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Yu S, Ge M, Zhang C, Chen L, Zhao L. Diagnosis and comprehensive treatment of a glucagonoma in a patient with residual intrahepatic metastases postoperatively: A case report and literature review. Oncol Lett 2024; 27:202. [PMID: 38516680 PMCID: PMC10955682 DOI: 10.3892/ol.2024.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/01/2024] [Indexed: 03/23/2024] Open
Abstract
Glucagonomas are rare neuroendocrine neoplasms of the pancreas with malignant potential. At present, their epidemiology is not entirely clear, so clinicians are not well versed, lacking any consensus on diagnosis or comprehensive treatment. The present study reports the case of a 32-year-old woman hospitalized for recurrent glossitis, perioral dermatitis and necrolytic migratory erythema (NME) of both lower limbs. Imaging studies revealed a low-density nodule (~2 cm) in the tail of the pancreas, as well as multiple space-occupying hepatic lesions. Surgical intervention was then selected, and distal pancreatectomy, splenectomy and palliative metastasectomies were performed. Tissue examination subsequently confirmed a primary pancreatic neuroendocrine tumor (grade 2), metastatic to the liver. The NME resolved postoperatively, aided by intramuscular injections of long-acting release octreotide (30 mg) every 28 days. A series of three percutaneous ablative treatments (microwave ablation) were also undertaken within a 2-year period, targeting the liver metastases. The present condition of the patient is good, with no cutaneous relapse to date. Palliative metastasectomies, in conjunction with ablative treatments and combination somatostatin analog (SSA) use, are unique aspects of this case that, to the best of our knowledge, have yet to be documented in the literature. Surgical palliation may benefit patients with liver involvement and prolong their survival time. Likewise, ablative treatments and SSA injections delivered together not only address hepatic spread, but also control hormone-related symptoms, having a positive impact on prognosis. As glucagonomas are so rare, there is no real agreement on their management. The present study aims to guide clinical practice by adding further to the available data.
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Affiliation(s)
- Shenghui Yu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Muxi Ge
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Cheng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lang Chen
- Department of Pancreatic and Biliary Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lei Zhao
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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Calpin GG, Davey MG, Calpin P, Browne F, Lowery AJ, Kerin MJ. The impact of liver resection on survival for patients with metastatic breast cancer - A systematic review and meta-analysis. Surgeon 2023; 21:242-249. [PMID: 36333192 DOI: 10.1016/j.surge.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION There is uncertainty surrounding the role of resection as an option for curative treatment of breast cancer with liver metastases (BCLM). AIM To perform a systematic review and meta-analysis evaluating the role of liver resection for BCLM. METHODS A systematic review was performed as per PRISMA guidelines. Hazard ratio (HR) for overall survival (OS) and standard error was obtained from each study and expressed using the generic inverse variance method, with a corresponding 95% confidence interval (CI). OS outcomes at 1- 3- and 5-years were expressed as dichotomous variables and pooled as odds ratios (OR) using the Mantel-Haenszel method. RESULTS Nine studies with 1732 patients were included. Of these, 24.5% underwent surgical resection of BCLM (424/1732) and 75.5% did not (1308/1732). Overall, OS was significantly better among those who underwent surgery versus controls (HR: 0.69, 95% CI: 0.59-0.80, P < 0.00001). Mortality rates were significantly reduced at 1-year (7.5% (10/134) vs 20.3% (79/390), OR: 0.25, 95% CI: 0.08-0.74, P = 0.010) and 5-years (54.0% (190/352) vs 75.3% (940/1249), OR: 0.46, 95% CI: 0.25-0.87, P = 0.020) respectively for those undergoing surgery versus controls. Mortality rates at 3 years after surgery were lower than the control group (19.1% (29/152) vs 53.0% (222/419)), however this failed to achieve statistical significance at meta-analysis (OR: 0.32, 95% CI: 0.09-1.12, P = 0.070). CONCLUSION Liver resection may be considered at multidisciplinary meetings for those with BCLM and offers a potentially curative option. However, judicious patient selection is crucial prior to making decisions in relation to resection of BCLM.
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Affiliation(s)
- Gavin G Calpin
- Department of Surgery, University Hospital Galway, Galway, Ireland.
| | - Matthew G Davey
- Department of Surgery, University Hospital Galway, Galway, Ireland; Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Pádraig Calpin
- Department of Anaesthesiology, University Hospital Galway, Galway, Ireland
| | - Ferdia Browne
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - Aoife J Lowery
- Department of Surgery, University Hospital Galway, Galway, Ireland; Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Michael J Kerin
- Department of Surgery, University Hospital Galway, Galway, Ireland; Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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Parghane RV, Bhandare M, Chaudhari V, Ostwal V, Ramaswamy A, Talole S, Shrikhande SV, Basu S. Surgical Feasibility, Determinants, and Overall Efficacy of Neoadjuvant 177Lu-DOTATATE PRRT for Locally Advanced Unresectable Gastroenteropancreatic Neuroendocrine Tumors. J Nucl Med 2021; 62:1558-1563. [PMID: 33637590 PMCID: PMC8612336 DOI: 10.2967/jnumed.120.258772] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/01/2021] [Indexed: 01/11/2023] Open
Abstract
We assessed 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) in the neoadjuvant setting in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs). We also evaluated the variables associated with resectability of the primary tumor after PRRT. Methods: This study included 57 GEP-NET patients who had a primary tumor that was unresectable (because of vascular involvement as defined using the pancreatic ductal adenocarcinoma criteria of the National Comprehensive Cancer Network) and who underwent 177Lu-DOTATATE therapy without any prior surgery. They were categorized into 2 groups: 23 patients without liver metastases (group 1) and 34 patients with potentially resectable liver metastases (group 2). 177Lu-DOTATATE was administered with mixed amino acid-based renal protection at a dose of 7.4 GBq (200 mCi) per cycle. Surgical resectability was evaluated using triphasic contrast-enhanced abdominal CT imaging at 3 different time points during the PRRT course. Four broad categories of overall PRRT response were evaluated. The Kaplan-Meier product-limit method was used to calculate progression-free survival (PFS) and overall survival (OS). Associations between variables and a resectable primary tumor after PRRT were analyzed using the χ2 test, with a P value of less than 0.05 considered statistically significant. Results: After 177Lu-DOTATATE therapy, the unresectable primary tumor became resectable in 15 of 57 (26.3%) patients (7 patients in group 1 and 8 patients in group 2). A complete or partial response to PRRT was seen in 48 patients (84%), 23 patients (40%), 18 patients (31%), and 23 patients (40%) using symptomatic, biochemical, molecular imaging, and anatomic imaging criteria, respectively. Estimated rates of PFS were 95% and 90% at 2 y in groups 1 and 2, respectively. The 2-y OS of the 2 groups combined was 92.1%. The rate at which the primary tumor was resectable after PRRT was significantly higher in patients who had duodenal neuroendocrine tumors, patients who had GEP-NETs with no regional lymph node involvement, patients for whom the primary tumor was smaller than 5 cm, patients for whom liver metastases were no larger than 1.5 cm, patients for whom there were no more than 3 liver metastases, and patients for whom 18F-FDG uptake in the primary tumor had an SUVmax of less than 5. Conclusion: In a moderate fraction of GEP-NET patients, with or without liver metastases, whose primary tumor was unresectable because of vascular involvement, the primary tumor converted from unresectable to resectable after 177Lu-DOTATATE therapy, signifying that neoadjuvant PRRT can be considered in such patients. The effective control of symptoms, favorable morphologic and functional imaging response, and durable PFS and OS that we observed after 177Lu-DOTATATE PRRT may lead to less morbidity and mortality in these patients.
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Affiliation(s)
- Rahul V Parghane
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Manish Bhandare
- Homi Bhabha National Institute, Mumbai, India
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikram Chaudhari
- Homi Bhabha National Institute, Mumbai, India
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India; and
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India; and
| | - Sanjay Talole
- Homi Bhabha National Institute, Mumbai, India
- Department of Biostatistics, Tata Memorial Centre, Mumbai, India
| | - Shailesh V Shrikhande
- Homi Bhabha National Institute, Mumbai, India
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, India;
- Homi Bhabha National Institute, Mumbai, India
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A Comparison of Liver-Directed Therapy and Systemic Therapy for the Treatment of Liver Metastases in Patients with Gastrointestinal Neuroendocrine Tumors: Analysis of the California Cancer Registry. J Vasc Interv Radiol 2021; 32:393-402. [PMID: 33358144 DOI: 10.1016/j.jvir.2020.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To compare the outcomes of patients with gastrointestinal neuroendocrine tumor liver metastases treated with liver-directed therapy (LDT) to those treated with systemic therapy (ST) in a statewide cancer database. MATERIALS AND METHODS A retrospective study was performed of patients with metastatic gastrointestinal tract neuroendocrine tumors treated with either LDT or ST alone between the years 2000-2012 in the California Cancer Registry. Overall survival and disease-specific survival were assessed using multivariable Cox proportional hazards analysis and propensity score matching. RESULTS A total of 154 patients (ST, n = 87 and LDT, n = 67) were studied. The median overall survival and disease-specific survival for patients that received ST was 29 and 35 months versus 51 and >60 months for patients that received LDT. On multivariate analysis, LDT and the resection of the primary tumor were associated with improved survival (hazard ratio [HR] 0.52, P = .002; HR 0.43, P = .001). Non-white race, Medicaid/uninsured status, and the presence of lung metastases were associated with poor survival (HR 1.76, P = .014; HR 2.29, P = .009; and HR 1.79, P = .031). Propensity score matching demonstrated an improvement in disease-specific survival for LDT compared to ST (HR 0.53, P = .036). The improvement in overall survival on propensity score matching did not achieve statistical significance (HR 0.70, P = .199). CONCLUSIONS LDT is associated with improved overall and disease-specific survival as compared to ST in patients with gastrointestinal neuroendocrine tumor liver metastases. Further investigation is needed to determine whether combination or sequential treatment can improve outcomes in this population.
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Rindi G, Wiedenmann B. Neuroendocrine neoplasia of the gastrointestinal tract revisited: towards precision medicine. Nat Rev Endocrinol 2020; 16:590-607. [PMID: 32839579 DOI: 10.1038/s41574-020-0391-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/06/2023]
Abstract
Over the past 5 years, a number of notable research advances have been made in the field of neuroendocrine cancer, specifically with regard to neuroendocrine cancer of the gastrointestinal tract. The aim of this Review is to provide an update on current knowledge that has proven effective for the clinical management of patients with these tumours. For example, for the first time in the tubular gastrointestinal tract, well-differentiated high-grade (grade 3) tumours and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) are defined in the WHO classification. This novel classification enables efficient identification of the most aggressive well-differentiated neuroendocrine tumours and helps in defining the degree of aggressiveness of MiNENs. The Review also discusses updates to epidemiology, cell biology (including vesicle-specific components) and the as-yet-unresolved complex genetic background that varies according to site and differentiation status. The Review summarizes novel diagnostic instruments, including molecules associated with the secretory machinery, novel radiological approaches (including pattern recognition techniques), novel PET tracers and liquid biopsy combined with DNA or RNA assays. Surgery remains the treatment mainstay; however, peptide receptor radionuclide therapy with novel radioligands and new emerging medical therapies (including vaccination and immunotherapy) are evolving and being tested in clinical trials, which are summarized and critically reviewed here.
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Affiliation(s)
- Guido Rindi
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Bertram Wiedenmann
- Charité, Campus Virchow Klinikum and Charité Mitte, University Medicine Berlin, Berlin, Germany
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Abstract
The liver is a common site of metastatic cancer spread, and metastatic lesions are the most common malignant liver tumors. Diagnosis of liver metastases often is established based on clinical assessment, laboratory tests, and appropriate imaging. Surgical resection is the treatment of choice for resectable colorectal and neuroendocrine liver metastases. Long-term survival outcome data after treatment of hepatic metastases of noncolorectal non-neuroendocrine tumors are less robust. The treatment strategy for patients with liver metastases should be determined case by case in a multidisciplinary setting.
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Affiliation(s)
- Nikdokht Rashidian
- Department of GI Surgery, Ghent University Hospital, C. Heymanslaan 10, 2K12C Route1275, UZ Gent, Ghent 9000, Belgium
| | - Adnan Alseidi
- Division of Pancreas, Liver and Biliary Surgery, Virginia Mason Medical Center, Virginia Mason HPB Surgery, 1100 Ninth Avenue, MC GS C6, Seattle, WA 98101, USA.
| | - Russell C Kirks
- Division of Pancreas, Liver and Biliary Surgery, Virginia Mason Medical Center, Virginia Mason HPB Surgery, 1100 Ninth Avenue, MC GS C6, Seattle, WA 98101, USA
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Abstract
OPINION STATEMENT Carcinoid syndrome (CS) is a complex disorder caused by functional neuroendocrine tumors (NETs). This debilitating disease is characterized by hyper-secretion of biologically active substances eliciting major hormonal symptoms burden and fibrotic changes that are often challenging for management. There have been a number of insights that have substantially advanced treatments since the introduction of somatostatin analogs (SSAs). Second-line treatments are needed in a substantial proportion of patients with advanced disease that have uncontrolled hormone secretion on the highest labeled doses of SSAs. International guidelines suggest several available options including dose escalation of SSAs, interferon alpha, everolimus, radionuclide therapy, liver-directed therapies, and the novel tryptophan hydroxylase 1 inhibitor, telotristat ethyl. The clear preference of one second-line therapy over the other is not stated since their relative and long-term efficacy are largely unknown, and standardized approach of hormonal response assessment is lacking in the literature. In the clinical setting, the treatment of CS is guided in conjunction with patients' performance status, tumor origin, grade, stage, and growth rate, with regard to both anti-hormonal, as well as anti-proliferative effect. There is an unmet need for further well-designed randomized placebo-controlled and head-to-head studies that systematically assess CS symptom control and biochemical response following a specific intervention.
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Vilatobá M, Hurtado-Gómez S, García-Juárez I, Huitzil-Melendez D, Gamboa-Domínguez A. Liver transplantation in a patient with metastatic neuroendocrine tumor: A first report in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:414-416. [PMID: 31257111 DOI: 10.1016/j.rgmx.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/28/2018] [Accepted: 09/06/2018] [Indexed: 10/26/2022]
Affiliation(s)
- M Vilatobá
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - S Hurtado-Gómez
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - I García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - D Huitzil-Melendez
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - A Gamboa-Domínguez
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
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Liver transplantation in a patient with metastatic neuroendocrine tumor: A first report in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2018.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Phase I Trial of Dose-escalated Whole Liver Irradiation With Hepatic Arterial Fluorodeoxyuridine/Leucovorin and Streptozotocin Followed by Fluorodeoxyuridine/Leucovorin and Chemoembolization for Patients With Neuroendocrine Hepatic Metastases. Am J Clin Oncol 2019; 41:326-331. [PMID: 26886946 DOI: 10.1097/coc.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We have previously shown that refractory neuroendocrine tumors can respond to moderate doses of chemoradiotherapy. We completed a dose-escalation phase I/II trial combining hepatic arterial (HA) chemotherapy, chemoembolization, and dose-escalated whole liver radiotherapy to determine the maximum safe dose of radiation that could be delivered and to make a preliminary assessment of response. MATERIALS AND METHODS From 2002 to 2009, 19 patients with symptomatic neuroendocrine liver metastases who failed somatostatin analog therapy were enrolled. HA fluorodeoxyuridine, leucovorin, and streptozotocin were delivered, as concurrent whole liver radiotherapy was dose escalated from 24 to 32 Gy in 2 Gy fractions, with a target rate of dose-limiting grade ≥3 radiation-induced liver disease of 10%. Eight weeks later, for patients without grade ≥3 liver or grade ≥4 any toxicity, a 72-hour infusion of HA fluorodeoxyuridine and leucovorin was given, followed by transarterial chemoembolization. RESULTS Eleven patients completed the entire protocol and received 24 to 32 Gy. No patients developed radiation-induced liver disease; 7 had grade 3 to 4 transiently increased liver function tests, and 4 had other grade 4 toxicities. Three patients (14%) had partial response, 16 (84%) stable disease. Median freedom from local progression and overall survival were 35.3 and 54.6 months, respectively. CONCLUSIONS Thirty-two in 2 Gy daily fractions can be delivered safely when combined with HA chemotherapy and subsequent transarterial chemoembolization. However, although objective responses were observed, this combination was not significantly better than our prior approaches. Further treatment intensification strategies, including individualized dose escalation for radiation-tolerant livers, and improved radiosensitization should be investigated, along with improved systemic therapy.
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Lv Y, Han X, Xu XF, Ji Y, Zhou YH, Sun HC, Zhou J, Fan J, Lou WH, Huang C. Risk factors affecting prognosis in metachronous liver metastases from WHO classification G1 and G2 gastroenteropancreatic neuroendocrine tumors after initial R0 surgical resection. BMC Cancer 2019; 19:335. [PMID: 30961559 PMCID: PMC6454726 DOI: 10.1186/s12885-019-5457-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/12/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Here we describe the treatments and prognosis for metachronous metastases from gastroenteropancreatic neuroendocrine tumors (GEP-NETs) after initial R0 surgical resection at a large center in China. METHODS The clinicopathological data and survival outcomes for 108 patients (median age, 54.0 years) with metachronous hepatic metastatic GEP-NETs disease who were initially treated using R0 surgical resection between August 2003 and July 2014 were analyzed using one-way comparisons, survival analysis, and a predictive nomogram. RESULTS Fifty-five (50.9%) patients had pancreatic NETs and 92 (85.2%) had G2 primary tumors. For treatment of the hepatic metastases, 48 (44.4%) patients received liver-directed local treatment (metastasectomy, radiofrequency ablation, transcatheter arterial chemoembolization, etc.), 15 (13.9%) received systemic treatment (interferon, somatostatin analogs, etc.), and 45 (41.7%) received both treatments. Multivariable analyses revealed that OS was associated with hepatic tumor number (P < 0.001), treatment modality (P = 0.045), and elevated Ki-67 index between the metastatic and primary lesions (P = 0.027). The predictive nomogram C-index was 0.63. CONCLUSIONS A higher Ki-67 index in metastases compared to primary tumor was an independent factor for poor prognosis. Local treatment was associated with prolonged survival of hepatic metastatic GEP-NET patients. Optimal treatment strategies based on clinicopathological characteristics should be developed.
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Affiliation(s)
- Yang Lv
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Xu Han
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Xue-Feng Xu
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Yuan Ji
- 0000 0004 1755 3939grid.413087.9Department of Pathology, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Yu-Hong Zhou
- 0000 0004 1755 3939grid.413087.9Department of Oncology, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Hui-Chuan Sun
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Jian Zhou
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Jia Fan
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Wen-Hui Lou
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Cheng Huang
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
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Cho CM. Recent Updates in the Management of Advanced Pancreatic Neuroendocrine Tumors. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:124-131. [PMID: 31013555 DOI: 10.4166/kjg.2019.73.3.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/07/2019] [Accepted: 02/14/2019] [Indexed: 12/30/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms arising from the pancreatic islet of Langerhans and can be functioning or non-functioning based on the clinical symptoms caused by hormonal secretions. PNETs are the second most common tumor of the pancreas and represent 1-2% of all pancreatic neoplasms. The incidence of pNETs appears to be rising and the prognosis seems to be improving, likely due to the improved treatment options. Recent updates of the World Health Organization classification and grading separate pNETs into 2 broad categories according to the histopathologic criteria, including the Ki-67 proliferative index and mitotic counts: well-differentiated NET and poorly-differentiated neuroendocrine carcinoma (NEC). The classification also incorporates a new subcategory of well-differentiated high-grade NEC (grade 3) to the well-differentiated NET category. This new classification algorithm aims to improve the prediction of the clinical outcomes and survival and help clinicians select better therapeutic strategies for patient care and management. The treatment of advanced or metastatic pNETs may include surgical resection, liver-directed therapies, and/or systemic treatments. In unresectable patients, the goals of these therapies are to palliate the tumor-related symptoms and prolong the lifespan. Systemic therapy consists of the following broad modalities: somatostatin analogues, molecular targeted therapy, systemic chemotherapy, and peptide receptor radionuclide therapy. In conclusion, pNETs are diagnosed increasingly throughout the world, usually with metastatic disease and requiring systemic therapy. Each patient should be evaluated thoroughly and discussed individually by a multidisciplinary and dedicated NET-expert team, which might consider all treatment options, including ongoing clinical trials before selecting the appropriate treatment sequence.
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Affiliation(s)
- Chang Min Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea,Center for Pancreatobiliary Tumors, Kyungpook National University Chilgok Hospital, Daegu, Korea
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Takase Y, Naito Y, Okabe Y, Ishida Y, Yamaguchi T, Abe H, Murata K, Ito T, Tanigawa M, Kawahara A, Yano H, Akiba J. Insulinoma-associated protein 1 expression in pancreatic neuroendocrine tumours in endoscopic ultrasound-guided fine-needle aspiration cytology: An analysis of 14 patients. Cytopathology 2018; 30:194-200. [PMID: 30290028 DOI: 10.1111/cyt.12640] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Insulinoma-associated protein 1 (INSM1) has been reported to be a useful marker for diagnosing pancreatic neuroendocrine tumours (PNETs). However, INSM1 expression in endoscopic ultrasound-guided fine needle aspiration cytology has not been examined. We evaluated INSM1 expression in the cytology of cases diagnosed with PNETs. METHODS We immunocytochemically stained INSM1 and Ki-67 in 14 PNET cases, and according to the 2017 World Health Organisation criteria, seven PNET Grade 1 cases, four Grade 2 cases and three Grade 3/neuroendocrine carcinoma cases were identified. As a control for INSM1 and Ki-67 expression, we used cytological specimens from 15 cases of pancreatic ductal adenocarcinoma. RESULTS In PNET cases, INSM1-expressing tumour cells were identified in all cytological specimens of PNET. The median INSM1 expression rate in Grade 1 cases was 49.8% (mean ± standard deviation: 55.1 ± 12.5%, min: 39.3%, max: 74.1%), and in Grade 2 and Grade 3/neuroendocrine carcinoma cases was 81.1% (mean ± standard deviation: 77.6 ± 18.6%, min: 50.3%, max: 100%). However, there was no correlation between INSM1 and Ki-67 expression (r = -0.15). The median expression rate in PNET cases was 64.3%, which was significantly higher than that in pancreatic ductal adenocarcinoma cases (P < 0.0001). CONCLUSION INSM1 immunocytochemistry of cytological specimens obtained from endoscopic ultrasound-guided fine needle aspiration cytology can accurately diagnose PNETs; therefore, INSM1 could be an important diagnostic tool in assessing therapeutic strategies, including molecular-targeted therapy.
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Affiliation(s)
- Yorihiko Takase
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Yoshiki Naito
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan.,Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yusuke Ishida
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tomohiko Yamaguchi
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Hideyuki Abe
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Kazuya Murata
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Takaaki Ito
- Department of Pathology and Experimental Medicine, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Masahiko Tanigawa
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Akihiko Kawahara
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Jun Akiba
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
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14
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Zaidi MY, Lopez-Aguiar AG, Poultsides GA, Dillhoff M, Rocha FG, Idrees K, Nathan H, Winslow ER, Fields RC, Cardona K, Maithel SK. The impact of failure to achieve symptom control after resection of functional neuroendocrine tumors: An 8-institution study from the US Neuroendocrine Tumor Study Group. J Surg Oncol 2018; 119:5-11. [PMID: 30481383 PMCID: PMC10181271 DOI: 10.1002/jso.25306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The goals of resection of functional neuroendocrine tumors (NETs) are two-fold: Oncological benefit and symptom control. The interaction between the two is not well understood. METHODS All patients with functional NETs of the pancreas, duodenum, and ampulla who underwent curative-intent resection between 2000 and 2016 were identified. Using Cox regression analysis, factors associated with reduced recurrence-free survival (RFS) were identified. RESULTS Two-hundred and thirty patients underwent curative-intent resection. Fifty-three percent were insulinomas, 35% gastrinomas, and 12% were other types. Twenty-one percent had a known genetic syndrome, 23% had lymph node (LN) positivity, 80% underwent an R0 resection, and 14% had no postoperative symptom improvement (SI). Factors associated with reduced RFS included noninsulinoma histology, the presence of a known genetic syndrome, LN positivity, R1 margin, and lack of SI. On multivariable analysis, only the failure to achieve SI following resection was associated with reduced RFS. Considering only those patients with an R0 resection, failure to achieve SI was associated with worse 3-year RFS compared with patients having SI (36% vs 80%; P = 0.006). CONCLUSIONS Failure to achieve symptomatic improvement after resection of functional NETs is associated with worse RFS. These patients may benefit from short-interval surveillance imaging postoperatively to assess for earlier radiographical disease recurrence.
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Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Flavio G Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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15
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Lee NJ, Hruban RH, Fishman EK. Pancreatic neuroendocrine tumor: review of heterogeneous spectrum of CT appearance. Abdom Radiol (NY) 2018; 43:3025-3034. [PMID: 29594467 DOI: 10.1007/s00261-018-1574-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Pancreatic neuroendocrine tumors (PanNETs) are uncommon pancreatic neoplasms and can be a diagnostic challenge with heterogeneous spectrum of CT appearance. We review CT findings of PanNETs and other mimics. CONCLUSION PanNETs are typically hypervascular and have avid enhancement on arterial and venous phase images. However, dedicated pancreas protocol may be needed due to their sometimes atypical appearance including transient enhancement. Careful evaluation of CT findings will help differentiate PanNETs from their mimics, and can be used to establish the diagnosis of a PanNETs. Although an accurate diagnosis can be based on serological, urine, and CT scan findings, confirmation is made via pathological examination.
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Affiliation(s)
- Nam Ju Lee
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N. Caroline Street, Baltimore, MD, 21287, USA.
| | - Ralph H Hruban
- Department of Pathology, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Elliot K Fishman
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N. Caroline Street, Baltimore, MD, 21287, USA
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16
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Holzner PA, Makowiec F, Klock A, Glatz T, Fichtner-Feigl S, Lang SA, Neeff HP. Outcome after hepatic resection for isolated non-colorectal, non-neuroendocrine liver metastases in 100 patients - the role of the embryologic origin of the primary tumor. BMC Surg 2018; 18:89. [PMID: 30373582 PMCID: PMC6206904 DOI: 10.1186/s12893-018-0424-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Background The indication for hepatic resection (HR) in patients suffering from liver metastases (LM) other than colorectal and neuroendocrine tumors is one focus of current multidisciplinary, oncologic considerations. This study retrospectively analyzes outcome after HR for non-colorectal, non-neuroendocrine (NCNNE) LM in the absence of distant or extrahepatic metastases. Methods We included 100 consecutive patients undergoing HR for isolated NCNNE LM from a prospective database in our institution, including postoperative follow-up. Primary tumors were of mesodermal origin in 44%, of ectodermal origin in 29% and of entodermal origin in 27%. Survival analysis was performed by univariate and multivariable methods. Mean follow-up after hepatic surgery was 3.6 years (0.25–16). Results Median age at the time of HR was 59.5 years. Kaplan-Meier-estimated survival after liver resection was 56.8%, 34.3% and 24.5% after 5, 10 and 15 years, respectively. Univariate analysis after HR revealed residual disease (hepatic or primary; p = 0.02), female gender (p = 0.013), entodermal origin (p = 0.009) and early onset of metastatic disease (≤24 months, p = 0.002), as negative prognostic factors. Multivariable survival analysis confirmed residual disease, female gender, entodermal embryologic origin and early onset of metastatic disease (≤24 months) as independent negative prognostic factors. Conclusion Overall outcome after HR of NCNNE LM results in acceptable long-term outcome. Although individual decision-making today mostly relies on clinical experience for this type of disease, risk factors derived from the embryologic origin of the tumor might help in patient selection.
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Affiliation(s)
- Philipp Anton Holzner
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany.
| | - Frank Makowiec
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
| | - Andrea Klock
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
| | - Torben Glatz
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
| | - Sven Arke Lang
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
| | - Hannes Philipp Neeff
- Department of General and Visceral Surgery, Center for Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, D-79106, Freiburg, Germany
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17
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Stella M, Decian F, Mithieux F, Meeus P, Rivoire M. Ileal Carcinoid with Liver Metastasis Presenting after Ten Years with Abdominal Mass and Right Heart Failure: Report of a Case. TUMORI JOURNAL 2018; 92:83-5. [PMID: 16683390 DOI: 10.1177/030089160609200115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A case of ileal carcinoid metastatic to the liver is reported. The diagnosis was made and treatment given ten years after the detection of a left hypervascular liver mass, which was first confounded with a hemangioma. The onset of right heart failure led to surgical replacement of the tricuspid and pulmonary valves. After cardiac surgery the patient underwent an ileal resection and left hepatectomy for a cystic left liver metastasis. Isolated right heart failure and cystic degeneration of a liver metastasis are uncommon features of metastatic carcinoid tumors; only a few cases have been described in the literature. Cardiac surgery is recommended before liver surgery to reduce venous pressure and consequent bleeding during hepatectomy. Surgical treatment of liver metastases may relieve endocrine symptoms and result in an overall five-year survival rate of 47%.
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Affiliation(s)
- Mattia Stella
- Department of Surgery, Centre Léon Bérard, Lyon, France.
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18
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Morgan RE, Pommier SJ, Pommier RF. Expanded criteria for debulking of liver metastasis also apply to pancreatic neuroendocrine tumors. Surgery 2017; 163:218-225. [PMID: 29103583 DOI: 10.1016/j.surg.2017.05.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/11/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recently, there has been a move toward decreasing the threshold for liver debulking for metastatic carcinoid tumors from 90% to 70%. The debulking threshold and factors that predict outcomes of liver debulking operations specifically among pancreatic neuroendocrine tumors are not well defined. METHODS Records of patients with pancreatic neuroendocrine tumors undergoing liver debulking with a threshold of 70% from 2006 to 2016 were reviewed. Extrahepatic metastases and positive margins by enucleation were allowed. Liver progression-free survival and overall survival were calculated by the Kaplan-Meier method for various factors and compared by log-rank. Factors also were correlated with liver progression-free survival and overall survival by multivariate regression analyses. RESULTS Forty-two patients underwent 44 operations, of which 24 resulted in 100% debulking, 12 resulted in ≥90% debulking, and 8 resulted in ≥70% debulking. Median liver progression-free survival was 11 months. The 5-year overall survival rate was 81%. There were no significant differences in outcome based on percent debulked. Only liver metastasis ≥5 cm correlated with liver progression-free survival and overall survival. CONCLUSION Consideration should be given to expanding the criteria for liver debulking in pancreatic neuroendocrine tumors to include a new threshold of >70% debulking, intermediate grade tumors, positive margins, and extrahepatic metastases; these criteria yield results indistinguishable from complete resection. Using these expanded criteria will increase the number of patients eligible for an operation and maintain high survival rates.
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Affiliation(s)
- Rosemary E Morgan
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - SuEllen J Pommier
- Department of Surgery, Oregon Health & Science University, Portland, OR; Division of Surgical Oncology, Oregon Health & Science University, Portland, OR
| | - Rodney F Pommier
- Department of Surgery, Oregon Health & Science University, Portland, OR; Division of Surgical Oncology, Oregon Health & Science University, Portland, OR.
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19
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Riechelmann RP, Pereira AA, Rego JFM, Costa FP. Refractory carcinoid syndrome: a review of treatment options. Ther Adv Med Oncol 2017; 9:127-137. [PMID: 28203303 PMCID: PMC5298401 DOI: 10.1177/1758834016675803] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Carcinoid syndrome (CSy) is a constellation of symptoms that may commonly present in patients with well differentiated neuroendocrine tumors (NETs), with somatostatin analogs (SSAs) being the first-line option for symptom management. However, symptomatic progression eventually occurs and in this scenario of a refractory CSy; several treatment options have been studied such as dose escalation of SSA, interferon and liver-directed therapies. Nevertheless, recent phase III trials have contributed to the understanding and management of this condition. We performed a comprehensive review of interventional studies examining refractory CSy to provide the evidence for current treatment options and propose a treatment sequence.
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Affiliation(s)
- Rachel P. Riechelmann
- Instituto do Câncer do Estado de São Paulo,Universidade de São Paulo, Ave. Dr Arnaldo, 251, São Paulo, SP – Brazil
| | - Allan A. Pereira
- Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - Juliana F. M. Rego
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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20
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Kaltsas G, Caplin M, Davies P, Ferone D, Garcia-Carbonero R, Grozinsky-Glasberg S, Hörsch D, Tiensuu Janson E, Kianmanesh R, Kos-Kudla B, Pavel M, Rinke A, Falconi M, de Herder WW. ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Pre- and Perioperative Therapy in Patients with Neuroendocrine Tumors. Neuroendocrinology 2017; 105:245-254. [PMID: 28253514 PMCID: PMC5637287 DOI: 10.1159/000461583] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/10/2017] [Indexed: 01/25/2023]
Abstract
Neuroendocrine tumors of the small intestine are the most common causes of the carcinoid syndrome. Carcinoid heart disease occurs in more than half of the patients with the carcinoid syndrome. Patients with carcinoid heart disease who need to undergo surgery should also undergo preoperative evaluation by an expert cardiologist. Treatment with long-acting somatostatin analogs aims at controlling the excessive hormonal output and symptoms related to the carcinoid syndrome and at preventing a carcinoid crisis during interventions. Patients with a gastrinoma require pre- and postoperative treatment with high doses of proton pump inhibitors. Patients with a glucagonoma require somatostatin analog treatment and nutritional supplementation. Patients with a VIPoma also require somatostatin analog treatment and intravenous fluid and electrolyte therapy. Insulinoma patients generally require intravenous glucose infusion prior to operation. In patients with localized operable insulinoma, somatostatin analog infusion should only be considered after the effect of this therapy has been electively studied.
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Affiliation(s)
- Gregory Kaltsas
- Endocrine Unit, Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
- *Gregory Kaltsas, Sector of Endocrinology, Department of Pathophysiology, National and Kapodistrian University of Athens, Mikras Assias 75, Goudi, GR-11527 Athens (Greece), E-Mail
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, UK
| | | | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research (CEBR), IRCCS AOU San Martino-IST, University of Genova, Genova, Italy
| | | | - Simona Grozinsky-Glasberg
- Neuroendocrine Unit, Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dieter Hörsch
- Gastroenterology and Endocrinology Center for Neuroendocrine Tumors Bad Berka, Bad Berka, Germany
| | - Eva Tiensuu Janson
- Department of Endocrine Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Reza Kianmanesh
- Department of Digestive and Endocrine Surgery, Robert Debré Hospital, Reims, France
| | - Beata Kos-Kudla
- Department of Pathophysiology and Endocrinology, Division of Endocrinology, Medical University of Silesia, Katowice, Poland
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin
| | - Anja Rinke
- Department of Gastroenterology, UKGM Marburg and Philipps University Marburg, Marburg, Germany
| | - Massimo Falconi
- Chirurgia del Pancreas, Pancreas Translational and Clinical Research Center, Ospedale San Raffaele, Università “Vita e Salute”, Milano, Italy
| | - Wouter W. de Herder
- ENETS Centre of Excellence, Erasmus MC Cancer Centre, Rotterdam, The Netherlands
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21
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Flaum N, Valle JW, Mansoor W, McNamara MG. Everolimus in the treatment of neuroendocrine tumors of the respiratory and gastroenteropancreatic systems. Future Oncol 2016; 12:2561-2578. [DOI: 10.2217/fon.16.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Neuroendocrine tumors (NETs) are a rare diverse group of malignancies occurring most commonly in the gastroenteropancreatic system and the lungs. The incidence of NETs is increasing worldwide; median survival for patients with metastatic NETs is 5–65 months. A growing body of evidence shows survival benefit in patients with advanced NETs (gastroenteropancreatic and lung) treated with mTOR inhibitor everolimus, with improvement in survival being demonstrated in the clinical trial and real-world setting. Everolimus has been shown to have a manageable safety profile, with the most common adverse events being stomatitis, rash, diarrhea, fatigue and infections. Due to the rarity of the condition, there are challenges in conducting clinical trials in these patients. Further research is required to clarify the role of adjuvant therapy, treatment sequencing and the use of multimodality treatments.
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Affiliation(s)
- Nicola Flaum
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
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22
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Jin K, Xu J, Chen J, Chen M, Chen R, Chen Y, Chen Z, Cheng B, Chi Y, Feng ST, Fu D, Hou B, Huang D, Huang H, Huang Q, Li J, Li Y, Liang H, Lin R, Liu A, Liu J, Liu X, Lu M, Luo J, Mai G, Ni Q, Qiu M, Shao C, Shen B, Sheng W, Sun J, Tan C, Tan H, Tang Q, Tang Y, Tian X, Tong D, Wang X, Wang J, Wang J, Wang W, Wang W, Wang Y, Wu Z, Xue L, Yan Q, Yang N, Yang Y, Yang Z, Yin X, Yuan C, Zeng S, Zhang R, Yu X. Surgical management for non-functional pancreatic neuroendocrine neoplasms with synchronous liver metastasis: A consensus from the Chinese Study Group for Neuroendocrine Tumors (CSNET). Int J Oncol 2016; 49:1991-2000. [PMID: 27826620 DOI: 10.3892/ijo.2016.3711] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 09/19/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (p-NENs) are slowly growing tumors with frequent liver metastasis. There is a variety of approaches to treat non-functional p-NENs with synchronous liver metastasis (LM) which complicates the determination of optimal treatment. Based on updated literature review, we discussed the treatment strategy determinants for p-NEN with LM. According to the resectability of primary tumor, the WHO 2010 grade classification and the radiological type of liver metastasis, the CSNET group reached agreements on a number of issues, including the following. Prior to treatment, biopsy is required to confirm pathology. Liver biopsy is important for more accurate grading of tumor and percutaneous core needle biopsy is more available than EUS-FNA. In patients with unresectable primary, surgical resection for liver-metastatic lesions should be avoided. Curative surgery is recommended for G1/G2 p-NET with type I LM and R1 resection also seems to improve overall survival rate. Cytoreductive surgery is recommended for G1/G2 p-NET with type II LM in select patients, and should meet stated requirements. Surgical resection for G1/G2 p-NET with type III LM and p-NEC with LM should be avoided, and insufficient evidence exists to guide the surgical treatment of G3 p-NET with LM. Liver transplantation may be an option in highly select patients. In addition, the optimal time for surgical approach is still required for more evidence.
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Affiliation(s)
- Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Jie Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Rufu Chen
- Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Ye Chen
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Zhiyu Chen
- Department of Medical Oncology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Bin Cheng
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Yihebali Chi
- Department of Medical Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Shi-Ting Feng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Baohua Hou
- Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, P.R. China
| | - Dan Huang
- Department of Pathology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China
| | - Qiang Huang
- Department of General Surgery, Anhui Provincial Hospital, Hefei, Anhui, P.R. China
| | - Jie Li
- Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Beijing Cancer Hospital, Beijing, P.R. China
| | - Ying Li
- Department of Radiology, Peking University Cancer Hospital, Beijing, P.R. China
| | - Houjie Liang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Rong Lin
- Department of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - An'an Liu
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Jixi Liu
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Xubao Liu
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Ming Lu
- Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Beijing Cancer Hospital, Beijing, P.R. China
| | - Jie Luo
- Department of Pathology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Gang Mai
- Department of Hepatobiliopancreatic Surgery, The People's Hospital of Deyang, Chengdu, Sichuan, P.R. China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Meng Qiu
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Chenghao Shao
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Weiqi Sheng
- Department of Pathology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Jian Sun
- Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Chunlu Tan
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Huangying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiyun Tang
- Department of Gastroenterology, Jiangsu People's Hospital, Nanjing, Jiangsu, P.R. China
| | - Yingmei Tang
- Department of Gastroenterology, The Second Affliated Hospital of Kunming Medical University, Yunnan Research Center for Liver Diseases, Kunming, Yunnan, P.R. China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, P.R. China
| | - Danian Tong
- Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Xiaohong Wang
- Department of Radiology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Jie Wang
- Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Wei Wang
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, P.R. China
| | - Wei Wang
- Department of Gastric and Pancreatic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, P.R. China
| | - Yu Wang
- Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, P.R. China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, P.R. China
| | - Ling Xue
- Department of Pathology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Qiang Yan
- Department of Hepatobiliopancreatic Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, P.R. China
| | - Ning Yang
- Hepatobiliary Surgery Department V, Eastern Hepatobiliary Surgery Hospital, Shanghai, P.R. China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, P.R. China
| | - Zhiying Yang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Xiaoyi Yin
- Department of Biliary-Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Chunhui Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, P.R. China
| | - Shan Zeng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Renchao Zhang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University; Shanghai, P.R. China
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Matsumoto K, Takeda Y, Onoyama T, Kawata S, Kurumi H, Ueki M, Miura N, Isomoto H. Role of the preoperative usefulness of the pathological diagnosis of pancreatic diseases. World J Gastrointest Oncol 2016; 8:656-662. [PMID: 27672423 PMCID: PMC5027020 DOI: 10.4251/wjgo.v8.i9.656] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/29/2015] [Accepted: 08/01/2016] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer is the fifth leading cause of cancer death and has the lowest survival rate of any solid cancer. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is currently capable of providing a cytopathological diagnosis of pancreatic malignancies with a higher diagnostic power, with a sensitivity and specificity of 85%-89% and 98%-99%, compared to pancreatic juice cytology (PJC), whose sensitivity and specificity are only 33.3%-93% and 83.3%-100%. However, EUS-FNA is not effective in the cases of carcinoma in situ and minimally invasive carcinoma because both are undetectable by endoscopic ultrasonography, although PJC is able to detect them. As for the frequency of complications such as post endoscopic retrograde cholangiopancreatography pancreatitis, EUS-FNA is safer than PJC. To diagnose pancreatic cancer appropriately, it is necessary for us to master both procedures so that we can select the best methods of sampling tissues while considering the patient’s safety and condition.
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24
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Personalized treatment approach to gastroenteropancreatic neuroendocrine tumors: a medical oncologist's perspective. Eur J Gastroenterol Hepatol 2016; 28:985-90. [PMID: 27257869 DOI: 10.1097/meg.0000000000000674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The medical management of gastroenteropancreatic neuroendocrine tumors involves treatment of symptomatic disease related to hormone secretions or bulky unresectable metastatic disease. Combining gallium DOTA with fluorine-18 fluorodeoxyglucose-PET along with histopathological grading helps to determine tumor heterogeneity and seek reasons for poor response to therapy. In the light of adding chemotherapy in selected patients with intermediate-grade tumors, the newer scan helps in personalization of the therapy along with the biopsy. The tumor dedifferentiation over the particular time period leading to aggressive behavior, a well-known entity, is contrasted with the redifferentiation phenomenon in some patients as a result of chemotherapy or targeted drug therapy. This may support the basis for combining peptide receptor-targeted radiotherapy/octreotide therapy with chemotherapy or mTOR inhibitors such as everolimus.
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25
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Parbhu SK, Adler DG. Pancreatic neuroendocrine tumors: contemporary diagnosis and management. Hosp Pract (1995) 2016; 44:109-19. [PMID: 27404266 DOI: 10.1080/21548331.2016.1210474] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pancreatic neuroendocrine tumors (PNETs) are neoplasms that arise from the hormone producing cells of the islets of Langerhans, also known as pancreatic islet cells. PNETs are considered a subgroup of neuroendocrine tumors, and have unique biology, natural history and clinical management. These tumors are classified as 'functional' or 'non-functional' depending on whether they release peptide hormones that produce specific hormone- related symptoms, usually in established patterns based on tumor subtype. This manuscript will review pancreatic neuroendocrine tumor subtypes, syndromes, diagnosis, and clinical management.
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Affiliation(s)
- Sheeva K Parbhu
- a Department of Internal Medicine, Division of Gastroenterology and Hepatology , University of Utah School of Medicine, Huntsman Cancer Center , Salt Lake City , Utah , USA
| | - Douglas G Adler
- a Department of Internal Medicine, Division of Gastroenterology and Hepatology , University of Utah School of Medicine, Huntsman Cancer Center , Salt Lake City , Utah , USA
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26
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Singla S, LeVea CM, Pokuri VK, Attwood KM, Wach MM, Tomaszewski GM, Kuvshinoff B, Iyer R. Ki67 score as a potential predictor in the selection of liver-directed therapies for metastatic neuroendocrine tumors: a single institutional experience. J Gastrointest Oncol 2016; 7:441-8. [PMID: 27284478 DOI: 10.21037/jgo.2016.02.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Neuroendocrine tumors (NETs) metastatic to the liver are treated with transarterial radioembolization (TARE) using yttrium-90 (Y-90) microspheres or transarterial chemoembolization (TACE). However the criteria for patient selection are not well defined. We sought to determine if Ki67 score could help select patients for one therapy over the other in the management of hepatic neuroendocrine metastases. METHODS Single institution analysis of patients treated with Y-90 or TACE between 2001 and 2014. Pathologists blinded to clinical information performed Ki67 staining. Data were analyzed using multivariate association for survival outcomes. RESULTS Amongst 72 patients (male: 39, female: 33, median age: 57 years) with metastatic NET, the most common site of origin was small bowel (n=35, 49%), while pancreas constituted 32% (n=23). Forty-four patients were treated with Y-90 (61%) and 28 patients received TACE (39%). Ki67 score was available in 28 patients (64%) treated with Y-90 and 16 patients (57%) with TACE. Within Y-90 group, there was greater use of Sandostatin (95% vs. 75%, P=0.02) and less number of total treatments completed (89% vs. 46%, P<0.001). There was no significant difference in overall survival (OS) between Y-90 and TACE when used without selection (median, 69 vs. 82 months, P=0.47). When adjusted for Ki67, patients with Ki67 score ≥3% had better OS with Y-90 compared to TACE (HR, 0.1; CI, 0.01-0.9), however for Ki67 <3%, OS was better when treated with TACE compared to Y-90 (HR, 13.5; CI, 1.22-148.87). CONCLUSIONS There is significant interaction between Ki-67 score and liver-directed treatment benefit in patients with hepatic neuroendocrine metastases. Ki-67 score ≥3% predicts greater benefit with Y-90 and a Ki-67 score <3% predicts greater benefit with TACE.
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Affiliation(s)
- Smit Singla
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Charles M LeVea
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Venkata K Pokuri
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Kristopher M Attwood
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Michael M Wach
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Garin M Tomaszewski
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Boris Kuvshinoff
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Renuka Iyer
- 1 Department of Surgical Oncology, 2 Department of Pathology, 3 Department of Medical Oncology, 4 Department of Biostatistics and Bioinformatics, 5 Department of Interventional Radiology, Roswell Park Cancer Institute, Buffalo, New York, USA
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27
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Thiels CA, Bergquist JR, Laan DV, Croome KP, Smoot RL, Nagorney DM, Thompson GB, Kendrick ML, Farnell MB, Truty MJ. Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified? J Gastrointest Surg 2016; 20:891-8. [PMID: 26925796 DOI: 10.1007/s11605-016-3102-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/02/2016] [Indexed: 01/31/2023]
Abstract
Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.
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Affiliation(s)
- Cornelius A Thiels
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - John R Bergquist
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Danuel V Laan
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael B Farnell
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.
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28
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Fabian E, Haas B, Kump P, Lipp R, Kornprat P, Lutfi A, Talakic E, Fuchsjäger M, Spindelboeck W, Lackner C, Zollner G, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 154: 32-year-old computer software engineer with nodular mass in the liver. Wien Klin Wochenschr 2016; 128:277-86. [PMID: 26919853 PMCID: PMC4861751 DOI: 10.1007/s00508-016-0965-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Haas
- Division of Gastroenterology and Infectious Diseases, Department of Internal Medicine, Landeskrankenhaus West, Graz, Graz, Austria
| | - Patrizia Kump
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Rainer Lipp
- Division of Nuclear Medicine, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Peter Kornprat
- Department of Surgery, Medical University of Graz, Graz, Austria
| | - Andre Lutfi
- Department of Radiology, Landeskrankenhaus West, Graz, Graz, Austria
| | - Emina Talakic
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Carolin Lackner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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29
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Kulik U, Lehner F, Bektas H, Klempnauer J. Liver Resection for Non-Colorectal Liver Metastases - Standards and Extended Indications. VISZERALMEDIZIN 2016; 31:394-8. [PMID: 26889142 PMCID: PMC4748777 DOI: 10.1159/000439419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Due to the uncertain benefit of liver resection for non-colorectal liver metastases (NCLM), patient selection for surgery is generally difficult. Therefore, the aim of this article was to propose standard and extended indications for liver resection in this heterogeneous disease collective. Methods Review of the literature. Results The myriad of biologically different primary tumor entities as well as the mostly small and retrospective studies investigating the benefit of surgery for NCLM limits the proposal of general recommendations. Only resection of neuroendocrine liver metastases (NELM) appears to offer a clear benefit with a 5- and 10-year overall survival (OS) of 74 and 51%, respectively, in the largest series. Resection of liver metastases from genitourinary primaries might offer reasonable benefit in selected cases – with a 5-year OS of up to 61% for breast cancer and of 38% for renal cell cancer. The long-term outcome following surgery for other entities was remarkably poorer, e.g., gastric cancer, pancreatic cancer, and melanoma reached a 5-year OS of 20-42, 17-25, and about 20%, respectively. Conclusion Liver resection for NELM can be defined as a standard indication for the resection of NCLM while lesions of genitourinary origin might be defined as an extended indication.
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Affiliation(s)
- Ulf Kulik
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hanover, Germany
| | - Frank Lehner
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hanover, Germany
| | - Hüseyin Bektas
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hanover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hanover, Germany
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30
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Abstract
Neuroendocrine neoplasms represent a heterogeneous group of cancers arising from a variety of neuroendocrine cell types. In general, these tumors (NET) are asymptomatic and are discovered late once metastatic disease is present (40-80%). The liver is the most common organ involved when metastases occur (40-93%), followed by bone (12-20%) and lungs (8-10%). A number of different therapeutic options are available for patients with hepatic metastases including surgical resection, transplantation, transarterial chemoembolization, radiofrequency and microwave ablation, radioembolization (Y90), chemotherapy, somatostatin analogues and molecular targeted therapies. Surgical resection is still considered the treatment of choice and provides excellent disease control with an overall survival of 47-92%. Liver transplantation has been advocated in selected patients with bilateral unresectable symptomatic liver metastases. The aim of this study is to review the existing literature emphasizing on the role of transplantation to treat patients with liver metastases from NET.
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Affiliation(s)
- Valery Vilchez
- Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Roberto Gedaly
- Department of Surgery-Transplant Division, University of Kentucky, Lexington, KY, USA.
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31
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Tamburrino D, Spoletini G, Partelli S, Muffatti F, Adamenko O, Crippa S, Falconi M. Surgical management of neuroendocrine tumors. Best Pract Res Clin Endocrinol Metab 2016; 30:93-102. [PMID: 26971846 DOI: 10.1016/j.beem.2015.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
During the last decades an increase in the incidence of neuroendocrine tumors (NETs) was observed. Gastroenteropancreatic NETs represent the majority of NETs. Compared with their epithelial counterpart they usually have a more indolent behaviour and surgical resection improves survival. Tumor diameter is one of the main parameter in the decision making process for nonfunctioning forms. Generally, small lesions can be treated conservatively whereas larger tumors should be treated with standard surgical resection and lymphadenectomy. Functioning tumors should be resected regardless the dimension of the lesion. Locally advanced and metastatic disease should be also treated with extended resections, keeping in consideration the grading, size, Ki67, and presence of extra-abdominal disease. In the case of metastases the panel of operative treatment includes resection, ablation, up to liver transplantation.
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Affiliation(s)
- Domenico Tamburrino
- HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London Pond Street NW3 2QG, London, UK.
| | - Gabriele Spoletini
- HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London Pond Street NW3 2QG, London, UK.
| | - Stefano Partelli
- Pancreatic Surgery Unit, "Vita e Salute" University, San Raffaele Hospital, Olgettina n. 60 e n. 48, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, "Vita e Salute" University, San Raffaele Hospital, Olgettina n. 60 e n. 48, 20132 Milan, Italy.
| | - Olga Adamenko
- Pancreatic Surgery Unit, "Vita e Salute" University, San Raffaele Hospital, Olgettina n. 60 e n. 48, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, "Vita e Salute" University, San Raffaele Hospital, Olgettina n. 60 e n. 48, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, "Vita e Salute" University, San Raffaele Hospital, Olgettina n. 60 e n. 48, 20132 Milan, Italy.
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Yang M, Ke NW, Zhang Y, Zeng L, Tan CL, Zhang H, Mai G, Tian BL, Liu XB. Survival Analyses for Patients With Surgically Resected Pancreatic Neuroendocrine Tumors by World Health Organization 2010 Grading Classifications and American Joint Committee on Cancer 2010 Staging Systems. Medicine (Baltimore) 2015; 94:e2156. [PMID: 26632896 PMCID: PMC4674199 DOI: 10.1097/md.0000000000002156] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In 2010, World Health Organization (WHO) reclassified pancreatic neuroendocrine tumors (p-NETs) into 4 main groups: neuroendocrine tumor G1 (NET G1), neuroendocrine tumor G2 (NET G2), neuroendocrine carcinoma G3 (NEC G3), mixed adeno and neuroendocrine carcinoma (MANEC). Clinical value of these newly updated WHO grading criteria has not been rigorously validated. The authors aimed to evaluate the clinical consistency of the new 2010 grading classifications by WHO and the 2010 tumor-node metastasis staging systems by American Joint Committee on Cancer (AJCC) on survivals for patients with surgically resected p-NETs. Moreover, the authors would validate the prognostic value of both criteria for p-NETs.The authors retrospectively collected the clinicopathologic data of 120 eligible patients who were all surgically treated and histopathologically diagnosed as p-NETs from January 2004 to February 2014 in our single institution. The new WHO criteria were assigned to 4 stratified groups with a respective distribution of 62, 35, 17, and 6 patients. Patients with NET G1 or NET G2 obtained a statistically better survival compared with those with NEC G3 or MANEC (P < 0.001). Survivals of NET G1 was also better than those of NET G2 (P = 0.023), whereas difference of survivals between NEC G3 and MANEC present no obvious significance (P = 0.071). The AJCC 2010 staging systems were respectively defined in 61, 36, 12, and 11 patients for each stage. Differences of survivals of stage I with stage III and IV were significant (P < 0.001), as well as those of stage II with III and IV (P < 0.001); whereas comparisons of stage I with stage II and stage III with IV were not statistically significant (P = 0.129, P = 0.286; respectively). Together with radical resection, these 2 systems were both significant in univariate and multivariate analysis (P < 0.05).The newly updated WHO 2010 grading classifications and the AJCC 2010 staging systems could consistently reflect the clinical outcome of patients with surgically resected p-NETs. Meanwhile, both criteria could be independent predictors for survival analysis of p-NETs.
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Affiliation(s)
- Min Yang
- From the Department of Pancreatic Surgery (MY, N-wK, YZ, C-lT, HZ, GM, B-lT, X-bL); General Ward of Sports Medicine & Cardiopulmonary Rehabilitation (LZ), West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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Yates CJ, Newey PJ, Thakker RV. Challenges and controversies in management of pancreatic neuroendocrine tumours in patients with MEN1. Lancet Diabetes Endocrinol 2015; 3:895-905. [PMID: 26165399 DOI: 10.1016/s2213-8587(15)00043-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/03/2015] [Indexed: 01/05/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant disorder, is characterised by the occurrence of pancreatic neuroendocrine tumours (P-NETs) in association with parathyroid and pituitary tumours. P-NETs, which include gastrinomas, insulinomas, and non-functioning tumours, occur in more than 80% of MEN1 patients and account for 50% of disease-specific deaths. However, there is no consensus about the optimal methods for detecting and treating P-NETs in MEN1 patients, and extrapolations from approaches used in patients with non-familial (sporadic) P-NETs require caution because of differences, such as the younger age of onset, multi-focality of P-NETs, and concomitant presence of other tumours in MEN1 patients. Thus, the early detection of P-NETs by circulating biomarkers and imaging modalities, and their appropriate treatments by surgical approaches and/or radionuclide therapy, chemotherapy, and biotherapy pose challenges and controversies. These challenges and controversies will be reviewed and possible approaches proposed.
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Affiliation(s)
- Christopher J Yates
- Academic Endocrine Unit, Radcliffe Department of Clinical Medicine, University of Oxford, Oxford, UK; Department of Diabetes and Endocrinology, Melbourne Health, Melbourne, VIC, Australia; Department of Diabetes and Endocrinology, Western Health, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Paul J Newey
- Academic Endocrine Unit, Radcliffe Department of Clinical Medicine, University of Oxford, Oxford, UK; Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Clinical Medicine, University of Oxford, Oxford, UK.
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34
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Condron ME, Pommier SJ, Pommier RF. Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis. Surgery 2015; 159:358-65. [PMID: 26603846 DOI: 10.1016/j.surg.2015.05.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/28/2015] [Accepted: 05/30/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operations and anesthesia in carcinoid patients can provoke carcinoid crises, which can have serious sequelae, including death. Prophylactic octreotide is recommended to prevent crises. Recommended prophylaxis regimens vary from octreotide long-acting repeatable to preoperative bolus to continuous octreotide infusion; however, efficacy data are lacking. We have shown previously that crises correlated with major complications and that octreotide long-acting repeatable and preoperative bolus failed to prevent crises. This study examines the impact of continuous octreotide infusion. METHODS A total of 127 patients (71% with liver metastases, 74% with carcinoid syndrome) who underwent 150 operations with continuous octreotide infusions were enrolled in this prospective case series. Our main outcome measures were the occurrence of intraoperative carcinoid crises and post-operative complications. RESULTS Crises occurred at a rate of 30% as compared with 24% in our previous series, which examined the impact of preoperative octreotide bolus. Crises were significantly associated with the presence of hepatic metastases (P = .02) or history of carcinoid syndrome (P = .006), although neither was required for crises. Prompt vasopressor treatment shortened the mean duration of hypotension to 8.7 minutes, compared with 19 minutes in our prior series. Crises no longer correlated with major complications (P = .481) unless instability persisted for greater than 10 minutes (P = .011). CONCLUSION Octreotide infusions do not prevent intraoperative crises. Patients without liver metastases or carcinoid syndrome can have intraoperative crises. Postoperative complications can be decreased by reducing the duration of crises. Further study is needed to determine how best to shorten hemodynamic instability during crises.
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Affiliation(s)
- Mary E Condron
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - SuEllen J Pommier
- Division of Surgical Oncology, Oregon Health & Science University, Portland, OR
| | - Rodney F Pommier
- Division of Surgical Oncology, Oregon Health & Science University, Portland, OR.
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Dieckhoff P, Runkel H, Daniel H, Wiese D, Koenig A, Fendrich V, Bartsch DK, Moll R, Müller D, Arnold R, Gress T, Rinke A. Well-differentiated neuroendocrine neoplasia: relapse-free survival and predictors of recurrence after curative intended resections. Digestion 2015; 90:89-97. [PMID: 25196446 DOI: 10.1159/000365143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/06/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Resection with curative intention is the cornerstone of treatment in patients with neuroendocrine tumors. A proportion of patients will relapse after R0 resection, but the factors predictive of recurrence are not well understood. METHODS A database established 1998 at the University Hospital Marburg was queried for all patients with documented R0 resection. Recurrence-free survival and overall survival were estimated using the Kaplan-Meier method. Uni- and multivariate analyses were performed. RESULTS 180 patients with a median age of 52 years entered the analysis. We observed 77 recurrences after a median time of 2.9 years. 24% of the recurrences occurred later than 5 years after operation. Median recurrence-free survival of the whole cohort was 101 months. In univariate analysis grade by Ki-67, stage, high lymph node ratio and microangioinvasion were significant predictors of recurrence. On multivariate analysis these parameters were confirmed as independent prognostic parameters with stage and microangioinvasion being the most important predictors. CONCLUSIONS After R0 resection of neuroendocrine tumors, postoperative surveillance should be extended to at least 10 years. Patients with distant metastases and microangioinvasion are at high risk of recurrence. Clinical trials of adjuvant treatment protocols are indicated in these patients.
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Affiliation(s)
- P Dieckhoff
- Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
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Deutsch GB, Lee JH, Bilchik AJ. Long-Term Survival with Long-Acting Somatostatin Analogues Plus Aggressive Cytoreductive Surgery in Patients with Metastatic Neuroendocrine Carcinoma. J Am Coll Surg 2015; 221:26-36. [PMID: 26027502 DOI: 10.1016/j.jamcollsurg.2015.03.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/18/2015] [Accepted: 03/25/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-acting somatostatin analogues (S-LAR) improve recurrence-free survival in patients with metastatic neuroendocrine tumor (NET) from gastrointestinal (GI) primary, but their impact on overall survival when combined with aggressive cytoreductive surgery is unclear. STUDY DESIGN We reviewed our institutional cancer database to identify patients who underwent cytoreductive surgery for metastatic NET from GI primary between December 1997 and June 2013. Additionally, a cohort selected from 3,384 metastatic neuroendocrine cases in the SEER-Medicare database (January 2003 to December 2009) was used to verify and expand on our results. RESULTS Most of the 49 patients from our institution had primary lesions in the small intestine (22 of 49 [44.9%]) or pancreas (14 of 49 [28.6%]); 37 patients (75.5%) had metastatic disease at initial diagnosis. These patients underwent 1 (32 of 49 [65.3%]), 2 (11 of 49 [22.4%]), or at least 3 (6 of 49 [12.3%]) surgical procedures; 33 patients (67.3%) underwent resection plus ablation, 19 (38.7%) underwent major hepatectomy, and 34 (69.4%) received S-LAR (29.4% administered preoperatively). Median follow-up was 112 months. Rates of 1-, 5-, 10-, and 15-year disease-specific survival (DSS) were 94%, 78%, 64%, and 31%, respectively, in the 34 patients undergoing aggressive cytoreductive surgery plus S-LAR. Of the SEER-Medicare population, 1,741 patients met inclusion criteria. The DSS for the 104 patients treated with combination therapy was 68.3% at 5 years and 60.6% at 10 years, as compared with 54.7% and 51.8%, respectively, for the 202 patients receiving surgery alone, and 50.0% and 36.0%, respectively, for the 342 patients receiving S-LAR alone (p < 0.0001). The group receiving neither treatment (n = 1,093) had 5-year and 10-year DSS of 34.3% and 26.3%, respectively. CONCLUSIONS Long-acting somatostatin analogues combined with aggressive cytoreductive surgery improves the long-term survival of select patients with metastatic NET from GI primary.
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Affiliation(s)
- Gary B Deutsch
- Gastrointestinal Research Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA
| | - Ji Hey Lee
- Department of Biostatistics, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA
| | - Anton J Bilchik
- Gastrointestinal Research Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA; California Oncology Research Institute, Los Angeles, CA.
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Doi R. Determinants of surgical resection for pancreatic neuroendocrine tumors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:610-7. [PMID: 25773163 DOI: 10.1002/jhbp.224] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/14/2015] [Indexed: 12/14/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) include functioning and non-functional tumors. Functioning tumors consist of tumors that produce a variety of hormones and their clinical effects. Therefore, determinants of resection of pNETs should be discussed for each group of tumors. Less than 10% of insulinomas are malignant, therefore more than 90% of the cases can be cured by surgical resection. Lymphadenectomy is generally not necessary in insulinoma operation. If preoperative localization of the insulinoma is completed, enucleation from the pancreatic body or tail, and distal pancreatectomy can be performed safely by laparoscopy. When preoperative localization of a sporadic insulinoma is not confirmed, surgical exploration is needed. Intraoperative localization of a tumor, intraoperative insulin sampling and frozen section are required. The crucial purpose of surgical resection is to control inappropriate insulin secretion by removing all insulinomas. Gastrinomas are usually located in the duodenum or pancreas, which secrete gastrin and cause Zollinger-Ellison syndrome (ZES). Duodenal gastrinomas are usually small, therefore they are not seen on preoperative imaging studies or endoscopic ultrasound, and can be found only at surgery if a duodenotomy is performed. In addition, lymph node metastasis is found in 40-60% of cases. Therefore, the experienced surgeons should direct operation for gastrinomas. Surgical exploration with duodenotomy should be performed at a laparotomy. Other functioning pNETs can occur in the pancreas or in other locations. Curative resection is always recommended whenever possible after optimal symptomatic control of the clinical syndrome by medical treatment. Indications for surgery depend on clinical symptom control, tumor size, location, extent, malignancy and presence of metastasis. A lot of non-functioning pNETs are found incidentally according to the quality improvement of imaging techniques. Localized, small, malignant non-functioning pNETs should be operated on aggressively, while in possibly benign tumors smaller than 2 cm the surgical risk-benefit ratio should be carefully weighted. Surgical liver resection is generally proposed in curative intent to all patients with operable metastases from G1 or G2 pNET. The benefits of surgical resection of liver metastases have been demonstrated in terms of overall survival and quality of life. Complete resection is associated with better long-term survival.
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Affiliation(s)
- Ryuichiro Doi
- Department of Surgery, Otsu Red Cross Hospital, 1-1-35 Nagara, Otsu, Shiga, 520-8511, Japan
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Carcinoid Tumors. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Atema JJ, Jilesen APJ, Busch ORC, van Gulik TM, Gouma DJ, van Dijkum EJMN. Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions. HPB (Oxford) 2015; 17:38-45. [PMID: 25041879 PMCID: PMC4266439 DOI: 10.1111/hpb.12319] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/18/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection for pancreatic neuroendocrine tumours (PNET) is suggested to be associated with an increased risk of a post-operative pancreatic fistula (POPF). The aim of this study was to describe morbidity after resections for PNET, focusing on POPF. Outcomes were compared with resections for other lesions. METHODS Patients undergoing an elective pancreatic resection during a 12-year period were retrospectively analysed. Morbidity was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definitions. RESULTS Eighty-eight out of 832 patients (10.6%) underwent a resection for PNET. Atypical pancreatic resections (enucleation and central pancreatectomy) and distal pancreatectomies were more frequently performed for PNET. The POPF rate was 22.7% in patients operated for PNET compared with 17.2% in other patients (P = 0.200). In univariate analysis, body mass index (BMI), pancreatic duct diameter, somatostatin analogue administration, type of resection and type of pathology were associated with a POPF. In multivariate analysis, BMI, a pancreatic duct diameter <3 mm and central pancreatectomy remained independent risk factors [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22-3.07 and OR 3.04, 95% CI 1.05-8.82, respectively]. CONCLUSIONS High rates of POPF were found in patients operated for PNET. However, this was mainly owing to the fact that atypical resections, known to be associated with a higher fistula rate, were performed more frequently in these patients.
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Affiliation(s)
| | | | | | | | | | - Els J M Nieveen van Dijkum
- Correspondence, Els J.M. Nieveen van Dijkum, Department of Surgery, Academic Medical Center, Meibergdreef 9; PO Box 22660, 1105 AZ Amsterdam, The Netherlands. Tel: +31 20 566 3067. Fax: +31 20 566 2659. E-mail:
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Kennedy A, Bester L, Salem R, Sharma RA, Parks RW, Ruszniewski P. Role of hepatic intra-arterial therapies in metastatic neuroendocrine tumours (NET): guidelines from the NET-Liver-Metastases Consensus Conference. HPB (Oxford) 2015; 17:29-37. [PMID: 25186181 PMCID: PMC4266438 DOI: 10.1111/hpb.12326] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/09/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Liver metastasis from a neuroendocrine tumour (NET) represents a significant clinical entity. A multidisciplinary group of experts was convened to develop state-of-the-art recommendations for its management. METHODS Peer-reviewed published reports on intra-arterial therapies for NET hepatic metastases were reviewed and the findings presented to a jury of peers. The therapies reviewed included transarterial embolization (TAE), transarterial chemoembolization (TACE) and radioembolization (RE). Two systems were used to evaluate the level of evidence in each publication: (i) the US National Cancer Institute (NCI) system, and (ii) the GRADE system. RESULTS Eighteen publications were reviewed. These comprised 11 reports on TAE or TACE and seven on RE. Four questions posed to the panel were answered and recommendations offered. CONCLUSIONS Studies of moderate quality support the use of TAE, TACE and RE in hepatic metastases of NETs. The quality and strength of the reports available do not allow any modality to be determined as superior in terms of imaging response, symptomatic response or impact on survival. Radioembolization may have advantages over TAE and TACE because it causes fewer side-effects and requires fewer treatments. Based on current European Neuroendocrine Tumor Society (ENETS) Consensus Guidelines, RE can be substituted for TAE or TACE in patients with either liver-only disease or those with limited extrahepatic metastases.
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Affiliation(s)
- Andrew Kennedy
- Radiation Oncology Research, Sarah Cannon Research InstituteNashville, TN, USA,Correspondence, Andrew S. Kennedy, Radiation Oncology Research, Sarah Cannon Research Institute, 3322 West End Avenue, Suite 800, Nashville, TN 37203, USA. Tel: + 1 615 524 4200. Fax: + 1 615 524 4700. E-mail:
| | - Lourens Bester
- Department of Radiology, St Vincent's Public HospitalSydney, NSW, Australia
| | - Riad Salem
- Department of Radiology, Northwestern UniversityChicago, IL, USA
| | - Ricky A Sharma
- Oncology Department, Gray Institute, University of Oxford, Churchill HospitalOxford, UK
| | - Rowan W Parks
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK
| | - Philippe Ruszniewski
- Centre for Gastroenterological and Pancreatic Disease, Beaujon Hospital, University of Paris Denis-DiderotParis, France
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Kondo NI, Ikeda Y. Practical management and treatment of pancreatic neuroendocrine tumors. Gland Surg 2014; 3:276-83. [PMID: 25493259 DOI: 10.3978/j.issn.2227-684x.2013.12.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/26/2013] [Indexed: 12/16/2022]
Abstract
Pancreatic neuroendocrine tumors (NETs) are uncommon disease, about which little is known. Pancreatic NETs are usually slow growing and their malignant potential are often underestimated. The management of this disease poses a challenge because of the heterogeneous clinical presentation and varying degrees of aggressiveness. Recently, several guidelines for the management of pancreatic NETs have been established and help to devise clinical strategy. In the treatment algorithms, however, a lot of uncertain points are included. Practical treatment decisions of pancreatic NETs are still sometimes made in a patient- and/or physicians-oriented manner. The tumor grading system proposed by the European Neuroendocrine Tumor Society (ENETS) gives important prognostic information, however, the implication of grading regarding medical treatment strategies to choose has not yet been clarified. Moreover, the place of surgical treatment is unclear in the overall management course of advanced pancreatic NETs. In some cases, practical management and treatment have to be individualized depending on predominant symptoms, tumor spread, and general health of the patients. Current issues and a few points to make a strategy in the management of pancreatic NETs would be reviewed.
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Affiliation(s)
- Naoko Iwahashi Kondo
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka City, Japan
| | - Yasuharu Ikeda
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka City, Japan
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Yang M, Zeng L, Zhang Y, Su AP, Yue PJ, Tian BL. Surgical treatment and clinical outcome of nonfunctional pancreatic neuroendocrine tumors: a 14-year experience from one single center. Medicine (Baltimore) 2014; 93:e94. [PMID: 25396335 PMCID: PMC4616315 DOI: 10.1097/md.0000000000000094] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Our primary aim of the present study was to analyze the clinical characteristics and surgical outcome of nonfunctional pancreatic neuroendocrine tumors (non-F-P-NETs), with an emphasis on evaluating the prognostic value of the newly updated 2010 grading classification of the World Health Organization (WHO).Data of 55 consecutive patients who were surgically treated and pathologically diagnosed as non-F-P-NETs in our single institution from January 2000 to December 2013 were retrospectively collected.This entirety comprised of 55 patients (31 males and 24 females), with a mean age of 51.24 ± 12.95 years. Manifestations of non-F-P-NETs were nonspecific. Distal pancreatectomy, pancreaticoduodenectomy, and local resection of pancreatic tumor were the most frequent surgical procedures, while pancreatic fistula was the most common but acceptable complication (30.3%). The overall 5-year survival rate of this entire cohort was 41.0%, with a median survival time of 60.4 months. Patients who underwent R0 resections obtained a better survival than those who did not (P < 0.005). As for the prognostic analysis, tumor size and lymph invasion were only statistically significant in univariate analysis (P = 0.046 and P < 0.05, respectively), whereas the newly updated 2010 grading classification of WHO (G1 and G2 vs G3), distant metastasis, and surgical margin were all meaningful in both univariate and multivariate analysis (P = 0.045, 0.001, and 0.042, respectively).Non-F-P-NETs are a kind of rare neoplasm, with mostly indolent malignancy. Patients with non-F-P-NETs could benefit from the radical resections. The new WHO criteria, distant metastasis and surgical margin, might be independent predictors for the prognosis of non-F-P-NETs.
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Affiliation(s)
- Min Yang
- Department of Hepato-bilio-pancreatic Surgery (MY, YZ, AS, PY, BT); and General Ward of Sports Medicine and Cardiopulmonary Rehabilitation (LZ), West China Hospital, Sichuan University, Chengdu, Sichuan Province, The People's Republic of China
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Abstract
The ideal management of NET must be addressed on a case-by-case basis, with consideration given to patient factors, disease burden, and clinical tumor activity. Outcome improvement for LT in the setting of metastatic disease requires better characterization of the biological behavior of NETs and further identification of factors to be included in the selection criteria. Box 3 summarizes the many areas that have been, and are currently, undergoing investigation. LT as an attempt for cure rather than palliation is a justified treatment option for well-selected patients with metastatic neuroendocrine tumors of the pancreas and GI system. Optimization of pretransplantation staging and patient management algorithms, patient selection, and posttransplant management options are areas that need to be better defined. Further investigations for defining reproducible prognostic factors, consistent histopathologic evaluation, and uniform preoperative staging and site-specific data are needed. With the advancement of newer treatment modalities, it is necessary to define the role of LT along with the optimal perioperative management of existing and recurrent disease.
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Evaluation of the World Health Organization 2010 grading system in surgical outcome and prognosis of pancreatic neuroendocrine tumors. Pancreas 2014; 43:1003-8. [PMID: 24945681 DOI: 10.1097/mpa.0000000000000153] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the clinical consistency of the new World Health Organization 2010 grading and the European Neuroendocrine Tumor Society 2006 TNM staging systems on the surgical outcome for patients with pancreatic neuroendocrine tumors (p-NETs). Moreover, we will discuss their prognostic value. METHODS The medical records of 110 consecutive patients with p-NETs who were surgically treated in our center from January 2002 to December 2012 were reviewed. RESULTS Sixty-five patients were diagnosed as having neuroendocrine tumor G1, 27 patients had neuroendocrine tumor G2, 14 patients had neuroendocrine carcinoma G3, and 4 patients had mixed adenoneuro endocrine carcinoma; the survival rates at 5 years were 82.6%, 52.7%, 25.7%, and 0%, respectively (P < 0.001). The TNM stage was I in 48 patients, II in 39 patients, III in 11 patients, and IV in 12 patients; the 5-year survival rates were 83.1%, 72.1%, 0%, and 0%, respectively (P < 0.001). The patients who underwent R0 resection gained a statistically longer survival time than those who did not (P < 0.001). CONCLUSIONS Both classifications accurately reflect the clinical outcome of p-NETs. Surgical margin, the World Health Organization 2010 grading, and the TNM staging systems may all be meaningful prognostic factors impacting the long-term survival of patients with p-NETs.
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Sofocleous CT, Petre EN, Gonen M, Reidy-Lagunes D, Ip IK, Alago W, Covey AM, Erinjeri JP, Brody LA, Maybody M, Thornton RH, Solomon SB, Getrajdman GI, Brown KT. Factors affecting periprocedural morbidity and mortality and long-term patient survival after arterial embolization of hepatic neuroendocrine metastases. J Vasc Interv Radiol 2014; 25:22-30; quiz 31. [PMID: 24365504 DOI: 10.1016/j.jvir.2013.09.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/07/2013] [Accepted: 09/23/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To identify factors affecting periprocedural morbidity and mortality and long-term survival following hepatic artery embolization (HAE) of hepatic neuroendocrine tumor (NET) metastases. MATERIALS AND METHODS This single-center, institutional review board-approved retrospective review included 320 consecutive HAEs for NET metastases performed in 137 patients between September 1996 and September 2007. Forty-seven HAEs (15%) were performed urgently to manage refractory symptoms in inpatients (urgent group), and 273 HAEs (85%) were elective (elective group). Overall survival (OS) was estimated by Kaplan-Meier methodology. Complications were categorized per Common Terminology Criteria for Adverse Events, version 4.0. Univariate and multivariate analyses were performed to determine independent predictors for OS, complications, and 30-day mortality. The independent factors were combined to develop clinical risk score groups. RESULTS Urgent HAE (P = .007), greater than 50% liver replacement by tumor (P < .0001), and extrahepatic metastasis (P = .007) were independent predictors for shorter OS. Patients with all three risk factors had decreased OS versus those with none (median, 8.5 vs 86 mo; P < .001). Thirty-day mortality was significantly lower in the elective (1%) versus the urgent group (8.5%; P = .0009). There were eight complications (3%) in the elective group and five (10.6%) in the urgent group (P = .03). Male sex and urgent group were independent factors for higher 30-day mortality rate (P = .023 and P =.016, respectively) and complications (P = .012 and P =.001, respectively). CONCLUSIONS Urgent HAE, replacement of more than 50% of liver by tumor, and extrahepatic metastasis are strong independent predictors of shorter OS. Male sex and urgent HAE carry higher 30-day mortality and periprocedural morbidity risks.
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Affiliation(s)
- Constantinos T Sofocleous
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065.
| | - Elena N Petre
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Diane Reidy-Lagunes
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Ivan K Ip
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - William Alago
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Anne M Covey
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Joseph P Erinjeri
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Lynn A Brody
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Majid Maybody
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Raymond H Thornton
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Stephen B Solomon
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - George I Getrajdman
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
| | - Karen T Brown
- Section of Interventional Radiology and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Suite H 118, New York, NY 10065
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Abstract
Pancreatic neuroendocrine tumors are a group of rare, heterogeneous neoplasms that have been increasing in incidence the past few decades largely because of the diagnosis of pancreatic incidentalomas on cross-sectional imaging. Although these tumors are classically associated with clinical syndromes that result from excess secretion of particular hormones, most pancreatic neuroendocrine tumors are nonfunctional tumors presenting with symptoms secondary to mass effect, metastatic disease, or as incidental findings. This article reviews the diagnostic algorithm, surgical management, and available systemic therapies for nonfunctional pancreatic neuroendocrine tumors.
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Affiliation(s)
- Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032, USA
| | - James A Lee
- COACH Education, Endocrine Surgery, Adrenal Center, New York Thyroid/Parathyroid Center, Simulation Center, Columbia University, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032, USA.
| | - John A Chabot
- Division of GI/Endocrine Surgery, Columbia University, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032, USA
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Gujral DM, Bhattacharyya S. Cardiac manifestations of gastrointestinal carcinoid tumor. Future Cardiol 2014; 9:479-88. [PMID: 23834689 DOI: 10.2217/fca.13.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Carcinoid tumors are rare, slow-growing tumors found primarily in the GI tract. Carcinoid syndrome develops when vasoactive substances (particularly serotonin) released by carcinoid tumors gain access to the systemic circulation. Carcinoid heart disease develops in patients with carcinoid syndrome and is commonly associated with the development of right-sided valve dysfunction and signs of symptoms of right heart failure. Timely surgical intervention provides relief from symptoms and may improve survival. Management of these patients should be undertaken in a specialized center by a multidisciplinary team with appropriate expertise.
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Affiliation(s)
- Dorothy M Gujral
- The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK
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Slotta JE, Schuld J, Distler S, Richter S, Schilling MK, Kollmar O. Hepatic resection of non-colorectal and non-neuroendocrine liver metastases - survival benefit for patients with non-gastrointestinal primary cancers - a case-controlled study. Int J Surg 2013; 12:163-8. [PMID: 24342081 DOI: 10.1016/j.ijsu.2013.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 09/26/2013] [Accepted: 12/06/2013] [Indexed: 02/08/2023]
Abstract
PURPOSE Whereas resection of colorectal liver metastases is gold standard, there is an ongoing debate on benefit of resection of non-colorectal (NCRC) and non-neuroendocrine (NNEC) liver metastases. METHODS The potential survival benefit of patients undergoing resection of NCRC or NNEC liver metastases was investigated. Data from a prospectively maintained database were reviewed over a 7-year period. Kaplan-Meier method was used for the evaluation of outcome following resection. RESULTS 101 patients underwent 116 surgical procedures for synchronous and metachronous NCRC or NNEC liver metastases with a morbidity of 23% and a mortality of ∼1%. 11 patients underwent repeated liver resection procedures. Overall 5-year survival after liver resection was 30% depending on primary tumour site. Median survival was significantly increased after resection of hepatic metastases from non-gastrointestinal primaries compared to gastrointestinal primaries. Resection of hepatic metastases from non-gastrointestinal primaries resulted in significantly increased median survival compared to exploration only. Patients with hepatic metastases from gastrointestinal primaries did not benefit from hepatic surgery. CONCLUSION Hepatic resection for liver metastases from NCRC or NNEC cancers is a save treatment procedure. However, the decision to perform surgery should depend on the primary cancer. Especially patients with liver metastases from non-gastrointestinal primaries profit from hepatic surgery.
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Affiliation(s)
- Jan E Slotta
- Department of General, Visceral and Paediatric Surgery, University Medical Center Göttingen, Germany; Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany.
| | - Jochen Schuld
- Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Sabrina Distler
- Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Sven Richter
- Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Martin K Schilling
- Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Otto Kollmar
- Department of General, Visceral and Paediatric Surgery, University Medical Center Göttingen, Germany; Department of General, Visceral, Vascular and Paediatric Surgery, Saarland University Medical Center, Homburg, Saar, Germany
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Fisher SB, Kneuertz PJ, Dodson RM, Patel SH, Maithel SK, Sarmiento JM, Russell MC, Cardona K, Choti MA, Staley CA, Pawlik TM, Kooby DA. A comparison of right posterior sectorectomy with formal right hepatectomy: a dual-institution study. HPB (Oxford) 2013; 15:753-62. [PMID: 23869439 PMCID: PMC3791114 DOI: 10.1111/hpb.12126] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/05/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Right posterior sectorectomy (RPS) preserves liver volume but typically requires a longer parenchymal transection distance than does right hepatectomy (RH). This study was conducted to define the advantages of one approach over the other. METHODS Databases at two institutions were retrospectively reviewed for all patients submitted to RPS or RH between January 2000 and August 2012. Primary outcomes were perioperative complications and 90-day mortality. RESULTS Patients undergoing RPS (n = 100) and RH (n = 480), respectively, were similar in demographics, comorbidities, operative indications and Model for End-stage Liver Disease (MELD) mean scores (7.8 in the RPS group and 7.7 in the RH group; P = 0.49). A comparison of the RPS group with the RH group showed no significant differences in mean estimated blood loss (697 ml versus 713 ml; P = 0.900), rate of transfusions (19.2% versus 17.1%; P = 0.720), margin-positive resection (9.2% versus 11.6%; P = 0.70), complications (41.8% versus 42.0%; P = 1.000), bile leak (3.0% versus 4.0%; P = 1.000), or length of stay (7.5 days versus 8.3 days; P = 0.360). Postoperative hepatic insufficiency (defined as a postoperative bilirubin level of >7 mg/dl or significant ascites), occurred less frequently after RPS (1.0% versus 8.5%; P = 0.005). Operation type remained an independent determinant of postoperative hepatic insufficiency after controlling for preoperative risk factors (RH: hazard ratio = 9.628, 95% confidence interval 1.295-71.573; P = 0.027). A total of 28 (4.8%) patients died within 90 days; these included 25 (5.2%) patients in the RH group and three (3.0%) in the RPS group (P = 0.449). CONCLUSIONS Despite similar blood loss and overall morbidity, RPS is associated with less hepatic insufficiency than RH. Right posterior sectorectomy is parenchyma-sparing and should be strongly considered when it is technically feasible and oncologically sound.
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Affiliation(s)
- Sarah B Fisher
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Peter J Kneuertz
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Rebecca M Dodson
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | | | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Michael A Choti
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
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Massimino K, Harrskog O, Pommier S, Pommier R. Octreotide LAR and bolus octreotide are insufficient for preventing intraoperative complications in carcinoid patients. J Surg Oncol 2013; 107:842-6. [PMID: 23592524 DOI: 10.1002/jso.23323] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/09/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgery in carcinoid patients can provoke a carcinoid crisis, which can have serious sequelae, including death. Octreotide prophylaxis is recommended to prevent carcinoid crisis, however there are few reports of outcomes and no large series examining its efficacy. We hypothesized that a 500 µg prophylactic octreotide dose is sufficient to prevent carcinoid crisis. METHODS Records of carcinoid patients undergoing abdominal operations during years 2007-2011 were retrospectively reviewed. Octreotide use and intraoperative and postoperative outcomes were analyzed. RESULTS Ninety-seven intraabdominal operations performed by a single surgeon were reviewed. Ninety percent of patients received preoperative prophylactic octreotide. Fifty-six percent received at least one additional intraoperative dose. Twenty-three patients (24%) experienced an intraoperative complication. Intraoperative complications correlated with presence of hepatic metastases but not presence of carcinoid syndrome. Postoperative complications occurred in 60% of patients with intraoperative complications versus 31% of those with none (P = 0.01). CONCLUSIONS Significant intraoperative complications occur frequently in patients with hepatic metastases regardless of presence of carcinoid syndrome and despite octreotide LAR or single dose prophylactic octreotide. Occurrence of such events correlates strongly with postoperative complications. Randomized controlled trials are needed to determine whether the administration of prophylactic octreotide is beneficial.
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Affiliation(s)
- Kristen Massimino
- Division of General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon 97239, USA
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