E97 Masterclass with Daryl Gray on Neuroendocrine Tumors (NETs)

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We've had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

On this episode, we have a masterclass on gastrointestinal neuroendocrine tumors by integrant and trauma surgeon Dr. Daryl Gray. Dr. Gray is Associate Professor of Surgery at Western in London, Ontario, and possibly one of the most interesting people in the world. We explore his life and in particular, his experience being the father of a teen television star. And of course, his passion, neuroendocrine tumors. Dr. Gray, thank you again for joining us on Cold Steel. Can you tell us a little bit about where you grew up and what your training pathway was?

Daryl Gray  01:46

Okay, great. Ameer, Chad, it's a pleasure to be on the podcast with you guys. I think it's a great venue and thanks for doing this stuff for surgical education and learning for everybody. I was born in Montreal, and that's why I'm a devout Montreal Canadienne fan. I have been ever since. My parents moved to Medicine Hat, Alberta when I was just probably less than a year old. And I grew up in a little town called Medicine Hat, it's in the southeast corner of Alberta. I grew up with horses all my life. My dad was in organic chemistry, he worked at the Defense Research establishment in Southfield. So, we were always involved in science and animals and things, and I did my high school there. And then I decided to travel the world a little bit more and expand my horizons. So, I was accepted into university at the University of Western, Ontario. It was called that then. Now it's called Western. I did my sciences there, got my science degree and got into medical school there as well. I finished my medical school training, completed a residency at Western in London. A general surgical five-year program. And then I got accepted down to Ann Arbor, Michigan, the University of Michigan hospital with Dr. Norman Thompson, the master of endocrine surgery. So, I completed an endocrine surgery fellowship with him, which was unbelievable. Torn between endocrine surgery and trauma surgery, I actually applied to several trauma fellowships as well because I didn't know which one I really wanted to do. But after experiencing a couple of days down there with Norm Thompson, I came home and reflected and said I'm going to do this instead. So, then I came back onto staff at Western in 1997. And I've been practicing there ever since. My practice, I was the director of the trauma program, believe it or not for the first 15 years there and now I, you know, explore. I do acute care surgery. I do a lot of endocrine surgery. I do a lot of neuroendocrine tumors, adrenals, you know, functional pancreatic tumors. And it's a great practice.

Chad Ball  04:03

Oh, that's interesting. I didn't know you trained with Dr. Thompson but that makes total sense for sure. You know, we're hoping to take a bit of a deep dive into gastrointestinal neuroendocrine tumors with you but first I want to talk if it's okay with you a little bit about your life, you know, outside maybe of the hospital, which I'll be honest and I realize nothing's as perfect as it looks from the outside, but your life looks amazing to most of us across the country. As you point out you know, you certainly ride horses. My understanding if I remember correctly is you play Polo. I know you fly, and you can land on your ranch. I'm curious, how did you not only develop such a wide sort of interests, but how did you nurture them and how did you maintain them with being such a busy clinical guy at work?

Daryl Gray  04:52

Yeah, great questions. I sleep not as much as most people. I sleep more than you, Chad, I'm sure, as I heard you don't sleep much. Growing up, my dad flew planes. We also had horses all my life. I rode all my life. At Western, and then out in London went into other things. And so, I was passionate about flying. When I finished my residency, I took a year as a research fellow, and during that time, I got my private pilot's license. And me and my buddy, my family Doctor buddy, did our licenses together. And then we actually ended up buying a plane. So, we fly, we enjoy flying, I find it fascinating. At the peak of Polo, our kids are all grown up and gone now. And I'm getting too old to play Polo because if I fall off a horse, I might not get back on one. But at the peak, we had 17 horses out here. We had two big horse trailers. We traveled up to Toronto or New York or down to Detroit and played Polo with four kids and two of us, so six people. And it was great. And you know, besides that Chad, just so you know, I also coached my three boys in hockey, I was a trainer for 17 years. We won four Ontario championships during those times. So, between all that other stuff and practices, two times a day, sometimes at five in the morning or whatever. And call and team leader, it was busy. And you organize your time. You don't watch TV. You go to bed at a decent time, so you can get up in the morning and continue your work. And it's organization, organization.

Chad Ball  06:45

Yeah, I think that's a common theme among, you know, all the hyper performers that we get to talk to, luckily and learn from on this show. It makes me think of Jocko Willink yet again, who, you know, you probably know as a navy seal, he does a lot of motivational organizational stuff. And he has this relatively well-known saying, I don't think it's unique to him, but "you obtain freedom basically through organization" and doing a lot of the things that you just mentioned. So, it all makes sense. I remember about 20 years ago, maybe I'm off a little bit in that date. You were followed around a little bit for sort of a TV show. I don't know if docu-drama is the right word. Tell us about that. And what was that experience like being stalked by a camera for a bit?

Daryl Gray  07:30

It was absolutely fascinating. So that show was called "The surgeons", and it was through the Discovery Channel and was around 2004 or so. And what they did on each episode is they followed a surgeon around, and they saw what their life was inside and outside of the hospital. And these guys showed up one day, and there was a camera man, a producer and a sound man. And they started in the morning, and they just started following me around. And they followed me through the hospital, into operating rooms, down to emerge, and then out to my life outside with my kids. And it was amazing. These guys, and I'm telling you, when they showed up, it was probably one of the busiest - they showed up on a Friday I think - and it was probably one of the busiest Fridays I've had. So, I was in the operating room and I was the trauma team leader. And I was the general surgeon on call that day. And so we were in and out of the operating room and down to see traumas and then back up to the operating room and then down to emerge to see emerge patients. And by nine o'clock at night we were operating on a bleeding gastric tumor, this poor lady she had a tumor that was bleeding, and we were doing a palliative procedure on her. And by nine at night, I'm sitting outside the operating room on the gurney, and this lady was with and I said you guys gonna stick around for this? And they said, well we're gonna stick around for a little while, but honestly Dr. Gray, we're exhausted, and we have to go to bed for a while. And I said do you understand that we have filmed three times as much footage on you today than we do usually in two or three days with the surgeons. I don't even know what we're gonna do with all this stuff. So, these poor guys, they finally left. They said we just have to go. We're done. And so, they came back the next day and you know, they came out and looked at the horses. They were watching me ride; they went onto the airplane. We flew around a little bit. They weren't allowed to fly with me. Their insurance didn't cover that. But they wanted to film that. It was fascinating. It was a great documentary. It was a great series if you ever get a chance to see it. They came down and took pictures of me. They made me the poster child. Like my poster was on bus stops and buses everywhere.

Chad Ball  09:57

That's fantastic. You know, it's interesting. We've been talking about doing that various format, sort of follow a surgeon around for 24 hours, either with a reporter or even doing some podcast element of it. And there's a couple of things maybe, you know, 15 years later that are interesting I do worry about - and I don't know what you think about this a little bit - but sort of the public perception that maybe that's unsafe in terms of how we work. And so, we've never triggered it. And of course, the medical legal side of it, too now is very different, I would argue as well, but we'd love to do it. And maybe we'll bug you a little bit for your insight.

Daryl Gray  10:34

You hit the nail on the head there with the medical legal stuff. And signing releases for everybody was a lot of work for those guys, for producers running around. And I think that the whole series actually probably got shut down because of that insurance slash medical legal part of it just being a little too difficult for production crews to do that in Canada. Maybe in other countries, but I think Canada is prohibitive.

Chad Ball  10:58

Right. That's interesting. You know, I know in some of these trauma and acute care surgery shows that intermittently pop up in the US, they get these waivers of consent for everything in their department. But you're right. In Canada, we can't do that. And it's true. The sort of the second last sort or personal or social part I was hoping you're willing to go into is: I know we all know you have four amazing kids, and they're all doing great and interesting to talk about. But we particularly wanted to ask you about your son Johnny. Nickelodeon had a show and I'm sure it's probably still on called Max & Shred. That was a massively popular show. And Johnny was sort of center and upfront in that show. I'm curious what that was like for him. We're curious what that was like for you. And you know, I know you have lots of great stories surrounding that whole scenario, but yeah, just curious how that all went.

Daryl Gray  11:57

Yeah, a fantastic experience for him. Johnny was our youngest son, our third child, amazing hockey player, great football player, unbelievable sports guy. I thought he was going to be a hockey player. But one day, there was an advertisement that came out internationally around the world for an audition to become the junior roving reporter for the King's Elephant Polo Tournament in Thailand. And the Elephant Polo tournament is a huge, huge thing. Their princes and queens and politicians and major sports people come to it to raise money for these elephants that are sort of street elephants, and they don't get fed well, so they raise money for them. Well, Johnny put in a two-minute video. And it was because we were playing Polo out here, it included that. And he actually got accepted as the junior reporter worldwide. So, Jacqueline, my wife, and Johnny went to Thailand for a week and a half. And we did this venue. And I didn't think that he could be a good presenter on TV or camera, or you know, speak well. He was kind of a rough and tumble hockey kid. And they loved him so much that he was on the Australia today show with a lady from Australia today showing her how to play Polo on an elephant. And everyone said this kid is an absolute natural at this, you should get him into this business. So, we decided to do that. And when we came home, when Jacqueline said, are you kidding? They're talking about Johnny? Like really? So, no kidding. We did and we got him an agent and got up to Toronto and I would fly him. So, for every show he ever got, we would probably do 20 to 30 auditions. And these auditions would be five-minute auditions up in Toronto. And I would fly up to Toronto Island airport, land, go down, audition for like seven minutes, get him up to the airport again, fly home. Or drive-up drive back. It was a lot of work to do that. Wow. He became a natural in this. And he got a show: Paranormal Witness. And then he was on another show on YTV called Annedroids. Then he got the show on Max & Shred and he was Max for two or three seasons. Then he did three films: that Bruno & Boots, a George Corman book series. They did three films Bruno & Boots, and he was Bruno. He was the main actor. And now he's on CTV with Jason Priestley on private eyes. He does probably six episodes a year with them. And what I find fascinating was this: when you sit watching him, he's just a regular kid, and he's kind of, you know, joking around and fooling around when the camera isn't running. And then when that director says action, it's a whole different kid. It's unbelievable how it happens. I'm fascinated to watch that when he does it. It's unbelievable, the natural tendencies he has for it. It was an incredible experience for him. Worldwide experience. He was on another show called Ride. We went over to Northern Ireland, filmed for four weeks to do these series called Ride. And it was fascinating for him. He's traveled all over the place down to California, down to the kids awards and stuff. It's been a great experience for him.

Chad Ball  15:28

Wow, that's a fascinating story. You know, he's a good looking smart, talented guy. So, I guess we all shouldn't be surprised by his success. But then, you know, that certainly also reflects on you and your wife as well. I am curious, what were some of the challenging aspects besides scheduling and time in that voyage?

Daryl Gray  15:51

Well, scheduling and time was quite a nightmare. There's no question about that. Trying to keep Johnny on track educationally. You know, they do have school during times that they're not filming. And they have little clinics, you know, or a classroom. They have a dedicated teacher. But it was a struggle. It was a big struggle. In fact, when Johnny finished grade 12, he actually didn't graduate because he was filming so much, he didn't have enough courses. So, we in fact had to finish school after that, which he's done. He's now in university, he's doing TV production and stuff like that. He loves it. But that was a big challenge for us. It was another big challenge to keep him grounded. If you can imagine a 14 year old kid, 15, that you know, girls are lined up waiting for him when he comes out the door. And, you know, they're making money. And it's very hard to you know, keep him grounded. You know, there's stories of guys like Justin Bieber kind of going off the rails in this world of TV and fandom. And you know, Instagram and Twitter. It was difficult. And it took a while to get him sort of grounded back again into him understanding sort of stuff as he matured.

Ameer Farooq  17:06

It almost feels like you've been living several lives in one. You know, you've written lots of interesting things, too. And in particular, one of the things that I think Dr. Ball and I loved was the pieces that you've written about. Roscoe Reed Graham for both the eponymous Rosco magazine that was published by CAGS, as well as within the Journal of Trauma. Can you talk a little bit about Roscoe and why you're so fascinated by him?

Daryl Gray  17:34

Roscoe Graham, I think epitomizes a surgeon. He had it all, even though it was back in the early 1900s. Like 1913 I think he went to school. He's born in 1890. But he epitomizes a surgeon that says number one, I'm going to take care of my patients first and foremost. Number two, I'm not going to accept status quo and there has to be different things that we can do and help our patients to get better improvement. And sure, surgery was very basic back then. But he epitomized that, and you know, the other reason I find him fascinating is he grew up... my firm is just outside of London. And it is probably about two minutes away from where Roscoe Graham grew up. He grew up in Lobo which is, right now Lobo has about five houses and a gas station. And that's where he grew up with his dad as a family doctor. He travelled around in a horse and cart seeing his patients. He had two other brothers who both went into medical school as well. But Roscoe, you know, he worked hard. He went to Toronto, studied as a surgeon, became a surgeon. And then I think like most surgeons, that became... well a lot of surgeons that became you know, excelled in their field. He went to war. He went to World War One. And he was in the Royal Canadian Medical Corps then on the number four General Hospital in London, England. And he trained there, and he also travelled the world to study and learn. He went to England, he went to Bern, Switzerland, and he tried to improve his craft and trade by education and learning and he had to travel around the world to get that back then. And you know, one of the fascinating things is, cuz I'm fascinated by endocrine surgery. I absolutely love it. And one of the coolest parts of endocrine surgery besides pheochromocytomas, which I find fascinating is insulinomas. It's a beautiful diagnosis. It's a beautiful workup and it's a beautiful curative treatment for a lot of people and Rosco Graham, because Banting in Canada figured out about insulin, then it became clear that there was something else going on and there was an insulinoma. They had no idea really. But Rosco Graham took a young lady, you know, 30-year-old lady who had these coma episodes and said there must be something going on with insulin and did a blind operation. And there were two others that did blind operations before but never found anything. But Roscoe Graham did a blind laparotomy, found an insulinoma, took it out. And the lady lived for another, you know, 30 or 40 years after that. And so, he was the first guy in the world to take out an insulinoma. A guy from Lobo, Ontario, just down the road. I thought that was fascinating. I think that's even more cool than his Graham patch. But then, you know, he went on, and he didn't take the status quo. And he said, you know, with these people that came in with perforated ulcers, which was very, very common back then, and you know, was common up until 30 years ago, it was a pretty common operation when I was a medical student. He said, why are we doing, you know, gastric resections on people with a perforated ulcer. Our rates of complications and mortality are massive, there has to be a better way. And he conceptualized and he thought about it. And he said, you know, less is more. And he made a Graham patch, he took three catgut sutures, he put it across the hole. He took omentum, whether it was free or fixed, plucked it in the hole, and his outcomes were unbelievable. And here's this guy from Lobo, Ontario trained in Canada, trained in Toronto, who if you go to any surgical textbook, probably in the world, even though you can't read everything, you will see his name in there saying this is the guy that taught you how to put in a Graham Patch. Actually fascinating. You know, and as typical master surgeons, he continued on with education. He became the head of the Division of Surgery, the surgical division in Toronto General Hospital. He was the president of I think it was called the Canadian Association of Clinical Surgeons, I think that might be Canadian Association of General Surgeons now. But you know, he was a pioneer of all that stuff and innovation, and he was a compassionate surgeon so he epitomizes... he's like my role model. He's the guy I want to be.

Chad Ball  22:21

Absolutely. You know, when Morad Hameed was conceptualizing the Roscoe journals for CAGS, he and I spent a lot of time trying to come up with what we thought was the right name and obviously we called it Roscoe at the end of the day for all the reasons that you mentioned. It's amazing to learn more about his career and I agree he should be a mold for all of us, eh? Like he should be the model in this country specifically. Totally.

Daryl Gray  22:49

It was a brilliant decision for Morad and you to decide to make that journal named Roscoe.

Chad Ball  22:58

Yeah, well, I mean, I don't think it was so brilliant on our part, but he's certainly a brilliant guy. You know, the other person that I think about when I think about the fusion of trauma and endocrine is Dave Luciana, who obviously, as you know, Neil and I are, you know, are biased to and you know him well. But, you know, if you ask him what his passion is over his entire almost 40-year career, it's always neuroendocrine tumors. It's not actually injury, although he's obviously superb at it and has changed that field forever. So, I think of you two guys in a similar light. I'm curious just to go back before we go deep on GI neuroendocrine tumors, to trauma. What is it about injury and trauma that you like so much? And I'm curious because certainly the fusion for me of HPB and trauma is interesting because the patient populations are so dichotomous, the way you talk to those patients, what their problems are, obviously, they're both extremely surgical, but very, very, very different. And I enjoy that variety, I think that most people probably don't. It'd be hard to convince an HPB surgeon to do trauma or vice versa. So it makes me a little bit weird. I'm curious if you feel that same way or how you process those two worlds?

Daryl Gray  24:15

Yeah, that's a great question. And you know, Dr. Feliciano, a master surgeon. My philosophy is this: I actually called endocrine surgery "gentlemen surgery". Because it's very finesse. It's nice, you think about things, you approach it in a very analytical way. You take your time and it's a beautiful outcome and then trauma is the absolute opposite where you know, I don't like to do the ortho adage like bone broke, me fix. But gunshot wound in the OR, and it's a fascinating surgery. So, in one aspect, you're taking an endocrine surgery, you're taking a patient and you're trying to cure them from some debilitating functional tumor, and you're very successful at doing that. And then trauma, you know, you see this patient that, you know clearly needs operative intervention. And you don't know what it is that's going on sometimes. You're a bit blinded by it. But it's the most exciting, fascinating part of your surgery day when that sort of patient comes in the door. And you have to make these split-second decisions. And that can be life altering for patients, and you don't have time to, you know, pontificate and think and scan and study and plan. And you sometimes fly by your bootstraps. And that's a fascinating, exciting factor in my life of surgery. I like that. I like the fact that you have to think very fast on your feet, you have to plan as you're going, you have to try to stay two or three steps ahead of your patient as you move them through the trauma pathway in your hospital. From, you know, the trauma bay to the operating room, to interventional, maybe to ICU, maybe back to the operating room, you know, into the ortho room. The whole forethought planning in a very fast paced system, I find very exciting. And that's why I love both of those fields. Absolutely love them. Our trauma systems, because of our injury prevention and because of our cars being so safe, and you know, unfortunately, guns and knives are still there. But you know, we've decreased our trauma laparotomy rates significantly. But in the heydays, when I was being a resident, you know, for the first 15 years on staff, it was absolutely fascinating to be a trauma surgeon then.

Chad Ball  26:47

I love the term "gentlemen surgery". That's fantastic. And, you know, I always learn so much from you, no matter what you speak about over many, many years. But that may be my favorite thing you've ever taught us for sure. I love it. You know, my mind immediately goes to the vision of you in Guy Ritchie's movie, "The Gentleman" because I can totally see you in that movie for sure. It's fantastic.

Daryl Gray  27:17

Maybe I'll trademark that!

Chad Ball  27:21

Yeah, well, you should, absolutely. And Dave Luciana would love it too. There's no doubt. Let's transition a little bit into gentleman surgery and see if we can pull up some of your expertise, particularly for trainees and our general surgery colleagues. So, I'm curious if you could start us off with sort of broadly how you define a GI neuroendocrine tumor and how that sort of compared to or contrasted with carcinoid in particular?

Daryl Gray  27:50

Yeah, great. That's a great segue into the neuroendocrine tumor. So, you know, originally, you know, again, maybe dating back to 1800s or early 1900s. These tumors of small bowel, predominantly appendix was found. And no one could really tell what they were, I think, because of the you know, inability for pathologists to really make good diagnosis in those days and, you know, neuroendocrine tumors became a malignancy of the enterochromaffin cells, which are almost present everywhere, in epithelial line, organs in the body. And they were trying to describe them back in the 1890s again, and Opendorfer was the first guy I think that called it karcinoids. Karcinoids with a k: KARZINOIDE. And he called them karcinoids because they were cancer like, and they were different than the adenocarcinomas that they were finding. And they weren't as aggressive, and they weren't slow. So, they call them cancer like tumors, and hence, was born the term carcinoid. And then bore the term carcinoid syndrome, where you have, you know, serotonin outputs that are causing cardiovascular collapse in the symptoms of carcinoid syndrome. But in the last, you know, 15 to 20 years, the term carcinoid has been... we've tried to remove that from the terminology. Not only from surgeons, but also family doctors and oncologists and endocrinologists, because it's a misnomer. And because of the term carcinoid, surgeons historically would say, oh, this is just a slow growing tumor. We're not going to do anything about it. Don't worry too much about it. It's not going to cause a lot of problems. And you know, Chad and Ameer, even now, I get referrals from you know, other places where the surgeon has been reluctant to operate on these because they're slow growing, they're not going to cause you problems. And that was sort of the education. So, the terminology, we've tried to actually eliminate the term carcinoid from our vocabulary simply for that reason. We want people to know that this is a tumor. This is a cancer. Its rates of progress are variable, sometimes not as aggressive as the other tumors that we see in the bell, primarily adenocarcinoma. But to remove that moniker of carcinoid is probably the best thing we've done from an education, patient care perspective, in the last 15 to 20 years. And we now call them neuroendocrine tumors, which is a way better way to treat them. They are tumors, they are cancer, they need proper workup and treatment.

Ameer Farooq  30:53

Yeah, I think that makes a lot of sense. It also feels like by changing the nomenclature a little bit, it kind of acknowledges how different these different neuroendocrine tumors potentially behave depending on their organ site. So just to start us off, in your practice, how do you typically kind of see these patients? Or how do they kind of make their way to you?

Daryl Gray  31:19

Yeah, so a great question. Typically, nowadays, with modern technology, with everyone getting CT scans and ultrasounds, we have really increased our rates of finding neuroendocrine tumors earlier. The education of CNETS Canada, you know, if this is the zebra, that's why they have this zebra ribbon. When you think of hoofbeats, you think of horses. But sometimes you have to think of zebras in this phenomenon. So, you know, people with crampy, abdominal pain, people with diarrhea, people with, you know, the carcinoid syndrome is not very common anymore, because we're picking these tumors up. But people that get truncal rashes, wheezing, these things, the doctors are now picking these up earlier because of education in the system. And the most common find now that I see that gets referred to me for surgical consultation is people getting CT scans, because of more vague symptoms that wouldn't have gotten CT scans before. They go to diagnosis for family doctors now, emerg physicians, is the CT scan. And we're picking up these neuroendocrine tumors, not the primary tumors in the small bowel because they're usually too small to see originally on CT. The less than a centimeter tumor is so common in neuronendrocine tumor size in small bowel. But we're seeing the lymph node spread, the mesenteric classic findings of the desmoplastic reaction, the stellate pattern. So, my practice, I'm getting these. They're almost always on a CT scan, they've been picked up early, good finds. Our prognoses are, you know, our outcomes are better because of the fact that we're doing earlier screening and finding. So patient education, doctors' education, people going online, patients going online finding these sorts of things and sort of cueing their doctors, like "do you think I have carcinoid syndrome?" It's a real thing and it's really helped our diagnosis and management of these patients.

Ameer Farooq  33:32

It's kind of remarkable now I think, how often these things just appear incidentally on imaging and, you know, we have these joint GI and colorectal surgery rounds here at St. Paul's and every week, almost there's a case where someone presents, you know, a CT scan with some bulky nodes, and the question gets asked, could this be a carcinoid. So let's say you get that referral, like you get that patient that, you know, the referral letter, typically, you know, it's always a one-sentence referral: "hey, please see this patient with carcinoid syndrome and manage". How do you kind of frame that whole thought process when you get that referral? Like how do you kind of think about it in your mind, you know? You typically talk about, as we've said, site of origin, grade, Ki-67, all those types of things. But how do you kind of approach that in your mind? Right from the moment you get that referral?

Daryl Gray  34:32

My approach Ameer...so I don't like to use the term "carcinoid" anymore. I think we should stop using that term. We should call these neuroendocrine tumors. My approach, first off, is I want to be as aggressive as I possibly can. Not even seeing a CT scan, just getting that one-line referral and I appreciate you saying that, if that is the case. The minute I see that referral, I think I'm going to try to cure this person. Now, neuroendocrine tumors are probably not curable. Julie Hallet always says, we're just going to continue to treat this patient all through their life, and they're not going to die of this. And I truly enter every room to see this patient thinking, the first thing I want to thank is, the patient is not going to die from this neuroendocrine tumor. Because we have such a wide armamentarium of what we can do. I'm going in there to fight, and we are going to see what we can do. Now sometimes that's not the case, obviously. But that's thought process when I go in and see people. And when I see them in their clinic, I kind of go through their history of physical: looking at the symptoms they're having, do they have carcinoid type syndrome? Very, very rarely do they do that. I want to look at their CT scan, I want to look at the extent of that on the CT scan, has anyone made the diagnosis? And if they have, so if I have pathology and I can move forward with that, the best part of... what I really look at is their grade. What grade of neuroendocrine tumors is this? Grade one, grade two, or grade three? And I use the Ki-67. As you know, World Health Organization scores, like the TNM classification is not the best for neuroendocrine tumors. So the WHO classification, Ki-67, Grade Ones, you know, less than three grade twos, less than 20, and grade threes greater than 20. Really has a huge bearing on their management from a surgical standpoint. The next thing that almost immediately enters my mind. I'm a firm believer, and I'm very aggressive. You know, I've presented talks on surgery first. Surgery first, I think is important. I think people need to think about surgery first, before they're seeing oncology, before they're doing chemotherapy, before they're doing other things. They need to see a surgeon to say, can we do something to improve the quality of life in this patient. And I think it's very, very important. I'm very aggressive with this. Some people disagree to some extent, but to leave a small bowel tumor with mesenteric nodes in there saying, you know, they have liver met, so let's not do this. That's not the first step for me. You know, this person is going to live for 5, 10, 15, 20 years with this and if you don't do something surgically at the time that you can with the desmoplastic reactions in the small bowel and the small bowel mesentery, when these people show up with a bowel obstruction because of a malignant process in their lymph nodes in their mesentery, they're non-operable. They're so stuck, they're so sucked in. There's such a fiberoptic response. You can't resect the bowel and you can barely bypass it sometimes, it's so tight and pulled in. So, I'm aggressive. Whether it's a cheer detent, a significant prolongation of survival attempt or a palliative attempt. I'm very aggressive about moving ahead with surgery with the proper investigations. And those proper investigations must include you know, is this functional or not. We want to look at the breakdown products in the year and we want to do a 25 or 24 hour 5-HIAA study to see if this is serotonin functioning. We want to do a serum chromogranin A for sure to see what is the baseline level. High, low, tells us what's functioning. With functioning tumors, we want to do an echocardiogram. You have to look at the valves of the heart. You have to get a baseline valve study to say, is this going to progress, what can we do about it? Where are we at right now? The CT scan, octreotide scans have now, fortunately, in our area in Toronto and Montreal, both have gallium scans. The gallium scan has absolutely revolutionized our practice of the surgical procedures for neuroendocrine tumors. And, you know, we don't even have gallium scans across Canada. But the gallium scan is so much more sensitive than the octreotide scan. It's absolutely phenomenal, what it's showing us, it's phenomenal. What it leads us to be able to do from a surgical standpoint, the aggressive nature of the surgical standpoint, small bowel neuroendrocine tumour can be multiple, most, a lot of times, you know. 50% of the time there's multiple tumors in the small bowel. Gallium scans are now picking up all these sub-centimeter nodules. They pick up all the lymph nodes that you can surgically dissect and remove. You can go to the philosophy of, if I can remove the primary tumor and take out the lymph nodes, all the lymph nodes in this small bowel mesentery that are positive on the gallium scan, I can then direct my goals to the liver therapy after that, because if it's liver only disease, there's a host of treatments and better armamentarium that we can use to help these patients. So that's how I that's how I approach these. I'm a pretty aggressive surgeon when it comes to this, but I think I've been doing it long enough that the process works. That you know, the European networks back this up a lot. The system backs it up. There's lots of surgeons in Europe, you know, that have revolutionized this before we ever did with gallium scans and octreotide scans.

Ameer Farooq  40:54

Just before we go on, because there's a lot of things that you said there that I want us to just pick apart a little bit. But just to back it down even to a medical student or junior resident kind of level. Can you talk a little bit about when you're seeing them in clinic, are there any really important history features that you look for? And then maybe we'll talk a little bit about some of the very commonly tested, you know, sort of exam questions like you know, the carcinoid syndrome, the insulinoma, that kind of thing.

Daryl Gray  41:26

Yeah, so for the neuroendocrine tumors in my clinic, I ask them, it's amazing how many people have chronic abdominal pain, that have gone through the years with it and no one's really diagnosed them. They've been labeled with irritable bowel, you know, chronic abdominal pain syndromes, things like that. Sort of going by the wayside now, because everyone can get a CT scan. But I ask for those symptoms first. Symptoms of GI tract neuro in tumors, it'll include crampy, abdominal pain. It may include diarrhea. And, unfortunately, these are so slow growing and insidious that people actually don't know that their body is changing slowly. It's like, you know, cortisol producing tumors, it happens so slowly, some people don't even know what's happening. But they will, you know, on history, you say, do you have diarrhea, and they go, well, no. I say, well, how many bowel movements do you have a day? They say seven. What? Well, that's not normal. Oh, well, I've been having those for 10 years. So I just thought it was normal. Those are my first go twos. The carcinoid syndrome, like I said, is very rare. But if they do, they usually will present with flushing. They will get a flushing reaction, sometimes with activity, sometimes with foods, but sometimes just spontaneous. And that would be almost pathognomonic of something that's going on to have an output of serotonin that's not being metabolized in the liver is first pass effects. So, you know, when someone presents with a carcinoid syndrome, those are usually bad actors. Either the liver has so much tumor in it that is not being able to be metabolized on first pass, or tumors like bronchial carcinoids, that would have that same effect. So, I'm not big on the carcinoid syndrome. It's not a common finding on my exam. It's mostly the GI tract symptoms that I would focus on most for the neuroendocrine tumors.

Ameer Farooq  43:36

It always comes up in exams, but does it actually come up. Thankfully, very often in real life, it doesn't seem like that's really the case, which is fantastic. Are there any physical exam things that you typically look for when you're seeing these patients in clinic?

Daryl Gray  43:53
No, not really. The physical exam findings, you know, unfortunately, if their liver was full of metastatic disease, you'd probably have a palpable liver because they do really get quite large, and they can be unfortunately, quite asymptomatic with that. So, you know, hepatomegaly is a finding you can see. You can look for the truncal rash. But if they're not having the crisis at that point in time, it's not very common to see it. There's not much else on physical exam that I would look for in someone with a GI tract, neuroendocrine tumor.

Ameer Farooq  44:31

Yeah. So, you know, clearly this seems like a very image driven and biochemical driven type of diagnosis and treatment algorithm. Can you talk a little bit about, you know, it always seems to come up as a question. You know, what lab tests should we be doing, especially when we already had the diagnosis often of like this neuroendocrine tumor on imaging. You know, can you talk a little bit about the biochemical workup or laboratory workup that you typically or routinely do when working on these patients.

Daryl Gray  45:05

Absolutely. The biochemical workup is you must do a 25-hour urine 5-HIAA, that is the metabolic byproduct that's in the urine from functioning serotonin producing neuroendocrine tumors. Not all of them have them. Not all of them have a functional output, but you need to do a 25-hour urine 5-HIAA, for sure to see if these are biochemically active. Because from a treatment standpoint, and surgical standpoint, that's very important to know. The other thing you want to do is a serum chromogranin A. It's best to do off proton pump inhibitors that can make false elevations, but the serum chromogranin A is important to get. It will tell you not only the baseline of your patient, but also, if it's high or elevated, it can be used as a tumor marker for these neuroendocrine tumors. So, both the 25-hour urine 5-HIAA and serum chromogranin A can be used as baselines, and then to see how is my treatment affecting? How effective is my treatment for my patient with surgery? With long-acting somatostatin analogs? Am I able to decrease the 5-HIAA? Am I able to stabilize or baseline or decrease my serum chromogranin A? So, those are the biochemical markers we can use to follow our patients and continue to direct our treatment for our patients based on those levels. Those are the two main biochemical studies I would do.

Ameer Farooq  46:42

Okay, and let's go back to the imaging thing, because I think that was such an important point that you brought up about the gallium studies. But is that sort of your go to thing? Or how do you sort of think about CT MR? And then of course, there's always the functional studies like octreotide scan.

Daryl Gray  47:00

Yeah, so I get to live in a bit of an ideal world because our center does so much neuroendocrine tumors and Toronto in active, and Sherbrooke, Quebec, have the ability to do a dotatate, gallium 68 dotatate CT PET scans. And like I said, it has revolutionized the neuroendrocine tumour process. It has made octreotide scans obsolete in some centers. Some nuclear medicine departments don't even do octreotide scans anymore. It is like the Cadillac of functional imaging of these neuroendocrine tumors. And that is my go-to now, if I am unable to do a gallium scan, I would be unhappy with that. I would do octreotide scans as the poor cousin of the gallium scan, but I really wouldn't be happy in surgical management of it. It is now through Cancer Care Ontario in Ontario; you can apply for gallium scans. And one of the checkboxes that gets you an automatic go to get a gallium scan is, are you planning surgical resection of this tumor based on your gallium scan? And if you check that off, you get an automatic scan for that. It has revolutionized our field. We would operate on people, we would take out their small bowel tumors, we would take out their pancreatic tumor, we would take out their lymph nodes that we saw on octreotide scans, and we thought we'd pat ourselves on the back. We've done such a great job guys, we're basically cured this person. And then when gallium scans came out, these people were going through gallium scans and we'd see other small bowel tumors or we'd see lymph nodes that are positive. We'd see liver mets, we'd see bone mets that we did not see on CT or MRs, or octreotides. We didn't see them. They're all negative. So unfortunately, it kind of deflates your bubble that thinks you're all that good. And all that in a bag of chips. And kind of humbled you to say, oh, we aren't as good as we thought. But let's keep going with this because now we have gallium scans This is even better. To be able to plan surgical resection, to be able to plan further treatments. It's my go to for high grade neuroendocrine tumors. So, for the residents and medical students. If you have a biopsy that shows that you know, from a liver method, this is grade three neuroendocrine tumors. So, Ki-67, you know, greater than 20%, there'll be 60 or 70%, very high grade. The gallium scans do not work for high grades and FDG-PET scan would be the go-to study on the grade three tumors. So, grade one, grade two, go to the gallium scan. Absolute must in my opinion and now becoming a worldwide. Grade threes go to the FDG-PET scan. So, the multiplicity, the multiple tumors in the small bowel, again for neuroendocrine tumors in the small bowel, they're more frequent the farther down the bowel you get. So they're less common in the jejunum, much more common in the ileum. You will find them, I don't know the actual stat on that, but at least 20% of the time, you will have multiple neuroendocrine tumors in the small bowel. And it is amazing how the gallium scans are now picking these up. I just did an operation on a man who on the gallium scan, it looked like he either had multiple small bowel disease or he had carcinomatosis so the the omentum was so close to the small bowel they said, this guy has metastatic disease in his omentum, so they said this is either small bowel disease, or it's carcinomatosis. We operated on him. He had no carcinomatosis whatsoever. He didn't have a stitch a tumor outside of his small bowel and his lymph nodes. And he had 23 neuroendocrine tumors in his small bowel that were that were removed with good safe length of his bowel remaining. And all of his lymph nodes. And four months after that operation, I repeated the gallium scan, you have to wait three to four months at least, to have the inflammation settle down. Four months after, his repeat gallium scan is completely clear. So, the gallium scan was incredible. To talk about that, you know, you might ask me about the surgical management, whether I do these laparoscopically or open. I don't do them laparoscopically. I just don't. And the reason is there's no way that you're going to be able to feel a neuroendocrine tumor that is, you know, four or five millimeters in size in the small bowel. You can barely feel with your fingers. You have to run, you have to be so careful running the small bowel, and you'll pick them up. They're subtle sometimes, but you will find them if you can feel them. If you can't feel them, you will miss them. And if you don't run the small bowel, you will miss them. So, you just can't go to the main tumor that you see. You know, on the old studies like the gallium scan or the octreotide scans and CT scans, you have to carefully run that bowel. And now, with surgical management, we've actually become so aggressive that with gallium scan showing lymph nodes only, I will dissect down to the superior mesenteric artery. Dissect out the major vessels. I will clamp the vessels with vascular clamps in the small bowel mesentery that are above the lymph nodes I want to remove. And then we will do ICG dye, who will shoot ICG dye and after the vascular vessels are clamped and look at the flow through the bowel and what's enhancing and what's not. And base our surgical resection margins on that. Or say, oh, we can't do this. We're going to take out too much small bowel. The outcome would be worse for that. So, you know, we've progressed with surgical technique and especially with our gallium scans telling us what we can and can't do. It's fascinating.

Ameer Farooq  53:19

That's so exciting. I'm just gonna wait for this ambulance to pass. Typical. St. Paul's 730 in the morning kind of sound. Time to go to work. This is the part where Dr. Ball asks me, "Ameer, have you been shot?"

Chad Ball  53:39

Welcome to St. Paul's!

Ameer Farooq  53:43
It's so fascinating to hear how kind of targeted and precise you can be doing these operations now. So just walk me through how you kind of approach this in the operating room. So, you have the patient, presumably you've got them supine, their arms are out, you do your laparotomy and then kind of walk me through how you systematically approach this.

Daryl Gray  54:09

Okay, so Ameer, for the residents and residents doing their exams or learning the medical students that are listening...actually, for anybody that's listening. The first thing you need to do before you ever get in the operating room is provide these patients with a somatostatin analogue. Whether they are functional or not, whether they have metastatic disease or not. I am now an absolute firm believer in using a somatostatin analogue to block the receptors to prevent interoperative cardiovascular collapse in the form of a carcinoid crisis. It is the most terrifying thing to ever have happen to you in an operating room and it's completely preventable. So, the pre-op management is very, very important. I do put these people on either center stand long acting or larazotide, either one is fine. I make sure that they are blocked down properly before I operate. I then talk specifically with my anesthesiologist to tell them that this is a neuroendocrine tumor. They will always ask me whether it's functional and I say yes or no, but it doesn't matter. I have these people blocked on a somatostatin analogue. We did a great study looking at outcomes for carcinoid crisis versus cardiovascular collapse versus not and saw benefit from the long-acting somatostatin analogue. So, I don't operate on these people until they have them on board. I make sure my anesthesiologist is 100% on board with this. He will have at least 1000 mikes of octreotide injectable available for this operation. If we're doing liver surgery, it will be an infusion of it. If it's bowel surgery, and we're not doing any liver surgery, we don't use infusions of it especially if they have a long-acting somatostatin analogue on board that's blocking them. The worst-case scenario you will ever see is a carcinoid cardiovascular collapse in your operating room. Your anesthesiologist is absolutely helpless. They can give fluids, they can give pressors, they can give whatever they want, and they are absolutely ineffective. It is the worst phenomenon to ever see in a patient and unfortunately how do I know that? It's because I've been there. So, before anything I block them. I make sure that me and my anesthesiologists are all on board, I make sure the octreotide is in the room. I don't want it down in block two in the pyxis system and my fingerprint doesn't work today. Now what are we going to do? And that's how I start my laparotomy. When I'm operating, I do a laparotomy, I make sure I followed my CT, I make sure I have reviewed my gallium scan absolutely. I actually go through my gallium scans with my nuclear medicine physician the day of the operation. We walk through it again, we walk through the CTs, we look at the nodes. I have, in my mind, a map of exactly how this is going to go. When I open again, thorough, thorough laparotomy. Feel everything. There can be two-millimeter nodules in the liver that you could not see, even with a gallium scan. And that changes your management sometimes. Thorough laparotomy, feel everything, and then complete running of the small bowel. This is a small bowel tumor complete run. Right from the deodenum, right around D one, D two, D three. Flip to looking at the traits. D four underneath, and then run jejunum all the way down and then ileum, and that's where you're going to start seeing the hot stuff start to pick up and you're going to be able to find these tumors. I marked the bowel with the babcock when I find one. We continue down and keep marking them so sometimes using a lot of these. Once I have a good knowledge of where my tumors are in my small bowel, the first thing I do is say what about the lymph nodes in the mesentery? How much mesentery do we have to remove? This is the important part. I start with my mesentery first. I don't resect bowel first. I start with my mesentery and start to take down the mesentery at the most proximal part where it is going to be involving the main vessels. Now if this isy, you know, distal mesentery, I still take all the mesenteric nodes out. I ligate te mesentery first and then I wait. If I have ICG green dye, I would shoot that. If I don't have ICG green dye, I then wait for my demarcation of my small bowel. Take your time. That's why I don't staple across the small bowel first. I always wait with mesentery floating in the breeze. What's purple, what's pink, where's my staple line going to be for removal of the neuroendocrine tumors. If I have to take out segmental areas based on the length of bowel I have, then I will do that. I will take out one section of you know, a foot and a half of bowel, and then move down to where the other tumors are and take out more sections of that based on the vascular spread and lymph nodes. That's my approach to those tumors.

Ameer Farooq  59:13

This is a fantastic overview. I'm curious, you know, you've talked a lot about the fact that some of these tumors are so small, that it can be hard to find them all and that's why it's so important to have the gallium study to kind of give you a roadmap. Do you do any other adjuncts to actually try and find these tumors? You know, they talk, and I think we've done this here at St. Paul's a few times where you've actually done on table kind of enteroscopy. Is that something that you use or is that not really necessary, given how good our imaging studies are now?

Daryl Gray  59:47

Yeah, that's a great question Ameer. So, neuroendrocine tumours of the small bowel are submucosal. Very, very small tumors of the small bowel, you won't see on endoscopy. You can do a push enteroscopy on these, unless they're big enough to see, you actually will miss them. Endoscopic ultrasound in the duodenal area if you're looking at doing duodenal neuroendocrine tumors, gastrinomas are very good for that. You can pick up you know, the millet size gastrinomas that are classic in the MEN-1 type syndromes. Two-millimeter, three-millimeter millet seed size, gastrinomas of the duodenum. So, EOS is great for up there. Obviously completely impractical for small bowel. Push endoscopies on table, small bowel studies with scopes. Again, nothing will beat your fingers. You can't beat the tactile feel of these.

Ameer Farooq  1:00:47

Yeah, that makes total sense. So, what about the scenario where you get into the operating room, and you do you find that they have lymph node disease quite down proximately on the mesentery, you know, near the root of the SME. How do you sort of approach that situation? Do you abort? Presumably you can't just pluck these lymph nodes. It really has to be a sort of an unblocked lymphadenectomy. But how do you approach that particular situation?

Daryl Gray  1:01:18

Hopefully, I'm not operating on someone that I haven't planned out this surgical procedure in a better fashion. Looking at their CT angiography, looking at their gallium scans, melding those together. Forming a proper roadmap. I don't want to be blindsided by, oh, I didn't know that lymph node was that high on the SMA, I can't take that out. So, I don't want to be there Ameer. I prefer to be planned in a better fashion. But having said that, when you look at these neuroendocrine tumours, lymph node metastases, they are not the same animal as adenocarcinomas. It's amazing how the desmoplastic reaction and the lymph nodes that are positive... so the lymph nodes are smaller than the mass that you're feeling. Always. From a philosophical standpoint, you need to remember that. The desmoplastic reaction around these lymph nodes is significant, and it makes it look daunting. But the desmoplastic reaction isn't actually malignancy, it's just fibrosis. The other fascinating phenomenon about the lymph nodes of the neuroendocrine tumor type are they almost to a fault, or almost routinely, respect the vasculature. They do not invade into arteries. You can actually dissect out arteries and peeling these lymph nodes away from the arteries to get more distal. So, with experience and in the hands of, you know, surgeons that are adept at trying to dissect out, not only SMA, but also the major branches coming off of the SMA into the major, you know, jejunal and ileal branches. It is absolutely possible to do this, if you have the knowledge to say, yes, I am not going to get into the blood vessels by dissecting these lymph nodes free. And I'm going to be able to perform a safe dissection and not compromise the outcomes with you know, completely devastated small bowel. You need to be experienced, you need to be knowledgeable, if you want to bring in one of your vascular surgery colleagues that have their nice loops, and they're very good at dissecting vessels. Do that. I do that sometimes as well. We have some very talented vascular surgeons that help me out with some of these difficult cases. But to go into an operating room Ameer, and say, you know, do all this work and then say, oh, I can't take this out. I think that's probably poor pre-op planning to begin with. I don't think he should be there wondering about that.

Ameer Farooq  1:03:59
The other scenario that comes up a lot that you refer to is this scenario where you have a small bowel neuroendocrine tumor, but you also have liver metastases. Kind of break that down for me, how do you approach that scenario preoperatively and which of these patients are you taking to the operating room? And how do you think about this kind of challenging scenario overall?

Daryl Gray  1:04:23

Yep, again, I'm a firm believer of surgery first. If it's that practical, healthy people are going to live a long time with this, their small bowel is going to cause a problem down the road. With our long-acting somatostatin analogue, they're chemo static, so these tumors kind of halt and don't grow, or they decrease in the amount of growing. Especially if they're grade one tumors. So, I'm aggressive with this and you know, based on our gallium scans, if we have if we have a scan that shows small bowel tumors and lymph nodes that are resectable and they have liver metastases, we will discuss this obviously at our neuroendocrine tumor board rounds. You do need to be discussing these. You have to have, you know, available to rounds, surgeons, oncologists that are very knowledgeable in this field. The nuclear medicine physicians are absolute mandatory. A pathologist is mandatory that has some sort of expertise in this field as well. But our standpoint is this: if it's a small bowel and mets, small bowel tumor with metastatic disease in the lymph nodes that we can resect, what can we do about deliberate lesions? There are so many things we can do. We will RFA if there's one or two mets in the liver, on table at the time of our operation. If it's more than that, and they might need a lobectomy performed for total tumor removal of the liver, then we will probably do that. And the next case, we won't do both at the same time, it gets to be quite a large operation for some of these people. But if they're healthy, and we deem it safe, we'll go ahead and do that. So well aggressively do lobectomies if it's one side only. We will do tumor, I say tumor resections if there's multiple tumors in both lobes, based on being safe and judgment, we will do operation and RFA at the same time. And our goal is this: well, our ultimate goal is to remove all the tumor. And if we do that, we help these people from a biochemical standpoint, from a heart valve fibrosing standpoint, from an outcome standpoint. If we are unable to take out all the liver tumor, we do try to decrease tumor load surgically. But then there's a host of other treatments that are armamentarium that we can use to do isolated liver treatment. And that concept is important because if you're able to say, listen, I have liver only disease now. We did an operation, we have a gallium scan, there's no other tumor in this person except for the liver. While the host of treatments becomes very large. You can do liver directed therapy with chemo embolization. You can do liver directed therapy with y-90. You can put them on a long-acting somatostatin analogue which they all would be on and if the disease is stable for a year, and a gallium scan shows no other disease still, these people you're treating are candidates for liver transplants. So, you know, when you have a 40-year-old person that has liver only disease and you want to offer him liver transplants, it's important to make sure that you're getting the rest of the small bowel tumors out and the lymph nodes out. So, the goal directed therapy to liver only disease offers significant amounts of treatment. Local therapy to the liver as opposed to systemic therapy. Systemic therapy is if they have not only liver disease, but other disease elsewhere. Bones, yes, there's lymph nodes that we can take out. So that's a systemic treatment. And they're still very effective treatments for that in the form of prrt lutetium, radioactive dotate label lutetium that we can use to treat neuroendocrine tumors that are systemic. So, the whole concept, the very important concept is, can I get this person to liver only disease? Because if I can, lots of further treatments, goal directed therapy to the liver only. Surgical resection, chemoembolization, y-90, direct  chemoembolization with it. Lipiadole - not used as much anymore. RFAs of new nodules coming up, our interventional radiologists are on board with this. They're very good at it. It's a very effective treatment for these patients. Because ultimately, you are in for, you know, a 20, 30-year treatment cycle with these patients.

Ameer Farooq  1:09:05

Yeah, it's fascinating to hear about all these new options that really kind of converts these metastatic patients into almost like a chronic illness that you just have to be ready to treat with all the armamentarium of tools that we now have. Dr. Gray, what do you do to follow these patients? So, let's say you have the patient, you've successfully resected their small bowel neuroendocrine tumors, you're happy that you achieved zero resection, how do you typically follow or surveil these patients moving forward?

Daryl Gray  1:09:39

Yeah, that's a great question Ameer, and it's changing. And you know what, we honestly don't know. We don't know how to yet because our modalities are changing and with again, the revolutionization of gallium scans. The follow up, historically the best follow up was CT scans and octreotide scans. Usually yearly, following their 24-hour urine 5-HIAA, routinely doing their serum chromogranin A's, again, on a yearly basis to see what was involved. That screening system we have is now in flux and changing because of the advent of the gallium scan. In an ideal world, you would be doing routine gallium scans at the one-year mark and two year mark and then nobody really knows how far to stretch that out. Whether you do it at two years and then every five years or you follow with something else. We don't know the real answers to this. But as gallium scans become more commonplace, you know gallium scans now, they're like MRIs when I was a medical student. You had to go to Buffalo to get an MRI. You got to go to Port Huron to get an MRI. There was like one MRI scanner in all of Ontario. That's sort of like the gallium scans now. You have to go to someplace to get one. But the gallium scans are going to be, you know, commonplace. It's going to be like getting an octreotide scan in any centre that wants it in the near future. And octreotide will go by the wayside. MIBG might go by the wayside too with it, we'll see. But when that becomes commonplace, the go to will be a gallium scan and falling biochemical markers.

Chad Ball  1:11:16

And it's so interesting to reflect not only hearing you talk but just managing this disease, how far the management and the options have come, eh? Like how much the understanding has changed so dramatically over the past decade or even two.

Daryl Gray  1:11:32

Their revolutionary changes have been with modern scanning techniques, modern treatment techniques. Somatostatin analogues have only been around for you know, 30 years or so. Modern abilities to perform interventional radiologic RFAs or surgical RFAs, the advent, even the advent of grade three tumors: capecitabine, temezolomide, sunitnib, everolimus. They have made unbelievable strides in the treatment of even the highest-grade tumors.

Chad Ball  1:12:09

First of all, thank you so much for your time, this is really a gift to all of our listeners and your review has been phenomenal. The question is, you know, I sort of think of you a little bit like the most interesting man in the world. You are the real-life inclination for the Dos Equis man. So, if you want to go back and talk to yourself and give yourself advice, maybe as a trainee, or as a young surgical attending, what would that advice be?

Daryl Gray  1:12:39

That's a great question. And stay thirsty, my friends. What I would tell myself... so, my dad always said: you have to do things in your day that you like doing. What makes a good day for you? And that should be your role in life. Because if you don't like what you do, you won't do well, and you won't like your life. So first of all, do the right thing that pleases you. So, I think I'm fortunate enough to find a niche that does that for me. And if I told myself, when I was a resident, probably I think I would tell myself to be...I think I'd say be more kind. And I'd be more kind to sit in probably three areas. First of all, I would say, be more kind to yourself, physically. And what I'm saying is, as surgeons, we don't take very good care of ourselves. We damage our bodies with poor posture, with poor instruments with poor monitors that don't go down low enough, with poor, you know, loops that don't make you tip your head down too much. You know, 70% of surgeons in a study showed that they had some sort of long-term disability from operating, but only 15 to 20% ever actually report it. And you know, I'm sure that the senior surgeons out there right now that are hearing this are probably saying, yeah, because I can't feel my little finger and middle finger. I have numbness down both my arms. That's a debilitating problem from operating all your life and standing in the ER and hurting your back and your neck. So, one thing I'd say back then is: be more kind to your body. Take better care of yourself. Don't tolerate people telling you that it's okay to have bad posture and bad skills and techniques that's going to hurt your body in the long run. Because you know, 20 years ago, you're fearless, nothing can hurt you. And you don't care about it. And then when you're 57 like me and an old man, you go, oh my god, like my fingers are kind of numb and my back hurts and my neck is funny and that happens. So that's the one thing I tell myself. The next thing I'd tell myself is to be more kind mentally to yourself. Again, we as surgeons, especially in the trauma world, but in all surgical fields, we face death, we face families that are suffering death of loved ones, we may have caused a major, you know, immortality. And we don't take care of ourselves. We don't debrief, you know, from a psychological standpoint, major traumas we've seen that have devastated you mentally. So, I think we as a group of surgeons need to do better with that. We need to take care of ourselves from a mental aspect in a better form. Because it does impact you in your life. So, I think that's an important point I would tell myself. If I was smart enough to listen, that's a different thing. And the last thing I'd say is, be more kind to everyone around you and your team. I think that's, you know, historically, I was taught by grumpy old surgeons. I shouldn't say that, because they were the kindest, wisest men that I worked with. But from a surgical lore standpoint, you were tough, you were, you know, the go-to. You were the guy that had to get things done. And we didn't work well with teams, then. And that's all changed now. And new surgeons are different and new team works are different. But, you know, if I could have gone back 20 years ago and said, listen, you know, in 30 years from now, here's how the world is going to be, so you got to be starting to do that. You got to get on the forefront of that. Don't be the old grumpy general surgeon that you saw and trained with and that was the role model. Be a different guy than that. I think that would have held me in really good stead. I think that's what I'd tell myself.

Ameer Farooq  1:17:08

You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.