Endocrine tumours of the gastrointestinal tract. Management of metastatic endocrine tumours

Large cell neuroendocrine carcinoma of the colon with brain metastasis: A case report

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Large cell neuroendocrine carcinoma of the colon is rare and aggressive, and its prognosis is very poor.

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Effective treatment of large cell neuroendocrine carcinoma of the colon has not been established.

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If local Large cell neuroendocrine carcinoma is completely resected, the 5-year survival rate has been reported to be 61%.

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Most patients are metastatic and not candidates for curative resection.

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The efficacy of systemic chemotherapy is highest in patients with poorly differentiated neuroendocrine tumors with a combination of cisplatin and etoposide.

Background

Large cell neuroendocrine carcinoma of the colon is rare, and its prognosis is very poor especially when diagnosed at a metastatic stage. Early diagnosis can allow early curative surgery that can increase the survival for more than 5 years.

Case report

We report a 62-year-old man who presented for neurologic signs and symptoms followed by constipation. He was diagnosed with large cell neuroendocrine carcinoma of the colon with brain metastasis. Patient was treated with right hemi colectomy due to obstructive gastro-intestinal symptoms, followed by chemotherapy (cisplatin and etoposide).

Discussion

Because of its rarity, effective treatment of large cell neuroendocrine carcinoma of the colon has not been established. If local large cell neuroendocrine carcinoma is completely resected, the prognosis can be largely influenced, and patients can benefit from a 5-year survival rate of 61% compared to 0% in patients without curative surgery. However, most patients are metastatic and not candidates for curative resection. The efficacy of systemic chemotherapy is highest in patients with poorly differentiated neuroendocrine tumors with a combination of cisplatin and etoposide.

Conclusion

Patient with metastatic large cell neuroendocrine tumor have very poor prognosis with a 1 year survival rate of 10% without curative surgery. Increasing awareness of these types of cancer and their prognosis, may allow better comprehension of the importance of screening to allow early diagnosis and better outcomes. In case of late presentation, palliative surgery is always a must in patients with obstruction, bleeding or perforation.

Resection of Liver Metastases: A Treatment Provides a Long-Term Survival Benefit for Patients with Advanced Pancreatic Neuroendocrine Tumors: A Systematic Review and Meta-Analysis

Purpose

Nonsurgical therapies, including biotherapy, chemotherapy, and liver-directed therapy, provided a limit survival benefit for PNET patients with hepatic metastases. With the development of liver resection technique, there was a controversy on whether to perform a liver resection for these patients.

Methods

A computerized search was made of the Medline/PubMed, EMbase, Cochrane Library, and SinoMed (CBM) before March 2018. A meta-analysis was performed to investigate the differences in the efficacy of liver resection and nonliver resection treatments based on the evaluation of morbidity, 30-day mortality, symptom relief rate, and 1-, 3-, and 5-year survival. Two investigators reviewed all included articles and extracted the data of them. The meta-analysis was performed via Review Manager 5.3 software.

Results

A total of 13 cohort studies with 1524 patients were included in this meta-analysis. Compared with the nonliver resection group, liver resection group had a longer 1-, 3-, and 5-year survival time and a higher symptom relief with an acceptable mortality and morbidity.

Conclusions

Liver resection is a safe treatment and could significantly prolong the long-term prognosis for highly selected patients with resectable liver metastases from PNET. Further randomized, controlled trials are needed.

Clinical Usefulness of Somatostatin Receptor Scintigraphy in Japanese Patients with Gastroenteropancreatic Neuroendocrine Tumors

BACKGROUND/AIMS

Somatostatin receptor (SSTR) scintigraphy (SRS) is the standard imaging modality for evaluation of gastroenteropancreatic neuroendocrine tumor (GEP-NET) in Western countries. However, this modality was not approved in Japan until recently. The purpose of this study was to evaluate the clinical efficacy of SRS for detecting GEP-NET in Japanese patients.

METHODS

Japanese patients with advanced GEP-NET were enrolled and evaluated by the SRS and CT. We also compared SRS and immunohistochemical expression of SSTR type 2a (SSTR2a).

RESULTS

We enrolled 16 patients and the primary sites were the pancreas in 9, the stomach in 1, the small intestine in 2, the colon in 3, and unknown in 1. SRS showed positive findings in 3 (100%) of grade 1 (G1) and in 12 (92.3%) of grade 2 (G2) lesions. In the liver, SRS and CT detected lesions in 13 and 14 cases, respectively. The concordance rate of SSTR2a expression with SRS findings was 93.8% in the whole body and 92.9% in the liver.

CONCLUSIONS

SRS could detect almost all of G1 and G2. SRS could be useful to detect lesions, with a high concordance rate with CT and pathological findings. We confirmed that SRS is a useful and reliable modality for Japanese patients.

Pancreatic neuroendocrine tumors: contemporary diagnosis and management

Pancreatic neuroendocrine tumors (PNETs) are neoplasms that arise from the hormone producing cells of the islets of Langerhans, also known as pancreatic islet cells. PNETs are considered a subgroup of neuroendocrine tumors, and have unique biology, natural history and clinical management. These tumors are classified as 'functional' or 'non-functional' depending on whether they release peptide hormones that produce specific hormone- related symptoms, usually in established patterns based on tumor subtype. This manuscript will review pancreatic neuroendocrine tumor subtypes, syndromes, diagnosis, and clinical management.

Calcitonin-secreting pancreatic endocrine tumors: systematic analysis of a rare tumor entity

OBJECTIVE

Pancreatic endocrine tumors (PETs) are characterized by the presence of hormone syndromes. Reports focusing on calcitonin-secreting PET (CTsPETs) are very rare. This study aimed to define a CTsPET-associated syndrome in regard to chemical, anatomical, and developmental aspects.

METHODS

A computerized MEDLINE search was conducted under the search items: "pancreatic endocrine tumor," "calcitonin," "neuroendocrine pancreatic tumor," and "pancreas." Results of clinical, histopathological, immunohistochemical, and biochemical assessments of all patients identified with CTsPET were registered and statistically analyzed.

RESULTS

Thirty-seven patients with CTsPET were identified. Mean serum calcitonin was elevated to the 89.2-fold of the upper reference value. Main symptoms were watery diarrhea (51.4%) and abdominal pain (35.1%). Most patients (59.5%) presented with metastatic spread at the time of diagnosis. Of all patients, 66.7% were alive after a mean follow-up of 28.9 months. Survival was higher in patients who underwent more aggressive surgical therapies independent from tumor sizes and in those with no metastases at the time of diagnosis.

CONCLUSIONS

High calcitonin levels should always raise suspicion of medullary thyroid carcinomas. However, when thyroid examination remains without pathological findings, a CTsPET should be excluded. An aggressive surgical approach even in cases with large primary tumor sizes may lead to a longer survival.

Synchronous large-cell neuroendocrine carcinoma and adenocarcinoma of the colon

Large-cell neuroendocrine carcinoma of the colon is a rare entity with a prognosis that is usually poor due to the high likelihood of early metastasis. A 61-year-old man had surgery for colon cancer of the transverse colon and cecum. Microscopic examination of the tumor showed that the location was the proximal transverse colon, with small nests containing rosettes and palisading patterns of large tumor cells with faintly granular cytoplasm. The immunohistochemistry was positive for synaptophysin and chromogranins. The tumors were diagnosed as a large-cell neuroendocrine carcinoma of the colon. In addition, the tumor of the cecum showed microscopic findings consistent with a well-differentiated adenocarcinoma. The immunohistochemical panel showed that the tumor was negative for neuroendocrine markers. There were no clinical findings suggestive of hormone hypersecretion. Cancer metastasis was found in the peritoneum section of the small bowel. Postoperative chemotherapy was applied. The patient was alive with good performance after, and there was no sign of tumor progression. This is the first case of a synchronous large-cell neuroendocrine carcinoma and adenocarcinoma of the colon. The patient was treated successfully with debulking surgery and systemic chemotherapy.

Gastric acid hypersecretory states: recent insights and advances

Gastric acid hypersecretory states are characterized by basal hypersecretion of gastric acid and historically include disorders associated with hypergastrinemia, hyperhistaminemia, and those of unknown etiology. Although gastric acid secretion is infrequently measured, it is important to recognize the role of gastric hypersecretion in the symptoms of these disorders because they share several features of pathogenesis and treatment. In this article, recent important articles reporting insights into their diagnosis, pathogenesis, and treatment are reviewed. Particular attention is paid to Zollinger-Ellison syndrome, because it has the most extreme acid hypersecretion of this group of disorders and because numerous recent articles deal with various aspects of the diagnosis, molecular pathogenesis, and treatment of the gastrinoma itself or the acid hypersecretion. Two new hypersecretory disorders are reviewed: rebound acid hypersecretion after the use of proton pump inhibitors and acid hypersecretion with cysteamine treatment in children with cystinosis.

[Minimally invasive resection of neuroendocrine pancreatic tumors]

Pancreatic endocrine tumors (PET) are a heterogeneous group of lesions with an annual incidence of 0.1 to 0.4 per 100,000. They account for 2-4% of pancreatic neoplasms. Due to their mostly small size, some are suited to a laparoscopic approach. Preoperative localization, intraoperative laparoscopic ultrasonography, and considerable experience in pancreatic endocrine surgery and sophisticated laparoscopic techniques are essential for successful laparoscopic treatment of these tumors. If definite or highly suspicious signs of malignancy occur, a conventional open approach should be preferred. Insulinomas and small nonfunctioning PET in the pancreatic body or tail or near the surface of the pancreatic head and not in contact with the portal vein or the main pancreatic duct are suited to a laparoscopic approach. Patients with MEN1 who have insulinomas or small nonfunctioning PET may also benefit from a laparoscopic spleen-preserving distal pancreatic resection. Neither sporadic and MEN1-associated gastrinomas nor the very rare glucagonomas and vasoactive intestinal peptide-producing tumors (vipomas), which are often large and malignant, should also be tackled laparoscopically.

[Contrast medium sonography of neuroendocrine tumors of the gastroenteropancreatic system]

Ultrasonography is at present the primary diagnostic imaging method in patients with abdominal complaints. The innovations in echo enhancers in the last decade in connection with improved software and hardware have substantially extended the diagnostic spectrum of ultrasonography. Thus contrast-enhanced sonography with pulse inversion technology at low mechanical index allows a continuous evaluation of the perfusion of organs and tumors. Neuroendocrine tumors represent a heterogeneous group of endodermal/epithelial tumors, which are often hypervascularized. The morphology and the perfusion behavior of neuroendocrine tumors should be known because the therapeutic options differ substantially from those of other tumors. Contrast-enhanced sonography has already proven to be a valuable alternative in the diagnosis of neuroendocrine neoplasms and their metastases in relation to the established radiological procedures.

Expression pattern and functional relevance of epidermal growth factor receptor and cyclooxygenase-2: novel chemotherapeutic targets in pancreatic endocrine tumors?

OBJECTIVES

Pancreatic endocrine tumors represent morphologically and biologically heterogeneous neoplasms. Well-differentiated endocrine tumors (benign or of uncertain behavior) can be distinguished from well-differentiated and poorly differentiated endocrine carcinomas. Although many well-differentiated endocrine carcinomas show rather low rates of tumor growth, more than two-thirds of pancreatic endocrine carcinomas display distant metastases at the time of diagnosis. As the currently applied therapies beyond surgery only achieve partial or complete response rates of approximately 15%, additional chemotherapeutic targets are needed, especially in the therapy of inoperable and progressive pancreatic endocrine carcinomas.

METHODS

The expression of epidermal growth factor receptor (EGFR) and cyclooxygenase (COX)-2 were investigated in 110 clinically and pathomorphologically well-characterized pancreatic endocrine tumors, using immunohistochemistry and immunoblot analyses. Functional tests were performed using the human pancreas carcinoid cell line BON and the mouse insulinoma cell line beta-TC-3.

RESULTS

The expression of EGFR correlated significantly with the grade of malignancy, increasing from low rates of expression in benign tumors and tumors of uncertain behavior to high rates of expression in well- and poorly differentiated endocrine carcinomas. The expression of COX-2 was independent of the malignant potential, but was more frequently expressed in primary tumors than in metastases. The treatment of the human pancreas carcinoid cell line BON and the mouse insulinoma cell line beta-TC-3 with EGFR and COX-2 inhibitors (monotherapy and combined therapy) resulted in a significant, dose-dependent reduction of cell viability coupled with increased apoptosis.

CONCLUSIONS

Our results suggest that EGFR and COX-2 may represent useful additional chemotherapeutic targets in pancreatic endocrine tumors.

Gastrointestinal neuroendocrine tumors: pancreatic endocrine tumors

Pancreatic endocrine tumors (PETs) have long fascinated clinicians and investigators despite their relative rarity. Their clinical presentation varies depending on whether the tumor is functional or not, and also according to the specific hormonal syndrome produced. Tumors may be sporadic or inherited, but little is known about their molecular pathology, especially the sporadic forms. Chromogranin A appears to be the most useful serum marker for diagnosis, staging, and monitoring. Initially, therapy should be directed at the hormonal syndrome because this has the major initial impact on the patient's health. Most PETs are relatively indolent but ultimately malignant, except for insulinomas, which predominantly are benign. Surgery is the only modality that offers the possibility of cure, although it generally is noncurative in patients with Zollinger-Ellison syndrome or nonfunctional PETs with multiple endocrine neoplasia-type 1. Preoperative staging of disease extent is necessary to determine the likelihood of complete resection although debulking surgery often is believed to be useful in patients with unresectable tumors. Once metastatic, biotherapy is usually the first modality used because it generally is well tolerated. Systemic or regional therapies generally are reserved until symptoms occur or tumor growth is rapid. Recently, a number of newer agents, as well as receptor-directed radiotherapy, are being evaluated for patients with advanced disease. This review addresses a number of recent advances regarding the molecular pathology, diagnosis, localization, and management of PETs including discussion of peptide-receptor radionuclide therapy and other novel antitumor approaches. We conclude with a discussion of future directions and unsettled problems in the field.

Neuroendocrine tumors of the gastrointestinal tract: a decade of experience at the Princess Margaret Hospital

OBJECTIVES

Neuroendocrine tumors (NETs) are uncommon malignancies with variable natural history and often indolent biological behavior. Over the past decade, novel treatment approaches have been developed. The purpose of this study was to review the experience at the Princess Margaret Hospital in treating patients with NET over the past decade.

METHODS

The Princess Margaret Hospital Cancer Registry identified 193 patients with NET of the gastrointestinal tract or unknown primary who had their initial visits between 1992 and 2002. A retrospective chart review was performed.

RESULTS

The median follow-up duration was 22.6 months. Demographics of the entire cohort of 193 patients were: male, 53%; mean age, 56 years; age-adjusted Charlson score 0, 71%. Anatomic distribution of the primary location revealed that 35% were from the foregut, 40% from midgut, 11% from hindgut, and 14% from unknown origin. Pathological distribution demonstrated that 72% were NET/carcinoids, 21% were islet cell tumors, and 6% were small cell carcinomas. At presentation, 53% of patients had distant metastases and 46% had loco-regional disease. Curative surgery was performed in 35% of the cohort, whereas radiotherapy and chemotherapy of any intent were delivered to 13% and 34%, respectively. For the entire cohort, 5-year survival was 58% (95% confidence interval, 50%-67%). In multivariate analysis, age, location of primary, and curative intent of surgery were independent predictors of survival. Of patients who underwent curative surgery, 86% were alive at 5 years.

CONCLUSION

Patients with NET who are offered curative surgery have a good outcome. Distant metastases are commonly found at presentation and portend a worse prognosis. These patients should be evaluated by a multidisciplinary team regarding new approaches to surgery and other therapies.

An orthotopic model of pancreatic somatostatin receptor (SSTR)-positive tumors allows bimodal imaging studies using 3T MRI and animal PET-based molecular imaging of SSTR expression

Somatostatin receptor (SSTR) scintigraphy is currently used as one standard imaging modality in neuroendocrine tumors (NETs). However, future optimization of NET imaging may be achieved with positron emission tomography based methods utilizing more sensitive and specific tracers in combination with computed tomography or magnetic resonance imaging. Here we established an orthotopic mouse model that reflects relevant aspects of human pancreatic NETs such as SSTR expression, dense vascularization and metastatic disease. This model was then utilized to test the feasibility of combined magnetic resonance imaging and animal positron emission tomography. Orthotopic implantation of amphicrine, SSTR-positive pancreatic AR42J cells resulted in rapidly growing tumors, with concomitant metastatic spread into abdominal lymph nodes and peritoneal cavity. Primary tumors as well as their metastases expressed the neuroendocrine markers chromogranin A and synaptophysin. For imaging experiments, the SSTR ligands (68)Ga-DOTATOC or (68)Ga-DOTANOC were injected intravenously, and animals were subsequently examined in an animal positron emission tomography scanner and a clinical 3T (tesla) magnetic resonance imager. All animals showed radionuclide accumulation in the primary tumor. Definite anatomical correlation was achieved using digital image fusion of the positron emission tomography and magnetic resonance imaging data. (68)Ga-DOTANOC strongly accumulated in the tumor tissue (mean 6.6-fold vs. control tissues) when compared to (68)Ga-DOTATOC, which showed a higher renal clearance. In good agreement with the biodistribution data, the kidney-to-tumor ratio was higher for (68)Ga-DOTATOC (2.43-fold vs. 1.75-fold). Consequently, (68)Ga-DOTANOC achieved better signal enhancement in the primary tumor and allowed for detection of metastatic lesions. In summary, we established a novel orthotopic pancreatic SSTR-positive tumor model and used this model to provide proof of principle for the diagnostic combination of SSTR-based molecular imaging and magnetic resonance imaging. Specifically, the animal model allowed the comparative evaluation of (68)Ga-DOTANOC and (68)Ga-DOTATOC, with (68)Ga-DOTANOC providing better tumor-specific accumulation and renal activity. We conclude that this animal model will be of innovative value for further investigation in the imaging of NETs.

X-linked hyper-IgM syndrome associated with poorly differentiated neuroendocrine tumor presenting as obstructive jaundice secondary to extensive adenopathy

X-Linked Hyper IgM Syndrome (XHIGM) is a rare B-cell immunodeficiency disease. Patients with XHIGM are unable to switch immunoglobulin production from IgM to IgG, IgA, and IgE. Patients with XHIGM require periodic intravenous immune globulin to help prevent infections, and are also at risk for a variety of neoplasms. We describe a young man with XHIGM who presented with obstructive jaundice from malignant adenopathy from widespread, poorly differentiated neuroendocrine tumor. This has not previously been reported and represents a new association with XHIGM.

SOCS1 silencing enhances antitumor activity of type I IFNs by regulating apoptosis in neuroendocrine tumor cells

IFN-alpha is commonly used for biotherapy of neuroendocrine carcinomas. However, its antitumor efficacy is often limited due to IFN resistance. In this study, we evaluate the role of suppressor of cytokine signaling protein 1 (SOCS1) in modulating the effects of type I IFNs (IFN-alpha and IFN-beta) in human neuroendocrine BON1 and CM tumor cells. In both cell lines, type I IFNs activated signal transducers and activators of transcription (STAT) and significantly decreased cell viability. However, the effects of IFN-beta were significantly more pronounced than those of IFN-alpha and involved the induction of the intrinsic apoptotic pathway as shown by cleavage of caspase-8, Bid, and caspase-9. Stable overexpression of SOCS1 completely abolished the apoptotic effects of both type I IFNs. In contrast, small interfering RNA (siRNA)-mediated silencing of SOCS1 resulted in strongly enhanced type I IFN signaling as shown by increased and prolonged STAT phosphorylation and stronger induction of apoptosis. Silencing of SOCS1 was associated with down-regulation of basal Bcl-2 and Bcl-xL and up-regulation of basal Bak and Bax, suggesting that reduced SOCS1 expression might lower the threshold of susceptibility to type I IFN-mediated apoptosis by decreasing the ratio of antiapoptotic to proapoptotic molecules. In summary, our results indicate an important role of SOCS1 in IFN resistance of neuroendocrine tumor cells, mediated through negative regulation of type I IFN-induced Jak/STAT signaling. Knocking down SOCS1 by siRNA is a promising new approach to enhance the therapeutic potency of type I IFNs in neuroendocrine tumors.

An aggressive surgical approach leads to long-term survival in patients with pancreatic endocrine tumors

OBJECTIVE

To evaluate the outcome of reoperations in patients with duodenopancreatic neuroendocrine tumors (PETs) in a tertiary referral center.

SUMMARY BACKGROUND DATA

The management of reoperations in PETs is still controversial.

METHODS

A total of 125 patients with PETs that underwent surgery between 1987 and 2004 at our institution were retrospectively evaluated. The diagnosis of PETs was based on clinical symptoms, biochemical tests, and histopathology. Patients with at least one reoperation were analyzed regarding clinical characteristics, pathology, operations, and long-term follow-up.

RESULTS

A total of 33 patients with a median age of 42 years were identified for this study: 13 patients had gastrinomas, 12 patients had nonfunctional islet cell tumors, 6 patients had insulinomas, and 2 patients had vipomas; 24 patients had sporadic NETs, 9 patients had a MEN-1-syndrome; 27 patients had histologically verified malignant tumors; 33 initial operations and 50 reoperations were performed. The initial procedures comprised 27 resections of the primary tumor and 6 explorative laparotomies; 28 of all reoperations were resections of distant metastases, including 15 liver resections; 19 resections of the pancreas or duodenum were performed during reoperations. The overall morbidity and mortality was 45% and 4.8%, respectively. After a median follow-up of 124 months (range, 16-384 months), 27 of 33 patients are still alive, 12 without evidence of disease. All 6 patients with benign tumors are still alive. The 5-, 10-, and actuarial 25-year survival rate for patients with malignant tumors were 81%, 72%, and 36%, respectively. The survival rate was significantly related to the patients age at time of initial operation and better in patients younger than 50 years compared with patients older than 50 years (P = 0.0007), and the presence or development of metastases (none or lymph node metastases versus distant metastases: P = 0.01).

CONCLUSION

We show that an aggressive surgical approach leads to long-term survival in patients with malignant PETs. Although long-term cure can only be achieved in a proportion of patients with malignant PETs, significant long-term palliation can be achieved.

Metastatic tumors in bone marrow: histopathology and advances in the biology of the tumor cells and bone marrow environment

The nonhematopoietic tumors most often diagnosed in the bone marrow are metastatic. Currently, accurate diagnosis of tumor metastasis requires integration of the clinical findings; morphological features; and results of immunohistochemical stains, cytogenetics, and molecular studies. This review focuses on a practical approach to the diagnosis of metastatic tumors in the bone marrow according to current standards of practice and discusses recent advances in understanding of tumor metastasis and the interaction between tumors and the bone marrow environment.

Treatment of Metastatic Disease in Patients with Neuroendocrine Tumors

Gastroenteropancreatic neuroendocrine tumors (GENTs) compromise a heterogeneous group of relatively uncommon neoplasms with a yearly incidence rate of 1.2 to 3.0 per 100,000 population. These tumors share numerous histologic and biologic features, allowing their consideration as a common entity. They are postulated to arise from neuroendocrine cells, but most are not from neural crest origin. Their predominant site of origin is the gastrointestinal tract, where most involve the small intestine and appendix, but are also found in the adrenal medulla, bronchopulmonary system, pancreas, thyroid, parathyroid, and paraganglia cells. A common feature is their often indolent course, but some tumors are poorly differentiated and behave aggressively. This article addresses the surgical management of endocrine malignancies and the treatment of metastatic disease in patients with neuroendocrine tumors.