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Abstract
BACKGROUND Neuroendocrine tumors (NETs) of the abdomen are rare tumors with an incidence of 3.56 per 100,000 in the general population. Obesity is a growing public health problem with varying effects on severity of other disease. We investigated the association between obesity and inpatient morbidity/mortality in patients with abdominal neuroendocrine tumors utilizing the Nationwide Inpatient Sample (NIS). METHODS We analyzed data from the NIS database to investigate the association between obesity and abdominal NETs using patient information from 22,096 patient-discharges from January 1, 2009 to December 31, 2010. RESULTS We demonstrate that obesity is strongly associated with decreased rates of inpatient mortality in patients with NET (OR = 0.6, multivariate P = 0.02) and that malnutrition is associated with nearly 5-fold higher odds of inpatient mortality (multivariate P < 0.0005). We did not find a statistical interaction between obesity and malnutrition; however, patients who were both malnourished and obese had a lower association with mortality risk than purely malnourished patients. CONCLUSIONS Our data suggests that nutritional status may be an important factor in inpatient mortality in patients with NETs with obesity being protective.
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Affiliation(s)
- Evan Glazer
- 1 Department of Surgery, The University of Arizona
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152
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Fraenkel M, Kim M, Faggiano A, de Herder WW, Valk GD. Incidence of gastroenteropancreatic neuroendocrine tumours: a systematic review of the literature. Endocr Relat Cancer 2014; 21:R153-63. [PMID: 24322304 DOI: 10.1530/erc-13-0125] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Based on the current medical literature, the worldwide incidence of neuroendocrine tumours (NETs) seems to have increased; however, a systematic literature overview is lacking. This study aimed to collect all available data on the incidence of gastroenteropancreatic (GEP)-NETs and characteristics of population to establish their epidemiology. A sensitive MEDLINE search was carried out. The papers were selected via a cascade process that restricted the initial pool of 7991 articles to 33, using predefined inclusion and exclusion criteria. Original articles evaluating the incidence of sporadic GEP-NETs in regional, institutional and national registries were considered. The majority of data originated from the US National Cancer Institute Surveillance, Epidemiology and End Results database and from national cancer registries in Western Europe. Generally, because of the retrospective nature of existing databases the outcomes of studies might be biased, which hinders the drawing of firm conclusions. The age-adjusted incidence of GEP-NETs has increased steadily over the past four decades (1973-2007), increasing 3.65-fold in the USA and 3.8- to 4.8-fold in the UK. Incidence has changed variably from one anatomical site to another. The greatest increase in incidence occurred for gastric and rectal NETs, while the smallest increase occurred for small intestine NETs. There were gender and racial differences, which differed site by site and, in some cases, changed over time. The incidence rates (IRs) of GEP-NETs have increased significantly in the last 40 years. Data are only available from North America, Western Europe and Japan. A site-by-site analysis revealed that the IRs of some NETs increased more than those of others.
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Affiliation(s)
- M Fraenkel
- Endocrinology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheeba, Israel Mount Sinai Medical Center, New York, New York, USA Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy Endocrinology, National Cancer Institute, Fondazione G. Pascale, Naples, Italy Erasmus MC, Rotterdam, The Netherlands Department of Internal Medicine, Division of Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
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153
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Baudin E, Caron P, Lombard-Bohas C, Tabarin A, Mitry E, Reznick Y, Taieb D, Pattou F, Goudet P, Vezzosi D, Scoazec JY, Cadiot G, Borson-Chazot F, Do Cao C. [Malignant insulinoma: recommendations for workup and treatment]. Presse Med 2014; 43:645-59. [PMID: 24857257 DOI: 10.1016/j.lpm.2013.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/15/2013] [Accepted: 08/19/2013] [Indexed: 02/09/2023] Open
Abstract
Insulinoma are malignant in 4 to 14 % of cases. Their rarity and the sparse data available in the literature have limited publication of specific guidelines for their management. The following review aim to provide up-to-date recommendations on initial evaluation including pathologic grading, measures to control hypoglycemia, antitumor strategies and long term follow-up. Will be discussed in detail respective indications of surgery, diazoxide, somatostatin analogs, everolimus, sunitinib, liver directed treatments including arterial embolization, chemotherapy and radiometabolic therapy. A Medline search using terms "insulinoma", "neuroendocrine pancreatic tumors", "islet cell carcinoma", "malignant insulinoma" was performed limiting the selection to English language articles and adult age cases, along with cross referencing.
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Affiliation(s)
- Eric Baudin
- Institut Gustave-Roussy, service de médecine nucléaire et d'oncologie endocrinienne, 94805 Villejuif cedex, France.
| | - Philippe Caron
- CHU Rangueil-Larrey, pôle cardiovasculaire et métabolique, service d'endocrinologie et maladies métaboliques, 31059 Toulouse cedex 9, France
| | | | - Antoine Tabarin
- Hôpital Haut-Lévêque, service d'endocrinologie, 33600 Pessac, France
| | - Emmanuel Mitry
- Institut Curie, hôpital René-Huguenin, service d'onco-gastroentérologie, 92210 Saint-Cloud, France
| | - Yves Reznick
- CHU Côte-de-Nacre, unité fonctionnelle d'endocrinologie et maladies métaboliques, 14033 Caen cedex, France
| | - David Taieb
- CHU de la Timone, service central de biophysique et de médecine nucléaire, 13005 Marseille, France
| | - François Pattou
- Hôpital Claude-Huriez, service de chirurgie endocrinienne, 59000 Lille, France
| | - Pierre Goudet
- CHU de Dijon, service de chirurgie générale et endocrinienne, 21000 Dijon, France
| | - Delphine Vezzosi
- CHU Rangueil-Larrey, pôle cardiovasculaire et métabolique, service d'endocrinologie et maladies métaboliques, 31059 Toulouse cedex 9, France
| | - Jean-Yves Scoazec
- Institut Gustave-Roussy, service de biologie et de pathologie médicales, 94805 Villejuif cedex, France
| | - Guillaume Cadiot
- Hôpital Robert-Debré, service d'hépato-gastro-entérologie et de cancérologie digestive, 51100 Reims, France
| | - Françoise Borson-Chazot
- Hospices Civils de Lyon, Fédération d'endocrinologie du pole Est, Fédération d'endocrinologie et centre de médecine nucléaire, 69500 Lyon, France
| | - Christine Do Cao
- Hôpital Claude-Huriez, service d'endocrinologie et de maladies métaboliques, 59000 Lille, France
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154
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Gratian L, Pura J, Dinan M, Roman S, Reed S, Sosa JA. Impact of extent of surgery on survival in patients with small nonfunctional pancreatic neuroendocrine tumors in the United States. Ann Surg Oncol 2014; 21:3515-21. [PMID: 24841347 DOI: 10.1245/s10434-014-3769-4] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Nonfunctional pancreatic neuroendocrine tumors (PNETs) ≤2 cm have uncertain malignant potential, and optimal treatment remains unclear. Objectives of this study were to better understand their malignant potential, determine whether extent of surgery or lymph node dissection is associated with overall survival (OS), and identify other factors associated with OS. METHODS Patients with nonfunctional PNETs ≤2 cm were identified from the National Cancer Data Base (1998 to 2011). Descriptive statistics were used for patient characteristics and surgical resection patterns. Five-year OS was estimated using Kaplan-Meier analyses across extent of surgery and compared using the log-rank test. Cox proportional regression modeling was used to test the association between survival and extent of surgery. RESULTS A total of 1854 patients with nonfunctional PNETs ≤2 cm were included. From 1998 to 2011, these tumors increased three-fold as a proportion of all PNETs. Among tumors ≤0.5 cm, 33 % presented with regional lymph node metastases and 11 % with distant metastases. Five-year OS for patients not undergoing surgery was 27.6 % vs. 83.0 % for partial pancreatectomy, 72.3 % for pancreaticoduodenectomy, and 86.0 % for total pancreatectomy (p < 0.01). Multivariate analysis demonstrated no difference in OS based on type of surgery or the addition of regional lymphadenectomy (p = 0.16). Younger age and later year of diagnosis were independently associated with improved survival. CONCLUSIONS Small nonfunctional PNETs represent an increasing proportion of all PNETs and have a significant risk of malignancy. Survival is improving over time despite older age at diagnosis. Type of surgical resection and the addition of lymph node resection were not associated with OS.
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Affiliation(s)
- Lauren Gratian
- Division of Endocrinology Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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155
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Zhang QQ, Ding Y, Lei Y, Qi CL, He XD, Lan T, Li JC, Gong P, Yang X, Geng JG, Wang LJ. Andrographolide suppress tumor growth by inhibiting TLR4/NF-κB signaling activation in insulinoma. Int J Biol Sci 2014; 10:404-14. [PMID: 24719558 PMCID: PMC3979993 DOI: 10.7150/ijbs.7723] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 01/26/2014] [Indexed: 01/07/2023] Open
Abstract
Insulinomas are rare tumors, and approximately 10% of insulinomas are malignant. Accumulating evidence has implicated that we still lack effective therapy to treat the patients who are diagnosed with rare malignant insulinoma. Previous studies have reported that Andrographolide (Andro) could inhibit cell cycle progression, reduce cell invasion and induce cell apoptosis in many common cancer cells. However, the effects of andro are cell type-dependent. So we emplored the β-TC-6 cells and the RIP1-Tag2 transgenic mouse model of endogenously growing insulinoma model to elucidate the possible anti-cancer effect of Andro on insulinoma, an uncommon type of malignant cancers in this study. Our experiments revealed that Andro significantly inhibited tumor growth at both the early-stage and the advanced-stage of insulinoma through targeting the TLR4/NF-κB signaling pathway. This work initially provides the evidence that the TLR4/NF-κB signaling pathway might be vital as a potential therapeutic target, and also indispensable in Andro-mediated anti-cancer effect in insulinoma.
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Affiliation(s)
- Qian-Qian Zhang
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Yi Ding
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Yan Lei
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Cui-Ling Qi
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Xiao-Dong He
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Tian Lan
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Jiang-Chao Li
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Ping Gong
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Xuesong Yang
- 3. Department of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical College of Jinan University, Guangzhou 510632, China
| | - Jian-Guo Geng
- 2. Department of Biologic and Materials Sciences, University of Michigan School of Dentistry, Ann Arbor, MI 48109, USA
| | - Li-Jing Wang
- 1. Vascular Biology Research Institute, Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou 510006, China
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156
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Krampitz GW, Norton JA. WITHDRAWN: Current Problems in Surgery: Pancreatic Neuroendocrine Tumors. Curr Probl Surg 2014. [DOI: 10.1067/j.cpsurg.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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157
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Kundel A, Thompson GB, Richards ML, Qiu LX, Cai Y, Schwenk FW, Lteif AN, Pittock ST, Kumar S, Tebben PJ, Hay ID, Grant CS. Pediatric endocrine surgery: a 20-year experience at the Mayo Clinic. J Clin Endocrinol Metab 2014; 99:399-406. [PMID: 24423286 DOI: 10.1210/jc.2013-2617] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Surgically managed endocrinopathies are rare in children. Most surgeons have limited experience in this field. Herein we report our operative experience with pediatric patients, performed over two decades by high-volume endocrine surgeons. SETTING The study was conducted at the Mayo Clinic (a tertiary referral center). PATIENTS Patients were <19 years old and underwent an endocrine operation (1993-2012). MAIN OUTCOME MEASURES Demographics, surgical procedure, diagnoses, morbidity, and mortality were retrospectively reviewed. RESULTS A total of 241 primary cases included 177 thyroid procedures, 13 neck dissections, 24 parathyroidectomies, 14 adrenalectomies, 7 paragangliomas, and 6 pancreatic procedures. Average age of patients was 14.2 years. There were 133 total thyroidectomies and 40 hemithyroidectomies. Fifty-three cases underwent a central or lateral neck dissection. Six-month follow-up was available for 98 total thyroidectomy patients. There were four cases of permanent hypoparathyroidism (4%) and no permanent recurrent laryngeal nerve (RLN) paralyses. Sequelae of neck dissections included temporary RLN neurapraxia and Horner's syndrome. Parathyroidectomy was performed on 24 patients: 20 with primary hyperparathyroidism (HPT), three with tertiary HPT, and one with familial hypocalciuric hypocalcemia. Three patients (16%) had recurrent HPT, all with multiglandular disease. One patient had temporary RLN neurapraxia. We performed seven bilateral and seven unilateral adrenalectomies; eight were laparoscopic. Indications included pheochromocytoma, Cushing's syndrome, adrenocortical carcinoma, congenital adrenal hyperplasia, and ganglioneuroma. One death was due to adrenocortical carcinoma. Five paraganglioma patients had succinate dehydrogenase subunit B mutations, and one recurred. Six patients with insulinoma underwent enucleation (n = 5) or distal pancreatectomy (n = 1). A single postoperative abscess was managed nonoperatively. CONCLUSION Pediatric endocrine procedures are uncommon but can be safely performed with complication rates comparable to those of the adult population. It is imperative that these operations be performed by high-volume surgeons.
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Affiliation(s)
- A Kundel
- Mayo Clinic, Rochester, Minnesota 55905
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158
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Weisbrod AB, Kitano M, Thomas F, Williams D, Gulati N, Gesuwan K, Liu Y, Venzon D, Turkbey I, Choyke P, Yao J, Libutti SK, Nilubol N, Linehan WM, Kebebew E. Assessment of tumor growth in pancreatic neuroendocrine tumors in von Hippel Lindau syndrome. J Am Coll Surg 2014; 218:163-9. [PMID: 24440063 PMCID: PMC3896892 DOI: 10.1016/j.jamcollsurg.2013.10.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 10/30/2013] [Accepted: 10/31/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of pancreatic neuroendocrine tumors (PNETs) is increasing, but only a subset of these heterogeneous tumors will progress to malignant disease, which is associated with a poor prognosis. Currently, there are limited data on the natural history of these tumors and it is difficult to determine which patients require surgical intervention because the risk of metastatic disease cannot be accurately determined. STUDY DESIGN We conducted a prospective study of 87 patients with von Hippel Lindau syndrome-associated solid pancreatic lesions to determine the natural history of these tumors with biochemical testing, follow-up anatomic and functional imaging, and advanced imaging analysis, with a median follow-up of 4 years. RESULTS Approximately 20% of consecutive tumor measurements during follow-up were decreased in size and 20% showed no change. This included 2 of 4 surgically proven malignant tumors, which had a net decrease in tumor size over time. Tumor volume, as derived from greatest diameter and volumetric measurements, showed good correlation to pathology tumor measurement of surgically resected tumors (Spearman rank correlation ρ = 0.72, p = 0.0011, and ρ = 0.83, p < 0.0001, respectively). Tumor density measurement had an inverse relationship with tumor size (Spearman rank correlation -0.22, p = 0.0047). A tumor density cutoff of 200 was 75% specific for malignant tumors. CONCLUSIONS Pancreatic neuroendocrine tumors demonstrate a nonlinear growth pattern, which includes periods of no growth and apparent decrease in size by imaging. These growth patterns are variable and are not associated with tumor grade and malignancy. Tumor density, as measured in this cohort, may offer a specific diagnostic tool for malignant disease.
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Affiliation(s)
- Allison B Weisbrod
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mio Kitano
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Francine Thomas
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - David Williams
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Neelam Gulati
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Krisana Gesuwan
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Yixun Liu
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - David Venzon
- Biostatistics and Data Management Section, Office of the Clinical Director, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Ismail Turkbey
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Peter Choyke
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jack Yao
- Diagnostic Radiology Department, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Steven K Libutti
- Department of Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| | - Naris Nilubol
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - William M Linehan
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Electron Kebebew
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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159
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160
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Resection of the primary pancreatic neuroendocrine tumor in patients with unresectable liver metastases: possible indications for a multimodal approach. Surgery 2013; 155:607-14. [PMID: 24582492 DOI: 10.1016/j.surg.2013.12.024] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/19/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) present in more than 50% of cases with liver metastases as the only systemic localization. Liver metastases are unresectable in 80% of cases at diagnosis. In the context of a metastatic disease, the benefit of primary tumor removal in terms of survival is controversial. METHODS A single-center series of patients with PNETs presenting with synchronous unresectable hepatic metastases and treated within a framework of a multidisciplinary team was analyzed retrospectively to assess the prognostic factors and the potential benefit of primary tumor resection on long-term survival. RESULTS At the time of diagnosis, 12 of 43 patients (28%) underwent primary tumor resection. After a median follow-up of 5 years (range, 0.6-14 years), 22 disease-related deaths were observed. The corresponding 5-year survival and median disease-specific duration of survival were 58% and 77 months, respectively. In the operated and nonoperated patients the 5-year disease-specific survival was 82% and 50%, respectively (P = .027). At multivariate analysis, patients with primary tumor removed had an improved survival compared with patients who did not (hazard ratio 0.18; 95% CI 0.05-0.66; P = .010). Other important factors associated with improved survival at multivariate analysis were lesser age, lesser Ki-67 index, and 25% less liver tumor burden. CONCLUSION In the present series of patients with PNETs and unresectable liver metastases, resection of the primary tumor was associated with an improved survival. This observation suggests that resection of the primary tumor should be part of a global therapeutic strategy and its indication and timing should be discussed within a multidisciplinary team.
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161
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Transcriptional regulatory network and protein-protein interaction to reveal the mechanism of pancreatic cancer. Mol Biol Rep 2013; 41:387-95. [PMID: 24307251 DOI: 10.1007/s11033-013-2872-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 11/08/2013] [Indexed: 10/25/2022]
Abstract
The development of pancreatic cancer (PC) may involve the over-expression of oncogenes, inactivation tumor suppressor genes or the deregulation of various signaling proteins. Thus identification and analysis of transcriptional regulatory relationship as well as protein-protein interaction (PPI) in PC to provide deep insights into the pathogenetic mechanism of pancreatic cancer. In this study, we downloaded the gene expression profile of PC from Gene Expression Omnibus and identified differentially expressed genes (DEGs) in PC patients compared with controls. To further understand how these DEGs act together to account for the initiation of pancreatic cancer, a transcriptional regulatory network was constructed to find the notes for GO function and KEGG pathways annotation, aiming to explore the clusters and pathways in PC. A total of 1,821 transcriptional regulatory relationships were identified. Then, a PPI network was constructed and noted by GO and KEGG, and some special modules, clusters and pathways were identified to involved in PC. Finally, we constructed the transcriptional regulatory network and PPI network of pancreatic cancer. Comparing the pathways involved in Transcriptional regulatory network and PPI network, pathway in cancer, PC, p53 signaling pathway, Hematopoietic cell lineage and graft-versus-host disease co-existed in these two network, so we predict these pathways may play key factors in development of cancer.
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162
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Halvorson SAC, Gilbert E, Hopkins RS, Liu H, Lopez C, Chu M, Martin M, Sheppard B. Putting the pieces together: necrolytic migratory erythema and the glucagonoma syndrome. J Gen Intern Med 2013; 28:1525-9. [PMID: 23681843 PMCID: PMC3797362 DOI: 10.1007/s11606-013-2490-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 03/19/2013] [Accepted: 04/30/2013] [Indexed: 12/29/2022]
Abstract
Glucagonomas are slow-growing, rare pancreatic neuroendocrine tumors. They may present with paraneoplastic phenomena known together as the "glucagonoma syndrome." A hallmark sign of this syndrome is a rash known as necrolytic migratory erythema (NME). In this paper, the authors describe a patient with NME and other features of the glucagonoma syndrome. The diagnosis of this rare tumor requires an elevated serum glucagon level and imaging confirming a pancreatic tumor. Surgical and medical treatment options are reviewed. When detected early, a glucagonoma is surgically curable. It is therefore imperative that clinicians recognize the glucagonoma syndrome in order to make an accurate diagnosis and refer for treatment.
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Affiliation(s)
- Stephanie A C Halvorson
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, BTE-119, Portland, OR, 97239, USA,
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163
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Fonseca PJ, Uriol E, Galván JA, Alvarez C, Pérez Q, Villanueva N, Berros JP, Izquierdo M, Viéitez JM. Prolonged clinical benefit of everolimus therapy in the management of high-grade pancreatic neuroendocrine carcinoma. Case Rep Oncol 2013; 6:441-9. [PMID: 24019785 PMCID: PMC3764965 DOI: 10.1159/000354754] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Treatment options for patients with high-grade pancreatic neuroendocrine tumors (pNET) are limited, especially for those with progressive disease and for those who experience treatment failure. Everolimus, an oral inhibitor of mammalian target of rapamycin (mTOR), has been approved for the treatment of patients with low- or intermediate-grade advanced pNET. In the randomized phase III RADIANT-3 study in patients with low- or intermediate-grade advanced pNET, everolimus significantly increased progression-free survival (PFS) and decreased the relative risk for disease progression by 65% over placebo. This case report describes a heavily pretreated patient with high-grade pNET and liver and peritoneal metastases who achieved prolonged PFS, clinically relevant partial radiologic tumor response, and resolution of constitutional symptoms with improvement in Karnofsky performance status while receiving a combination of everolimus and octreotide long-acting repeatable (LAR). Radiologic and clinical responses were maintained for 19 months, with minimal toxicity over the course of treatment. This case supports the findings that the combination of everolimus plus octreotide LAR may be considered for use in patients with high-grade pNET and progressive disease. Although behavior and aggressiveness are different between low- or intermediate-grade and high-grade pNET, some high-grade pNET may express mTOR; hence, everolimus should be considered in a clinical trial.
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Affiliation(s)
- Paula J Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
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164
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Hickey R, Vouche M, Sze D, Hohlastos E, Collins J, Schirmang T, Memon K, Ryu RK, Sato K, Chen R, Gupta R, Resnick S, Carr J, Chrisman H, Nemcek A, Vogelzang R, Lewandowski RJ, Salem R. Cancer concepts and principles: primer for the interventional oncologist-part II. J Vasc Interv Radiol 2013; 24:1167-88. [PMID: 23810312 PMCID: PMC3800031 DOI: 10.1016/j.jvir.2013.04.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 04/20/2013] [Accepted: 04/20/2013] [Indexed: 02/07/2023] Open
Abstract
This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.
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Affiliation(s)
- Ryan Hickey
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Michael Vouche
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Daniel Sze
- Department of Radiology, Stanford University, Palo Alto, CA
| | - Elias Hohlastos
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Jeremy Collins
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Todd Schirmang
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Khairuddin Memon
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Robert K Ryu
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Kent Sato
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Richard Chen
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Ramona Gupta
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Scott Resnick
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - James Carr
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Howard Chrisman
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Al Nemcek
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Robert Vogelzang
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Robert J Lewandowski
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
| | - Riad Salem
- Department of Radiology, Division of Interventional Oncology, Northwestern University, Chicago IL
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165
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Choi YH, Han HS, Lim SN, Lee SY, Koo JH, Lee OJ, Lee KH, Kim ST. Multiple cardiac metastases from a nonfunctioning pancreatic neuroendocrine tumor. Cancer Res Treat 2013; 45:150-4. [PMID: 23864849 PMCID: PMC3710965 DOI: 10.4143/crt.2013.45.2.150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 11/01/2011] [Indexed: 11/21/2022] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which most commonly metastasize to the liver. However, intrathoracic metastases from pNETs are encountered infrequently. This report describes a case of nonfunctioning pNET with multiple cardiac metastases. A 56-year-old male presented with a palpable abdominal mass that showed progressive enlargement. Findings on computed tomography (CT) of the abdomen revealed two relatively well-marginated inhomogeneous low-attenuation masses, one in the head of the pancreas and the other in the tail. Multiple enhancing masses in the left pericardium with myocardial involvement were observed on chest CT and transthoracic echocardiography. Needle biopsies were performed on the mass in the tail of the pancreas and the left ventricular apical pericardium; histologic examination by hematoxylin and eosin morphology and immunohistochemical staining showed pNET in both. This is the first report of pNET with multiple cardiac metastases to previously undescribed metastatic sites.
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Affiliation(s)
- Yong Hyeok Choi
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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166
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Zhang J, Francois R, Iyer R, Seshadri M, Zajac-Kaye M, Hochwald SN. Current understanding of the molecular biology of pancreatic neuroendocrine tumors. J Natl Cancer Inst 2013; 105:1005-17. [PMID: 23840053 PMCID: PMC6281020 DOI: 10.1093/jnci/djt135] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 04/05/2013] [Accepted: 04/06/2013] [Indexed: 12/11/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are complicated and often deadly neoplasms. A recent increased understanding of their molecular biology has contributed to expanded treatment options. DNA sequencing of samples derived from patients with PanNETs and rare genetic syndromes such as multiple endocrine neoplasia type 1 (MEN1) and Von Hippel-Lindau (VHL) syndrome reveals the involvement of MEN1, DAXX/ATRX, and the mammalian target of rapamycin (mTOR) pathways in PanNET tumorigenesis. Gene knock-out/knock-in studies indicate that inactivation of factors including MEN1 and abnormal PI3K/mTOR signaling uncouples endocrine cell cycle progression from the control of environmental cues such as glucose, leading to islet cell overgrowth. In addition, accumulating evidence suggests that further impairment of endothelial-endocrine cell interactions contributes to tumor invasion and metastasis. Recent phase III clinical trials have shown that therapeutic interventions, such as sunitinib and everolimus, targeting those signal transduction pathways improve disease-free survival rates. Yet, cure in the setting of advanced disease remains elusive. Further advances in our understanding of the molecular mechanisms of PanNETs and improved preclinical models will assist in developing personalized therapy utilizing novel drugs to provide prolonged control or even cure the disease.
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Affiliation(s)
- Jianliang Zhang
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
| | - Rony Francois
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
| | - Renuka Iyer
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
| | - Mukund Seshadri
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
| | - Maria Zajac-Kaye
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
| | - Steven N. Hochwald
- Affiliations of authors:Department of Surgical Oncology (JZ, SNH), Department of Medical Oncology (RI), and Department of Pharmacology and Therapeutics (MS), Roswell Park Cancer Institute, Buffalo, NY; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL (RF, MZ-K)
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167
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Abstract
Pancreatic neuroendocrine tumors (PanNETs) have increased in incidence in the USA over the last 20 years. Although PanNETs are often misconceived as being indolent tumors as they have a far more favorable prognosis over pancreatic adenocarcinoma, roughly 60-70% of patients have metastatic disease at the time of diagnosis due to presentation late in the disease process. While improvements in imaging modalities allow for early detection and better tumor localization, recent advancements in basic science, as well as surgical and medical management of PanNETs have further improved the prognosis. The mainstay of therapy for localized PanNETs is surgical intervention, which has become safer and is slowly shifting towards a more minimally invasive approach. However, the prognosis still remains relatively bleak for patients with unresectable disease. Fortunately, novel molecular targeted therapies, such as everolimus and sunitinib, have recently come into the limelight and have shown significant promise for the treatment of locally advanced and metastatic disease.
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Affiliation(s)
- Miral R Sadaria
- Department of Surgery, University of Colorado Anschutz Medical Campus, Division of GI, Tumor and Endocrine Surgery, Academic Office One, 12631 East 17th Avenue, C311, Aurora, CO 80045, USA
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168
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Kuo EJ, Salem RR. Population-level analysis of pancreatic neuroendocrine tumors 2 cm or less in size. Ann Surg Oncol 2013; 20:2815-21. [PMID: 23771245 DOI: 10.1245/s10434-013-3005-7] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a paucity of evidence regarding incidence and predictors of survival in pancreatic neuroendocrine tumors (PNETs)≤2 cm in size. METHODS Patients having undergone resection for nonfunctioning PNETs were selected from the SEER database (1988-2009) and an institutional pathology database (1996-2012). PNETs≤2 cm were compared with PNETs>2 cm. Data were analyzed with χ2 tests, ANOVA, the Kaplan-Meier method, log rank tests, and Cox proportional hazard, and binary logistic regression. RESULTS The incidence of PNETs≤2 cm in the United States has increased by 710.4% over the last 22 years. Rates of extrapancreatic extension, nodal metastasis, and distant metastasis in PNETs≤2 cm in the SEER database were 17.9, 27.3, and 9.1%, respectively. The rate of nodal metastasis in our institutional series was 5.7%. Disease-specific survival at 5, 10, and 15 years for PNETs≤2 cm was 91.5, 84.0, and 76.8%. Decreased disease-specific survival was not associated with nodal metastasis, but rather with high grade [moderately differentiated, hazard ratio (HR) 37.2, 95% confidence interval (CI) 2.7-518.8; poorly differentiated, HR 94.2, 95% CI 4.9-1,794.4; reference, well differentiated], and minority race (Asian, HR 30.2, 95% CI 3.1-291.7; Black, HR 60.1, 95% CI 2.1-1,027.9; reference, White). CONCLUSIONS Pancreatic neuroendocrine tumors≤2 cm are increasingly common, and the most significant predictors of disease-specific survival are grade and race. The SEER database excludes PNETs considered to be benign, and rates of extrapancreatic extension, nodal metastasis, and distant metastasis are overestimated. Small size, however, does not preclude malignant behavior.
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Affiliation(s)
- Eric J Kuo
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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169
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Zhang WY, Li ZS, Jin ZD. Endoscopic ultrasound-guided ethanol ablation therapy for tumors. World J Gastroenterol 2013; 19:3397-3403. [PMID: 23801831 PMCID: PMC3683677 DOI: 10.3748/wjg.v19.i22.3397] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/05/2013] [Accepted: 05/19/2013] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a diagnostic modality nearly three decades ago. In particular, EUS-guided fine-needle injection has proven a successful minimally invasive approach for treating benign lesions such as pancreatic cysts, relieving pancreatic pain through celiac plexus neurolysis, and controlling local tumor growth of unresectable malignancies by direct delivery of anti-tumor agents. One such ablative agent, ethanol, is capable of safely ablating solid or cystic lesions in hepatic tissues via percutaneous injection. Recent research and clinical interest has focused on the promise of EUS-guided ethanol ablation as a safe and effective method for treating pancreatic tumor patients with small lesions or who are poor operative candidates. Although it is not likely to replace radical resection of localized lesions or systemic treatment of metastatic tumors in all patients, EUS-guided ablation is an ideal method for patients who refuse or are not eligible for surgery. Moreover, this treatment modality may play an active role in the development of future pancreatic tumor treatments. This article reviews the most recent clinical applications of EUS-guided ethanol ablation in humans for treating pancreatic cystic tumors, pancreatic neuroendocrine tumors, and metastatic lesions.
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MESH Headings
- Ablation Techniques
- Endosonography
- Ethanol/administration & dosage
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Neuroendocrine Tumors/diagnostic imaging
- Neuroendocrine Tumors/pathology
- Neuroendocrine Tumors/surgery
- Pancreatic Cyst/diagnostic imaging
- Pancreatic Cyst/pathology
- Pancreatic Cyst/surgery
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Treatment Outcome
- Ultrasonography, Interventional/methods
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170
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Identification and characterization of poorly differentiated invasive carcinomas in a mouse model of pancreatic neuroendocrine tumorigenesis. PLoS One 2013; 8:e64472. [PMID: 23691228 PMCID: PMC3653861 DOI: 10.1371/journal.pone.0064472] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 04/15/2013] [Indexed: 11/19/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are a relatively rare but clinically challenging tumor type. In particular, high grade, poorly-differentiated PanNETs have the worst patient prognosis, and the underlying mechanisms of disease are poorly understood. In this study we have identified and characterized a previously undescribed class of poorly differentiated PanNETs in the RIP1-Tag2 mouse model. We found that while the majority of tumors in the RIP1-Tag2 model are well-differentiated insulinomas, a subset of tumors had lost multiple markers of beta-cell differentiation and were highly invasive, leading us to term them poorly differentiated invasive carcinomas (PDICs). In addition, we found that these tumors exhibited a high mitotic index, resembling poorly differentiated (PD)-PanNETs in human patients. Interestingly, we identified expression of Id1, an inhibitor of DNA binding gene, and a regulator of differentiation, specifically in PDIC tumor cells by histological analysis. The identification of PDICs in this mouse model provides a unique opportunity to study the pathology and molecular characteristics of PD-PanNETs.
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171
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Heparanase promotes lymphangiogenesis and tumor invasion in pancreatic neuroendocrine tumors. Oncogene 2013; 33:1799-808. [PMID: 23644656 DOI: 10.1038/onc.2013.142] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 03/12/2013] [Accepted: 03/14/2013] [Indexed: 01/09/2023]
Abstract
Heparan sulfate proteoglycans are an important and abundant component of the extracellular matrix, which undergo substantial remodeling throughout tumorigenesis via the enzymatic activity of heparanase. Heparanase has been shown to be upregulated in many human cancers; however, its specific functions in human pancreatic neuroendocrine tumors (PanNETs) and spontaneous mouse models of cancer have not been evaluated. Here, we investigated the role of heparanase in PanNETs using patient samples and the RIP1-Tag2 (RT2) PanNET-transgenic mouse model. High heparanase expression significantly correlated with more advanced tumor stage, higher tumor grade and the presence of distant metastasis in PanNET patients. We genetically manipulated heparanase levels in the RT2 model using heparanase-transgenic mice, which constitutively overexpress heparanase, and heparanase-knockout mice. Heparanase was found to have a critical role in promoting tumor invasion, through both macrophage and cancer cell sources in the tumor microenvironment. In addition, elevated heparanase levels significantly increased peritumoral lymphangiogenesis in vivo and promoted the trans-differentiation of macrophages into lymphatic endothelial cell-like structures in culture. Conversely, we found that heparanase deletion led to increased angiogenesis and pericyte coverage. Together, these data identify important roles for heparanase in regulating several critical aspects of tumorigenesis, demonstrating that heparanase represents a potential therapeutic target for PanNET patients.
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172
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Ito T, Igarashi H, Uehara H, Berna MJ, Jensen RT. Causes of death and prognostic factors in multiple endocrine neoplasia type 1: a prospective study: comparison of 106 MEN1/Zollinger-Ellison syndrome patients with 1613 literature MEN1 patients with or without pancreatic endocrine tumors. Medicine (Baltimore) 2013; 92:135-181. [PMID: 23645327 PMCID: PMC3727638 DOI: 10.1097/md.0b013e3182954af1] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is classically characterized by the development of functional or nonfunctional hyperplasia or tumors in endocrine tissues (parathyroid, pancreas, pituitary, adrenal). Because effective treatments have been developed for the hormone excess state, which was a major cause of death in these patients in the past, coupled with the recognition that nonendocrine tumors increasingly develop late in the disease course, the natural history of the disease has changed. An understanding of the current causes of death is important to tailor treatment for these patients and to help identify prognostic factors; however, it is generally lacking.To add to our understanding, we conducted a detailed analysis of the causes of death and prognostic factors from a prospective long-term National Institutes of Health (NIH) study of 106 MEN1 patients with pancreatic endocrine tumors with Zollinger-Ellison syndrome (MEN1/ZES patients) and compared our results to those from the pooled literature data of 227 patients with MEN1 with pancreatic endocrine tumors (MEN1/PET patients) reported in case reports or small series, and to 1386 patients reported in large MEN1 literature series. In the NIH series over a mean follow-up of 24.5 years, 24 (23%) patients died (14 MEN1-related and 10 non-MEN1-related deaths). Comparing the causes of death with the results from the 227 patients in the pooled literature series, we found that no patients died of acute complications due to acid hypersecretion, and 8%-14% died of other hormone excess causes, which is similar to the results in 10 large MEN1 literature series published since 1995. In the 2 series (the NIH and pooled literature series), two-thirds of patients died from an MEN1-related cause and one-third from a non-MEN1-related cause, which agrees with the mean values reported in 10 large MEN1 series in the literature, although in the literature the causes of death varied widely. In the NIH and pooled literature series, the main causes of MEN1-related deaths were due to the malignant nature of the PETs, followed by the malignant nature of thymic carcinoid tumors. These results differ from the results of a number of the literature series, especially those reported before the 1990s. The causes of non-MEN1-related death for the 2 series, in decreasing frequency, were cardiovascular disease, other nonendocrine tumors > lung diseases, cerebrovascular diseases. The most frequent non-MEN1-related tumor deaths were colorectal, renal > lung > breast, oropharyngeal. Although both overall and disease-related survival are better than in the past (30-yr survival of NIH series: 82% overall, 88% disease-related), the mean age at death was 55 years, which is younger than expected for the general population.Detailed analysis of causes of death correlated with clinical, laboratory, and tumor characteristics of patients in the 2 series allowed identification of a number of prognostic factors. Poor prognostic factors included higher fasting gastrin levels, presence of other functional hormonal syndromes, need for >3 parathyroidectomies, presence of liver metastases or distant metastases, aggressive PET growth, large PETs, or the development of new lesions.The results of this study have helped define the causes of death of MEN1 patients at present, and have enabled us to identify a number of prognostic factors that should be helpful in tailoring treatment for these patients for both short- and long-term management, as well as in directing research efforts to better define the natural history of the disease and the most important factors determining long-term survival at present.
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Affiliation(s)
- Tetsuhide Ito
- From the Department of Medicine and Bioregulatory Science (TI, HI), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Digestive Diseases Branch (TI, HI, HU, MJB, RTJ), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Hôpital Kirchberg (MJB), Luxembourg, Luxembourg
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173
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Abstract
Pancreatic neuroendocrine tumors account for 1% to 2% of pancreatic neoplasms and may occur sporadically or as part of a hereditary syndrome. Patients may present with symptoms related to hormone secretion by functional tumors or to locally advanced or metastatic nonfunctional tumors. Asymptomatic pancreatic neuroendocrine tumors are increasingly detected incidentally during abdominal imaging performed for other reasons. The management of localized pancreatic neuroendocrine tumors is surgical resection. Hepatic metastases are common and their management involves a variety of liver-directed therapies, which should be tailored according to extent of disease, symptoms, presence of extrahepatic metastases, and patient performance status.
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Affiliation(s)
- Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 208, Memphis, TN 38163, USA
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174
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Ma DW, Kim MK, Yoon SO, Rhee K, Yoon DS, Park H. [A case of double primary neuroendocrine tumor from duodenum and pancreas]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 61:155-9. [PMID: 23575234 DOI: 10.4166/kjg.2013.61.3.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Gastrointestinal neuroendocrine tumors arise from cells of the diffuse neuroendocrine system and can take place almost anywhere within the gastrointestinal tract. A 40-year-old man admitted to evaluate a duodenal subepithelial lesion which was incidentally found at health check-up. The polypoid duodenal subepithelial lesion, measuring about 7 mm, was removed by the endoscopic mucosal resection and the pathology confirmed a neuroendocrine tumor. Abdominopelvic computed tomography, done for staging work up, revealed a mass in the pancreatic head and the patient received pylorus preserving pancreaticoduodenectomy. Mass at the pancreas also found out to be neuroendocrine tumor but showed different histopathologic traits under immunohistochemical staining. The patient was also diagnosed as hyperparathyroidism and pituitary microadenoma. Finally, multiple endocrine neoplasia type 1 was confirmed, which was accompanied by duodenal neuroendocrine tumor.
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Affiliation(s)
- Dae Won Ma
- Departments of Internal Medicine, Pathology and Surgery,Yonsei University College of Medicine, Seoul, Korea
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175
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Yao JC, Phan AT, Jehl V, Shah G, Meric-Bernstam F. Everolimus in advanced pancreatic neuroendocrine tumors: the clinical experience. Cancer Res 2013; 73:1449-53. [PMID: 23436795 DOI: 10.1158/0008-5472.can-12-3923] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The incidence of neuroendocrine tumors (NET) has increased dramatically in the past 30 years. This information has revitalized basic and clinical research into the molecular biology of NET and has resulted in the recent approval of new therapies for pancreatic NET (pNET), including the oral inhibitor of the mTOR everolimus. Everolimus significantly improved progression-free survival among patients with pNET in the phase III RADIANT-3 study. Here, we review the clinical studies showing the efficacy of everolimus in pNET and summarize the translational science from these studies. To understand the mechanisms of resistance and cause of treatment failure, we compared the type of progression events observed in the everolimus and placebo arms of the RADIANT-3 study. Comparison of the everolimus arm to the placebo arm indicated the fractions of progression events due to new metastasis only (21% vs. 22%), growth of preexisting lesions only (54% vs. 49%), and new metastasis along with growth of preexisting lesions (24% vs. 27%) were similar. These results suggest that although everolimus delays disease progression in patients with pNET, patients who experience disease progression while on everolimus do not appear to have a more aggressive metastatic phenotype than those whose disease progresses while on placebo.
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Affiliation(s)
- James C Yao
- Departments of Gastrointestinal Medical Oncology and Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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176
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Wolin EM. PI3K/Akt/mTOR pathway inhibitors in the therapy of pancreatic neuroendocrine tumors. Cancer Lett 2013; 335:1-8. [PMID: 23419523 DOI: 10.1016/j.canlet.2013.02.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 02/06/2013] [Accepted: 02/08/2013] [Indexed: 02/07/2023]
Abstract
The phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) pathway is implicated in the pathogenesis of pancreatic neuroendocrine tumors (pNETs). Activation of this pathway is driven by aberrant tyrosine kinase receptor activities. Mutations in the PI3K/Akt/mTOR pathway occur in 15% of pNETs, and expression of genes of the PI3K/Akt/mTOR pathway is altered in the majority of pNETs. The mTOR inhibitor everolimus has been approved by the FDA for the treatment of pNET, but its efficacy may be limited by its inability to prevent mTORC2-mediated activation of Akt. Specific inhibitors of PI3K, Akt, or other pathway nodes, and their concomitant use with mTOR inhibitors, or agents with dual activity, may be more effective. Preclinical studies demonstrate that inhibitors of the PI3K pathway have antitumor activity in pNET cells, either through direct inhibition of individual pathway nodes or indirect inhibition of molecular chaperones such as heat-shock protein 90. Clinical studies are underway evaluating individual node and dual node inhibitors.
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Affiliation(s)
- Edward M Wolin
- Division of Hematology/Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA.
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177
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Abstract
OBJECTIVE Pancreatic cancer continues to have a poor prognosis despite impressive improvements in the outcomes of many other types of cancer, often because most pancreatic neoplasms are found to be unresectable at diagnosis. The purpose of this review is to provide an overview of pancreatic cancer and the role of modern imaging in its diagnosis and management with an emphasis on (18)F-FDG PET/CT fusion imaging. CONCLUSION Multimodality imaging is critical in the diagnosis and management of pancreatic cancer. PET/CT is increasingly viewed as a useful, accurate, and cost-effective modality in diagnosing and managing pancreatic cancer, but further studies are warranted. Early data suggest that contrast-enhanced PET/CT performed with modern PET/CT scanners yields high-resolution anatomic information for surgical and radiotherapeutic planning and functional information for whole-body staging in the care of patients with this disease.
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178
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Muniraj T, Vignesh S, Shetty S, Thiruvengadam S, Aslanian HR. Pancreatic neuroendocrine tumors. Dis Mon 2013; 59:5-19. [DOI: 10.1016/j.disamonth.2012.10.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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179
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Ogawa M, Kawaguchi Y, Maruno A, Ito H, Nakagohri T, Hirabayashi K, Yamamuro H, Yamashita T, Mine T. Small serotonin-positive pancreatic endocrine tumors caused obstruction of the main pancreatic duct. World J Gastroenterol 2012; 18:6669-73. [PMID: 23236243 PMCID: PMC3516203 DOI: 10.3748/wjg.v18.i45.6669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/01/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
Abstract
We report 2 cases of pancreatic endocrine tumors that caused obstruction of the main pancreatic duct (MPD). A 49-year-old asymptomatic man was referred to our institution because dilation of the MPD was revealed by abdominal ultrasonography (US). No tumor was detected by endoscopic ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). The diameter of the MPD was > 20 mm at the body, and no dilation was noted at the head. Although malignancy was not confirmed through cytology or imaging, pancreatic cancer was strongly suspected. Pancreaticoduo- denectomy was performed. Pathological and immunohistochemical examination revealed a 5 mm × 3 mm serotonin-positive endocrine tumor. Fibrosis was present around the MPD and seemed to cause stricture. A 32-year-old asymptomatic man had elevated serum amylase, and US demonstrated dilation of the MPD. No tumor was detected by CT and MRI. Pancreatic cancer was suspected due to stricture and dilation of the MPD. Pancreatectomy of middle part of pancreas was performed. Pathological and immunohistochemical examination revealed a serotonin-positive endocrine tumor sized 5 mm × 4 mm. We report 2 cases of serotonin-positive pancreatic endocrine tumors that caused stricture of the MPD in spite of the small size of the tumor.
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180
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Fraenkel M, Kim MK, Faggiano A, Valk GD. Epidemiology of gastroenteropancreatic neuroendocrine tumours. Best Pract Res Clin Gastroenterol 2012; 26:691-703. [PMID: 23582913 DOI: 10.1016/j.bpg.2013.01.006] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 01/10/2013] [Indexed: 01/31/2023]
Abstract
Gastroenteropancreatic neuroendocrine tumours are a heterogeneous group of tumours arising from diffuse endocrine cells, causing unique clinical syndromes. These tumours, formerly named carcinoid, can involve any part of the gastrointestinal tract and the endocrine pancreas and have a wide range of malignant potential: from benign to poorly differentiated tumours. In this review we will summarize the data available on the epidemiology of gastroenteropancreatic tumours as it is reported from around the world. This includes annual incidence rates at the various anatomic sites, and trends in incidence rates with time. In addition age and stage at presentation, gender and racial differences and finally prognosis and survival were collected when reported.
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Affiliation(s)
- M Fraenkel
- Endocrinology Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Yitzchag Rager, Beer Sheva, Israel.
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181
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Costa FP, Gumz B, Pasche B. Selecting patients for cytotoxic therapies in gastroenteropancreatic neuroendocrine tumours. Best Pract Res Clin Gastroenterol 2012; 26:843-54. [PMID: 23582923 DOI: 10.1016/j.bpg.2012.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 12/27/2012] [Indexed: 02/07/2023]
Abstract
Gastroenteropancreatic neuroendocrine tumours (GEP-NET) have heterogenic clinical presentations. The majority of GEP-NET tumours have an indolent behaviour, but patients will eventually develop symptoms of tumour progression or hormone secretion that may require systemic medical interventions. Cytotoxic chemotherapy has been tested in GEP-NETs since the 80s, but treatment recommendations are controversial in many instances. Patient selection is mandatory for optimal use of chemotherapy. Important prognostic factors such as primary tumour site, tumour differentiation, tumour staging and proliferation index have been identified and validated in retrospective and prospective series. The combination of those factors and the natural history of GEP-NET provide valuable information with respect to treatment planning. In this report we provide treatment recommendations to improve systemic therapy in patients with advanced GEP-NETs based on a comprehensive review of the literature.
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Affiliation(s)
- F P Costa
- Centro de Oncologia, Hospital Sírio Libanês, Rua Dona Adma Jafet 90, São Paulo, SP, CEP 01308-050, Brazil.
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182
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Ito T, Okusaka T, Ikeda M, Igarashi H, Morizane C, Nakachi K, Tajima T, Kasuga A, Fujita Y, Furuse J. Everolimus for advanced pancreatic neuroendocrine tumours: a subgroup analysis evaluating Japanese patients in the RADIANT-3 trial. Jpn J Clin Oncol 2012; 42:903-11. [PMID: 22859827 PMCID: PMC3448379 DOI: 10.1093/jjco/hys123] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/02/2012] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Everolimus, an inhibitor of the mammalian target of rapamycin, has recently demonstrated efficacy and safety in a Phase III, double-blind, randomized trial (RADIANT-3) in 410 patients with low- or intermediate-grade advanced pancreatic neuroendocrine tumours. Everolimus 10 mg/day provided a 2.4-fold improvement compared with placebo in progression-free survival, representing a 65% risk reduction for progression. The purpose of this analysis was to investigate the efficacy and safety of everolimus in the Japanese subgroup enrolled in the RADIANT-3 study. METHODS Subgroup analysis of the Japanese patients was performed comparing efficacy and safety between everolimus 10 mg/day orally (n = 23) and matching placebo (n = 17). The primary endpoint was progression-free survival. Safety was evaluated on the basis of the incidence of adverse drug reactions. RESULTS Progression-free survival was significantly prolonged with everolimus compared with placebo. The median progression-free survival was 19.45 months (95% confidence interval, 8.31-not available) with everolimus vs 2.83 months (95% confidence interval, 2.46-8.34) with placebo, resulting in an 81% risk reduction in progression (hazard ratio, 0.19; 95% confidence interval, 0.08-0.48; P< 0.001). Adverse drug reactions occurred in all 23 (100%) Japanese patients receiving everolimus and in 13 (77%) patients receiving placebo; most were grade 1/2 in severity. The most common adverse drug reactions in the everolimus group were rash (n = 20; 87%), stomatitis (n = 17; 74%), infections (n = 15; 65%), nail disorders (n = 12; 52%), epistaxis (n = 10; 44%) and pneumonitis (n = 10; 44%). CONCLUSIONS These results support the use of everolimus as a valuable treatment option for Japanese patients with advanced pancreatic neuroendocrine tumours.
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Affiliation(s)
- Tetsuhide Ito
- Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
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183
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Vascular pancreatic lesions: spectrum of imaging findings of malignant masses and mimics with pathologic correlation. ACTA ACUST UNITED AC 2012; 38:802-17. [DOI: 10.1007/s00261-012-9954-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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184
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Rui M, Li L, Jiang-Feng M, Feng G, Hui-Juan Z, Wen-Hui L, Yu-Xiu L. Hypercalcemia appeared in a patient with glucagonoma treated with octreotide acetate long-acting release. CHINESE MEDICAL SCIENCES JOURNAL = CHUNG-KUO I HSUEH K'O HSUEH TSA CHIH 2012; 27:182-184. [PMID: 23062642 DOI: 10.1016/s1001-9294(14)60053-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PABCREATIC neuroendocrine tumours are uncommon neoplasms of the pancreas. They may cause a clinical syndrome due to hormone overproduction. Glucagonoma is a rare kind of pancreatic tumors. Here we report a case of glucagonoma. Hypercalcemia occurred when the patient underwent octreotide acetate long-acting release.
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Affiliation(s)
- Min Rui
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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185
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Ito T, Igarashi H, Jensen RT. Therapy of metastatic pancreatic neuroendocrine tumors (pNETs): recent insights and advances. J Gastroenterol 2012; 47:941-60. [PMID: 22886480 PMCID: PMC3754804 DOI: 10.1007/s00535-012-0642-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 06/23/2012] [Indexed: 02/08/2023]
Abstract
Neuroendocrine tumors (NETs) [carcinoids, pancreatic neuroendocrine tumors (pNETs)] are becoming an increasing clinical problem because not only are they increasing in frequency, but they can frequently present with advanced disease that requires diagnostic and treatment approaches different from those used in the neoplasms that most physicians are used to seeing and treating. In the past few years there have been numerous advances in all aspects of NETs including: an understanding of their unique pathogenesis; specific classification systems developed which have prognostic value; novel methods of tumor localization developed; and novel treatment approaches described. In patients with advanced metastatic disease these include the use of newer chemotherapeutic approaches, an increased understanding of the role of surgery and cytoreductive methods, the development of methods for targeted delivery of cytotoxic agents, and the development of targeted medical therapies (everolimus, sunitinib) based on an increased understanding of the disease biology. Although pNETs and gastrointestinal NETs share many features, recent studies show they differ in pathogenesis and in many aspects of diagnosis and treatment, including their responsiveness to different therapies. Because of limited space, this review will be limited to the advances made in the management and treatment of patients with advanced metastatic pNETs over the past 5 years.
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Affiliation(s)
- Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hisato Igarashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Robert T. Jensen
- Digestive Diseases Branch, NIDDK, NIH, Building 10, Room 9C-103, Bethesda, MD 20892, USA
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186
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Qadan M, Visser B, Kim J, Pai R, Triadafilopoulos G. Abdominal mass, anemia, diabetes mellitus, and necrolytic migratory erythema. Dig Dis Sci 2012; 57:1465-8. [PMID: 22089253 DOI: 10.1007/s10620-011-1967-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 11/01/2011] [Indexed: 12/09/2022]
Affiliation(s)
- Motaz Qadan
- Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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187
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Grewal P, Salopek TG. Is necrolytic migratory erythema due to glucagonoma a misnomer? A more apt name might be mucosal and intertriginous erosive dermatitis. J Cutan Med Surg 2012; 16:76-82. [PMID: 22513058 DOI: 10.2310/7750.2011.10134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In dermatology, many conditions are given names that ultimately prove to be a misnomer (eg, mycosis fungoides, pyogenic granuloma). For most misnomers, continued use of the inappropriate word(s) rarely results in a delay in diagnosis and/or treatment. An argument can be made that the term necrolytic migratory erythema (NME) due to glucagonoma results in a delay in diagnosis, often with fatal consequences. OBJECTIVE We reviewed the literature of the past 30 years concerning the dermatologic and histologic findings of NME in association with glucagonoma. The most striking feature evident in nearly all reported cases is the presence of mucosal lesions and annular, eroded, eczematous patches and plaques of intertriginous areas. CONCLUSION We propose the renaming of the eruption associated with glucagonoma to one that emphasizes its unique localization to the mucosa and intertriginous areas: mucosal and intertriginous erosive dermatitis. It is hoped that this will lead to a more timely recognition of the condition and a possible improvement in prognosis.
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Affiliation(s)
- Parbeer Grewal
- Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB
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188
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Cen P, Amato RJ. Treatment of advanced pancreatic neuroendocrine tumors: potential role of everolimus. Onco Targets Ther 2012; 5:217-24. [PMID: 22870038 PMCID: PMC3411331 DOI: 10.2147/ott.s16289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are frequently diagnosed at unresectable stage and remain a medical challenge. Everolimus (RAD001, Afinitor®, Novartis, Basel, Switzerland), an orally administered inhibitor of mammalian target of rapamycin (mTOR), was recently approved by the Food and Drug Administration to treat patients with advanced PanNETs. This review will examine the mechanism of action of everolimus, the function of mTOR and its inhibition, PanNETs and the mTOR pathway, and clinical trials of everolimus in PanNETs. Future investigations will focus on everolimus combination therapy to treat PanNETs and the discovery of predictive biomarkers for response to everolimus.
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Affiliation(s)
- Putao Cen
- Division of Oncology, Department of Internal Medicine, University of Texas Health Science Center at Houston (Medical School), Houston, TX, USA
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189
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Hubner RA, Valle JW. Sunitinib for advanced pancreatic neuroendocrine tumors. Expert Rev Anticancer Ther 2012; 11:1817-27. [PMID: 22117148 DOI: 10.1586/era.11.171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent recognition of the high prevalence of neuroendocrine tumors in combination with a sustained failure to improve outcomes for patients with advanced disease has elevated their priority for research and drug development. Sunitinib (SU11248, Sutent; Pfizer Inc. NY, USA) potently inhibits multiple-receptor tyrosine kinases, resulting in antiangiogenic effects. A growing body of evidence indicates angiogenesis is a clinically relevant therapeutic target in pancreatic neuroendocrine tumors, culminating in a Phase III randomized study of sunitinib in patients with advanced progressive pancreatic neuroendocrine tumors. Sunitinib has recently gained regulatory approval as a single agent in this setting, and future studies will investigate most appropriate patient selection, and sequencing and combination with other targeted and cytotoxic agents. Here, we discuss in detail the molecular properties, clinical efficacy and safety of sunitinib in the context of pancreatic neuroendocrine tumors.
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Affiliation(s)
- Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
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190
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Affiliation(s)
- Daniel M Halperin
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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191
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Riccardi F, Rizzo M, Festino L, Ambrosio F, Molino C, Uomo G, Cartenì G. Therapy innovation for the treatment of pancreatic neuroendocrine tumors. Expert Opin Ther Targets 2012; 16 Suppl 2:S91-102. [PMID: 22372544 DOI: 10.1517/14728222.2012.665880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Traditional therapeutic approaches for patients with advanced neuroendocrine tumors (NETs) have included treatment with somatostatin analogs, hepatic-directed therapies, interferon and cytotoxic chemotherapy. Current knowledge about biological behavior of pancreatic neuroendocrine tumors (pNETs) has increased in the last decade, and some studies have been conducted to translate in the clinical setting. Among several molecular agents investigated in patients with progressive pNETs, everolimus and sunitinib have been studied in large Phase III trials. Both have produced significant benefit, with improvement in progression-free survival. These results were published last year by NEJM and were updated at the ASCO Annual Meeting in June 2011. AREAS COVERED This review focuses on the potential molecular targets in pancreatic NETs in the light of recent advances. Furthermore, it summarizes the available data for targeted agents from Phase II and III trials open to patients with this tumor. EXPERT OPINION These new agents are likely to play an increasingly important role in the future management of advanced pNETs. Their use in earlier phases of the disease could improve clinical outcome, avoiding side effects of the more toxic chemotherapy. The challenge in medical treatment of pNET is to define the patients who can benefit from this innovative therapy; future research should be directed to find predictive markers for response to the targeted agent.
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Affiliation(s)
- Ferdinando Riccardi
- UOSC di Oncologia Medica, Gruppo NET Cardarelli, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Napoli, Italy.
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192
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Dong M, Phan AT, Yao JC. New strategies for advanced neuroendocrine tumors in the era of targeted therapy. Clin Cancer Res 2012; 18:1830-6. [PMID: 22338018 DOI: 10.1158/1078-0432.ccr-11-2105] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low- to intermediate-grade neuroendocrine tumor (NET) constitutes a group of indolent malignancies that share the capacity for secreting hormones and neuroamines. Until recently, there were few therapeutic options for oncologic control. The PROMID study showed that octreotide long-acting repeatable formulation can delay tumor growth in midgut NETs. And, recent phase III studies showed both everolimus and sunitinib improved progression-free survival in pancreatic NETs, validating the phosphoinositide 3-kinase/Akt/mTOR pathway and angiogenesis as important targets for further advances. Ongoing and planned pivotal studies targeting these pathways in other NET subtypes may widen their therapeutic application. Development of rational combinations may further improve therapeutic outcome. These successes and our improved understanding of the underlying molecular biology are likely to lead to further important advances on the horizon.
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Affiliation(s)
- Mei Dong
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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193
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Kamp K, Damhuis RAM, Feelders RA, de Herder WW. Occurrence of second primary malignancies in patients with neuroendocrine tumors of the digestive tract and pancreas. Endocr Relat Cancer 2012; 19:95-9. [PMID: 22194442 DOI: 10.1530/erc-11-0315] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An increased association between neuroendocrine tumors of the gastrointestinal tract and pancreas (GEP-NET) and other second primary malignancies has been suggested. We determined whether there is indeed an increased risk for second primary malignancies in GEP-NET patients compared with an age- and sex-matched control group of patients with identical malignancies. The series comprised 243 men and 216 women, diagnosed with a GEP-NET between 2000 and 2009 in a tertiary referral center. The timeline, before-at-after diagnosis, and the type of other malignancies were studied using person-year methodology. Poisson distributions were used for testing statistical significance. All data were cross-checked with the Dutch National Cancer Registry. Out of 459 patients with GEP-NET, 67 (13.7%) had a second primary cancer diagnosis: 25 previous cancers (5.4%), 13 synchronous cancers (2.8%), and 29 metachronous cancers (6.3%). The most common types of second primary cancer were breast cancer (n=10), colorectal cancer (n=8), melanoma (n=6), and prostate cancer (n=5). The number of patients with a cancer history was lower than expected, although not significant (n=25 vs n=34.5). The diagnosis of synchronous cancers, mainly colorectal tumors, was higher than expected (n=13 vs n=6.1, P<0.05). Metachronous tumors occurred as frequent as expected (n=29 vs n=25.2, NS). In conclusion, our results are in contrast to previous studies and demonstrate that only the occurrence of synchronous second primary malignancies, mainly colorectal cancers, is increased in GEP-NET patients compared with the general population.
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Affiliation(s)
- Kimberly Kamp
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC, S-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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194
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Oberstein PE, Saif MW. Safety and efficacy of everolimus in adult patients with neuroendocrine tumors. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:41-51. [PMID: 22253554 PMCID: PMC3256980 DOI: 10.4137/cmo.s7319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Neuroendocrine tumors (NETs) consist of a diverse family of tumors which are derived from the neuroendocrine system. Most NETs are well or moderately differentiated tumors with a relatively indolent growth pattern. However, these tumors can cause significant clinical disease due to release of functional products that mediate the carcinoid syndrome and other diverse sequela. They also can grow progressively and cause symptoms from local invasion or distant metastasis. NETs are optimally treated with surgery and somatosatin analogs (SSA’s) to control symptoms but are relatively insensitive to systemic chemotherapy. As a result, patients with advanced unresectable NETs have a poor prognosis. In 2011, two targeted therapies, sunitinib and everolimus were approved in the subset of progressive pancreatic NETs (pNETs). Everolimus is an oral inhibitor of the growth stimulatory mTOR pathway. In Phase 2 trials in NETs and pNETs, everolimus was well tolerated and associated with some response and widespread disease stabilization. In follow-up, randomized Phase 3 trials, everolimus was compared to placebo. In the RADIANT-2 trial, everolimus and a somatostatin analog were used in patients with functional NETs and treatment was associated with an an improvement in progression-free survival (PFS). In the RADIANT-3 trial, patients with pNET were randomized to receive everolimus or placebo along with best supportive care. Everolimus was again associated with improvement in PFS compared to placebo and it has been approved by the FDA for patients with progressive pNET. Everolimus is associated with frequent low grade toxicity but is also notable for increased rates of infection as well as non-infectious pneumonitis. mTOR inhibition with everolimus represents a significant advance in the treatment of advanced neuroendocrine tumors.
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Affiliation(s)
- Paul E Oberstein
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA. Pancreas Center, Presbyterian Hospital, New York, NY, USA
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195
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Sakurai A, Yamazaki M, Suzuki S, Fukushima T, Imai T, Kikumori T, Okamoto T, Horiuchi K, Uchino S, Kosugi S, Yamada M, Komoto I, Hanazaki K, Itoh M, Kondo T, Mihara M, Imamura M. Clinical features of insulinoma in patients with multiple endocrine neoplasia type 1: analysis of the database of the MEN Consortium of Japan. Endocr J 2012; 59:859-66. [PMID: 22785103 DOI: 10.1507/endocrj.ej12-0173] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
More than 50% of patients with multiple endocrine neoplasia type 1 (MEN1) develop gastroenteropancreatic neuroendocrine tumors (GEPNETs), and insulinoma is the second most common functioning GEPNET. Compared to other functioning and nonfunctioning GEPNETs in MEN1, insulinoma is considered to develop at a younger age. To clarify the clinical features of insulinoma developed in Japanese patients with MEN1, a recently constructed database of Japanese MEN1 patients was analyzed. Among 560 registered cases, insulinoma was seen in 69 patients and information on age at diagnosis was available for 54 patients. Tumors predominantly occurred in the body and tail of the pancreas. The mean age at diagnosis of insulinoma (34.8 ± 16.7 yrs) was significantly younger than that of gastrinoma (50.6 ± 14.3 yrs) and nonfunctioning tumor (44.7 ± 13.3 yrs) in patients with MEN1. Patients diagnosed as having insulinoma during middle-age (30 - 49 yrs) tended to have a long period from appearance of hypoglycemic symptoms to diagnosis of the tumor. Of note, 13 patients (24%) were diagnosed as having insulinoma before 20 yrs of age. Such young onset was not seen in other GEPNETs. Since the development of GEPNETs during adolescence is quite rare, insulinoma diagnosed before 20 yrs strongly suggests the presence of MEN1 and warrants further investigation, including MEN1 genetic testing. Also, clinicians should be aware that insulinoma can often be missed in middle-aged patients.
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Affiliation(s)
- Akihiro Sakurai
- Department of Medical Genetics, Shinshu University School of Medicine, Matsumoto 390-8621, Japan.
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196
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Kunz PL. A renaissance in therapeutic options for pancreatic neuroendocrine tumors. Am Soc Clin Oncol Educ Book 2012:271-274. [PMID: 24451747 DOI: 10.14694/edbook_am.2012.32.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The field of pancreatic neuroendocrine tumors (NETs) has seen a remarkable renaissance in recent years with exponential increases in published research, clinical trials, and U.S. Food and Drug Administration (FDA)-approved treatments. Surgical resection remains the foundation for management of locoregional disease. However, for patients with advanced disease, novel therapeutic options have emerged. Two separate randomized placebo-controlled studies have shown prolonged progression-free survival (PFS) with everolimus or sunitinib. Future studies are designed to answer questions about the role of somatostatin analogs as antiproliferative agents, combinations of biologic therapies, and new cytotoxic chemotherapy backbones.
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Affiliation(s)
- Pamela L Kunz
- From the Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA
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197
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Roland CL, Bian A, Mansour JC, Yopp AC, Balch GC, Sharma R, Xie XJ, Schwarz RE. Survival impact of malignant pancreatic neuroendocrine and islet cell neoplasm phenotypes. J Surg Oncol 2011; 105:595-600. [PMID: 22006521 DOI: 10.1002/jso.22118] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 09/21/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND The low incidence of malignant "functional" (F) or "nonfunctional" (NF) neuroendocrine islet cell tumors (ICTs) of the pancreas represents a challenge to precise post-therapeutic survival prediction. This study examined the survival impact of malignant pancreatic ICT morphologic subtypes. METHODS A pancreatic ICT data set was created from a US-based population database from 1980-2004. Prognostic factors with survival impact and relationships between surgical therapy and overall survival (OS) were analyzed. RESULTS There were 2,350 individuals with malignant ICTs. Histologic subtypes included carcinoid tumors, islet cell carcinomas, neuroendocrine carcinomas, and malignant gastrinomas, insulinomas, glucagonomas, or VIPomas. There was no difference in resection rates between FICTs and NFICTs (23% vs. 20%, P = ns). Median OS was 30 months, with group differences ranging from NE carcinomas (21) to VIPomas (96; P < 0.0001). Median OS of resected versus unresected FICTs was 172 versus 37 months, while that of NFICTs was 113 versus 18 months (P < 0.0001). Compared to neuroendocrine carcinomas, hazard ratios were: VIPomas 0.48, gastrinomas 0.65, carcinoid tumors 0.76, insulinomas 0.84, glucagonomas 0.93, and islet cell carcinomas 1.0. CONCLUSIONS When controlled for other established prognostic parameters, histopathologic subtype assignment of pancreatic ICTs affects survival prediction. Resection is associated with superior survival for all tumor types.
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Affiliation(s)
- Christina L Roland
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-9155, USA
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198
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Di Florio A, Adesso L, Pedrotti S, Capurso G, Pilozzi E, Corbo V, Scarpa A, Geremia R, Delle Fave G, Sette C. Src kinase activity coordinates cell adhesion and spreading with activation of mammalian target of rapamycin in pancreatic endocrine tumour cells. Endocr Relat Cancer 2011; 18:541-54. [PMID: 21712346 DOI: 10.1530/erc-10-0153] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pancreatic endocrine tumours (PETs) are rare and heterogeneous neoplasms, often diagnosed at metastatic stage, for which no cure is currently available. Recently, activation of two pathways that support proliferation and invasiveness of cancer cells, the Src family kinase (SFK) and mammalian target of rapamycin (mTOR) pathways, was demonstrated in PETs. Since both pathways represent suitable targets for therapeutic intervention, we investigated their possible interaction in PETs. Western blot and immunofluorescence analyses indicated that SFK and mTOR activity correlate in PET cell lines. We also found that SFKs coordinate cell adhesion and spreading with activation of the mTOR pathway in PET cells. Live cell metabolic labelling and biochemical studies demonstrated that SFK activity enhance mTOR-dependent translation initiation. Furthermore, microarray analysis of the mRNAs associated with polyribosomes revealed that SFKs regulate mTOR-dependent translation of specific transcripts, with an enrichment in mRNAs encoding cell cycle proteins. Importantly, a synergic inhibition of proliferation was observed in PET cells concomitantly treated with SFK and mTOR inhibitors, without activation of the phosphatidylinositol 3-kinase/AKT pro-survival pathway. Tissue microarray analysis revealed activation of Src and mTOR in some PET samples, and identified phosphorylation of 4E-BP1 as an independent marker of poor prognosis in PETs. Thus, our work highlights a novel link between the SFK and mTOR pathways, which regulate the translation of mRNAs for cell cycle regulators, and suggest that crosstalk between these pathways promotes PET cell proliferation.
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Affiliation(s)
- Alessia Di Florio
- Department of Public Health and Cell Biology, University of Rome Tor Vergata, Italy
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199
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Soldic Z, Zitnjak D, Bolanca A, Kusic Z. Long-time survival of a patient with metastatic pancreatic cancer: a case report. Case Rep Oncol 2011; 4:367-70. [PMID: 21941484 PMCID: PMC3177791 DOI: 10.1159/000330775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Pancreatic cancer is a malignant neoplasm of the pancreas. It does not cause any symptoms in the early stage, and later symptoms are nonspecific, thus the disease is usually diagnosed when already advanced. In 2008, pancreatic cancer ranked eighth on the list of the 10 most common cancers among men in Croatia and tenth on the list of the most common cancers among Croatian women. Pancreatic cancer has a poor prognosis, with a survival time of only 6-8 months for metastatic disease. Gemcitabine is the standard chemotherapeutic option. Other chemotherapeutic agents include5-fluorouracil and leucovorin. In this paper, we present a case of a patient diagnosed with locally advanced and metastatic pancreatic cancer, who is still alive and currently receives his fourth line of chemotherapy 5 years after the diagnosis. Following disease progression on gemcitabine chemotherapy, he was treated with chemoradiotherapy which, however, had no effect. We then applied cisplatin monochemotherapy which offered excellent disease control, was well tolerated by the patient and, although somewhat obsolete in this form, showed to be a valuable chemotherapeutic option.
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Affiliation(s)
- Zeljko Soldic
- Department of Oncology and Nuclear Medicine, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
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Manasanch EE, Smith JK, Bodnari A, McKinney J, Gray C, McDade TP, Tseng JF. Tumor registry versus physician medical record review: a direct comparison of patients with pancreatic neuroendocrine tumors. J Oncol Pract 2011; 7:111-6. [PMID: 21731519 DOI: 10.1200/jop.2010.000097] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Tumor registry (TR) data are becoming more prominently cited in research through increased use of the National Cancer Database. We aimed to establish the accuracy of TR data by comparing them with physician medical record review (MD review) using pancreatic neuroendocrine tumors (NETs) as an example. METHODS For MD review, the health information system of an academic medical center was queried for patients with pancreatic International Classification of Diseases, ninth revision (ICD-9), codes from January 2000 to August 2008. A single physician investigator analyzed those medical records and identified patients with pancreatic NETs. For TR data, patients with pancreatic NETs were identified by two separate strategies. For the period of January 2000 to December 2006, patients were identified through manual review of pathology reports, admission and discharge sheets, and clinic visit logs. For January 2007 to August 2008, patients were identified using an automated case-finding program. RESULTS In MD review, 1,192 patients with pancreatic ICD-9 codes were identified, 34 of whom were found to have pancreatic NETs. The TR indicated 15 patients with pancreatic NETs, four of whom were not identified during MD review. Of the total 38 patients identified by either strategy, pancreatic NET identification rate of the TR was 39.5% compared with 89.5% in MD review. CONCLUSION Academic TR analysis indicates a substantial proportion of patients with pancreatic NETs are not identified when compared with MD review. Most instances of patients going unidentified are the result of registry time lag and case-finding methodologies; specifically, physicians may define tumors with malignant potential differently. This may be applicable to other individual tumor registries as well as aggregate registry-based national studies.
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Affiliation(s)
- Elisabet E Manasanch
- Surgical Outcomes Analysis and Research and Tumor Registry, University of Massachusetts Medical School, Worcester, MA
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