Table 1.

Comparison of 4 guidelines on the management of small bowel neuroendocrine tumors.

Guidelines Situations	Canadian Consensus Guidelines 2016 (12)	NANETS (North American Neuroendocrine Tumor Society) Guidelines 2017 (13–14)	NCCN (National Comprehensive Cancer Network) Guidelines 2018 (15)	ENETS (European Neuroendocrine Tumor Society) Guidelines 2016 (16–17)
Locoregional disease	→ Complete resection of the primary tumor and the associated lymphatic drainage field → Evaluate for multifocality (Unclear if favor open vs. laparoscopic minimally invasive)	→ Complete open resection of primary tumor and the associated lymphatic drainage field → Laparoscopic resection is acceptable if bowel can be completely run through a small incision	→ Complete resection of the primary tumor and the associated lymphatic drainage field → Evaluate for multifocality (Unclear if favor open vs. laparoscopic/ minimally invasive)	→ Complete open (or in selected patient laparoscopic) resection of primary tumor and the associated lymphatic drainage field
Residual disease or positive margins post-primary resection	→ Definitive resection when technically feasible	→ Not addressed	→ Not addressed	→ Not addressed
Synchronous primary and metastatic disease	→ Resection of primary tumor(s), lymph nodes in combination with liver metastases	→ Resection of primary tumor(s), lymph nodes in combination with liver metastases	→ Resection of primary tumor(s), lymph nodes in combination with liver metastases	→ Local radical open resection of primary tumor(s), lymph nodes in combination with liver metastases
Liver metastases	→ Resection of liver metastases with the goal of preserving liver parenchyma and both left and right inflow and outflow vascular patency when possible. → Image-guided ablation either alone for limited disease (tumors ideally < 3 cm) or in combination with surgery → If cytoreductive surgical/ablative procedures not indicated; bland embolization, chemoembolization or radioembolization	→ Resection of liver metastases should be attempted when feasible and low morbidity/mortality → Parenchymal sparing procedures should be considered → Patients with any number or size of metastases, intermediate grade, extrahepatic disease should be considered for liver debulking operations if a 70% debulking threshold can be achieved. → If cytoreductive surgery not indicated; bland embolization, chemoembolization or radioembolization	→ Resection of liver metastases or ablative therapies such as RFA (Radio-Frequency Ablation) or cryoablation may be considered if near-complete treatment of tumor burden can be achieved. → If cytoreductive surgical/ablative procedures not indicated; bland embolization, chemoembolization or radioembolization	→ Resection of liver metastases when feasible → Image-guided ablation can be combined with surgical resection → If cytoreductive surgical procedures not indicated: radio-frequency ablation, laser-induced thermotherapy, transarterial chemoembolization, transarterial embolization or selective internal radiation therapy (investigational)
Peritoneal metastases	→ Surgical resection when feasible and synchronous resection of peritoneal disease and hepatic metastasectomy is an option.	→ Surgical resection when feasible → No evidence supporting use of HIPEC (hyperthermic intraperitoneal chemotherapy)	→ Not addressed	→ Not addressed
Abdominal disease in setting of extra-abdominal metastases	→ Cytoreduction should be considered in selected patients for symptom control	→ Not addressed	→ Not addressed	→ Not addressed
Prophylactic cholecystectomy	→ Consider as part of any abdominal surgical procedure	→ If future treatment with SSA is anticipated, a prophylactic cholecystectomy can be considered	→ If future treatment with SSA is anticipated, a prophylactic cholecystectomy can be considered	→ If future treatment with SSA is anticipated, a prophylactic cholecystectomy can be considered
Systemic therapy for metastatic or unresectable disease	→ First line: somatostatin analogues (octreotide LAR (Long Acting Release), lanreotide autogel) → Second line: everolimus single agent OR everolimus + SSA OR PRRT (Peptide Radionuclide Radiation Therapy)	→ First line: somatostatin analogues (octreotide LAR, lanreotide autogel) → Second line: PRRT (preferred) OR everolimus → Other less favored modalities: Interferon alpha 2b or locoregional therapy	→ First line: somatostatin analogues (octreotide LAR, lanreotide autogel) or watch and wait if asymptomatic with low tumor burden → Second line: start SSA if prior watch and wait OR everolimus OR PRRT OR locoregional therapy OR interferon alpha 2b OR cytotoxic chemotherapy if no other options feasible	→ First line: somatostatin analogues (octreotide LAR, lanreotide autogel) or watch and wait if G1, low tumor burden, stable and asymptomatic → Second line: Start SSA if prior watch and wait OR locoregional therapy OR PRRT OR everolimus OR interferon alpha 2b
Symptom control—Carcinoid syndrome	→ First line: somatostatin analogues (octreotide LAR, lanreotide Autogel) → Short-acting octreotide recommended for two weeks after first long-acting SSA injection → Refractory to SSA: telotristat etiprate OR interferon alpha OR SSA dose escalation	→ First line: somatostatin analogues (octreotide LAR, lanreotide autogel) → Short-acting octreotide recommended for two weeks after first long-acting SSA injection → Refractory to SSA: telotristate etiprate	→ First line: Somatostatin analogues (Octreotide LAR, Lanreotide Autogel) → Short-acting octreotide recommended for two weeks after first long-acting SSA injection → Refractory to SSA: Telotristate etiprate	→ First line: somatostatin analogues (octreotide LAR, lanreotide autogel) → Refractory to SSA: SSA dose increase OR add-on interferon alpha 2b OR pasireotide OR PRRT OR telotristat etiprate
Symptom control—Bone and brain metastases	→ External beam radiotherapy is an option	→ Not addressed	→ Not addressed	→ Not addressed

→ Major differences between guidelines are italicized in Table 1.