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Zaher EA, Eshan SH, Patel P, Rafa ZI, Zaher D. A Rare Case of Hepatic Gastrinoma. Cureus 2023; 15:e43383. [PMID: 37700944 PMCID: PMC10495076 DOI: 10.7759/cureus.43383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/14/2023] Open
Abstract
Zollinger-Ellison syndrome (ZES) is a rare condition caused by gastrin-secreting neuroendocrine tumors known as gastrinomas. We present a case of hepatic ZES presenting as upper gastrointestinal (GI) bleeding in a 70-year-old female. Initial evaluation revealed the patient to be in severe sepsis with septic shock secondary to a urinary tract infection, and her hospitalization was complicated by hematemesis and melena in the setting of multiple duodenal ulcers. Subsequent investigations, including elevated gastrin levels and a somatostatin receptor scan, confirmed the diagnosis of gastrinoma.
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Affiliation(s)
- Eli A Zaher
- Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, USA
| | | | - Parth Patel
- Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, USA
| | - Zahin Islam Rafa
- Department of Internal Medicine, Ibn Sina Medical College Hospital, Dhaka, BGD
| | - Daria Zaher
- Department of Internal Medicine, University Clinical Hospital in Bialystok, Bialystok, POL
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Menz A, Bauer R, Kluth M, Marie von Bargen C, Gorbokon N, Viehweger F, Lennartz M, Völkl C, Fraune C, Uhlig R, Hube-Magg C, De Wispelaere N, Minner S, Sauter G, Kind S, Simon R, Burandt E, Clauditz T, Lebok P, Jacobsen F, Steurer S, Wilczak W, Krech T, Marx AH, Bernreuther C. Diagnostic and prognostic impact of cytokeratin 19 expression analysis in human tumors: a tissue microarray study of 13,172 tumors. Hum Pathol 2021; 115:19-36. [PMID: 34102222 DOI: 10.1016/j.humpath.2021.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022]
Abstract
To evaluate cytokeratin 19 (CK19) expression in normal and cancerous tissues, 15,977 samples from 122 tumor types and 608 samples of 76 normal tissue types were analyzed by immunohistochemistry (IHC). In normal tissues, CK19 expression occurred in epithelial cells of most glandular organs but was strictly limited to the basal cell layer of nonkeratinizing squamous epithelium and absent in the skin. CK19 expression in ≥90% of cases was seen in 34% of the tumor entities including the adenocarcinomas of the pancreas (99.4%), colorectum (99.8%), esophagus (98.7%), and stomach (97.7%), as well as breast cancer (90.0%-100%), high-grade serous (99.1%) or endometrioid (97.8%) ovarian cancer, and urothelial carcinoma (92.6%-100%). A low CK19 positivity rate (0.1-10%) was seen in 5 of 122 tumor entities including hepatocellular carcinoma and seminoma. A comparison of tumor versus normal tissue findings demonstrated that upregulation and downregulation of CK19 can occur in cancer and that both alterations can be linked to unfavorable phenotypes. CK19 downregulation was linked to high grade (p = 0.0017) and loss of estrogen receptor- and progesterone receptor-expression (p < 0.0001 each) in invasive breast carcinoma of no special type. CK19 upregulation was linked to nodal metastases in neuroendocrine tumors and papillary thyroid carcinomas (p < 0.05 each) and to poor grade in clear cell renal cell carcinoma (p < 0.05). CK19 upregulation was particularly common in squamous cell carcinomas. We concluded that CK19 IHC might separate primary liver cell carcinoma from liver metastases, seminoma from other testicular tumors, and helps in the detection of early neoplastic transformation in squamous epithelium.
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Affiliation(s)
- Anne Menz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Rifka Bauer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Martina Kluth
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Clara Marie von Bargen
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Natalia Gorbokon
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Florian Viehweger
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Maximilian Lennartz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Cosima Völkl
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Christoph Fraune
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ria Uhlig
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Claudia Hube-Magg
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Noémi De Wispelaere
- Department and Clinic of Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Sarah Minner
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Guido Sauter
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Simon Kind
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ronald Simon
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Eike Burandt
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Till Clauditz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Patrick Lebok
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Frank Jacobsen
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Stefan Steurer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Waldemar Wilczak
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Till Krech
- Institute of Pathology, Clinical Center Osnabrueck, 49076 Osnabrueck, Germany
| | - Andreas H Marx
- Department of Pathology, Academic Hospital Fuerth, 90766 Fuerth Germany
| | - Christian Bernreuther
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Prognostic significance of cytokeratin 19 expression in pancreatic neuroendocrine tumor: A meta-analysis. PLoS One 2017; 12:e0187588. [PMID: 29136022 PMCID: PMC5685577 DOI: 10.1371/journal.pone.0187588] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/23/2017] [Indexed: 01/11/2023] Open
Abstract
Background Pancreatic neuroendocrine tumor (PNET) comprises 1–2% of all pancreatic tumors, but its incidence is increasing. Although many studies have investigated the correlation between cytokeratin 19 (CK-19) and PNET, the prognostic significance of CK-19 expression in PNET is inconclusive. Methods Eligible studies were retrieved from Pubmed, Elsevier, Embase, Cochrane Library and Web of Science databases. All relevant data were extracted to analyze the relationship between CK-19 and PNET. We utilized a fixed or random effects model to calculate the pooled odds ratio (OR) with 95% confidence intervals (CI). Results Pooled data indicated CK-19 expression was significantly associated with poor 3- and 5-year overall survival (OS) for PNET, but not for 1-year overall survival. Additionally, positive CK-19 expression was correlated with large tumor size, advanced differentiation grade in World Health Organization-2010 (WHO-2010) and WHO-2004, vascular invasion, lymph node metastasis and liver metastasis. Conclusions Positive CK-19 expression can be used as a predictor of poor prognosis of PNET.
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Metz DC, Cadiot G, Poitras P, Ito T, Jensen RT. Diagnosis of Zollinger-Ellison syndrome in the era of PPIs, faulty gastrin assays, sensitive imaging and limited access to acid secretory testing. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017; 4:167-185. [PMID: 29326808 DOI: 10.2217/ije-2017-0018] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years the diagnosis of Zollinger-Ellison syndrome (ZES) has become increasingly controversial with several new approaches and criteria proposed, differing from the classical biochemical criterion of inappropriate hypergastrinemia (i.e., hypergastrinemia in the presence of hyperchlorhydria) (Table 1). These changes have come about because of the difficulty and potential dangers of stopping proton pump inhibitors (PPIs) for gastric acid analysis; the recognition than many of the current assays used to assess gastrin concentrations are unreliable; the development of sensitive imaging modalities that detect neuroendocrine tumors (NETs) including an increasing number of the primary gastrinomas; the increased use of percutaneous or endoscopic ultrasound (EUS)-directed biopsies/cytology and the general lack of availability of acid secretory testing. In this article we will discuss the basis for these controversies, review the proposed changes in diagnostic approaches and make recommendations for supporting the diagnosis of ZES in the modern era.
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Affiliation(s)
- David C Metz
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, PA, 19104, USA
| | - Guillaume Cadiot
- Service d"Hepato-Gastroenterologie, Centre Hospitalier Universitaire de Reims, Hopital Robert Debre, F-51092, Reims, France
| | - Pierre Poitras
- Department of Gastroenterology, CHUM, Université de Montréal, Montreal, Canada
| | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, Maryland, 20817, USA
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Ito T, Cadiot G, Jensen RT. Diagnosis of Zollinger-Ellison syndrome: Increasingly difficult. World J Gastroenterol 2012; 18:5495-503. [PMID: 23112541 PMCID: PMC3482635 DOI: 10.3748/wjg.v18.i39.5495] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/03/2012] [Accepted: 09/12/2012] [Indexed: 02/06/2023] Open
Abstract
In the present paper the increasing difficulty of diagnosis of Zollinger-Ellison syndrome (ZES) due to issues raised in two recent papers is discussed. These issues involve the difficulty and need to withdraw patients suspected of ZES from treatment with Proton Pump Inhibitors (omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole) and the unreliability of many gastrin radioimmunoassays. The clinical context of each of these important issues is reviewed and the conclusions in these articles commented from the perspective of clinical management.
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Wong H, Yau T, Chan P, Ng IOL, Chan G, Hui P, Law WL, Lo CM, Hedley AJ, Epstein RJ. PPI-delayed diagnosis of gastrinoma: oncologic victim of pharmacologic success. Pathol Oncol Res 2009; 16:87-91. [PMID: 19693706 PMCID: PMC2953631 DOI: 10.1007/s12253-009-9192-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 07/23/2009] [Indexed: 12/03/2022]
Abstract
Functional neuroendocrine tumors are often low-grade malignant neoplasms that can be cured by surgery if detected early, and such detection may in turn be accelerated by the recognition of neuropeptide hypersecretion syndromes. Uniquely, however, relief of peptic symptoms induced by hypergastrinemia is now available from acid-suppressive drugs such as proton-pump inhibitors (PPIs). Here we describe a clinical case in which time to diagnosis from the onset of peptic symptoms was delayed more than 10 years, in part reflecting symptom masking by continuous prescription of the PPI omeprazole. We propose diagnostic criteria for this under-recognized new clinical syndrome, and recommend that physicians routinely measure serum gastrin levels in persistent cases of PPI-dependent dyspepsia unassociated with H. pylori.
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Affiliation(s)
- Hilda Wong
- Division of Hematology/Oncology, Department of Medicine, Queen Mary Hospital, Hong Kong, Hong Kong
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Ruscica M, Dozio E, Motta M, Magni P. Role of neuropeptide Y and its receptors in the progression of endocrine-related cancer. Peptides 2007; 28:426-34. [PMID: 17204352 DOI: 10.1016/j.peptides.2006.08.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Accepted: 08/20/2006] [Indexed: 10/23/2022]
Abstract
The neuropeptide Y (NPY) family of peptides, in addition to its many physiological actions, has also been involved in the modulation of tumor progression, with specific reference to endocrine-related cancers such as neuroendocrine tumors, breast and prostate cancers. These have been found either to express NPY receptors, or to secrete NPY-related peptides, or both. The study of the role of the NPY family of peptides in the biology of endocrine-related tumors, specifically concerning cell proliferation, angiogenesis, invasion and metastatization, may help to clarify some aspects of tumor pathophysiology, as well as to indicate novel diagnostic markers and therapeutical approaches.
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Affiliation(s)
- Massimiliano Ruscica
- Center for Endocrinological Oncology, Istituto di Endocrinologia, Università degli Studi di Milano, via Balzaretti 9, Milan 20133, Italy
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Berna MJ, Hoffmann KM, Serrano J, Gibril F, Jensen RT. Serum gastrin in Zollinger-Ellison syndrome: I. Prospective study of fasting serum gastrin in 309 patients from the National Institutes of Health and comparison with 2229 cases from the literature. Medicine (Baltimore) 2006; 85:295-330. [PMID: 17108778 PMCID: PMC9806863 DOI: 10.1097/01.md.0000236956.74128.76] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The assessment of fasting serum gastrin (FSG) is essential for the diagnosis and management of patients with the Zollinger-Ellison syndrome (ZES). Although many studies have analyzed FSG levels in patients with gastrinoma, limited information has resulted from these studies because of their small size, different methodologies, and lack of correlations of FSG levels with clinical, laboratory, or tumor features in ZES patients. To address this issue, we report the results of a prospective National Institutes of Health (NIH) study of 309 patients with ZES and compare our results with those of 2229 ZES patients in 513 small series and case reports in the literature. In the NIH and literature ZES patients, normal FSG values were uncommon (0.3%-3%), as were very high FSG levels >100-fold normal (4.9%-9%). Two-thirds of gastrinoma patients had FSG values <10-fold normal that overlap with gastrin levels seen in more common conditions, like Helicobacter pylori infection or antral G-cell hyperplasia/hyperfunction. In these patients, FSG levels are not diagnostic of ZES, and gastrin provocative tests are needed to establish the diagnosis. Most clinical variables (multiple endocrine neoplasia type 1 status, presence or absence of the most common symptoms, prior medical treatment) are not correlated with FSG levels, while a good correlation of FSG values was found with other clinical features (prior gastric surgery, diarrhea, duration from onset to diagnosis). Increasing basal acid output, but not maximal acid output correlated closely with increasing FSG. Numerous tumoral features correlated with the magnitude of FSG in our study, including tumor location (pancreatic > duodenal), primary size (larger > smaller) and extent (liver metastases > local disease). In conclusion, this detailed analysis of FSG in a large number of patients with ZES allowed us to identify important clinical guidelines that should contribute to improved diagnosis and management of patients with ZES.
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Affiliation(s)
- Marc J Berna
- From Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Kwekkeboom DJ, Teunissen JJ, Bakker WH, Kooij PP, de Herder WW, Feelders RA, van Eijck CH, Esser JP, Kam BL, Krenning EP. Radiolabeled somatostatin analog [177Lu-DOTA0,Tyr3]octreotate in patients with endocrine gastroenteropancreatic tumors. J Clin Oncol 2005; 23:2754-62. [PMID: 15837990 DOI: 10.1200/jco.2005.08.066] [Citation(s) in RCA: 460] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE There are few treatment options for patients with metastasized or inoperable endocrine gastroenteropancreatic (GEP) tumors. Chemotherapy can be effective, but the response is usually less than 1 year. Here, we present the results of treatment with a radiolabeled somatostatin analog, [177Lu-DOTA0,Tyr3]octreotate (177Lu-octreotate). PATIENTS AND METHODS One hundred thirty-one patients with somatostatin receptor-positive tumors were treated with up to a cumulative dose of 600 to 800 mCi (22.2 to 29.6 GBq) of 177Lu-octreotate. RESULTS One patient developed renal insufficiency, and another patient developed hepatorenal syndrome. Creatinine clearance did not change significantly in the other patients. WHO hematologic toxicity grade 3 or 4 occurred after less than 2% of the administrations. We observed complete remission in three patients (2%), partial remission in 32 patients (26%), minor response (tumor diameter decrease of 25% to 50%) in 24 patients (19%), stable disease (SD) in 44 patients (35%), and progressive disease (PD) in 22 patients (18%). Higher remission rates were positively correlated with high uptake on pretherapy somatostatin receptor imaging and a limited number of liver metastases, whereas PD was significantly more frequent in patients with a low performance score and extensive disease. Median time to progression in 103 patients who either had SD or tumor regression was more than 36 months. CONCLUSION Treatment with 177Lu-octreotate results in tumor remission in a high percentage of patients with GEP tumors. Serious side effects are rare. The median time to progression compares favorably with chemotherapy. Results are better in patients with a limited tumor load. Therefore, early treatment, even in patients who have no PD, may be better.
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Affiliation(s)
- Dik J Kwekkeboom
- Department of Nuclear Medicine, Erasmus Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, Netherlands.
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