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Murakami M, Hirahata K, Fujimori N, Yamamoto T, Oda Y, Kozono S, Ueda K, Ito T, Nakamura M, Ogawa Y. Two cases of pancreatic neuroendocrine tumors with ectopic ACTH syndrome during their disease course. Clin J Gastroenterol 2024; 17:363-370. [PMID: 38244178 DOI: 10.1007/s12328-023-01908-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024]
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are rare malignant tumors that occur in the pancreas. They are divided into functioning and non-functioning tumors based on the presence or absence of their specific hormonal hyper-expression symptoms. Adrenocorticotropic hormone (ACTH)-producing PanNETs are rare, functional tumors, and their clinical characteristics and outcomes have not been well reported.Here, we report the cases of two patients with PanNETs who presented with ectopic ACTH syndrome (EAS) during the course of their disease. Case 1 involved a non-functioning PanNET at the time of surgery. During treatment for recurrent liver metastases, the patient presented with EAS and tumor-associated hypercalcemia, probably due to ACTH and parathyroid hormone-related peptide (PTHrP) production from the liver tumor. Case 2 was a gastrinoma, and similar to Case 1, this patient presented with EAS during the treatment of recurrent liver metastases.It is not uncommon for patients with PanNETs to have multiple hormones and develop secondary hormone secretion during their disease course, although tumor phenotypes differ between primary and metastatic sites. In patients with functioning PanNETs, symptom control with anti-hormonal therapy is essential, in addition to anti-tumor therapy, especially for EAS, which is an endocrine emergency disease that requires prompt diagnosis and treatment.
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Affiliation(s)
- Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keisuke Hirahata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Takeo Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shingo Kozono
- Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Keijiro Ueda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Testuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, Fukuoka, Japan
- Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Giannetta E, Sesti F, Modica R, Grossrubatscher EM, Ragni A, Zanata I, Colao A, Faggiano A. What Lies behind Paraneoplastic Hypercalcemia Secondary to Well-Differentiated Neuroendocrine Neoplasms? A Systematic Review of the Literature. J Pers Med 2022; 12:1553. [PMID: 36294693 PMCID: PMC9604936 DOI: 10.3390/jpm12101553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Neuroendocrine neoplasms (NEN) originate from neuroendocrine cells ubiquitously spread throughout the body. Hypercalcemia associated with cancer is the most common life-threatening metabolic disorder in patients with advanced stage cancer. Paraneoplastic hypercalcemia is more commonly associated with hematological malignancies, renal and breast carcinomas, and squamous cell carcinomas, but it has also been described in patients with well-differentiated NEN, where it often remains undiagnosed. Among its causes, systemic secretion of parathyroid hormone-related protein (PTHrP) and ectopic production of 1,25-dihydroxyvitamin D and parathyroid hormone (PTH) may be considered paraneoplastic causes of hypercalcemia. In order to clarify the diagnostic work up of paraneoplastic hypercalcemia in patients with NEN, we perform a systematic review, which is lacking in the literature. METHODS We performed a data search using MEDLINE and SCOPUS including papers from 1961 to 2021. We selected articles on paraneoplastic hypercalcemia associated with well-differentiated NEN. RESULTS The search led to the selection of 78 publications for a total of 114 patients. Pooled data showed that the most frequent primary tumor site associated with paraneoplastic hypercalcemia was pancreatic NEN, followed by Pheochromocytoma. In most cases, paraneoplastic hypercalcemia was caused by PTHrP production and secretion. In more than two thirds of cases, paraneoplastic hypercalcemia was present at the time of NEN diagnosis and, in metachronous cases, was related to local recurrence, distant metastasis development, or tumor progression. In most patients, a combination of therapeutic approaches was employed, and reduction of the tumor burden was essential to control the paraneoplastic syndrome. DISCUSSION The onset of hypercalcemia associated with cancer in patients with well-differentiated NEN represents a major clinical challenge. The complex clinical and therapeutical management of paraneoplastic hypercalcemia implies the need for a multidisciplinary approach, aimed at controlling the clinical syndrome and tumor growth.
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Affiliation(s)
- Elisa Giannetta
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberta Modica
- Department of Clinical Medicine and Surgery, University “Federico II”, 80138 Naples, Italy
| | | | - Alberto Ragni
- Endocrinology and Metabolic Diseases Unit, SS. Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy
| | - Isabella Zanata
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Annamaria Colao
- Department of Clinical Medicine and Surgery, University “Federico II”, 80138 Naples, Italy
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
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Li WX, Miao F, Xu XQ, Zhang J, Wu ZY, Chen KM, Yan FH, Lin XZ. Pancreatic Neuroendocrine Neoplasms: CT Spectral Imaging in Grading. Acad Radiol 2021; 28:208-216. [PMID: 32111466 DOI: 10.1016/j.acra.2020.01.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/26/2020] [Accepted: 01/26/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to define the CT spectral imaging characteristics of pancreatic neuroendocrine neoplasms (PNENs) and evaluate their potential for differential diagnosis of nonlow grade (non-LG) PNENs from low grade (LG) PNENs. MATERIALS AND METHODS CT spectral imaging data of 54 pathologically proven PNENs were retrospectively reviewed. Patients were divided into two groups: 40 cases with grade 1 in LG PNENs group and 14 cases with grade 2 and grade 3 in non-LG PNENs group. RESULTS Gender, calcification, inhomogeneity, invasiveness, PD dilatation, lymph node enlargement, size, normalized iodine (water) concentration in arterial phase (AP) (Iodine (ap)), normalized effective-Z (Zap), slope of normalized CT spectral curves in both AP, and portal venous phase were found to be significant variables for differentiating non-LG PNENs from LG PNENs (p < 0.05). Non-LG PNENs had larger size and lower Zap and Iodine (ap) than LG PNENs. The tumor size, Zap and Iodine (ap) had fair to good diagnostic performance with the area under receiver-operating-characteristic curve (AUC) 0.843, 0.733, and 0.728, respectively. Multivariate analysis with logistic regression had higher AUC (p<0.05) than all the single parameters except for size. CONCLUSION There were significant differences in CT spectral imaging parameters between non-LG and LG PNENs. Tumor size was the most promising independent parameter and the combination of quantitative parameters with qualitative parameters is the best predictor in differentiating of non-LG PNENs from LG PNENs. CT spectral imaging can help determine the malignancy of PNENs, which can better assist in surgical planning.
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Affiliation(s)
- Wei-Xia Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fei Miao
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xue-Qin Xu
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Zhang
- Department of Radiology, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Jiading, Shanghai, China
| | - Zhi-Yuan Wu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ke-Min Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fu-Hua Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao-Zhu Lin
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai, China.
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Symington M, Davies L, Kaltsas G, Weickert MO. Malignant hypercalcaemia related to parathyroid hormone-related peptide (PTHrP) secretion from a metastatic pancreatic neuroendocrine tumour (NET). BMJ Case Rep 2017; 2017:bcr2017219692. [PMID: 28331027 PMCID: PMC5372178 DOI: 10.1136/bcr-2017-219692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 11/04/2022] Open
Abstract
A 54-year-old woman presented to our centre with acute abdominal pain and vomiting. Routine blood tests showed severe hypercalcaemia (>4 mmol/L). Serum parathyroid hormone (PTH) was suppressed. CT scan detected a pancreatic mass and some liver lesions, initially suspicious for metastatic pancreatic adenocarcinoma. Liver biopsy however revealed the presence of a well-differentiated, grade 1, metastatic neuroendocrine tumour (NET) where prognosis is considerably better. Serum PTHrP was raised, indicating paraneoplastic hypercalcaemia, most likely secondary to the pancreatic NET. Following injection of a short-acting somatostatin analogue octreotide, serum PTHrP levels normalised within 24 hours, causing a rapid drop of serum calcium below the lower limit of normal and an immediate compensatory rise of serum PTH. Ongoing treatment with long-acting somatostatin analogues together with replacement with calcium carbonate, vitamin D3 and once weekly alendronic acid resulted in stable normal adjusted calcium levels over a 3-month follow-up period.
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Affiliation(s)
- Megan Symington
- The ARDEN NET Centre, ENETS CoE, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Louise Davies
- The ARDEN NET Centre, ENETS CoE, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Gregory Kaltsas
- The ARDEN NET Centre, ENETS CoE, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Martin O Weickert
- The ARDEN NET Centre, ENETS CoE, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Ghazi AA, Amirbaigloo A, Dezfooli AA, Saadat N, Ghazi S, Pourafkari M, Tirgari F, Dhall D, Bannykh S, Melmed S, Cooper O. Ectopic acromegaly due to growth hormone releasing hormone. Endocrine 2013; 43:293-302. [PMID: 22983831 PMCID: PMC3553305 DOI: 10.1007/s12020-012-9790-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/31/2012] [Indexed: 12/20/2022]
Abstract
Acromegaly secondary to extra-pituitary tumors secreting growth hormone releasing hormone (GHRH) is rarely encountered. We review the literature on ectopic acromegaly and present the index report of ectopic acromegaly secondary to GHRH secretion from a mediastinal paraganglioma. Clinical and pathological manifestations and therapeutic management of 99 patients with ectopic acromegaly are reviewed. Acromegaly secondary to ectopic GHRH secretion is usually caused by a neuroendocrine tumor in the lung and pancreas. We report an additional cause of ectopic acromegaly from a mediastinal paraganglioma. Diagnostic criteria of ectopic GHRH syndrome include biochemical and pathologic tumoral confirmation of GHRH secretion and expression. Management of ectopic acromegaly consists of surgical resection of the primary tumor and biochemical normalization, with possible adjuvant use of somatostatin analogs. The review demonstrates that there are several tumor types, including paragangliomas which may secrete GHRH, leading to acromegaly. Clinical and laboratory manifestations of the syndrome and challenges in diagnosis and management of these rarely encountered patients require early diagnosis and appropriate treatment to prevent long-term morbidity and mortality with ectopic acromegaly.
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Affiliation(s)
- Ali A Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Amirbaigloo
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azizollah Abbasi Dezfooli
- Department of Thoracic Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Navid Saadat
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siavash Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marina Pourafkari
- Department of Radiology, Taleghani General Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farrokh Tirgari
- Department of pathology, Imam Khomeini General Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Dheepti Dhall
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Serguei Bannykh
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Odelia Cooper
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Vinik AI, Gonzales MRC. New and emerging syndromes due to neuroendocrine tumors. Endocrinol Metab Clin North Am 2011; 40:19-63, vii. [PMID: 21349410 DOI: 10.1016/j.ecl.2010.12.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neuroendocrine tumors (NETs) are rare, slow-growing neoplasms characterized by their ability to store and secrete different peptides and neuroamines. Some of these substances cause specific clinical syndromes whereas others are not associated with specific syndromes or symptom complexes. NETs usually have episodic expression that makes diagnosis difficult, erroneous, and often late. For these reasons a high index of suspicion is needed, and it is important to understand the pathophysiology of each tumor to decide which biochemical markers are more useful and when they should be used.
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Affiliation(s)
- Aaron I Vinik
- Eastern Virginia Medical School, Strelitz Diabetes Center, 855 West Brambleton Avenue, Norfolk, VA 23510, USA.
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Shirai K, Inoue I, Kato J, Maeda H, Moribata K, Shingaki N, Ueda K, Deguchi H, Maekita T, Iguchi M, Yanaoka K, Tamai H, Oka M, Kawai M, Yamaue H, Yasuoka H, Nakamura Y, Iso-O N, Ichinose M. A case of a giant glucagonoma with parathyroid hormone-related peptide secretion showing an inconsistent postsurgical endocrine status. Intern Med 2011; 50:1689-94. [PMID: 21841327 DOI: 10.2169/internalmedicine.50.5357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 53-year-old woman was admitted because of a giant pancreatic tumor. Hypercalcemia and a high serum parathyroid hormone-related peptide (PTHrP) level were observed. A hypoglycemic attack occurred during pancreatectomy, and the surgical specimen revealed a PTHrP-secreting glucagonoma. Liver metastases developed 1 and 5.5 years later, and bone metastases appeared 6 years after surgery. Her serum PTHrP concentrations remained normal after surgery, despite re-elevation of the serum glucagon concentration after recurrence. The clinical course of this case illustrates the process of development of neuroendocrine tumors secreting two or more hormones.
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Affiliation(s)
- Kiyokazu Shirai
- The Second Department of Internal Medicine, Wakayama Medical University, Japan.
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Morita Y, Suzuki S, Sakaguchi T, Oishi K, Suzuki A, Fukumoto K, Inaba K, Baba S, Takehara Y, Konno H. Pancreatic neuroendocrine cell tumor secreting parathyroid hormone-related protein and gastrin: Report of a case. Surg Today 2010; 40:1192-6. [PMID: 21110169 DOI: 10.1007/s00595-009-4190-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Accepted: 11/19/2009] [Indexed: 10/18/2022]
Abstract
This report presents a case of pancreatic neuroendocrine cell carcinoma with multiple liver metastases secreting gastrin and parathyroid hormone-related protein (PTHrP) related to lumbar bone fracture and hypercalcemia. A 58-year-old woman visited an affiliated hospital with a chief complaint of lumbago without any evidence of trauma. She was diagnosed with hepatic dysfunction and hypercalcemia as well as multiple lumbar compression fractures without osteolytic lesions. Abdominal computed tomography (CT) showed a hypervascular mass in the pancreatic tail and multiple liver tumors. Duodenal ulcers were found with gastrointestinal endoscopy. There was a marked increase in the serum gastrin level. She was diagnosed as gastrinoma with multiple liver metastases and was admitted to the hospital. She had an increase in serum PTHrP level without the elevation of intact parathyroid hormone at the time of admission. She underwent an extended right hepatectomy in addition to a distal pancreatectomy with a regional lymphadenectomy and splenectomy. The postoperative course was uneventful, and serum gastrin and PTHrP activities reduced to normal levels. She remained symptom-free, and serum calcium, gastrin, and PTHrP levels remain within the normal ranges 19 months after surgery without adjuvant therapy.
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Affiliation(s)
- Yoshifumi Morita
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Kulke MH, Anthony LB, Bushnell DL, de Herder WW, Goldsmith SJ, Klimstra DS, Marx SJ, Pasieka JL, Pommier RF, Yao JC, Jensen RT. NANETS treatment guidelines: well-differentiated neuroendocrine tumors of the stomach and pancreas. Pancreas 2010; 39:735-52. [PMID: 20664472 PMCID: PMC3100728 DOI: 10.1097/mpa.0b013e3181ebb168] [Citation(s) in RCA: 370] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Well-differentiated neuroendocrine tumors (NETs) of the stomach and pancreas represent 2 major subtypes of gastrointestinal NETs. Historically, there has been little consensus on the classification and management of patients with these tumor subtypes. We provide an overview of well-differentiated NETs of the stomach and pancreas and describe consensus guidelines for the treatment of patients with these malignancies.
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Affiliation(s)
- Matthew H Kulke
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston MA 02115, USA.
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Contrast-enhanced sonography of nonfunctioning pancreatic neuroendocrine tumors. AJR Am J Roentgenol 2009; 192:424-30. [PMID: 19155405 DOI: 10.2214/ajr.07.4043] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Diagnosis of malignancy and prognostic assessment continue to be problems in the management of nonfunctioning pancreatic endocrine tumors. Histologic examination is the reference standard. The aim of our study was to compare B-mode and contrast-enhanced sonographic findings regarding nonfunctioning pancreatic endocrine tumors. Signs of malignancy, such as Ki67 index and presence of hepatic metastasis, were considered. MATERIALS AND METHODS We retrospectively reviewed the cases of 38 consecutively registered patients with nonfunctioning pancreatic endocrine tumors evaluated with B-mode and contrast-enhanced sonography and resected. At contrast-enhanced sonography all lesions were divided into hypovascular lesions and isovascular or hypervascular lesions. On the basis of homogeneity of enhancement, lesions were classified as homogeneous and inhomogeneous. During the late phase of contrast enhancement, all solid focal hypoechoic liver lesions detected at contrast-enhanced sonography were considered hepatic metastatic lesions. Among pathologic data, grading, mitotic index, and Ki67 index were evaluated. Spearman's test was used to compare contrast-enhanced sonographic enhancement pattern with pathologic grade. RESULTS In the arterial phase, 24 of 38 nonfunctioning pancreatic endocrine tumors (63.1%) were hypervascular, seven (18.4%) were isovascular, and seven (18.4%) were hypovascular. Positive correlation was found between contrast-enhanced sonographic findings and Ki67 index (r(s) = 0.62; p < 0.0001). The difference between contrast-enhanced and B-mode sonography in the diagnosis of nonfunctioning pancreatic endocrine tumors was statistically significant (p < 0.05). Use of contrast-enhanced sonography increased diagnostic confidence in the detection of hepatic metastasis. The areas under the receiver operating characteristic curves were 0.916 for B-mode sonography and 1.000 for contrast-enhanced sonography (p < 0.05). There was moderate positive correlation between contrast-enhanced sonographic enhancement pattern and the presence of hepatic metastasis at diagnosis (r(s) = 0.46; p = 0.004) and between Ki67 index and the presence of hepatic metastasis (r(s) = 0.48; p = 0.0022). CONCLUSION The contrast-enhanced sonographic enhancement pattern of nonfunctioning pancreatic endocrine tumors has a positive correlation with Ki67 index, which is considered the most reliable independent predictor of the presence of malignancy.
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Müssig K, Petersenn S, Wehrmann M, Horger M, Vierling P, Häring HU, Gallwitz B. Somatostatin receptor expression in a parathyroid hormone-related peptide-secreting pancreatic neuroendocrine tumour causing severe hypercalcaemia. Eur J Gastroenterol Hepatol 2007; 19:719-23. [PMID: 17625444 DOI: 10.1097/01.meg.0000223908.00987.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Humoral hypercalcaemia is a common complication of malignancy with parathyroid hormone-related protein (PTHrP) as a major cause. Breast and lung cancer are relatively common sources of ectopic PTHrP secretion leading to increased osteoclastic bone resorption. CASE REPORT We report the rare case of a 40-year-old man with severe hypercalcaemia due to a PTHrP-secreting poorly differentiated endocrine carcinoma of the pancreas. On immunohistochemistry, the tumour was positive for PTHrP and somatostatin receptors sst1, sst2, and sst3, whereas sst4 and sst5 were not detected. We demonstrate the transient improvement of hypercalcaemia after adding octreotide to the treatment mainstays in hypercalcaemia of malignancy (fluid repletion, administration of bisphosphonates, loop diuretics, and glucocorticoids). CONCLUSION To the best of our knowledge, this is the first report showing somatostatin receptor expression in a PTHrP-secreting pancreatic neuroendocrine tumour.
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Affiliation(s)
- Karsten Müssig
- Department of Endocrinology, University Hospital of Internal Medicine, University of Tübingen, Germany.
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Mittendorf EA, Shifrin AL, Inabnet WB, Libutti SK, McHenry CR, Demeure MJ. Islet Cell Tumors. Curr Probl Surg 2006; 43:685-765. [PMID: 17055796 DOI: 10.1067/j.cpsurg.2006.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Only relatively recently has there been an increased clinical recognition and characterization of the heterogeneous group of rare gastroenteropancreatic neuroendocrine neoplasms. Most have endocrine function and exhibit varying degrees of malignancy. This review summarizes the derivation of these tumors and the advances in their diagnosis and treatment over the past decade and a half. They are varied in their biological behavior and clinical courses and, depending on their cell type, can produce different hormones causing distinct clinical endocrine syndromes (insulinoma [hypoglycemia], gastrinoma [Zollinger-Ellison syndrome (ZES)], vasoactive intestinal peptideoma [VIPoma], watery diarrhea, hypokalemia-achlorhydria [WDHA], glucagonoma [glucagonoma syndrome], and so forth). In addition to surgery for cure or palliation (by excision and a variety of other cytoreductive techniques), they each are treated with anti-hormonal agents or drugs targeted to each tumor's specific product or its effects. The majority have benefited from the gut hormone-inhibiting action of somatostatin analogs. Because of their usual slow rate of growth it is recommended that, even when they are advanced and incurable, unlike in patients with common and more malignant cancers, patients with neuroendocrine tumors often can be palliated and appear to survive longer when managed with an active approach using sequential multimodality treatment. Advances in these various therapies are reviewed and the beneficial emergence of global self-help patient support groups is noted.
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Affiliation(s)
- Richard R P Warner
- Gastrointestinal Division, Department of Medicine, The Mount Sinai School of Medicine, New York, New York 10128, USA.
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Ichimura T, Kondo S, Okushiba S, Morikawa T, Katoh H. A calcitonin and vasoactive intestinal peptide-producing pancreatic endocrine tumor associated with the WDHA syndrome. ACTA ACUST UNITED AC 2004; 33:99-102. [PMID: 14716055 DOI: 10.1385/ijgc:33:2-3:99] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although pancreatic endocrine tumor can produce a variety of hormones, few pancreatic tumors produce a high systemic calcitonin concentration. Furthermore, calcitonin-producing pancreatic tumors rarely produce elevations of VIP in addition. METHODS We evaluated and treated a 50-yr-old woman with the WDHA syndrome. Abdominal computed tomography (CT) detected a tumor in the tail of the pancreas. Peripheral plasma calcitonin and VIP concentrations were markedly increased to 2000 pg/mL (normal, <74 pg/mL) and 7200 pg/mL (normal, <100 pg/mL), respectively. We diagnosed a calcitonin- and VIP-producing pancreatic endocrine tumor, which was removed by distal pancreatectomy including splenectomy. RESULTS Plasma calcitonin and VIP were determined in blood from the vein draining the tumor and splenic vein, sampled at operation. These secreted concentrations were extremely high: 4640 and 3610 pg/mL for calcitonin; 24700 and 13500 pg/mL for VIP. Calcitonin and VIP were also highly elevated in the resected tumor. Plasma calcitonin and VIP rapidly decreased after tumor resection. The patient has been well without recurrence for over 20 yr. CONCLUSION An unusual pancreatic tumor secreting vasoactive intestinal peptide (VIP) caused WDHA syndrome (watery diarrhea, hypokalemia, and achlorhydria/hypochlorhydria) and also hypercalcemia. The latter was only partially offset by a large excess of calcitonin also secreted by the tumor.
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Affiliation(s)
- Tatsunosuke Ichimura
- Hokkaido University Graduate School of Medicine, Division of Cancer Medicine, Cancer Medicine, Surgical Oncology, Sapporo, Japan.
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Dionisi S, Minisola S, Pepe J, De Geronimo S, Paglia F, Memeo L, Fitzpatrick LA. Concurrent parathyroid adenomas and carcinoma in the setting of multiple endocrine neoplasia type 1: presentation as hypercalcemic crisis. Mayo Clin Proc 2002; 77:866-9. [PMID: 12173721 DOI: 10.4065/77.8.866] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We describe a patient with multiple endocrine neoplasia type 1 characterized by the simultaneous occurrence of parathyroid cancer, parathyroid adenomas, and pancreatic gastrinoma, who presented with an episode of acute hypercalcemia. The rapid parathyroid hormone assay provided a basis for the diagnosis of parathyroid hyperfunction. Mediastinal metastasis of the parathyroid carcinoma was found at autopsy. However, the staining of pancreatic and gastric tissue for parathyroid hormone-related protein does not make it possible to exclude completely the contribution of this peptide in mediating the hypercalcemia. To our knowledge, this is the first reported case of parathyroid carcinoma as part of the multiple endocrine neoplasia type 1 syndrome.
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Affiliation(s)
- Simona Dionisi
- Department of Clinical Sciences, University of Rome La Sapienza, Italy
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17
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Takeuchi Y, Fukumoto S, Nakayama K, Tamura Y, Yanagisawa A, Fujita T. Parathyroid hormone-related protein induced coupled increases in bone formation and resorption markers for 7 years in a patient with malignant islet cell tumors. J Bone Miner Res 2002; 17:753-7. [PMID: 12009004 DOI: 10.1359/jbmr.2002.17.5.753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Parathyroid hormone-related protein (PTHrP) and PTH share the common PTH/PTHrP receptor. Although an elevated level of circulating PTHrP in patients with malignancies causes hypercalcemia as does PTH, chronic and systemic effects of PTHrP on bone metabolism in humans are not well understood because tumor-burden patients showing hypercalcemia usually have a poor prognosis. We investigated bone and calcium metabolism in a patient with malignant islet cell tumors showing hypercalcemia due to the elevated plasma PTHrP level for 7 years. Hypercalcemia and hypercalciuria continued throughout the clinical course in spite of frequent infusions of bisphosphonates. Bone resorption markers and a bone formation marker were consistently elevated as seen in primary hyperparathyroidism, a disease caused by an autonomous hypersecretion of PTH. Based on biochemical measurements including bone markers and serum 1,25-dihydroxyvitamin D, the clinical features of this case essentially are the same as those of primary hyperparathyroidism except for the elevated level of plasma PTHrP with suppressed intact PTH level. Therefore, it is suggested that chronic and systemic effects of PTHrP on bone as well as calcium metabolism are indistinguishable from those of PTH in human.
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Affiliation(s)
- Yasuhiro Takeuchi
- Department of Medicine, University of Tokyo School of Medicine, Japan
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18
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Papazachariou IM, Virlos IT, Williamson RCN. Parathyroid hormone-related peptide in pancreatic neuroendocrine tumours associated with hypercalcaemia. HPB (Oxford) 2001; 3:221-5. [PMID: 18333019 PMCID: PMC2020623 DOI: 10.1080/136518201753242253] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypercalcaemia is a common paraneoplastic syndrome. In the context of pancreatic neuroendocrine tumours, it is occasionally caused by secretion of parathyroid hormone-related peptide (PTH-rP). CASE OUTLINES Two patients are reported in whom persistent hypercalcaemia was traced to a large neuroendocrine pancreatic tumour hypersecreting PTH-rP. Resection of the tumour reduced serum levels of calcium and PTH-rP transiently in each case until the patient developed bulky metastatic disease. A 33-year-old woman remained hypercalcaemic after the removal of all four hyperplastic parathyroid glands had rendered circulating parathormone levels undetectable. Radical distal pancreatectomy was followed over the next 4 years by operative debulking of liver metastases, multiple hepatic artery embolisations, octreotide injections and repeated admissions for intravenous fluid and biphosphonate therapy. A 41-year-old man presented with hypercalcaemia as well as features of somatostatinoma syndrome. Symptomatic improvement after radical distal pancreatectomy was short-lived, and hepatic artery embolisation failed to control his rapidly progressive disease. DISCUSSION Malignant hypercalcaemia associated with a neuroendocrine pancreatic tumour hypersecreting PTH-rP is difficult to treat and can be life-threatening. Aggressive surgical treatment is recommended initially, while somatostatin analogues and hepatic artery embolisation are alternative therapeutic options for metastatic disease.
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Affiliation(s)
| | - IT Virlos
- Department of Surgery, Hammersmith HospitalLondonUK
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19
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Abstract
Pancreatic endocrine tumors arise from the amine precursor uptake and decarboxylation (APUD) cells of the pancreas and behave in a different fashion both biologically and clinically from pancreatic adenocarcinoma. Gastrinomas and insulinomas are the two most common pancreatic endocrine tumors. Unlike pancreatic adenocarcinoma, in which tumor stage, resectability, and prognosis are determined by the tumor, nodes, and metastasis (TNM) classification, the prognosis of pancreatic endocrine tumors is determined by the presence of liver but not regional lymph node metastasis. This review focuses predominantly on the different diagnostic tools available to the clinician and the relative merits of each modality. The sensitivities of computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, endoscopic ultrasound, and angiography with venous sampling for diagnosing islet cell tumors are compared. A diagnostic algorithm for the management of these tumors is provided at the end of the discussion.
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Affiliation(s)
- L Somogyi
- Division of Digestive Diseases, University of Cincinnati, 231 Bethesda Avenue, Cincinnati, OH 45267-0595, USA.
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20
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Abstract
Pancreatic endocrine tumors (PET's) can be divided on a clinical and pathologic basis into ten classes [insulinomas, gastrinomas (Zollinger-Ellison syndrome), VIPomas (Verner-Morrison syndrome, WDHA, pancreatic cholera), glucagonomas, somatostatinomas, ACTH-releasing tumors (ACTHomas), growth hormone-releasing factor secreting tumors (GRFomas), nonfunctioning or pancreatic polypeptide secreting tumors (non-functioning PET), PET's causing carcinoid syndrome and PET's causing hypercalcemia)]. Recent reports suggest calcitonin-secreting PET's also rarely occur but whether they cause a distinct clinical syndrome is unclear. PET's resemble carcinoid tumors histologically; in their ability to synthesize and frequently secrete multiple peptides such as neuroendocrine cell markers (chromogranins); their biologic behavior and their tumor growth patterns. Both groups of tumors are highly vascular, have high densities of somatostatin receptors and similar tumor localization studies including somatostatin receptor scintigraphy are used for both. PET's, similar to carcinoids causing the carcinoid syndrome, require two separate treatment options be considered: treatment directed against the hormone-excess state and treatment directed against the tumor per se because of their malignant nature. In the last few years there have been advances in tumor diagnosis, localization methods, treatment approaches particularly related to the use of synthetic somatostatin analogues, and the definition of the role of surgical procedures in these diseases. Important other advances include insights into the long-term natural history of PET's particularly from studies of gastrinomas, which allow prognostic factors to be identified and the timing of treatment options to better planned, as well as insights into the molecular basis of these disorders. The latter includes both a description of the molecular basis of the genetic inherited syndromes associated with PET's or carcinoid tumors, as well as an increased understanding of the molecular basis for sporadic PET's or carcinoid tumors. Each of these areas will be briefly highlighted in this presentation.
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Affiliation(s)
- R T Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
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21
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Kakizaki S, Ohya N, Yoshinaga T, Higuchi T, Kitazawa R, Takayama H, Takagi H, Nagamine T, Mori M. Undifferentiated pancreatic cancer associated with humoral hypercalcemia of malignancy. Jpn J Clin Oncol 1998; 28:563-6. [PMID: 9793031 DOI: 10.1093/jjco/28.9.563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We present a case of undifferentiated pancreatic cancer associated with humoral hypercalcemia of malignancy (HHM) in which parathyroid hormone-related protein (PTH-rP) is identified as the causative factor of hypercalcemia. A 61-year-old man was hospitalized with right hypochondralgia. Ultrasound examination and computed tomography demonstrated a large mass in the pancreatic head with liver metastases. Biopsy of the pancreatic tumor demonstrated undifferentiated carcinoma. Serum calcium level and PTH-rP were elevated. Bone scan with technetium-99 demonstrated no accumulation in the bones. Immunohistochemical staining for PTH-rP was weakly positive in the tumor cells. We considered that PTH-rP was the causative factor of HHM in this case from laboratory data and immunohistochemical findings. This rare case was successfully treated with pamidronate disodium, which is a type of bisphosphonate derivative. We compared this case with previously reported cases.
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Affiliation(s)
- S Kakizaki
- Department of Internal medicine, Saiseikai Maebashi Hospital, Japan.
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22
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Wu TJ, Lin CL, Taylor RL, Kvols LK, Kao PC. Increased parathyroid hormone-related peptide in patients with hypercalcemia associated with islet cell carcinoma. Mayo Clin Proc 1997; 72:1111-5. [PMID: 9413289 DOI: 10.4065/72.12.1111] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To report the high prevalence of increased parathyroid hormone-related peptide (PTHrP) in patients with islet cell carcinoma and associated hypercalcemia. DESIGN We conducted a retrospective study of PTHrP levels in patients with hypercalcemia and eucalcemia associated with islet cell carcinoma and compared these findings with those in healthy subjects. MATERIAL AND METHODS Using a sensitive PTHrP immunochemiluminometric assay, we measured PTHrP levels in 17 patients with islet cell carcinoma and 110 healthy subjects. The differences between PTHrP levels in patients with normal and those with high serum calcium concentrations were analyzed statistically. RESULTS PTHrP levels were significantly higher (P < 0.01) in 10 patients with hypercalcemia and islet cell carcinoma (median, 14.0 pmol/L; range, undetectable to 40.1) than in 7 patients with eucalcemia and islet cell carcinoma (median, undetectable; range, undetectable to 1.3 pmol/L) or in the 110 healthy subjects (median, undetectable; range, undetectable to 4.2 pmol/L). The range of increased PTHrP levels in hypercalcemic islet cell carcinoma was 2 to 20 times the upper normal limit (2.0 pmol/L). Decreased PTHrP and serum calcium and increased parathyroid hormone levels were demonstrated in two patients after effective therapy. For all seven eucalcemic patients with islet cell carcinoma, PTHrP levels did not differ significantly from those in healthy subjects. CONCLUSION PTHrP levels are increased in a substantial proportion of patients with hypercalcemia and islet cell carcinoma and seem to decrease after treatment of the underlying tumor. Measurement of PTHrP levels may be useful for confirming the diagnosis of hypercalcemia associated with malignant disease and for monitoring of therapy.
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Affiliation(s)
- T J Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, MN 55905, USA
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Goldstone AP, Scott-Coombes DM, Lynn JA. Surgical management of gastrointestinal endocrine tumours. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1996; 10:707-36. [PMID: 9113319 DOI: 10.1016/s0950-3528(96)90020-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The surgical management of gastrointestinal endocrine tumours must involve a multidisciplinary approach. The importance of accurate diagnosis, rendering the patient safe, and, in our opinion, localizing the tumour(s) before embarking on surgery cannot be overemphasized. Surgery is the only available treatment for cure. Occult primary tumours are now rarely a problem with novel imaging techniques, which can also improve detection and hence clearance of local spread. Surgical management in extensive metastatic or multicentric disease is less rigidly defined, and is dependent on the endocrine syndrome. A better understanding of tumour pathology, for example in MEN 1, has not always simplified matters. An appreciation of the benefit of chemotherapy, use of somatostatin analogues and hepatic artery embolization are vital to target appropriate palliative surgery. Hepatic transplantation may have an increasing role in the future. Surgical strategies must adapt to new medical treatments. If therapeutically relevant, advances in tumour biology (for example somatostatin receptor subtypes and growth factors) will influence surgical strategies in the future.
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Affiliation(s)
- A P Goldstone
- Department of Endocrinology and Metabolism, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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