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Briganti V, Cuccurullo V, Di Stasio GD, Mansi L. Gamma Emitters in Pancreatic Endocrine Tumors Imaging in the PET Era: Is there a Clinical Space for 99mTc-peptides? Curr Radiopharm 2019; 12:156-170. [DOI: 10.2174/1874471012666190301122524] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/15/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
Background:
Pancreatic Neuroendocrine Tumors (PNETs) are rare neoplasms, sporadic or
familial, even being part of a syndrome. Their diagnosis is based on symptoms, hormonal disorders or
may be fortuitous. The role of Nuclear Medicine is important, mainly because of the possibility of a
theranostic strategy. This approach is allowed by the availability of biochemical agents, which may be
labeled with radionuclides suitable for diagnostic or therapeutic purposes, showing almost identical
pharmacokinetics. The major role for radiopharmaceuticals is connected with radiolabeled Somatostatin
Analogues (SSA), since somatostatin receptors are highly expressed on some of the neoplastic
cell types.
Discussion:
Nowadays, in the category of radiolabeled SSA, although 111In-pentetreotide, firstly
commercially proposed, is still used, the best choice for diagnosis is related to the so called DOTAPET
radiotracers labeled with 68-Gallium (Ga), such as 68Ga-DOTATATE, 68Ga-DOTANOC, and
68Ga-DOTATOC. More recently, labeling with 64-Copper (Cu) (64Cu-DOTATATE) has also been
proposed. In this review, we discuss the clinical interest of a SAA (Tektrotyd©) radiolabeled with
99mTc, a gamma emitter with better characteristics, with respect to 111Indium, radiolabeling Octreoscan
©. By comparing both pharmacokinetics and pharmacodynamics of Octreoscan©, Tektrotyd©
and PET DOTA-peptides, on the basis of literature data and of our own experience, we tried to highlight
these topics to stimulate further studies, individuating actual clinical indications for all of these
radiotracers.
Conclusion:
In our opinion, Tektrotyd© could already find its applicative dimension in the daily practice
of NETs, either pancreatic or not, at least in centers without a PET/CT or a 68Ga generator. Because
of wider availability, a lower cost, and a longer decay, compared with respect to peptides labeled
with 68Ga, it could be also proposed, in a theranostic context, for a dosimetry evaluation of patients
undergoing Peptide Receptor Radionuclide Therapy (PRRT), and for non-oncologic indications
of radiolabelled SSA. In this direction, and for a more rigorous cost/effective evaluation, more precisely
individuating its clinical role, further studies are needed.
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Affiliation(s)
- Vittorio Briganti
- Nuclear Medicine Unit - Azienda Ospedaliero Universitaria Careggi Firenze, Italy
| | - Vincenzo Cuccurullo
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Giuseppe Danilo Di Stasio
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Luigi Mansi
- Health and Development Section, Interuniversitary Research Center for Sustainable Development, Napoli-Roma, Italy
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Soresi E, Invernizzi G, Boffi R, Borghini U, Schiraldi G, Mantellini PV, Gramegna G, Liuzzi A. Effect of Octreotide on Neuroenolase Levels in Patients with Small Cell Lung Cancer. TUMORI JOURNAL 2018; 80:332-4. [PMID: 7839460 DOI: 10.1177/030089169408000503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background The somatostatin analog octreotide has an antiproliferative effect on small cell lung cancer lines in vitro and in experimental xenograft transplantation systems in vivo. Thus it is worth investigating octreotide activity in the clinical setting. Methods We studied the effect of octreotide (200 μg three times a day subcutaneously for seven days) on serum levels of the tumor marker neuroenolase in 13 patients with small cell lung cancer. Results A decrease in neuroenolase levels was observed at day 7 during octreotide treatment, with a mean ± SD of 32.6 ± 42.0 ng/ml compared to basal values of 44.4 ± 57.7 ng/ml and to washout values of 50.3 ± 65.7 ng/ml ( P < 0.03). Conclusions Our results indicate that octreotide is effective in reducing neuroenolase levels in small cell lung cancer patients. These data suggest a possible role for octreotide in the treatment of this kind of tumor.
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Affiliation(s)
- E Soresi
- Servizio di Fisiopatologia, Ospedale Maggiore Niguarda, Milano, Italy
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3
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Iwasaki M, Tsuchida K, Jinnai H, Komatsubara T, Arisaka T, Tsunemi M, Nakano M, Iijima M, Hiraishi H. Multimodal Treatment of Vasoactive Intestinal Polypeptide-producing Pancreatic Neuroendocrine Tumors with Liver Metastases. Intern Med 2017; 56:517-522. [PMID: 28250297 PMCID: PMC5399202 DOI: 10.2169/internalmedicine.56.7512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A 53-year-old man presented with diarrhoea and hypokalaemia and was diagnosed with a neuroendocrine tumour of unknown origin with multiple liver metastases. Somatostatin analogues led to a reduction in the size of the tumours and improvement of his symptoms. However, after several years, the tumours grew in size, and the patient's clinical symptoms recurred. The patient underwent transcatheter arterial embolization (TAE) of the hepatic artery to treat the liver metastases. Immediately after embolization, the symptoms disappeared. Although the patient had an unresectable vasoactive intestinal polypeptide-producing neuroendocrine tumour, the endocrine symptoms were able to be controlled with chemotherapy and TAE, resulting in a long-term survival.
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Affiliation(s)
- Mari Iwasaki
- Department of Gastroenterology, Dokkyo Medical University, Japan
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4
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Ito T, Lee L, Jensen RT. Treatment of symptomatic neuroendocrine tumor syndromes: recent advances and controversies. Expert Opin Pharmacother 2016; 17:2191-2205. [PMID: 27635672 DOI: 10.1080/14656566.2016.1236916] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Neuroendocrine tumors(NETs), once thought rare, are increasing in frequency in most countries and receiving increasing-attention. NETs present two-treatment problems. A proportion is aggressive and a proportion has a functional, hormone-excess-state(F-NET), each of which must be treated. Recently, there have been many advances, well-covered in reviews/consensus papers on imaging-NETs; new, novel anti-tumor treatments and understanding their pathogenesis. However, little attention has been paid to advances in the treatment of the hormone-excess-state. These advances are usually reported in case-series, and case-reports with few large studies. In this paper these advances are reviewed. Areas covered: Advances in the last 5-years are concentrated on, but a review of literature from the last 10-years was performed. PubMed and other databases (Cochrane, etc.) were searched for F-NET-syndromes including carcinoid-syndrome, as well as meeting-abstracts on NETs. All advances that controlled hormone-excess-states or facilitated-control were covered. These include new medical-therapies [serotonin-synthesis inhibitors(telotristat), Pasireotide, new agents for treating ACTHomas], increased dosing with conventional therapies (octreotide-LAR, Lanreotide-Autogel), mTor inhibitors(everolimus), Tyrosine-kinase inhibitors(sunitinib),cytoreductive surgery, liver-directed therapies (embolization, chemoembolization, radioembolization, RFA), peptide radio-receptor-therapy(PRRT) and 131I-MIBG, ablation of primary F-NETs. Expert opinion: Although many of the newer therapies controlling the hormone-excess-states in F-NETs are reported in relatively few patients, all the approaches show promise. Their description also generates some controversies/unresolved areas,such as the order of these new treatments, their longterm-efficacy, and effectiveness of combinations which may require large,controlled studies.
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Affiliation(s)
- Tetsuhide Ito
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Lingaku Lee
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Robert T Jensen
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
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5
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Parbhu SK, Adler DG. Pancreatic neuroendocrine tumors: contemporary diagnosis and management. Hosp Pract (1995) 2016; 44:109-19. [PMID: 27404266 DOI: 10.1080/21548331.2016.1210474] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pancreatic neuroendocrine tumors (PNETs) are neoplasms that arise from the hormone producing cells of the islets of Langerhans, also known as pancreatic islet cells. PNETs are considered a subgroup of neuroendocrine tumors, and have unique biology, natural history and clinical management. These tumors are classified as 'functional' or 'non-functional' depending on whether they release peptide hormones that produce specific hormone- related symptoms, usually in established patterns based on tumor subtype. This manuscript will review pancreatic neuroendocrine tumor subtypes, syndromes, diagnosis, and clinical management.
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Affiliation(s)
- Sheeva K Parbhu
- a Department of Internal Medicine, Division of Gastroenterology and Hepatology , University of Utah School of Medicine, Huntsman Cancer Center , Salt Lake City , Utah , USA
| | - Douglas G Adler
- a Department of Internal Medicine, Division of Gastroenterology and Hepatology , University of Utah School of Medicine, Huntsman Cancer Center , Salt Lake City , Utah , USA
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6
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Health-related quality of life in well-differentiated metastatic gastroenteropancreatic neuroendocrine tumors. Cancer Metastasis Rev 2015; 34:381-400. [DOI: 10.1007/s10555-015-9573-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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7
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Chihaya K, Morita S, Sone M, Kishi Y, Okusaka T, Arai Y. Strategy for treatment of a nonfunctioning pancreatic neuroendocrine neoplasm with liver metastases. Int Cancer Conf J 2015. [DOI: 10.1007/s13691-015-0226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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8
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Marciello F, Di Somma C, Del Prete M, Marotta V, Ramundo V, Carratù A, de Luca di Roseto C, Camera L, Colao A, Faggiano A. Combined biological therapy with lanreotide autogel and cabergoline in the treatment of MEN-1-related insulinomas. Endocrine 2014; 46:678-81. [PMID: 24385268 DOI: 10.1007/s12020-013-0145-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/04/2013] [Indexed: 01/01/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a hereditary syndrome associated with the development of many endocrine tumors, involving mainly pituitary, parathyroids, pancreas, although a proliferative state interests all neuroendocrine system. MEN1 pancreatic neuroendocrine tumors (pNETs) are multiples and can secrete different hormones. The therapeutic approach is based on surgery which usually is followed by tumor relapse or persistence unless to be highly aggressive. Biotherapy with somatostatin analogs and dopamine agonists could be of great benefit to manage these patients without altering their life quality. We report a case of a 36-year-old MEN1 man affected with multicentric pNETs associated with insulinoma syndrome. Therapy with symptomatic agents (diazoxide), as well as biotherapy (lanreotide, cabergoline) was started. At 6-month follow-up, symptomatic agents were stopped and disease control was only based on lanreotide plus cabergoline. This combined biotherapy was able to control endocrine syndromes and tumor growth. Subsequently, a safer and selective surgical intervention on pNETs was performed. An excellent response to therapy with lanreotide autogel and cabergoline has been observed in a MEN1 patient with pNETs associated with insulinoma syndrome. The potential synergistic effects of lanreotide autogel and cabergoline on insulin-secreting neuroendocrine tumors are discussed.
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Affiliation(s)
- Francesca Marciello
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy,
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9
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Ro C, Chai W, Yu VE, Yu R. Pancreatic neuroendocrine tumors: biology, diagnosis,and treatment. CHINESE JOURNAL OF CANCER 2012; 32:312-24. [PMID: 23237225 PMCID: PMC3845620 DOI: 10.5732/cjc.012.10295] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic neuroendocrine tumors (PNETs), a group of endocrine tumors arising in the pancreas, are among the most common neuroendocrine tumors. The genetic causes of familial and sporadic PNETs are somewhat understood, but their molecular pathogenesis remains unknown. Most PNETs are indolent but have malignant potential. The biological behavior of an individual PNET is unpredictable; higher tumor grade, lymph node and liver metastasis, and larger tumor size generally indicate a less favorable prognosis. Endocrine testing, imaging, and histological evidence are necessary to accurately diagnose PNETs. A 4-pronged aggressive treatment approach consisting of surgery, locoregional therapy, systemic therapy, and complication control has become popular in academic centers around the world. The optimal application of the multiple systemic therapeutic modalities is under development; efficacy, safety, availability, and cost should be considered when treating a specific patient. The clinical presentation, diagnosis, and treatment of specific types of PNETs and familial PNET syndromes, including the novel Mahvash disease, are summarized.
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Affiliation(s)
- Cynthia Ro
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Karpathakis A, Caplin M, Thirlwell C. Hitting the target: where do molecularly targeted therapies fit in the treatment scheduling of neuroendocrine tumours? Endocr Relat Cancer 2012; 19:R73-92. [PMID: 22474226 DOI: 10.1530/erc-12-0050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neuroendocrine tumours (NETs) are a rare and heterogeneous group of tumours whose incidence is increasing and their prevalence is now greater than that of any other upper gastrointestinal tumour. Diagnosis can be challenging, and up to 25% of patients present with metastatic disease. Following the recent FDA approval of two new molecularly targeted therapies for the treatment of advanced pancreatic NETs (pNETs), the first in 25 years, we review all systemic therapies and suggest where these newer targeted therapies fit in the treatment schedule for these challenging tumours. Clinical trial data relating to the routine use of sunitinib and everolimus in low-intermediate-grade pNETs are summarised alongside newer molecularly targeted agents undergoing clinical assessment in NETs. We particularly focus on the challenge of optimal scheduling of molecularly targeted treatments around existing systemic and localised treatment such as chemotherapy or radiotargeted therapy. We also discuss application of current evidence to subgroups of patients who have not so far been directly addressed such as those with poorer performance status or patients receiving radical surgery who may benefit from adjuvant treatment.
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Affiliation(s)
- Anna Karpathakis
- University College London Cancer Institute, Paul O'Gorman Building, Huntley Street, London WC1E 6BT, UK
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11
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Strosberg JR, Cheema A, Kvols LK. A Review of Systemic and Liver-Directed Therapies for Metastatic Neuroendocrine Tumors of the Gastroenteropancreatic Tract. Cancer Control 2011; 18:127-137. [DOI: 10.1177/107327481101800207] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Jonathan R. Strosberg
- Department of Gastrointestinal Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Asima Cheema
- Department of Gastrointestinal Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Larry K. Kvols
- Department of Gastrointestinal Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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13
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Cirillo F. Role of Somatostatin Analogs in the Management of Neuroendocrine Tumors. TUMORI JOURNAL 2010; 96:191-7. [DOI: 10.1177/030089161009600202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroendocrine tumors are rare neoplasms. During the last two decades, somatostatin analogs, exerting their activity through both receptor binding and enzymatic inhibition mechanisms, have been a key option in the management of neuroendocrine tumors. The treatment of neuroendocrine tumors with high doses of somatostatin analogs determined high rates of tumor stabilization, but the dose-response of somatostatin analogs on symptomatic relief and stabilization of tumor growth remains unpredictable. Several studies have indicated a higher efficacy of somatostatin analogs in well-differentiated, low-grade malignancy tumors that express a high density of somatostatin receptors. Synthesis of new, more effective molecules, with different pharmacokinetic profiles, receptor affinity and binding stability, will ease the clinician's tasks and improve patient expectancies in terms of survival and quality of life. Further studies are needed to clarify mechanisms underlying the better antiproliferative effect of higher doses of somatostatin analogs and to determine the optimum dose to saturate specific receptor subtypes
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Affiliation(s)
- Fernando Cirillo
- Dipartimento di Chirurgia Generale, UO di Chirurgia Generale, Polo Tumori Ormonali Rari, AO Istituti Ospitalieri, Cremona; Scuola di Specializzazione in Endocrinologia e Malattie del Ricambio, Università degli Studi di Parma
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Abstract
Insulinoma is a rare neuroendocrine tumor that causes oversecretion of insulin and, as a result, patients present with symptoms of hypoglycemia. Fortunately, insulinomas are usually benign and solitary, and surgical cure rates are highly favorable. Most of these tumors occur sporadically, but they can also be associated with multiple endocrine neoplasia type-1 syndrome. The diagnosis is confirmed by a supervised fast, and early detection is important. Several preoperative and intraoperative techniques with various success rates have been employed in order to localize the lesion. When technically feasible, tumor enucleation is the procedure of choice; however, a more formal resection may be necessary for certain tumors. In the age of laparoscopy, the role of laparoscopic surgery in the management of insulinomas is continuing to attract attention. This review will discuss the historical background, pathogenesis, diagnosis, localization and management of insulinomas.
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Affiliation(s)
- Joyce J Shin
- Montefiore Medical Center/Albert Einstein, College of Medicine, Greene Medical Arts, Pavilion 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Phillip Gorden
- NIDDK, National Institutes of Health, Building 10-CRC, Room 6-5952, 10 Center Dr., Bethesda, MD, USA, Tel.: +1 301 402 7340, Fax: +1 301 435 5873
| | - Steven K Libutti
- Montefiore-Einstein Center for Cancer Care, NY, USA and Department of Surgery, Montefiore, Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA, Tel.: +1 718 920 4231, Fax: +1 718 798 0309
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15
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Arts J, Caenepeel P, Bisschops R, Dewulf D, Holvoet L, Piessevaux H, Bourgeois S, Sifrim D, Janssens J, Tack J. Efficacy of the long-acting repeatable formulation of the somatostatin analogue octreotide in postoperative dumping. Clin Gastroenterol Hepatol 2009; 7:432-7. [PMID: 19264574 DOI: 10.1016/j.cgh.2008.11.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 10/16/2008] [Accepted: 11/26/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several studies have established symptomatic and mechanistic benefits of the somatostatin analogue octreotide in patients with dumping syndrome, but clinical use is hampered by the requirement for subcutaneous administration 3 times daily. We compared the efficacy of subcutaneous octreotide with that of the long-acting repeatable (LAR) octreotide formulation, which is administered monthly, in patients with dumping syndrome. METHODS The study included 30 consecutive patients with postoperative dumping, evidenced by oral glucose tolerance test (OGTT) results and insufficient response to dietary measures. OGTT, dumping severity score (summary of scores 0-3 for 8 early and 6 late dumping symptoms), and quality-of-life data were evaluated at baseline, after 3 days of subcutaneous administration of octreotide (0.5 mg), and then after 3 monthly intramuscular injections of octreotide LAR (20 mg). RESULTS Both formulations of octreotide significantly reduced total dumping severity scores (21.7 +/- 1.6 at baseline, 11.2 +/- 1.2 for subcutaneous and 14.0 +/- 1.8 for LAR formulations; P < .05). This reduction was associated with significant improvements in the increase in pulse rate (13.8 +/- 5.8 at baseline vs -0.3 +/- 2.2 and 1.9 +/- 1.7; P < .05) as well as the increase in hematocrit level (4.0 +/- 1.4 at baseline vs 0.3 +/- 0.9. and 0.4 +/- 1.0; P < .05), and the lowest glycemia level in the OGTT (54.1 +/- 6.7 at baseline vs 98.9 +/- 7.1 and 67.8 +/- 5.9; P < .05). LAR octreotide administration significantly improved patients' quality of life. Patients' evaluations of their overall treatment efficacy was higher on LAR compared with the subcutaneous formulation (83% vs 52%; P = .01). Gallbladder stones occurred in 4 patients. CONCLUSIONS Monthly administration of LAR octreotide improves OGTT results, symptoms, and quality of life in patients with postoperative dumping.
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Affiliation(s)
- Joris Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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16
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Metz DC, Jensen RT. Gastrointestinal neuroendocrine tumors: pancreatic endocrine tumors. Gastroenterology 2008; 135:1469-92. [PMID: 18703061 PMCID: PMC2612755 DOI: 10.1053/j.gastro.2008.05.047] [Citation(s) in RCA: 509] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 03/25/2008] [Accepted: 05/12/2008] [Indexed: 12/14/2022]
Abstract
Pancreatic endocrine tumors (PETs) have long fascinated clinicians and investigators despite their relative rarity. Their clinical presentation varies depending on whether the tumor is functional or not, and also according to the specific hormonal syndrome produced. Tumors may be sporadic or inherited, but little is known about their molecular pathology, especially the sporadic forms. Chromogranin A appears to be the most useful serum marker for diagnosis, staging, and monitoring. Initially, therapy should be directed at the hormonal syndrome because this has the major initial impact on the patient's health. Most PETs are relatively indolent but ultimately malignant, except for insulinomas, which predominantly are benign. Surgery is the only modality that offers the possibility of cure, although it generally is noncurative in patients with Zollinger-Ellison syndrome or nonfunctional PETs with multiple endocrine neoplasia-type 1. Preoperative staging of disease extent is necessary to determine the likelihood of complete resection although debulking surgery often is believed to be useful in patients with unresectable tumors. Once metastatic, biotherapy is usually the first modality used because it generally is well tolerated. Systemic or regional therapies generally are reserved until symptoms occur or tumor growth is rapid. Recently, a number of newer agents, as well as receptor-directed radiotherapy, are being evaluated for patients with advanced disease. This review addresses a number of recent advances regarding the molecular pathology, diagnosis, localization, and management of PETs including discussion of peptide-receptor radionuclide therapy and other novel antitumor approaches. We conclude with a discussion of future directions and unsettled problems in the field.
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Affiliation(s)
- David C Metz
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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17
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Vezzosi D, Bennet A, Courbon F, Caron P. Short- and long-term somatostatin analogue treatment in patients with hypoglycaemia related to endogenous hyperinsulinism. Clin Endocrinol (Oxf) 2008; 68:904-11. [PMID: 18031316 DOI: 10.1111/j.1365-2265.2007.03136.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The long-term efficacy of somatostatin analogues on insulinomas has not been studied. DESIGN A prospective study to evaluate the response of octreotide in 21 patients with hypoglycaemia related to endogenous hyperinsulinism who were not treated by surgery. RESULTS Reasons for not undergoing surgery were: refusal (n = 3), old age with multiple diseases (n = 5), unlocalized insulinomas (n = 2), malignant unresectable insulinomas (n = 5), multiple insulinomas (n = 3) and diffuse beta-cell disease (n = 3). Hypoglycaemia was responsive to octreotide in 14 of the 21 patients. A short 100-microg octreotide test correctly predicted the efficacy of treatment in six patients with benign insulinomas. Octreoscan scintigraphy was positive in 6 of the 16 patients of whom three were responsive and three unresponsive to octreotide. Octreoscan scintigraphy was negative in 10 of the 16 patients, eight of whom were responsive to octreotide. Subcutaneous octreotide treatment was prolonged for > 6 months (7-144 months, 67 +/- 47 months) in 11 responsive patients. No tachyphylaxis was observed. However, the octreotide dose had to be increased in two patients after 3 and 18 months, respectively. Only one patient suffered from symptomatic biliary lithiasis after 3 years of treatment. CONCLUSION Long-term octreotide treatment can be used to control hypoglycaemia in patients with endogenous hyperinsulinism who are not eligible for surgery; octreotide efficacy on hypoglycaemia could be predicted by a short 100 microg-octreotide test in patients with benign insulinomas, but was not correctly predicted by Octreoscan scintigraphy.
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Affiliation(s)
- D Vezzosi
- Department of Endocrinology, Centre Hospitalier Universitaire, Toulouse, France
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18
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Nesidioblastosis and hyperplasia of alpha cells, microglucagonoma, and nonfunctioning islet cell tumor of the pancreas: review of the literature. Pancreas 2008; 36:428-31. [PMID: 18437091 DOI: 10.1097/mpa.0b013e31815ceb23] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report a rare case of nesidioblastosis and hyperplasia of alpha cells, microglucagonoma, and nonfunctioning islet cell tumor of the pancreas. The patient's clinical presentation, diagnosis, treatment, pancreas pathology, and follow-up are reviewed. A 60-year-old patient was incidentally found to harbor a pancreatic mass with markedly elevated glucagon levels but without glucagonoma syndrome. She was initially diagnosed with glucagonoma, and the tumor was resected. Pathological examination demonstrated that the tumor was a nonfunctioning islet cell tumor and revealed nesidioblastosis and hyperplasia of alpha cells and microglucagonoma in the apparently normal surgical margin. The patient still had high postoperative glucagons levels which were suppressed by somatostatin analog treatment. No pancreatic tumors recurred 36 months after surgery. This is the third case of alpha-cell nesidioblastosis reported in the English literature. Nesidioblastosis and hyperplasia of alpha cells should be considered in the differential diagnosis of hyperglucagonemia. Somatostatin analog may be used to suppress glucagon secretion in alpha-cell hyperplasia.
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Abstract
Endocrine pancreatic tumors (EPTs) are uncommon, having an incidence of one per 100,000 people. They may appear as sporadic tumors or be associated with hereditary syndromes. EPTs are categorized as functioning or nonfunctioning tumors, based on the presence or absence of clinical syndromes. Among the former, insulinomas and gastrinomas are the most common. For the histopathological investigation of EPTs, chromogranin A and synaptophysin immunostainings are recommended. Measurement of circulating chromogranin A is also the cornerstone for the biochemical diagnosis of these tumors. Furthermore, specific hormones produced and released by the neoplastic cells can be identified by immunostaining and used for biochemical evaluation. To locate EPTs, both noninvasive (ultrasonography, computerized tomography, MRI and radionuclear imaging) and invasive techniques (arterial stimulation with venous sampling) can be used. Debulking procedures (surgery, radiofrequency ablation, embolization/chemoembolization and liver transplantation) and/or medical treatment (chemotherapy, biotherapy and peptide receptor radionuclide therapy) are the options available for the treatment of EPTs. Understanding the molecular events underlying the pathobiology of EPTs will aid the development of more accurate diagnostic/prognostic markers and give guidance for improved therapeutic modalities.
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Affiliation(s)
- Apostolos V Tsolakis
- a Department of Medical Sciences, Section of Endocrine Oncology, University Hospital, 751 85 Uppsala, Sweden.
| | - Eva T Janson
- b Department of Medical Sciences, Section of Endocrine Oncology, University Hospital, 751 85 Uppsala, Sweden.
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Delaunoit T, Neczyporenko F, Rubin J, Erlichman C, Hobday TJ. Medical management of pancreatic neuroendocrine tumors. Am J Gastroenterol 2008; 103:475-83; quiz 484. [PMID: 18028508 DOI: 10.1111/j.1572-0241.2007.01643.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNET) are rare malignancies frequently diagnosed at a late stage, with symptoms related to bulky disease. Hormonal secretion, when responsible for symptoms, permits, on the other hand, early diagnosis of the disease. Surgery remains the cornerstone of therapeutic management. However, due to advanced disease, many patients are not candidates for aggressive surgical therapy. Tumor growth control and symptom management are thus achieved through medical approaches, including somatostatin (SST) analogs, chemotherapy, interferon, and more recently, targeted therapy. The purpose of this review is to collect, examine, and analyze data available in the literature regarding contemporary therapeutic management of PNET, with emphasis on medical approaches. It also offers perspectives on the future of molecular targeted therapies in these neoplasms. However, we point out that much of the literature published to date includes noncomparative studies (mainly phase II studies), leading to thorny interpretation of the results. METHODS A systematic search of all the literature in English regarding PNET was performed, based on a MEDLINE search (Pubmed) carried out from January 1970 to May 2005. RESULTS Approximately 40 trials, including over 1,000 patients, have been retrieved from our MEDLINE search. SST analogs and interferon therapies do allow control over hormone secretion and subsequent symptoms in the majority of treated subjects, but offer a poor tumor growth control rate. Chemotherapies, although more efficient in reducing tumor burden, are often toxic. New approaches such as immunotherapy and targeted therapies are still under investigation. CONCLUSIONS Whether alone or in combination with surgery, conventional medical therapies represent a crucial aspect of PNET management. Hopefully, in the near future, a new era of antitumoral agents, such as targeted therapies, will strengthen our therapeutic arsenal, either alone or combined with other therapies.
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Affiliation(s)
- Thierry Delaunoit
- Molecular Medicine Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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21
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Ghaferi AA, Chojnacki KA, Long WD, Cameron JL, Yeo CJ. Pancreatic VIPomas: subject review and one institutional experience. J Gastrointest Surg 2008; 12:382-93. [PMID: 17510774 DOI: 10.1007/s11605-007-0177-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
VIPomas are rare pancreatic endocrine tumors associated with a well-defined clinical syndrome characterized by watery diarrhea, hypokalemia, and metabolic acidosis. The objective of this study was to review a single institution's experience with VIPomas, as well as to review the English literature. A retrospective review of the Johns Hopkins pancreatic database revealed four cases of VIPoma, with three patients being male. All patients presented with watery diarrhea, hypokalemia, hypercalcemia, and acidosis. All patients had no family history of multiple endocrine neoplasia. Computed tomography revealed the primary pancreatic tumor in all patients, with three tumors located in the tail of the pancreas. One tumor involved the entire pancreas. Computed tomography and/or octreotide radionuclide scans identified hepatic metastasis in three patients. Mean serum vasoactive intestinal polypeptide levels were 683 pg/ml (range 293 to 1,500 pg/ml). All patients underwent resection of the pancreatic primary tumor. Two patients also had simultaneous liver resections. All patients had evidence of malignancy as defined by the presence of metastatic lymph nodes and/or hepatic metastases. Two patients had complete resolution of symptoms after surgical resection. One patient required radioablation of liver metastases and adjuvant octreotide therapy for control of symptoms. One patient died of progressive metastatic disease 96 months after surgery, whereas the other three remain alive. Extended, meaningful survival can be achieved for VIPoma patients, combining an aggressive surgical approach with additional strategies for treatment of unresected disease.
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Affiliation(s)
- Amir A Ghaferi
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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22
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Usukura M, Yoneda T, Oda N, Yamamoto Y, Takata H, Hasatani K, Takeda Y. Medical treatment of benign insulinoma using octreotide LAR: a case report. Endocr J 2007; 54:95-101. [PMID: 17124362 DOI: 10.1507/endocrj.k05-157] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In some patients with insulinoma, surgery is not possible due to either difficulties in detecting the tumor or advanced age. These patients need medical treatment for hypoglycemia. We report a case of benign insulinoma using the long-acting octreotide formulation, octreotide long-acting repeatable (octreotide LAR), as a medical therapy. A 67-year-old woman was referred to our hospital for examinations of hypoglycemia. A blood sample taken during a hypoglycemic episode revealed low plasma glucose concentration, hyperinsulinemia and a high C-peptide level. An abdominal CT scan demonstrated a hypervascular tumor in the body of pancreas. She was diagnosed with insulinoma. As the patient refused surgical resection of the pancreas tumor, we started to use the somatostatin analogue, octreotide, for treatment of hypoglycemia. After the treatment her plasma glucose levels were elevated and serum immunoreactive insulin (IRI) levels were decreased. For long-term treatment, we changed the treatment from daily subcutaneous injection of octreotide to monthly intramuscular administration of octreotide LAR. This treatment was also effective and hypoglycemic attacks disappeared. Both plasma glucose levels and serum IRI levels were improved. Our case demonstrated that octreotide LAR was useful for long-term medical treatment of insulinoma.
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Affiliation(s)
- Mikiya Usukura
- Molecular Genetics of Cardiovascular Disorders, Graduate School of Medical Science, Kanazawa University, Japan
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23
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Gomez D, Malik H, Al-Mukthar A, Menon K, Toogood G, Lodge J, Prasad K. Hepatic resection for metastatic gastrointestinal and pancreatic neuroendocrine tumours: outcome and prognostic predictors. HPB (Oxford) 2007; 9:345-51. [PMID: 18345317 PMCID: PMC2225511 DOI: 10.1080/13651820701504199] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment modalities for hepatic metastases from neuroendocrine tumours (NETs) include surgery, somatostatin analogues and arterial embolization. The aims of this study were to evaluate the outcome of patients following surgery and to identify prognostic predictors of recurrent disease. PATIENTS AND METHODS This was a retrospective clinico-pathological analysis of patients managed with hepatic NET metastases over a 13-year period (January 1994 to December 2006). RESULTS Eighteen patients with hepatic metastases from NET were identified with a median age of 53 years (range 31-75). The localization of the primary tumour was the terminal ileum (n=8), pancreas (n=7), appendix (n=2) or duodenum (n=1). Twelve patients had synchronous disease and six patients developed metachronous hepatic tumours over a median period of 20 months (range 6-144). Presenting symptoms included abdominal pain (n =13), recurrent diarrhoea (n=7) and flushing (n=7). Fifteen patients underwent surgery with complete cytoreduction and three patients had partial cytoreduction. The overall 2- and 5-year actuarial survival rates were 94% and 86%, respectively. The 2- and 5-year disease-free rates following hepatic resection with complete cytoreduction were both 66%. Partial or complete control of endocrine-related symptoms was achieved in all patients with functioning tumours following surgery. Recurrent disease occurred in four patients following complete cytoreductive surgery. Resection margin involvement was associated with developing recurrent disease (p=0.041). CONCLUSION Surgical resection for hepatic NET metastases results in good long-term survival in selected patients and resection margin involvement was associated with recurrent disease.
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Affiliation(s)
- D. Gomez
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - H.Z. Malik
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - A. Al-Mukthar
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - K.V. Menon
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - G.J. Toogood
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - J.P.A. Lodge
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - K.R. Prasad
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS TrustLeedsUK
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24
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Robben JH, van den Brom WE, Mol JA, van Haeften TW, Rijnberk A. Effect of octreotide on plasma concentrations of glucose, insulin, glucagon, growth hormone, and cortisol in healthy dogs and dogs with insulinoma. Res Vet Sci 2006; 80:25-32. [PMID: 15946716 DOI: 10.1016/j.rvsc.2005.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 03/04/2005] [Accepted: 03/17/2005] [Indexed: 12/18/2022]
Abstract
The inhibitory effect of the somatostatin analogue octreotide on the secretion of insulin could be used in the treatment of insulinoma. However, current information on the effectiveness of octreotide in dogs is conflicting. Therefore, the endocrine effects of a single subcutaneous dose of 50 microg octreotide were studied in healthy dogs in the fasting state (n=7) and in dogs with insulinoma (n=12). Octreotide did not cause any adverse effects. In healthy dogs in the fasting state, both plasma insulin and glucagon concentrations declined significantly. Basal (non-pulse related) GH and ACTH concentrations were not affected. A slight but significant decrease in the plasma glucose concentrations occurred. Dogs with insulinoma had significantly higher baseline insulin concentrations and lower baseline glucose concentrations than healthy dogs in the fasting state. Plasma glucagon, GH, ACTH, and cortisol concentrations did not differ from those in healthy dogs. Baseline plasma insulin concentrations decreased significantly in dogs with insulinoma after octreotide administration, whereas plasma concentrations of glucagon, GH, ACTH, and cortisol did not change. In contrast to the effects in the healthy dogs, in the dogs with insulinoma plasma glucose concentrations increased. Thus, the consistent suppression of plasma insulin concentrations in dogs with insulinoma, in the absence of an suppressive effect on counter-regulatory hormones, suggests that further studies on the effectiveness of slow-release preparations in the long-term medical treatment of dogs with insulinoma are warranted.
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Affiliation(s)
- J H Robben
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, P.O. Box 80.154, NL-3508 TD, Utrecht, The Netherlands.
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25
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Abstract
Endocrine pancreatic tumours (EPTs) are uncommon tumours occurring in approximately 1 in 100,000 of the population, representing 1-2% of all pancreatic neoplasms. Some of the tumours may be part of multiple endocrine neoplasia type one (MEN-1) syndrome or von Hippel-Lindau (vHL) disease. EPTs are classified as functioning or non-functioning tumours on the basis of their clinical manifestation. The biochemical diagnosis of EPT is based on hormones and amines released. Besides specific markers such as insulin, there are also general tumour markers such as chromogranin A, which is the most valuable marker and has been reported to be increased in plasma in 50-80% of patients with EPTs and correlates with tumour burden. The location of endocrine tumours of the pancreas includes different techniques, from endoscopic investigations to scintigraphy (e.g. somatostatin receptor scintigraphy) and positron emission tomography. The medical treatment of endocrine pancreatic tumours consists of chemotherapy, somatostatin analogues and alpha-interferon. None of these can cure a patient with malignant disease. In future, therapy will be custom-made and based on current knowledge of tumour biology and molecular genetics.
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Affiliation(s)
- Kjell Oberg
- Department of Medical Sciences, University Hospital, 751 85 Uppsala, Sweden.
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26
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Katabami T, Kato H, Shirai N, Naito S, Saito N. Successful long-term treatment with once-daily injection of low-dose octreotide in an aged patient with insulinoma. Endocr J 2005; 52:629-34. [PMID: 16284444 DOI: 10.1507/endocrj.52.629] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The patient was an 83-year-old woman who was admitted to our hospital for evaluation and treatment of chronic hypoglycemia that was first identified 3 years earlier. Serum insulin and C-peptide levels were both elevated during hypoglycemia. Contrast abdominal computed tomography revealed a tumor in the body of the pancreas with blushing during the early phase, and insulinoma was diagnosed. The patient declined surgery because of advanced age, so treatment was started with octreotide, a somatostatin analogue. Hypoglycemia has been successfully controlled with low-dose, once-daily octreotide over 33 months. Few reports have described long-term octreotide administration for benign insulinoma. Moreover, this case is interesting from the perspective of hypoglycemic control using only low-dose, once-daily octreotide. Although somatostatin may induce hypoglycemia in insulinoma, treatment may be useful in patients who are not candidates for surgery, provided that careful monitoring is maintained.
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Affiliation(s)
- Takuyuki Katabami
- Department of Internal Medicine, Division of Metabolism and Endocrinology, St. Marianna University School of Medicine, Kawasaki, Japan
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27
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Hirshberg B, Cochran C, Skarulis MC, Libutti SK, Alexander HR, Wood BJ, Chang R, Kleiner DE, Gorden P. Malignant insulinoma: spectrum of unusual clinical features. Cancer 2005; 104:264-72. [PMID: 15937909 PMCID: PMC4136659 DOI: 10.1002/cncr.21179] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant insulinoma occurs in a few patients with insulinoma. Due to the small sample of patients, there are little data regarding their clinical manifestation as well as the preferred treatment modalities. The aims of the current study were to summarize the National Institutes of Health experience during the last two decades and to conduct a critical review of the current literature. METHODS The authors identified 10 patients with metastatic insulinoma. RESULTS The patients presented with four patterns of clinical behavior. First, four patients presented with lymph node metastasis and, after surgical excision, maintained a prolonged tumor-free survival. Second, four patients presented with metastatic disease to the liver, which appeared years after the initial diagnosis and presumed curative surgery. Third, one patient presented with a large alpha-fetoprotein-secreting liver mass. Finally, 9 of the 10 patients had a prolonged survival. Various treatment modalities were used to control hypoglycemia. Short-term benefits were most often achieved with embolization and diazoxide. Less successful modalities included radiofrequency ablation, radical debulking surgery, verapamil therapy, octreotide therapy, and chemotherapy. CONCLUSIONS The current study, as well as others, suggested that metastatic insulinoma may have a variable natural history. After the initial surgical resection, the biology of the tumor, rather than any treatment modality, was most likely the major determinant of long-term survival.
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Affiliation(s)
- Boaz Hirshberg
- Division of Intramural Research, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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28
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Shah T, Caplin M. Endocrine tumours of the gastrointestinal tract. Biotherapy for metastatic endocrine tumours. Best Pract Res Clin Gastroenterol 2005; 19:617-36. [PMID: 16183531 DOI: 10.1016/j.bpg.2005.02.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Somatostatin analogues have been the mainstay of symptomatic management of patients with neuroendocrine tumours (NETs) for two decades with the main mechanism of action being inhibition of peptide release. Evidence base for interferon use is perhaps less clear. It may contribute to symptom control by abrogating peptide release, and there is some evidence that it has an anti-proliferative action. Combination of somatostatin analogues and interferon provides symptom control, mainly by effecting a reduction in the amount of circulating, physiologically active, peptide hormones. Treatment can also provide disease stabilisation in a proportion of patients. In a minority of patients treatment may lead to partial response.
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Affiliation(s)
- Tahir Shah
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, Royal Free Hospital, London, UK
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29
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Plöckinger U, Wiedenmann B. Endocrine tumours of the gastrointestinal tract. Management of metastatic endocrine tumours. Best Pract Res Clin Gastroenterol 2005; 19:553-76. [PMID: 16183527 DOI: 10.1016/j.bpg.2005.02.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Gastroenteropancreatic tumours are rare. They compromise a heterogenous class of neoplasm. If there is no hypersecretion syndrome, symptoms may be uncharacteristic and thus diagnosis occurs rather late after the first manifestations of the disease. The most important prognostic parameters are histological classification, the localisation of the primary, the tumour size and stage at diagnosis, and the presence or absence of metachronous or synchronous neoplasia. The article will focus on the importance of each of these parameters for the various treatment options in patients with metastatic disease.
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Affiliation(s)
- U Plöckinger
- Interdisziplinäres Stoffwechsel-Centrum: Endokrinologie, Diabetes und Stoffwechsel, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Charité Universitätsmedizin Berlin, Campus-Virchow-Klinikum, Germany.
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30
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Abstract
During the last decade significant advances in gene therapy have made it possible to treat various pancreatic disorders in both animal models and in humans. For example, insulin gene delivery to non-beta-cell tissues has been shown to reverse hyperglycemia in diabetic mice, and islet transplantation, based on in vitro differentiation of beta cells and concomitant gene targeting to prevent host autoimmune responses, has become more feasible. Additionally, introduction of the glucokinase regulatory protein and protein kinase C-zeta have been shown to improve glucose tolerance in non-insulin-dependent diabetes mellitus animal models. Pancreatic cancer studies utilize several DNA-based strategies for tumor treatment including introduction of tumor suppressor genes, suppression of oncogenes, suicide gene/prodrug therapy, and restricted replication-competent virus therapy. Tumor-specific targeting is an important part of suicide gene therapy, and tumor-specific promoters are used for cell-specific targeting. Tumor-specific suicide gene therapy directed by the rat insulin promoter has been used to eliminate insulinoma tumors in a mouse model. This review compiles a compendium of information related to the treatment of pancreatic disorders using gene therapy.
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Affiliation(s)
- Kiichi Tamada
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030, USA
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31
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Delaunoit T, Rubin J, Neczyporenko F, Erlichman C, Hobday TJ. Somatostatin analogues in the treatment of gastroenteropancreatic neuroendocrine tumors. Mayo Clin Proc 2005; 80:502-6. [PMID: 15819288 DOI: 10.4065/80.4.502] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Gastroenteropancreatic neuroendocrine tumors constitute a heterogeneous group of neoplasms that are often associated with typical symptoms due to excessive and uncontrolled release of diverse hormones. Because these tumors are usually slow growing, surgery is the cornerstone of treatment. However, these rare tumors can present with rapid progression that requires aggressive systemic therapy or diffuse metastatic disease not amenable to surgical palliation. For most patients, medical approaches are necessary at some point in the course of their disease, especially since most tumors are at an advanced stage at the time of diagnosis. Most gastroenteropancreatic neuroendocrine tumors express high levels of somatostatin receptors, which are bound by somatostatin or its synthetic analogues. These agents, alone or combined with other therapies, such as Interferon or radioisotopes, are therefore used frequently to control hormone-related symptoms and, for some patients, the growth of the disease Itself. This article reviews the evidence for the use of somatostatin analogues in the treatment of gastroenteropancreatic neuroendocrine tumors based on a MEDLINE search of literature published from January 1970 to July 2003.
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Affiliation(s)
- Thierry Delaunoit
- Department of Oncology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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32
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Kouvaraki MA, Solorzano CC, Shapiro SE, Yao JC, Perrier ND, Lee JE, Evans DB. Surgical treatment of non-functioning pancreatic islet cell tumors. J Surg Oncol 2005; 89:170-85. [PMID: 15719379 DOI: 10.1002/jso.20178] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pancreatic endocrine tumors (PETs) are rare neoplasms originating from the amine precursor uptake and decarboxylation (APUD) stem cells. Although the majority of PETs are sporadic, they frequently occur in familial syndromes. PETs may cause a variety of functional syndromes or symptoms of local progression if they are non-functional. General neuroendocrine tumor markers are highly sensitive in the diagnostic assessment of a PET. Imaging studies for tumor localization and staging include computer tomography (CT) scan, magnetic resonance imaging (MRI), In(111)-octreotide scan, MIBG, and endoscopic ultrasonography (EUS). Treatment of PETs often requires a multi-modality approach; however, surgical resection remains the only curative therapy for localized (non-metastatic) disease. Treatment of metastatic disease includes biologic agents, cytotoxic chemotherapy, and liver-directed therapies.
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Affiliation(s)
- Maria A Kouvaraki
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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33
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Kouvaraki MA, Ajani JA, Hoff P, Wolff R, Evans DB, Lozano R, Yao JC. Fluorouracil, doxorubicin, and streptozocin in the treatment of patients with locally advanced and metastatic pancreatic endocrine carcinomas. J Clin Oncol 2005; 22:4762-71. [PMID: 15570077 DOI: 10.1200/jco.2004.04.024] [Citation(s) in RCA: 387] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The role of systemic chemotherapy in the management of pancreatic endocrine carcinoma (islet cell carcinoma; PEC) is an area of considerable controversy. Response rates ranging from 6% to 69% have been reported for streptozocin-based chemotherapy. We retrospectively studied 84 patients with locally advanced or metastatic PEC who had been treated with fluorouracil, doxorubicin, and streptozocin (FAS) to determine the objective response rate, duration of progression-free survival (PFS), and duration of overall survival (OS). PATIENTS AND METHODS Eligible patients had histologic or cytologic confirmation of their tumor and measurable disease on computed tomography or magnetic resonance imaging scans. Response to treatment was evaluated in this study using the new international criteria proposed by the Response Evaluation Criteria in Solid Tumors Committee. RESULTS Sixty-one of the patients were male and 23 were female, with a median age of 54 years (range, 24 to 78 years). The response rate (RR) to FAS was 39%, with a median response duration of 9.3 months. The 2-year PFS rate was 41%, and the 2-year OS rate was 74%. The extent of liver metastatic disease correlated with a worse PFS (P = .01 by log-rank test) and a worse OS (P < .0001 by log-rank test). Analyses showed that metastatic replacement of more than 75% of the liver and prior chemotherapy were independently associated with inferior PFS. CONCLUSION Patients with locally advanced or metastatic PEC who are treated with FAS may have a reasonable RR, and responders may experience longer PFS and OS. The volume of metastases in the liver is the most important predictor of outcome.
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Affiliation(s)
- Maria A Kouvaraki
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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34
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Pratz KW, Ma C, Aubry MC, Vrtiska TJ, Erlichman C. Large cell carcinoma with calcitonin and vasoactive intestinal polypeptide-associated Verner-Morrison syndrome. Mayo Clin Proc 2005; 80:116-20. [PMID: 15667039 DOI: 10.1016/s0025-6196(11)62968-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Verner-Morrison syndrome, characterized by diarrhea, hypokalemia, and hypochlorhydria, is caused most commonly by vasoactive intestinal polypeptide-secreting islet cell tumors of the pancreas. Verner-Morrison syndrome has not been described as a paraneoplastic syndrome in non-small cell lung cancer. We describe a 38-year-old man with metastatic non-small cell lung cancer of large cell carcinoma with neuroendocrine differentiation who presented with bone metastasis and intractable secretory diarrhea that was unresponsive to pharmacological treatment, including octreotide. Laboratory evaluation indicated elevated serum calcitonin and vasoactive intestinal polypeptide levels. Chemotherapy resulted in a transient response in the patient's diarrhea and neuroendocrine markers. The patient did not respond to further therapy and died 5 months after onset of back pain. To our knowledge, this is the first published case of large cell carcinoma with neuroendocrine differentiation associated with treatment-responsive paraneoplastic Verner-Morrison syndrome.
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Affiliation(s)
- Keith W Pratz
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
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35
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Sarmiento JM, Heywood G, Rubin J, Ilstrup DM, Nagorney DM, Que FG. Surgical treatment of neuroendocrine metastases to the liver: a plea for resection to increase survival. J Am Coll Surg 2003; 197:29-37. [PMID: 12831921 DOI: 10.1016/s1072-7515(03)00230-8] [Citation(s) in RCA: 514] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic metastases from neuroendocrine tumors have a protracted natural history and are associated with endocrinopathies. Resection is indicated for symptom control. Previous reports have suggested improvement in survival for patients undergoing debulking procedures. STUDY DESIGN The records of all consecutive patients undergoing resection of hepatic metastases from neuroendocrine tumors between 1977 and 1998 were reviewed. Tumors were classified according to histology, endocrine activity, and primary location. Patients lost to followup before 1 year were excluded. Followups were based on outpatient evaluations and were updated by correspondence. The Kaplan-Meier method was used to generate survival and recurrence curves, and the log-rank test was used for comparison. RESULTS A total of 170 patients fulfilled the inclusion criteria, of whom 73 were men. Mean age (+/-SD) was 57 (+/-11.5) years. Carcinoid (n = 120) and nonfunctioning islet cell tumors (n = 18) predominated; the ileum (n = 85) and the pancreas (n = 52) were the most common primary sites. Major hepatectomy (one or more lobes) was performed in 91 patients (54%). The postoperative complication rate was 14%, and two patients died (1.2%). Operation controlled symptoms in 104 of 108 patients, but the recurrence rate at 5 years was 59%. Operation decreased 5-hydroxyindoleacetic acid levels considerably, and no patient experienced carcinoid heart disease postoperatively. Recurrence rate was 84% at 5 years. Overall survival was 61% and 35% at 5 and 10 years, respectively, with no difference between carcinoid and islet cell tumors. CONCLUSIONS Hepatic resection for metastatic neuroendocrine tumors is safe and achieves symptom control in most patients. Debulking extends survival, although recurrence is expected. Hepatic resection is justified by its effects on survival and quality of life.
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Affiliation(s)
- Juan M Sarmiento
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Fjällskog ML, Sundin A, Westlin JE, Oberg K, Janson ET, Eriksson B. Treatment of malignant endocrine pancreatic tumors with a combination of alpha-interferon and somatostatin analogs. Med Oncol 2002; 19:35-42. [PMID: 12025889 DOI: 10.1385/mo:19:1:35] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Somatostatin analogs and alpha-interferon induce good responses as single drugs in the treatment of endocrine pancreatic tumors. We examined the efficacy and tolerability of the combination of alpha-interferon and somatostatin analogs in 16 patients with metastatic endocrine pancreatic tumors. All patients except one had received prior treatment and were in a progressive state. Doses of alpha-interferon and somatostatin analogs were individually titrated. The alpha-interferon doses varied between 9 and 25 million units per week and were combined with 100-1500 microg of octreotide or 6000 microg of lanreotide daily. Radiological response was seen in 3 of 16 (19%) patients (median duration 23 mo). Biochemical response was seen in 10 of 16 (62.5%) patients (median duration 22 mo). All three patients previously progressing on both alpha-interferon and somatostatin analog as single drugs achieved a stabilization of the disease when treated with the combination (median duration 10 mo). Seven of eight (88%) patients previously progressing on alpha-interferon treatment benefited from the combination with biochemical partial response or stabilization. All six patients previously progressing during somatostatin analog treatment achieved biochemical partial response or stabilization. More than 80% of patients who progressed during previous treatment with either drug benefited from the combined treatment, which also was well tolerated. Thus, a combination of alpha-interferon and somatostatin analogs may be considered for patients previously progressing on treatment with alpha-interferon or somatostatin analogs. However, in this study, the value of sequential treatment has not been evaluated.
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Affiliation(s)
- M L Fjällskog
- Department of Medical Sciences, University Hospital, Uppsala, Sweden.
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Shojamanesh H, Gibril F, Louie A, Ojeaburu JV, Bashir S, Abou-Saif A, Jensen RT. Prospective study of the antitumor efficacy of long-term octreotide treatment in patients with progressive metastatic gastrinoma. Cancer 2002; 94:331-43. [PMID: 11900219 DOI: 10.1002/cncr.10195] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Malignant pancreatic endocrine tumors (PETs) have a poor prognosis and existing antitumor treatments are unsatisfactory. Recent studies have shown somatostatin analogues to have antitumor growth effects in patients with malignant PETs; however, to the authors' knowledge, little information exists regarding their efficacy or effect on survival in patients with progressive malignant gastrinoma, the most common symptomatic malignant PET. The purpose of the current study was to study prospectively the efficacy, safety, and effect on survival of long-term treatment with octreotide in consecutive patients with progressive malignant gastrinoma. METHODS Fifteen consecutive patients with malignant gastrinoma with progressive hepatic metastases were studied. All patients underwent conventional imaging studies (computed tomography scan, magnetic resonance imaging, ultrasound, and, if needed, selective angiography) and somatostatin receptor scintigraphy prior to treatment and at 3-6-month intervals while receiving treatment. The patients all were treated initially with octreotide, 200 microg every 12 hours, and at last follow-up were being maintained on long-acting release octreotide, 20-30 mg every month. Tumor size and/or number were used to classify patient responses as either no tumor response or tumor response (stabilization or decrease in size). Treatment response was correlated with tumor and clinical characteristics. RESULTS Tumors in 8 of the 15 patients studied (53%) responded at 3 months, with 47% (7 of 15 patients) demonstrating tumor stabilization and 6% (1 of 15 patients) demonstrating a decrease in tumor size. The mean duration of response was 25.0+/-6.1 months (range, 5.5-54.1 months). Six of the eight responders were continuing to respond at the time of last follow-up. Tumor response did not correlate with any clinical parameter (e.g., tumor extent, fasting gastrin, or acid secretory rates). However, slow-growing tumors were more likely to respond prior to treatment (86% vs. 0%) (P < 0.0014). During follow-up (range, 4-8 years), 25% of the responders died compared with 71% of the nonresponders, a difference that approached statistical significance (P = 0.10). Two patients (13%) developed serious side effects that required the withdrawal of octreotide. CONCLUSIONS Octreotide is an effective antitumor treatment in patients with progressive malignant gastrinoma. In approximately 50% of these patients octreotide has an antigrowth effect; treatment is associated with a low incidence of serious side effects compared with other antitumor treatments commonly used and, in contrast to many studies, the growth response is long-lasting. The results of the current study suggest that octreotide treatment should replace chemotherapy as the standard treatment for these patients, especially those patients with slow-growing tumors. Additional studies involving larger numbers of patients will be needed to determine a convincing effect on survival.
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Affiliation(s)
- Homayoun Shojamanesh
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892-1804, USA
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Abstract
Pancreatic endocrine tumours (PET) are rare but nonetheless important to recognize and treat in a timely fashion. Significant morbidity occurs due to excess secretion of hormones, with all of the PET having some degree of malignant potential. Surgeons must plan directed operative strategies to deal with these tumours and be prepared to undertake aggressive palliative debulking resections if indicated. Somatostatin receptor scintigraphy and endoscopic ultrasound have been particularly helpful in both localizing and staging patients with PET. Other important advances in management include the use of long-acting somatostatin analogues to inhibit hormonal secretion and tumour growth. The possibility of multiple endocrine neoplasia type 1 (MEN-1) should be considered in any patient with a PET. The present article will review the various classes of PET, describe MEN-1 in relation to PET and examine advances in imaging and localization. The role of surgery for PET is also discussed in the present review.
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Affiliation(s)
- M H Mullan
- Department of Surgery, Division of Endocrine Surgery, University of Michigan Hospital, Ann Arbor 48109-0331, USA
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Chamberlain RS, Canes D, Brown KT, Saltz L, Jarnagin W, Fong Y, Blumgart LH. Hepatic neuroendocrine metastases: does intervention alter outcomes? J Am Coll Surg 2000; 190:432-45. [PMID: 10757381 DOI: 10.1016/s1072-7515(00)00222-2] [Citation(s) in RCA: 492] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In most instances, advanced neuroendocrine tumors follow an indolent course. Hepatic metastases are common, and although they can cause significant pain, incapacitating endocrinopathy, and even death, they are usually asymptomatic. The appropriate timing and efficacy of interventions, such as hepatic artery embolization (HAE) and operation, remain controversial. STUDY DESIGN The records of 85 selected patients referred for treatment of hepatic neuroendocrine tumor metastases between 1992 and 1998 were reviewed from a prospective database. A multidisciplinary group of surgeons, radiologists, and oncologists managed all patients. Overall survival among this cohort is reported and prognostic variables, which may be predictive of survival, are analyzed. RESULTS There were 37 men and 48 women, with a median age of 52 years. There were 41 carcinoid tumors, 26 nonfunctional islet cell tumors, and 18 functional islet cell tumors. Thirty-eight patients had extrahepatic metastases, and in 84% of patients, the liver metastases were bilobar. Eighteen patients were treated with medical therapy or best supportive care, 33 patients underwent HAE, and 34 patients underwent hepatic resection. Both the HAE-related mortality and the 30-day operative mortality rates were 6%. By univariate analysis, earlier resection of the primary tumor, curative intent of treatment, and initial surgical treatment were associated with prolonged survival (p < 0.05). On multivariate analysis, only curative intent to treat remained significant (p < 0.04). Patients with bilobar or more than 75% liver involvement by tumor were least likely to benefit from surgical resection. One-, 3-, and 5-year survival rates for the entire group were 83%, 61%, and 53%, respectively. The 1-, 3-, and 5-year survivals for patients treated with medical therapy, HAE, and operation were 76%, 39%, and not available; 94%, 83%, and 50%; and 94%, 83%, and 76%, respectively. CONCLUSIONS Hepatic metastases from neuroendocrine tumors are best managed with a multidisciplinary approach. Both HAE and surgical resection provide excellent palliation of hormonal and pain symptoms. In select patients, surgical resection of hepatic metastases may prolong survival, but is rarely curative.
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Affiliation(s)
- R S Chamberlain
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Eriksson B, Oberg K. Summing up 15 years of somatostatin analog therapy in neuroendocrine tumors: future outlook. Ann Oncol 1999; 10 Suppl 2:S31-8. [PMID: 10399030 DOI: 10.1093/annonc/10.suppl_2.s31] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Neuroendocrine gastrointestinal tumors express somatostatin receptors (ssts) in 80%-90% of cases and somatostatin analogs have become increasingly important in the management of these patients. Most of the presently available somatostatin analogs (octreotide, RC-160, and lanreotide) bind to the sst2 and sst5, and in higher doses to sst3 of the ssts 1-5 described. Clinical improvement during somatostatin analog therapy is mainly mediated via a direct inhibitory effect on hormone production from the tumors, seen in 30%-70% of the patients. Also indirect non-tumor mediated effects on peripheral target organs contribute to the subjective improvement, achieved in 30%-70% of patients. Recently, significant improvement of quality of life has been demonstrated with long-acting depot formulations. There is little or no effect on tumor growth during octreotide therapy; tumor shrinkage has been reported in 10%-20% of patients, but stabilization of tumor growth can be achieved in about half of the patients with a duration of 8-16 months. Recently, induction of apoptosis has been described with high doses of lanreotide (12 mg/d). Eventually, however, all patients escape from somatostatin analog therapy with regard both to hormonal production and tumor growth, and the mechanism behind the tachyphylaxis is not yet known. Studies of optimal dosage and modes of administration, development of new slow release formulations, the potential value of high-dose somatostatin analog therapy and novel somatostatin receptor subtype specific analogs are important directions for the use of somatostatin analogs in the future. In addition, assessment of somatostatin receptor status for each patient and studies of tumor biology, e.g., inhibition of exocytosis, antiproliferative effects and induction of apoptosis during treatment will help to optimize treatment and provide new insights into mechanisms of action of somatostatin analogs.
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Affiliation(s)
- B Eriksson
- Department of Endocrine Oncology, University Hospital, Uppsala, Sweden.
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Frank M, Klose KJ, Wied M, Ishaque N, Schade-Brittinger C, Arnold R. Combination therapy with octreotide and alpha-interferon: effect on tumor growth in metastatic endocrine gastroenteropancreatic tumors. Am J Gastroenterol 1999; 94:1381-7. [PMID: 10235222 DOI: 10.1111/j.1572-0241.1999.01090.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We investigated the antiproliferative efficacy of the addition of alpha-interferon to the somatostatin analogue octreotide in patients with metastasized gastroenteropancreatic tumors unresponsive to octreotide monotherapy. METHODS In an open prospective trial, 21 patients with metastasized neuroendocrine gastroenteropancreatic tumors (nine patients with carcinoid syndrome, eight with nonfunctioning tumors, four with gastrinoma) were treated with 5 x 10(6) IU alpha-interferon tiw in addition to 200 microg of octreotide tid. All patients, including 16 patients with preceding monotherapy with 200 microg of octreotide tid, had tumor progression documented by computed tomography before entering the study. Growth response (computed tomography documented) and biochemical response were assessed at 3-month intervals. RESULTS Inhibition of tumor growth was observed in 14 patients (67%), 11 of whom had preceding octreotide monotherapy; complete regression was observed in one patient lasting for 49 months and stable disease (stand-still) in 13 patients lasting for 3 to 52 months (median, 12 months). Seven patients failing this combination therapy exhibited a significantly shorter overall survival (median, 23 months; range, 5 to 42 months) than the 14 patients responding to this regimen (median, 68 months; range, 12 to 112 months; p = 0.007). Two patients are still alive. Biochemical response was achieved in 69% of patients with functioning tumors: in three of four patients with gastrinoma and in six of nine patients with carcinoid syndrome. CONCLUSIONS These data suggest that the addition of alpha-interferon to octreotide has antiproliferative efficacy in a subgroup of patients with advanced metastatic disease unresponsive to octreotide monotherapy. Prolonged survival was seen in the responder group.
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Affiliation(s)
- M Frank
- Department of Internal Medicine, Philipps University, Marburg, Germany
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Pelley RJ, Bukowski RM. Recent advances in systemic therapy for gastrointestinal neuroendocrine tumors. Curr Opin Oncol 1999; 11:32-7. [PMID: 9914875 DOI: 10.1097/00001622-199901000-00008] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Neuroendocrine tumors of the gastrointestinal tract are rare tumors which can be classified as amine precursor uptake and decarboxylation tumors (APU-Domas). Although the majority of clinically apparent tumors are malignant, they are frequently slow growing. Despite this characteristic, they may generate disabling hormonal syndromes requiring aggressive treatment to achieve palliation. Recent advances in understanding the pathophysiology of these tumors has led to better medical therapy with chemotherapeutic agents, somatostatin analogues, and biologic therapies. This review will update the recent efforts in systemic therapies of the gastrointestinal neuroendocrine tumors.
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Affiliation(s)
- R J Pelley
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Ohio 44195, USA
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Smith SL, Branton SA, Avino AJ, Martin JK, Klingler PJ, Thompson GB, Grant CS, van Heerden JA. Vasoactive intestinal polypeptide secreting islet cell tumors: a 15-year experience and review of the literature. Surgery 1998; 124:1050-5. [PMID: 9854582 DOI: 10.1067/msy.1998.92005] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Vasoactive intestinal polypeptide (VIP)-secreting tumors of the pancreas represent a rare subtype of pancreatic islet cell tumors with an estimated incidence of 0.2 to 0.5 per million per year. We provide data on a relatively large series of patients with VIP-secreting tumors and review current literature regarding this specific entity. METHODS A retrospective review was performed of all patients with VIP-secreting tumors of the pancreas treated from 1977 to 1992 at our institution. Presenting signs, symptoms, mode of diagnosis, extent of disease, surgical resectability, tumor size, treatments, hormone levels, and survival were assessed. RESULTS Eighteen patients were identified, 9 male and 9 female. Ages ranged from 23 to 74 years (mean 51 years). Secretory diarrhea was the most common symptom, occurring in 16 of 18 patients (89%). The most common tumor location was the tail of the pancreas (9 patients). Fourteen patients (78%) had liver metastasis at diagnosis. Curative resections were attempted in only 5 patients (28%). The mean survival was 3.6 years with the longest disease-free survival being 15 years and longest overall survival 15 years. CONCLUSIONS VIP-secreting tumors are extremely rare entities and usually metastatic at the time of diagnosis. Despite advanced disease, these patients can have extended survival.
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Affiliation(s)
- S L Smith
- Department of Surgery, Mayo Clinic, Jacksonville, Fla. 32224, USA
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45
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Abstract
Insulinomas are a relatively rare tumour which occur predominantly in the pancreas. The majority of the tumours are benign, but have profound effects upon the patient. The diagnosis of insulinoma is often elusive, and the management may involve demanding surgery with a significant morbidity. In this review article, all clinical aspects of insulinomas are examined. Particular emphasis is placed on the myriad modes of presentation, and the methods used to localise the tumour pre-operatively. Medical, as well as surgical treatments are discussed and their role in the management of both malignant and benign tumours. Despite potential difficulties encountered in managing patients with this tumour, a large majority may be either cured or achieve useful palliation.
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Affiliation(s)
- R D Bliss
- Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, U.K
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Abstract
In a limited number of case reports in infants, octreotide raised the blood glucose concentrations and decreased glucose requirements sufficiently to avoid pancreatectomy. This response occurs in the presence of frequent feedings and diazoxide therapy, and lasts from 1 month to greater than 5 years. As expected, octreotide reduces growth indices such as growth factors and growth rate in short-term assessment. However, an insufficient sample size, a lack of follow-up, and poor study design provide inconclusive data. Among the few case reports in adults with benign or malignant insulinoma, octreotide can significantly raise blood glucose concentrations. In long-term follow-up, octreotide has alleviated or reduced the frequency of hypoglycemic episodes for periods of 5 months to 2.5 years. Octreotide was administered subcutaneously in regimens of 100-1500 micrograms in three to four divided doses or as a continuous infusion. Continuous subcutaneous infusion may be attempted in patients intolerant to intermittent administration. Octreotide may worsen existing hypoglycemia as result of suppressing glucagon and growth hormone in the presence of unresponsive pancreatic hyperinsulinism. While the long-term effects of growth remain undetermined, current findings suggest octreotide may provide a reasonable addition or alternative to diazoxide in controlling symptoms of congenital hyperinsulinism. Octreotide may be useful in management of hypoglycemic symptoms in adult patients requiring medical treatment for insulinoma who are refractory or intolerant of diazoxide. Additional long-term studies are needed to address the cost effectiveness of octreotide therapy, identify patients most likely to respond, and determine the impact of octreotide on height.
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Affiliation(s)
- R W Barrons
- College of Pharmacy, Xavier University Drug Information Center, Tulane University Hospital and Clinics, Xavier University of Louisiana, New Orleans 70112, USA
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Abstract
Since the description of the Zollinger-Ellison syndrome in two patients in 1955, there have been significant advances in the understanding of its pathogenesis, natural history, relationship to multiple endocrine neoplasia type 1, diagnosis, methods of tumour localization and management. The main focus in treatment is now shifting from management of the gastric acid hypersecretory state which can now be controlled medically in almost every patient, to the management of the gastrinoma. Recent studies are beginning to provide insights into the natural history of gastrinomas, factors that are associated with invasiveness in some gastrinomas, defining the role of surgery in managing patients with different disease extents, or with MEN 1 and being able to provide insights into molecular abnormalities that may be important in their pathogenesis. In this article each of these advances is briefly reviewed with emphasis primarily on recent advances.
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Affiliation(s)
- R T Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20891, USA
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Arnold R, Frank M. Gastrointestinal endocrine tumours: medical management. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1996; 10:737-59. [PMID: 9113320 DOI: 10.1016/s0950-3528(96)90021-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
With the introduction of longer-acting somatostatin analogues symptomatic relief is easy to achieve in patients with functionally active endocrine tumours and will be further facilitated by still longer-acting formulations. The consequences of gastric acid hypersecretion in patients with Zollinger-Ellison syndrome can be prevented by all proton-pump inhibitors currently on the market. Despite the various antiproliferative strategies that have been offered to patients with metastatic disease, available data are controversial and, more importantly, are supported by few prospective and controlled studies. Most experts agree that surgery with curative extirpation of the primary in the absence of metastases and tumour debulking in metastatic disease should be intended wherever possible. Controversy concerns residual disease. According to our view, any further antiproliferative strategy should consider the growth characteristics and biology of a given tumour (Figure 4). In the case of rapid progression, chemotherapy should be offered if tumours originate from the pancreas or reveal an undifferentiated histology. In contrast, chemotherapy should not be offered to patients with well-differentiated non-functional or functional tumours (carcinoid syndrome) arising from the intestine. The same applies for patients with tumours with no or only slow growth within an given observation period of 3-12 months. These patients should be treated only symptomatically. Patients with tumours of slow progression might favourably respond to long-acting somatostatin analogues. We start with octreotide and offer patients not responding to octreotide monotherapy additional IFN alpha. If further tumour progression takes place, hepatic artery embolization is the next step (Figure 5) followed by chemotherapy, the latter in patients with tumours of pancreatic origin only. This strategy recognizes the severity of side-effects of the different therapeutic modalities and starts with octreotide because of its very few side-effects. Other groups start with chemoembolization followed by octreotide, alpha-interferon or its combinations (Ahlman et al, 1996). Ongoing studies will, it is hoped, answer the question of the ideal sequence of therapeutic strategies. Every available patient with metastasised gastrointestinal endocrine tumours should be included in one of the ongoing European multicentre trials.
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Affiliation(s)
- R Arnold
- Department of Internal Medicine, Philipps University Marburg, Germany
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49
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Abstract
Neuroendocrine gut and pancreatic tumours have provided a diagnostic and therapeutic challenge over the years. These rather slowly growing neoplasms have been assigned a good prognosis but when liver metastases are present the prognosis is not better than that of most other malignant tumours. Despite the development of improved diagnostic procedures many patients are still referred at a stage of the disease too late for surgical cure, at which time medical treatment is warranted. The diagnosis is based on histopathological diagnosis including silver stainings (Grimelius, Masson) and immunohistochemistry for chromogranin A and synaptophysin. Analysis of chromogranin A in the plasma is an important adjunct in the screening for various types of neuroendocrine gut and pancreatic tumours. About 80%-100% of patients with verified neuroendocrine gastrointestinal tumours have elevated circulating levels of this glycoprotein. Depending on clinical symptoms the chromogranin A analysis is supplemented by other peptide hormone analyses as well as urinary 5-HIAA for patients with midgut carcinoid tumours. In the past the localization procedures were based on CT, MRI and ultrasound investigations but in recent years somatostatin receptor scintigraphy (octreoscan) and endoscopic ultrasonography have significantly improved the diagnostic potential. Almost 80% of neuroendocrine gastrointestinal tumours present somatostatin receptor subtype 2 binding 111Indium-labelled octreotide which can be used for staging of the disease, and which also indicates whether or not somatostatin analogues can be used in the treatment of these tumours. Surgery is still a cornerstone in the treatment of neuroendocrine gastrointestinal tumours, even if the patients are beyond cure. Debulking procedures and bypassing operations are important for improving clinical condition and facilitating impending medical treatment, and during the past decade a more aggressive surgical approach has emerged. The medical treatment is based on chemotherapy, and the use of somatostatin analogues and alpha-interferons. Chemotherapy, in particular the combination of streptozotocin with 5-FU or doxorubicin, is still first-line treatment for most endocrine pancreatic tumours, while somatostatin analogues and alpha-interferons are considered first-line for classical midgut carcinoids. Chemotherapy and biotherapy can be combined in many patients, and changes from one medical treatment to another during the course of the disease is mandatory for control of the disease. It is important to realise that most patients with malignant tumours are not cured by medical treatment but that the disease can be controlled for extended periods of time. In the future it will be possible to individualize treatments on the basis of new information about such features of tumour biology as proliferation capacity, expression of adhesion molecules, and growth factors and their receptors.
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Affiliation(s)
- K Oberg
- Department of Internal Medicine, University Hospital, Uppsala, Sweden
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Van Dam J, Catalano MF, Ferguson DR, Barnes DS, Zuccaro G, Sivak MV. A prospective, double-blind trial of somatostatin analog (octreotide) versus glucagon for the inhibition of small intestinal motility during endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 1995; 42:321-4. [PMID: 8536900 DOI: 10.1016/s0016-5107(95)70130-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Glucagon is effective when used as an antimotility agent during ERCP, but at high doses it may cause nausea and vomiting. Octreotide acetate, a long-acting synthetic analog of somatostatin, inhibits contractility of the small intestine and is generally well tolerated. The purpose of this study was to determine if octreotide given prior to ERCP reduced the requirement for glucagon and enhanced patient tolerance for the procedure. METHODS Patients undergoing ERCP (n = 100) performed for a variety of indications (but not sphincter of Oddi manometry) were randomly assigned to receive normal saline solution or octreotide at a total dose of 25 micrograms, 50 micrograms, or 100 micrograms diluted in normal saline solution prior to the procedure. Glucagon was subsequently administered (as needed, to inhibit intestinal motility) by endoscopists who were blinded to the test substance given prior to the procedure. RESULTS For all treatment groups, the dose of glucagon required to inhibit intestinal motility in patients who received octreotide prior to the procedure was not significantly different from the dose administered to patients who received normal saline solution. There was no significant difference in the incidence of nausea and vomiting when individual test groups were compared to the control group. CONCLUSION Nausea and vomiting after ERCP were uncommon in all treatment groups. Administration of octreotide prior to ERCP did not significantly reduce the dose of glucagon required to inhibit intestinal motility. Tolerance for ERCP was similar for patients given octreotide when compared with those given glucagon to inhibit small intestinal motility.
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Affiliation(s)
- J Van Dam
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio, USA
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