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Padmanabhan Nair Sobha R, Jensen CT, Waters R, Calimano-Ramirez LF, Virarkar MK. Appendiceal Neuroendocrine Neoplasms: A Comprehensive Review. J Comput Assist Tomogr 2024; 48:545-562. [PMID: 37574653 DOI: 10.1097/rct.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
ABSTRACT Appendiceal neuroendocrine neoplasm (NEN) is the most common adult appendiceal malignant tumor, constituting 16% of gastrointestinal NENs. They are versatile tumors with varying morphology, immunohistochemistry, secretory properties, and cancer genomics. They are slow growing and clinically silent, to begin with, or present with features of nonspecific vague abdominal pain. Most acute presentations are attributed clinically to appendicitis, with most cases detected incidentally on pathology after an appendectomy. Approximately 40% of them present clinically with features of hormonal excess, which is likened to the functional secretory nature of their parent cell of origin. The symptoms of carcinoid syndrome render their presence clinically evident. However, slow growing and symptomatically silent in its initial stages, high-grade neuroendocrine tumors and neuroendocrine carcinomas of the appendix are aggressive and usually have hepatic and lymph node metastasis at presentation. This review article focuses on imaging characteristics, World Health Organization histopathological classification and grading, American Joint Committee on Cancer/Union or International Cancer Control, European Neuroendocrine Tumor Society staging, European Neuroendocrine Tumor Society standardized guidelines for reporting, data interpretation, early-stage management protocols, and advanced-stage appendiceal NENs. Guidelines are also set for the follow-up and reassessment. The role of targeted radiotherapy, chemotherapy, and high-dose somatostatin analogs in treating advanced disease are discussed, along with types of ablative therapies and liver transplantation for tumor recurrence. The search for newer location-specific biomarkers in NEN is also summarized. Regarding the varying aggressiveness of the tumor, there is a scope for research in the field, with plenty of data yet to be discovered.
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Affiliation(s)
| | - Corey T Jensen
- From the Department of Radiology, University of Texas MD Anderson Cancer Center
| | - Rebecca Waters
- Department of Pathology and Lab Medicine MD Anderson Cancer Center, Houston, TX
| | | | - Mayur K Virarkar
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL
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2
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Yogo A, Paciorek A, Kasai Y, Moon F, Hirose K, Corvera CU, Bergsland EK, Nakakura EK. Long-Term Survival Outcomes After Minimally Invasive Surgery for Ileal Neuroendocrine Tumors. Ann Surg Oncol 2024:10.1245/s10434-024-15468-6. [PMID: 38797790 DOI: 10.1245/s10434-024-15468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Ileal neuroendocrine tumors (i-NETs) are characterized by their multifocality and bulky mesenteric mass. Having shown that minimally invasive surgery (MIS) utilizing a hand-access port device has favorable short-term outcomes and achieves the goals of surgery for i-NETs, we sought to analyze long-term survival outcomes of MIS. METHODS One hundred and sixty-eight patients who underwent resection of primary i-NETs at a single institution between January 2007 and February 2023 were retrospectively studied. Patients were categorized into the MIS or open surgery cohorts on an intention-to-treat basis. Open surgery was selected mainly based on the need for hepatectomy or bulky mesenteric mass resection. Overall survival was analyzed using log-rank tests with propensity score matching (PSM) and Cox proportional hazards regression. PSM was performed to reduce standardized mean differences of the variables to <0.2. RESULTS Overall, 129 (77%) patients underwent MIS and 39 (23%) underwent open surgery. Twenty-seven MIS patients were converted to an open procedure. The median follow-up time was 49 months (interquartile range 23-87 months). In the PSM cohorts, overall survival did not differ significantly between the MIS and open surgery cohorts {median 99 months (95% confidence interval [CI] 91-not applicable [NA]) vs. 103 months (95% CI 86-NA), p = 0.77; hazard ratio 0.87 (95% CI 0.33-2.2), p = 0.77}. CONCLUSIONS MIS is an alternative to open surgery for i-NETs, achieving similar short- and long-term oncological outcomes. Bulky mesenteric mass and a plan for concurrent liver resection are potential criteria for open surgery.
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Affiliation(s)
- Akitada Yogo
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Alan Paciorek
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Yosuke Kasai
- Department of Surgery, Kyoto University, Kyoto, Japan
| | - Farhana Moon
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Carlos U Corvera
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Emily K Bergsland
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eric K Nakakura
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
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3
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Gonzalez RS, La Rosa S, Ma C, Polydorides AD, Shi C, Yang Z, Cox B, Karamchandani DM. Debating Deposits, Redux: Substantial Interobserver Agreement Exists in Distinguishing Tumor Deposits From Nodal Metastases in Small Bowel Neuroendocrine Tumors. Arch Pathol Lab Med 2024; 148:581-587. [PMID: 37639446 DOI: 10.5858/arpa.2023-0169-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Recent data suggest mesenteric tumor deposits (MTDs) indicate poor prognosis in small bowel well-differentiated neuroendocrine tumors (SB-NETs), including compared to positive lymph nodes, making their distinction crucial. OBJECTIVE To study interobserver agreement in distinguishing SB-NET MTDs from positive nodes. DESIGN Virtual slides from 36 locally metastatic SB-NET foci were shared among 7 gastrointestinal pathologists, who interpreted each as an MTD or a positive node. Observers ranked their 5 preferred choices among a supplied list of potentially useful histologic features, for both options. Diagnostic opinions were compared using Fleiss multirater and Cohen weighted κ analyses. RESULTS Preferred criteria for MTD included irregular shape (n = 7, top choice for 5), perineural invasion/nerve entrapment (n = 7, top choice for 2), encased thick-walled vessels (n = 7), and prominent fibrosis (n = 6). Preferred criteria for positive nodes included peripheral lymphoid follicles (n = 6, top choice for 4), round shape (n = 7, top choice for 2), peripheral lymphocyte rim (n = 7, top choice for 1), subcapsular sinuses (n = 7), and a capsule (n = 6). Among 36 foci, 10 (28%) each were unanimously diagnosed as MTD or positive node. For 13 foci (36%), there was a diagnosis favored by most observers (5 or 6 of 7): positive node in 8, MTD in 5. Only 3 cases (8%) had a near-even (4:3) split. Overall agreement was substantial (κ = .64, P < .001). CONCLUSIONS Substantial interobserver agreement exists for distinguishing SB-NET MTDs from lymph node metastases. Favored histologic criteria in making the distinction include irregular shape and nerve/vessel entrapment for MTD, and peripheral lymphocytes/lymphoid follicles and round shape for positive nodes.
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Affiliation(s)
- Raul S Gonzalez
- From the Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia (Gonzalez)
| | - Stefano La Rosa
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy (La Rosa)
| | - Changqing Ma
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri (Ma)
| | - Alexandros D Polydorides
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (Polydorides)
| | - Chanjuan Shi
- Department of Pathology, Duke University Medical Center, Durham, North Carolina (Shi)
| | - Zhaohai Yang
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (Yang)
| | - Brian Cox
- Pacific Rim Pathology, San Diego, California (Cox)
| | - Dipti M Karamchandani
- the Department of Pathology, UT Southwestern Medical Center, Dallas, Texas (Karamchandani)
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4
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Kalifi M, Deguelte S, Faron M, Afchain P, de Mestier L, Lecomte T, Pasquer A, Subtil F, Alghamdi K, Poncet G, Walter T. The Need for Centralization for Small Intestinal Neuroendocrine Tumor Surgery: A Cohort Study from the GTE-Endocan-RENATEN Network, the CentralChirSINET Study. Ann Surg Oncol 2023; 30:8528-8541. [PMID: 37814184 DOI: 10.1245/s10434-023-14276-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The concept of surgical centralization is becoming more and more accepted for specific surgical procedures. OBJECTIVE The aim of this study was to evaluate the relationship between procedure volume and the outcomes of surgical small intestine (SI) neuroendocrine tumor (NET) resections. METHODS We conducted a retrospective national study that included patients who underwent SI-NET resection between 2019 and 2021. A high-volume center (hvC) was defined as a center that performed more than five SI-NET resections per year. The quality of the surgical resections was evaluated between hvCs and low-volume centers (lvCs) by comparing the number of resected lymph nodes (LNs) as the primary endpoint. RESULTS A total of 157 patients underwent surgery in 33 centers: 90 patients in four hvCs and 67 patients in 29 lvCs. Laparotomy was more often performed in hvCs (85.6% vs. 59.7%; p < 0.001), as was right hemicolectomy (64.4% vs. 38.8%; p < 0.001), whereas limited ileocolic resection was performed in 18% of patients in lvCs versus none in hvCs. A bi-digital palpation of the entire SI length (95.6% vs. 34.3%, p < 0.001), a cholecystectomy (93.3% vs. 14.9%; p < 0.001), and a mesenteric mass resection (70% vs. 35.8%; p < 0.001) were more often performed in hvCs. The proportion of patients with ≥8 LNs resected was significantly higher (96.3% vs. 65.1%; p < 0.001) in hvCs compared with lvCs, as was the proportion of patients with ≥12 LNs resected (87.8% vs. 52.4%). Furthermore, the number of patients with multiple SI-NETs was higher in the hvC group compared with the lvC group (43.3% vs. 25.4%), as were the number of tumors in those patients (median of 7 vs. 2; p < 0.001). CONCLUSIONS Optimal SI-NET resection was significantly more often performed in hvCs. Centralization of surgical care of SI-NETs is recommended.
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Affiliation(s)
- Maroin Kalifi
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
| | - Sophie Deguelte
- Department of Digestive Surgery, Reims University Hospital, Robert Debré Hospital, Reims, France
| | - Matthieu Faron
- Departments of Surgical Oncology and Statistics, Gustave Roussy Cancer Campus® Grand Paris, Villejuif, France
| | - Pauline Afchain
- Department of Oncology, CHU Saint-Antoine, APHP, Paris, France
| | - Louis de Mestier
- Department of Pancreatology and Digestive Oncology, ENETS Centre of Excellence, Beaujon Hospital (APHP Nord), Université Paris-Cité, Clichy, France
| | - Thierry Lecomte
- Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital of Tours, UMR INSERM 1069, Tours University, Tours, France
| | - Arnaud Pasquer
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
| | - Fabien Subtil
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France
- Department of Biostatistic, Hospices Civils de Lyon, Lyon, France
| | | | - Gilles Poncet
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France.
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne Cedex, France.
- Pavillon D, Chirurgie Digestive, Hôpital Edouard Herriot, Lyon Cedex 03, France.
| | - Thomas Walter
- Department of Gastroenterology and Digestive Oncology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne Cedex, France
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Kmiotek E, Lakda S, Borakati A, Ogunbiyi O, Mandair D, Caplin M, Toumpanakis C, Mirnezami R. Management Strategies and Outcomes for Small Intestinal Neuroendocrine Tumours with Involvement of the Superior Mesenteric Vessels: A Systematic Review. Curr Oncol 2023; 30:9192-9204. [PMID: 37887564 PMCID: PMC10605700 DOI: 10.3390/curroncol30100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/26/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
Small intestinal neuroendocrine tumours (SI-NETs) are the most common small intestinal tumours. A particularly challenging subset of these tumours is those that involve the superior mesenteric artery or vein for which the role and feasibility of surgery are often questioned. This systematic review aimed to identify and evaluate the management strategies used for these complex SI-NETs. The identified studies showed positive outcomes with surgery and multimodality therapy.
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Affiliation(s)
- Elizabeth Kmiotek
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
| | - Sakina Lakda
- University College London Medical School, 74 Huntley Street, London WC1E 6DE, UK;
| | - Aditya Borakati
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital Campus, 9th Floor, Pond Street, Hampstead, London NW3 2QG, UK;
| | - Olagunju Ogunbiyi
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Dalvinder Mandair
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Reza Mirnezami
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
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6
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Grillo F, Albertelli M, Malandrino P, Dotto A, Pizza G, Cittadini G, Colao A, Faggiano A. Prognostic Effect of Lymph Node Metastases and Mesenteric Deposits in Neuroendocrine Tumors of the Small Bowel. J Clin Endocrinol Metab 2022; 107:3209-3221. [PMID: 35639999 DOI: 10.1210/clinem/dgac326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/19/2022]
Abstract
Well-differentiated, low-grade neuroendocrine tumors (NETs) are the most frequent tumor types of the small bowel. Despite their generally indolent growth patterns and grade, these tumors tend to metastasize; indeed, at presentation, approximately 50% show nodal metastases and 30% of patients have distant metastases, even though they potentially show long survival. Little is available in the literature concerning the optimal nodal yield in small-bowel resections, and the clinical significance of nodal metastases and lymph node ratio (LNR) at this site is still debated. The aim of this review, through a systematic literature search, is to explore and analyze data regarding nodal status, adequacy of lymphadenectomy, and LNR on the prognosis of small bowel NETs using defined end points (progression-free survival, recurrence-free survival, and overall survival). Some surgical series have demonstrated that extended regional mesenteric lymphadenectomy, together with primary tumor resection, is associated with improved patient survival, and LNR is proving a prognostically important parameter. The new feature of mesenteric tumor deposits (MTDs; neoplastic deposits found in the mesenteric perivisceral adipose tissue that are not LN associated) seems to be a better prognostic predictor in small-bowel NETs compared to nodal metastases, and this feature is explored and critiqued in this review. In particular, increasing number of tumor deposits is correlated with increased risk of disease-specific death, and MTDs seem to correlate with peritoneal carcinomatosis.
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Affiliation(s)
- Federica Grillo
- Anatomic Pathology Unit, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa 16132, Italy
| | - Manuela Albertelli
- IRCCS Ospedale Policlinico San Martino, Genoa 16132, Italy
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova , Genoa, 16132, Italy
| | - Pasqualino Malandrino
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania and Garibaldi-Nesima Medical Center, Catania 95122, Italy
| | - Andrea Dotto
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), University of Genova , Genoa, 16132, Italy
| | - Genoveffa Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80138, Italy
| | - Giuseppe Cittadini
- Radiology Unit, IRCCS Ospedale Policlinico San Martino , Genoa 16132, Italy
| | - Annamaria Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80138, Italy
- Health Education and Sustainable Development, Federico II University, Naples 80138, Italy
| | - Antongiulio Faggiano
- Department di Clinical and Molecular Medicine, Sapienza University, Rome 00185, Italy
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Levy S, Arthur JD, Banks M, Kok NFM, Fenwick SW, Diaz-Nieto R, van Leerdam ME, Cuthbertson DJ, Valk GD, Kuhlmann KFD, Tesselaar MET. Primary Tumor Resection is Associated with Improved Disease-Specific Mortality in Patients with Stage IV Small Intestinal Neuroendocrine Tumors (NETs): A Comparison of Upfront Surgical Resection Versus a Watch and Wait Strategy in Two Specialist NET Centers. Ann Surg Oncol 2022; 29:7822-7832. [PMID: 35842528 DOI: 10.1245/s10434-022-12030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Small intestinal neuroendocrine tumors (SI-NETs) often present with metastatic disease. An ongoing debate exists on whether to perform primary tumor resection (PTR) in patients with stage IV SI-NETs, without symptoms of the primary tumor and inoperable metastatic disease. OBJECTIVE The aim of this study was to compare a treatment strategy of upfront surgical resection versus a surveillance strategy of watch and wait. METHODS This was a retrospective cohort study of patients with stage IV SI-NETs at diagnosis, between 2000 and 2018, from two tertiary referral centers (Netherlands Cancer Institute [NKI] and Aintree University Hospital [AUH]) who had adopted contrasting treatment approaches: upfront surgical resection and watch and wait, respectively. Patients without symptoms related to the primary tumor were included. Multivariable intention-to-treat (ITT), per-protocol (PP), and instrumental variable (IV) analyses using 'institute' as an IV were performed to assess the influence of PTR on disease-specific mortality (DSM). RESULTS A total of 557 patients were identified, with 145 patients remaining after exclusion of stage I-III disease or symptoms of the primary tumor (93 from the NKI and 52 from AUH). The cohorts differed in performance status (PS; p = 0.006) and tumor grade (p < 0.001). PTR was independently associated with reduced DSM irrespective of statistical methods employed: ITT hazard ratio [HR] 0.60, p = 0.005; PP HR 0.58, p < 0.001; and IV HR 0.07, p = 0.019. Other factors associated with DSM were age, PS, high chromogranin A, and somatostatin analog treatment. CONCLUSION Taking advantage of contrasting institutional treatment strategies, this study identified PTR as an independent predictor of DSM. Future prospective studies should aim to validate these results.
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Affiliation(s)
- Sonja Levy
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - James D Arthur
- Department of Surgery, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Melissa Banks
- Department of Surgery, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Niels F M Kok
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stephen W Fenwick
- Department of Surgery, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Rafael Diaz-Nieto
- Department of Surgery, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Monique E van Leerdam
- Department of Gastroenterologic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Daniel J Cuthbertson
- Institute of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.,Department of Endocrinology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Koert F D Kuhlmann
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Margot E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Siebenhüner AR, Langheinrich M, Friemel J, Schaefer N, Eshmuminov D, Lehmann K. Orchestrating Treatment Modalities in Metastatic Pancreatic Neuroendocrine Tumors-Need for a Conductor. Cancers (Basel) 2022; 14:cancers14061478. [PMID: 35326628 PMCID: PMC8946777 DOI: 10.3390/cancers14061478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Pancreatic neuroendocrine tumors (pNET) are a heterogeneous and challenging entity, and today’s guidelines offer a variety of treatment modalities, while surgery has a clear role for patients with resectable tumors and early stages, advanced, or metastatic pNET may benefit from treatments that were evaluated in randomized controlled studies during the last year. With this review, we aim to provide an updated view on treatment options for metastatic pNET. Abstract Pancreatic neuroendocrine tumors (pNETs) are a vast growing disease. Over 50% of these tumors are recognized at advanced stages with lymph node, liver, or distant metastasis. An ongoing controversy is the role of surgery in the metastatic setting as dedicated systemic treatments have emerged recently and shown benefits in randomized trials. Today, liver surgery is an option for advanced pNETs if the tumor has a favorable prognosis, reflected by a low to moderate proliferation index (G1 and G2). Surgery in this well-selected population may prolong progression-free and overall survival. Optimal selection of a treatment plan for an individual patient should be considered in a multidisciplinary tumor board. However, while current guidelines offer a variety of modalities, there is so far only a limited focus on the right timing. Available data is based on small case series or retrospective analyses. The focus of this review is to highlight the right time-point for surgery in the setting of the multimodal treatment of an advanced pancreatic neuroendocrine tumor.
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Affiliation(s)
- Alexander R. Siebenhüner
- Clinic for Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
- ENETS Center of Excellence Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
- Correspondence: ; Tel.: +41-44-255-11-11
| | - Melanie Langheinrich
- Department of Visceral Surgery, University Hospital Greifswald, Ferdinand-Sauerbruch-Strasse, D-17475 Greifswald, Germany;
| | - Juliane Friemel
- Institute for Pathologie, University Bern, Murtenstrasse 31, CH-3008 Bern, Switzerland;
| | - Niklaus Schaefer
- Department of Nuclear Medicine, University Hospital Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland;
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
| | - Kuno Lehmann
- ENETS Center of Excellence Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
- Department of Surgery and Transplantation, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
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9
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Deguelte S, Metoudi A, Rhaiem R, Hoeffel C, Brixi H, Cadiot G, Kianmanesh R. Small Intestinal Neuroendocrine Neoplasm: Factors Associated with the Development of Local Tumor-Related Symptoms. Neuroendocrinology 2022; 112:252-262. [PMID: 33853084 DOI: 10.1159/000516514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Clinical presentations of small intestinal neuroendocrine neoplasms (SiNENs) can range from asymptomatic to life-threatening complications. Other than primary tumor(s), mesenteric mass (MM) can provide local tumor-related (LTR) symptoms. Although some expert centers propose routine primary resection to avoid complications in stage IV patients, some guidelines suggest avoiding primary tumor resection unless in the presence of symptoms. This study was aimed to identify factors associated with the presence or development of LTR symptoms. METHODS From 2012 to 2019, SiNEN patients with appropriate initial morphological imaging were included. All initial imaging was reviewed. Associations between factors and LTR symptoms were assessed by logistic regression. RESULTS Among 144 SiNEN patients, 66 met the inclusion criteria. Multivariate analysis identified on initial morphological imaging (i) any visible primary tumor (p < 0.01) and (ii) MM contact ≥180° with the superior mesenteric vessels (p ≤ 0.02), as independent factors associated with LTR symptoms in the whole study population as well as in the subgroup of primary resected patients. Among the 14 (21%) patients with both factors on initial cross-sectional conventional imaging, 12 (18%) were straightaway symptomatic at diagnosis and the remaining became symptomatic during the follow-up. All asymptomatic patients, without upfront surgery and without any predictive factor 16/18 (89%), stayed asymptomatic during the 2.7-year median follow-up. The absence of association between these 2 factors yielded a sensitivity of 100%, a specificity of 62%, and a negative predictive value of 100% for the occurrence of LTR symptoms. CONCLUSION The presence of any visible primary tumor and/or MM superior mesenteric vessels contact ≥180° at initial cross-sectional imaging are 2 easily identifiable factors, which can help physicians for the decision-making regarding timing and type of surgery for SiNENs. Larger multicenter studies should endorse these results.
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Affiliation(s)
- Sophie Deguelte
- Department of Endocrine, Digestive and Oncological Surgery, Robert Debré University-Hospital, Reims, France
- Faculty of Medicine, EA 3797, University of Reims Champagne-Ardenne, Reims, France
| | - Alicia Metoudi
- Department of Endocrine, Digestive and Oncological Surgery, Robert Debré University-Hospital, Reims, France
| | - Rami Rhaiem
- Department of Endocrine, Digestive and Oncological Surgery, Robert Debré University-Hospital, Reims, France
| | - Chirstine Hoeffel
- Department of Radiology, Robert Debré University-Hospital, Reims, France
- Reims Medical School, University of Reims Champagne Ardennes, Reims, France
| | - Hedia Brixi
- Department of Hepato-Gastro-Enterology, Robert Debré University-Hospital, Reims, France
| | - Guillaume Cadiot
- Reims Medical School, University of Reims Champagne Ardennes, Reims, France
- Department of Hepato-Gastro-Enterology, Robert Debré University-Hospital, Reims, France
| | - Reza Kianmanesh
- Department of Endocrine, Digestive and Oncological Surgery, Robert Debré University-Hospital, Reims, France
- Reims Medical School, University of Reims Champagne Ardennes, Reims, France
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10
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Kaçmaz E, Engelsman AF, Bemelman WA, Tanis PJ, Nieveen van Dijkum EJM. International survey on opinions and use of minimally invasive surgery in small bowel neuroendocrine neoplasms. Eur J Surg Oncol 2021; 48:1251-1257. [PMID: 34823919 DOI: 10.1016/j.ejso.2021.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/25/2021] [Accepted: 11/08/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Although minimally invasive surgery is becoming the standard technique in gastrointestinal surgery, implementation for small bowel neuroendocrine neoplasms (SB-NEN) is lagging behind. The aim of this international survey was to gain insights into attitudes towards minimally invasive surgery for resection of SB-NEN and current practices. METHODS An anonymous survey was sent to surgeons between February and May 2021 via (neuro)endocrine and colorectal societies worldwide. The survey consisted of questions regarding experience of the surgeon with minimally invasive SB-NEN resection and training. RESULTS A total of 58 responses from five societies across 20 countries were included. Forty-one (71%) respondents worked at academic centers. Thirty-seven (64%) practiced colorectal surgery, 24 (41%) endocrine surgery and 45 (78%) had experience in advanced minimally invasive surgery. An open, laparoscopic or robotic approach was preferred by 23 (42%), 24 (44%), and 8 (15%) respondents, respectively. Reasons to opt for a minimally invasive approach were mainly related to peri-operative benefits, while an open approach was preferred for optimal mesenteric lymphadenectomy and tactile feedback. Additional training in minimally invasive SB-NEN resection was welcomed by 29 (52%) respondents. Forty-three (74%) respondents were interested in collaborating in future studies, with a cumulative median (IQR) annual case load of 172 (86-258). CONCLUSIONS Among respondents, 69% applies minimally invasive surgery for resection of SB-NEN. Arguments for specific operative approaches differ, and insufficient training in advanced laparoscopic techniques seems to be a barrier. Future collaborative studies can provide better insight in selection criteria and optimal technique.
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Affiliation(s)
- Enes Kaçmaz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Center for Endocrine and Neuroendocrine Tumours, Amsterdam UMC, Amsterdam, the Netherlands.
| | - Anton F Engelsman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Center for Endocrine and Neuroendocrine Tumours, Amsterdam UMC, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Center for Endocrine and Neuroendocrine Tumours, Amsterdam UMC, Amsterdam, the Netherlands
| | - Elisabeth J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Center for Endocrine and Neuroendocrine Tumours, Amsterdam UMC, Amsterdam, the Netherlands.
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11
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Multifocal Small Bowel Neuroendocrine Tumours. World J Surg 2021; 45:208-212. [PMID: 32613346 DOI: 10.1007/s00268-020-05663-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In contemporary surgical series, the incidence of multifocal tumours (MFT) in small bowel neuroendrocrine tumours (SBNET) is as high as 50%. Familial forms of SBNET appear to have an even higher rate of MFTs in the range of 80%. Multifocal disease poses several challenges and questions for the operating surgeon, including the cause of the disease whether it is local metastases or a genetic field defect, the extent of the resection, and the prognosis. The etiology of these multiple tumours appears to be multifactorial and may represent localized metastases in some, a genetic mutation resulting in the rare familial form of this disease in others, or the integration of genetic and epigenetic events within the bowel. Contrary to historical series, recent data suggest that MFT are not associated with a poorer prognosis. The challenge remains on the long-term surveillance of these unique tumours.
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12
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Wonn SM, Ratzlaff AN, Pommier SJ, Limbach KE, Bassale S, McCully BH, Pommier RF. Evaluation of the prognosis for N2 status in patients with small bowel neuroendocrine tumors. Am J Surg 2021; 221:1135-1140. [PMID: 33785207 DOI: 10.1016/j.amjsurg.2021.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND The 8th edition AJCC Staging for small bowel neuroendocrine tumors created a novel N2 classification. This study investigates if it is independently prognostic. METHODS Records of patients from 2008 to 2019 were reviewed. Survival rates were estimated by Kaplan-Meier method and compared by log-rank. The Cox Proportional Hazards model was used to determine factors associated with overall survival (OS) via multivariate analysis. RESULTS Among 300 patients, 225 were N2 and 60 were N1. No differences were seen in pathologic markers for N1 compared to N2. N2 were more likely to have liver metastases (LM) (p = 0.048) but rates of resectability were similar. Median OS for N1 with >70% liver cytoreduction was not yet reached compared to 121 months for N2 (p = 0.005). On multivariate analysis, LM was associated with shorter survival (p = 0.028), but nodal status was not. CONCLUSIONS Unlike LM, N2 status is not independently prognostic, but a marker for aggressive LM.
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Affiliation(s)
- Sarah M Wonn
- Department of Surgery, Oregon Health & Science University, United States
| | - Anna N Ratzlaff
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, United States
| | - SuEllen J Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, United States
| | - Kristen E Limbach
- Department of Surgery, Oregon Health & Science University, United States
| | - Solange Bassale
- Knight Cancer Biostatistician, Oregon Health & Science University, United States
| | - Belinda H McCully
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, United States
| | - Rodney F Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, United States.
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13
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Kaçmaz E, Slooter MD, Nieveen van Dijkum EJM, Tanis PJ, Engelsman AF. Fluorescence angiography guided resection of small bowel neuroendocrine neoplasms with mesenteric lymph node metastases. Eur J Surg Oncol 2021; 47:1611-1615. [PMID: 33353827 DOI: 10.1016/j.ejso.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/24/2020] [Accepted: 12/13/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Surgery for small bowel neuroendocrine neoplasms (SB-NEN) might result in vascular compromise of the remaining bowel due to resection of lymph node metastases in close proximity to main mesenteric vessels. Fluorescence angiography (FA) has been described as a safe technique to assess perfusion during gastro-intestinal surgery. This study aimed to evaluate the potential value of intraoperative FA during surgery for SB-NEN. METHODS This study included patients undergoing surgery for SB-NEN of any stage. The planned level of transection was marked by the surgeon, after which FA using indocyanine green (ICG) was performed. The primary study outcome was change in management due to FA. RESULTS Ten consecutive patients with SB-NEN were included, all with metastatic lymph nodes close to main mesenteric vessels. FA use led to management changes in eight patients (80%); four patients had less bowel resected with a preserved length of 5-35 cm. The other four patients had more extended bowel resections with an additional length varying from 3 to 25 cm. The median postoperative stay was 4 days (interquartile range 4-6). No anastomotic leakage occurred. CONCLUSION This is the first known series describing preliminary results of FA during SB-NEN surgery. FA led to a management change in 80% of patients with better tailoring the extent of resection of small bowel. Structural implementation of FA to assess small bowel perfusion after dissection for small bowel NET results in change of management, either by preserving small bowel or resecting ill-perfused small bowel.
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Affiliation(s)
- E Kaçmaz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - E J M Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands; ENETS Center of Excellence, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A F Engelsman
- Cancer Center Amsterdam, Amsterdam, the Netherlands; ENETS Center of Excellence, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands.
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14
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Gangi A, Anaya DA. Surgical Principles in the Management of Small Bowel Neuroendocrine Tumors. Curr Treat Options Oncol 2020; 21:88. [PMID: 32862334 DOI: 10.1007/s11864-020-00784-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT Small bowel neuroendocrine tumors (SB NETs) are increasing in frequency and becoming more common in surgical practice. It is often difficult to make the diagnosis of a SB NET at an early stage, as the primary tumor tends to be small and patients are asymptomatic until there is regional or distant metastasis, when they develop abdominal pain, partial obstruction, or bleeding and/or develop carcinoid syndrome. Despite this advanced presentation at the time of diagnosis, patients with metastatic SB NETs, as compared to other gastrointestinal malignancies, have favorable survival, which can be improved by appropriate surgical interventions. With the lack of randomized studies, there is reasonable controversy surrounding the optimal management of patients with SB NETs. As such, treatment of these patients is driven primarily by physician experience and available data based predominantly on retrospective studies. Based on this, current recommendations advocate for patients with SB NETs (localized or metastatic) to be managed at experienced centers by a multidisciplinary team. Eligible patients should undergo surgical resection of primary and regional disease as outlined in this article. Additionally, patients with metastatic disease should be evaluated on a case by case basis to evaluate surgical options that may mitigate bowel symptoms (i.e., pain, intestinal angina, obstruction) and carcinoid symptoms (flushing, diarrhea, hemodynamic instability) and prolong survival. Unlike other gastrointestinal malignancies, aggressive surgical management of these patients, even in the context of unresectable metastatic disease, can improve patients' symptoms and long-term survival. The principles outlined in this article are geared to guide appropriate management of SB NET patients with improvement in quality of life and overall survival outcomes.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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15
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Kasai Y, Nakakura EK. Awareness of a mesenteric mass as a common manifestation of ileal neuroendocrine tumor. Surg Case Rep 2020; 6:110. [PMID: 32448968 PMCID: PMC7246261 DOI: 10.1186/s40792-020-00875-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/14/2020] [Indexed: 11/12/2022] Open
Abstract
Omori et al. reported a case of multiple liver metastases originating from synchronous double cancer of “primary mesenteric neuroendocrine tumor” and rectal cancer. However, the “primary mesenteric neuroendocrine tumor” might be a misrecognition of mesenteric metastasis from ileal neuroendocrine tumor. Ileal neuroendocrine tumor is extremely rare in Japan. Herein, we aim to describe the characteristics of ileal neuroendocrine tumor and mesenteric mass as its common manifestation in reference to their reported case.
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Affiliation(s)
- Yosuke Kasai
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA, 94143-1932, USA.
| | - Eric K Nakakura
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA, 94143-1932, USA
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16
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Kasai Y, Mahuron K, Hirose K, Corvera CU, Kim GE, Hope TA, Shih BE, Warren RS, Bergsland EK, Nakakura EK. A novel stratification of mesenteric mass involvement as a predictor of challenging mesenteric lymph node dissection by minimally invasive approach for ileal neuroendocrine tumors. J Surg Oncol 2020; 122:204-211. [PMID: 32291778 DOI: 10.1002/jso.25930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/09/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES We classified the extent of mesenteric mass (MM) involvement that predicts challenging mesenteric lymph node dissection (mLND) by minimally invasive surgery (MIS) for ileal neuroendocrine tumors (i-NETs). METHODS Patients who underwent surgery for i-NETs were retrospectively reviewed. MM involvement was classified as region-0: no MM; region-1: >2 cm from the origins of the ileocolic artery/vein; region-2: ≤2 cm from the origins; and region-3: more proximal superior mesenteric artery/vein. Logistic regression analysis was used to evaluate the predictive value of MM regions for gross positive mesenteric margin (mR2) and/or conversion among the MIS cohort. The open surgery cohort was used as a reference for mR2 rates. RESULTS Of 108 patients, 83 patients (77%) underwent MIS. MMs in region-2 and region-3 were independent risk factors for mR2 and/or conversion (odds ratio [95% confidence interval]: 4.25 [1.17-16.4] and 8.51 × 107 [11.0-], respectively, against regions-0 and 1]. mR2 rates of MIS and open surgery cohorts per region did not differ significantly (4% and 7% for regions-0 and 1; 17% and 25% for region-2; and 100% and 83% for region-3). CONCLUSIONS The novel stratification of MM regions was predictive of challenging mLND by MIS. Surgeons should have a low threshold for conversion for MMs in proximal regions.
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Affiliation(s)
- Yosuke Kasai
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Kelly Mahuron
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kenzo Hirose
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Carlos U Corvera
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Grace E Kim
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Thomas A Hope
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Brandon E Shih
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Robert S Warren
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Emily K Bergsland
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Medicine, University of CFACS, California, San Francisco, San Francisco, California
| | - Eric K Nakakura
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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17
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Jiang S, Zhao L, Xie C, Su H, Yan Y. Prognostic Performance of Different Lymph Node Staging Systems in Patients With Small Bowel Neuroendocrine Tumors. Front Endocrinol (Lausanne) 2020; 11:402. [PMID: 32733379 PMCID: PMC7358303 DOI: 10.3389/fendo.2020.00402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022] Open
Abstract
Background: The prognostic significance of the lymph node (LN) classification for small bowel neuroendocrine tumors (SBNETs) remains unknown. The aim of the present study was to evaluate and compare the prognostic assessment of different LN staging systems. Methods: Patients with SBNETs were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The X-tile program was used to determine the cutoff value of the resected lymph nodes (RLNs), negative lymph nodes (NLNs), lymph node ratio (LNR), and the log odds of positive lymph nodes (LODDS). Survival analyses were performed using Kaplan-Meier curves with log-rank test. Logistic regression analysis was used to evaluate the differences between different periods. Univariate and multivariate Cox proportional hazards models were used to assess the prognostic value of different LN staging systems on cause-specific survival (CSS). The relative discriminative abilities of the different LN staging systems were assessed using the Akaike information criterion (AIC) and the Harrell consistency index (HCI). Result: A total of 3,680 patients were diagnosed with SBNETs between 1988 and 2014 from the SEER database. A significant difference over time (1988-1999 vs. 2000-2014) was seen in age (P <0.001), tumor differentiation (P <0.001), T stage (P <0.001), and RLN (P <0.001) subgroups. Multivariate Cox survival analysis identified that LN status stratified by the number of RLNs, NLNs, LNR, and LODDS all predicted CSS in patients with SBNETs (all P <0.05), whereas the number of positive lymph nodes (PLNs) failed (P = 0.452). When assessed using categorical variables, LODDS staging systems showed the best prognostic performance (HCI: 0.766, AIC: 7,575.154) in the whole population. Further analysis based on different RLNs after eliminating the missing data showed that when the RLNs are <12, the LODDS (HCI: 0.769, AIC: 1,088.731) maintained the best prognostic performance as well when the RLNs are ≥12 (HCI: 0.835, AIC: 825.692). Among patients with LNR scores of 0 or 1, there was a residual heterogeneity of outcomes that were better stratified and characterized by the LODDS. Conclusion: LODDS was a better predicator of survival when LN status was stratified as a categorical variable and should be considered when assessing the prognosis of patients with SBNETs to allow a more reliable means to stratify patient survival.
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Affiliation(s)
- Sujing Jiang
- Department of Radiation and Medical Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lihao Zhao
- Department of Radiation and Medical Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Congying Xie
- Department of Radiation and Medical Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huafang Su
- Department of Radiation and Medical Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Yan
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Ye Yan
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