Neuroendocrine Tumors

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're super excited to have Dr. Michelle Kim, who is our new Chair of Cleveland Clinic's, Department of Gastroenterology, Hepatology, and Nutrition. Michelle, welcome to Butts & Guts.

Dr. Michelle Kim: It's nice to be here, Scott. Thanks so much for having me.

Dr. Scott Steele: Awesome. So today we're going to talk a little bit about neuroendocrine tumors. But before we jump into that, we want to know a little bit more about you. So, where are you from, where'd you train, and how did it come to the point that we got you so luckily here at the Cleveland Clinic?

Dr. Michelle Kim: So, this has been quite a transition and really quiet an adventure, as well. I was originally born in Oklahoma, but spent most of my years in the Northeast, mostly in New York. And for the last 17 years I have been fortunate enough to have been faculty at Mount Sinai. And when this opportunity arose about a year ago, there was just something about it that was impossible to turn away from. And honestly, the opportunity to be here, to be a leader in gastroenterology, hepatology, nutrition, and to outline a vision that everyone was aligned with, I thought was very exciting. And so, here I am.

Dr. Scott Steele: And we're very, very lucky to have you here. And so today, we're going to talk a little bit about neuroendocrine tumors. And I guess two questions to start off, maybe a 50,000-foot view, is first of all, what are neuroendocrine cells before we talk about tumors, and what do they do? And then what are neuroendocrine tumors? You're one of the leaders in this, how did you get involved in neuroendocrine tumors?

Dr. Michelle Kim: So, neuroendocrine cells are widely dispersed throughout the body, the vast majority in the gastrointestinal tract and in the lungs. And they essentially serve, sort of, as intermediaries between the brain and also being able to secrete peptide hormones into the bloodstream. And so, what happens in terms of these cells becoming tumors is obviously there's cell dysregulation, and these become a form of cancer.

And what I think a lot of us learn about in medical school is some of the dramatic symptoms that can be associated with these tumors. But I think what's important to know is that these are becoming increasingly common and that gastroenterologists are really particularly well poised to care for patients with these tumors.

And in terms of how I got involved with this, it was, as I said, an unusual tumor. You don't usually see much of it during your training. It's something you only read about in textbooks. But at Mount Sinai, I was very fortunate to have been mentored by somebody and to have seen a very large number of patients with these tumors. And so, before I knew it, I was seeing patients with these tumors and trying to understand the course of their clinical disease and I think really was very fortunate to have seen a lot of them and then, again, hoping to do this more in Cleveland Clinic.

Dr. Scott Steele: Oh, that's awesome. And I think it's a very interesting tumor. They've been called a lot of different things. And so, what are the different types of neuroendocrine tumors? And you mentioned that these neuroendocrine cells are all over the body. So where do these tumors, where are they most commonly found?

Dr. Michelle Kim: So, the nomenclature, I would say, has been very erratic over the years. We used to call them carcinoid tumors. Now, my favorite terminology is actually to call them neuroendocrine tumors. And the way that we call them is also in terms of how they present clinically and in terms of how we classify our patients.

So, one way to think about them is sort of functioning versus non-functioning tumors. Functioning tumors, meaning that there is a clinical syndrome associated with it. Non-functioning, usually meaning that there are rather non-specific symptoms associated with it.

Carcinoid is a very particular brand of neuroendocrine tumor that often is associated with an overproduction of serotonin. And so, these patients will often have a very dramatic syndrome called carcinoid syndrome associated with flushing, diarrhea, palpitations, and wheezing. And so, these carcinoid patients, again, this term is somewhat going out of favor, but are associated with a very specific clinical syndrome.

Dr. Scott Steele: So, truth or myth? Truth or myth: the average age of a neuroendocrine tumor diagnosis is between age 50 and 60.

Dr. Michelle Kim: That's about right. So, the vast majority of neuroendocrine tumors, especially in the GI tract, are those in the small bowel and the rectum. And so, although the range can be quite different, the actual average age is probably somewhere in the 50s.

Dr. Scott Steele: So, you mentioned a little bit before about where they are and when they occur and everything, but how do you diagnose them? And if I'm a patient out there thinking, "I wonder if I have a neuroendocrine tumor." You talked a little bit about that syndrome that we'll talk about. But let's talk about diagnosis and then maybe a little bit of an overview of treatment options that are available.

Dr. Michelle Kim: Sure. So, I think the first thing is that it's not usually something you wonder about too much just because it's not very common. It's much more common if you have gastrointestinal symptoms that you're going to have irritable bowel syndrome or inflammatory bowel disease or something much more common like that.

I think that it comes to diagnosis in two ways. One is that if you have symptoms, and if you're under the care, let's say of a gastroenterologist, and I think what's fair is that if you're not doing so well, if your symptoms are not being well controlled, that at least raising the question with your physician I think is reasonable. If you're doing very well with your medical treatment or on surgery or whatever you've been treated for, that's one thing. But if you're not doing well, you're still not feeling well. I think it's at least fair to raise the question with your physician.

The other way that this gets diagnosed is sort of by accident, incidentally. Oftentimes, people are having endoscopies or colonoscopies for one reason or another, or perhaps having a CT scan or an ultrasound, and then these are getting found by accident. And luckily, in that way, that's often diagnosed early and it's something that's very treatable.

Dr. Scott Steele: So, walk me through this. So, I'm a patient out there and I had a scope and they said, "Hey, listen, we saw something, we took a biopsy of it," and either biopsy, because it's a little deeper sometimes, didn't come back at that or they think it's a neuroendocrine tumor and they're in your clinic now. So, what type of follow up tests and everything do they do? And do all of them need surgery? Are there medications that can just make them go away? Can you put a topical medication on it depending on where it is? What does that involve?

Dr. Michelle Kim: So, the first thing is that I usually give a healthy dose of realism and just say, "You know what? Just calm down." Actually, most people are going to do quite well with these. It's what we consider oftentimes an inconvenience because you need to follow them, and you need to certainly survey patients. But oftentimes, our patients will do quite well.

The first thing is really we want to understand the stage and the grade of the tumor. Like any cancer, you need to know the stage. This relates to how extensive it is. And then you also need to know the tumor grade, which is a sort of general broad category of how aggressive tumor biology is.

Once that happens, and depending on where the tumor is, then we have an understanding and particularly when you come to a specialized center like we have here at Cleveland Clinic that we actually have broad experience with this, and we understand which tumors you have to worry about and which ones you don't. And therefore, we can really tailor and personalize the treatment, whether it comes to endoscopic treatment, whether it's related to surgical treatment or medical treatment or even radiation. And we can luckily handle all of this in a very multidisciplinary tumor board where these patients are seen.

Dr. Scott Steele: So, are there any advancements on the horizon for neuroendocrine tumors, either in the diagnosis or the management?

Dr. Michelle Kim: I think what's been really terrific is because of these large scale international randomized control trials that we actually now have really great data. And so, on the diagnosis side, I would say that we have gallium dotatate scans, which have really revolutionized the way that we stage these tumors. And in terms of the treatment, I would say that peptide receptor radionuclide therapy or PRRT, is by far the newest kid on the block, the most promising kid on the block. That has really, again, revolutionized the treatment of neuroendocrine tumors in this country.

Dr. Scott Steele: So, now it's time for our quick hitters where we get the chance to know you just a little bit better. So first of all, what is your favorite food?

Dr. Michelle Kim: So, I would say Korean food as a generality. There's something, especially, as I get older that I think I'm reverting back to my youth. And so, those comfort foods that I used to eat as a kid with my parents still, I think, really hit the spot these days.

Dr. Scott Steele: What's your favorite sport to watch and/or to play?

Dr. Michelle Kim: So, favorite sport to watch, I'm going to say is maybe Duke Fencing because my son fences for the Duke Fencing Team. And in terms of playing, I would say tennis. I love playing tennis. Not very good, but I love to play it.

Dr. Scott Steele: Two-handed backhand, or a one-handed backhand?

Dr. Michelle Kim: Two handed.

Dr. Scott Steele: There we go. I like it. What was one of your favorite trips?

Dr. Michelle Kim: This is tough. There have been a lot of them. I'm going to go with perhaps a recent trip to Vietnam the summer. Just in terms of one of the most memorable trips in terms of the people, the culture, the food. I do have two kids, but this one was a mother/son trip. And just because I think the dynamic there was really quite memorable.

Dr. Scott Steele: Oh, that's awesome. I heard they have beautiful beaches too. Never been. So, you've been to a lot of different places. And so, tell us something that you've liked in the time that you spent here in Northeast Ohio.

Dr. Michelle Kim: So, I have to say I love the nature here. The summer and the fall, so far, have been spectacular. I'm really enjoying the Metroparks here, and just every weekend or so that I have time really getting to explore some of those areas. And so, I'm really trying to squeeze that in before the winter and the lake effect blows in. So, we'll have to see how much I can accomplish in the next few months.

Dr. Scott Steele: That is absolutely something that's true here. So, give us a final take home message for our listeners about neuroendocrine tumors.

Dr. Michelle Kim: So, while these tumors are not very common, they are increasing in prevalence. I think if you're diagnosed with one, not to worry, that this is something that's very treatable, and I think the most important advice I can give is really to be seen at a specialty center. If you haven't been diagnosed with one, but you think you might have it, again, the chances are, because of the rarity of the disease, that you're probably not going to have it, but it's reasonable to at least raise the question with your gastroenterologist or with your treating physician to ask if it might be possible and if it's something that should be considered.

Dr. Scott Steele: Well, that's fantastic. And so, to schedule an appointment or learn more about neuroendocrine treatment options here at the Cleveland Clinic, please call 216-444-8675. That's 216-444-8675. Dr. Kim, thanks so much for joining us on Butts and Guts.

Dr. Michelle Kim: Thanks so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.