosis of Cushing syndrome have been published,
ingested in 10 minutes to produce the maximum response. Af- although some of the recommendations are based on low-quality
ter completion of the meal, blood sample is collected at 10, 15, evidence. Their proposed approach is as follows.
30, 45, 60, 120, and 180 minutes to measure glucose, insulin, After excluding exogenous glucocorticoid use (iatrogenic
C-peptide, motilin, PP, and GLP-1 levels.5 An exaggerated in- Cushing syndrome), patients with unusual features for age such as
sulin and GLP-1 response to the meal is found in gastric bypass osteoporosis or hypertension, patients with multiple and progres-
patients with the syndrome, although the case and relationship sive features predictive of Cushing syndrome (easy bruising,
between the hormonal overproduction and the clinical syndrome facial plethora, proximal myopathy or muscle weakness, reddish/
remain controversial. purple striae, weight gain in children with decreasing growth
velocity), and patients with adrenal incidentaloma compatible
Pellagra with adenoma should undergo testing for Cushing syndrome
Pellagra is caused by niacin deficiency caused by the starting with 1 test with a high diagnostic accuracy: urine free
detour of the tryptophan pathway toward the production of cortisol (at least 2 measurements), late-night salivary cortisol
increased amounts of serotonin. Biochemical evidence of sub- (2 measurements), 1-mg overnight dexamethasone suppression
clinical pellagra was found in one third of the patients with test or longer low-dose dexamethasone suppression test (2 mg/d
newly diagnosed untreated carcinoid syndrome in a study by for 48 hours). If the test is negative and the pretest probability
Shah et al.53 was low, then follow-up in 6 months is recommended if there
Glucagonoma or the ‘‘Sweet’’ Syndrome is progression of symptoms; in case of a negative test but with a
high pretest probability, then more than 1 test should be per-
Diabetes accompanied by the 4D syndrome (dermatosis
formed. In some cases, a serum midnight cortisol or dexameth-
[necrolytic migratory erythema], depression, deep venous throm-
asone corticotropin-releasing hormone test should be done.56
bosis, and diarrhea) is the clinical presentation of glucagonomas.
Glucose intolerance in the glucagonoma syndrome may CLASSIFICATION OF THE BIOCHEMICAL
relate to tumor size. Fasting plasma glucagon levels tend to be MARKERS ACCORDING TO THEIR USE
higher in patients with large hepatic metastases than in those
without hepatic metastases,54 and all patients with large hepatic Diagnostic
metastases have glucose intolerance. Massive hepatic metastases
may decrease the ability of the liver to metabolize splanchnic CgA and CgB
glucagon, thus increasing peripheral plasma glucagon levels. Both CgA and CgB are part of the granin family. They are
Glucagon may not directly induce hyperglycemia, however, un- stored and secreted from vesicles present in the neuroendocrine
less metabolism of glucose by the liver is directly compromised. cells, together with other peptides, amines, and neurotransmit-
Another factor may be variation in the molecular species of ters.57 Chromogranin A is the best studied58 and most used. But
glucagon that is present in each case and its biological potency.50 CgA is not perfect. Stridsberg et al59 reported that there are some
In previously reported cases of glucagonoma in which common conditions that can increase the levels of this marker
plasma glucagon concentrations were measured by radioimmu- and give false-positive measurements including decreased renal
noassay, fasting plasma glucagon concentrations were 2100 T function and treatment with PPIs59 and even essential hyper-
334 pg/mL. These levels are markedly higher than those reported tension60; these problems are not seen with CgB, so they pro-
in normal fasting subjects (ie, 150 pg/mL) or in those with other posed the measurement of CgB as a complement to CgA.59
disorders causing hyperglucagonemia, including diabetes melli- The most important characteristic of these markers is that
tus, burn injury, acute trauma, bacteremia, cirrhosis, renal failure, they are not only secreted by the functional tumors but also by
or Cushing syndrome, where fasting plasma glucagon concentra- those less well-differentiated NETs that do not secrete known
tions often are elevated but less than 500 pg/mL. hormones.2
As with other islet cell neoplasms, glucagonomas may over- Chromogranin A has been shown to be increased in 50% to
produce multiple hormones such as insulin, ACTH, PP, PTH 100% of patients with NETs.61 Chromogranin A levels may be
or substances with parathyroid hormone-like activity, gastrin, se- associated with the primary type (gastrinomas, 100%; pheochro-
rotonin, VIP, and melanocyte-stimulating hormone in that order mocytomas, 89%; carcinoid tumors, 80%; nonfunctioning tumors
of frequency.55 of the endocrine pancreas, 69%; and medullary thyroid carcino-
mas, 50%). In addition, blood levels depend upon tumor mass,
Acromegaly or Gigantism burden, or progression, and malignant nature of the tumor.25,62
Acromegaly or gigantism can present when any NET se- Small tumors may be associated with normal CgA levels.
cretes GH or GHRH. Basal levels of GH and IGF-1 are usually Sensitivity and specificity of CgA depend on many factors.
enough to make a diagnosis; but in 15% to 20% of the patients, For example, sensitivity varies from 77.8% to 84% and spec-
further investigation is needed to show nonsuppressibility of ificity from 71.3% to 85.3%, depending on the assay used, and
GH to an oral glucose tolerance test, a somatostatin inhibi- of great importance is to establish the cutoff value that gives
tion test, or a bromocriptine suppression test. The oral glucose the highest sensitivity without compromising the specificity.63

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

Another use of CgA is to discriminate between patients with Follow-up, Treatment Response, and Prognosis
and those without metastasis, which also depends on the as-
say and the cutoff values used, with a sensitivity of 57% to CgA
63.3% and specificity of 55.6% to 71.4%.63 Other than the applications of CgA previously discussed,
this marker can be used for prognosis and follow-up. Jensen
Pancreatic Polypeptide et al66 found that a reduction in CgA levels greater than or equal
to 80% after cytoreductive surgery for carcinoid tumors predicts
Pancreatic polypeptide is considered another nonspecific
symptom relief and disease control; it is associated with im-
biochemical marker (Fig. 8). In a study conducted by Panzuto
proved patient outcomes even after incomplete cytoreduction.66
et al64 in Rome, Italy, in 2004, PP sensitivity was 54% in func-
tioning tumors, 57% in nonfunctioning tumors, 63% in pan-
creatic tumors, and 53% in GI tumors. Specificity was 81% Pancreastatin
compared with disease-free patients and 67% compared with One of the posttranslational processing products of CgA
nonendocrine tumor patients. But when combined with CgA, has been found to be an indicator of poor outcome when its
the sensitivity increased compared with either of the markers concentration in plasma is elevated before treatment in pa-
alone. When used in combination, the sensitivity of these mark- tients with NETs. A level greater than 500 pmol/L is an inde-
ers is 96% for gastroenteropancreatic NETs, 95% for nonfunc- pendent indicator of poor outcome. This marker is also known
tioning tumors, and 94% for pancreatic tumors.64 to correlate with the number of liver metastasis, so it would be
appropriate to use it in the follow-up of NET patients. Further-
Neuron-Specific Enolase more, Stronge et al67 found that an increase in pancreastatin
Neuron-specific enolase is an enzyme that occurs mainly levels after somatostatin analogue therapy is associated with
in cells of neuronal and neuroectodermal origin. The NSE has poor survival. Other studies have shown that pancreastatin
been found in thyroid and prostatic carcinomas, neuroblasto- should be measured before treatment and monitored during and
mas, small-cell lung carcinoma, carcinoids, gastroenteropancre- after it. Plasma levels of this marker greater than 5000 pg/mL
atic NETs, and pheochromocytomas. Despite its high sensitivity pretreatment were associated with increased periprocedural
(100%), its use is limited as a blood biochemical marker for mortality in patients with NETs who underwent hepatic artery
NETs because of its very low specificity (32.9%).65 chemoembolization.68

FIGURE 8. Primary structure of the CgA molecule showing several peptides that are derived after the enzymatic cleavage of CgA,
such as pancreastatin, catestatin, vasostatin, which have biological activity and may contribute to the clinical syndrome.

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Vinik et al Pancreas & Volume 38, Number 8, November 2009

was associated with an 87% survival at 1 year compared with

40% if it increased. They also concluded that any alteration in
NKA predicts improved or worsening survival.69

BIOCHEMICAL MARKERS FOR

BONE METASTASIS
Metastases from NETs can be either lytic and/or osteoblastic.
There may be an increased osteoclast activity contributing to
lytic lesions and/or an increase in osteoblastic activity responsible
for blastic metastases. Bone markers in lytic and osteoblastic
metastases that may assist in the evaluation of stage as well as
response to therapy include bone alkaline phosphatase (bAP), an
indicator of osteoblast function, and urinary N-telopeptide, which
reflects osteoclast activity or bone resorption. Somewhat para-
doxically, only blastic metastases show an increase in both
markers as indicated in Figure 9.70
FIGURE 9. Bone markers in patients with lytic and blastic Increased osteoclast activity predicts a poor outcome, with
metastases. BCE indicates bone collagen equivalents.70 relative risks for high N-telopeptide (9100 nmol bone collagen
equivalents/mM creatinine) of 3.3 (P G 0.001) for skeletal-
related events, 2.0 (P G 0.001) for disease progression, and 4.6
These observations suggest that pancreastatin is potentially (P G 0.001) for death.71
a very useful marker not only for diagnosis but more importantly The following markers are recommended.
for monitoring treatment response. Bone formation markers: serum PINP, serum bAP, serum
osteocalcin, osteoprotegrin.
Neurokinin A Bone resorption markers: urine N-telopeptide, serum CTX,
Neurokinin A has been shown to have a strong prognostic serum N-telopeptide, and serum RankL
value. Turner et al69 in 2006 showed that in patients with midgut Markers of malignancy: PTH-related protein (PTHrp) in
carcinoid that have raised plasma NKA, a reduction of this blood. Perhaps IGF-1. Calcitonin, transforming growth factor-A,
biochemical marker after somatostatin analogue (SSA) therapy and endothelin 1.

FIGURE 10. Algorithm for diagnosis and follow-up of NETs.8,76,77 NTx indicates N-telopeptide.

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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

Markers of cytokine excess: serum interleukin 1 and in- 3. Lamberts SWJ, Hofland LJ, Nobels FRE. Neuroendocrine tumor
terleukin 6. Vitamin D metabolism: serum 25-hydroxyvitamin D markers. Front Neuroendocrinol. 2001;22(4):309Y339.
and ionized calcium. 4. Vinik A, Moattari AR. Use of somatostatin analog in management of
carcinoid syndrome. Dig Dis Sci. 1989;34:14SY27S.
5. Vinik A, O’Dorisio T, Woltering E, et al. Neuroendocrine Tumors:
A Comprehensive Guide to Diagnosis and Management, 1st ed.
BIOCHEMICAL MARKERS FOR Interscience Institute; 2006.
CARDIAC INVOLVEMENT 6. Modlin IM, Oberg K, Chung DC, et al. Gastroenteropancreatic
Carcinoid heart disease is a unique cardiac disease associ- neuroendocrine tumours. Lancet Oncol. 2008;9(1):61Y72.
ated with NETs and may be seen in up to 60% of patients with 7. Faggiano A, Mansueto G, Ferolla P, et al. Diagnostic and prognostic
metastatic carcinoid. Valvular disease is the most common patho- implications of the World Health Organization classification of
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valve disease is found in 88%, with 88% displaying insuffi- 8. Vinik AI, Feliberti E, Perry RR, et al. Carcinoid tumors. In: de Groot
ciency and 49% displaying stenosis. The distinctive carcinoid LC, ed. Diffuse Hormonal Systems and Endocrine Tumor Syndromes.
lesion consists of deposits of fibrous tissue devoid of elastic fi- Endotext; 2008.
bers known as carcinoid plaque. The deposits are found on the 9. Gustafsson BI, Kidd M, Chan A, et al. Bronchopulmonary
endocardial surface on the ventricular aspect of the tricuspid neuroendocrine tumors. Cancer. 2008;113(1):5Y21.
leaflet and on the arterial aspect of the pulmonary valve cusps.72 10. Oberg K, Jelic S. Neuroendocrine bronchial and thymic tumors:
Although the precise cause for the plaque formation is ESMO clinical recommendation for diagnosis, treatment and follow-up.
not entirely clear, the direct actions of serotonin and bradykinin Ann Oncol. 2008;19(suppl 2):ii102Yii103.
have been implicated in animal studies. This finding is cor- 11. Stachura T, Strzalka M, Bolt L. Type 1 carcinoids and ECL-cell
roborated by the observation that the appetite suppressant drug hyperplasia of the gastric mucosa. Przegl Lek. 2003;60(12):782Y788.
fenfluramine, which releases serotonin, has been noted to cause 12. le Roux CW, Patterson M, Vincent RP, et al. Postprandial plasma ghrelin
valvular distortion similar to that seen in carcinoid heart dis- is suppressed proportional to meal calorie content in normal-weight but
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consort with the development of carcinoid heart disease. Possibly 13. Tsolakis AV, Stridsberg M, Grimelius L, et al. Ghrelin immunoreactive
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ProYbrain natriuretic peptide (NT-pro-BNP) can be used as a pancreatic tumor/carcinoma: insulinoma. Neuroendocrinology. 2006;
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biomarker for the detection of carcinoid heart disease with a high
specificity and sensitivity and used as an adjunct to deciding who 15. Hirshberg B, Livi A, Bartlett DL, et al. Forty-eight-hour fast: the
diagnostic test for insulinoma. J Clin Endocrinol Metab. 2000;85(9):
requires echocardiography (Bhattacharyya et al74).
3222Y3226.
16. Quinkler M, Strelow F, Pirlich M, et al. Assessment of suspected
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For those patients Bescaping[ symptomatic control with 17. Jensen RT, Niederle B, Mitry E, et al. Gastrinoma (duodenal and
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of the steps for diagnosis and management of NETs starting at tumours. Best Pract Res Clin Endocrinol Metab. 2007;21(1):15Y31.
the presentation of a suggestive clinical scenario. 21. Bolanowski M, Jarzab B, Handkiewicz-Junak D, et al. Neuroendocrine
It is the purpose of this chapter to show the importance tumors of the small intestine and the appendix - management guidelines
of recognizing, as early as possible, the clinical syndromes that (recommended by The Polish Network of Neuroendocrine Tumors)
suggest a NET as one of the differential diagnosis, and once [In Polish]. Endokrynol Pol. 2008;59(1):87Y96.
suspected, look for the appropriate biochemical markers that will 22. Tseng WW, Liu CD. Peptide YY and cancer: current findings and
confirm the diagnosis or confidently discard it. potential clinical applications. Peptides. 2002;23(2):389Y395.
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usually with episodic expression that makes diagnosis difficult, defining the most sensitive test. Ann Surg. 2006;243(1):102Y107.
erroneous, and often late; for these reasons, a high index of sus- 24. Giovanella L, Squin N, Ghelfo A, et al. Chromogranin A
picion is needed and it is important to understand the patho- immunoradiometric assay in diagnosis of pheochromocytoma:
physiology of each tumor to decide which biochemical markers comparison with plasma metanephrines and 123I-MIBG scan. Q J Nucl
are more useful and when they should be used. Med Mol Imaging. 2006;50(4):344Y347.
25. Bilek R, Safarik L, Ciprova V, et al. Chromogranin A, a member of
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Pancreas & Volume 38, Number 8, November 2009 Biochemical Tests for NETs

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