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Abstract
Primary hyperparathyroidism is a disease that occurs more frequently than generally thought and is often overlooked. Classical symptoms are bone pain and osteoporosis, renal calculi and peptic ulcers. Many patients are asymptomatic or have unspecific complaints. It is easy to establish the biochemical diagnosis based on calcium and parathormone (PTH) levels and 24-h urine calcium excretion. The most sensitive localization procedures for parathyroid adenomas are sonography and Tc-99m-MIBI scintigraphy. The indication for surgery is undisputed in symptomatic patients; however, there is controversy concerning patients without classical symptoms. Operative therapy is highly successful. Focused operative procedures are currently available besides the traditional 4‑gland exploration. When focused techniques are used, the operative success should be confirmed by intraoperative determination of the parathormone level.
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Affiliation(s)
- C Nies
- Klinik für Allgemein- und Viszeralchirurgie, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Bischofsstr. 1, 49074, Osnabrück, Deutschland.
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2
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van Leeuwaarde RS, de Laat JM, Pieterman CRC, Dreijerink K, Vriens MR, Valk GD. The future: medical advances in MEN1 therapeutic approaches and management strategies. Endocr Relat Cancer 2017; 24:T179-T193. [PMID: 28768698 DOI: 10.1530/erc-17-0225] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 12/21/2022]
Abstract
Multiple endocrine neoplasia type 1 is a rare autosomal inherited disorder associated with a high risk for patients to simultaneously develop tumors of the parathyroid glands, duodenopancreatic neuroendocrine tumors and tumors of the anterior pituitary gland. Early identification of MEN1 in patients enables presymptomatic screening of manifestations, which makes timely interventions possible with the intention to prevent morbidity and mortality. Causes of death nowadays have shifted toward local or metastatic progression of malignant neuroendocrine tumors. In early cohorts, complications like peptic ulcers in gastrinoma, renal failure in hyperparathyroidism, hypoglycemia and acute hypercalcemia were the primary causes of early mortality. Improved medical treatments of these complications led to a significantly improved life expectancy. The MEN1 landscape is still evolving, considering the finding of breast cancer as a new MEN1-related manifestation and ongoing publications on follow-up and medical care for patients with MEN1. This review aims at summarizing the most recent insights into the follow-up and medical care for patients with MEN1 and identifying the gaps for future research.
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Affiliation(s)
| | - Joanne M de Laat
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Carolina R C Pieterman
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Koen Dreijerink
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine SurgeryUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
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3
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Manoharan J, Lopez CL, Hackmann K, Albers MB, Pehl A, Kann PH, Slater EP, Schröck E, Bartsch DK. An unusual phenotype of MEN1 syndrome with a SI-NEN associated with a deletion of the MEN1 gene. Endocrinol Diabetes Metab Case Rep 2016; 2016:160011. [PMID: 27076911 PMCID: PMC4828980 DOI: 10.1530/edm-16-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 12/12/2022] Open
Abstract
We report about a young female who developed an unusual and an aggressive phenotype of the MEN1 syndrome characterized by the development of a pHPT, malignant non-functioning pancreatic and duodenal neuroendocrine neoplasias, a pituitary adenoma, a non-functioning adrenal adenoma and also a malignant jejunal NET at the age of 37 years. Initial Sanger sequencing could not detect a germline mutation of the MEN1 gene, but next generation sequencing and MPLA revealed a deletion of the MEN1 gene ranging between 7.6 and 25.9 kb. Small intestine neuroendocrine neoplasias (SI-NENs) are currently not considered to be a part of the phenotype of the MEN1-syndrome. In our patient the SI-NENs were detected during follow-up imaging on Ga68-Dotatoc PET/CT and could be completely resected. Although SI-NENs are extremely rare, these tumors should also be considered in MEN1 patients. Whether an aggressive phenotype or the occurrence of SI-NENs in MEN1 are more likely associated with large deletions of the gene warrants further investigation.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Caroline L Lopez
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Karl Hackmann
- Faculty of Medicine Carl Gustav Carus, Institute for Clinical Genetics, TU Dresden, Fetscherstrasse 7401307, Dresden, Germany; German Cancer Consortium (DKTK), Dresden, Germany, German Cancer Research Center (DKFZ), Heidelberg, Germany, National Center for Tumor Diseases (NCT), Dresden, Germany
| | - Max B Albers
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Anika Pehl
- Department of Pathology, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Peter H Kann
- Division of Endocrinology and Diabetology, Department of Gastroenterology and Endocrinology, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Emily P Slater
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Evelin Schröck
- Faculty of Medicine Carl Gustav Carus, Institute for Clinical Genetics, TU Dresden, Fetscherstrasse 7401307, Dresden, Germany; German Cancer Consortium (DKTK), Dresden, Germany, German Cancer Research Center (DKFZ), Heidelberg, Germany, National Center for Tumor Diseases (NCT), Dresden, Germany
| | - Detlef K Bartsch
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
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4
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de Laat JM, Pieterman CR, van den Broek MF, Twisk JW, Hermus AR, Dekkers OM, de Herder WW, van der Horst-Schrivers AN, Drent ML, Bisschop PH, Havekes B, Vriens MR, Valk GD. Natural course and survival of neuroendocrine tumors of thymus and lung in MEN1 patients. J Clin Endocrinol Metab 2014; 99:3325-33. [PMID: 24915123 DOI: 10.1210/jc.2014-1560] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT The natural course and survival of neuroendocrine tumors (NETs) of thymus (Th) and lung in multiple endocrine neoplasia type 1 (MEN1) patients are still unknown. OBJECTIVE Our objective was to assess prevalence, tumor growth, and survival of Th and lung NETs in an unselected MEN1 population with long-term follow-up. DESIGN This was an observational study. PATIENTS AND METHODS A longitudinal study was performed using the Dutch national MEN1 database, including >90% of the Dutch MEN1 population >16 years of age. Patients under care of the Dutch University Medical Centers (1990-2011) (n = 323) were included. MAIN OUTCOME MEASURES The prevalence and survival of Th and lung NETs were assessed. Linear mixed-models analysis was applied to assess tumor growth with age as a possible confounder and gender, genotype and baseline tumor size as possible effect modifiers. RESULTS Th NETs occurred in 3.4% of patients, almost exclusively in males with a 10-year survival of 25% (95% confidence interval = 8%-80%). A thoracic computed tomography scan was available in 188 patients (58.2%). A lung NET was identified in 42 patients (13.0%) with a 10-year survival of 71.1% (95% confidence interval = 51%-100%). Tumor volume of lung NETs increased 17% per year (P < .001) (tumor doubling time 4.5 years). Tumor doubling time in males was 2.5 vs 5.5 years in females (P = .05). Lung NET growth was not associated with genotype or with baseline tumor size (<1 vs ≥1 cm). CONCLUSION In MEN1 patients, Th NETs almost exclusively occurred in males and had a very low prevalence and a high mortality. Lung NETs occurred more often than previously thought, had an indolent course, and occurred equally in both sexes. Tumor growth in males was double compared with female patients.
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Affiliation(s)
- Joanne M de Laat
- Departments of Internal Medicine (J.M.d.L., C.R.P., M.F.v.d.B., G.D.V.) and Surgery (M.R.V.), University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands; Department of Clinical Epidemiology and Biostatistics (J.W.T.), VU University Medical Center, 1007 MB, Amsterdam, The Netherlands; Department of Endocrinology (A.R.H.), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; Departments of Endocrinology and Metabolism and Clinical Epidemiology (O.M.D.), Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Department of Internal Medicine (W.W.d.H.), Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; Department of Endocrinology (A.N.v.d.H.-S.), University Medical Center Groningen, 9700 RB Groningen, The Netherlands; Department of Internal Medicine (M.L.D.), Section of Endocrinology, VU University Medical Center, 6202 AZ Amsterdam, The Netherlands; Department of Endocrinology and Metabolism (P.H.B.), Academic Medical Center, 1100 DD Amsterdam, The Netherlands; and Department of Internal Medicine (B.H.), Division of Endocrinology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
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Ito T, Igarashi H, Uehara H, Berna MJ, Jensen RT. Causes of death and prognostic factors in multiple endocrine neoplasia type 1: a prospective study: comparison of 106 MEN1/Zollinger-Ellison syndrome patients with 1613 literature MEN1 patients with or without pancreatic endocrine tumors. Medicine (Baltimore) 2013; 92:135-181. [PMID: 23645327 PMCID: PMC3727638 DOI: 10.1097/md.0b013e3182954af1] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is classically characterized by the development of functional or nonfunctional hyperplasia or tumors in endocrine tissues (parathyroid, pancreas, pituitary, adrenal). Because effective treatments have been developed for the hormone excess state, which was a major cause of death in these patients in the past, coupled with the recognition that nonendocrine tumors increasingly develop late in the disease course, the natural history of the disease has changed. An understanding of the current causes of death is important to tailor treatment for these patients and to help identify prognostic factors; however, it is generally lacking.To add to our understanding, we conducted a detailed analysis of the causes of death and prognostic factors from a prospective long-term National Institutes of Health (NIH) study of 106 MEN1 patients with pancreatic endocrine tumors with Zollinger-Ellison syndrome (MEN1/ZES patients) and compared our results to those from the pooled literature data of 227 patients with MEN1 with pancreatic endocrine tumors (MEN1/PET patients) reported in case reports or small series, and to 1386 patients reported in large MEN1 literature series. In the NIH series over a mean follow-up of 24.5 years, 24 (23%) patients died (14 MEN1-related and 10 non-MEN1-related deaths). Comparing the causes of death with the results from the 227 patients in the pooled literature series, we found that no patients died of acute complications due to acid hypersecretion, and 8%-14% died of other hormone excess causes, which is similar to the results in 10 large MEN1 literature series published since 1995. In the 2 series (the NIH and pooled literature series), two-thirds of patients died from an MEN1-related cause and one-third from a non-MEN1-related cause, which agrees with the mean values reported in 10 large MEN1 series in the literature, although in the literature the causes of death varied widely. In the NIH and pooled literature series, the main causes of MEN1-related deaths were due to the malignant nature of the PETs, followed by the malignant nature of thymic carcinoid tumors. These results differ from the results of a number of the literature series, especially those reported before the 1990s. The causes of non-MEN1-related death for the 2 series, in decreasing frequency, were cardiovascular disease, other nonendocrine tumors > lung diseases, cerebrovascular diseases. The most frequent non-MEN1-related tumor deaths were colorectal, renal > lung > breast, oropharyngeal. Although both overall and disease-related survival are better than in the past (30-yr survival of NIH series: 82% overall, 88% disease-related), the mean age at death was 55 years, which is younger than expected for the general population.Detailed analysis of causes of death correlated with clinical, laboratory, and tumor characteristics of patients in the 2 series allowed identification of a number of prognostic factors. Poor prognostic factors included higher fasting gastrin levels, presence of other functional hormonal syndromes, need for >3 parathyroidectomies, presence of liver metastases or distant metastases, aggressive PET growth, large PETs, or the development of new lesions.The results of this study have helped define the causes of death of MEN1 patients at present, and have enabled us to identify a number of prognostic factors that should be helpful in tailoring treatment for these patients for both short- and long-term management, as well as in directing research efforts to better define the natural history of the disease and the most important factors determining long-term survival at present.
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Affiliation(s)
- Tetsuhide Ito
- From the Department of Medicine and Bioregulatory Science (TI, HI), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Digestive Diseases Branch (TI, HI, HU, MJB, RTJ), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Hôpital Kirchberg (MJB), Luxembourg, Luxembourg
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6
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Pieterman CRC, Vriens MR, Dreijerink KMA, van der Luijt RB, Valk GD. Care for patients with multiple endocrine neoplasia type 1: the current evidence base. Fam Cancer 2010; 10:157-71. [DOI: 10.1007/s10689-010-9398-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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7
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Pancreatic metastasis of thymic neuroendocrine carcinoma: is there a role for endoscopic ultrasound?: report of a case and review of the literature. Pancreas 2009; 38:230-2. [PMID: 19238027 DOI: 10.1097/mpa.0b013e3181816700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Goretzki PE, Wirowski D, Schwarz K, Pohl P, Böhner H, Starke A, Lammers BJ. [Indication and performance of endocrine surgery. The significance of molecular genetic examination]. Chirurg 2008; 80:122-9. [PMID: 19096808 DOI: 10.1007/s00104-008-1615-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The molecular genetic changes from certain endocrine tumors are already understood, reflecting as they do the etiology of these sporadic familial disorders. This already has clinical consequences to the treatment of familial endocrine tumors, which often appear in the course of syndromatic disorders. These consequences consist in slight changes to surgical technique, the search for other active and usually endocrinal tumors, and examination of family members for other gene carriers (of disease-specific mutations) and the most suitable prophylactic tumor therapy. In contrast, for sporadic endocrine tumors there exists far less clinically relevant knowledge. Starting with anamnesis and clinical findings of active endocrine tumors, we discuss the current possibilities for molecular genetic determination of disease-specific mutations (germline and tumor DNA) and their effect on surgical procedure.
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Affiliation(s)
- P E Goretzki
- Chirurgische Klinik 1, Städtisches Lukaskrankenhaus Neuss und Insulinoma und GEP-Tumor Center Neuss-Düsseldorf, Preussenstrasse 84, Neuss, Germany.
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9
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Tonelli F, Fratini G, Nesi G, Tommasi MS, Batignani G, Falchetti A, Brandi ML. Pancreatectomy in multiple endocrine neoplasia type 1-related gastrinomas and pancreatic endocrine neoplasias. Ann Surg 2006; 244:61-70. [PMID: 16794390 PMCID: PMC1570585 DOI: 10.1097/01.sla.0000218073.77254.62] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the results of pancreatic resection in pancreatic endocrine neoplasias (PENs) in patients affected by multiple endocrine neoplasia type 1 (MEN1) syndrome. BACKGROUND Since these tumors often show an indolent course, the role of diagnostic procedures and type of surgical approach are controversial. Experience with new diagnostic approaches and more aggressive surgery is still limited. METHODS Sixteen MEN1 patients were referred to our Surgical Unit (1992-2003) and were operated on for the indications of hypergastrinism, hypoglycemia, and/or pancreatic endocrine neoplasias larger than 1 cm. Zollinger-Ellison syndrome (ZES) was present in 13 patients, 2 of whom experienced a recurrence after previous surgery. Preoperative tumor localization was carried out using ultrasonography (US), computed tomography (CT), endoscopic ultrasonography (EUS), somatostatin receptor scintigraphy (SSRS), or selective arterial secretin injection (SASI). Rapid intraoperative gastrin measurement (IGM) was carried out in 8 patients, and 1 patient also underwent an intraoperative secretin provocative test. RESULTS Either pancreatoduodenectomy (PD) or total pancreatectomy (TP) or distal pancreatectomy was performed. There was no postoperative mortality; 37% complications included pancreatic (27%) and biliary (6%) fistulas, abdominal collection (6%), and acute pancreatitis (6%). EUS and SSRS were the most sensitive preoperative imaging techniques. At follow-up, 10 of 13 hypergastrinemic patients (77%) are currently eugastrinemic with negative secretin provocative test, while 3 are showing a recurrence of the disease. All patients affected by insulinoma were cured. CONCLUSIONS MEN1 tumors should be considered surgically curable diseases. IGM may be of value in the assessment of surgical cure. Our experience suggests that PD is superior to less radical surgical approaches in providing cure with limited morbidity in MEN1 gastrinomas and pancreatic neoplasias.
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Affiliation(s)
- Francesco Tonelli
- Department of Clinical Physiopathology, University of Florence, Medical School, Florence, Italy.
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Brunaud L, Bresler L, Ayav A, Muresan M, Klein M, Weryha G, Boissel P. Prise en charge chirurgicale des tumeurs endocrines du tractus gastro-intestinal. ACTA ACUST UNITED AC 2004; 129:563-70. [PMID: 15581816 DOI: 10.1016/j.anchir.2004.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Surgical management of gastro-intestinal endocrine tumors has to be adapted to tumor localization and disease extension (local and general). The aim of this literature review was to define surgical management of these unfrequent tumors.
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Affiliation(s)
- L Brunaud
- Service de chirurgie viscérale, digestive et endocrinienne, CHU Nancy-Brabois, 11, allée du Morvan, 54511 Vandoeuvre-les-Nancy, France.
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11
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Alexakis N, Connor S, Ghaneh P, Lombard M, Smart HL, Evans J, Hughes M, Garvey CJ, Vora J, Vinjamuri S, Sutton R, Neoptolemos JP. Hereditary pancreatic endocrine tumours. Pancreatology 2004; 4:417-33; discussion 434-5. [PMID: 15249710 DOI: 10.1159/000079616] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The two main types of hereditary pancreatic neuroendocrine tumours are found in multiple endocrine neoplasia type 1 (MEN-1) and von Hippel-Lindau disease (VHL), but also in the rarer disorders of neurofibromatosis type 1 and tuberous sclerosis. This review considers the major advances that have been made in genetic diagnosis, tumour localization, medical and surgical treatment and palliation with systemic chemotherapy and radionuclides. With the exception of the insulinoma syndrome, all of the various hormone excess syndromes of MEN-1 can be treated medically. The role of surgery however remains controversial ranging from no intervention (except enucleation for insulinoma), intervening for tumours diagnosed only by biochemical criteria, intervening in those tumours only detected radiologically (1-2 cm in diameter) or intervening only if the tumour diameter is > 3 cm in diameter. The extent of surgery is also controversial, although radical lymphadenectomy is generally recommended. Pancreatic tumours associated with VHL are usually non-functioning and tumours of at least 2 cm in diameter should be resected. Practice guidelines recommend that screening in patients with MEN-1 should commence at the age of 5 years for insulinoma and at the age of 20 years for other pancreatic neuroendocrine tumours and variously at 10-20 years of age for pancreatic tumours in patients with VHL. The evidence is increasing that the life span of patients may be significantly improved with surgical intervention, mandating the widespread use of tumour surveillance and multidisciplinary team management.
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Affiliation(s)
- N Alexakis
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, UK
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Abstract
BACKGROUND The optimum management of neuroendocrine liver metastases, particularly the role of liver transplantation is ill-defined. Current strategies are based on anecdotal reports and small retrospective studies, rather than prospective data. This, as well as the failure to standardize treatment, has probably contributed to the reported variations in outcome. DATA SOURCES To formulate a putative management protocol and to reevaluate the role of liver transplantation in patients with neuroendocrine liver metastases, a review of the published literature (Medline search) was conducted. CONCLUSIONS Isolated hepatic metastases should be resected when suitable. Chemoembolization of liver metastases should precede resection of bulky disease and be used to palliate those with unresectable disease. Radiofrequency ablation is suitable for smaller metastatic lesions (<3 cm diameter) in the liver. Systemic treatment with somatostatin analogues or radioactive metaiodobenzylguanidine (MIBG) is appropriate to reduce symptoms and slow disease progression, but prospective data is required to define their exact roles as adjuvant and therapeutic agents. Although current systemic chemotherapy, applied in isolation, may have a role in patients in whom other therapies have failed, its efficacy remains unproven. Restriction of liver transplantation to the treatment of patients with carcinoid metastases with biologically favorable features, limited tumor bulk and without systemic disease may make transplantation a curative rather than a palliative treatment option in selected patients.
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Affiliation(s)
- Robert Sutcliffe
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
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Gibril F, Schumann M, Pace A, Jensen RT. Multiple endocrine neoplasia type 1 and Zollinger-Ellison syndrome: a prospective study of 107 cases and comparison with 1009 cases from the literature. Medicine (Baltimore) 2004; 83:43-83. [PMID: 14747767 DOI: 10.1097/01.md.0000112297.72510.32] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
In patients with multiple endocrine neoplasia type 1 (MEN1), the most common functional pancreatic endocrine tumor (PET) syndrome is Zollinger-Ellison syndrome (ZES). ZES has been well studied in its sporadic form (that is, without MEN1); however, there are limited data on patients with MEN1 and ZES (MEN1/ZES), and the long-term natural history is largely unknown. To address this issue we report the results of a prospective long-term National Institutes of Health (NIH) study of 107 MEN1/ZES patients and compare our results with those of 1009 MEN1/ZES patients in 278 case reports and small series in the literature. Patients were clinically, radiologically, and biochemically evaluated yearly for all MEN1 manifestations (mean follow-up, 10 yr; range, 0.1-31 yr). Compared with patients from the literature, the NIH MEN1/ZES patients more frequently had pituitary (60%) and adrenal (45%) disease and carcinoid tumors (30%), but had equal frequency of hyperparathyroidism (94%), thyroid disease (6%), or lipomas (5%). Twenty-five percent of both the NIH and the literature patients lacked a family history of MEN1; ZES was the initial clinical manifestation of MEN1 in 40%. ZES onset preceded the diagnosis of hyperparathyroidism in 45%. However, ZES was rarely (8%) the only initial manifestation of MEN1 if careful testing was done. ZES occurred before age 40 years in 50%-60% of the current patients, in contrast to older studies. The diagnosis of ZES is delayed 3-5 years from its onset and is delayed as long as in sporadic ZES cases. Pituitary disease and carcinoid tumors (gastric > bronchial, thymic) are more frequent than generally reported, whereas a second functional PET is uncommon. In patients with MEN1/ZES without a family history of MEN1, the MEN1 manifestations are not as severe. This study shows that MEN1/ZES patients differ in many aspects from those commonly reported in older studies involving few MEN1/ZES patients. In this study we have identified a number of important clinical and laboratory features of MEN1/ZES that were not previously appreciated, which should contribute to earlier diagnosis and improve both short- and long-term management.
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Affiliation(s)
- Fathia Gibril
- From Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Gibril F, Chen YJ, Schrump DS, Vortmeyer A, Zhuang Z, Lubensky IA, Reynolds JC, Louie A, Entsuah LK, Huang K, Asgharian B, Jensen RT. Prospective study of thymic carcinoids in patients with multiple endocrine neoplasia type 1. J Clin Endocrinol Metab 2003; 88:1066-81. [PMID: 12629087 DOI: 10.1210/jc.2002-021314] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Little is known of the natural history of thymic carcinoids in multiple endocrine neoplasia type 1 (MEN1). This is important because in 1993 they were identified as a frequent cause of death, yet only small retrospective studies and case reports exist. We report results of a prospective study of 85 patients with MEN1 evaluated for pancreatic endocrine tumors and followed over a mean of 8 yr with serial chest computed tomography, magnetic resonance imaging (MRI), chest x-ray, and, since 1994, octreoscans [somatostatin receptor scintigraphy (SRS)]. Seven patients (8%) developed thymic carcinoids. Patients with and without carcinoids did not differ in clinical, laboratory, or MEN1 tumor features, except for male gender and the presence of a gastric carcinoid. All thymic tumors were hormonally inactive. Four thymic carcinoids lacked 11q loss of heterozygosity, although it was found in three pancreatic endocrine tumors. Computed tomography and/or MRI were more sensitive than SRS or chest x-ray in detecting tumors initially or with recurrence. All patients underwent resection of the thymic carcinoid, and in all patients followed more than 1 yr, the tumor recurred. Bone metastases developed in two patients and were detected early only on MRI, not SRS. This study provides information on early thymic carcinoids and allows modifications of existing guidelines to be recommended for their diagnosis, surveillance, and treatment.
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Affiliation(s)
- Fathia Gibril
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), Bethesda, Maryland 20892, USA
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Glascock MJ, Carty SE. Multiple endocrine neoplasia type 1: fresh perspective on clinical features and penetrance. Surg Oncol 2002; 11:143-50. [PMID: 12356510 DOI: 10.1016/s0960-7404(01)00031-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN-1) is an interesting genetic syndrome of polyendocrinopathies. Clinical knowledge about MEN-1 is essential as it appears to be significantly under-diagnosed. New data from several prospective series shows not only that as a many as 40% of patients manifest a first feature of MEN-1 after age 40, but also that as many as a third of gene carriers do not present with hyperparathyroidism as the first feature, as previously believed. Mutational analysis for frequently involved exons of the gene menin on chromosome 11 is now available, but negative results should be interpreted with caution in patients with clinical MEN-1. Disease-specific mortality is significant, arises largely from pancreatic islet carcinoma and malignant thymic carcinoid, and renders this disorder worthy of careful and early prospective diagnosis and treatment.
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Affiliation(s)
- Matthew J Glascock
- Section of Endocrine Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Abstract
Multiple endocrine neoplasia type I is a rare autosomal dominant disorder with many endocrine and nonendocrine manifestations. Hyperparathyroidism, islet cell tumors, and pituitary tumors are diagnosed most commonly in these patients. There is controversy regarding treatment of the different manifestations and screening modalities of this disorder because no large series has determined the best therapeutic approach. Our institution advocates early screening with biochemical and radiographic testing in patients with a definite predilection for this disorder. Patients with hyperparathyroidism should undergo early surgical intervention of at least three and a half glands combined with bilateral upper thymectomy through a cervical incision. Although the recurrence rate is high, disease-free survival can be for as long as 30 years. Pituitary tumors are predominantly prolactinomas and growth hormone-releasing tumors. Prolactinomas usually require pharmacologic therapy, whereas growth hormone-releasing tumors are treated surgically. Enteropancreatic tumors should be treated surgically or medically, depending on the hormone secreted. Insulinomas respond well to distal pancreatectomy, with enucleation of the tumor from the head and uncinate process of the pancreas. However, there is controversy regarding the surgical treatment of gastrinomas. Carcinoid tumors should be treated with early surgical intervention. Adrenal lesions are thought to occur in association with pancreatic lesions and commonly have an indolent course. Adrenocortical cancers are uncommon in patients with multiple endocrine neoplasia type I. Skin lesions can be excised when cosmetically unappealing.
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Affiliation(s)
- Rasa Zarnegar
- University of California San Francisco/Mount Zion Medical Center, 1600 Divisadero Street, Box 1674, 94143-1674, USA
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17
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Norton JA, Alexander HR, Fraker DL, Venzon DJ, Gibril F, Jensen RT. Comparison of surgical results in patients with advanced and limited disease with multiple endocrine neoplasia type 1 and Zollinger-Ellison syndrome. Ann Surg 2001; 234:495-505; discussion 505-6. [PMID: 11573043 PMCID: PMC1422073 DOI: 10.1097/00000658-200110000-00009] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the role of surgery in patients with Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia type 1 (MEN1) with either limited or advanced pancreatic endocrine tumors (PETs). SUMMARY BACKGROUND DATA The role of surgery in patients with MEN1 and ZES is controversial. There have been numerous previous studies of surgery in patients with PETs; however, there are no prospective studies on the results of surgery in patients with advanced disease. METHODS Eighty-one consecutive patients with MEN1 and ZES were assigned to one of four groups depending on the results of imaging studies. Group 1 (n = 17) (all PETs smaller than 2.5 cm) and group 3 (n = 8) (diffuse liver metastases) did not undergo surgery. All patients in group 2A (n = 17; single PET 2.5-6 cm [limited disease]) and group 2B (n = 31; two or more lesions, 2.5 cm in diameter or larger, or one lesion larger than 6 cm) underwent laparotomy. Tumors were preferably removed by simple enucleation, or if not feasible resection. Patients were reevaluated yearly. RESULTS Pancreatic endocrine tumors were found in all patients at surgery, with groups 2A and 2B having 1.7 +/- 0.4 and 4.8 +/- 1 PETs, respectively. Further, 35% of the patients in group 2A and 88% of the patients in group 2B had multiple PETs, 53% and 84% had a pancreatic PET, 53% and 68% had a duodenal gastrinoma, 65% and 71% had lymph node metastases, and 0% and 12% had liver metastases. Of the patients in groups 2A and 2B, 24% and 58% had a distal pancreatectomy, 0% and 13% had a hepatic resection, 0% and 6% had a Whipple operation, and 53% and 68% had a duodenal resection. No patient was cured at 5 years. There were no deaths. The early complication rate, 29%, was similar for groups 2A and 2B. Mean follow-up from surgery was 6.9 +/- 0.8 years, and during follow-up liver metastases developed in 6% of the patients in groups 2A and 2B. Groups 1, 2A, and 2B had similar 15-year survival rates (89-100%); they were significantly better than the survival rate for group 3 (52%). CONCLUSIONS Almost 40% of patients with MEN1 and ZES have advanced disease without diffuse distant metastases. Despite multiple primaries and a 70% incidence of lymph node metastases, tumor can be removed with no deaths and complication rates similar to those in patients with limited disease. Further, despite previous studies showing that patients with advanced disease have decreased survival rates, in this study the patients with advanced tumor who underwent surgical resection had the same survival as patients with limited disease and patients without identifiable tumor. This suggests that surgical resection should be performed in patients with MEN1 who have ZES and advanced localized PET.
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Affiliation(s)
- J A Norton
- Department of Surgery, University of California, San Francisco, CA, USA
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18
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Abstract
Gastrinoma treatment has evolved considerably in the last 20 years. In particular, the advent of effective acid-reducing pharmacologic agents has changed the primary morbidity of this disease entity from one of acid hypersecretion to one of tumor growth and spread. Thus, while symptoms can be temporized using histamine receptor antagonists, proton pump inhibitors, or somatostatin analogs, cure can be effected only by surgical means. Recent advances in operative techniques and pre- and intra-operative imaging studies, including routine duodenotomy, somatostatin-receptor scintigraphy, and intraoperative ultrasound, have allowed for identification and subsequent resection of more than 95% of gastrinoma tumors. Most experts agree that all sporadic cases of localized gastrinoma should be excised. In addition, debulking of metastatic tumor may improve symptoms and survival when cure cannot be ascertained. There is, however, some controversy as to the surgical approach for gastrinoma found in the setting of multiple endocrine neoplasia, type 1. Because of the usual multiplicity and particular indolence of these tumors, two primary strategies have emerged: aggressive approaches have been advocated in an effort to eradicate all present and potential tumor; and less aggressive, or nonoperative, approaches have been suggested because it is unclear whether intervention offers survival or disease-free benefit in this population. We advocate surgical intervention for patients with gastrinoma and multiple endocrine neoplasia, type 1 when tumors exceed 2.5 cm in size. This tumor size has been associated with a higher likelihood of hepatic metastases, which ultimately affects survival. The role of adjuvant therapies for gastrinoma remains limited.
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Affiliation(s)
- M L Li
- Department of Surgery, University of California, San Francisco, USA
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