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Oncology Neuroendocrine Tumors Diagnosis NETs arising from the endocrine cells ofthe pancreas are called pancreatic NETs, whereas those arising from the digestive tract are called gastrointestinal NETs. Most NETs are hormonally nonfunctioning, but about 25% manifest a hormone. Gastrointestinal NETs can produce serotonin, which may cause diarrhea and facial flushing, and gastrin, which may cause peptic ulcer disease. Pancreatic NETs may produce insulin, gastrin, glucagon, somatostatin, or vasoactive intestinal peptide, with resulting hormonal syndromes based on the type of hormone elaborated. This tumor may be part of the multiple endocrine neoplasia type 1 (MENI) syndrome (primary hyperparathyroidism, pituitary tumors, enteropancreatic tumors). Nonfunctioning tumors may be asymptomatic and develop metastatic disease many years before diagnosis. Testing Initial evaluation of NETs includes CT imaging. Imaging with radiolabeled somatostatin analogues or MRI is used in tumor localization. Treatment Most NETs are indolent and can be followed until symptomatic. Surgery can be used to remove localized tumors. Hormonally active tumors with somatostatin receptors may be treated with the somatostatin analogue octreotide or lanreotide. Cervical Cancer Prevention and Screening See General Internal Medicine, Cervical Cancer Screening. Diagnosis Most cancers are asymptomatic, but abnormal vaginal bleeding is the most common clinical presentation (postmenopausal, postcoital, and intermenstrual). Associated pain and abnormal discharge are usually signs of advanced disease. Testing Punch biopsy ofobvious lesions or colposcopy-directed biopsy is usually required for diagnosis. Imaging studies are obtained for moderate-risk or high-risk stage cancers or as symptoms or physical findings warrant. Treatment Early (stage I) cancers may be treated with loop electrosurgical excision or cervical conization to preserve childbearing; patients who have finished childbearing may undergo hysterectomy without lymph node dissection. Radiation therapy and cisplatin chemotherapy are used for patients with stage II, III, or IV disease. Treat patients with recurrent disease or distant metastases with local radiation (for local control) and chemotherapy plus bevacizumab. 321