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Sharma A, Muralitharan M, Ramage J, Clement D, Menon K, Srinivasan P, Elmasry M, Reed N, Seager M, Srirajaskanthan R. Current Management of Neuroendocrine Tumour Liver Metastases. Curr Oncol Rep 2024; 26:1070-1084. [PMID: 38869667 PMCID: PMC11416395 DOI: 10.1007/s11912-024-01559-w] [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] [Accepted: 05/22/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE OF REVIEW This article aims to illustrate the current state of investigations and management of liver metastases in patients with Neuroendocrine Neoplasms. Neuroendocrine tumours (NETs) are rising in incidence globally and have become the second most prevalent gastrointestinal malignancy in UK and USA. Frequently, patients have metastatic disease at time of presentation. The liver is the most common site of metastases for gastro-enteropancreatic NETs. Characterisation of liver metastases with imaging is important to ensure disease is not under-staged. RECENT FINDINGS Magnetic resonance imaging and positron emission tomography are now becoming standard of care for imaging liver metastases. There is an increasing armamentarium of therapies available for management of NETs and loco-regional therapy for liver metastases. The data supporting surgical and loco-regional therapy is reviewed with focus on role of liver transplantation. It is important to use appropriate imaging and classification of NET liver metastases. It is key that decisions regarding approach to treatment is undertaken in a multidisciplinary team and that individualised approaches are considered for management of patients with metastatic NETs.
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Affiliation(s)
- Aditya Sharma
- Department of Gastroenterology, King's College Hospital, SE5 9RS, London, U.K
| | | | - John Ramage
- Neuroendocrine Tumour Unit, Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K
| | - Dominique Clement
- Department of Gastroenterology, King's College Hospital, SE5 9RS, London, U.K
- Neuroendocrine Tumour Unit, Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K
| | - Krishna Menon
- Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K
| | - Mohamed Elmasry
- Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K
| | - Nick Reed
- Department of Oncology, Beatson Centre, G12 0YN, Glasgow, U.K
| | - Matthew Seager
- Department of Radiology, King's College Hospital, SE5 9RS, London, U.K
| | - Rajaventhan Srirajaskanthan
- Department of Gastroenterology, King's College Hospital, SE5 9RS, London, U.K..
- Neuroendocrine Tumour Unit, Institute of Liver Studies, King's College Hospital, SE5 9RS, London, U.K..
- Neuroendocrine Tumour Unit Institute of liver studies, King's College Hospital, SE5 9RS, London, U.K..
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Yang XR, Li YL, Li ZY, Chai XM. Primary hepatic neuroendocrine neoplasms: imaging characteristics and misdiagnosis analysis. Front Oncol 2024; 14:1391663. [PMID: 38807765 PMCID: PMC11130405 DOI: 10.3389/fonc.2024.1391663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
Objective To analyze the CT and MR features of Primary hepatic neuroendocrine neoplasms (PHNENs) in order to enhance the diagnostic accuracy of this disease. Methods A retrospective analysis was conducted on patients diagnosed with hepatic neuroendocrine neoplasms, excluding other sites of origin through general examination and postoperative follow-up. The CT and MR signs were analyzed according to the 2018 version of Liver Imaging Reporting and Data System (LI-RADS), along with causes of misdiagnosis. Results Twelve patients, including 6 males and 6 females, were enrolled in this study. There was no significant increase in liver tumor markers among all cases. Most masses were multiple (9/12), exhibiting low attenuation on pre-contrast CT scans, T1-hypointense signal, T2-hyperintense signal, and restricted diffusion. The majority of these masses (7/10) demonstrated similar rim arterial phase hyper-enhancement as well as peripheral "washout" during venous portal phase and delayed phase imaging. Three cases had incomplete capsules while one case had a complete capsule. Cyst/necrosis was observed in 7 out of all cases following administration of contrast agent, with 5 mainly distributed in the periphery. All masses lacked fat, calcification, vascular or bile duct tumor thrombus formation. Conclusion The imaging findings associated with PHNENs possess certain specificity, often presenting as multiple masses within the liver accompanied by peripheral cyst/necrosis, similar rim arterial phase hyper-enhancement during venous portal phase and delayed phase imaging.
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Affiliation(s)
- Xiu-Rong Yang
- Department of Radiology, Xing Lin Branch of the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Ying-Li Li
- Department of Radiology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Zi-Yan Li
- Department of Radiology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xiao-Ming Chai
- Department of Radiology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical College of Fujian Medical University, Fuzhou, China
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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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Fohlen A, Beaudouin R, Alvès A, Bouhier-Leporrier K, Pasik C, Pelage JP. Conventional Transarterial Chemo embolization Using Streptozocin in Patients with Unresectable Neuroendocrine Liver Metastases. Cancers (Basel) 2023; 15:4021. [PMID: 37627049 PMCID: PMC10452304 DOI: 10.3390/cancers15164021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical, biological and radiological responses to, and tolerability of, conventional transarterial chemoembolization (cTACE) using streptozocin for unresectable neuroendocrine liver metastases. PATIENTS AND METHODS A total of 52 patients with predominant liver disease were treated with cTACE using an emulsion of streptozocin, Lipiodol and embolization particles. A sequential approach was favored in patients with high liver tumor burden. Clinical, biological and radiological responses were evaluated using carcinoid symptoms, biomarkers and mRecist criteria, respectively. RESULTS A total of 127 procedures were performed with a sequential approach in 65% of patients. All patients received streptozocin and Lipiodol. Carcinoid syndrome was improved in 69% of patients after treatment (p = 0.01). Post-embolization syndrome was reported in 78% of patients. At the end of all cTACE, objective response and non-progressive disease were 32% and 70%, respectively. Progression-free survival was 18.3 ± 13.3 months (median 14.9) and median overall survival (OS) from start of treatment was 74 months. The OS at 1 year, 2 years, 3 years and 5 years was 91% (IC = 84-99%), 84% (CI = 72-95%), 69% (CI = 53-84%) and 63% (C = 46-81%), respectively. CONCLUSIONS cTACE using streptozocin is an effective and well-tolerated palliative option for patients with neuroendocrine liver metastases, associated with prolonged survival and delayed time to progression.
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Affiliation(s)
- Audrey Fohlen
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
- Centre National de la Recherche Scientifique, Imaging & Therapeutic Strategies for Cancer & Brain Tissue UMR 6030 GIP CYCERON “ISTCT-CERVOxy”, Normandie Caen University, 14000 Caen, France
| | - Remi Beaudouin
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
| | - Arnaud Alvès
- Department of Digestive Surgery, Caen University Medical Center, 14033 Caen, France;
- Interdisciplinary Research Unit for Cancer Prevention and Treatment “ANTICIPE”, Inserm Unity UMR 1086, Normancy Caen University, Calvados General Tumor Registry, Centre François Baclesse, 14000 Caen, France
| | - Karine Bouhier-Leporrier
- Department of Hepato-Gastroenterology and Digestive Oncology, Caen University Medical Center, 14033 Caen, France;
| | | | - Jean-Pierre Pelage
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
- Centre National de la Recherche Scientifique, Imaging & Therapeutic Strategies for Cancer & Brain Tissue UMR 6030 GIP CYCERON “ISTCT-CERVOxy”, Normandie Caen University, 14000 Caen, France
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Alexander ES, Ziv E. Neuroendocrine Tumors: Genomics and Molecular Biomarkers with a Focus on Metastatic Disease. Cancers (Basel) 2023; 15:cancers15082249. [PMID: 37190177 DOI: 10.3390/cancers15082249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/08/2023] [Accepted: 04/08/2023] [Indexed: 05/17/2023] Open
Abstract
Neuroendocrine tumors (NETs) are considered rare tumors that originate from specialized endocrine cells. Patients often present with metastatic disease at the time of diagnosis, which negatively impacts their quality of life and overall survival. An understanding of the genetic mutations that drive these tumors and the biomarkers used to detect new NET cases is important to identify patients at an earlier disease stage. Elevations in CgA, synaptophysin, and 5-HIAA are most commonly used to identify NETs and assess prognosis; however, new advances in whole genome sequencing and multigenomic blood assays have allowed for a greater understanding of the drivers of NETs and more sensitive and specific tests to diagnose tumors and assess disease response. Treating NET liver metastases is important in managing hormonal or carcinoid symptoms and is imperative to improve patient survival. Treatment for liver-dominant disease is varied; delineating biomarkers that may predict response will allow for better patient stratification.
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Affiliation(s)
- Erica S Alexander
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Etay Ziv
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Luo S, Wang J, Wu L, Wang C, Yang J, Li M, Zhang L, Ge J, Sun C, Li E, Lei J, Liao Y, Zhou F, Liao W. Epidemiological trends for functional pancreatic neuroendocrine tumors: A study combining multiple imputation with age adjustment. Front Endocrinol (Lausanne) 2023; 14:1123642. [PMID: 37113484 PMCID: PMC10126336 DOI: 10.3389/fendo.2023.1123642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
Purpose The purpose of this study was to examine trends in the incidence and incidence-based (IB) mortality of functional pancreatic neuroendocrine tumors(F-PNETs), and to identify factors associated with survival times. Methods Data were obtained from the Surveillance, Epidemiology, and End Results database from 2000 to 2017. Trends in the age-adjusted incidence of F-PNETs and IB mortality were examined using the Joinpoint Regression Program. Statistical analyses were run using chi-square tests, Kaplan-Meier curves, and the Cox proportional hazards model. Multiple imputation was used to deal with missing data. Results A total of 142 patients with F-PNETs met the study inclusion criteria. It was found that the incidence of F-PNETs decreased over the study period, with an annual percent change (APC) of -2. 5% (95% CI [-4. 3, -0. 5], P<0. 05). This decrease was found to be significant for women, and also when limited to cases with distant disease or rare F-PNETs, with APCs of -4. 2% (95% CI [-7. 4, -0. 9], P<0. 05), -6. 7% (95% CI [-10. 4, -2. 8], P<0. 05), and -9. 1% (95% CI [-13. 5, -4. 4], P<0. 05), respectively. The Cox regression analysis revealed that the tumor size, tumor stage, tumor type, and surgical resection were associated with F-PNETs mortality. Conclusions This was the first population-based epidemiological study of F-PNETs and we found a continual decrease in the incidence of F-PNETs from 2000 to 2017. The prognosis and survival times were closely related to the calendar year at diagnosis, tumor stage, and tumor size.
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Affiliation(s)
- Shuaiwu Luo
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiakun Wang
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linquan Wu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Cong Wang
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Yang
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Min Li
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ligan Zhang
- Department of Hepatological and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin Ge
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chi Sun
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Enliang Li
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Lei
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuting Liao
- Department of Nursing, Gannan Medical College, Ganzhou, China
| | - Fan Zhou
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenjun Liao
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Wenjun Liao,
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Doan NV, Duc NM, Ngan VK, Anh NV, Khuyen HTK, Nhan NT, Giang BV, Thong PM. Hypovascular pancreatic neuroendocrine tumor with hepatic metastases: A case report and literature review. Radiol Case Rep 2021; 16:1424-1427. [PMID: 33912257 PMCID: PMC8063702 DOI: 10.1016/j.radcr.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/23/2022] Open
Abstract
Hypovascular pancreatic neuroendocrine tumors are uncommon pancreatic tumors and commonly misdiagnosed as pancreatic ductal adenocarcinoma or chronic mass-forming pancreatitis. The liver is the organ most commonly affected by neuroendocrine tumor metastases but hepatic neuroendocrine tumor metastases are quite difficult to discriminate from other hepatic metastases and primary hepatic tumors. We describe a case of a 47-year-old man with incidentally detected multiple hepatic lesions on ultrasound. On further imaging technique including computed tomography and magnetic resonance imaging, the patient had an abnormal hypoenhancing lesion at the pancreatic tail and multiple hyperenhancing hepatic metastases that were diagnosed as hypovascular pancreatic well-differentiated neuroendocrine tumor Grade 2 with multiple hypervascular hepatic metastases after liver biopsy and surgery. Neuroendocrine tumor is a rare etiology among hypoenhancing pancreatic tumors, and must be considered to discriminate from pancreatic adenocarcinomas in cases there are multiple hyperenhancing hepatic metastases on the arterial phase without typical washout on the portal venous phase.
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Affiliation(s)
- Ngo-Van Doan
- Department of Radiology, Vinmec Times City International Hospital, Ha Noi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Ha Noi Medical University, Ha Noi, Vietnam.,Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Vietnam.,Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Vuong Kim Ngan
- Department of Radiology, Vinmec Times City International Hospital, Ha Noi, Vietnam
| | - Nguyen-Van Anh
- Department of Radiology, Vinmec Times City International Hospital, Ha Noi, Vietnam
| | - Hoang-Thi Kim Khuyen
- Department of Radiology, Vinmec Times City International Hospital, Ha Noi, Vietnam
| | - Nguyen-Thi Nhan
- Department of Radiology, Vinmec Times City International Hospital, Ha Noi, Vietnam
| | - Bui-Van Giang
- Department of Radiology, Ha Noi Medical University, Ha Noi, Vietnam
| | - Pham Minh Thong
- Department of Radiology, Ha Noi Medical University, Ha Noi, Vietnam
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Raymond LM, Korzun T, Kardosh A, Kolbeck KJ, Pommier R, Mittra ES. The State of Peptide Receptor Radionuclide Therapy and Its Sequencing among Current Therapeutic Options for Gastroenteropancreatic Neuroendocrine Tumors. Neuroendocrinology 2021; 111:1086-1098. [PMID: 33744879 DOI: 10.1159/000516015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common form of neuroendocrine neoplasia, but there is no current consensus for the sequencing of approved therapies, particularly with respect to peptide receptor radionuclide therapy (PRRT). This comprehensive review evaluates the data supporting approved therapies for GEP-NETs and recommendations for therapeutic sequencing with a focus on how PRRT currently fits within sequencing algorithms. The current recommendations for PRRT sequencing restrict its use to metastatic, inoperable, progressive midgut NETs; however, this may change with emerging data to suggest that PRRT might be beneficial as neoadjuvant therapy for inoperable tumors, is more tolerable than other treatment modalities following first-line standard dose somatostatin analogs, and can be used as salvage therapy after disease relapse following prior successful cycles of PRRT. PRRT has also been shown to reduce tumor burden, improve quality of life, and prolong the time to disease progression in a broad spectrum of patients with GEP-NETs. As the various potential benefits of PRRT in GEP-NET therapy continues to expand, it is necessary to review and critically evaluate our treatment algorithms for GEP-NETs.
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Affiliation(s)
- Lauren M Raymond
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA,
| | - Tetiana Korzun
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Adel Kardosh
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Hematology/Medical Oncology, Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kenneth J Kolbeck
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Interventional Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rodney Pommier
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Erik S Mittra
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Nuclear Medicine & Molecular Imaging, Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon, USA
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Effectiveness of Liver-Directed Therapy for the Management of Intractable Hypoglycemia in Metastatic Insulinoma. Pancreas 2020; 49:763-767. [PMID: 32541627 DOI: 10.1097/mpa.0000000000001569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate efficacy of chemoembolization and radioembolization in treating patients with recurrent hypoglycemia secondary to metastatic insulinoma. METHODS A retrospective review was performed of all patients with metastatic insulinoma treated with liver-directed therapy (LDT) at a large academic medical center from January 1998 to August 2017. Primary outcomes included blood glucose levels, occurrence of symptomatic hypoglycemic episodes, and tumor imaging response rates. RESULTS Seven patients were identified (4 male patients). The mean age at the first LDT was 60.9 (standard deviation [SD], 9.2) years. The median follow-up was 1.8 years. Thirty-three sessions of LDT were performed including 30 sessions of chemoembolization and 3 sessions of radioembolization. Technical success rate was 97% (32/33 procedures) with an initial clinical success rate of 100%, defined as absence of recurrent symptomatic hypoglycemia within 1 month after first cycle of LDT and overall clinical success rate of 85%. Random daytime glucose levels increased from 75.0 (SD, 26) mg/dL to 152.8 (SD, 52.4) mg/dL after LDT. The mean time to recurrence of intractable hypoglycemia was 21 (SD, 9) months. No severe complications were reported. CONCLUSIONS Liver-directed therapy with chemoembolization or radioembolization is effective for treatment of symptomatic hypoglycemia secondary to malignant insulinoma metastatic to liver.
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Houat ADP, von Atzingen AC, Velloni FG, de Oliveira RAS, Torres UDS, D'Ippolito G. Hepatic neuroendocrine neoplasm: imaging patterns. Radiol Bras 2020; 53:195-200. [PMID: 32587429 PMCID: PMC7302895 DOI: 10.1590/0100-3984.2019.0038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors with distinct morphological and biological manifestations, the liver being the main organ affected by its metastases. However, primary hepatic involvement is quite rare. Hepatic NENs can have a variety of radiological presentation forms and can therefore mimic other lesions, making their diagnosis challenging. Nonetheless, certain imaging aspects allow NENs to be included among the main differential diagnoses of hepatic lesions and can guide the search for an extrahepatic primary site when the probable diagnosis is metastases.
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Affiliation(s)
- Abdallah de Paula Houat
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | | | | | | | - Giuseppe D'Ippolito
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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11
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Feretis M, Wang T, Ghorani E, Balakrishnan A, Harper SJ, Jah A, Huguet EL, Praseedom RK, Liau SS. A rational approach to postoperative surveillance for resected non-functional pancreatic neuro-endocrine tumours. Pancreatology 2019; 19:1000-1007. [PMID: 31445889 DOI: 10.1016/j.pan.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/07/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-functional pancreatic neuroendocrine tumours (NF-PNETs) are rare and have highly variable outcomes. Current guidelines recommend surveillance for NF-PNETs <2 cm. Patients who ultimately have surgical resection are at risk of disease recurrence, and data to support postoperative surveillance protocols are lacking. The aims of this study were to i) identify post-operative predictors of recurrence and ii) risk stratify patients at risk of recurrence. METHODS Consecutive patients who underwent surgery for NF-PNETs between 2002 and 2015 were identified retrospectively. Data were collected on demographics, pre-operative laboratory results and histopathological tumour characteristics. Statistical analyses were based on penalised Cox-regression modelling and a decision-tree model. Comparison of the variables identified was performed using ROC curves to identify the most sensitive and specific variable associated with disease recurrence. RESULTS We identified 73 patients (38 males) with a median age of 61.5 years (range: 31-79). The median period of follow-up was 49 months (5-131). During follow up, 10 deaths (13.9%) were recorded and disease recurrence occurred in 12 patients (16.4%). The Kaplan-Meier predicted 1-,3- and 5-year recurrence-free survival rates were 98.6% (95% CI = 95.9, 100%), 85.4% (76.9-94.8%) and 72% (58.7-88.2%) respectively. Cox multivariate analysis identified poor tumour differentiation (WHO G3 grade) and lymph node ratio (LNR) as independent predictors for recurrence (p < 0.05). A simple criterion of 'tumour grade G3 or LNR ≥0.1' was found to be sensitive and specific in detecting disease recurrence. CONCLUSION Our results have identified a simple and sensitive criterion for risk stratifying post-resection surveillance. Prospective validation in larger patient cohort is now warranted.
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Affiliation(s)
- M Feretis
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - T Wang
- Department of Statistics, University of Cambridge, UK
| | - E Ghorani
- Department of Oncology, University College London, UK
| | - A Balakrishnan
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - S J Harper
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - A Jah
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - E L Huguet
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - R K Praseedom
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK
| | - S-S Liau
- Department of Hepatobiliary Surgery, Hepatopancreatobiliary (HPB) Surgical Unit, Addenbrooke's Hospital, Cambridge, UK.
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Demonstration of Treatment Response to Trans-arterial Radio-embolization (TARE) on 68Ga-DOTANOC PET/CT in a Patient With Metastatic Neuroendocrine Tumor. Clin Nucl Med 2018; 43:e312-e313. [PMID: 29939955 DOI: 10.1097/rlu.0000000000002177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Here we report a 31-year-old man with a peri-ampullary neuroendocrine tumor (NET), who underwent Ga DOTANOC-PET/CT for recurrence evaluation, which revealed isolated metastatic lesion in liver segment V. He underwent trans-arterial radio-embolization (TARE) of the isolated hepatic metastasis with Rhenium-microspheres in a lipiodol matrix. The second Ga DOTANOC-PET/CT was performed one month after the TARE therapy revealed resolution of the tracer uptake with good retention of the lipiodol complex replacing the metastasis suggesting a complete response.
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13
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Jia Z, Wang W. Yttrium-90 radioembolization for unresectable metastatic neuroendocrine liver tumor: A systematic review. Eur J Radiol 2018; 100:23-29. [PMID: 29496075 DOI: 10.1016/j.ejrad.2018.01.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/11/2017] [Accepted: 01/07/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the value of yttrium-90 (90Y) microspheres in the management of unresectable liver metastases secondary to neuroendocrine tumors (NETs). MATERIALS AND METHODS PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the "gray" literature (Google Scholar) were searched for all studies related to 90Y therapy for unresectable liver metastases of NETs. RESULTS A total of 11 studies and 7 abstracts involving 870 patients were included in the final analysis. In 11 of these studies, 19.8% (77/388) of patients had undergone transarterial bland embolization (TABE) or transarterial chemoembolization (TACE) before 90Y therapy. The median disease control rate among all patients was 86% at 3 months after 90Y therapy. The median survival was 28 months, with 1-, 2-, and 3-year survival rates of 72.5%, 57%, and 45%, respectively. The median survival values for patients who received resin- and glass-based 90Y treatment were 27.6 and 31.7 months, respectively. The survival values for patients with carcinoid, pancreatic, and unclassified origin of NETs were 56, 31, and 28 months, respectively; the survival values for patients with grade I, II, and III NETs were 71, 56, and 28 months, respectively. Carcinoid syndrome was reported in 52.4% (55/105) of patients, and 69.1% of those with clinical symptoms demonstrated improvement in symptoms after 90Y radioembolization. Complications were reported in 9 studies, including radiation gastritis (n = 4), duodenal ulcer (n = 2), death due to liver failure (n = 1), and radiation cholecystitis (n = 1). The most common side effects were abdominal pain (median, 32.6%), nausea/vomiting (median, 32.5%), and fatigue (median, 30.4%). CONCLUSIONS 90Y radioembolization can be used as an alternative therapy for unresectable liver metastases of NETs, with an improved survival rate and tumor response. This treatment is also effective for patients who have undergone unsuccessful TABE/TACE therapy and for the relief of symptoms in patients with carcinoid syndrome.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Changzhou, 213003, China
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Chansanti O, Jahangiri Y, Matsui Y, Adachi A, Geeratikun Y, Kaufman JA, Kolbeck KJ, Stevens JS, Farsad K. Tumor Dose Response in Yttrium-90 Resin Microsphere Embolization for Neuroendocrine Liver Metastases: A Tumor-Specific Analysis with Dose Estimation Using SPECT-CT. J Vasc Interv Radiol 2017; 28:1528-1535. [DOI: 10.1016/j.jvir.2017.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 10/18/2022] Open
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Jia Z, Paz-Fumagalli R, Frey G, Sella DM, McKinney JM, Wang W. Single-institution experience of radioembolization with yttrium-90 microspheres for unresectable metastatic neuroendocrine liver tumors. J Gastroenterol Hepatol 2017; 32:1617-1623. [PMID: 28132407 DOI: 10.1111/jgh.13752] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to assess the effectiveness of yttrium-90 (90 Y) microspheres for the treatment of unresectable metastatic liver neuroendocrine tumors (NET). METHODS From February 2006 to September 2015, 36 patients (19 male and 17 female, age 63.6 ± 9.4 years) who underwent 90 Y therapy for unresectable liver metastases of NET were included and analyzed retrospectively. All patients received a variety of treatments before 90 Y therapy. The radiological response, symptoms improvement of carcinoid syndrome, tumor marker changes, complications, side effects/toxicity, survival, and factors related to survival were evaluated and analyzed. RESULTS Of the 36 patients, the mean delivered dose of 90 Y was 1.8 ± 0.7 GBq with a total of 40 treatments. Overall disease control rate was 88.9% (32/36) at 3 months following therapy. In 16 patients with carcinoid syndrome, 15 (93.8%) patients had symptomatic improvement. Tumor marker response (5-hydroxyindoleacetic acid [n = 7] and chromogranin A [n = 13]) at 3 months after treatment were as follows: none (n = 0, 4), partial (n = 6, 7), and complete (n = 1, 2). Radiation-induced gastrointestinal ulcers (n = 2, 5.6%) were identified. Side effects included fatigue (n = 31, 86.1%), anorexia (n = 26, 72.2%), nausea (n = 15, 41.7%), vomiting (n = 14, 38.9%), abdominal pain (n = 10, 27.8%), and fever (n = 8, 22.2%). The mean follow-up was 27.0 ± 16.4 months, with a median survival of 41.0 months. Child-Pugh classification (P = 0.008) and lymph node metastases (P = 0.045) had statistically significant influence on overall survival. CONCLUSIONS Yttrium-90 radioembolization can be effective in the treatment of unresectable liver metastases of NET who failed to respond to other treatments.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, The Second People's Hospital of Changzhou, Nanjing Medical University, Changzhou, China
| | | | - Gregory Frey
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - David M Sella
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - J Mark McKinney
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
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Iwata T, Ueno H, Itami J, Ito Y, Inaba K, Morizane C, Kondo S, Sakamoto Y, Shiba S, Sasaki M, Koga F, Okusaka T. Efficacy of radiotherapy for primary tumor in patients with unresectable pancreatic neuroendocrine tumors. Jpn J Clin Oncol 2017; 47:826-831. [PMID: 28591817 DOI: 10.1093/jjco/hyx081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/19/2017] [Indexed: 01/20/2023] Open
Abstract
Background Detailed information regarding the clinical efficacy of radiotherapy (RT) for primary tumor in patients with unresectable pancreatic neuroendocrine tumors (pNETs) is unknown. We therefore performed a retrospective study to evaluate the efficacy and safety of RT for primary pancreatic tumors in patients with pNETs. Methods We investigated 11 patients with pNETs who received RT to the primary site between January 1997 and June 2015. Seven patients had Grade 2 neuroendocrine tumors (NET-G2) and four had neuroendocrine carcinoma (NEC) according to the 2010 WHO histopathological classification. Results The tumor response and control rates were 27.2% and 100%, respectively (3: partial response, 8: stable disease). Among patients with NET-G2 tumors, the response rate was 28.5% (2/7 patients) and symptomatic improvement was noted in 33.3% of the patients (1/3 patients). The response rate for patients with NEC were 25% (1/4), one NEC patients with symptoms exhibited symptomatic improvement. The median overall survival and median progression-free survival were 35.9 months and 5.5 months, respectively. Grade 3 diarrhea as an acute toxicity and Grade 3 gastrointestinal hemorrhage as a late toxicity were observed. Conclusions RT to the primary cancer site in patients with pNETs was an effective modality for local disease control and the treated patients had good outcomes. If metastatic tumors are under control, RT to the primary site may be beneficial for patients with pNETs.
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Affiliation(s)
- Tomoyuki Iwata
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Hideki Ueno
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Shunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Yasunari Sakamoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Satoshi Shiba
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Futa Koga
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital
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Do Minh D, Chapiro J, Gorodetski B, Huang Q, Liu C, Smolka S, Savic LJ, Wainstejn D, Lin M, Schlachter T, Gebauer B, Geschwind JF. Intra-arterial therapy of neuroendocrine tumour liver metastases: comparing conventional TACE, drug-eluting beads TACE and yttrium-90 radioembolisation as treatment options using a propensity score analysis model. Eur Radiol 2017; 27:4995-5005. [PMID: 28677067 DOI: 10.1007/s00330-017-4856-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/05/2017] [Accepted: 04/18/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To compare efficacy, survival outcome and prognostic factors of conventional transarterial chemoembolisation (cTACE), drug-eluting beads TACE (DEB-TACE) and yttrium-90 radioembolisation (Y90) for the treatment of liver metastases from gastroenteropancreatic (GEP) neuroendocrine tumours (NELM). METHODS This retrospective analysis included 192 patients (58.6 years mean age, 56% men) with NELM treated with cTACE (N = 122), DEB-TACE (N = 26) or Y90 (N = 44) between 2000 and 2014. Radiologic response to therapy was assessed according to Response Evaluation Criteria in Solid Tumours (RECIST) and World Health Organization (WHO) criteria using periprocedural MR imaging. Survival analysis included propensity score analysis (PSA), median overall survival (MOS), hepatic progression-free survival, Kaplan-Meier using log-rank test and the uni- and multivariate Cox proportional hazards model (MVA). RESULTS MOS of the entire study population was 28.8 months. As for cTACE, DEB-TACE and Y90, MOS was 33.8 months, 21.7 months and 23.6 months, respectively. According to the MVA, cTACE demonstrated a significantly longer MOS as compared to DEB-TACE (p <.01) or Y90 (p = .02). The 5-year survival rate after initial cTACE, DEB-TACE and Y90 was 28.2%, 10.3% and 18.5%, respectively. CONCLUSIONS Upon PSA, our study suggests significant survival benefits for patients treated with cTACE as compared to DEB-TACE and Y90. This data supports the therapeutic decision for cTACE as the primary intra-arterial therapy option in patients with unresectable NELM until proven otherwise. KEY POINTS • cTACE achieved a significantly longer overall survival in patients with unresectable NELM. • Patients treated with cTACE showed a prolonged hepatic progression-free survival. • cTACE, DEB-TACE and Y90 radioembolisation demonstrated comparable safety and toxicity profiles. • Age >70 years, extrahepatic metastases and tumour burden >50% were identified as negative predictors. • Propensity score analysis suggests the superiority of cTACE over DEB-TACE and Y90.
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Affiliation(s)
- Duc Do Minh
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Julius Chapiro
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Boris Gorodetski
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Qiang Huang
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.,Department of Interventional Radiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Cuihong Liu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.,The Ultrasound Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Susanne Smolka
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn Jeanette Savic
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - David Wainstejn
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - MingDe Lin
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.,U/S Imaging and Interventions (UII), Philips Research North America, Cambridge, MA, USA
| | - Todd Schlachter
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Bernhard Gebauer
- Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Campus Virchow Klinikum, Berlin, Germany
| | - Jean-François Geschwind
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA. .,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 330 Cedar Street, TE 2-230, New Haven, CT, 06520, USA.
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18
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Valadares LJ, Costa Junior W, Ribeiro HSC, Diniz AL, Coimbra FJF, Herman P. Resection of liver metastasis from neuroendocrine tumors: evaluation of results and prognostic factors. Rev Col Bras Cir 2017; 42:25-31. [PMID: 25992697 DOI: 10.1590/0100-69912015001006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/20/2014] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES to determine the prognostic factors that may impact on morbidity and mortality and survival of patients undergoing surgical treatment of liver metastases from neuroendocrine tumors. METHODS We studied 22 patients undergoing liver resection for metastases from neuroendocrine tumors between 1997 and 2007. Epidemiological and clinical data were correlated with morbidity and mortality and overall and disease-free survivals. RESULTS twelve patients were male and ten female, with a mean age of 48.5 years. Bilobar disease was present in 17 patients (77.3%). In ten patients (45.5%) the primary tumor originated in the pancreas, terminal ileum in eight, duodenum in two, rectum in one and jejunum in one. Complete surgical resection (R0) was achieved in 59.1% of patients. Eight patients (36.3%) developed complications in the immediate postoperative period, one of them dying from septicemia. All patients undergoing re-hepatectomy and/or two-stage hepatectomy had complications in the postoperative period. The overall survival at one and five years was 77.3% and 44.2%. The disease-free survival at five years was 13.6%. The primary pancreatic neuroendocrine tumor (p = 0.006) was associated with reduced overall survival. Patients with number of metastatic nodules < 10 (p = 0.03) and asymptomatic at diagnosis (p = 0.015) had higher disease-free survival. CONCLUSION liver metastases originating from pancreatic neuroendocrine tumors proved to be a negative prognostic factor. Symptomatic patients with multiple metastatic nodules showed a significant reduction in disease-free survival.
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Affiliation(s)
| | | | | | - Alessandro L Diniz
- Department of Abdominal Surgery, Hospital A. C. Camargo, São Paulo, Brazil
| | - Felipe J F Coimbra
- Department of Abdominal Surgery, Hospital A. C. Camargo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Faculty of Medicine, Universidade de São Paulo, São Paulo, Brazil
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Vennarecci G, Mascianà G, de Werra E, Guglielmo N, Levi Sandri GB, Coluzzi M, Ettorre GM. Rectal Carcinoid Tumor With Liver Metastases Treated by Local Excision and Orthotopic Liver Transplant With Long-term Follow-up. EXP CLIN TRANSPLANT 2017; 16:506-510. [PMID: 28350289 DOI: 10.6002/ect.2016.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients affected by unresectable liver metastases from neuroendocrine tumor, liver transplant represents currently the only realistic chance for cure. The first attempt to establish selection criteria for liver transplant in patients affected by neuroendocrine tumor liver metastases was made by Mazzaferro and associates in 2007. We report the case of a 46-year-old man who came to our institution in 2006 with right upper quadrant abdominal pain. Diagnosis of rectal neuroendocrine tumor with bilobar liver nodules was made; the patient underwent transanal local resection. A liver biopsy confirmed the metastatic nature of the hepatic lesion, showing a low-grade neuroendocrine tumor (G1, proliferation index Ki-67 <2%). The patient underwent 2 sessions of transarterial chemoembolization that resulted in stable disease. Afterward, the patient underwent a liver transplant, using the piggyback technique without a venous-venous bypass. His postoperative course was uneventful. The patient has been disease-free for 3 years. Posttransplant treatment has played a key role in increasing the overall survival of the patient and assuring him a good quality of life. He died 9 years (102 mo) after liver transplant.
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Affiliation(s)
- Giovanni Vennarecci
- Department of Surgical Oncology and Liver Transplantation, San Camillo Hospital, POIT San Camillo-INMI Lazzaro Spallanzani, Rome, Italy
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20
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Bonne L, Verslype C, Laenen A, Cornelissen S, Deroose CM, Prenen H, Vandecaveye V, Van Cutsem E, Maleux G. Safety and efficacy of doxorubicin-eluting superabsorbent polymer microspheres for the treatment of liver metastases from neuroendocrine tumours: preliminary results. Radiol Oncol 2017; 51:74-80. [PMID: 28265235 PMCID: PMC5330173 DOI: 10.1515/raon-2017-0007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/12/2017] [Indexed: 01/08/2023] Open
Abstract
Background The aim of the study was to retrospectively evaluate the symptom control, tumour response, and complication rate in patients with liver-predominant metastatic neuroendocrine tumours treated with transarterial chemoembolization using doxorubicin-eluting superabsorbent polymer (SAP) microspheres. Patients and methods Patients with neuroendocrine liver metastases who underwent hepatic transarterial chemoembolization using doxorubicin-eluting SAP-microspheres (50–100 μm Hepasphere/Quadrasphere Microsphere® particles, Merit Medical, South Jordan, Utah, USA) were included in this study. Pre-and post-procedure imaging studies were evaluated to assess short and intermediate-term tumour response using modified RECIST criteria. Symptom relief and procedure-related complications were evaluated. Results A total of 27 embolization procedures were performed on 17 patients. Twelve of 17 patients (70%) were symptomatic, including carcinoid syndrome (n = 8) and severe, uncontrollable hypoglycemia (n = 4). Eight of 12 patients (67%) had complete symptom relief, and the remaining 4 (33%) had partial relief. One patient developed ischemic cholecystitis (6%). No other hepatobiliary complications occurred. Short-term and intermediate-term imaging follow-up was available for 15/17 patients (88%) and 12/14 patients (86%) respectively. At short-term follow-up (< 3 months), 14 patients (93%) showed partial response and the remaining patient had progressive disease (7%). At intermediate-term imaging follow-up (> 3 months), partial response, stable disease and progressive disease were found respectively in 7 (58%), 3 (25%) and 2 (17%) patients. Conclusions Chemoembolization with doxorubicin-eluting SAP-microspheres is a safe and effective treatment option for neuroendocrine liver metastases and is associated with a low complication rate. In particular, no clinically evident liver necrosis or bile duct complications were encountered.
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Affiliation(s)
- Lawrence Bonne
- Department of Radiology, University Hospitals Leuven, Belgium
| | - Chris Verslype
- Department of Hepatology and Gastroenterology, University Hospitals Leuven, Belgium
| | - Annouschka Laenen
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, Catholic University of Leuven and University Hasselt, Belgium
| | | | | | - Hans Prenen
- Department of Hepatology and Gastroenterology, University Hospitals Leuven, Belgium
| | | | - Eric Van Cutsem
- Department of Hepatology and Gastroenterology, University Hospitals Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Belgium
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Cidon EU. New therapeutic approaches to metastatic gastroenteropancreatic neuroendocrine tumors: A glimpse into the future. World J Gastrointest Oncol 2017; 9:4-20. [PMID: 28144395 PMCID: PMC5241526 DOI: 10.4251/wjgo.v9.i1.4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/13/2016] [Accepted: 11/21/2016] [Indexed: 02/05/2023] Open
Abstract
Neuroendocrine (NE) gastroenteropancreatic tumors are a heterogeneous group of neoplasias arising from neuroendocrine cells of the embryological gut. Their incidence have increased significantly over the past 3 decades probably due to the improvements in imaging and diagnosis. The recent advances in molecular biology have translated into an expansion of therapeutic approaches to these patients. Somatostatin analogs, which initially were approved for control of hormonal syndromes, have recently been proven to inhibit tumor growth. Several new drugs such as antiangiogenics and others targeting mammalian target of rapamycin pathways have been approved to treat progressive pancreatic neuroendocrine tumors (NETs) although their role in non-pancreatic is still controversial. The treatment of NETs requires a coordinated multidisciplinary approach. The management of localized NETs primarily involves surgical resection followed by surveillance. However, the treatment of unresectable and/or metastatic disease may involve a combination of surgical resection, systemic therapy, and liver-directed therapies with the goal of alleviating symptoms of peptide release and controlling tumor growth. This article will review the current therapeutic strategies for metastatic gastroenteropancreatic NETs and will take a glimpse into the future approaches.
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Pelage JP, Fohlen A, Mitry E, Lagrange C, Beauchet A, Rougier P. Chemoembolization of Neuroendocrine Liver Metastases Using Streptozocin and Tris-acryl Microspheres: Embozar (EMBOsphere + ZAnosaR) Study. Cardiovasc Intervent Radiol 2016; 40:394-400. [PMID: 28035432 DOI: 10.1007/s00270-016-1535-7] [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] [Received: 09/23/2016] [Accepted: 12/08/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this prospective observational study was to evaluate the efficacy and tolerability of transarterial chemoembolization (TACE) for neuroendocrine liver metastases using a combination of streptozocin, Lipiodol, and tris-acryl microspheres. PATIENTS AND METHODS A total of 16 men and 9 women aged 59.6 ± 11.3 years, all with predominant liver disease, underwent 54 courses of TACE using an emulsion of 1.5 g of streptozocin and 10 ml of Lipiodol. Additional embolization was performed using 300-500 µm tris-acryl microspheres. Morphological response was evaluated using the RECIST criteria on multi-detector computed tomography or MRI. Clinical efficacy was evaluated particularly in patients with carcinoid syndrome. RESULTS The primary tumor was located in the small bowel or pancreas in 21 (84%) patients. Eleven (44%) patients presented with a carcinoid syndrome. Nineteen (76%) patients presented with more than 10 liver nodules. One delayed case of ischemic cholecystitis was treated conservatively. After a median follow-up of 36.1 months, 1 (4%) patient had a complete response, 12 (48%) patients had a partial response, and 7 (28%) patients had a stable disease corresponding to a disease control rate of 80%. All patients with carcinoid syndrome had significant improvement. Median time to progression was 18.8 months and overall survival was 100, 100, and 92% at 1, 2, and 3 years, respectively. Seven patients presented with extrahepatic progression with abdominal lymphadenopathies or metastases to the brain, ovary, adrenal gland, or lung. CONCLUSION Optimized TACE using a combination of streptozocin, Lipiodol, and tris-acryl microspheres is effective and well tolerated.
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Affiliation(s)
- Jean-Pierre Pelage
- Department of Diagnostic Imaging and Interventional Radiology, Caen University and Medical Center, Avenue Cote de Nacre, 14033, Caen Cedex 9, France. .,CERVOxy, CEA, CNRS, ISTCT - Imagerie et Stratégie Thérapeutiques des Pathologies Cérébrales et Tumorales (M Bernaudin), Université de Basse-Normandie UNICAEN, Caen, France.
| | - Audrey Fohlen
- Department of Diagnostic Imaging and Interventional Radiology, Caen University and Medical Center, Avenue Cote de Nacre, 14033, Caen Cedex 9, France.,CERVOxy, CEA, CNRS, ISTCT - Imagerie et Stratégie Thérapeutiques des Pathologies Cérébrales et Tumorales (M Bernaudin), Université de Basse-Normandie UNICAEN, Caen, France
| | - Emmanuel Mitry
- Department of Hepatogastroenterology and Oncology, Hopital Ambroise Pare, 9, Avenue Charles de Gaulle, 92104, Boulogne Cedex, France
| | - Christine Lagrange
- Department of Radiology, Hopital Ambroise Pare, 9, Avenue Charles de Gaulle, 92104, Boulogne Cedex, France
| | - Alain Beauchet
- Department of Biostatistics and Public Health, Hopital Ambroise Pare, 9, Avenue Charles de Gaulle, 92104, Boulogne Cedex, France
| | - Philippe Rougier
- Department of Hepatogastroenterology and Oncology, Hopital Ambroise Pare, 9, Avenue Charles de Gaulle, 92104, Boulogne Cedex, France
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Kouri BE, Abrams RA, Al-Refaie WB, Azad N, Farrell J, Gaba RC, Gervais DA, Gipson MG, Kolbeck KJ, Marshalleck FE, Pinchot JW, Small W, Ray CE, Hohenwalter EJ. ACR Appropriateness Criteria Radiologic Management of Hepatic Malignancy. J Am Coll Radiol 2016; 13:265-73. [PMID: 26944037 DOI: 10.1016/j.jacr.2015.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022]
Abstract
Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Brian E Kouri
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia, American College of Surgeons
| | - Nilofer Azad
- Sidney Kimmel Cancer Center at Johns Hopkins University, Baltimore, Maryland, American Society of Clinical Oncology
| | - James Farrell
- Interventional Endoscopy and Pancreatic Diseases, New Haven, Connecticut, American Gastroenterological Association
| | - Ron C Gaba
- University of Illinois Hospital, Chicago, Illinois
| | | | - Matthew G Gipson
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Charles E Ray
- University of Illinois Hospital and Health Science System, Chicago, Illinois
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Peker A, Çiçek O, Soydal Ç, Küçük NÖ, Bilgiç S. Radioembolization with yttrium-90 resin microspheres for neuroendocrine tumor liver metastases. Diagn Interv Radiol 2016; 21:54-9. [PMID: 25430526 DOI: 10.5152/dir.2014.14036] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE We aimed to evaluate the effectiveness and safety of radioembolization with yttrium-90 (90Y) microspheres in cases with unresectable neuroendocrine tumor liver metastases (NETLMs). METHODS Thirty patients (mean age, 55 years) underwent resin-based 90Y radioembolization for unresectable NETLM at a single institution between April 2008 and June 2013. Post-treatment tumor response was assessed by cross-sectional imaging using the Response Evaluation Criteria in Solid Tumors (RECIST). Prognostic variables that affected survival were determined. RESULTS The mean follow-up was 23.0±19.4 months and the median overall survival was 39 months (95% CI, 12.6-65.4 months), with one- and two-year survival rates of 71% and 45%, respectively. Imaging follow-up using RECIST at three-month intervals demonstrated partial response in 43%, complete remission in 3%, stable disease in 37%, and progressive disease in 17% of patients. Extent of tumor involvement was found to have a statistically significant influence on overall survival (P = 0.03). The existence of extrahepatic disease at the time of radioembolization, radiographic response, age, and primary neuroendocrine tumor site were not significant prognostic factors. CONCLUSION The current study demonstrates the effectiveness and safety of radioembolization for the treatment of unresectable NETLMs. We identified that the extent of tumor involvement has a significant effect on overall survival. The use of imaging methods reflecting metabolic activity or cellularity such as scintigraphy or diffusion-weighted MRI would be more appropriate, for the response evaluation of liver metastases after radioembolization.
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Affiliation(s)
- Ahmet Peker
- Department of Radiology, Ankara University Medical School, Ankara, Turkey.
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Prospective Longitudinal Quality of Life Assessment in Patients With Neuroendocrine Tumor Liver Metastases Treated With 90Y Radioembolization. Clin Nucl Med 2016; 41:e493-e497. [DOI: 10.1097/rlu.0000000000001383] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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26
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Kitano M, Davidson GW, Shirley LA, Schmidt CR, Guy GE, Khabiri H, Dowell JD, Shah MH, Bloomston M. Transarterial Chemoembolization for Metastatic Neuroendocrine Tumors With Massive Hepatic Tumor Burden: Is the Benefit Worth the Risk? Ann Surg Oncol 2016; 23:4008-4015. [DOI: 10.1245/s10434-016-5333-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Indexed: 11/18/2022]
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Mohammadi H, Chuong MD, Moeslein FM, Sharma NK. Selective internal radiation therapy for the treatment of inoperable neuroendocrine tumor liver metastases. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016. [DOI: 10.2217/ije.15.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Neuroendocrine tumor liver metastases are commonly present at the time of neuroendocrine tumor diagnosis. Surgical resection is potentially curative and achieves the best long-term results but is not feasible in many patients. Angiographic liver-directed treatment modalities such as transarterial embolization, transarterial chemoembolization and selective internal radiotherapy using Yttrium-90 ([90]Y)-labeled microspheres have been shown to be effective treatments with liver predominant disease. Here, we review the management of neuroendocrine tumor liver metastases including selective internal radiotherapy.
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Affiliation(s)
- Homan Mohammadi
- School of Medicine & Health Sciences, The George Washington University, 2300 Eye Street NW Washington, DC 20006, USA
| | - Michael D Chuong
- Department of Radiation Oncology, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Fred M Moeslein
- Department of Diagnostic Radiology & Nuclear Medicine, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Navesh K Sharma
- Division of Radiation Oncology, Penn State Hershey Cancer Institute, 500 University Drive, Hershey, PA 17033, USA
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Rodríguez-Fraile M, Iñarrairaegui M. Radioembolization with 90Y-microspheres for liver tumors. Rev Esp Med Nucl Imagen Mol 2015. [DOI: 10.1016/j.remnie.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Acute thrombocytopenia: An uncommon complication occurring following transarterial chemoembolization in a patient with neuroendocrine hepatic metastases. Oncol Lett 2015; 10:247-249. [PMID: 26171007 DOI: 10.3892/ol.2015.3232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 04/30/2015] [Indexed: 11/05/2022] Open
Abstract
Neuroendocrine tumors are a group of carcinomas that secrete various polypeptides with hormonal activity. A significant percentage of patients already have hepatic metastases at the time of initial diagnosis, and 80-90% of these tumors are inoperable at the time of presentation. Transarterial chemoembolization (TACE) is the preferred approach for the management of neuroendocrine hepatic metastases. Although the technique is relatively safe, it is associated with several complications. The present study reported the case of a patient with neuroendocrine hepatic metastases who developed acute thrombocytopenia following TACE. To the best of our knowledge, acute thrombocytopenia occurring after TACE in a patient with neuroendocrine hepatic metastases has not been previously reported. In the present study, the hypothetical etiopathogenetic mechanisms were also discussed.
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30
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Rodríguez-Fraile M, Iñarrairaegui M. [Radioembolization with (90)Y-microspheres for liver tumors]. Rev Esp Med Nucl Imagen Mol 2015; 34:244-57. [PMID: 25911062 DOI: 10.1016/j.remn.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/16/2022]
Affiliation(s)
- M Rodríguez-Fraile
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, Navarra; Área de Oncología Hepatobiliopancreática, Clínica Universidad de Navarra, Pamplona, Navarra, España; Instituto de Investigaciones Sanitarias de Navarra (IDISNA), España.
| | - M Iñarrairaegui
- Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, Navarra, España; Área de Oncología Hepatobiliopancreática, Clínica Universidad de Navarra, Pamplona, Navarra, España; Instituto de Investigaciones Sanitarias de Navarra (IDISNA), España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Pamplona, España
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Mohan H, Nicholson P, Winter DC, O'Shea D, O'Toole D, Geoghegan J, Maguire D, Hoti E, Traynor O, Cantwell CP. Radiofrequency ablation for neuroendocrine liver metastases: a systematic review. J Vasc Interv Radiol 2015; 26:935-942.e1. [PMID: 25840836 DOI: 10.1016/j.jvir.2014.12.009] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 10/08/2014] [Accepted: 12/08/2014] [Indexed: 12/18/2022] Open
Abstract
To determine the efficacy of radiofrequency (RF) ablation in neuroendocrine tumor (NET) liver metastases. A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight studies were included (N = 301). Twenty-six percent of RF ablation procedures were percutaneous (n = 156), with the remainder conducted at surgery. Forty-eight percent of patients had a concomitant liver resection. Fifty-four percent of patients presented with symptoms, with 92% reporting symptom improvement following RF ablation (alone or in combination with surgery). The median duration of symptom improvement was 14-27 months. However, recurrence was common (63%-87%). RF ablation can provide symptomatic relief in NET liver metastases alone or in combination with surgery.
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Affiliation(s)
- Helen Mohan
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland.
| | - Patrick Nicholson
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Des C Winter
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Donal O'Shea
- Department of Radiology, and Endocrinology, St. Vincent's University Hospital, Dublin, Ireland
| | - Dermot O'Toole
- Department of Clinical Medicine and Gastroenterology, Trinity Centre for Health Sciences, St. James Hospital and Trinity College Dublin, Dublin, Ireland
| | - Justin Geoghegan
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Donal Maguire
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Emir Hoti
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Oscar Traynor
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Colin P Cantwell
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
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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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Gupta S. Intra-arterial liver-directed therapies for neuroendocrine hepatic metastases. Semin Intervent Radiol 2014; 30:28-38. [PMID: 24436515 DOI: 10.1055/s-0033-1333651] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatic metastases, which are frequently seen in patients with neuroendocrine tumors (NETs), have a major adverse impact on the patient's quality of life and survival. Surgery is the treatment of choice for hepatic metastases but is possible in only a small percentage of patients. Systemic chemotherapy yields disappointing results. Somatostatin analogs are effective in controlling symptoms in many of these patients; however, the disease can become refractory to treatment. Transcatheter intra-arterial liver-directed therapies, such as hepatic artery embolization, chemoembolization, and radioembolization are frequently used in patients with NETs metastatic to the liver, especially in patients with refractory, unresectable, or recurrent disease. These treatments are effective in palliating the hormonal symptoms as well as achieving objective tumor responses. This review focuses on the technique, safety, and clinical efficacy of hepatic artery embolization, chemoembolization, and radioembolization in patients with metastatic NETs.
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Affiliation(s)
- Sanjay Gupta
- Department of Diagnostic Radiology, the University of Texas MD Anderson Cancer Center, Houston, Texas
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Abstract
PURPOSE OF REVIEW Liver transplantation is a validated treatment of primary hepatobiliary tumours. Over the last decade, a renewed interest for liver transplantation as a curative treatment of colorectal liver metastasis (CR-LM) and neuro-endocrine metastasis (NET-LM) has developed. RECENT FINDINGS The ELTR and UNOS analyses showed that liver transplantation may offer excellent disease-free survival (ranging from 30 to 77%) in case of NET-LM, on the condition that stringent selection criteria are implemented. The interest for liver transplantation in the treatment of CR-LM has been fostered by the Norwegian SECA study. Five-year A 5-year survival rate of 60% could be reached. Despite the high recurrence rate (90%), one-third of patients were disease free following pulmonary surgery for metastases. SUMMARY Liver transplantation will take a more prominent place in the therapeutic algorithm of CR-LM and NET-LM. Larger experiences are necessary to improve knowledge about tumour biology and to refine selection criteria. A multimodal approach adding neo and adjuvant medical treatment to the transplant procedure will be key to bring this oncologic transplant project into the clinical arena. The preserved liver function in these patients will allow a more deliberate access to split liver and living donation for these indications.
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Del Prete M, Fiore F, Modica R, Marotta V, Marciello F, Ramundo V, Di Sarno A, Carratù A, di Roseto CDL, Tafuto S, Tatangelo F, Baldelli R, Colao A, Faggiano A. Hepatic arterial embolization in patients with neuroendocrine tumors. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2014; 33:43. [PMID: 24887262 PMCID: PMC4038067 DOI: 10.1186/1756-9966-33-43] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 05/05/2014] [Indexed: 12/23/2022]
Abstract
Liver metastases occur in 46-93% of patients with neuroendocrine neoplasms (NENs). Presence and extension of liver metastases are considered important prognostic factors, as they may significantly impair the patient's quality of life, because of either tumor bulk or hormonal hypersecretion. Therapies for NEN liver metastases include surgical resection, liver transplantation, chemotherapy and biotherapy. Surgery is the gold standard for curative therapy, but in most of NEN patients with liver metastases, when surgery can not be applied, minimally invasive therapeutic approaches are adopted. They include trans-arterial embolization (TAE), trans-arterial chemoembolization (TACE), radiofrequency thermal ablation and new emerging techniques.TAE is based on selective infusion of particles in the branch of the hepatic artery supplying the tumor lesions. The goal of TAE is to occlude tumor blood vessels resulting in ischemia and necrosis. Many reports have shown that TAE can reduce tumor size and hormone output, resulting in palliation of symptoms without the use of cytotoxic drugs, resulting in better tolerability. This review will focus on TAE performance and safety in NEN patients with liver metastases.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Antongiulio Faggiano
- Divisione di Endocrinologia, Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Naples, Italy.
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Nadler A, Cukier M, Milot L, Singh S, Law CH. Hepatic parenchymal preserving technique in the management of diffuse bilateral neuroendocrine tumour liver metastases: a feasible approach. Can J Surg 2014; 57:E2-8. [PMID: 24666455 DOI: 10.1503/cjs.014112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Aggressive surgical resection of neuroendocrine tumour liver metastases (NET-LM) is associated with symptomatic relief. Debulking up to 90% of tumour burden, even with positive margins, may be beneficial. However, patients with diffuse hepatic metastases may not qualify for resection owing to associated insufficient remnant liver parenchyma. The purpose of this study is to describe an early experience with a hepatic parenchymal preserving (HPP) approach. METHODS We retrospectively reviewed our institutional neuroendocrine tumours database to identify patients with NET-LM, including symptomatic patients with extensive bilobar involvement, who underwent virtual volumetric assessment (VVA) combined with HPP resection between October 2008 and July 2011. RESULTS Our study involved 9 patients. The median number of liver metastases resected was 10 (range 4-50). Symptomatic improvement was observed in all patients. Immediate postoperative normalization of 5-HIAA 24-hour urine levels occurred in 89% of patients. Symptomatic and biochemical response remained stable or improved in 75% of patients at 12 months of follow-up. Four patients had postoperative complications. There was no 90-day mortality. CONCLUSION The described HPP approach is feasible and safe. Most patients experienced symptomatic and biochemical improvement. This reproducible approach could expand surgical resection options for patients with NET-LM and diffuse bilobar involvement.
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Affiliation(s)
- Ashlie Nadler
- The Division of General Surgery, University of Toronto, Toronto, Ont
| | - Moises Cukier
- The Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Laurent Milot
- The Division of Medical Imaging, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Simron Singh
- The Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Calvin H Law
- The Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ont
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Ceelen F, Theisen D, de Albéniz XG, Auernhammer CJ, Haug AR, D'Anastasi M, Paprottka PM, Rist C, Reiser MF, Sommer WH. Towards new response criteria in neuroendocrine tumors: which changes in MRI parameters are associated with longer progression-free survival after radioembolization of liver metastases? J Magn Reson Imaging 2014; 41:361-8. [PMID: 24446275 DOI: 10.1002/jmri.24569] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 12/28/2013] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate the association of therapy-related changes in imaging parameters with progression-free survival (PFS) of patients with unresectable liver metastases from neuroendocrine tumors (NETLMs). MATERIALS AND METHODS Forty-five radioembolized patients (median age: 62 years; range: 43-75) received a pre- and 3 months posttherapeutic magnetic resonance imaging (MRI) examination. The latter were evaluated for tumor size, arterial enhancement, and necrosis pattern. Influences of therapy-related changes on PFS were analyzed. Statistical analysis included Student's t-test, Wilcoxon test, Cox regression analysis, and Kaplan-Meier curves. RESULTS The median percentage decrease in sum of diameters was 9.7% (range: 43.9% decrease to 15.4% increase). Twenty-one patients (47%) showed increased necrosis. Three parameters were associated with significantly longer PFS: a decrease of diameter (hazard ratio [HR]: 0.206; 95% confidence interval [CI]: 0.058-0.725; P = 0.0139), a decrease in tumor arterial enhancement (HR: 0.143; 95% CI: 0.029-0.696; P = 0.0160), and an increase in necrosis after 3 months (HR: 0.321; 95% CI: 0.104-0.990; P = 0.0480). Multivariate analysis revealed that changes in diameter and arterial enhancement have complementary information and are associated independently with long PFS. CONCLUSION A decrease both in sum of diameters and arterial enhancement of metastases, as well as an increase in necrosis, are associated with significantly longer PFS after radioembolization.
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Affiliation(s)
- Felix Ceelen
- Department of Clinical Radiology, University Hospitals-Grosshadern, Ludwig-Maximilians University, Munich, Germany; Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospitals-Grosshadern, Ludwig-Maximilians University, Munich, Germany
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Long term survival analysis of hepatectomy for neuroendocrine tumour liver metastases. ScientificWorldJournal 2014; 2014:524045. [PMID: 24526905 PMCID: PMC3913525 DOI: 10.1155/2014/524045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 10/24/2013] [Indexed: 01/26/2023] Open
Abstract
Background. Liver is the commonest site for metastasis in patients with neuroendocrine tumour (NET). A vast majority of treatment strategies including liver directed nonsurgical therapy, liver directed surgical therapy, and nonliver directed therapy have been proposed. In this study we aim to investigate the outcome of liver resection in neuroendocrine tumour liver metastases (NELM). Method. 293 patients had hepatectomy for liver metastasis in our hospital between June 1996 and December 2010. Twelve patients were diagnosed to have NET in their final pathology and their data were reviewed. Results. The median ages of the patients were 48.5 years (range 20–71 years). Eight of the patients received major hepatectomy. Four patients received minor hepatectomy. The median operation time was 418 minutes (range 195–660 minutes). The median tumor size was 8.75 cm (range 0.9–21 cm). There was no hospital mortality. The overall one-year and three-year survivals were 91.7% and 55.6%. The one-year and three-year disease-free survivals were 33.3% and 16.7%. Conclusion. Hepatectomy is an effective and safe treatment for NELM. Reasonable outcome on long term overall survival and disease-free survival can be achieved in this group of patients with a low morbidity rate.
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Alistar A, Sung M, Kim M, Holcombe RF. Clinical pathways for pancreatic neuroendocrine tumors. J Gastrointest Cancer 2013; 43:532-40. [PMID: 22661335 DOI: 10.1007/s12029-012-9397-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) represent a group of diseases that pose diagnostic and therapeutic challenges due to their clinical and pathological heterogeneity as well as the limited number of patients available for clinical trials. Over the last couple of decades, a major progress in understanding tumor biology led to the discovery of new potential targets for the medical treatment of these tumors. DISCUSSION There are numerous novel targeted agents in various stages of preclinical and clinical development that offer considerable promise as monotherapy or combination therapy for PNETs. The question of whether traditional clinical research methods are appropriate for the development of novel, targeted anticancer agents has been the subject of many discussions. Major challenges include identifying a valid target, the most effective agent within a target class, the right subset of population to benefit from the drug, and the most appropriate setting to use the drug. As new agents emerge, oncologists are faced with making clinical decisions sometimes before having a high level of evidence. In this review, we attempt to address some of the management steps involved in treating patients with pancreatic neuroendocrine tumors, particularly well to moderately differentiated tumors. The purpose of this review is to offer a therapeutic sequence including surgery, liver-directed therapy, chemotherapy, and targeted therapy for this disease.
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Affiliation(s)
- Angela Alistar
- Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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Kouri BE, Funaki BS, Ray CE, Abou-Alfa GK, Burke CT, Darcy MD, Fidelman N, Greene FL, Harrison SA, Kinney TB, Kostelic JK, Lorenz JM, Nair AV, Nemcek AA, Owens CA, Saad WEA, Vatakencherry G. ACR Appropriateness Criteria radiologic management of hepatic malignancy. J Am Coll Radiol 2013. [PMID: 23206650 DOI: 10.1016/j.jacr.2012.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Management of hepatic malignancy is a challenging clinical problem involving several different medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and locoregional therapies, such as thermal ablation and transarterial embolization. The authors discuss treatment strategies for the 3 most common subtypes of hepatic malignancy treated with locoregional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Brian E Kouri
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.
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Survival outcomes and prognostic factors of transcatheter arterial chemoembolization for hepatic neuroendocrine metastases. J Vasc Interv Radiol 2013; 24:947-56; quiz 957. [PMID: 23602421 DOI: 10.1016/j.jvir.2013.02.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/26/2013] [Accepted: 02/26/2013] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To report survival outcomes in patients with neuroendocrine tumor (NET) with hepatic metastasis who were treated by transcatheter arterial chemoembolization and determine prognostic factors that affect clinical outcome. MATERIALS AND METHODS Patients with NET with hepatic metastasis who underwent chemoembolization between April 2002 and July 2011 were included in this single-center, retrospective study. Progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier method. The influence of possible prognostic factors on survival was analyzed by log-rank method and multivariate Cox proportional-hazards method. RESULTS Forty-six patients with hepatic metastasis from nonpancreatic NETs (npNETs; n = 24) or pancreatic NETs (pNETs; n = 22) were included. The median PFS and OS times for the entire group were 16.2 and 38.6 months, respectively, and response rate was 58.1%. Patients with npNET had a similar PFS (17.4 mo vs 15.3 mo) and longer OS (55.0 mo vs 27.6 mo) compared with those with pNET, but there were no significant differences in PFS and OS between groups (P = .398 and P = .375, respectively). By univariate analysis, enterobiliary communication, hepatic tumor burden, and extrahepatic metastasis before the first chemoembolization were significant prognostic factors for poor OS (P = .001, P = .010, and P<.0001, respectively). By multivariate analysis, the same prognostic factors were significant and had relative risks of 4.63, 2.71, and 5.09, respectively. CONCLUSIONS Transcatheter arterial chemoembolization is an effective treatment modality for hepatic metastasis from NETs, with a median OS of 38.6 months and response rate of 58%. Enterobiliary communication, large hepatic tumor burden, and extrahepatic metastasis were significant risk factors for poor survival outcome.
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Pathak S, Dash I, Taylor MR, Poston GJ. An overview of the surgical management of hepatic neuroendocrine metastases. Indian J Surg Oncol 2013; 3:20-5. [PMID: 23449915 DOI: 10.1007/s13193-012-0133-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/30/2012] [Indexed: 11/26/2022] Open
Abstract
Neuroendocrine tumours (NET) frequently metastasise to the liver (NLM) and are associated with significant morbidity and mortality. Numerous treatment options have been implemented both for cure, and to implement disease control. Surgical treatment includes curative resection, palliative cytoreductive resection and transplantation. Complete surgical resection is only possible in a subset of people with NLMs due to excessive metastatic burden and anatomical location. Ablative therapies may be used either as an adjunct to surgery or as a primary treatment. The purpose of the following article is to summarise surgical treatment strategies in the management of patients with hepatic neuroendocrine metastases, based on the available literature.
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Affiliation(s)
- S Pathak
- Royal United Hospital Bath NHS Trust, Combe Park, Bath, BA1 3NG UK
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Pathak S, Dash I, Taylor MR, Poston GJ. The surgical management of neuroendocrine tumour hepatic metastases. Eur J Surg Oncol 2013; 39:224-8. [PMID: 23290582 DOI: 10.1016/j.ejso.2012.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 11/24/2012] [Accepted: 12/03/2012] [Indexed: 12/14/2022] Open
Abstract
Although rare in incidence, patients with neuroendocrine tumours (NET) live for many years and so have a high prevalence, and NETs frequently metastasise to the liver (NLM). Numerous treatment options have been implemented both for cure, and to implement disease control. Surgical treatment consists of curative resection, palliative cytoreductive resection and transplantation. Complete surgical resection is possible only in a subset of people with NLMs due to various factors. Ablative therapies may also be used, either as an adjunct to surgery or as a primary treatment. The purpose of the article is to summarise surgical treatment strategies in the management of patients with hepatic neuroendocrine metastases.
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Affiliation(s)
- S Pathak
- Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, United Kingdom
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Abstract
Pancreatic neuroendocrine tumors (pancreatic NETs) are rare, low- to intermediate-grade neoplasms thought to arise from the pancreatic islets. Recent advances in pathology and our understanding of the biological behavior of this group of tumors has resulted in changes in their nomenclature and how we treat them. This review puts into perspective our current understanding of pancreatic NETs in terms of their incidence, pathology, and management.
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Gowdra Halappa V, Corona-Villalobos CP, Bonekamp S, Li Z, Reyes D, Cosgrove D, Pawlik TM, Diaz LA, Bhagat N, Eng J, Geschwind JF, Kamel IR. Neuroendocrine liver metastasis treated by using intraarterial therapy: volumetric functional imaging biomarkers of early tumor response and survival. Radiology 2012. [PMID: 23192780 DOI: 10.1148/radiol.12120495] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To determine if volumetric changes of diffusion-weighted and contrast material-enhanced magnetic resonance (MR) imaging can help assess early tumor response to intraarterial therapy (IAT) in neuroendocrine liver metastasis (NELM). MATERIALS AND METHODS This retrospective single-center comprehensive imaging analysis was performed in compliance with HIPAA and was institutional review board approved. Informed patient consent was waived. Seventy-one patients (39 men; mean age, 62.3 years) with NELM treated with IAT were analyzed retrospectively. MR studies were performed before and 3-4 weeks after therapy. The index lesion was segmented to provide volumetric functional analysis of apparent diffusion coefficient (ADC) and contrast-enhanced MR imaging in the hepatic arterial phase (HAP) and portal venous phase (PVP). Tumor response was defined as increase in volumetric ADC of 15% or greater and decrease in volumetric enhancement of 25% or greater during the HAP or of 50% or greater during the PVP. Patient overall survival was the primary end point after therapy initiation. Univariate analysis included Kaplan-Meier survival curves. The Cox proportional hazards regression model was used to detect interactions between volumetric ADC and contrast-enhanced MR imaging and to calculate the hazard ratio. RESULTS There was significant increase in mean volumetric ADC (27%, P < .0001) and significant decrease in mean volumetric enhancement during the HAP (-25.3%, P < .0001) and the PVP (-22.4%, P < .0001) in all patients. Patients who had 15% or greater volumetric ADC increase (n = 49) after therapy had better prognosis than those who had less than 15% increase in volumetric ADC (n = 22) (log-rank test, P < .002). Patients who had 25% or greater decrease in volumetric arterial enhancement (n = 40) or 50% or greater decrease in venous enhancement (n = 18) had better prognosis than those who had less than 25% decrease in volumetric arterial enhancement (n = 31) or less than 50% decrease in venous enhancement (n = 53) (log-rank test, P < .02). CONCLUSION Volumetric functional MR imaging criteria may act as biomarkers of early response, indicating that these criteria may be important to incorporate in future NELM clinical trials.
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Affiliation(s)
- Vivek Gowdra Halappa
- Russell H. Morgan Department of Radiology and Radiological Sciences, Sidney Kimmel Comprehensive Cancer Center, and Department of Surgery, Johns Hopkins Hospital, 600 N Wolfe St, Room 143, Baltimore, MD 21287, USA
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Kandil E, Noureldine SI, Koffron A, Yao L, Saggi B, Buell JF. Outcomes of laparoscopic and open resection for neuroendocrine liver metastases. Surgery 2012; 152:1225-31. [PMID: 23068086 DOI: 10.1016/j.surg.2012.08.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 08/16/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND We sought to compare the outcomes in patients with hepatic carcinoid tumor metastases treated with open versus laparoscopic liver resection. METHODS A retrospective analysis of our liver surgery database was performed. All patients who underwent liver resection for hepatic carcinoid tumor metastases were included. Patients were divided into 2 groups depending on the surgical approach. Patients with concomitant primary and metastatic liver lesions underwent open resection. RESULTS Thirty-six patients underwent resection over a 10-year period (21 open and 15 laparoscopic). Both groups were similar in terms of gender, body mass index, tumor size, incidence of carcinoid syndrome, and extent of resection (P > .05). The laparoscopic group had less mean operative time (2.7 vs 5.4 hours), less mean blood loss (158.3 vs 538.9 mL), and a shorter hospital stay (3.2 vs 7.5 days; P < .05 for all). Complications were similar in both groups (20% vs 33%; P = .21). Two laparoscopic cases required conversion. The 3-year disease-free survival for the laparoscopic group was 73.3% compared to 47.6% for the open group (P = .2). CONCLUSION To our knowledge, this is the first reported study comparing laparoscopic versus open liver resection in the treatment of liver metastases from carcinoid tumors. Our series confirms that selective cases can safely be managed laparoscopically.
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Affiliation(s)
- Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA 70112, USA
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Integrating radioembolization into the treatment paradigm for metastatic neuroendocrine tumors in the liver. Am J Clin Oncol 2012; 35:393-8. [PMID: 21278561 DOI: 10.1097/coc.0b013e3182005768] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Surgical resection of hepatic metastases from neuroendocrine tumors (mNETs) is controversial because the potential survival benefit of this intervention must be balanced against the risk of surgical morbidity and mortality. In patients with unresectable mNETs in the liver, radioembolization has been used to treat tumors from a range of primary sites, including carcinoid and islet cell carcinomas as well as nonfunctional, asymptomatic tumors. Initial clinical studies and retrospective studies on a large cohort of patients indicate that radioembolization is well tolerated and highly effective in achieving a durable hepatic tumor response and ameliorating symptoms. Radioembolization using Yttrium-90 ((90)Y)-labeled resin or glass microspheres offers effective disease control and possible improved quality of life and thus merits consideration as an option for both functional and nonfunctional mNETs. Benefits of this intervention seem to extend from use in early lines of treatment to salvage of refractory disease. Radioembolization also offers a potential somatostatin analog-sparing effect in symptomatic disease.
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Krampitz GW, Norton JA, Poultsides GA, Visser BC, Sun L, Jensen RT. Lymph nodes and survival in pancreatic neuroendocrine tumors. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 2012; 147:820-7. [PMID: 22987171 PMCID: PMC3448121 DOI: 10.1001/archsurg.2012.1261] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
HYPOTHESIS Lymph node metastases decrease survival in patients with pancreatic neuroendocrine tumors (pNETs). DESIGN Prospective database searches. SETTING National Institutes of Health (NIH) and Stanford University Hospital (SUH). PATIENTS A total of 326 patients underwent surgical exploration for pNETs at the NIH (n = 216) and SUH (n = 110). MAIN OUTCOME MEASURES Overall survival, disease-related survival, and time to development of liver metastases. RESULTS Forty patients (12.3%) underwent enucleation and 305 (93.6%) underwent resection. Of the patients who underwent resection, 117 (35.9%) had partial pancreatectomy and 30 (9.2%) had a Whipple procedure. Forty-one patients also had liver resections, 21 had wedge resections, and 20 had lobectomies. Mean follow-up was 8.1 years (range, 0.3-28.6 years). The 10-year overall survival for patients with no metastases or lymph node metastases only was similar at 80%. As expected, patients with liver metastases had a significantly decreased 10-year survival of 30% (P < .001). The time to development of liver metastases was significantly reduced for patients with lymph node metastases alone compared with those with none (P < .001). For the NIH cohort with longer follow-up, disease-related survival was significantly different for those patients with no metastases, lymph node metastases alone, and liver metastases (P < .001). Extent of lymph node involvement in this subgroup showed that disease-related survival decreased as a function of the number of lymph nodes involved (P = .004). CONCLUSIONS As expected, liver metastases decrease survival of patients with pNETs. Patients with lymph node metastases alone have a shorter time to the development of liver metastases that is dependent on the number of lymph nodes involved. With sufficient long-term follow-up, lymph node metastases decrease disease-related survival. Careful evaluation of number and extent of lymph node involvement is warranted in all surgical procedures for pNETs.
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Affiliation(s)
| | | | | | | | - Lixian Sun
- Department of Surgery, Stanford University School of Medicine
| | - Robert T. Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
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Chan G, Kocha W, Reid R, Taqi A, Wall W, Quan D. Liver transplantation for symptomatic liver metastases of neuroendocrine tumours. ACTA ACUST UNITED AC 2012; 19:217-21. [PMID: 22876148 DOI: 10.3747/co.19.950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Numerous reports have demonstrated that liver transplantation for neuroendocrine tumour metastasis is feasible. However, perioperative risks and long-term recurrences remain significant concerns. When liver transplantation is combined with extensive intestinal or pancreatic resection, the risk is particularly high.We report our institutional experience of liver transplantations performed for liver metastases secondary to neuroendocrine tumours, and in combination with a review of the literature, we propose a set of selection criteria. The key points include unresectable hepatic metastases of neuroendocrine origin, absence of extrahepatic metastases, symptomatic disease that is refractory to medical therapy, a Ki-67 level less than 2%, previous resection of the primary disease, and previous therapy for metastatic neuroendocrine tumour.In our experience, the patient in the first case had, post-transplantation, rapid disease progression because of an unidentified primary, and patient in the second case had primary non-function of the liver graft, requiring urgent re-transplantation. More recently, two liver transplantations were successfully performed. The indications were, in the first case, refractory hormonal secretion and, in the other, secondary biliary cirrhosis attributable to hepatic artery therapy with tumour in situ. Subclinical and stable recurrent disease has been detected by scintigraphy in the mesentery and lumbar spine in the former patient. A mesenteric recurrence developed in the latter patient 2 years post transplantation and was subsequently completely resected. At 4 and 5 years post transplantation, both patients are symptom-free.Recurrence after transplantation remains a significant concern, even with careful patient selection, but recurrences may remain indolent. If recurrences are progressive, they may still be amenable to additional medical or surgical therapy. A national or international consensus between oncologists and transplant specialists regarding the indications for liver transplantation is vital, because future progress will depend on careful patient selection and prospective study.
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Affiliation(s)
- G Chan
- Hôpital Maisonneuve-Rosemont, l'Université de Montréal, Montreal, QC
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Radioembolization and chemoembolization for unresectable neuroendocrine liver metastases - a systematic review. Surg Oncol 2012; 21:299-308. [PMID: 22846894 DOI: 10.1016/j.suronc.2012.07.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 06/28/2012] [Accepted: 07/14/2012] [Indexed: 01/15/2023]
Abstract
This review examines the clinical efficacy and safety of the use of hepatic arterial chemoembolization, bland embolization and radioembolization in the treatment of unresectable neuroendocrine tumor liver metastases (NETLM). Response to treatment, survival outcome and toxicity were examined in this review of 37 studies comprising 1575 patients. These therapies are safe and effective in the treatment of NETLM. Prospective clinical trials to compare the relative efficacy and toxicity are warranted.
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