Neuroendocrine Tumors

Diagnosis and Surgical Treatment of Gastroenteropancreatic Neuroendocrine Neoplasms: A Literature Review

This review aimed to highlight the characteristics and surgical treatments of tumours, and answer questions regarding the assessment of gastrointestinal neuroendocrine neoplasms (NENs) and optimal therapy. NENs comprise tumours that can produce hormones and cause a secretory syndrome. The diagnostic method and accuracy differ depending on the site of occurrence; hence, the relevant scientific society has created NEN treatment guidelines for each organ. Gastroenteric pancreatic (GEP) NENs have been unified and classified together according to the 2019 World Health Organization classification. Treatment is based on complete tumour resection, and when metastatic or primary lesions cannot be completely resected, lesions and symptoms are treated. Except for surgery for NENs, chemotherapy, molecularly targeted drugs, transarterial chemoembolization, etc., have also been confirmed as treatments. GEP NEN treatment methods will continue to advance and change because of surgery and other advances in treatment and diagnostic methods.

68Ga-DOTATATE PET/CT versus 111In-octreotide scintigraphy in patients with neuroendocrine tumors: a prospective study

Objective

To compare ⁶⁸Ga-DOTA-DPhe1,Tyr3-octreotate (⁶⁸Ga-DOTATATE) positron-emission tomography/computed tomography (PET/CT) findings with those of conventional ¹¹¹In-octreotide scintigraphy in patients with neuroendocrine tumors (NETs).

Materials and Methods

This was a single-center prospective study including 41 patients (25 males; mean age, 55.4 years) with biopsy-proven NETs who underwent whole-body ¹¹¹In-octreotide scintigraphy and whole-body ⁶⁸Ga-DOTATATE PET/CT. The patients had been referred for tumor staging (34.1%), tumor restaging (61.0%), or response evaluation (4.9%). Images were compared in a patient-by-patient analysis to identify additional lesions, and we attempted to determine the impact that discordant findings had on treatment planning.

Results

Compared with ¹¹¹In-octreotide scintigraphy, ⁶⁸Ga-DOTATATE PET/CT revealed more lesions, the additional lesions typically being in the liver or bowel. Changes in management owing to the additional information provided by ⁶⁸Ga-DOTATATE PET/CT occurred in five patients (12.2%), including intermodal changes in three (7.3%) and intramodal changes in two (4.9%). In addition, ⁶⁸Ga-DOTATATE PET/CT yielded incidental findings unrelated to the primary NET in three patients (7.3%): Hürthle cell carcinoma of the thyroid, bowel non-Hodgkin lymphoma, and a suspicious breast lesion.

Conclusion

We conclude that ⁶⁸Ga-DOTATATE PET/CT is superior to conventional ¹¹¹In-octreotide scintigraphy for the management of NETs because of its ability to determine the extent of the disease more accurately, which, in some cases, translates to changes in the treatment plan.

Risk Factors Associated with the Development of Metastases in Patients with Gastroenteropancreatic Neuroendocrine Tumors: A Retrospective Analysis

Neuroendocrine tumors develop from systemic endocrine and nerve cells, and their occurrence has increased recently. Since these tumors are heterogeneous, pathological classification has been based on the affected organ. In 2019, the World Health Organization introduced a change expected to influence neuroendocrine tumor research, as gastroenteropancreatic neuroendocrine tumors are now included within a unified classification. This retrospective study aimed to investigate the characteristics (e.g., lymph node metastases and all other metastases) of gastroenteropancreatic neuroendocrine tumors using this new classification in 50 cases. Tumor size, depth, MIB-1 index, lymphatic invasion, venous invasion, and neuroendocrine tumor grade were significantly correlated with lymph node metastasis and other metastases. The venous invasion was more strongly correlated with lymph node metastasis and all other types of metastases than with lymphatic invasion. Identification rates for lymphatic invasion were considered lower because of structural problems such as lymphatic vessels being much thinner than veins. However, venous invasion was considered effective in compensating for the low identification rate in cases of lymphatic invasion. In future research, a unified classification and standardized framework for assessment will be important when analyzing the characteristics of neuroendocrine tumors, and large-scale studies are required.

Ultrasonography in infectious and neoplastic diseases of the bowel and peritoneum

Ultrasonography is not the most cited imaging technique for the evaluation of infectious and neoplastic diseases of the gastrointestinal tract and the peritoneum, but it is often the initial technique used in the initial workup for nonspecific clinical syndromes. Despite its limitations, ultrasonography's strengths enable it to provide meaningful diagnostic information. To discuss the most important ultrasonographic, clinical, and epidemiological findings for infectious disease, we follow a topographical approach: stomach (Anisakis), proximal small bowel (Giardia lamblia, Strongyloides stercoralis, Mycobacterium avium-intracellulare complex, and Cryptosporidium), distal small bowel (Yersinia, Salmonella, and Campylobacter), terminal ileum and cecum (tuberculosis), right colon (Entamoeba histolytica), left colon (Shigella), sigmoid colon and rectum, pancolitis (Clostridium difficile, Cytomegalovirus, and Escherichia coli), and peritoneum. To discuss the ultrasonographic and clinical findings of the most common neoplastic diseases, we follow a nosological approach: polyploid lesions as precursors of tumors, carcinomas, neuroendocrine tumors, hematological tumors, mesenchymal tumors, and metastases. We briefly discuss tumors of the peritoneum and the use of ultrasonography to guide percutaneous biopsy procedures.

Racial/Ethnic Disparities and Survival Characteristics in Non-Pancreatic Gastrointestinal Tract Neuroendocrine Tumors

Simple Summary

The impact of race and ethnicity on survival characteristics in non-pancreatic gastrointestinal tract neuroendocrine tumors is understudied. We evaluated the survival outcomes and racial/ethnic disparities in the gastrointestinal tract neuroendocrine tumors, including the esophagus, stomach, small intestine, colon, rectum, and appendix. Survival trends were determined among three groups: Hispanic, non-Hispanic White, and non-Hispanic Black. We analyzed a large national database and found that race/ethnicity is an independent prognostic factor in patients with gastrointestinal neuroendocrine tumors. Hispanic patients had better overall survival than non-Hispanic White patients, whereas non-Hispanic Black patients had favorable cause-specific survival compared to non-Hispanic White patients. This survival disparity can be attributed to differences in the site of origin, age, and stage at presentation between various race/ethnicity. Understanding these differences between race and ethnicity is needed to reduce disparities in cancer outcomes.

Abstract

Background: We studied the effect of race and ethnicity on disease characteristics and survival in gastrointestinal neuroendocrine tumors. Methods: The Surveillance, Epidemiology, and End Results database was used to select patients with non-pancreatic gastrointestinal neuroendocrine tumors diagnosed between 2004 and 2015. Trends in survival were evaluated among three groups: Hispanic, non-Hispanic White, and non-Hispanic Black. Kaplan–Meier and Cox regression methods were performed to calculate overall survival and cause-specific survival after adjusting for patient and tumor characteristics. Results: A total of 26,399 patients were included in the study: 65.1% were non-Hispanic White, 19.9% were non-Hispanic Black, and 15% were Hispanic. Non-Hispanic White patients were more likely to be male (50.0%, p < 0.001), older than 60 years (48.0%, p < 0.001), and present with metastatic disease (17.7%, p < 0.001). Non-Hispanic White patients had small intestine neuroendocrine tumors, while Hispanic and non-Hispanic Black patients had rectum neuroendocrine tumors as the most common primary site. Hispanic patients had better overall survival, while non-Hispanic Black patients had better cause-specific survival versus non-Hispanic White patients. This finding was confirmed on multivariable analysis where Hispanic patients had improved overall survival compared to non-Hispanic White patients (Hazard ratio (HR): 0.89 (0.81–0.97)), whereas non-Hispanic Black patients had better cause-specific survival compared to non-Hispanic White patients (HR: 0.89 (0.80–0.98)). Conclusions: Race/ethnicity is an independent prognostic factor in patients with gastrointestinal neuroendocrine tumors.

Insuficiencia cardíaca por un síndrome carcinoide: un reto diagnóstico. Reporte de caso

Introducción. La insuficiencia cardiaca es una patología frecuente que no solo es causada por isquemia miocárdica, hipertensión o valvulopatías, sino también por un gran número de enfermedades; sin embargo, en la práctica, muy pocas veces se aborda su etiología, y, por lo tanto, su manejo usualmente es sintomático, situación que puede afectar la efectividad del tratamiento, ya que es sabido que un diagnóstico etiológico oportuno puede mejorar el pronóstico de cualquier enfermedad. Los principales signos clínicos del tumor carcinoide típico son diarrea, flushing facial y broncoespamos, sin embargo el compromiso cardiaco también ha sido descrito en pacientes con esta condición (menos del 20%).Presentación del caso. Paciente masculino de 77 años que acudió al servicio de urgencias con un cuadro clínico de insuficiencia cardiaca descompensada. Teniendo en cuenta la pobre respuesta del paciente ante el manejo propuesto y la evidencia de diarrea crónica, se realizaron varios estudios diagnósticos, lo que permitió diagnosticarlo con un tumor neuroendocrino.Conclusiones. La insuficiencia cardíaca es una patología frecuente en la población general, sin embargo la identificación temprana de causas poco comunes, tales como el síndrome carcinoide, permitirá implementar un manejo oportuno e identificar complicaciones asociadas como la cardiopatía carcinoide, lo que tendrá un impacto positivo en la calidad de vida y pronóstico del paciente.

Double contrast-enhanced ultrasonography of a small intestinal neuroendocrine tumor: a case report of a recommendable imaging modality

A 57-year-old male presenting with spontaneously relieved abdominal cramp and distension was admitted to the West China Hospital. The diagnosis remained unclear after colonoscopy and computed tomography. Double contrast-enhanced ultrasonography was then performed and a neoplasm in the small intestine was suspected, supported by a thin-section computed tomography and positron emission tomography/computed tomography. This was confirmed pathologically after surgery to be a small intestinal G1 neuroendocrine tumor. Surgery was performed to remove approximately 25 cm of small bowel and a 3-cm solid mass located in the mesentery. The patient had a complete recovery and was tumor-free at the final follow-up. Small intestinal tumors including neuroendocrine tumors have always posed a diagnostic challenge. This case indicated that double contrast-enhanced ultrasonography is feasible in detection of small intestinal neuroendocrine tumors, and it may be an advisable approach assisting diagnosis of small intestinal tumors.

The journey from gene knockout to clinical medicine: telotristat and sotagliflozin

Gene knockout has been a powerful technique to evaluate the physiologic role of selected gene products. Lexicon pioneered high-throughput gene knockout technology and went further in designing agents to inhibit products of gene expression. Two agents have entered late-stage development. Telotristat is an inhibitor of tryptophan hydroxylase (TPH), preventing the production of serotonin. Although this agent blocks the two isoforms of TPH, it does not cross the blood–brain barrier, thus avoiding central neurologic manifestations. It inhibits the peripheral production of serotonin, and in particular prevents serotonin action in the intestines, resulting in decreased peristaltic action. Lexicon successfully developed telotristat to treat carcinoid syndrome not responding adequately to somatostatin inhibitors. Sotagliflozin development proceeded from the observation that dual inhibition of SGLT2 in the kidneys and SGLT1 in the intestines resulted in increased renal glucose excretion, reduced early-phase glucose absorption, as well as increased blood levels of GLP-1 and PYY. Initial development efforts focused on type 1 diabetes and have shown reduced postprandial glucose levels, less tendency to hypoglycemia, and lower HbA1c. Several other SGLT2 inhibitors have been associated with increased frequency of diabetic ketoacidosis (DKA). In the type 1 trials, sotagliflozin-treated individuals experienced DKA at a higher rate than placebo-treated patients. The sotagliflozin development program has now been extended to trials on type 2 diabetes. Long-term clinical trials will determine the benefits and risks of the agent in comparison to other currently marketed SGLT2 inhibitors.

Prognostic value of inflammation-based markers in advanced or metastatic neuroendocrine tumours

Background

The role of systemic inflammation-based markers remains uncertain in advanced or metastatic neuroendocrine tumours (nets).

Methods

Systemic inflammatory factors, such as levels of circulating white blood cells and other blood components, were combined to yield inflammation-based prognostic scores [high-sensitivity inflammation-based Glasgow prognostic score (hsgps), neutrophil:lymphocyte ratio (nlr), platelet:lymphocyte ratio (plr), high-sensitivity inflammation-based prognostic index (hspi), and prognostic nutritional index (pni)], whose individual values as prognostic markers were retrospectively determined. Univariate and multivariate analyses were used to examine the association of inflammatory markers with overall survival (os).

Results

The study included 135 patients. Univariate analysis revealed that elevated white blood cell count, elevated neutrophil count, low serum albumin, elevated high-sensitivity C-reactive protein, and elevated hspi, hsgps, and nlr scores were significantly associated with worse os. Multivariate analyses demonstrated that, apart from pathology grade and original site of the tumour, elevated hspi (p = 0.004) was an independent prognostic factor for worse os.

Conclusions

In the present study, elevated pretreatment hspi was observed to be an independent predictor of shorter os in patients with inoperable advanced or metastatic net. The hspi might thus provide additional guidance for therapeutic decision-making in such patients.

Delays and routes to diagnosis of neuroendocrine tumours

Background

Neuroendocrine tumours are uncommon tumours; there is often a long period between the onset of symptoms and diagnosis. This study aims to address the symptoms prior to diagnosis of people with known neuroendocrine tumours and also the involvement of healthcare providers prior to the diagnosis.

Methods

A web based survey was designed to cover two broad areas of patient symptoms and healthcare interactions prior to diagnosis. This was tested and adapted by patient and clinician input prior to distribution via Survey Monkey.

Results

The results demonstrated a median time from first symptom to diagnosis of 53.8 months. The most frequent initial symptoms were of pain, change in bowel habit and fatigue. 31% of respondents noted weight loss prior to diagnosis. 80% of respondents visited their GP regarding the symptoms a median of 11 times. 58% of respondents were referred to secondary care where they were seen a median 3 times. 30% presented acutely to A&E and this led to their diagnosis.

Conclusion

In conclusion, there is a long time from onset of symptoms to diagnosis in all types of NETs. This is despite many respondents having alarm symptoms at diagnosis. Further education and awareness regarding malignancy may help with earlier diagnosis.

Pan-Cancer Molecular Classes Transcending Tumor Lineage Across 32 Cancer Types, Multiple Data Platforms, and over 10,000 Cases

Purpose: The Cancer Genome Atlas data resources represent an opportunity to explore commonalities across cancer types involving multiple molecular levels, but tumor lineage and histology can represent a barrier in moving beyond differences related to cancer type.Experimental Design: On the basis of gene expression data, we classified 10,224 cancers, representing 32 major types, into 10 molecular-based "classes." Molecular patterns representing tissue or histologic dominant effects were first removed computationally, with the resulting classes representing emergent themes across tumor lineages.Results: Key differences involving mRNAs, miRNAs, proteins, and DNA methylation underscored the pan-cancer classes. One class expressing neuroendocrine and cancer-testis antigen markers represented ∼4% of cancers surveyed. Basal-like breast cancers segregated into an exclusive class, distinct from all other cancers. Immune checkpoint pathway markers and molecular signatures of immune infiltrates were most strongly manifested within a class representing ∼13% of cancers. Pathway-level differences involving hypoxia, NRF2-ARE, Wnt, and Notch were manifested in two additional classes enriched for mesenchymal markers and miR200 silencing.Conclusions: All pan-cancer molecular classes uncovered here, with the important exception of the basal-like breast cancer class, involve a wide range of cancer types and would facilitate understanding the molecular underpinnings of cancers beyond tissue-oriented domains. Numerous biological processes associated with cancer in the laboratory setting were found here to be coordinately manifested across large subsets of human cancers. The number of cancers manifesting features of neuroendocrine tumors may be much higher than previously thought, which disease is known to occur in many different tissues. Clin Cancer Res; 24(9); 2182-93. ©2018 AACR.

Prescription patterns of long-acting somatostatin analogues

Background:

Acromegaly and endocrine tumors are uncommon morbidities that are currently treated with different drugs.

Objective:

To determine the prescription patterns of somatostatin analogues in patients affiliated with the Health System of Colombia.

Methods:

Retrospective cohort study of patients of any age and sex treated with octreotide or lanreotide between January 2011 and August 2015. Socio-demographic, clinical (indications) and pharmacological (comedications) variables were considered. Multivariate analysis was performed with SPSS 23.0.

Results:

We identified 289 patients, with a mean age of 56.6 ± 14.0 years and female predominance (59.5%), who underwent treatment during the 56 months of monitoring. Octreotide was used in 56.1% of cases, followed by lanreotide (43.9%), both at approved doses. We found that 4.5% of subjects changed from one drug to another over the course of therapy, which was associated with being diabetic and receiving insulin (odds ratio: 4.27; 95% confidence interval: 1.23–14.84; p = 0.014). The most common indications were acromegaly (52.2% of cases) followed by neuroendocrine tumors (15.9%). The most common comorbidities were hypertension (39.4% of cases), depression (27.3%), dyslipidemia (23.3%), diabetes mellitus (23.5%) and hypothyroidism (23.5%). Being male (odds ratio: 0.57; 95% confidence interval: 0.35–0.94; p = 0.029) and belonging to the age group between 45 and 65 years (odds ratio: 0.44; 95% confidence interval: 0.21–0.90; p = 0.024) were significantly associated with a lower risk of receiving comedications.

Conclusion:

Somatostatin analogues are being used at recommended doses, especially in patients with acromegaly and neuroendocrine tumors. Variables associated with change in therapy were identified.