Dr. Dwight C. Kaufman, MD 720 West Forest Avenue, Jackson, TN 38301

"Attention : DR.Kaufman Dwight , From: Dr. A.Naser Nourallah MD.FACP Consultant and Head of Hematology/Medical Oncology service, Alman Group of Hospitals 54 yo f diagnosed with low grade NET, ileum, almost 19 mo ago full work_up including ct-scan(pet was not available) was c/w. Liver mets wth elevated 5 HIAA of 89... Started on afinitor and sandostatin LAR 20 mg with sig improvement in sx and drop of 5HIAA to 9 Ct scan showed sig improvement Recently, sx started to recur on and off. Ct scan there are very mild progression and 5HIAA is now 42 Chronogranin in was elevated in range of 400 to 500 relatively stable afinitor is on hold I have presented this case before regarding lines of treatment. Pt continued on afinitor 10mg and sandostatin LAR 30mg . with almost stable disease. Couple of months ago, pt developed respiratory distress and dry cough. Ct Scan and echo were done . Findings were c/w increased thickening with mod pulmonary hypertension . Afinitor was held and oral steroid was initiated . Shortly , pt experienced significant improvement and ct scan was repeated after almost one month which showed sig improvement with disappearance of previous findings Despite mild progression was noted in liver mets, afinitor is still on hold . what do you recommend next?? continue same regimen without afinitor or start afinitor with reduced dose 5mg or others? thank you and best regards,"