Neuroendocrine tumors (NETs) arise from the diffuse neuroendocrine system and therefore appear widespread over the whole body, especially in the gastrointestinal tract and the bronchopulmonary system [1,2]. NETs secreting hormones lead to a symptomatic disease. Nonsecreting NETs may occur initially asymptomatic or with delayed symptoms due to progressive increase in tumor mass [3,4]. Therefore, differences in functional behavior are the basis of a classification system categorizing functioning and nonfunctioning NETs [4]. Other reported classification systems are based on embryological origin or histopathological findings. In 2010, The World Health Organization (WHO) presented a new classification on the basis of tumor grading using histopathological criteria such as Ki67 index, mitotic count, and presence or absence of necrosis [5].

NETs is a relatively rare disease with an incidence of 1-3 per 100,000 [6,7]. The large range of reported incidence might be due to the fact that NETs often present initially asymptomatic and are often found accidentally or in autopsies [4]. Predominantly, NETs emerge sporadically (>90%) and are traditionally assigned to multiple endocrine neoplasia type 1 (MEN1), neurofibromatosis-type 1 (NF1), and Von-Hippel-Lindau syndrome [1,4]. The clinical picture of NETs spans over different effects of excessive hormone secretion such as hypergastrinemia in Zollinger-Ellison Syndrome (ZES) with hyperchlorhydria, hyperinsulinemia in insulinoma, flushing and diarrhoea in the serotoninergic carcinoid syndrome. In the case of nonsecreting NETs, symptoms present due to the adverse effects of the growing primary tumor or metastases [8].

Hormones secreted from NETs can be used as specific markers for NETs. Moreover, NETs express, store, and secrete characteristic neuronal proteins such as acid glycoprotein chromogranin A (a component of the membrane neurosecretory granula), neuron-specific-enolase (NSE), and synaptophysin [3,9]. These proteins derived from neuronal structures could serve as markers and are even positive in nonfunctioning NETs [1,3]. Since more than one half of NETs are nonsecreting, these proteins play a crucial role [4]. Assessment of different biochemical markers depends on various parameters, such as threshold cut-off level, detecting method of urine, serum or plasma as well as location of the primary tumor or metastases and extension of the disease. Due to the large variety and number of evaluation parameters, it is difficult to compare the studies [10,11].

Ki67 is a monoclonal antibody, which was introduced in 1984 by Gerdes et al [11]. It detects a growth rate depending on the nuclear antigen Ki67 which is only expressed during active cell cycle phases (S, G2, and M-phase). Ki67 is completely absent during the resting phase G0. Therefore, cell proliferation is assessed by the immunohistologic presence of Ki67 positive cells per area in stained tissue blocks [11].

For various human neoplasms such as breast, lung, and solid cancers, Ki67 proliferation index has been successfully established as a predictive marker [12,13]. The higher the cell proliferation, the greater is the probability for metastases resulting in decreased patient survival. The primary location of NETs metastases is the liver [14-17]. The occurrence of hepatic metastases is a prognostic factor which strongly influences the survival of patients suffering from NET [18-20].

To stratify outcomes in patients undergoing resection of primary NET, a simple scoring system using tumor size, histological grade, nodal metastases, and resection margin status has been introduced [21]. Nevertheless, current classification systems for NETs other than positron emission tomography (PET) fail to predict the clinical course and the response to treatment [22]. The discrepancy might be explained either by an insufficient accuracy of these classification systems or an adaptive NET behavior [23]. These limitations of the pathologic classifications have led to the investigation of other predictive parameters based on genetic signatures as well as the presence of circulating tumor cells [24,25]. These novel predictive parameters have to be included in the classification systems in order to account for the biological behavior, the likelihood for developing metastases as well as the choice of treatment [25].

Imaging methods are used to diagnose neuroendocrine tumors (NETs) and their metastases [26]. Beside conventional morphologic imaging methods, functional imaging modalities have been introduced in order to improve accuracy in detecting NETs and liver metastases [27]. Functional imaging methods have their limitations with a great impact on a possible therapeutic strategy, where differentiation between pancreatic foci and neighbouring lymph nodes as well as exact demarcation of a suspicious focus to a liver segment is crucial [28]. Advanced techniques such as contrast-enhanced ultrasound may assist in earlier detection of hepatic metastases, and could therefore offer a wider therapeutic range either surgically, with radiofrequency thermal ablation, or with systemic chemotherapy [29].

The most common site of neuroendocrine tumor (NET) metastases is the liver [30]. The presence of hepatic metastases is a strong prognostic factor for the survival of patients with NETs, regardless of the primary tumor site [31]. Histologic examination is the most sensitive diagnostic method and forms the basis for treatment decisions [32]. However, the value of the biopsy for treatment decision making involving primary NETs and their liver metastases is not well defined [33,34].