Liver VIPoma: report of two cases and literature review

Surgicopathological classification of hepatic space-occupying lesions: A single-center experience with literature review

Accompanying rapid developments in hepatic surgery, the number of surgeries and identifications of histological types of primary hepatic space-occupying lesions (PHSOLs) have increased dramatically. This has led to many changes in the surgicopathological spectrum of PHSOLs, and has contributed to a theoretical basis for modern hepatic surgery and oncological pathology. Between 1982 and 2009 at the Eastern Hepatobiliary Surgery Hospital (EHBH) in Shanghai, 31 901 patients underwent surgery and were diagnosed as having a PHSOL. In this paper, we present an analysis of the PHSOL cases at the EHBH for this time period, along with results from a systematic literature review. We describe a surgicopathological spectrum comprising more than 100 types of PHSOLs that can be stratified into three types: tumor-like, benign, and malignant. We also stratified the PHSOLs into six subtypes derived from hepatocytes; cholangiocytes; vascular, lymphoid and hemopoietic tissues; muscular, fibrous and adipose tissues; neural and neuroendocrine tissues; and miscellaneous tissues. The present study provides a new classification system that can be used as a current reference for clinicians and pathologists to make correct diagnoses and differential diagnoses among various PHSOLs.

To investigate the role of the nervous system of bone in steroid-induced osteonecrosis in rabbits

SUMMARY

Glucocorticoid treatment frequently causes osteonecrosis of the femoral head. The precise mechanism in the pathogenesis of osteonecrosis remains highly controversial. Normal bone metabolism requires a coordinated interaction between the sensory/sympathetic nervous system and cells within the bone tissue. So we speculated that neural lesions may be involved in osteonecrosis.

OBJECTIVE

using a rabbit model, we investigated the relationship between neural factors and steroid-induced osteonecrosis of the femoral head.

METHODS

Japanese white rabbits weighing about 3.5 kg each were injected with a single intramuscular dose of methylprednisolone 4 mg/kg and then divided into three groups (groups A, B and C) consisting of 15 rabbits each. The rabbits of group A were killed after 3 days, those of group B after 1 week, and those of group C after 2 weeks. As a control group, 10 rabbits (group N) were fed under the same conditions but did not receive a steroid injection. An immunohistochemical study of the femoral heads was conducted using the monoclonal antibodies CGRP, SP, VIP, NPY and NGF. Also, using the software Image Pro Plus, the areas showing positive immunoreactivity in each group were calculated and the four groups were compared.

RESULTS

significant changes were seen in the expression of CGRP, SP, VIP and NPY nerve fibres and of NGF immunoreactivity in the subchondral bone of the femoral head and these changes were associated with the process of osteonecrosis. Furthermore, CGRP, SP, NPY and NGF (but not VIP) showed marked changes in expression 1 week after steroid administration, and this is the time when osteonecrosis is thought to occur in this model.

CONCLUSION

This study showed that osteonecrosis in rabbits is chronologically associated with changes in neural factors.

VIPoma with expression of both VIP and VPAC1 receptors in a patient with WDHA syndrome

We report a case of VIPoma in a 72-year-old female patient who presented with excessive diarrhea, severe hypokalemia, and acidemia. She had been referred to our hospital three times because of severe diarrhea. No primary tumor site was found by conventional techniques, including contrast-enhanced CT and MRI, angiography, endoscopy, and positron emission tomography (PET), but a tumor was subsequently found in the head of the pancreas by octreotide scanning. Her diarrhea diminished dramatically after octreotide treatment, while her diarrhea has ceased without the therapy of octreotide at the first admission in the course of 2 years of her disease. Immunohistochemial analysis of the excised tumor tissue revealed the expression of both vasoactive intestinal peptide (VIP) and VIP and pituitary adenylate cyclase-activating peptide 1 (VPAC1) receptors. This is the first case report of a VIPoma that immunostains for VIP and VPAC1 receptors and indicates that abundant VIP produced by VIPoma might inhibit its growth and reduce VIP secretion via the VPAC1 receptor in vivo.

[Surgical treatment of gastric, enteric, and pancreatic endocrine tumors Part 1. Treatment of primary endocrine tumors]

Endocrine tumors (ET) of the digestive tract (formerly called neuroendocrine tumors) are rare. They are classified into two principal types: gastrointestinal ET's (formerly called carcinoid tumors) which are the most common, and pancreaticoduodenal ET's. Functioning ET's secrete polypeptide hormones which cause characteristic hormonal syndromes. The management of ET is multidisciplinary. Poorly-differentiated ET's have a poor prognosis and are treated by chemotherapy. Surgical excision is the only curative treatment of well-differentiated ET's. The surgical goals are to: 1. prolong survival by resecting the primary tumor and any nodal or hepatic metastases, 2. control the symptoms related to hormonal secretion, 3. prevent or treat local complications. The most common sites of gastrointestinal ET's ( carcinoids) are the appendix and the rectum; these are often small (<1 cm), benign, and discovered fortuitously at the time of appendectomy or colonoscopic removal. Ileal ET's, even if small, are malignant, frequently multiple, and complicated in 30-50% of cases by bowel obstruction, mesenteric invasion, or bleeding. The carcinoid syndrome (consisting of abdominal pain, flushing, diarrhea, hypertension, bronchospasm, and right sided cardiac vegetations) is caused by the hypersecretion of serotonin into the systemic circulation; it occurs in 10% of cases and is usually associated with hepatic metastases. More than half of the cases of pancreatic ET are non-functional. They are usually malignant and of advanced stage at diagnosis presenting as a palpable or obstructing mass or as liver metastases. Insulinoma and gastrinoma (cause of the Zollinger-Ellison syndrome) are the most common functional ET's. 80% are sporadic; in these cases, tumor size, location, and malignant potential determine the type of resection which may vary from a simple enucleation to a formal pancreatectomy. In 10-20% of cases, pancreaticoduodenal ET presents in the setting of multiple endocrine neoplasia (NEM type I), an autosomal-dominant genetic disease with multifocal endocrine involvement of the pituitary, parathyroid, pancreas, and adrenal glands. For insulinoma with NEM-I, enucleation of lesions in the pancreatic head plus a caudal pancreatectomy is the most appropriate procedure. For gastrinoma with NEM-I, the benefit of surgical resection for tumors less than 2-3 cm in size is not clear. The lesions are frequently small, multiple, and widespread and recurrence is frequent after excision. The long-term prognosis is nevertheless fairly good. But the eventual development of liver metastases which are the most common cause of mortality still argues for an aggressive surgical approach in the early stages of the disease.

Expression and regulatory role of receptors for vasoactive intestinal peptide in bone cells

An intense network of nerve fibers can be demonstrated in skeletal tissues, not only in the periosteum but also within cortical bone, growth plate, and bone marrow. This neuro-osteogenic network expresses a restricted number of signalling molecules, including neuropeptides, neurotransmitters, and neurotrophins. Several lines of evidence indicate that receptors for these molecules are present on bone cells and that activation of these receptors leads to changes in bone cell activities. In addition, deletion of signalling molecules has been shown to alter bone metabolism. In the present review, these studies are summarized with a focus on distribution and effects of vasoactive intestinal peptide.

Vasoactive intestinal peptide regulates osteoclast activity via specific binding sites on both osteoclasts and osteoblasts

Clinical and experimental observations, together with immunohistochemical findings, suggest that neuro-osteogenic interactions may occur in the skeleton. In this study, we have examined the effect of vasoactive intestinal peptide (VIP), one of the neuropeptides present in bone, on the activity of the bone-resorbing osteoclast. Effects on bone resorption were assessed by counting the number of pits formed by rat osteoclasts incubated on devitalized slices of bovine cortical bone. Under conditions with an initially sparse density of stromal cells/osteoblasts, VIP caused a rapid cytoplasmic contraction and decreased motility of osteoclasts. This was coupled with a decrease in the number of resorption lacunae and a decrease in the total area resorbed by the osteoclasts in 48-h cultures. Time-course experiments revealed that the inhibitory effects on contraction and motility were transient and that the cells gradually regained their activity, such that, when culture time was prolonged to 120 h, a stimulatory effect by VIP on bone resorption was observed. When osteoclasts were incubated on bone slices, in the presence of an initially large number of stromal cells/osteoblasts, VIP treatment increased the number of resorption pits and total bone area resorbed in 48-h cultures. Using atomic force microscopy, we provide direct evidence that both osteoclasts and stromal cells/osteoblasts bind VIP. Also, VIP was shown to cause a rapid rise of intracellular calcium in osteoclasts and in a proportion (20%) of stromal cells/osteoblasts. Taken together, these data suggest that differentiated osteoclasts are equipped with receptors for VIP that are linked to a transient inhibition of osteoclast activity and, in addition, that stromal cells/osteoblasts have VIP receptors coupled to a delayed stimulation of osteoclastic resorption.

Neuroendocrine tumors of the pancreas: spectrum of appearances on MRI

We reviewed our 8.5 year experience with magnetic resonance imaging (MRI) in the demonstration of neuroendocrine tumors of the pancreas using precontrast fat-suppressed T1-weighted, fat-suppressed T2-weighted, and serial post-gadolinium T1-weighted images, to describe the spectrum of appearances of these tumors. All MR examinations of patients with histologically proven neuroendocrine tumors were retrospectively reviewed. Histological type, tumor location, tumor diameter, signal intensity on precontrast images, enhancement patterns, and presence and appearance of metastases were determined. Twenty-two patients had histologically proved neuroendocrine tumors detected by MRI over the 8.5 year period. Histological types were gastrinoma (n = 8), insulinoma (n = 3), glucagonoma (n = 2), somatostatinoma (n = 1), VIPoma (n = 1), ACTHoma (n = 1), carcinoid (n = 1), and five untyped tumors. Primary tumors ranged in diameter from 1 to 6.2 cm. There was one histopathology-proven false-positive neuroendocrine tumor. The positive predictive value for MRI in the detection of these tumors was 96%. The most common appearance on precontrast images was low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, which was observed in tumors in 18 of 22 patients. Moderate or intense early enhancement of all or portions of the primary tumors was observed in tumors in 19 of 22 patients either as uniform homogeneous, ring, or diffuse heterogeneous enhancement. Enhancement was minimal on these images in the other three patients. Gastrinomas enhanced in a ring pattern in 7 of 8 patients whereas the majority (9 of 11 patients) of noninsulinoma-nongastrinoma and untyped tumors enhanced in a diffuse heterogeneous fashion. Liver metastases were present in 13/22 patients including 3/8 with gastrinoma and 9/11 with noninsulinoma-nongastrinoma tumors. Most neuroendocrine tumors of the pancreas are low signal intensity on fat-suppressed T1-weighted images and moderately high in signal intensity on fat-suppressed T2-weighted images, although variations do exist. Tumors most often enhance in an early moderately intense fashion. Gastrinomas are often different in appearance than other neuroendocrine tumors in that they usually enhance in a ring fashion whereas nongastrinoma-noninsulinoma tumors usually enhance in a heterogeneous fashion.

Neuro-hormonal control of bone metabolism: vasoactive intestinal peptide stimulates alkaline phosphatase activity and mRNA expression in mouse calvarial osteoblasts as well as calcium accumulation mineralized bone nodules

Based upon the immunohistochemical demonstration of neuropeptides in the skeleton, including vasoactive intestinal peptide (VIP), we have addressed the question of whether neuropeptides may exert regulatory roles on bone tissue metabolism or not. In the present communication, we have investigated if VIP can affect anabolic processes in osteoblasts. Osteoblasts were isolated from neonatal mouse calvariae by time sequential enzyme-digestion and subsequently cultured for 2-28 days in the presence of VIP and other modulators of cyclic AMP formation. VIP (10(-6) M) stimulated ALP activity and calcium content. The cyclic AMP phosphodiesterase inhibitors ZK 62 711 (10(-4) M) and isobutyl-methylxanthine (10(-4) M) stimulated ALP activity and synergistically potentiated the effect of VIP. Neither VIP, nor isobutyl-methylxanthine or ZK 62 711, in the absence or presence of VIP, affected cell number. The stimulatory effect of VIP on ALP activity, in the presence of ZK 62 711, was dependent on time and concentration of VIP. The stimulatory effects of VIP and ZK 62 711 on ALP activity was seen also in cells stained for ALP. VIP (10(-6) M), in the presence of ZK 62 711 (10(-6) M), significantly enhanced mRNA for tissue non-specific ALP. VIP (10(-6) M), in the presence of ZK 62 711, stimulated cyclic AMP production. Forskolin and choleratoxin stimulated ALP activity and cyclic AMP formation in a concentration-dependent manner, without affecting cell number. VIP (10(-6) M) and ZK 62 711 (10(-5) M) stimulated, and their combination synergistically enhanced, calcium content in bone noduli. These data show that VIP, without affecting cell proliferation, can stimulate osteoblastic ALP biosynthesis and bone noduli formation by a mechanism mediated by cyclic AMP. Our observations suggest a possibility that anabolic processes in bone are under neurohormonal control.

MR imaging of metastatic pancreatic VIPoma

The MR findings in a 32-year-old man with pancreatic VIPoma and liver metastases are described. A 2-cm mass was present in the region of the tail of the pancreas that was best shown on T1-weighted fat-suppressed images as a low-signal intensity mass. Multiple liver metastases were present that showed intense peripheral ring enhancement on immediate post gadolinium spoiled gradient echo images.

Vasoactive intestinal polypeptide-secreting tumours: biology and therapy

VIP-secreting tumours are rare, but they produce a dramatic clinical picture, the most prominent feature being profuse, watery diarrhoea and hypokalaemia. VIPomas are malignant and require sophisticated diagnostic and localization techniques in order to identify their presence. Delays in diagnosis are the rule rather than the exception. Improvements in the diagnosis of VIPomas appear to result in an increase in resectability rates. A definitive diagnosis is aided by the determination of plasma VIP concentrations through the use of sensitive radioimmunoassays. With heightened awareness of this syndrome, increasing numbers of patients can be identified and more effective treatments developed for the refractory and recurrent tumours.

Adenocarcinoid of the liver arising within an area of hamartoma with predominant bile duct component

Malignant transformation in bile duct hamartomas has been previously reported in very rare instances. Here, we describe a unique case of a neuroendocrine tumor of the liver arising within an area of unusually large hamartoma with predominant bile duct component, hitherto unreported and distinct from the conventional von Meyenburg complex. The tumor was apparently secreting gastrin and chromogranin, with associated gastrinoma syndrome over several years. The histologic picture was reminiscent of a moderately differentiated adenocarcinoid, with positive mucin staining in a signet ring pattern. Tumor cells showed positive staining for neuron-specific enolase, chromogranin A, gastrin, and serotonin. Staining for pancreatic hormone peptides was negative. Resection of the tumor was apparently curative, with complete resolution of the patient's symptoms.