A gastric factor in the pathogenesis of the Zollinger-Ellison syndrome

The influence of surgery in MEN-1 syndrome: observations over 150 years

BACKGROUND

Efficacy and timing of operative intervention in patients with multiple endocrine neoplasia type 1 (MEN-1) syndrome remains controversial. This report utilizes a novel approach to evaluate the influence of evolving operative interventions for patients with MEN-1 syndrome.

METHODS

Six generations from a large MEN-1 family pedigree were studied. The number of operations for MEN-1 related pathology was recorded according to birth eras over 150 years. Length of life was a primary outcome measurement.

RESULTS

Inheritance of the MEN-1 trait was near 50%. There were no instances of a skipped generation. Affected individuals born before 1900 died from gastrointestinal hemorrhage and without any surgical intervention. After 1900, there were increasing numbers of gastric, parathyroid, and pancreatic operations in successive eras. Death occurred >20 years earlier in MEN-1 individuals than unaffected family members in eras 1 and 2. Family members with MEN-1 lived longer in succeeding eras with increasing number of operative and pharmacologic interventions.

CONCLUSION

MEN-1 family members invariably have pathologic changes in pituitary, parathyroid, and pancreatic islets when long lived, the "all-or-none" phenomenon. Patients are not cured with operative interventions, although they may live longer and without symptoms with a good quality of life. This model may allow better comparisons with other MEN-1 patients when evaluating outcomes of new medical and operative management schemes and long-term follow-up.

Is hypergastrinaemia dangerous for man?

Several gastric mucosal diseases and the response to powerful gastric secretory inhibitors are accompanied by hypergastrinaemia. When the gastric mucosa is functioning normally, hypergastrinaemia may be dangerous as a consequence of gastric hypersecretion. When the gastric mucosa is functionally abnormal, hypergastrinaemia produces no apparent adverse effects on health. However, the diseases giving rise to hypergastrinaemia are very dangerous because they are often the precursors of gastric cancer. In view of the probable mechanisms of gastric carcinogenesis, it is argued that therapeutic achlorhydria is also potentially dangerous irrespective of the absence or presence of 'hypergastrinaemia'.

Favourable response to conservative surgery for extra-pancreatic gastrinoma with lymph node metastases

Five patients with the Zollinger-Ellison syndrome who had extra-pancreatic (duodenal or paraduodenal) gastrinoma with lymph node metastases responded favourably to simple excision or mere shelling out of macroscopic tumour. Acid studies, serum gastrin and the secretin test became normal in all cases in the immediate postoperative period and remained so in three of the five patients when tested at 57, 33 and 8 months. The tests became abnormal in two patients when tested 8 and 53 months after surgery, but both patients are currently well-controlled on ranitidine 150 mg b.d. 22 and 65 months respectively after surgery. These results suggest that in patients with extra-pancreatic gastrinoma who have lymph node metastases simple excision of all macroscopic tumours may offer the prospect of long-term control. The place of total gastrectomy in such patients is questioned.

Gastrinoma

Although there are multiple etiologies of clinical hypergastrinemia, the most important cause is gastrinoma [Zollinger-Ellison (ZE) syndrome]. The most significant advance in the management of patients with the ZE syndrome has been the development of the ability to establish firmly the correct preoperative diagnosis by radioimmunoassay. We believe that all patients who have the ZE syndrome should undergo operation for two reasons: to identify and resect all tumor and because in patients in whom no tumor is found or in whom all tumor cannot be resected, the most reliable relief of hypersecretory symptoms for the life of the patient can be achieved by total gastrectomy.

Increase in duodenal tissue gastrin in dogs following antrectomy with gastroduodenostomy and after total gastrectomy with oesophagoduodenostomy

The gastrin concentration in plasma and duodenal tissue was determined in dogs following antrectomy and total gastrectomy as well as in unoperated control animals. The first week after both types of operations, during which time the dogs were parenterally fed the basal plasma gastrin concentration was markedly reduced, and then it slightly increased. The increase in plasma gastrin concentration from the second postoperative week until sacrifice was found to be statistically significant in one of six antrectomized dogs and in two of three dogs in which the whole stomach had been resected. In unoperated controls the gastrin concentration in the proximal third of the duodenum was found to be 6.8 +/- 0.8 pmol/g tissue wet weight (mean value +/- SE, n = 11). Following antrectomy a time dependent increase was seen, the corresponding values being 11.0 +/- 2.5 (n = 4), 36.4 +/- 15.7 (n = 6) and 136.1 +/- 44.2 (n = 6) pmol/g at 3, 9-10 and 14-16 weeks after operation, respectively. A similar increase was seen following total gastrectomy. 8 weeks after this type of operation the concentration was 22.2 +/- 12.5 (n = 3) pmol/g. The gastrin concentration of the middle and distal thirds of the duodenum was not changed by the operations. The results show that removal of the main source of gastrin, i.e. the pyloric antrum, induces an increase in the tissue level of gastrin in the upper portion of the duodenum.

The role of surgery in patients with Zollinger-Ellison syndrome (ZES) managed medically

From 1975 to 1981, the authors' deliberate intent was to treat all patients with Zollinger-Ellison syndrome (ZES) medically. This allowed the authors to ask the question of the need for surgical intervention in patients managed medically. Twenty-six patients followed for an average of 37 months (range 2 to 147 months) from diagnosis were maintained on cimetidine for a mean of 32 months (2 to 64 months). Six of these patients (23%) were unable to be maintained on cimetidine and required surgery during this period. Four received total gastrectomy, and two had lesser operations. Analysis of survival curves in this small group does not illustrate a difference between outcome based on surgical or medical management. Prospective studies based on aggressive attempts at preoperative localization with staging laparotomy and tumor resection seem justified.

Treatment of the Zollinger-Ellison syndrome. A 25 year assessment

An assessment of treatment methods for the Zollinger-Ellison syndrome over 25 years suggests that the dual surgical approach of excision of resectable tumor and total gastrectomy provides the greatest possibility of attaining tumor and serum gastrin control. Normal serum gastrin levels and reduction of tumor status, not observed with nonoperative management, were attained by surgical treatment, particularly when the tumor (or hyperplasia) was limited to the pancreas, stomach, duodenum and regional lymph nodes. Eleven of 16 such operations resulted in tumor control, and 10 of these patients developed normal serum gastrin concentrations. In elective clinical situations combined medical and surgical therapy is a rational approach allowing confirmation of diagnosis and safe, definitive surgical control of the syndrome before metastases occur.

Results of surgical management in 92 consecutive patients with Zollinger-Ellison syndrome

Hospital records and follow-up information on 92 patients with surgically proven Zollinger-Ellison syndrome have been reviewed, and data relating to symptomatology, age and sex incidence, pathologic findings, and early and late results of surgical procedures have been summarized. The postoperative mortality rate was 15%, and was adversely affected by previous peptic ulcer surgery, by the necessity of urgent operation for complications of peptic ulcer, and by employment of a procedure that failed to control acid secretion. Thirteen patients were found to have primary gastrinomas of the duodenum and an additional 13 patients had islet cell hyperplasia without evidence of frank neoplasm; prognosis in these two groups appears to be particularly favorable. Despite the current availability of effective nonoperative measures for control of gastric hypersecretion, surgical exploration is warranted in all patients to determine location and extent of tumor and to attempt to control the ulcer diathesis by resection of tumor. Long-term therapy with H2 receptor antagonists is advised for patients whose hypersecretory state has not been alleviated by tumor resection or whose gastrinoma cannot be removed. Total gastrectomy is still indicated in patients whose tumors are not amenable to resection and who are resistant to, or cannot follow, a rigid medical regimen.

Studies with bombesin in the Zollinger--Ellison syndrome

Preliminary data showed that bombesin stimulated serum gastrin levels in patients with the Zollinger-Ellison syndrome (ZES). In this study, the total immunoreactive gastrin and the different molecular forms of gastrin were measured in 16 patients with ZES (11 with proved pancreatic gastrinoma, 2 with proved duodenal gastrinoma and 3 with uncertain tumour localization) following bombesin infusion and following calcium infusion in 13 patients. In all patients with gastrinoma (both pancreatic and duodenal) bombesin augmented serum gastrin levels. In patients with pancreatic gastrinoma calcium infusion was a more potent stimulator of gastrin secretion than bombesin. In the 2 patients with duodenal gastrinoma bombesin was more potent than calcium in stimulating serum gastrin levels with a basal/stimulated gastrin level ratio similar to the ratio found in patients with incomplete antrectomy. These data suggest that gastrin-producing cells from duodenal gastrinomas may be more closely related to the normal antral G cells than to the gastrin-producing cells from pancreatic gastrinomas. Furthermore, the comparison between the basal/calcium and the basal/bombesin stimulated gastrin levels may help in differentiating preoperatively patients with pancreatic gastrinoma from patients with retained antral mucosa. In all the patients studied, bombesin augmented the concentration of all of the gastrin components considered. These data support the hypothesis that G 34, G 17 and the N-terminal G 17 fragment are all present in gastrinomas.

Calcium infusion test before and after total gastrectomy in the Zollinger-Ellison syndrome

1. In a preopertive group of patients suspected of having the Zollinger-Ellison syndrome the serum gastrin and gastric acid response to calcium infusion may be highly diagnostic. 2. In a group of Zollinger-Ellison syndrome patients following total gastrectomy, the gastrin response to calcium infusion correlates well with presence or absence of tumor.

The influence of total gastrectomy on survival in malignant Zollinger-Ellison tumors

The effect of total gastrectomy on the biologic behavior of malignant gastrinomas was studied from patient data collected in the ZE tumor registry. A total of 267 patients with documented metastatic tumor had definitive gastric operations. In the 137 patients who had total gastrectomy, survival was 75% at one year, 55% at five years and 42% at ten years. In the 130 patients who had lesser gastric operations, survival was 51% at one year, 27% at five years and 18% at ten years. Deaths from progressive tumor growth occurred in 17% of the patients at risk after total gastrectomy and 30% of the patients at risk after lesser gastric operations. A subgroup of 127 patients with documented liver metastasis had definitive gastric operations. Seventythree patients with liver metastasis had total gastrectomy with survival of 68% at one year, 42% at five years and 30% at ten years. Fifty-four patients with liver metastasis had lesser gastric operations with survival of 44% at one year, 7% at five years and none at ten years. Deaths from progressive tumor growth occurred in 25% of the patients at risk after total gastrectomy and 50% of the patients at risk after lesser gastric operations. Regression of metastatic ZE tumor was clearly documented in only four patients; all had total gastrectomy. Presumptive regression of primary tumor occurred in seven patients, five had total gastrectomy. The study clearly demonstrated that total gastrectomy was the procedure of choice for malignant ZE tumors, even in the presence of widespread metastasis. The results provided indirect evidence to support a gastric feedback effect which influences growth of gastrinomas; however, the results also show that total gastrectomy furnished neither predictable nor permanent protection from subsequent tumor growth and metastasis.

Zollinger-Ellison syndrome type 1: clinical and pathological correlations in a case

Some patients with the Zollinger-Ellison syndrome appear to have hypergastrinaemia and hyperplasia of the antral G cells but no tumour. This subgroup has been classified as Zollinger-Ellison syndrome type 1. We have treated such a patient by vagotomy and antrectomy, the fasting plasma gastrin and acid secretion subsequently returning to normal.A 17-year-old male had a four-year history of duodenal ulcer. Gastric secretion tests showed acid hypersecretion. Fasting plasma gastrin was 8350 pg/ml (normal 50-170 pg/ml). At laparotomy duodenal ulceration was confirmed but no pancreatic or other tumours were found. Truncal vagotomy and antrectomy was performed with distal pancreatectomy. Immunofluorescent staining showed hyperplasia of G cells in the resected antrum but a normal pancreas and duodenum. Six months after operation he was symptom free and acid secretion was reduced by 92%. The fasting plasma gastrin at two months was <50 pg/ml. These findings suggest that type 1 Zollinger-Ellison syndrome may be a clinical entity.

Genetic aspects of the Z-E syndrome: prospective studies in two kindred; antral gastrin cell hyperplasia

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The detection and measurement of circulating gastrin-like activity by bioassay

A perfused rat stomach technique which can detect synthetic human gastrin I in amounts greater than 10 ng and measure by block assay amounts greater than 50 ng was used to study circulating gastrin-like activity in normal subjects, patients with peptic ulcer, and patients with the Zollinger-Ellison syndrome. No detectable activity was found in normal subjects or patients with gastric ulcer before or after meals. No activity was found in the fasting plasma of patients with duodenal ulcer but after meals activity could be detected in duplicate samples in seven of 20 patients. In nine proven cases of the Zollinger-Ellison syndrome, gastrin-like activity in the plasma ranged from 15 to 356 ng/ml. The gastrin-like content of two tumours was 6.4 and 29.1 mug/g of tissue. The significance of these findings in relation to immunoassay is described.

Serum gastrin levels in malignant Zollinger-Ellison Syndrome after total gastrectomy and hypophysectomy

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Pulmonary resection for metastasis in nonbeta islet cell tumor of pancreas

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