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Periferakis A, Tsigas G, Periferakis AT, Tone CM, Hemes DA, Periferakis K, Troumpata L, Badarau IA, Scheau C, Caruntu A, Savulescu-Fiedler I, Caruntu C, Scheau AE. Agonists, Antagonists and Receptors of Somatostatin: Pathophysiological and Therapeutical Implications in Neoplasias. Curr Issues Mol Biol 2024; 46:9721-9759. [PMID: 39329930 PMCID: PMC11430067 DOI: 10.3390/cimb46090578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/29/2024] [Accepted: 08/31/2024] [Indexed: 09/28/2024] Open
Abstract
Somatostatin is a peptide that plays a variety of roles such as neurotransmitter and endocrine regulator; its actions as a cell regulator in various tissues of the human body are represented mainly by inhibitory effects, and it shows potent activity despite its physiological low concentrations. Somatostatin binds to specific receptors, called somatostatin receptors (SSTRs), which have different tissue distributions and associated signaling pathways. The expression of SSTRs can be altered in various conditions, including tumors; therefore, they can be used as biomarkers for cancer cell susceptibility to certain pharmacological agents and can provide prognostic information regarding disease evolution. Moreover, based on the affinity of somatostatin analogs for the different types of SSTRs, the therapeutic range includes conditions such as tumors, acromegaly, post-prandial hypotension, hyperinsulinism, and many more. On the other hand, a number of somatostatin antagonists may prove useful in certain medical settings, based on their differential affinity for SSTRs. The aim of this review is to present in detail the principal characteristics of all five SSTRs and to provide an overview of the associated therapeutic potential in neoplasias.
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Affiliation(s)
- Argyrios Periferakis
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Elkyda, Research & Education Centre of Charismatheia, 17675 Athens, Greece
- Akadimia of Ancient Greek and Traditional Chinese Medicine, 16675 Athens, Greece
| | - Georgios Tsigas
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Aristodemos-Theodoros Periferakis
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Elkyda, Research & Education Centre of Charismatheia, 17675 Athens, Greece
| | - Carla Mihaela Tone
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daria Alexandra Hemes
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Konstantinos Periferakis
- Akadimia of Ancient Greek and Traditional Chinese Medicine, 16675 Athens, Greece
- Pan-Hellenic Organization of Educational Programs, 17236 Athens, Greece
| | - Lamprini Troumpata
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioana Anca Badarau
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cristian Scheau
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Radiology and Medical Imaging, "Foisor" Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 030167 Bucharest, Romania
| | - Ana Caruntu
- Department of Oral and Maxillofacial Surgery, The "Carol Davila" Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, "Titu Maiorescu" University, 031593 Bucharest, Romania
| | - Ilinca Savulescu-Fiedler
- Department of Internal Medicine, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Internal Medicine and Cardiology, Coltea Clinical Hospital, 030167 Bucharest, Romania
| | - Constantin Caruntu
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Dermatology, "Prof. N.C. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
| | - Andreea-Elena Scheau
- Department of Radiology and Medical Imaging, Fundeni Clinical Institute, 022328 Bucharest, Romania
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Grubor NM, Grubor NN, Micev M. Diagnostic Challenges in Difficult-to-Localize Insulinomas: A Case Report and Review of Literature. Diagnostics (Basel) 2024; 14:1600. [PMID: 39125476 PMCID: PMC11311322 DOI: 10.3390/diagnostics14151600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Non-somatostatin receptor expressing hypovascular insulinomas can be challenging to prove through imaging. This case highlights the utility of a structured approach to molecular imaging in patients with confirmed endogenous hyperinsulinemia. A 54-year-old woman was admitted because of a sudden loss of consciousness. Her relative reported that she complained of dizziness, intense sweating, blurry vision, and upper extremity tingling before becoming unresponsive for 20 min, after which the patient had little recollection of the event. She experienced similar episodes of shorter duration, trouble recalling everyday events, and unintentional weight gain of over 10 kg during the previous two years. Abdominal magnetic resonance imaging (MRI) and multidetector computerized tomography (MDCT) were unremarkable. Selective arterial calcium stimulation significantly increased hepatic venous insulin concentrations when the superior mesenteric and gastroduodenal arteries were stimulated. Technetium-99m (99mTc) octreotide single-photon emission computed tomography (SPECT) did not localize the lesion. Gallium-68 DOTA-Exendin-4 PET/CT acquisition was performed. A single intense 2 cm hyperperfused pancreatic lesion was located anteriorly in the head of the pancreas. Earlier targeted PET/CT imaging and recognition of significant neuropsychiatric symptoms attributable to the patient's hypoglycemic state might have accelerated the resolution of her condition and obviated the need for unnecessary testing.
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Affiliation(s)
- Nikica M. Grubor
- Department for HBP Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovića 6, 11000 Belgrade, Serbia;
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Dr Subotića 8, 11000 Belgrade, Serbia
| | - Nikola N. Grubor
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Dr Subotića 15, 11000 Belgrade, Serbia
| | - Marjan Micev
- Department for Pathology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovića 6, 11000 Belgrade, Serbia;
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Pellegrino F, Granata V, Fusco R, Grassi F, Tafuto S, Perrucci L, Tralli G, Scaglione M. Diagnostic Management of Gastroenteropancreatic Neuroendocrine Neoplasms: Technique Optimization and Tips and Tricks for Radiologists. Tomography 2023; 9:217-246. [PMID: 36828370 PMCID: PMC9958666 DOI: 10.3390/tomography9010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) comprise a heterogeneous group of neoplasms, which derive from cells of the diffuse neuroendocrine system that specializes in producing hormones and neuropeptides and arise in most cases sporadically and, to a lesser extent, in the context of complex genetic syndromes. Furthermore, they are primarily nonfunctioning, while, in the case of insulinomas, gastrinomas, glucagonomas, vipomas, and somatostatinomas, they produce hormones responsible for clinical syndromes. The GEP-NEN tumor grade and cell differentiation may result in different clinical behaviors and prognoses, with grade one (G1) and grade two (G2) neuroendocrine tumors showing a more favorable outcome than grade three (G3) NET and neuroendocrine carcinoma. Two critical issues should be considered in the NEN diagnostic workup: first, the need to identify the presence of the tumor, and, second, to define the primary site and evaluate regional and distant metastases. Indeed, the primary site, stage, grade, and function are prognostic factors that the radiologist should evaluate to guide prognosis and management. The correct diagnostic management of the patient includes a combination of morphological and functional evaluations. Concerning morphological evaluations, according to the consensus guidelines of the European Neuroendocrine Tumor Society (ENETS), computed tomography (CT) with a contrast medium is recommended. Contrast-enhanced magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI), is usually indicated for use to evaluate the liver, pancreas, brain, and bones. Ultrasonography (US) is often helpful in the initial diagnosis of liver metastases, and contrast-enhanced ultrasound (CEUS) can solve problems in characterizing the liver, as this tool can guide the biopsy of liver lesions. In addition, intraoperative ultrasound is an effective tool during surgical procedures. Positron emission tomography (PET-CT) with FDG for nonfunctioning lesions and somatostatin analogs for functional lesions are very useful for identifying and evaluating metabolic receptors. The detection of heterogeneity in somatostatin receptor (SSTR) expression is also crucial for treatment decision making. In this narrative review, we have described the role of morphological and functional imaging tools in the assessment of GEP-NENs according to current major guidelines.
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Affiliation(s)
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Naples, Italy
| | - Francesca Grassi
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80127 Naples, Italy
| | - Salvatore Tafuto
- S.C. Sarcomi e Tumori Rari, Istituto Nazionale Tumori, IRCCS, Fondazione “G. Pascale”, 80131 Naples, Italy
| | - Luca Perrucci
- Ferrara Department of Interventional and Diagnostic Radiology, Ospedale di Lagosanto, Azienda AUSL, 44023 Ferrara, Italy
| | - Giulia Tralli
- Department of Radiology, Ospedale Santa Maria della Misericordia, 45100 Rovigo, Italy
| | - Mariano Scaglione
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
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Prosperi D, Gentiloni Silveri G, Panzuto F, Faggiano A, Russo VM, Caruso D, Polici M, Lauri C, Filice A, Laghi A, Signore A. Nuclear Medicine and Radiological Imaging of Pancreatic Neuroendocrine Neoplasms: A Multidisciplinary Update. J Clin Med 2022; 11:jcm11226836. [PMID: 36431313 PMCID: PMC9694730 DOI: 10.3390/jcm11226836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are part of a large family of tumors arising from the neuroendocrine system. PanNENs show low-intermediate tumor grade and generally high somatostatin receptor (SSTR) expression. Therefore, panNENs benefit from functional imaging with 68Ga-somatostatin analogues (SSA) for diagnosis, staging, and treatment choice in parallel with morphological imaging. This narrative review aims to present conventional imaging techniques and new perspectives in the management of panNENs, providing the clinicians with useful insight for clinical practice. The 68Ga-SSA PET/CT is the most widely used in panNENs, not only fr diagnosis and staging purpose but also to characterize the biology of the tumor and its responsiveness to SSAs. On the contrary, the 18F-Fluordeoxiglucose (FDG) PET/CT is not employed systematically in all panNEN patients, being generally preferred in G2-G3, to predict aggressiveness and progression rate. The combination of 68Ga-SSA PET/CT and 18F-FDG PET/CT can finally suggest the best therapeutic strategy. Other radiopharmaceuticals are 68Ga-exendin-4 in case of insulinomas and 18F-dopamine (DOPA), which can be helpful in SSTR-negative tumors. New promising but still-under-investigation radiopharmaceuticals include radiolabeled SSTR antagonists and 18F-SSAs. Conventional imaging includes contrast enhanced CT and multiparametric MRI. There are now enriched by radiomics, a new non-invasive imaging approach, very promising to early predict tumor response or progression.
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Affiliation(s)
- Daniela Prosperi
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Guido Gentiloni Silveri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Francesco Panzuto
- Digestive Disease Unit, Department of Medical-Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, ENETS Center of Excellence, Sapienza University of Rome, 00189 Roma, Italy
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, ENETS Center of Excellence, Sapienza University of Rome, 00189 Roma, Italy
| | - Vincenzo Marcello Russo
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Damiano Caruso
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Michela Polici
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
- Correspondence:
| | - Angelina Filice
- Nucler Medicine Unit, AUSL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Laghi
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
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Sharma A, Varshney P, Kasliwal R, Nagar A, Venkatatelikicherla K, Sarin S, Choubey RP, Kapoor VK. Insulinoma—Accurate Preoperative Localization Is the Key to Management: An Initial Experience. Indian J Surg Oncol 2022; 13:403-411. [DOI: 10.1007/s13193-022-01534-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
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Frey S, Mirallié E, Le Bras M, Regenet N. What Are the Place and Modalities of Surgical Management for Pancreatic Neuroendocrine Neoplasms? A Narrative Review. Cancers (Basel) 2021; 13:5954. [PMID: 34885063 PMCID: PMC8656750 DOI: 10.3390/cancers13235954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are a heterogeneous group of tumors derived from cells with neuroendocrine differentiation. They are considered malignant by default. However, their outcomes are variable depending on their presentation in the onset of hereditary syndromes, hormonal secretion, grading, and extension. Therefore, although surgical treatment has long been suggested as the only treatment of pancreatic neuroendocrine neoplasms, its modalities are an evolving landscape. For selected patients (small, localized, non-functional panNENs), a "wait and see" strategy is suggested, as it is in the setting of multiple neuroendocrine neoplasia type 1, but the accurate size cut-off remains to be established. Parenchyma-sparring pancreatectomy, aiming to limit pancreatic insufficiency, are also emerging procedures, which place beyond the treatment of insulinomas and small non-functional panNENs (in association with lymph node picking) remains to be clarified. Furthermore, giving the fact that the liver is generally the only metastatic site, surgery keeps a place of choice alongside medical therapies in the treatment of metastatic disease, but its modalities and extensions are still a matter of debate. This narrative review aims to describe the current recommended surgical management for pancreatic NENs and controversies in light of the actual recommendations and recent literature.
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Affiliation(s)
- Samuel Frey
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- L’institut du Thorax, Université de Nantes, CNRS, INSERM, CHU de Nantes, 44000 Nantes, France
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Eric Mirallié
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Maëlle Le Bras
- Endocrinologie, Diabétologie et Nutrition, L’institut du Thorax, CHU Nantes, 44000 Nantes, France;
| | - Nicolas Regenet
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
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Schulte Am Esch J, Krüger M, Barthlen W, Förster C, Mohnike K, Empting S, Benhidjeb T, Vossschulte H. Technical aspects of paediatric robotic pancreatic enucleation based on a case of an insulinoma. Int J Med Robot 2021; 17:e2317. [PMID: 34297475 DOI: 10.1002/rcs.2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Insulinomas are rare insulin-producing pancreatic neuroendocrine tumours leading to severe episodes of hypoglycaemia. Surgery is the predominant curative therapy. METHODS We report here the first paediatric case of an insulinoma of the pancreatic body resected completely robotically under ultrasound guidance in a 10-year-old male with multiple endocrine neoplasia type 1. The port set-up was adapted for the narrowed dimensions of the paediatric peritoneal space. We comment on technical key steps for the organ-preserving procedure that was performed in close proximity to critical anatomic structures, with supporting video. Preoperative diagnostics, including endoscopic ultrasound, to determine surgical management are highlighted. RESULTS Following an uneventful post-operative course, the boy was discharged on day 11 with normalised glucose-metabolism. A pseudocyst developing after 4 weeks was treated with endoscopic stenting. CONCLUSIONS The applicability of a robotic surgical system in limited space conditions such as found in the paediatric abdominal cavity is demonstrated here for pancreatic surgery.
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Affiliation(s)
- Jan Schulte Am Esch
- Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Martin Krüger
- Department of Internal Medicine and Gastroenterology, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Christine Förster
- Institute of Pathology, KRH Hospital Nordstadt, affiliated with the University Hospital of the University of Bielefeld, Campus Bielefeld-Bethel, Hannover, Germany
| | | | - Susann Empting
- Department of Pediatrics, University Hospital Magdeburg, Magdeburg, Germany
| | - Tahar Benhidjeb
- Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Hendrik Vossschulte
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
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Effraimidis G, Knigge U, Rossing M, Oturai P, Rasmussen ÅK, Feldt-Rasmussen U. Multiple endocrine neoplasia type 1 (MEN-1) and neuroendocrine neoplasms (NENs). Semin Cancer Biol 2021; 79:141-162. [PMID: 33905872 DOI: 10.1016/j.semcancer.2021.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/03/2021] [Accepted: 04/16/2021] [Indexed: 12/14/2022]
Abstract
Neuroendocrine neoplasms (NENs) are relatively rare neoplasms with 6.4-times increasing age-adjusted annual incidence during the last four decades. NENs arise from neuroendocrine cells, which release hormones in response to neuronal stimuli and they are distributed into organs and tissues. The presentation and biological behaviour of the NENs are highly heterogeneous, depending on the organ. The increased incidence is mainly due to increased awareness and improved detection methods both in the majority of sporadic NENs (non-inherited), but also the inherited groups of neoplasms appearing in at least ten genetic syndromes. The most important one is multiple endocrine neoplasia type 1 (MEN-1), caused by mutations in the tumour suppressor gene MEN1. MEN-1 has been associated with different tumour manifestations of NENs e.g. pancreas, gastrointestinal tract, lungs, thymus and pituitary. Pancreatic NENs tend to be less aggressive when arising in the setting of MEN-1 compared to sporadic pancreatic NENs. There have been very important improvements over the past years in both genotyping, genetic counselling and family screening, introduction and validation of various relevant biomarkers, as well as newer imaging modalities. Alongside this development, both medical, surgical and radionuclide treatments have also advanced and improved morbidity, quality of life and mortality in many of these patients. Despite this progress, there is still space for improving insight into the genetic and epigenetic factors in relation to the biological mechanisms determining NENs as part of MEN-1. This review gives a comprehensive update of current evidence for co-occurrence, diagnosis and treatment of MEN-1 and neuroendocrine neoplasms and highlight the important progress now finding its way to international guidelines in order to improve the global management of these patients.
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Affiliation(s)
- Grigoris Effraimidis
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulrich Knigge
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Peter Oturai
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Åse Krogh Rasmussen
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulla Feldt-Rasmussen
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, Copenhagen University, Denmark.
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9
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Usefulness of selective arterial calcium injection tests for functional pancreatic neuroendocrine tumors. Sci Rep 2021; 11:235. [PMID: 33420290 PMCID: PMC7794566 DOI: 10.1038/s41598-020-80538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022] Open
Abstract
The selective arterial calcium injection (SACI) test is useful for patients with functional pancreatic neuroendocrine tumors (F-PNETs). This study evaluated which patients with F-PNETs would benefit from the SACI test. We retrospectively analyzed the preoperative findings of patients on computed tomography (CT), magnetic resonance imaging (MRI), CT angiography (CTA), and the SACI test. Fourteen patients who underwent pancreatectomy between January 1997 and September 2016 for F-PNETs were evaluated. We classified these patients into groups A, B, and C; group A, one tumor detected by either CT or MRI; group B, multiple tumors detected; and group C, the tumor location was accordant on CT, MRI, and CTA, but the SACI test revealed another tumor. In group A, the tumor was also detected by CTA and the SACI test was positive on calcium injection. In group B, the focus tumor among the multiple tumors was detected by the SACI test. In group C, another tumor was identified by the SACI test, whose location was different from that detected using CT and MRI. The SACI test is more useful for multiple F-PNETs on CT or MRI. If CT or MRI detects a single tumor, the SACI test or CTA may be unnecessary.
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Cuthbertson DJ, Barriuso J, Lamarca A, Manoharan P, Westwood T, Jaffa M, Fenwick SW, Nuttall C, Lalloo F, Prachalias A, Pizanias M, Wieshmann H, McNamara MG, Hubner R, Srirajaskanthan R, Vivian G, Ramage J, Weickert MO, Pritchard DM, Vinjamuri S, Valle J, Yip VS. The Impact of 68Gallium DOTA PET/CT in Managing Patients With Sporadic and Familial Pancreatic Neuroendocrine Tumours. Front Endocrinol (Lausanne) 2021; 12:654975. [PMID: 34163434 PMCID: PMC8215358 DOI: 10.3389/fendo.2021.654975] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/11/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Pancreatic neuroendocrine tumours (panNETs) arise sporadically or as part of a genetic predisposition syndrome. CT/MRI, endoscopic ultrasonography and functional imaging using Octreoscan localise and stage disease. This study aimed to evaluate the complementary role of 68Gallium (68Ga)-DOTA PET/CT in managing patients with panNETs. DESIGN A retrospective study conducted across three tertiary UK NET referral centres. METHODS Demographic, clinical, biochemical, cross-sectional and functional imaging data were collected from patients who had undergone a 68Ga-DOTA PET/CT scan for a suspected panNET. RESULTS We collected data for 183 patients (97 male): median (SD) age 63 (14.9) years, 89.1 vs. 9.3% (n=163 vs. 17) alive vs. dead (3 data missing), 141 sporadic vs. 42 familial (MEN1, n=36; 85.7%) panNETs. Non-functional vs. functional tumours comprised 73.2 vs. 21.3% (n=134 vs. 39) (10 missing). Histological confirmation was available in 89% of individuals (n=163) but tumour grading (Ki67 classiifcation) was technically possible only in a smaller cohort (n=143): grade 1, 50.3% (n=72); grade 2, 46.2% (n=66) and grade 3, 3.5% (n=5) (40 histopathological classification either not technically feasible or biopsy not perfomed). 60.1% (n=110) were localised, 14.2% (n=26) locally advanced and 23.5% (n=43) metastatic (4 missing). 224 68Ga-DOTA PET/CT scans were performed in total for: diagnosis/staging 40% (n=88), post-operative assessment/clinical surveillance 53% (n=117) and consideration of peptide receptor radionuclide therapy (PRRT) 8% (n=17) (2 missing). PET/CT results confirmed other imaging findings (53%), identified new disease sites (28.5%) and excluded suspected disease (5%). Overall, 68Ga-DOTA PET/CT imaging findings provided additional information in 119 (54%) patients and influenced management in 85 (39%) cases. CONCLUSION 68Ga-DOTA PET/CT imaging more accurately stages and guides treatment in patients with sporadic/familial panNETs with newly diagnosed/recurrent disease.
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Affiliation(s)
- Daniel J. Cuthbertson
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- *Correspondence: Daniel J. Cuthbertson,
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Prakash Manoharan
- Department of Radiology and Nuclear Medicine, The Christie NHS Foundation Trust ENETS Centre of Excellence, Manchester, United Kingdom
| | - Thomas Westwood
- Department of Radiology and Nuclear Medicine, The Christie NHS Foundation Trust ENETS Centre of Excellence, Manchester, United Kingdom
| | - Matthew Jaffa
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
| | - Stephen W. Fenwick
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
| | - Christina Nuttall
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Fiona Lalloo
- Department of Clinical Genetics, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Saint Mary’s Hospital, Manchester, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Michail Pizanias
- Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Hulya Wieshmann
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
| | - Mairead G. McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Richard Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Raj Srirajaskanthan
- Neuroendocrine Tumour Unit, KHP ENETS Centre of Excellence, Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Gillian Vivian
- Neuroendocrine Tumour Unit, KHP ENETS Centre of Excellence, Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - John Ramage
- Neuroendocrine Tumour Unit, KHP ENETS Centre of Excellence, Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Martin O. Weickert
- The Arden Neuroendocrine Centre, ENETS Centre of Excellence, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - D Mark Pritchard
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sobhan Vinjamuri
- Liverpool University Hospitals NHS Foundation Trust, ENETS Centre of Excellence, Liverpool, United Kingdom
| | - Juan Valle
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, ENETS Centre of Excellence, Manchester, United Kingdom
| | - Vincent S. Yip
- Barts and the London HPB Centre, Royal London Hospital, London, United Kingdom
- Department of Pancreatobiliary Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom
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11
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Calabrò D, Argalia G, Ambrosini V. Role of PET/CT and Therapy Management of Pancreatic Neuroendocrine Tumors. Diagnostics (Basel) 2020; 10:E1059. [PMID: 33297381 PMCID: PMC7762240 DOI: 10.3390/diagnostics10121059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are heterogeneous neoplasms with neuroendocrine differentiation that show peculiar clinical and histomorphological features, with variable prognosis. In recent years, advances in knowledge regarding the pathophysiology and heterogeneous clinical presentation, as well as the availability of different diagnostic procedures for panNEN diagnosis and novel therapeutic options for patient clinical management, has led to the recognition of the need for an active multidisciplinary discussion for optimal patient care. Molecular imaging with positron emission tomography/computed tomography (PET/CT) has become indispensable for the management of panNENs. Several PET radiopharmaceuticals can be used to characterize either panNEN receptor expression or metabolism. The aim of this review is to offer an overview of all the currently used radiopharmaceuticals and of the new upcoming tracers for pancreatic neuroendocrine tumors (panNETs), and their clinical impact on therapy management. [68Ga]Ga-DOTA-peptide PET/CT (SSA-PET/CT) has high sensitivity, specificity, and accuracy and is recommended for the staging and restaging of any non-insulinoma well-differentiated panNEN cases to carry out detection of unknown primary tumor sites or early relapse and for evaluation of in vivo somatostatin receptors expression (SRE) to select patient candidates for peptide receptor radiometabolic treatment (PRRT) with 90Y or 177Lu and/or cold analogs. SSA-PET/CT also has a strong impact on clinical management, leading to a change in treatment in approximately a third of the cases. Its role for treatment response assessment is still under debate due to the lack of standardized criteria, even though some semiquantitative parameters seem to be able to predict response. [18F]FDG PET/CT generally shows low sensitivity in small growing and well-differentiated neuroendocrine tumors (NET; G1 and G2), while it is of utmost importance in the evaluation and management of high-grade NENs and also provides important prognostic information. When positive, [18F]FDG PET/CT impacts therapeutical management, indicating the need for a more aggressive treatment regime. Although FDG positivity does not exclude the patient from PRRT, several studies have demonstrated that it is certainly useful to predict response, even in this setting. The role of [18F]FDOPA for the study of panNET is limited by physiological uptake in the pancreas and is therefore not recommended. Moreover, it provides no information on SRE that has crucial clinical management relevance. Early acquisition of the abdomen and premedication with carbidopa may be useful to increase the accuracy, but further studies are needed to clarify its utility. GLP-1R agonists, such as exendin-4, are particularly useful for benign insulinoma detection, but their accuracy decreases in the case of malignant insulinomas. Being a whole-body imaging technique, exendin-PET/CT gives important preoperative information on tumor size and localization, which is fundamental for surgical planning as resection (enucleation of the lesion or partial pancreatic resection) is the only curative treatment. New upcoming tracers are under study, such as promising SSTR antagonists, which show a favorable biodistribution and higher tumor-to-background ratio that increases tumor detection, especially in the liver. [68Ga]pentixafor, an in vivo marker of CXCR4 expression associated with the behavior of more aggressive tumors, seems to only play a limited role in detecting well-differentiated NET since there is an inverse expression of SSTR2 and CXCR4 in G1 to G3 NETs with an elevation in CXCR4 and a decrease in SSTR2 expression with increasing grade. Other tracers, such as [68Ga]Ga-PSMA, [68Ga]Ga-DATA-TOC, [18F]SiTATE, and [18F]AlF-OC, are also under investigation.
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Affiliation(s)
- Diletta Calabrò
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
| | - Giulia Argalia
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
| | - Valentina Ambrosini
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
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12
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Somatostatin Receptor PET/CT Imaging for the Detection and Staging of Pancreatic NET: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:diagnostics10080598. [PMID: 32824388 PMCID: PMC7459584 DOI: 10.3390/diagnostics10080598] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
We investigated the diagnostic performance of Somatostatin Receptor Positron Emission Tomography/Computed Tomography (SSR-PET/CT) for the detection of primary lesion and initial staging of pancreatic neuroendocrine tumors (pNETs). A comprehensive literature search up to January 2020 was performed selecting studies in presence of: sample size ≥10 patients; index test (i.e., 68Ga-DOTATOC or 68Ga-DOTANOC or 68Ga-DOTATATE PET/CT); and outcomes (i.e., detection rate (DR), true positive, true negative, false positive, and false-negative). The methodological quality was evaluated with QUADAS-2. Pooled DR and pooled sensitivity and specificity for the identification of the primary tumor were assessed by a patient-based and a lesion-based analysis. Thirty-eight studies were selected for the qualitative analysis, while 18 papers were included in the meta-analysis. The number of pNET patients ranged from 10 to 142, for a total of 1143 subjects. At patient-based analysis, the pooled sensitivity and specificity for the assessment of primary pNET were 79.6% (95% confidence interval (95%CI): 71–87%) and 95% (95%CI: 75–100%) with a heterogeneity of 59.6% and 51.5%, respectively. Pooled DR for the primary lesion was 81% (95%CI: 65–90%) and 92% (95%CI: 80–97%), respectively, at patient-based and lesion-based analysis. In conclusion, SSR-PET/CT has high DR and diagnostic performances for primary lesion and initial staging of pNETs.
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13
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Maggio I, Mollica V, Brighi N, Lamberti G, Manuzzi L, Ricci AD, Campana D. The functioning side of the pancreas: a review on insulinomas. J Endocrinol Invest 2020; 43:139-148. [PMID: 31368049 DOI: 10.1007/s40618-019-01091-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Insulinomas are a rare type of neuroendocrine tumors, originating in the pancreas, difficult to diagnose and to treat. Due to its rarity, insulinomas are a not well-known pathological entity; thus, the diagnostic process is frequently a medical challenge with many possible differential diagnoses. The diagnostic process varies between non-invasive procedures, such as the fasting test or imaging techniques, and invasive ones. Insulinomas are rarely malignant, but the glycemic imbalance correlated with this tumor can frequently alter the quality of life of the patients and the consequent hypoglycemia can be extremely dangerous. Moreover, insulinomas can be associated with different genetic syndromes, such as Multiple Endocrine Neoplasia 1, accompanied by other specific symptoms. There are many different treatment strategies, depending on the need to control symptoms or control diseases progression, the only curative one being surgery. METHODS AND RESULTS We reviewed the evidences present in the literature on insulinomas and reported its main clinical characteristics and management strategies. CONCLUSION The aim of this review of the literature is to present the current knowledge on insulinomas, exploring the main clinical characteristics, the diagnostic tools, and the therapeutic strategies.
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Affiliation(s)
- I Maggio
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - V Mollica
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - N Brighi
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- NET Team Bologna ENETS Center of Excellence, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - G Lamberti
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - L Manuzzi
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A D Ricci
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - D Campana
- NET Team Bologna ENETS Center of Excellence, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
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14
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 220] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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15
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Majala S, Seppänen H, Kemppainen J, Sundström J, Schalin-Jäntti C, Gullichsen R, Schildt J, Mustonen H, Vesterinen T, Arola J, Kauhanen S. Prediction of the aggressiveness of non-functional pancreatic neuroendocrine tumors based on the dual-tracer PET/CT. EJNMMI Res 2019; 9:116. [PMID: 31872324 PMCID: PMC6928175 DOI: 10.1186/s13550-019-0585-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/10/2019] [Indexed: 02/06/2023] Open
Abstract
Background Predicting the aggressive behavior of non-functional pancreatic neuroendocrine tumors (NF-PNET) remains controversial. We wanted to explore, in a prospective setting, whether the diagnostic accuracy can be improved by dual-tracer functional imaging 68Ga-DOTANOC and 18F-FDG-PET/CT in patients with NF-PNETs. Methods Thirty-one patients with NF-PNET (90% asymptomatic) underwent PET-imaging with 18F-FDG and 68Ga-DOTANOC, followed by surgery (n = 20), an endoscopic ultrasonography and fine-needle biopsy (n = 2) or follow-up (n = 9). A focal activity on PET/CT greater than the background that could not be identified as physiological activity was considered to indicate tumor tissue. The imaging results were compared to histopathology. The mean follow-up time was 31.3 months. Results Thirty-one patients presented a total of 53 lesions (40 histologically confirmed) on PET/CT. Thirty patients had a 68Ga-DOTANOC-positive tumor (sensitivity 97%) and 10 patients had an 18F-FDG-positive tumor. In addition, one 68Ga-DOTANOC-negative patient was 18F-FDG-positive. 18F-FDG-PET/CT was positive in 19% (3/16) of the G1 tumors, 63% (5/8) of the G2 tumors and 1/1 of the well-differentiated G3 tumor. 68Ga-DOTANOC-PET/CT was positive in 94% of the G1 tumors, 100% of the G2 tumors and 1/1 of the well-differentiated G3 tumor. Two out of six (33%) of the patients with lymph node metastases (LN+) were 18F-FDG-positive. The 18F-FDG-PET/CT correlated with tumor Ki-67 (P = 0.021). Further, the Krenning score correlated with tumor Ki-67 (P = 0.013). 18F-FDG-positive tumors were significantly larger than the 18F-FDG-negative tumors (P = 0.012). 18F-FDG-PET/CT showed a positive predictive value of 78% in the detection of potentially aggressive tumors (G2, G3, or LN + PNETs); the negative predictive value was 69%. Conclusions 18F-FDG-PET/CT is useful to predict tumor grade but not the LN+ of NF-PNETs. Patients with 18F-FDG-avid NF-PNETs should be referred for surgery. The 68Ga-DOTANOC-PET/CT also has prognostic value since the Krenning score predicts the histopathological tumor grade. Trial registration The study has been registered at ClinicalTrials.gov; Non-functional Pancreatic NET and PET imaging, NCT02621541.
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Affiliation(s)
- Susanna Majala
- Division of Digestive Surgery and Urology, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland.,Turku PET Centre, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland
| | - Hanna Seppänen
- Department of Abdominal Surgery, Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FIN-00029, Helsinki, Finland
| | - Jukka Kemppainen
- Turku PET Centre, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland.,Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland
| | - Jari Sundström
- Department of Pathology, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland
| | - Camilla Schalin-Jäntti
- Department of Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FIN-00029, Helsinki, Finland
| | - Risto Gullichsen
- Division of Digestive Surgery and Urology, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland
| | - Jukka Schildt
- Department of Clinical Physiology and Nuclear Medicine, Helsinki University Hospital, Haartmaninkatu 4, FIN-00029, Helsinki, Finland
| | - Harri Mustonen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FIN-00029, Helsinki, Finland
| | - Tiina Vesterinen
- HUSLAB, Department of Pathology, University of Helsinki and Helsinki University Hospital, P.O. Box 400, FIN-00029, Helsinki, Finland.,Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, P.O. Box 20, FI-00014, Helsinki, Finland
| | - Johanna Arola
- HUSLAB, Department of Pathology, University of Helsinki and Helsinki University Hospital, P.O. Box 400, FIN-00029, Helsinki, Finland
| | - Saila Kauhanen
- Division of Digestive Surgery and Urology, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland. .,Turku PET Centre, Turku University Hospital, P.O. Box 52, FIN-20521, Turku, Finland.
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16
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Lancellotti F, Sacco L, Cerasari S, Bellato V, Cicconi S, Ciardi A, Muttillo EM, Feola T, Caronna R, Chirletti P. Intrapancreatic accessory spleen false positive to 68Ga-Dotatoc: case report and literature review. World J Surg Oncol 2019; 17:117. [PMID: 31288823 PMCID: PMC6617599 DOI: 10.1186/s12957-019-1660-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/28/2019] [Indexed: 02/08/2023] Open
Abstract
Background Intrapancreatic accessory spleen (IPAS) is an uncommon finding of pancreatic mass. Differential diagnosis with pancreatic tumor, especially with non-functional neuroendocrine tumor (NF-NET), may be very hard and sometimes it entails unnecessary surgery. A combination of CT scan, MRI, and nuclear medicine can confirm the diagnosis of IPAS. 68-Ga-Dotatoc PET/CT is the gold standard in NET diagnosis and it can allow to distinguish between IPAS and NET. Case presentation A 69-year-old man was admitted to our hospital for an incidental nodule in the tail of the pancreas with focal uptake of 68-Ga-dotatate at PET/CT. NET was suspected and open distal splenopancreatectomy was performed. Pathologic examination revealed an IPAS. Conclusion This is the second IPAS case in which a positive 68Ga-Dotatoc uptake led to a false diagnosis of pancreatic NET. Here is a proposal of a literature review.
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Affiliation(s)
- Francesco Lancellotti
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Luca Sacco
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Saverio Cerasari
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Vittoria Bellato
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Simone Cicconi
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Antonio Ciardi
- Department of Radiological Oncological and Pathological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Edoardo Maria Muttillo
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Piero Chirletti
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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17
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Bergeret S, Charbit J, Ansquer C, Bera G, Chanson P, Lussey-Lepoutre C. Novel PET tracers: added value for endocrine disorders. Endocrine 2019; 64:14-30. [PMID: 30875057 DOI: 10.1007/s12020-019-01895-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 03/05/2019] [Indexed: 02/07/2023]
Abstract
Nuclear medicine has been implicated in the diagnosis and treatment of endocrine disorders for several decades. With recent development of PET tracers, functional imaging now plays a major role in endocrine tumors enabling with high performance to their localization, characterization, and staging. Besides 18F-FDG, which may be used in the management and follow-up of endocrine tumors, new tracers have emerged, such as 18F-DOPA for neuroendocrine tumors (NETs) (medullary thyroid carcinoma, pheochromocytomas and paragangliomas and well-differentiated NETs originating from the midgut) and 18F-Choline in the field of primary hyperparathyroidism. Moreover, some peptides such as somatostatin analogs can also be used for peptide receptor radionuclide therapy. In this context, Gallium-68 labeled somatostatin analogs (68Ga-SSA) can help to tailor therapeutic choices and follow the response to treatment in the so-called "theranostic" approach. This review emphasizes the usefulness of these three novel PET tracers (18F-Choline, 18F-FDOPA, and 68Ga-SSA) for primary hyperparathyroidism and neuroendocrine tumors.
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Affiliation(s)
- Sébastien Bergeret
- Sorbonne University, Nuclear Medicine Department, Pitié-Salpêtrière Hospital, 47-83 Bd de l'Hôpital, 75013, Paris, France
| | - Judith Charbit
- Sorbonne University, Nuclear Medicine Department, Pitié-Salpêtrière Hospital, 47-83 Bd de l'Hôpital, 75013, Paris, France
| | - Catherine Ansquer
- Nuclear Medicine Department, CHU-Hôtel Dieu, 1 Place Alexis Ricordeau, 44093, Nantes Cedex1, France
- CIRCINA INSERM, Angers University, 8 quai Moncousu, 44000, Nantes, France
| | - Géraldine Bera
- Sorbonne University, Nuclear Medicine Department, Pitié-Salpêtrière Hospital, 47-83 Bd de l'Hôpital, 75013, Paris, France
- INSERM U1146, Laboratoire d'imagerie Biomedicale (LIB), Sorbonne University, Paris, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin Bicêtre, F-94275, France
- INSERM UMR S1185, Fac Med Paris Sud, Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, F-94276, France
| | - Charlotte Lussey-Lepoutre
- Sorbonne University, Nuclear Medicine Department, Pitié-Salpêtrière Hospital, 47-83 Bd de l'Hôpital, 75013, Paris, France.
- INSERM U970, Georges Pompidou European Hospital Cardiovascular Research Center, 56 rue Leblanc, 75015, Paris, France.
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18
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Gao H, Wang W, Xu H, Wu C, Jin W, Zhang S, Xu J, Ni Q, Yu X, Liu L. Distinct clinicopathological and prognostic features of insulinoma with synchronous distant metastasis. Pancreatology 2019; 19:472-477. [PMID: 30850220 DOI: 10.1016/j.pan.2019.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/22/2019] [Accepted: 02/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The clinicopathological and prognostic features of insulinoma with synchronous metastases are unclear. This study aimed to verify the distinct clinicopathological and prognostic features of insulinoma with synchronous distant metastasis. METHODS Patients with pancreatic neuroendocrine tumor (PanNET) were retrospectively enrolled and divided into cohort 1 (Fudan University Shanghai Cancer Center) and cohort 2 (Surveillance, Epidemiology, and End Results Program database). Both cohorts were further divided into three subgroups: insulinoma, nonfunctioning pancreatic neuroendocrine tumor (NF-PanNET), and non-insulinoma functioning pancreatic neuroendocrine tumor (NiF-PanNET). RESULTS Cohorts 1 and 2 comprised 505 and 2761 patients (1566 M0 patients and 1195 M1 patients), respectively. In cohort 1 and cohort 2 M0 subgroup, insulinoma showed longer disease-free survival, overall survival (OS), and disease-specific survival (DSS) than NiF-PanNET and NF-PanNET (not reached vs. 48 and 60months, p < 0.001; 183months vs. 87 and 109months, p < 0.001; 247months vs. 121 and 140months, p = 0.002). However, in cohort 2 M1, the mDSS for metastatic insulinoma was shorter than that for NiF-PanNET (31months vs. 61months, p = 0.045), while the mDSS and mOS were similar to those for NF-PanNET. The percentage of T1 and N0 patients was similar between the metastatic insulinoma subgroup and NiF-PanNET and NF-PanNET subgroups. The Ki-67 index and recurrence had a positive linear relationship only for NiF-PanNET and NF-PanNET (p = 0.009). CONCLUSIONS Insulinoma with synchronous metastasis showed clinicopathological and prognostic characteristics similar to those of NF-PanNET. Metastatic insulinoma had worse prognosis than non-insulinoma F-PanNET. These findings may help in the clinical management of metastatic insulinoma.
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Affiliation(s)
- Heli Gao
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Wenquan Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Huaxiang Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Chuntao Wu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Wei Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Shirong Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Jinzhi Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China.
| | - Liang Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China; Shanghai Pancreatic Cancer Institute, Shanghai, 200032, PR China; Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, PR China.
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Early 18F-FDOPA PET/CT imaging after carbidopa premedication as a valuable diagnostic option in patients with insulinoma. Eur J Nucl Med Mol Imaging 2019; 46:686-695. [DOI: 10.1007/s00259-018-4245-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022]
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Razik A, Singh AN, Roy SG, Madhusudhan KS. Mesenteric Tuberculosis Masquerading as Carcinoid Tumor on Conventional Imaging and DOTANOC Positron Emission Tomography/Computed Tomography: Uncommon Presentation of a Common Disease. Indian J Nucl Med 2019; 34:216-219. [PMID: 31293302 PMCID: PMC6593933 DOI: 10.4103/ijnm.ijnm_29_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Carcinoid tumor of the mesentery has a classical imaging morphology. A specific diagnosis can often be provided on the basis of clinical history, elevated serum neuroendocrine markers, and uptake on somatostatin receptor-based radiotracer studies. Although a number of inflammatory and neoplastic conditions may mimic carcinoid tumor on many of these modalities, uptake on 68Ga-DOTANOC positron emission tomography/computed tomography (PET/CT) is considered specific. We report a case of a 28-year-old male presenting with a mesenteric mass along with elevated serum neuroendocrine markers and uptake on DOTANOC PET/CT, all suggestive of carcinoid tumor. However, the histopathologic examination after surgical resection revealed necrotizing granulomas consistent with tuberculosis (TB). This case highlights the great masquerader that TB can be and stresses the importance of keeping a high index of suspicion for TB, especially in endemic areas.
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Affiliation(s)
- Abdul Razik
- Department of Radio-Diagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Shambo Guha Roy
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Liang M, Jiang J, Dai H, Hong X, Han X, Cong L, Tong A, Li F, Luo Y, Liu W, Zhou L, Di W, Wu W, Zhao Y. Robotic enucleation for pediatric insulinoma with MEN1 syndrome: a case report and literature review. BMC Surg 2018; 18:44. [PMID: 29921249 PMCID: PMC6009035 DOI: 10.1186/s12893-018-0376-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/11/2018] [Indexed: 01/20/2023] Open
Abstract
Background A patient with a rare pediatric insulinoma and MEN1 syndrome was treated by robotic enucleation surgery. Case presentation We present a case of a 9-year-old girl presenting with repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. She was previously misdiagnosed with epilepsy in another hospital. We further examined her while she was hospitalized. By combining her medical history and imaging examination and lab test results, a diagnosis of insulinoma was confirmed. Sanger-directed sequencing on a peripheral blood sample revealed an MEN1 gene mutation, indicating pediatric insulinoma with MEN1 syndrome. The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The surgery was successfully completed within 65 min, and the girl recovered well postoperatively and no longer experienced symptoms of hypoglycemia. Conclusion This is the first report of a case of pediatric insulinoma treated using robotic enucleation. This experience demonstrates the feasibility and safety of combining robotic surgery with the enucleation procedure as an excellent strategy for pediatric insulinoma.
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Affiliation(s)
- Mei Liang
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jialin Jiang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongmei Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiafei Hong
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Fang Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yaping Luo
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Weinan Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Liangrui Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wenyu Di
- Department of Pathology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
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Dalvi AN, Garale MN, Takalkar YP, Rege SA, Thapar PM, Anurag L, Shah NS. Laparoscopic surgery for solitary insulinoma in the absence of IOUS. J Minim Access Surg 2018; 14:9-12. [PMID: 28782747 PMCID: PMC5749208 DOI: 10.4103/jmas.jmas_6_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Insulinomas are the most common pancreatic neuroendocrine neoplasms. In spite of adequate pre-operative localisation, conventional surgical methods rely on intraoperative palpation. Intraoperative ultrasonography (IOUS) is said to aid in accurate localisation, decreases morbidity. Laparoscopic removal of pancreatic endocrine neoplasms is beneficial due to magnification and minimal invasion; however, in the absence of IOUS, error of judgement may lead to conversion to open surgery, thereby relying on 'palpation method' to localise the tumour. We combined laparoscopic surgical removal of insulinomas using an innovative method of 'laparoscopic finger palpation' with intraoperative blood glucose monitoring and frozen section for surgical cure. MATERIALS AND METHODS Patients were evaluated and investigated by the department of endocrinology and referred for surgical management of insulinoma. Pre-operative localisation of insulinoma was done by either contrast-enhanced computerised tomography angiogram - arterial and venous phase, or endoscopic ultrasound (EUS) or DOTATATE scan. Intraoperative localisation was done by laparoscopic dissection and 'laparoscopic finger palpation'. After enucleation, the specimen was sent for frozen section, and in the interim period, serial monitoring of blood glucose was done by the anaesthetist. Maintenance of glucose levels for more than 45 min after enucleation and confirmation of neuroendocrine tumour on frozen section was the end point of surgical procedure. RESULTS A total of 19 patients were subjected to laparoscopic removal of solitary insulinomas. Enucleation was performed in 16 patients successfully. In three patients, laparoscopic distal pancreatectomy was performed. Three patients had pancreatic duct leak, of which two patients responded to conservative approach and the third patient required drainage by USG-guided pigtail catheter. All patients are cured of their disease and no patient has had recurrence so far. CONCLUSION Multidisciplinary approach involving laparoscopic palpation, frozen sections and intraoperative blood sugar monitoring helps laparoscopic management of solitary insulinomas without IOUS.
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Affiliation(s)
- Abhay Narendra Dalvi
- Department of General Surgery, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Mahadeo Namdeo Garale
- Department of General Surgery, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Yogesh Prabhakar Takalkar
- Department of General Surgery, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sameer Ashok Rege
- Department of General Surgery, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Pinky Manoharlal Thapar
- Department of General Surgery, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Lila Anurag
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini Samir Shah
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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PET–Computed Tomography and Precision Medicine in Pancreatic Adenocarcinoma and Pancreatic Neuroendocrine Tumors. PET Clin 2017; 12:407-421. [DOI: 10.1016/j.cpet.2017.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Ferrari MC, Miele L, Guidi L, Rindi G, Rocchi C, Castaldi P, Alfieri S, Gasbarrini A, Grieco A, Rapaccini G. Watery stools and metabolic acidosis. Intern Emerg Med 2017; 12:487-492. [PMID: 28382558 DOI: 10.1007/s11739-017-1656-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Maria Chiara Ferrari
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy
| | - Luca Miele
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy.
| | - Luisa Guidi
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy
| | - Guido Rindi
- Institute of Human Pathology and Oncology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Rome, Italy
| | - Carlo Rocchi
- Institute of Emergency Medicine and Anaesthesiology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Rome, Italy
| | - Paola Castaldi
- PET-CT Center, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Rome, Italy
| | - Sergio Alfieri
- Institute of Surgery and Abdominal Surgery Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Rome, Italy
| | - Antonio Gasbarrini
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy
| | - Antonio Grieco
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy
| | - Gianlodovico Rapaccini
- Institute of Internal Medicine and Gastroenterology Area, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del S. Cuore, Largo Gemelli, 00168, Rome, Italy
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Ito T, Jensen RT. Molecular imaging in neuroendocrine tumors: recent advances, controversies, unresolved issues, and roles in management. Curr Opin Endocrinol Diabetes Obes 2017; 24:15-24. [PMID: 27875420 PMCID: PMC5195891 DOI: 10.1097/med.0000000000000300] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The purpose is to review recent advances in molecular imaging of neuroendocrine tumors (NETs), discuss unresolved issues, and review how these advances are affecting clinical management. RECENT FINDINGS Molecular imaging of NETs underwent a number of important changes in the last few years, leading to some controversies, unresolved issues, and significant changes in clinical management. The most recent changes are reviewed in this article. Particularly important is the rapid replacement in somatostatin receptor scintigraphy of In-diethylenetriamine penta-acetic acid-single-photon emission computed tomography/computed tomography (CT) by Ga-fluorodopa(F-D)PA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-peptide-PET/CT imaging, which is now approved in many countries including the USA. Numerous studies in many different types of NETs demonstrate the greater sensitivity of Ga-DOTA-peptide PET/CT, its high specificity, and its impact on management. Other important developments in somatostatin receptor scintigraphy/molecular imaging include demonstrating the prognostic value of both Ga-DOTA-peptide PET/CT and F-fluoro-deoxyglucose PET/CT; how their use can be complementary; comparing the sensitivities and usefulness of Ga-DOTA-peptide PET/CT and F-FDOPA PET/CT; introducing new linkers and radiolabeled ligands such as Cu-DOTA-peptides with a long half-life, enhancing utility; and the introduction of somatostatin receptor antagonists which show enhanced uptake by NETs. In addition, novel ligands which interact with other receptors (GLP-1, bombesin, cholecystokinin, gastric inhibitory polpeptide, integrin, chemokines) are described, which show promise in the imaging of both NETs and other tumors. SUMMARY Molecular imaging is now required for all aspects of the management of patients with NETs. Its results are essential not only for the proper diagnostic management of the patient, but also for assessing whether the patient is a candidate for peptide receptor radionuclide therapy with Lu and also for providing prognostic value.
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Affiliation(s)
- Tetsuhide Ito
- aDepartment of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan bDigestive Diseases Branch, NIDDK, NIH, Bethesda, Maryland, USA
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The Accessory Spleen Is an Important Pitfall of 68Ga-DOTANOC PET/CT in the Workup for Pancreatic Neuroendocrine Neoplasm. Pancreas 2017; 46:157-163. [PMID: 27846139 DOI: 10.1097/mpa.0000000000000728] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of the study was to assess the value and potential pitfalls of Ga-DOTANOC positron emission tomography/computed tomography (PET/CT) in patients with suspected pancreatic neuroendocrine neoplasms (pNEN). METHODS Consecutive patients referred for Ga-DOTANOC PET/CT for suspected pNEN between May 1, 2011, and October 31, 2014, were retrospectively assessed. Scan data were compared with cytological/histological final diagnosis. Pancreatic neuroendocrine neoplasm detection rate was determined on per-patient and per-lesion basis. Maximum standardized uptake values of lesions were determined. RESULTS Fifty-eight patients with 65 lesions were enrolled. Twelve patients had nonconfirmed diagnosis; of these, 7 were positive and 5 negative at PET/CT. Of 46 patients with confirmed diagnosis, 36 had pNEN; of these, 33 were positive, 1 negative, and 2 nonevaluable at PET/CT. Ten patients had non-NE lesions, of which 8 were positive, 1 negative, and 1 nonevaluable at PET/CT. Of 48 patients with positive PET/CT, 8 proved to have non-NE lesions, of which 6 were intrapancreatic accessory spleen. No significant maximum standardized uptake values difference was found between pNEN and non-NE lesions. CONCLUSIONS Intrapancreatic accessory spleen is an important pitfall in Ga-DOTANOC PET/CT for suspected pNEN. Cytological/histological confirmation is mandatory before any surgical procedure is undertaken.
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Virgolini I, Gabriel M, Kroiss A, von Guggenberg E, Prommegger R, Warwitz B, Nilica B, Roig LG, Rodrigues M, Uprimny C. Current knowledge on the sensitivity of the (68)Ga-somatostatin receptor positron emission tomography and the SUVmax reference range for management of pancreatic neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2016; 43:2072-83. [PMID: 27174220 PMCID: PMC5007271 DOI: 10.1007/s00259-016-3395-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/11/2016] [Indexed: 02/08/2023]
Abstract
Physiologically increased pancreatic uptake at the head/uncinate process is observed in more than one-third of patients after injection of one of the three 68Ga-labelled octreotide-based peptides used for somatostatin (sst) receptor (r) imaging. There are minor differences between these 68Ga-sstr-binding peptides in the imaging setting. On 68Ga-sstr-imaging the physiological uptake can be diffuse or focal and usually remains stable over time. Differences in the maximal standardised uptake values (SUVmax) reported for the normal pancreas as well as for pancreatic neuroendocrine tumour (PNET) lesions may be related to several factors, including (a) differences in the peptide binding affinities as well as differences in sstr subtype expression of pancreatic α- and β-cells, and heterogeneity / density of tumour cells, (b) differences in scanner resolution, image reconstruction techniques and acquisition protocols, (c) mostly retrospective study designs, (d) mixed patient populations, or (e) interference with medications such as treatment with long-acting sst analogues. The major limitation in most of the studies lies in the lack of histopathological confirmation of abnormal findings. There is a significant overlap between the calculated SUVmax-values for physiological pancreas and PNET-lesions of the head/uncinate process that do not favour the use of quantitative parameters in the clinical setting. Anecdotal long-term follow-up studies have even indicated that increased uptake in the head/uncinate process still can turn out to be malignant over years of follow up. SUVmax-data for the pancreatic body and tail are limited. Therefore, any visible focal tracer uptake in the pancreas must be considered as suspicious for malignancy irrespective of quantitative parameters. In general, sstr-PET/CT has significant implications for the management of NET patients leading to a change in treatment decision in about one-third of patients. Therefore, follow-up with 68Ga-sstr-PET/CT is mandatory in the clinical setting if uptake in the head/uncinate process is observed.
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Affiliation(s)
- Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Michael Gabriel
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alexander Kroiss
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Elisabeth von Guggenberg
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Rupert Prommegger
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Boris Warwitz
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Nilica
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Llanos Geraldo Roig
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Margarida Rodrigues
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christian Uprimny
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics. Eur Radiol 2016; 26:3697-705. [PMID: 26815370 DOI: 10.1007/s00330-016-4216-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 12/30/2015] [Accepted: 01/13/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to determine the frequency of isoattenuating insulinomas, to investigate their clinicopathological features and to assess their regional pancreatic perfusion characteristics. METHODS Institutional review board approval was obtained, and patient informed consent was waived. From July 2010 to June 2014, 170 patients (66 male, 104 female) with endogenous hyperinsulinemic hypoglycemia underwent biphasic contrast-enhanced CT before surgery, and 129 of those patients also received preoperative whole-pancreas CT perfusion. A total of 181 tumours were proved histopathologically after surgery. Enhancement pattern and regional pancreatic perfusion characteristics were analyzed. Clinical features, tumour size and pathological grading were investigated. RESULTS The frequency of isoattenuating tumours was 24.9 %. Tumour size and WHO grading was not significantly different between isoattenuating and hyperattenuating tumours. Tumour-free regions had identical blood flow (BF) regardless of their location (p = 0.35). Isoattenuating tumour-harbouring regions had lower BF compared with hyperattenuating tumour-harbouring regions; both showed higher BF compared with tumour-free neighbourhood regions (all p < 0.01). For patients with isoattenuating tumours, the overall hospital stay was longer (p < 0.01). CONCLUSIONS A substantial subset of insulinomas were isoattenuating on biphasic CT. CT perfusion showed higher BF in tumour-harbouring regions compared to tumour-free regions, providing a clue for tumour regionalization. KEY POINTS • About a quarter of all insulinomas were isoattenuating on biphasic contrast-enhanced CT. • CT perfusion finds tumour-harbouring regions have higher blood-flow compared to tumour-free regions. • CT perfusion provides important information for tumour regionalization, for isoattenuating tumours.
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Falconi M, Eriksson B, Kaltsas G, Bartsch DK, Capdevila J, Caplin M, Kos-Kudla B, Kwekkeboom D, Rindi G, Klöppel G, Reed N, Kianmanesh R, Jensen RT. ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors. Neuroendocrinology 2016; 103:153-71. [PMID: 26742109 PMCID: PMC4849884 DOI: 10.1159/000443171] [Citation(s) in RCA: 904] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Molecular response assessed by (68)Ga-DOTANOC and survival after (90)Y microsphere therapy in patients with liver metastases from neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2015; 43:432-40. [PMID: 26323577 DOI: 10.1007/s00259-015-3178-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/14/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE We investigated the prognostic role of (68)Ga-DOTANOC in patients affected by hepatic metastases from neuroendocrine tumours (NET) undergoing (90)Y radioembolization ((90)Y-RE). METHODS A group of 15 consecutive patients with unresectable NET liver metastases underwent (68)Ga-DOTANOC PET at baseline and 6 weeks after (90)Y-RE. Molecular response was defined as a reduction of >50% in the tumour-to-spleen ratio (ΔT/S). The patients were divided into two groups (responders with ΔT/S >50% and nonresponders with ΔT/S <50%) Patients were followed up by imaging and laboratory tests every 3 months until death or for at least 36 months following (90)Y-RE. Statistical analysis was performed to identify factors predicting overall survival (OS) and progression-free survival (PFS). RESULTS A decrease in T/S ratio was seen in all patients on (68)Ga-DOTANOC PET scans performed after (90)Y-RE. Nine patients were classified as responders and six as nonresponders. The mean OS in all patients was 31.0 months. Responders had a significantly (p < 0.001) longer OS (mean 36.0 ± 2.5 months) and PFS (mean 29.7 ± 3.4 months) than nonresponders. In a multivariate analysis, none of the other examined variables including age, unilobar vs. bilobar locations, bilirubin levels, radiological response or the presence of extrahepatic disease significantly predicted patient outcome. CONCLUSION Molecular response assessed with (68)Ga-DOTANOC PET might be a useful predictor of survival in patients affected by NET liver metastases treated with (90)Y-RE.
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Somatostatin receptor based imaging and radionuclide therapy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:917968. [PMID: 25879040 PMCID: PMC4387942 DOI: 10.1155/2015/917968] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 01/15/2015] [Accepted: 01/20/2015] [Indexed: 01/09/2023]
Abstract
Somatostatin (SST) receptors (SSTRs) belong to the typical 7-transmembrane domain family of G-protein-coupled receptors. Five distinct subtypes (termed SSTR1-5) have been identified, with SSTR2 showing the highest affinity for natural SST and synthetic SST analogs. Most neuroendocrine tumors (NETs) have high expression levels of SSTRs, which opens the possibility for tumor imaging and therapy with radiolabeled SST analogs. A number of tracers have been developed for the diagnosis, staging, and treatment of NETs with impressive results, which facilitates the applications of human SSTR subtype 2 (hSSTr2) reporter gene based imaging and therapy in SSTR negative or weakly positive tumors to provide a novel approach for the management of tumors. The hSSTr2 gene can act as not only a reporter gene for in vivo imaging, but also a therapeutic gene for local radionuclide therapy. Even a second therapeutic gene can be transfected into the same tumor cells together with hSSTr2 reporter gene to obtain a synergistic therapeutic effect. However, additional preclinical and especially translational and clinical researches are needed to confirm the value of hSSTr2 reporter gene based imaging and therapy in tumors.
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Herrmann K, Czernin J, Wolin EM, Gupta P, Barrio M, Gutierrez A, Schiepers C, Mosessian S, Phelps ME, Allen-Auerbach MS. Impact of 68Ga-DOTATATE PET/CT on the management of neuroendocrine tumors: the referring physician's perspective. J Nucl Med 2014; 56:70-5. [PMID: 25500825 DOI: 10.2967/jnumed.114.148247] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
UNLABELLED Somatostatin receptor imaging with (68)Ga-DOTATATE PET/CT (DOTATATE) is increasingly used for managing patients with neuroendocrine tumors. The objective of this study was to determine referring physicians' perspectives on the impact of DOTATATE on the management of neuroendocrine tumors. METHODS A set of 2 questionnaires (pre-PET and post-PET) was sent to the referring physicians of 100 consecutive patients with known or suspected neuroendocrine tumors, who were evaluated with DOTATATE. Questionnaires on 88 patients were returned (response rate, 88%). Referring physicians categorized the DOTATATE findings on the basis of the written PET reports as negative, positive, or equivocal for disease. The likelihood for metastatic disease was scored as low, moderate, or high. The intended management before and changes as a consequence of the PET study were indicated. RESULTS The indications for PET/CT were initial and subsequent treatment strategy assessments in 14% and 86% of patients, respectively. Referring physicians reported that DOTATATE led to a change in suspicion for metastatic disease in 21 patients (24%; increased and decreased suspicion in 9 [10%] and 12 [14%] patients, respectively). Intended management changes were reported in 53 of 88 (60%) patients. Twenty patients (23%) scheduled to undergo chemotherapy were switched to treatments without chemotherapy, and 6 (7%) were switched from watch-and-wait to other treatment strategies. Conversely, 5 patients (6%) were switched from their initial treatment strategy to watch-and-wait. CONCLUSION This survey of referring physicians demonstrates a substantial impact of DOTATATE on the intended management of patients with neuroendocrine tumors.
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Affiliation(s)
- Ken Herrmann
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Czernin
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Edward M Wolin
- Carcinoid/Neuroendocrine Tumor Program, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Pawan Gupta
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin Barrio
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Antonio Gutierrez
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Christiaan Schiepers
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Sherly Mosessian
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michael E Phelps
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin S Allen-Auerbach
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
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