1
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Goudet P, Cadiot G, Barlier A, Baudin E, Borson-Chazot F, Brunaud L, Caiazzo R, Cardot-Bauters C, Castinetti F, Chanson P, Cuny T, Dansin E, Gaujoux S, Giraud S, Groussin L, Le Bras M, Lifante JC, Mathonnet M, de Mestier L, Mirallié E, Pattou F, Romanet P, Sebag F, Tresallet C, Vezzosi D, Walter T, Tabarin A. French guidelines from the GTE, AFCE and ENDOCAN-RENATEN (Groupe d'étude des Tumeurs Endocrines/Association Francophone de Chirurgie Endocrinienne/Reseau national de prise en charge des tumeurs endocrines) for the screening, diagnosis and management of Multiple Endocrine Neoplasia Type 1. ANNALES D'ENDOCRINOLOGIE 2024; 85:2-19. [PMID: 37739121 DOI: 10.1016/j.ando.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Affiliation(s)
- Pierre Goudet
- Department of Digestive and Endocrine Surgery, Dijon University Hospital, Dijon, France; INSERM, U1231, EPICAD Team UMR "Lipids, Nutrition, Cancer", Dijon, France; INSERM, CIC1432, Clinical epidemiology Dijon, Dijon, France.
| | - Guillaume Cadiot
- Department of Hepato-Gastro-Enterology and Digestive Oncology, Robert Debré Hospital, Reims, France.
| | - Anne Barlier
- Aix Marseille Univ, APHM, INSERM, MMG, Laboratory of Molecular Biology Hospital La Conception, Marseille, France.
| | - Eric Baudin
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus, Villejuif, France.
| | - Françoise Borson-Chazot
- Federation of Endocrinology, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon1 University and INSERM U1290, Lyon, France.
| | - Laurent Brunaud
- Department of Gastrointestinal, Visceral, Metabolic, and Cancer Surgery (CVMC), University Hospital of Nancy (CHRU Nancy), University of Lorraine, 54511 Vandoeuvre-les-Nancy, France; INSERM U1256 NGERE, Lorraine University, 11, allée du Morvan, 54511 Vandoeuvre-les-Nancy, France.
| | - Robert Caiazzo
- General and Endocrine Surgery Department, University Hospital Center of Lille, Lille, France.
| | | | - Frédéric Castinetti
- Aix Marseille University, Marseille Medical Genetics, INSERM U1251 and Assistance Publique Hopitaux de Marseille, La Conception Hospital, Department of Endocrinology, Marseille, France.
| | - Philippe Chanson
- University Paris-Saclay, INSERM, Endocrine Physiology and Pathophysiology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Service of Endocrinology and Reproductive Diseases, National Reference Center for Rare Pituitary Diseases, 94275 Le Kremlin-Bicêtre, France.
| | - Thomas Cuny
- APHM, Marseille Medical Genetics, INSERM U1251, Conception Hospital, Endocrinology Department, Aix Marseille University, Marseille, France.
| | - Eric Dansin
- Department of Medical Oncology, Oscar Lambret Center, 59000 Lille, France.
| | - Sébastien Gaujoux
- Department of Endocrine and Pancreatic Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
| | - Sophie Giraud
- Cancer Genetics Unit, Institut Bergonié, Bordeaux, France.
| | - Lionel Groussin
- Department of Endocrinology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France.
| | - Maëlle Le Bras
- Department of Endocrinology, Nantes University Hospital, Nantes, France.
| | - Jean-Christophe Lifante
- Department of Digestive and Endocrine Surgery, University Hospital of Lyon Sud, Lyon, France; EA 7425 HESPER, Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France.
| | - Muriel Mathonnet
- Department of Surgery, Dupuytren University Hospital of Limoges, Limoges, France.
| | - Louis de Mestier
- Paris-Cité University, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (AP-HP-Nord), Clichy, France.
| | - Eric Mirallié
- Department of Oncological, Digestive and Endocrine Surgery (CCDE) Hôtel Dieu, CIC-IMAD, Nantes, France.
| | - François Pattou
- Department of General and Endocrine Surgery, University Hospital. Lille, INSERM U1190, Lille, France.
| | - Pauline Romanet
- Aix Marseille University, APHM, INSERM, MMG, Laboratory of Molecular Biology, La Conception Hospital, Marseille, France.
| | - Frédéric Sebag
- Department of General Endocrine and Metabolic Surgery, Conception University Hospital, APHM, Aix Marseille University, Marseille, France.
| | - Christophe Tresallet
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne University Hospital, Sorbonne Paris Nord Universty, Assistance Pubique des Hôpitaux de Paris (APHP), Paris, France.
| | - Delphine Vezzosi
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059 Toulouse Cedex, France.
| | - Thomas Walter
- Medical Oncology Department, Edouard-Herriot Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Antoine Tabarin
- Endocrinology Department, INSERM Unit 1215, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France.
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2
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Manoharan J, Albers M, Bartsch DK. [Indication and Surgical Procedures for MEN1-associated Duodenopancreatic Neuroendocrine Neoplasms]. Zentralbl Chir 2023; 148:483-491. [PMID: 37604166 DOI: 10.1055/a-2103-3525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The optimal therapy of duodenopancreatic neuroendocrine neoplasia (dpNEN), which occurs in the context of multiple endocrine neoplasia type 1, is still a major challenge and is controversial. Due to the rarity of the disease, there is a lack of prospective randomised studies, so that most recommendations regarding the surgical indication and procedure are based on retrospective case series. In summary, surgical therapy is indicated for non-functional dpNEN > 2 cm, suspected malignancy and functionally active dpNEN. Enucleation or formal pancreatic resections with or without lymphadenectomy may be considered. The aim of therapy should be to eliminate hormone-associated symptoms and prevent an aggressive metastatic disease. At the same time, pancreatic function and quality of life should be preserved in the mostly young patients by resections that save as much parenchyma as possible.
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Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Max Albers
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
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3
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Tonelli F, Marini F, Giusti F, Iantomasi T, Giudici F, Brandi ML. Pancreatic Neuroendocrine Tumors in MEN1 Patients: Difference in Post-Operative Complications and Tumor Progression between Major and Minimal Pancreatic Surgeries. Cancers (Basel) 2023; 15:4919. [PMID: 37894286 PMCID: PMC10605506 DOI: 10.3390/cancers15204919] [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: 09/05/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (PNENs) affect over 80% of patients with multiple endocrine neoplasia type 1 (MEN1). Surgery is usually the therapy of choice, but the real immediate and long-term therapeutic benefit of a partial extensive pancreatic resection remains controversial. We analyzed, in 43 PNEN MEN1 patients who underwent 19 pancreaticoduodenectomies (PD), 19 distal pancreatectomies (DP), and 5 minimal pancreatectomies, the prevalence of surgery-derived early complications and post-operative pancreatic sequelae, and the PNEN relapse-free survival time after surgery, comparing major (PD+DP) and minimal pancreatic surgeries. No post-operative mortality was observed. Metastatic cancers were found in 12 cases, prevalently from duodenal gastrinoma. Long-term cure of endocrine syndromes, by the 38 major pancreatic resections, was obtained in 78.9% of gastrinomas and 92.9% of insulinomas. In only one patient, hepatic metastases, due to gastrinoma, progressed to death. Out of the 38 major surgeries, only one patient was reoperated for the growth of a new PNEN in the remnant pancreas. No functioning PNEN persistence was reported in the five minimal pancreatic surgeries, PNEN relapse occurred in 60% of patients, and 40% of cases needed further pancreatic resection for tumor recurrence. No significant difference in PNEN relapse-free survival time after surgery was found between major and minimal pancreatic surgeries.
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Affiliation(s)
- Francesco Tonelli
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
| | - Francesca Marini
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50139 Florence, Italy
| | - Teresa Iantomasi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50139 Florence, Italy
| | - Francesco Giudici
- Department of Clinical and Experimental Medicine, Surgical Unit, University of Florence, 50139 Florence, Italy
| | - Maria Luisa Brandi
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
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4
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Camera L, Boccadifuoco F, Modica R, Messerini L, Faggiano A, Romeo V, Gaudieri V, Colao A, Maurea S, Brunetti A. Gastrinomas and non-functioning pancreatic endocrine tumors in multiple endocrine neoplasia syndrome type-1 (MEN-1). Endocrine 2023; 81:459-463. [PMID: 37099246 DOI: 10.1007/s12020-023-03373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/08/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Luigi Camera
- Department of Advanced Biomedical Sciences, Section of Radiology, University "Federico II", Naples, Italy.
| | - Francesca Boccadifuoco
- Department of Advanced Biomedical Sciences, Section of Radiology, University "Federico II", Naples, Italy
| | - Roberta Modica
- Department of Endocrinology, University "Federico II", Naples, Italy
| | - Luca Messerini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Valeria Romeo
- Department of Advanced Biomedical Sciences, Section of Radiology, University "Federico II", Naples, Italy
| | - Valeria Gaudieri
- Department of Advanced Biomedical Sciences, Section of Nuclear Medicine, University "Federico II", Naples, Italy
| | - Annamaria Colao
- Department of Endocrinology, University "Federico II", Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, Section of Radiology, University "Federico II", Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, Section of Radiology, University "Federico II", Naples, Italy
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5
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van Beek DJ, Takkenkamp TJ, Wong-Lun-Hing EM, de Kleine RHJ, Walenkamp AME, Klaase JM, Nijkamp MW, Valk GD, Molenaar IQ, Hagendoorn J, van Santvoort HC, Borel Rinkes IHM, Hoogwater FJH, Vriens MR. Risk factors for complications after surgery for pancreatic neuroendocrine tumors. Surgery 2022; 172:127-136. [PMID: 35341591 DOI: 10.1016/j.surg.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/03/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for pancreatic neuroendocrine tumors. The choice for the type of procedure is influenced by the expected oncological benefit and the anticipated risk of procedure-specific complications. Few studies have focused on complications in these patients. This cohort study aimed to assess complications and risk factors after resections of pancreatic neuroendocrine tumors. METHODS Patients undergoing resection of a pancreatic neuroendocrine tumor were identified within 2 centers of excellence. Complications were assessed according to the Clavien-Dindo classification and the comprehensive complication index. Logistic regression was performed to compare surgical procedures with adjustment for potential confounders (Clavien-Dindo ≥3). RESULTS The cohort comprised 123 patients, including 12 enucleations, 50 distal pancreatectomies, 51 pancreatoduodenectomies, and 10 total/combined pancreatectomies. Mortality was 0.8%, a severe complication occurred in 41.5%, and the failure-to-rescue rate was 2.0%. The median comprehensive complication index was 22.6 (0-100); the comprehensive complication index increased after more extensive resections. After adjustment, a pancreatoduodenectomy, as compared to a distal pancreatectomy, increased the risk for a severe complication (odds ratio 3.13 [95% confidence interval 1.32-7.41]). Of the patients with multiple endocrine neoplasia type 1 or von Hippel-Lindau, 51.9% developed a severe complication vs 38.5% with sporadic disease. After major resections, morbidity was significantly higher in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau (comprehensive complication index 45.1 vs 28.9, P = .029). CONCLUSION Surgery for pancreatic neuroendocrine tumors is associated with a high rate of complications but low failure-to-rescue in centers of excellence. Complications are procedure-specific. Major resections in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau appear to increase the risk of complications.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim J Takkenkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Edgar M Wong-Lun-Hing
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruben H J de Kleine
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemiek M E Walenkamp
- Department of Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Frederik J H Hoogwater
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
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6
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Giusti F, Cioppi F, Fossi C, Marini F, Masi L, Tonelli F, Brandi ML. Secretin Stimulation Test and Early Diagnosis of Gastrinoma in MEN1 Syndrome: Survey on the MEN1 Florentine Database. J Clin Endocrinol Metab 2022; 107:e2110-e2123. [PMID: 34922358 DOI: 10.1210/clinem/dgab903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Multiple endocrine neoplasia type 1 (MEN1) is a rare inherited endocrine cancer syndrome. Multiple gastro-entero-pancreatic neuroendocrine tumors (GEP-NETs) affect 30% to 80% of MEN1 patients, with the most common functioning GEP-NET being gastrinoma. Biochemical identification of hypergastrinemia may help to recognize the presence of gastrinomas before they are detectable by instrumental screening, enabling early diagnosis and start of therapy, preferably before tumor progression and metastases occurrence. OBJECTIVE Evaluate the effectiveness of secretin stimulation test to precociously diagnose the presence of gastrin-secreting tumors. DESIGN Results of secretin stimulation tests, performed between 1991 and February 2020, were retrospectively analyzed, as aggregate, in a cohort of MEN1 patients with GEP-NETs. SETTING Data were extracted from the MEN1 Florentine database. PATIENTS The study included 72 MEN1 patients with GEP-NETs who underwent a secretin stimulation test for the evaluation of gastrin secretion. OUTCOMES A positive secretin stimulation test was assumed with a difference between basal fasting serum gastrin (FSG) and the maximum stimulated value of gastrin over 120 pg/mL. RESULTS The secretin stimulation test showed a secretin-induced hypergastrinemia in 27.8% (20/72) of patients with GEP-NETs, and a positive test in 18 cases. The test allowed the identification of a positively stimulated hypergastrinemia in 75.0% (3/4) of patients who presented a basal FSG within the normal range. CONCLUSIONS Diagnosis of gastrinoma is complex, difficult, and controversial. Results of this study confirm that a positive secretin stimulation test allows early diagnosis of gastrinomas, even in the presence of borderline or normal levels of nonstimulated FSG.
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Affiliation(s)
- Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Federica Cioppi
- Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - Caterina Fossi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- F.I.R.M.O. Italian Foundation for Research on Bone Diseases, Florence, Italy
| | - Laura Masi
- Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - Francesco Tonelli
- F.I.R.M.O. Italian Foundation for Research on Bone Diseases, Florence, Italy
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for Research on Bone Diseases, Florence, Italy
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7
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Kong W, Albers MB, Manoharan J, Goebel JN, Kann PH, Jesinghaus M, Bartsch DK. Pancreaticoduodenectomy Is the Best Surgical Procedure for Zollinger-Ellison Syndrome Associated with Multiple Endocrine Neoplasia Type 1. Cancers (Basel) 2022; 14:cancers14081928. [PMID: 35454834 PMCID: PMC9032426 DOI: 10.3390/cancers14081928] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023] Open
Abstract
Simple Summary Approximately 30% of patients with multiple endocrine neoplasia type 1 (MEN1) develop the Zollinger–Ellison syndrome (ZES), caused by solitary or multiple duodenal gastrinomas. Its management, especially regarding indication, timing, and type of surgery, is highly controversial. Therefore, the present study evaluated the long-term outcomes of pancreaticoduodenectomy (PD) versus non-PD resections in MEN1-ZES with regard to biochemical cure and quality of life. We found in a series of 35 patients that initial PD is the superior surgical procedure for MEN1-ZES, leading to long-term cure in about 80% of patients, fewer duodenopancreatic reoperations and an acceptable quality of life. Based on the results of this study, MEN1-ZES should be considered a surgically curable disease. Abstract Aim: The aim of this research was to evaluate the long-term outcome of pancreaticoduodenectomy (PD) versus other duodenopancreatic resections (non-PD) for the surgical treatment of the Zollinger–Ellison syndrome (ZES) in patients with multiple endocrine neoplasia type 1 (MEN1). Methods: Prospectively recorded patients with biochemically confirmed MEN1-ZES who underwent duodenopancreatic surgery were retrospectively analyzed in terms of clinical characteristics, complications, cure rate, and long-term morbidity, including quality of life assessment (EORTC QLQ-C30). Results: 35 patients (16 female, 19 male) with MEN1-ZES due to duodenopancreatic gastrinomas with a median age of 42 (range 30–74) years were included. At the time of diagnosis, 28 (80%) gastrinomas were malignant, but distant metastases were only present in one (3%) patient. Eleven patients (31.4%) underwent pancreatoduodenectomy (PD) as the initial procedure, whereas 24 patients underwent non-PD resections involving duodenotomy with gastrinoma excision, enucleation of the pNEN from the head of the pancreas, and peripancreatic lymphadenectomy, either with or without distal pancreatectomy (i.e., either Thompson procedure, n = 12, or DUODX, n = 12). There was no significant difference in perioperative morbidity and mortality between the two groups (p ≥ 0.05). One (9%) patient of the PD group required reoperation for recurrent or metastatic ZES compared to eight (22.8%) patients of the non-PD resection groups. After a median follow-up time of 134 months (range 6–480) nine of 11 (82%) patients in the PD group, two of 12 (16%) patients in the Thompson procedure group, and three of 12 (25%) patients in the DUODX group had normal serum gastrin levels. In addition, the global health QoLScore was better in the PD group (76.9) compared to the Thompson procedure (57.4) and DUODX (59.5) groups. Conclusions: Initial PD seems to be the superior surgical procedure for MEN1-ZES, resulting in a long-term cure rate of about 80%, fewer duodenopancreatic reoperations, and an acceptable quality of life.
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Affiliation(s)
- Weihua Kong
- Department of Surgery, Philipps-University, 35041 Marburg, Germany; (M.B.A.); (J.M.); (D.K.B.)
- Correspondence: ; Tel.: +49-6421-5866441; Fax: +49-6421-5868995
| | - Max Benjamin Albers
- Department of Surgery, Philipps-University, 35041 Marburg, Germany; (M.B.A.); (J.M.); (D.K.B.)
| | - Jerena Manoharan
- Department of Surgery, Philipps-University, 35041 Marburg, Germany; (M.B.A.); (J.M.); (D.K.B.)
| | - Joachim Nils Goebel
- Department of Gastroenterology, Division of Endocrinology and Diabetology, Philipps-University, 35043 Marburg, Germany; (J.N.G.); (P.H.K.)
| | - Peter Herbert Kann
- Department of Gastroenterology, Division of Endocrinology and Diabetology, Philipps-University, 35043 Marburg, Germany; (J.N.G.); (P.H.K.)
| | - Moritz Jesinghaus
- Department of Pathology, Philipps-University, 35043 Marburg, Germany;
| | - Detlef Klaus Bartsch
- Department of Surgery, Philipps-University, 35041 Marburg, Germany; (M.B.A.); (J.M.); (D.K.B.)
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8
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Hackeng WM, van Beek DJ, Kok ASM, van Emst M, Morsink FHM, van Treijen MJC, Borel Rinkes IHM, Dreijerink KMA, Offerhaus GJA, Valk GD, Vriens MR, Brosens LAA. Metastatic Patterns of Duodenopancreatic Neuroendocrine Tumors in Patients With Multiple Endocrine Neoplasia Type 1. Am J Surg Pathol 2022; 46:159-168. [PMID: 34560682 DOI: 10.1097/pas.0000000000001811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with multiple endocrine neoplasia 1 syndrome (MEN1) often develop multifocal duodenopancreatic neuroendocrine tumors (dpNETs). Nonfunctional pancreatic neuroendocrine tumors (PanNETs) and duodenal gastrinomas are the most frequent origins of metastasis. Current guidelines recommend surgery based on tumor functionality, size ≥2 cm, grade or presence of lymph node metastases. However, in case of multiple primary tumors it is often unknown which specific tumor metastasized. This study aims to unravel the relationship between primary dpNETs and metastases in patients with MEN1 by studying endocrine differentiation. First, it was shown that expression of the endocrine differentiation markers ARX and PDX1 was concordant in 18 unifocal sporadic neuroendocrine tumors (NETs) and matched metastases. Thereafter, ARX, PDX1, Ki67 and gastrin expression, and the presence of alternative lengthening of telomeres were determined in 137 microscopic and macroscopic dpNETs and 36 matched metastases in 10 patients with MEN1. ARX and PDX1 H-score clustering was performed to infer relatedness. For patients with multiple metastases, similar intrametastases transcription factor expression suggests that most metastases (29/32) originated from a single NET of origin, while few patients may have multiple metastatic primary NETs. In 6 patients with MEN1 and hypergastrinemia, periduodenopancreatic lymph node metastases expressed gastrin, and clustered with minute duodenal gastrinomas, not with larger PanNETs. PanNET metastases often clustered with high grade or alternative lengthening of telomeres-positive primary tumors. In conclusion, for patients with MEN1-related hypergastrinemia and PanNETs, a duodenal origin of periduodenopancreatic lymph node metastases should be considered, even when current conventional and functional imaging studies do not reveal duodenal tumors preoperatively.
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Affiliation(s)
- Wenzel M Hackeng
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht
| | - Aranxa S M Kok
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Madelon van Emst
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Folkert H M Morsink
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Mark J C van Treijen
- Department of Endocrine Oncology, University Medical Center Utrecht Cancer Center, Utrecht
| | | | - Koen M A Dreijerink
- Department of Endocrinology and Internal Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht Cancer Center, Utrecht
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht
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Marini F, Giusti F, Brandi ML. Epigenetic-based targeted therapies for well-differentiated pancreatic neuroendocrine tumors: recent advances and future perspectives. Expert Rev Endocrinol Metab 2021; 16:295-307. [PMID: 34554891 DOI: 10.1080/17446651.2021.1982382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Well-differentiated pancreatic neuroendocrine tumors (PanNETs) are a heterogeneous group of primary tumors of the endocrine pancreas. Dysregulation of chromatin remodeling, gene expression alteration, global DNA hypomethylation of non-coding regions, DNA hypermethylation and silencing of tumor suppressor gene promoters are frequent epigenetic changes in PanNETs. These changes exert a role in neoplastic transformation and progression. As epigenetic mechanisms, converse to genetic mutations, are potentially reversible, they are an interesting and promising therapeutic target for the treatment of PanNETs. AREAS COVERED We reviewed main epigenetic alterations associated with the development, biological and clinical features and progression of PanNETs, as well as emerging therapies targeting epigenetic changes, which may prove effective for the treatment of human PanNETs. EXPERT OPINION Constant advances in the PanNET medical approach, as reported in the clinical and therapeutic recommendations of ESMO, improved the overall survival of patients over the years. However, over 60% of the patients with metastatic disease still have poor prognosis. Epigenetic regulator drugs, currently approved to treat some human malignancies, that showed anti-tumoral activity also on PanNETs, in pre-clinical and clinical studies, could concur to ameliorate the prognosis and OS of advanced and metastatic PanNET, in combination with surgery and currently employed medical therapies.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of refereFlorence, Florence, Italy
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of refereFlorence, Florence, Italy
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
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Maekawa A, Kudo A, Kishino M, Murase Y, Watanabe S, Ishikawa Y, Ueda H, Akahoshi K, Ogawa K, Ono H, Tanaka S, Kinowaki Y, Tanabe M. Hormonal tumor mapping for liver metastases of gastroenteropancreatic neuroendocrine neoplasms: a novel therapeutic strategy. J Cancer Res Clin Oncol 2021; 148:697-706. [PMID: 33904982 DOI: 10.1007/s00432-021-03650-2] [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: 02/10/2021] [Accepted: 04/20/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE In patients with metastatic functional gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs), it is unknown what degree of tumor reduction is required to eliminate hormonal symptoms. We aimed to reduce hormonal symptoms derived from advanced GEP-NENs by efficient minimal intervention, constructing a hormonal tumor map of liver metastases. METHODS Between 2013 and 2019, we treated 12 insulinoma or gastrinoma patients with liver metastases. Liver segments containing hormone-producing tumors were identified by injecting calcium gluconate via the hepatic arteries and monitoring the change in serum hormone concentration in the three hepatic veins. A greater-than-twofold increase in hormone concentration indicated a tumor-feeding vessel. RESULTS Cases included eight insulinomas and four gastrinomas. Primary lesions were functional in three patients and nonfunctional in 9. Nine patients showed hormonal step-up indicating the presence of functional lesions; eight showed step-up in tumor-bearing liver segments, while one with synchronous liver metastases showed step-up only in the pancreatic region. Five patients underwent surgery. Serum hormone concentration decreased markedly after removing the culprit lesions in 3; immediate improvement in hormonal symptoms was achieved in all patients. Three patients with previous surgical treatment who showed step-up underwent transcatheter arterial embolization, achieving temporary improvement of hormonal symptoms. Four patients showed unclear localization of the hormone-producing tumors; treatment options were limited, resulting in poor outcomes. CONCLUSION Hormonal tumor mapping demonstrated heterogeneity in hormone production among primary and metastatic tumors of GEP-NENs. Minimally invasive treatment based on hormonal mapping may be a viable alternative to conventional cytoreduction.
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Affiliation(s)
- Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Mitsuhiro Kishino
- Department of Radiology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Shuichi Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroki Ueda
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kosuke Ogawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroaki Ono
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Shinji Tanaka
- Department of Molecular Oncology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuko Kinowaki
- Department of Human Pathology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Marini F, Giusti F, Tonelli F, Brandi ML. Pancreatic Neuroendocrine Neoplasms in Multiple Endocrine Neoplasia Type 1. Int J Mol Sci 2021; 22:4041. [PMID: 33919851 PMCID: PMC8070788 DOI: 10.3390/ijms22084041] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are a rare group of cancers accounting for about 1-2% of all pancreatic neoplasms. About 10% of pNETs arise within endocrine tumor syndromes, such as Multiple Endocrine Neoplasia type 1 (MEN1). pNETs affect 30-80% of MEN1 patients, manifesting prevalently as multiple microadenomas. pNETs in patients with MEN1 are particularly difficult to treat due to differences in their growth potential, their multiplicity, the frequent requirement of extensive surgery, the high rate of post-operative recurrences, and the concomitant development of other tumors. MEN1 syndrome is caused by germinal heterozygote inactivating mutation of the MEN1 gene, encoding the menin tumor suppressor protein. MEN1-related pNETs develop following the complete loss of function of wild-type menin. Menin is a key regulator of endocrine cell plasticity and its loss in these cells is sufficient for tumor initiation. Somatic biallelic loss of wild-type menin in the neuroendocrine pancreas presumably alters the epigenetic control of gene expression, mediated by histone modifications and DNA hypermethylation, as a driver of MEN1-associated pNET tumorigenesis. In this light, epigenetic-based therapies aimed to correct the altered DNA methylation, and/or histone modifications might be a possible therapeutic strategy for MEN1 pNETs, for whom standard treatments fail.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
| | - Francesco Tonelli
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
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Geslot A, Vialon M, Caron P, Grunenwald S, Vezzosi D. New therapies for patients with multiple endocrine neoplasia type 1. ANNALES D'ENDOCRINOLOGIE 2021; 82:112-120. [PMID: 33839123 DOI: 10.1016/j.ando.2021.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/18/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
In 1953, for the first time, Paul Wermer described a family presenting endocrine gland neoplasms over several generations. The transmission was autosomal dominant and the penetrance was high. Forty years later in 1997, the multiple endocrine neoplasia type 1 (MEN1) gene was sequenced, thus enabling diagnosis and early optimal treatment. Patients carrying the MEN1 gene present endocrine but also non-endocrine tumors. Parathyroid, pancreatic and pituitary impairment are the three main types of endocrine involvement. The present article details therapeutic management of hyperparathyroidism, neuroendocrine pancreatic tumors and pituitary adenomas in patients carrying the MEN1 gene. Significant therapeutic progress has in fact been made in the last few years. As concerns the parathyroid glands, screening of family members and regular monitoring of affected subjects now raise the question of early management of parathyroid lesions and optimal timing of parathyroid surgery. As concerns the duodenum-pancreas, proton-pump inhibitors are able to control gastrin-secreting syndrome, reducing mortality in MEN1 patients. Mortality in MEN1 patients is no longer mainly secondary to uncontrolled hormonal secretion but to metastatic (mainly pancreatic) disease progression. Tumor risk requires regular monitoring of morphological assessment, leading to iterative pancreatic surgery in a large number of patients. Finally, pituitary adenomas in MEN1 patients are traditionally described as aggressive, invasive and resistant to medical treatment. However, regular pituitary screening showed them to be in fact infra-centimetric and non-secreting in the majority of patients. Consequently, it is necessary to regularly monitor MEN1 patients, with regular clinical, biological and morphological work-up. Several studies showed that this regular monitoring impairs quality of life. Building a relationship of trust between patients and care provider is therefore essential. It enables the patient to be referred for psychological or psychiatric care in difficult times, providing long-term support and preventing any breakdown in continuity of care.
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Affiliation(s)
- Aurore Geslot
- Service d'endocrinologie, hôpital Larrey, 24, chemin de Pouvourville, 31029 Toulouse cedex 9, France
| | - Magaly Vialon
- Service d'endocrinologie, hôpital Larrey, 24, chemin de Pouvourville, 31029 Toulouse cedex 9, France
| | - Philippe Caron
- Service d'endocrinologie, hôpital Larrey, 24, chemin de Pouvourville, 31029 Toulouse cedex 9, France
| | - Solange Grunenwald
- Service d'endocrinologie, hôpital Larrey, 24, chemin de Pouvourville, 31029 Toulouse cedex 9, France
| | - Delphine Vezzosi
- Institut CardioMet, Toulouse, France; Service d'endocrinologie, hôpital Larrey, 24, chemin de Pouvourville, 31029 Toulouse cedex 9, France.
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Brandi ML, Agarwal SK, Perrier ND, Lines KE, Valk GD, Thakker RV. Multiple Endocrine Neoplasia Type 1: Latest Insights. Endocr Rev 2021; 42:133-170. [PMID: 33249439 PMCID: PMC7958143 DOI: 10.1210/endrev/bnaa031] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 02/06/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1), a rare tumor syndrome that is inherited in an autosomal dominant pattern, is continuing to raise great interest for endocrinology, gastroenterology, surgery, radiology, genetics, and molecular biology specialists. There have been 2 major clinical practice guidance papers published in the past 2 decades, with the most recent published 8 years ago. Since then, several new insights on the basic biology and clinical features of MEN1 have appeared in the literature, and those data are discussed in this review. The genetic and molecular interactions of the MEN1-encoded protein menin with transcription factors and chromatin-modifying proteins in cell signaling pathways mediated by transforming growth factor β/bone morphogenetic protein, a few nuclear receptors, Wnt/β-catenin, and Hedgehog, and preclinical studies in mouse models have facilitated the understanding of the pathogenesis of MEN1-associated tumors and potential pharmacological interventions. The advancements in genetic diagnosis have offered a chance to recognize MEN1-related conditions in germline MEN1 mutation-negative patients. There is rapidly accumulating knowledge about clinical presentation in children, adolescents, and pregnancy that is translatable into the management of these very fragile patients. The discoveries about the genetic and molecular signatures of sporadic neuroendocrine tumors support the development of clinical trials with novel targeted therapies, along with advancements in diagnostic tools and surgical approaches. Finally, quality of life studies in patients affected by MEN1 and related conditions represent an effort necessary to develop a pharmacoeconomic interpretation of the problem. Because advances are being made both broadly and in focused areas, this timely review presents and discusses those studies collectively.
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Affiliation(s)
| | | | - Nancy D Perrier
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Gerlof D Valk
- University Medical Center Utrecht, CX Utrecht, the Netherlands
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Pancreatoduodenectomy for Neuroendocrine Tumors in Patients with Multiple Endocrine Neoplasia Type 1: An AFCE (Association Francophone de Chirurgie Endocrinienne) and GTE (Groupe d'étude des Tumeurs Endocrines) Study. World J Surg 2021; 45:1794-1802. [PMID: 33649917 PMCID: PMC8093175 DOI: 10.1007/s00268-021-06005-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/18/2022]
Abstract
Aim To assess postoperative complications and control of hormone secretions following pancreatoduodenectomy (PD) performed on multiple endocrine neoplasia type 1 (MEN1) patients with duodenopancreatic neuroendocrine tumors (DP-NETs). Background The use of PD to treat MEN1 remains controversial, and evaluating the right place of PD in MEN1 disease makes sense. Methods Thirty-one MEN1 patients from the Groupe d’étude des Tumeurs Endocrines MEN1 cohort who underwent PD for DP-NETs between 1971 and 2013 were included. Early and late postoperative complications, secretory control and overall survival were analyzed. Results Indication for surgery was: Zollinger–Ellison syndrome (n = 18; 58%), nonfunctioning tumor (n = 9; 29%), insulinoma (n = 2; 7%), VIPoma (n = 1; 3%) and glucagonoma (n = 1; 3%). Mean follow-up was 141 months (range 0–433). Pancreatic fistulas occurred in 5 patients (16.1%), distant metastases in 6 (mean onset of 43 months; range 13–110 months), postoperative diabetes mellitus in 7 (22%), and pancreatic exocrine insufficiency in 6 (19%). Five-year overall survival was 93.3% [CI 75.8–98.3] and ten-year overall survival was 89.1% [CI 69.6–96.4]. After a mean follow-up of 151 months (range 0–433), the biochemical cure rate for MEN-1 related gastrinomas was 61%. Conclusion In MEN1 patients, pancreatoduodenectomy can be used to control hormone secretions (gastrin, glucagon, VIP) and to remove large NETs. PD was found to control gastrin secretions in about 60% of cases.
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15
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van Beek DJ, Nell S, Vorselaars WMCM, Bonsing BA, van Eijck CHJ, van Goor H, Nieveen van Dijkum EJ, Dejong CHC, Valk GD, Borel Rinkes IHM, Vriens MR. Complications After Major Surgery for Duodenopancreatic Neuroendocrine Tumors in Patients with MEN1: Results from a Nationwide Cohort. Ann Surg Oncol 2021; 28:4387-4399. [PMID: 33521900 PMCID: PMC8253708 DOI: 10.1245/s10434-020-09496-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/01/2020] [Indexed: 12/16/2022]
Abstract
Background Little is known about complications after major duodenopancreatic surgery for duodenopancreatic neuroendocrine tumors (dpNETs) in multiple endocrine neoplasia type 1 (MEN1). Therefore, the incidence and severity of complications after major surgery for MEN1-related dpNETs were assessed. Methods Patients were selected from the population-based Dutch MEN1 database if they had undergone a Whipple procedure or total pancreatectomy from 2003 to 2017. Complications were graded according to the Clavien–Dindo classification (grade III or higher complications were considered a severe complication) and definitions from the International Study Group of Pancreatic Surgery. The Cumulative Complication Index (CCI®) was calculated as the sum of all complications weighted for their severity. Univariable logistic regression was performed to assess potential associations between predictor candidates and a severe complication. Results Twenty-seven patients (median age 43 years) underwent a major duodenopancreatic resection, including 14 Whipple procedures and 13 total pancreatectomies. Morbidity and mortality were 100% (27/27) and 4% (1/27), respectively. A severe complication occurred in 17/27 (63%) patients. The median CCI® was 47.8 [range 8.7–100]. Grade B/C pancreatic fistulas, delayed gastric emptying, bile leakage, hemorrhage, and chyle leakage occurred in 7/14 (50%), 10/27 (37%), 1/27 (4%), 7/27 (26%), 3/27 (11%) patients, respectively. Patients with a severe complication had longer operative time and higher blood loss. After Whipple, new-onset endocrine and exocrine insufficiency occurred in 1/13 and 9/14 patients, respectively. Conclusions Major duodenopancreatic surgery in MEN1 is associated with a very high risk of severe complications and cumulative burden of complications and should therefore be reserved for a select subgroup of patients with MEN1-related dpNETs. Supplementary Information The online version of this article (10.1245/s10434-020-09496-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd Nell
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wessel M C M Vorselaars
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Usefulness of selective arterial calcium injection tests for functional pancreatic neuroendocrine tumors. Sci Rep 2021; 11:235. [PMID: 33420290 PMCID: PMC7794566 DOI: 10.1038/s41598-020-80538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022] Open
Abstract
The selective arterial calcium injection (SACI) test is useful for patients with functional pancreatic neuroendocrine tumors (F-PNETs). This study evaluated which patients with F-PNETs would benefit from the SACI test. We retrospectively analyzed the preoperative findings of patients on computed tomography (CT), magnetic resonance imaging (MRI), CT angiography (CTA), and the SACI test. Fourteen patients who underwent pancreatectomy between January 1997 and September 2016 for F-PNETs were evaluated. We classified these patients into groups A, B, and C; group A, one tumor detected by either CT or MRI; group B, multiple tumors detected; and group C, the tumor location was accordant on CT, MRI, and CTA, but the SACI test revealed another tumor. In group A, the tumor was also detected by CTA and the SACI test was positive on calcium injection. In group B, the focus tumor among the multiple tumors was detected by the SACI test. In group C, another tumor was identified by the SACI test, whose location was different from that detected using CT and MRI. The SACI test is more useful for multiple F-PNETs on CT or MRI. If CT or MRI detects a single tumor, the SACI test or CTA may be unnecessary.
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Total gastrectomy for severe proton pump inhibitor-induced hypomagnesemia in a MEN1/Zollinger Ellison syndrome patient. Pancreatology 2021; 21:236-239. [PMID: 33309626 DOI: 10.1016/j.pan.2020.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
We report here the first case of life-threatening hypomagnesemia in a Zollinger-Ellison syndrome patient with multiple endocrine neoplasia type 1 (MEN1) syndrome. The severe symptomatic hypomagnesemia proved to be due to proton pump inhibitors (PPIs), but withdrawal of PPIs led to early severe peptic complications despite a substitution by histamine H2-receptor antagonist therapy. Simultaneous management of life-threatening hypomagnesemia, severe gastric acid hypersecretion and MEN1-associated gastrinomas was complex. A total gastrectomy was performed in order to definitely preclude the use of PPIs in this frail patient who was not eligible for curative pancreatoduodenal resection.
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Hayashi R, Minami I, Sasahara Y, Izumiyama H, Yoshimoto T, Kishino M, Kudo A, Tateishi U, Tanabe M, Yamada T. Diagnostic accuracy of selective arterial calcium injection test for localization of gastrinoma. Endocr J 2020; 67:305-315. [PMID: 31813923 DOI: 10.1507/endocrj.ej19-0413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The appropriate localization of gastrinoma is still difficult. We aimed to evaluate the diagnostic accuracy of selective arterial calcium injection (SACI) for localization of gastrinomas including multiple lesions. This retrospective study included ten patients with surgically proven gastrinomas (gastrinoma group) and six patients without any findings suggesting Zollinger-Ellison syndrome (non-gastrinoma group). For SACI, calcium gluconate was injected into the arteries supplying pancreas, duodenum, and liver. Blood samples from the hepatic vein were obtained before and 30, 60, and 120 seconds after each injection. The results were considered positive when the increase in serum immunoreactive gastrin (IRG) levels within 60 seconds of calcium gluconate injection were more than 80 pg/mL and more than 20% from baseline. We evaluated the efficacy of SACI by comparing the SACI responses with definitive locations diagnosed by clinical and histopathological findings. In the gastrinoma group, false-positive responses were confirmed in seven of the ten patients. False-negative response was observed in one of the feeding arteries of one patient with gastrinomas in multiple locations. Conversely, the greatest increase in serum gastrin levels from baseline at 30 seconds indicated the true-positive responses in all patients with gastrinomas. In the non-gastrinoma group, calcium gluconate injection into gastroduodenal artery evoked positive responses in five of the six patients. In conclusion, our data suggest the strongest gastrin response evoked by SACI indicates the definitive location in patients with gastrinomas. In contrast, SACI could not accurately locate multiple gastrin-secreting lesions due to poor specificity.
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Affiliation(s)
- Ruriko Hayashi
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Isao Minami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology, Yokohama City Minato Red Cross Hospital, Kanagawa, Japan
| | - Yuriko Sasahara
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endocrinology and Metabolism, Soka Municipal Hospital, Saitama, Japan
| | - Hajime Izumiyama
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Diabetes and Endocrinology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Mitsuhiro Kishino
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ukihide Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Gong S, Li Z, Liu XB, Wang X, Shen WW. Gastrinoma in multiple endocrine neoplasia type 1 after total pancreatectomy: A case report. Medicine (Baltimore) 2019; 98:e18275. [PMID: 31852099 PMCID: PMC6922403 DOI: 10.1097/md.0000000000018275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Surgery for patients with multiple endocrine neoplasia type 1(MEN-1) related gastrinoma remains controversial and total pancreatectomy (TP) has rarely been performed. We reported a case of patient with MEN-1 related gastrinoma treated by TP. PATIENT CONCERNS A 46-year-old female was admitted to our hospital due to abdominal distension and diarrhea for 2 years. The patient underwent pituitary tumor resection and kidney stone lithotripsy 10 years ago. DIAGNOSES Abdominal computed tomography showed single lesion in the duodenum and multiple lesions throughout the pancreas. The patient's gastrin level was significantly increased (1080 pg/ml). These findings in combination with the pituitary tumor history suggested the presence of gastrinoma associated with MEN-1 syndrome. INTERVENTION An exploratory laparotomy was performed. Intraoperative ultrasound confirmed the numerous tumors diffusely distributed throughout the pancreas and the patient eventually underwent TP. OUTCOMES Twelve months later, the patient was hospitalized again for anastomotic fistula and underwent a partial gastrectomy, small bowel resection and drainage of the abscess. One month later, she received gastrostomy and jejunostomy due to digestive tract fistula, and died a month later (14 months after TP). LESSONS There still might be the possibility of recurrence even after radical surgical resection of gastrinomas, and we suggest the need to measure the basal acid output and maintain regular anti-acid therapy in the long-term follow-up of patients with MEN-1 related gastrinoma.
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Affiliation(s)
- Shu Gong
- Department of Pancreatic Surgery
| | - Zhi Li
- Department of Pancreatic Surgery
| | | | - Xin Wang
- Department of Pancreatic Surgery
| | - Wen-Wu Shen
- Outpatient Department, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Albers MB, Manoharan J, Bartsch DK. Contemporary surgical management of the Zollinger-Ellison syndrome in multiple endocrine neoplasia type 1. Best Pract Res Clin Endocrinol Metab 2019; 33:101318. [PMID: 31521501 DOI: 10.1016/j.beem.2019.101318] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
About 30% of patients with MEN1 develop a Zollinger-Ellison syndrome. Meanwhile it is well established that the causative gastrinomas are almost exclusively localized in the duodenum and not in the pancreas, MEN1 gastrinomas occur multicentric and are associated with hyperplastic gastrin cell lesions and tiny gastrin-producing micro tumors in contrast to sporadic duodenal gastrinomas. Regardless of the high prevalence of early lymphatic metastases, the survival is generally good with an aggressive course of disease in only about 20% of patients. Symptoms can be controlled medically. The indication, timing, type, and extent of surgery are highly controversial and are discussed in detail in this article by a thorough and critical review of literature. More radical procedures, like partial pancreaticoduodenectomy, are weighed against less aggressive local excision of gastrinomas and the pros and cons of both approaches are discussed in terms of long-term morbidity, biochemical cure, and survival.
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Affiliation(s)
- Max B Albers
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany.
| | - Jerena Manoharan
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
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Shao QQ, Zhao BB, Dong LB, Cao HT, Wang WB. Surgical management of Zollinger-Ellison syndrome: Classical considerations and current controversies. World J Gastroenterol 2019; 25:4673-4681. [PMID: 31528093 PMCID: PMC6718045 DOI: 10.3748/wjg.v25.i32.4673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Zollinger-Ellison syndrome (ZES) is characterized by gastric acid hypersecretion causing severe recurrent acid-related peptic disease. Excessive secretion of gastrin can now be effectively controlled with powerful proton pump inhibitors, but surgical management to control gastrinoma itself remains controversial. Based on a thorough literature review, we design a surgical algorithm for ZES and list some significant consensus findings and recommendations: (1) For sporadic ZES, surgery should be routinely undertaken as early as possible not only for patients with a precisely localized diagnosis but also for those with negative imaging findings. The surgical approach for sporadic ZES depends on the lesion location (including the duodenum, pancreas, lymph nodes, hepatobiliary tract, stomach, and some extremely rare sites such as the ovaries, heart, omentum, and jejunum). Intraoperative liver exploration and lymphadenectomy should be routinely performed; (2) For multiple endocrine neoplasia type 1-related ZES (MEN1/ZES), surgery should not be performed routinely except for lesions > 2 cm. An attempt to perform radical resection (pancreaticoduodenectomy followed by lymphadenectomy) can be made. The ameliorating effect of parathyroid surgery should be considered, and parathyroidectomy should be performed first before any abdominal surgery for ZES; and (3) For hepatic metastatic disease, hepatic resection should be routinely performed. Currently, liver transplantation is still considered an investigational therapeutic approach for ZES. Well-designed prospective studies are desperately needed to further verify and modify the current considerations.
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Affiliation(s)
- Qian-Qian Shao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China
| | - Bang-Bo Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China
| | - Liang-Bo Dong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China
| | - Hong-Tao Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China
| | - Wei-Bin Wang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China
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Management of MEN1 Related Nonfunctioning Pancreatic NETs: A Shifting Paradigm: Results From the DutchMEN1 Study Group. Ann Surg 2019; 267:1155-1160. [PMID: 28257328 DOI: 10.1097/sla.0000000000002183] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess if surgery for Multiple Endocrine Neoplasia type 1 (MEN1) related nonfunctioning pancreatic neuroendocrine tumors (NF-pNETs) is effective for improving overall survival and preventing liver metastasis. BACKGROUND MEN1 leads to multiple early-onset NF-pNETs. The evidence base for guiding the difficult decision who and when to operate is meager. METHODS MEN1 patients diagnosed with NF-pNETs between 1990 and 2014 were selected from the DutchMEN1 Study Group database, including > 90% of the Dutch MEN1 population. The effect of surgery was estimated using time-dependent Cox analysis with propensity score restriction and adjustment. RESULTS Of the 152 patients, 53 underwent surgery and 99 were managed by watchful waiting. In the surgery group, tumors were larger and faster-growing, patients were younger, more often male, and were more often treated in centers that operated more frequently. Surgery for NF-pNETs was not associated with a significantly lower risk of liver metastases or death, [adjusted hazard ratio (HR) = 0.73 (0.25-2.11)]. Adjusted HR's after stratification by tumor size were: NF-pNETs <2 cm = 2.04 (0.31-13.59) and NF-pNETs 2-3 cm = 1.38 (0.09-20.31). Five out of the 6 patients with NF-pNETs >3 cm managed by watchful waiting developed liver metastases or died compared with 6 out of the 16 patients who underwent surgery. CONCLUSIONS MEN1 patients with NF-pNETs <2 cm can be managed by watchful waiting, hereby avoiding major surgery without loss of oncological safety. The beneficial effect of a surgery in NF-pNETs 2 to 3 cm requires further research. In patients with NF-pNETs >3 cm, watchful waiting seems not advisable.
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23
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Tonelli F, Giusti F, Marini F, Brandi ML. Hereditary Syndromes and Abdominal Neuroendocrine Tumors. Updates Surg 2018. [DOI: 10.1007/978-88-470-3955-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sadowski SM, Cadiot G, Dansin E, Goudet P, Triponez F. The future: surgical advances in MEN1 therapeutic approaches and management strategies. Endocr Relat Cancer 2017; 24:T243-T260. [PMID: 28811298 DOI: 10.1530/erc-17-0285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/16/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a hereditary autosomal dominant disorder associated with numerous neuroendocrine tumors (NETs). Recent advances in the management of MEN1 have led to a decrease in mortality due to excess hormones; however, they have also led to an increase in mortality from malignancy, particularly NETs. The main challenges are to localize these tumors, to select those that need therapy because of the risk of aggressive behavior and to select the appropriate therapy associated with minimal morbidity. This must be applied to a hereditary disease with a high risk of recurrence. The overall aim of management in MEN1 is to ensure that the patient remains disease- and symptom-free for as long as possible and maintains a good quality of life. Herein, we review the changes that occurred in the last 20 years in the surgical management of MEN1-associated functional and non-functional pancreatico-duodenal NETs and thymic and bronchial NETs.
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Affiliation(s)
- S M Sadowski
- Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of Geneva, Geneva, Switzerland
| | - G Cadiot
- Gastroenterology and HepatologyUniversity Hospital of Reims, Reims, France
| | - E Dansin
- OncologyOscar Lambret Cancer Center, University of Lille, Lille, France
| | - P Goudet
- Endocrine SurgeryUniversity Hospital of Dijon, and INSERM, U866, Epidemiology and Clinical Research in Digestive Oncology Team, and INSERM, CIC1432, Clinical Epidemiology Unit, University Hospital of Dijon, Clinical Investigation Centre, Clinical Epidemiology/Clinical Trials Unit, Dijon, France
| | - F Triponez
- Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of Geneva, Geneva, Switzerland
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van Leeuwaarde RS, de Laat JM, Pieterman CRC, Dreijerink K, Vriens MR, Valk GD. The future: medical advances in MEN1 therapeutic approaches and management strategies. Endocr Relat Cancer 2017; 24:T179-T193. [PMID: 28768698 DOI: 10.1530/erc-17-0225] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 12/21/2022]
Abstract
Multiple endocrine neoplasia type 1 is a rare autosomal inherited disorder associated with a high risk for patients to simultaneously develop tumors of the parathyroid glands, duodenopancreatic neuroendocrine tumors and tumors of the anterior pituitary gland. Early identification of MEN1 in patients enables presymptomatic screening of manifestations, which makes timely interventions possible with the intention to prevent morbidity and mortality. Causes of death nowadays have shifted toward local or metastatic progression of malignant neuroendocrine tumors. In early cohorts, complications like peptic ulcers in gastrinoma, renal failure in hyperparathyroidism, hypoglycemia and acute hypercalcemia were the primary causes of early mortality. Improved medical treatments of these complications led to a significantly improved life expectancy. The MEN1 landscape is still evolving, considering the finding of breast cancer as a new MEN1-related manifestation and ongoing publications on follow-up and medical care for patients with MEN1. This review aims at summarizing the most recent insights into the follow-up and medical care for patients with MEN1 and identifying the gaps for future research.
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Affiliation(s)
| | - Joanne M de Laat
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Carolina R C Pieterman
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Koen Dreijerink
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine SurgeryUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
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Cioppi F, Cianferotti L, Masi L, Giusti F, Brandi ML. The LARO-MEN1 study: a longitudinal clinical experience with octreotide Long-Acting Release in patients with Multiple Endocrine Neoplasia type 1 Syndrome. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2017; 14:123-130. [PMID: 29263719 PMCID: PMC5726195 DOI: 10.11138/ccmbm/2017.14.1.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a rare hereditary tumoral syndrome, featured by a combination of neoplasms of various endocrine and nonendocrine tissues. Approximately 33% of MEN1-related deaths are due to the malignant behaviour of well-differentiated neuroendocrine tumors (NETs), for which a preventive surgical treatment is not feasible. Somatostatin analogues (SSA) have been employed in the treatment of NETs in the stage of advanced or metastatic disease, in order to control the growth and secretion of tumor lesions. A longitudinal, open label study named "LARO-MEN1" was undertaken in order to assess whether early medical treatment with long-acting SSA could act as a preventive approach in small MEN1-related gastroenteropancreatic (GEP) NETs. Thirty consecutive patients affected by MEN1 were screened and 8 patients with small (<2 cm) NETs and abnormal laboratory values of at least one of the GEP hormones were administered octreotide acetate slow-release formulation (LAR) (10 mg i.m. every 28 days). Octreotide LAR was effective in decreasing GEP hormones and overall safe in the majority of patients up to six years of treatment, maintaining the disease stable also in terms of tumor size. The positive outcomes of this study in MEN1 patients reinforce the results obtained in advanced NETs on the use of SSA, opening to the opportunity for preventive use of octreotide LAR, aimed to delay or even avoid surgery in these patients.
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Affiliation(s)
- Federica Cioppi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Luisella Cianferotti
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Laura Masi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Francesca Giusti
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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Complicated Case Presentation: Management of Pancreatic Neuroendocrine Tumors in Multiple Endocrine Neoplasia Type 1. Pancreas 2017; 46:416-426. [PMID: 28187108 DOI: 10.1097/mpa.0000000000000770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is an inherited predisposition to tumors of the parathyroid glands, anterior pituitary, and pancreatic islet cells. In this review, we discuss the clinical case of a 45-year-old woman with MEN1 that was presented at the 2015 North American Neuroendocrine Tumor Society Symposium. In our review of this patient's complicated clinical course and subsequent operative management, we highlight controversies in the diagnosis and management of pancreatic neuroendocrine tumors in MEN1. In particular, this case illustrates the lack of consensus regarding the optimal biochemical and radiologic screening for pancreatic neuroendocrine tumors and absence of guidelines about the appropriate surgical approach for treatment. We review these controversies and discuss possible approaches to management.
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Tonelli F, Giudici F, Nesi G, Batignani G, Brandi ML. Operation for insulinomas in multiple endocrine neoplasia type 1: When pancreatoduodenectomy is appropriate. Surgery 2016; 161:727-734. [PMID: 27863775 DOI: 10.1016/j.surg.2016.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Distal pancreatectomy is the most frequent operation for insulinomas complicating multiple endocrine neoplasia type 1 insulinoma, although there are conditions for which a different operative approach might be preferable. In this article, we report the operative experience of a referral center for multiple endocrine neoplasia type 1 insulinoma. METHODS Twelve patients underwent operations between 1992 and 2015: 8 underwent a distal pancreatic resection, and 4 underwent a pancreatoduodenectomy. Enucleation of other macroadenomas present in the remnant pancreas was performed in 9 out of these 12 patients. RESULTS Operative complications (2 pancreatic fistulas and 2 cases of pancreatitis) occurred in 4 of the 8 distal pancreatic resections. In 1 patient, reoperation was required to resolve the complications of the first operation. At pathologic analysis, multiple insulinomas were found in 5 patients, lymph-nodal metastasis positive for insulin in 2 patients, multiple nonfunctioning pancreatic tumors in all patients, glucagonoma in 4 patients, and gastrinoma in the duodenum or lymph nodes in 4 patients. All the patients were treated successfully for the hypoglycemic/hyperinsulinemic syndrome with no clinical recurrence at a mean follow-up of 85 months (range 4-242 months). Recurrent nonfunctioning pancreatic tumor macroadenomas in the remnant pancreas occurred in only 1 of the 12 patients, and no progression of the gastrinomas was observed. None of the patients developed diabetes mellitus. CONCLUSION Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent malignant progression of nonfunctioning pancreatic tumors in patients with multiple endocrine neoplasia type 1. If the head of the pancreas is the most affected site and the Zollinger-Ellison syndrome is concomitant, then pancreatoduodenectomy should be preferred over distal pancreatectomy.
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Affiliation(s)
- Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy.
| | - Francesco Giudici
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Gabriella Nesi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Giacomo Batignani
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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Nell S, Brunaud L, Ayav A, Bonsing BA, Groot Koerkamp B, Nieveen van Dijkum EJ, Kazemier G, de Kleine RH, Hagendoorn J, Molenaar IQ, Valk GD, Borel Rinkes IH, Vriens MR. Robot-assisted spleen preserving pancreatic surgery in MEN1 patients. J Surg Oncol 2016; 114:456-61. [DOI: 10.1002/jso.24315] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 05/21/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Sjoerd Nell
- Department of Endocrine Surgical Oncology and Endocrine Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Laurent Brunaud
- Department of Digestive, Hepatobiliary and Endocrine Surgery; Université de Lorraine, Hôpital Brabois Adultes, CHU Nancy; Nancy France
| | - Ahmet Ayav
- Department of Digestive, Hepatobiliary and Endocrine Surgery; Université de Lorraine, Hôpital Brabois Adultes, CHU Nancy; Nancy France
| | - Bert A. Bonsing
- Department of Surgery; Leiden University Medical Center; Leiden The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery; Erasmus Medical Center; Rotterdam The Netherlands
| | | | - Geert Kazemier
- Department of Surgery; VU University Medical Center; Amsterdam The Netherlands
| | - Ruben H.J. de Kleine
- Department of Hepatobiliary Surgery and Liver Transplantation; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Oncology and Hepato-Pancreato-Biliary Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - I. Quintus Molenaar
- Department of Surgical Oncology and Hepato-Pancreato-Biliary Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Gerlof D. Valk
- Department of Endocrine Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgical Oncology and Endocrine Surgical Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Menno R. Vriens
- Department of Endocrine Surgical Oncology; University Medical Center Utrecht; Utrecht The Netherlands
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Ito T, Jensen RT. Imaging in multiple endocrine neoplasia type 1: recent studies show enhanced sensitivities but increased controversies. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016; 3:53-66. [PMID: 26834963 DOI: 10.2217/ije.15.29] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In multiple endocrine neoplasia type 1 (MEN1) patients, a number of recent studies compare the ability of different, new imaging modalities to existing modalities to localize the important neuroendocrine tumors (NETs) that contribute to their decreased life expectancy (pancreatic NETs [pNETs] and thymic carcinoids). These included the use of 68Ga-DOTATOC-PET/CT, endoscopic ultrasound and MRI. The current paper analyzes these results in light of current guidelines and controversies involved in the treatment/management of MEN1 patients. Particular attention is paid to results in these studies with thymic carcinoids and nonfunctional pNETs/gastrinomas, which recent studies show are particularly important in determining long-term survival. These studies show a number of promising imaging results but also raise a number of controversies, which will need to be addressed both in their use initially and for serial studies in these patients.
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Affiliation(s)
- Tetsuhide Ito
- Department of Medicine & Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20817, USA
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Partelli S, Tamburrino D, Lopez C, Albers M, Milanetto AC, Pasquali C, Manzoni M, Toumpanakis C, Fusai G, Bartsch D, Falconi M. Active Surveillance versus Surgery of Nonfunctioning Pancreatic Neuroendocrine Neoplasms ≤2 cm in MEN1 Patients. Neuroendocrinology 2016; 103:779-86. [PMID: 26731608 DOI: 10.1159/000443613] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/20/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy of conservative treatment for nonfunctioning pancreatic neuroendocrine neoplasms (NF-PNEN) ≤2 cm in multiple endocrine neoplasia type 1 (MEN1)-affected patients compared with surgical treatment. METHODS The databases of 4 tertiary referral institutions (San Raffaele Scientific Institute, Milan; Philipps-Universität Marburg, Marburg; University of Padua, Padua; Royal Free Hospital, London) were analyzed. A comparison of conservative management and surgery at initial diagnosis of NF-PNEN ≤2 cm between 1997 and 2013 was performed. RESULTS Overall, 27 patients (45%) underwent up-front surgery and 33 patients (55%) were followed up after the initial diagnosis. A higher proportion of patients in the surgery group were female (70 vs. 33%, p = 0.004). Patients were mainly operated on in the period 1997-2007 as compared with the period 2008-2013 (n = 17; 63 vs. 37%; p = 0.040). The rate of multifocal tumors was higher in the surgery group (n = 24; 89%) than in the 'no surgery' group (n = 22; 67%; p = 0.043). After a median follow-up of 126 months, 1 patient deceased due to postoperative complications within 30 days after surgery. The 5-, 10-, and 15-year progression-free survival (PFS) rates were 63, 39, and 10%, respectively. The median PFS was similar in the two groups. Overall, 13 patients (32.5%) were operated on after initial surgical or conservative treatment. The majority of the surgically treated patients had stage 1 (77.5%), T1 (77.5%), and G1 (85%) tumors. CONCLUSIONS NF-PNEN ≤2 cm in MEN1 patients are indolent neoplasms posing a low oncological risk. Surgical treatment of these tumors at initial diagnosis is rarely justified in favor of conservative treatment.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Department of Internal Medicine, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Bartsch DK, Albers MB. Controversies in surgery for multiple endocrine neoplasia type 1-associated Zollinger–Ellison syndrome. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Zollinger–Ellison syndrome (ZES) is a common manifestation of multiple endocrine neoplasia type 1 (MEN1). At least 90% of MEN1-ZES patients have multiple duodenal gastrinomas, making the duodenum the target organ of ZES. The indication and the timing of surgery in MEN1-ZES is controversial, since there is yet no parameter that indicates an aggressive course of disease and long-term survival is generally good. An imageable, most likely nonfunctioning pancreatic neuroendocrine neoplasm (pNEN) >1–2 cm seems to be a good surrogate parameter to indicate surgery in order to prevent distant metastatic pNEN disease, although some groups indicate surgery at the time of biochemical ZES evidence. The optimal surgical procedure is also controversial. Different strategies encomprise local excision via duodenotomy with or without distal pancreatic resection and regional lymphadenectomy to partial pancreaticoduodenectomy. At present, the timing and type of surgery for MEN1-ZES should be individualized according to patient’s characteristics and preference.
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Affiliation(s)
- Detlef K Bartsch
- Department of Visceral, Thoracic & Vascular Surgery, University Hospital Gießen/Marburg GmbH, Philipps-University Marburg, Baldingerstrasse, 35043 Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic & Vascular Surgery, University Hospital Gießen/Marburg GmbH, Philipps-University Marburg, Baldingerstrasse, 35043 Marburg, Germany
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Abstract
Pancreatic neuroendocrine tumors (PNETs) are uncommon tumors with a range of clinical behavior. Some PNETs are associated with symptoms of hormone secretion, with increased systemic levels of insulin, gastrin, glucagon, or other hormones. More commonly, PNETs are nonfunctional, without hormone secretion. Surgical resection is the mainstay of therapy, particularly for localized disease. Surgical therapy must be tailored to tumor and clinical characteristics. Resection may be particularly indicated in the setting of hormone hypersecretion. Small, incidental PNETs are increasingly managed nonoperatively. Surgery may also be indicated in some instances of metastatic disease, if all metastatic foci may be removed.
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Affiliation(s)
- Thomas E Clancy
- Division of Surgical Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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34
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Norton JA, Krampitz G, Jensen RT. Multiple Endocrine Neoplasia: Genetics and Clinical Management. Surg Oncol Clin N Am 2015; 24:795-832. [PMID: 26363542 DOI: 10.1016/j.soc.2015.06.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Early diagnosis of multiple endocrine neoplasia (MEN) syndromes is critical for optimal clinical outcomes; before the MEN syndromes can be diagnosed, they must be suspected. Genetic testing for germline alterations in both the MEN type 1 (MEN1) gene and RET proto-oncogene is crucial to identifying those at risk in affected kindreds and directing timely surveillance and surgical therapy to those at greatest risk of potentially life-threatening neoplasia. Pancreatic, thymic, and bronchial neuroendocrine tumors are the leading cause of death in patients with MEN1 and should be aggressively considered by at least biannual computed tomography imaging.
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Affiliation(s)
- Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Geoffrey Krampitz
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Robert T Jensen
- Cell Biology Section, Digestive Diseases Branch, National Institute of Arthritis, Diabetes, Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD 20892-2560, USA
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35
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Doi R. Determinants of surgical resection for pancreatic neuroendocrine tumors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:610-7. [PMID: 25773163 DOI: 10.1002/jhbp.224] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/14/2015] [Indexed: 12/14/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) include functioning and non-functional tumors. Functioning tumors consist of tumors that produce a variety of hormones and their clinical effects. Therefore, determinants of resection of pNETs should be discussed for each group of tumors. Less than 10% of insulinomas are malignant, therefore more than 90% of the cases can be cured by surgical resection. Lymphadenectomy is generally not necessary in insulinoma operation. If preoperative localization of the insulinoma is completed, enucleation from the pancreatic body or tail, and distal pancreatectomy can be performed safely by laparoscopy. When preoperative localization of a sporadic insulinoma is not confirmed, surgical exploration is needed. Intraoperative localization of a tumor, intraoperative insulin sampling and frozen section are required. The crucial purpose of surgical resection is to control inappropriate insulin secretion by removing all insulinomas. Gastrinomas are usually located in the duodenum or pancreas, which secrete gastrin and cause Zollinger-Ellison syndrome (ZES). Duodenal gastrinomas are usually small, therefore they are not seen on preoperative imaging studies or endoscopic ultrasound, and can be found only at surgery if a duodenotomy is performed. In addition, lymph node metastasis is found in 40-60% of cases. Therefore, the experienced surgeons should direct operation for gastrinomas. Surgical exploration with duodenotomy should be performed at a laparotomy. Other functioning pNETs can occur in the pancreas or in other locations. Curative resection is always recommended whenever possible after optimal symptomatic control of the clinical syndrome by medical treatment. Indications for surgery depend on clinical symptom control, tumor size, location, extent, malignancy and presence of metastasis. A lot of non-functioning pNETs are found incidentally according to the quality improvement of imaging techniques. Localized, small, malignant non-functioning pNETs should be operated on aggressively, while in possibly benign tumors smaller than 2 cm the surgical risk-benefit ratio should be carefully weighted. Surgical liver resection is generally proposed in curative intent to all patients with operable metastases from G1 or G2 pNET. The benefits of surgical resection of liver metastases have been demonstrated in terms of overall survival and quality of life. Complete resection is associated with better long-term survival.
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Affiliation(s)
- Ryuichiro Doi
- Department of Surgery, Otsu Red Cross Hospital, 1-1-35 Nagara, Otsu, Shiga, 520-8511, Japan
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Fernández-Cruz L, Pelegrina A. [Surgery for gastrinoma: Short and long-term results]. Cir Esp 2015; 93:390-5. [PMID: 25748044 DOI: 10.1016/j.ciresp.2014.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/19/2014] [Accepted: 10/26/2014] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Zollinger-Ellison syndrome (Z-E) is characterized by gastrin-secreting tumors, responsible for causing refractory and recurrent peptic ulcers in the gastrointestinal tract. The optimal approach and the extension of tumor resection remains the subject of debate. METHODS During the period February 2005 and February 2014, 6 patients with Z-E underwent surgery, 4 men and 2 women with a median age 46.8 years (22-61). Two patients were affected with multiple endocrine neoplasia type-1 (MEN-1). Fasting gastrin levels greater than 200pg/ml (NV: <100) was diagnostic. Radiologic imaging to localize the lesion included octreoscan 6/6, computer tomography (CT) 6/6, and endoscopic ultrasonography (EUS) 1/6. RESULTS The octreoscan was positive in 5 patients. The CT localized the tumor in the pancreas in 2 patients, in the duodenum in 3 patients (1 confirmed by EUS) and between the common bile duct and vena cava in one patient. The laparoscopic approach was used in 4 patients, 2 patients converted to open surgery. The following surgical techniques were performed: 2 pylorus-preserving pancreatico-duodenectomy (PPPD), one spleen-preserving distal pancreatectomy, one duodenal nodular resection, 1 segmental duodenectomy and one extrapancreatic nodular resection. Pathological studies showed lymph nodes metástasis in 2 patients with pancreatic gastrinomas, and in one patient with duodenal gastrinoma. The median follow-up was 76,83 months (5-108) and all patients presented normal fasting gastrin levels. CONCLUSIONS Surgery may offer a cure in patients with Z-E. The laparoscopic approach remains limited to selected cases.
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Affiliation(s)
- Laureano Fernández-Cruz
- Departamento de Cirugía, Universidad de Barcelona, Hospital Clínic de Barcelona, Barcelona, España.
| | - Amalia Pelegrina
- Departamento de Cirugía, Universidad de Barcelona, Hospital Clínic de Barcelona, Barcelona, España
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37
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Vezzosi D, Cardot-Bauters C, Bouscaren N, Lebras M, Bertholon-Grégoire M, Niccoli P, Levy-Bohbot N, Groussin L, Bouchard P, Tabarin A, Chanson P, Lecomte P, Guilhem I, Carrere N, Mirallié E, Pattou F, Peix JL, Goere D, Borson-Chazot F, Caron P, Bongard V, Carnaille B, Goudet P, Baudin E. Long-term results of the surgical management of insulinoma patients with MEN1: a Groupe d'étude des Tumeurs Endocrines (GTE) retrospective study. Eur J Endocrinol 2015; 172:309-19. [PMID: 25538206 DOI: 10.1530/eje-14-0878] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Management of insulinomas in the context of MEN1 remains poorly studied. The aim of this study was to evaluate long-term results of various surgical approaches in a large cohort of insulinoma-MEN1 patients. DESIGN AND METHODS Consecutive insulinoma-MEN1 patients operated on for a nonmetastatic insulinoma between 1957 and 2010 were retrospectively selected from the MEN1 database of the French Endocrine Tumor Group. The type of surgery was categorized as distal pancreatectomy (DP), total pancreatectomy/cephalic duodenopancreatectomy (TP/CDP), or enucleation (E). Primary endpoint was time until recurrence of hypoglycemia after initial surgery. Secondary endpoints were post-operative complications. RESULTS The study included 73 patients (median age=28 years). Surgical procedures were DP (n=46), TP/CDP (n=9), or E (n=18). After a median post-operative follow-up of 9.0 years (inter-quartile range (IQR): 2.5-16.5 years), 60/73 patients (82.2%) remained hypoglycemia free. E and TP/CDP were associated with a higher risk of recurrent hypoglycemia episodes (unadjusted hazard ratio: 6.18 ((95% CI: 1.54-24.8); P=0.010) for E vs DP and 9.51 ((95% CI: 1.85-48.8); P=0.007) for TP/CDP vs DP. After adjustment for International Union against Cancer pTNM classification, enucleation remained significantly associated with a higher probability of recurrence. Long-term complications had occurred in 20 (43.5%) patients with DP, five (55.6%) with TP/CDP, but in none of the patients who have undergone E (P=0.002). CONCLUSION In the French Endocrine database, DP is associated with a lower risk for recurrent hypoglycemia episodes. Due to lower morbidity, E alone might be considered as an alternative.
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Affiliation(s)
- Delphine Vezzosi
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Catherine Cardot-Bauters
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Nicolas Bouscaren
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Maëlle Lebras
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Mireille Bertholon-Grégoire
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Patricia Niccoli
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Nathalie Levy-Bohbot
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Lionel Groussin
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Philippe Bouchard
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Antoine Tabarin
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Philippe Chanson
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Pierre Lecomte
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Isabelle Guilhem
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Nicolas Carrere
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Eric Mirallié
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - François Pattou
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Jean Louis Peix
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Diane Goere
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Françoise Borson-Chazot
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Philippe Caron
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Vanina Bongard
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Bruno Carnaille
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Pierre Goudet
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
| | - Eric Baudin
- Service d'EndocrinologieMaladies Métaboliques et Nutrition, Centre Hospitalier Universitaire Rangueil-Larrey, Université Paul Sabatier et INSERM U1037, Toulouse, FranceCHRU de LilleClinique Marc-Linquette, Service d'Endocrinologie-Métabolisme, Lille, FranceService d'EpidémiologieCentre Hospitalier Universitaire, Toulouse, FranceClinique d'EndocrinologieCentre Hospitalier Universitaire, Nantes, FranceService d'EndocrinologieCentre Hospitalier Est, Hospices Civils de Lyon, Université Lyon 1 et INSERM U1052, Lyon, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, Centre Hospitalier Universitaire La Timone, Marseille, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Reims, Hôpital Robert Debré, Reims, FranceService d'EndocrinologieCentre Hospitalier Universitaire de Cochin, Paris, FranceService d'EndocrinologieGroupement Hospitalier Universitaire Est, Hôpital Saint Antoine, Paris, FranceService d'EndocrinologieCentre Hospitalier Universitaire, Hôpital du Haut Levêque, Pessac, FranceService d'Endocrinologie et des Maladies de la ReproductionHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, FranceUnité ENDCHRU Bretonneau, Tours, FranceService d'EndocrinologieDiabète et Maladies Métaboliques, CHU de Rennes, Hôpital Sud, Rennes, FranceService de Chirurgie digestiveCHU Purpan, Toulouse, FranceClinique de Chirurgie Digestive et EndocrinienneCHU Nantes, Nantes, FranceService de Chirurgie Générale et EndocrinienneCHU Lille, Lille Cedex, FranceService de Chirurgie EndocrinienneHospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, FranceService de Chirurgie OncologiqueInstitut Gustave Roussy, Villejuif, FranceService de Chirurgie EndocrinienneCentre Hospitalier Universitaire de Dijon, Dijon, FranceService de Médecine Nucléaire et de Cancérologie EndocrineInstitut Gustave Roussy, Villejuif, France
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Halperin DM, Kulke MH, Yao JC. A tale of two tumors: treating pancreatic and extrapancreatic neuroendocrine tumors. Annu Rev Med 2014; 66:1-16. [PMID: 25341008 DOI: 10.1146/annurev-med-061813-012908] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Despite their perceived rarity, gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rising in incidence and prevalence. The biology, natural history, and therapeutic options for GEP-NETs are heterogeneous: NETs arising in the pancreas can be distinguished from those arising elsewhere in the gastrointestinal tract, and therapy is dichotomized between these two groups. Somatostatin analogues are the mainstay of oncologic management of bowel NETs; everolimus, streptozocin, and sunitinib are approved to treat pancreatic NETs. There are significant differences in molecular genetics between pancreatic and extrapancreatic NETs, and studies are evaluating whether additional NET patients may benefit from targeted agents. We discuss the distinguishing features of these two groups of tumors, as well as the therapeutic implications of the distinction. We also examine the evolving therapeutic landscape and discuss the likelihood that treatment will be developed independently for pancreatic and extrapancreatic gastrointestinal NETs, with novel therapeutics effective for newly identified pathologically or molecularly defined subgroups.
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Affiliation(s)
- Daniel M Halperin
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030; ,
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Partelli S, Maurizi A, Tamburrino D, Baldoni A, Polenta V, Crippa S, Falconi M. GEP-NETS update: a review on surgery of gastro-entero-pancreatic neuroendocrine tumors. Eur J Endocrinol 2014; 171:R153-62. [PMID: 24920289 DOI: 10.1530/eje-14-0173] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of neuroendocrine tumors (NETs) has increased in the last decades. Surgical treatment encompasses a panel of approaches ranging from conservative procedures to extended surgical resection. Tumor size and localization usually represent the main drivers in the choice of the most appropriate surgical resection. In the presence of small (<2 cm) and asymptomatic nonfunctioning NETs, a conservative treatment is usually recommended. For localized NETs measuring above 2 cm, surgical resection represents the cornerstone in the management of these tumors. As they are relatively biologically indolent, an extended resection is often justified also in the presence of advanced NETs. Surgical options for NET liver metastases range from limited resection up to liver transplantation. Surgical choices for metastatic NETs need to consider the extent of disease, the grade of tumor, and the presence of extra-abdominal disease. Any surgical procedures should always be balanced with the benefit of survival or relieving symptoms and patients' comorbidities.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Angela Maurizi
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Andrea Baldoni
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Vanessa Polenta
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Stefano Crippa
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
| | - Massimo Falconi
- Pancreatic Surgery UnitUniversità Politecnica delle Marche, Via Conca, 71, 60126 Ancona, ItalyDepartment of SurgeryUniversity of Verona, Verona, Italy
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Lee NE, Lee YJ, Yun SH, Lee JU, Park MS, Kim JK, Kim JW, Cho JW. A case of Zollinger-Ellison syndrome in multiple endocrine neoplasia type 1 with urolithiasis as the initial presentation. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 61:333-7. [PMID: 23877214 DOI: 10.4166/kjg.2013.61.6.333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Zollinger-Ellison syndrome (ZES) is characterized by gastrinoma and resultant hypergastrinemia, which leads to recurrent peptic ulcers. Because gastrinoma is the most common pancreatic endocrine tumor seen in multiple endocrine neoplasia type I (MEN 1), the possibility of gastrinoma should be investigated carefully when patients exhibit symptoms associated with hormonal changes. Ureteral stones associated with hyperparathyroidism in the early course of MEN 1 are known to be its most common clinical manifestation; appropriate evaluation and close follow-up of patients with hypercalcemic urolithiasis can lead to an early diagnosis of gastrinoma. We report a patient with ZES associated with MEN 1, and urolithiasis as the presenting entity. A 51-year-old man visited the emergency department with recurrent epigastric pain. He had a history of calcium urinary stone 3 years ago, and 2 years later he had 2 operations for multiple jejunal ulcer perforations; these surgeries were 9 months apart. He was taking intermittent courses of antiulcer medication. Multiple peripancreatic nodular masses, a hepatic metastasis, parathyroid hyperplasia, and a pituitary microadenoma were confirmed by multimodal imaging studies. We diagnosed ZES with MEN 1 and performed sequential surgical excision of the gastrinomas and the parathyroid adenoma. The patient received octreotide injection therapy and close follow-up.
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Affiliation(s)
- Na Eun Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
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Pieterman CRC, Conemans EB, Dreijerink KMA, de Laat JM, Timmers HTM, Vriens MR, Valk GD. Thoracic and duodenopancreatic neuroendocrine tumors in multiple endocrine neoplasia type 1: natural history and function of menin in tumorigenesis. Endocr Relat Cancer 2014; 21:R121-42. [PMID: 24389729 DOI: 10.1530/erc-13-0482] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mutations of the multiple endocrine neoplasia type 1 (MEN1) gene lead to loss of function of its protein product menin. In keeping with its tumor suppressor function in endocrine tissues, the majority of the MEN1-related neuroendocrine tumors (NETs) show loss of heterozygosity (LOH) on chromosome 11q13. In sporadic NETs, MEN1 mutations and LOH are also reported, indicating common pathways in tumor development. Prevalence of thymic NETs (thNETs) and pulmonary carcinoids in MEN1 patients is 2-8%. Pulmonary carcinoids may be underreported and research on natural history is limited, but disease-related mortality is low. thNETs have a high mortality rate. Duodenopancreatic NETs (dpNETs) are multiple, almost universally found at pathology, and associated with precursor lesions. Gastrinomas are usually located in the duodenal submucosa while other dpNETs are predominantly pancreatic. dpNETs are an important determinant of MEN1-related survival, with an estimated 10-year survival of 75%. Survival differs between subtypes and apart from tumor size there are no known prognostic factors. Natural history of nonfunctioning pancreatic NETs needs to be redefined because of increased detection of small tumors. MEN1-related gastrinomas seem to behave similar to their sporadic counterparts, while insulinomas seem to be more aggressive. Investigations into the molecular functions of menin have led to new insights into MEN1-related tumorigenesis. Menin is involved in gene transcription, both as an activator and repressor. It is part of chromatin-modifying protein complexes, indicating involvement of epigenetic pathways in MEN1-related NET development. Future basic and translational research aimed at NETs in large unbiased cohorts will clarify the role of menin in NET tumorigenesis and might lead to new therapeutic options.
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Affiliation(s)
- C R C Pieterman
- Division of Internal Medicine and Dermatology, Department of Internal Medicine, University Medical Center Utrecht, Internal post number L.00.408, PO Box 85500, 3508 GA Utrecht, The Netherlands Division of Biomedical Genetics, Department of Molecular Cancer Research Division of Surgical Specialties, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Thakker RV. Multiple endocrine neoplasia type 1 (MEN1) and type 4 (MEN4). Mol Cell Endocrinol 2014; 386:2-15. [PMID: 23933118 PMCID: PMC4082531 DOI: 10.1016/j.mce.2013.08.002] [Citation(s) in RCA: 224] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/31/2013] [Accepted: 07/31/2013] [Indexed: 01/03/2023]
Abstract
Multiple endocrine neoplasia (MEN) is characterized by the occurrence of tumors involving two or more endocrine glands within a single patient. Four major forms of MEN, which are autosomal dominant disorders, are recognized and referred to as: MEN type 1 (MEN1), due to menin mutations; MEN2 (previously MEN2A) due to mutations of a tyrosine kinase receptor encoded by the rearranged during transfection (RET) protoncogene; MEN3 (previously MEN2B) due to RET mutations; and MEN4 due to cyclin-dependent kinase inhibitor (CDNK1B) mutations. Each MEN type is associated with the occurrence of specific tumors. Thus, MEN1 is characterized by the occurrence of parathyroid, pancreatic islet and anterior pituitary tumors; MEN2 is characterized by the occurrence of medullary thyroid carcinoma (MTC) in association with phaeochromocytoma and parathyroid tumors; MEN3 is characterized by the occurrence of MTC and phaeochromocytoma in association with a marfanoid habitus, mucosal neuromas, medullated corneal fibers and intestinal autonomic ganglion dysfunction, leading to megacolon; and MEN4, which is also referred to as MENX, is characterized by the occurrence of parathyroid and anterior pituitary tumors in possible association with tumors of the adrenals, kidneys, and reproductive organs. This review will focus on the clinical and molecular details of the MEN1 and MEN4 syndromes. The gene causing MEN1 is located on chromosome 11q13, and encodes a 610 amino-acid protein, menin, which has functions in cell division, genome stability, and transcription regulation. Menin, which acts as scaffold protein, may increase or decrease gene expression by epigenetic regulation of gene expression via histone methylation. Thus, menin by forming a subunit of the mixed lineage leukemia (MLL) complexes that trimethylate histone H3 at lysine 4 (H3K4), facilitates activation of transcriptional activity in target genes such as cyclin-dependent kinase (CDK) inhibitors; and by interacting with the suppressor of variegation 3-9 homolog family protein (SUV39H1) to mediate H3K methylation, thereby silencing transcriptional activity of target genes. MEN1-associated tumors harbor germline and somatic mutations, consistent with Knudson's two-hit hypothesis. Genetic diagnosis to identify individuals with germline MEN1 mutations has facilitated appropriate targeting of clinical, biochemical and radiological screening for this high risk group of patients for whom earlier implementation of treatments can then be considered. MEN4 is caused by heterozygous mutations of CDNK1B which encodes the 196 amino-acid CDK1 p27Kip1, which is activated by H3K4 methylation.
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Affiliation(s)
- Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Headington, Oxford OX3 7LJ, United Kingdom.
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Tonelli F, Giudici F, Nesi G, Batignani G, Brandi ML. Biliary tree gastrinomas in multiple endocrine neoplasia type 1 syndrome. World J Gastroenterol 2013; 19:8312-8320. [PMID: 24363522 PMCID: PMC3857454 DOI: 10.3748/wjg.v19.i45.8312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/29/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe our patients affected with ectopic biliary tree gastrinoma and review the literature on this topic.
METHODS: Between January 1992 and June 2012, 28 patients affected by duodenopancreatic endocrine tumors in multiple endocrine neoplasia type 1 (MEN1) syndrome underwent surgery at our institution. This retrospective review article analyzes our experience regarding seventeen of these patients subjected to duodenopancreatic surgery for Zollinger-Ellison syndrome (ZES). Surgical treatment consisted of duodenopancreatectomy (DP) or total pancreatectomy (TP). Regional lymphadenectomy was always performed. Any hepatic tumoral lesions found were removed during surgery. In MEN1 patients, removal of duodenal lesions can sometimes lead to persistence or recurrence of hypergastrinemia. One possible explanation for this unfavorable outcome could be unrecognized ectopic localization of gastrin-secreting tumors. This study described three cases among the seventeen patients who were found to have an ectopic gastrinoma located in the biliary tree.
RESULTS: Seventeen MEN1 patients affected with ZES were analyzed. The mean age was 40 years. Fifteen patients underwent DP and two TP. On histopathological examination, duodeno pancreatic endocrine tumors were found in all 17 patients. Eighty-one gastrinomas were detected in the first three portions of the duodenum. Only one gastrinoma was found in the pancreas. The mean number of gastrinomas per patient was 5 (range 1-16). Malignancy was established in 12 patients (70.5%) after lymph node, liver and omental metastases were found. Three patients exhibited biliary tree gastrinomas as well as duodenal gastrinoma(s). In two cases, the ectopic gastrinoma was removed at the same time as pancreatic surgery, while in the third case, the biliary tree gastrinoma was resected one year after DP because of recurrence of ZES.
CONCLUSION: These findings suggest the importance of checking for the presence of ectopic gastrinomas in the biliary tree in MEN1 patients undergoing ZES surgery.
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Abstract
Zollinger-Ellison syndrome (ZES) is an endocrinopathy characterized by gastrin-secreting tumors, responsible for causing the formation of multiple, refractory, and recurrent peptic ulcers in the distal duodenum and proximal jejunum. Two main variants have been described, sporadic and those found in association with parathyroid and pituitary tumors, a genetic disorder known as multiple endocrine neoplasia-1 (MEN-1). Biochemical serum evaluation for elevated gastrin, followed by radiological or nuclear localization of the primary lesion, is mandated for establishing diagnosis. The mainstays of treatment include management of hypersecretory state with medical suppression of gastric acid production and surgical resection of primary tumor for the prevention of malignant transformation and metastatic complications. Medical therapy with proton pump inhibitors has virtually eliminated the need for acid-reducing surgical procedures. Surgical approach to sporadic and MEN-1-associated ZES varies based on our understanding of the natural history of the condition and the probability of cure; however, resection to a negative microscopic margin is indicated in both cases. Postoperative surveillance involves measurement of gastrin level, followed by imaging if elevation is detected. Re-excision of recurrent or resection of metastatic disease is a subject of controversy; however, at the present time aggressive cytoreductive approach is favored.
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Affiliation(s)
- Irene Epelboym
- Department of Surgery, Columbia University Medical Center, New York, New York, USA; Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
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Ito T, Igarashi H, Uehara H, Berna MJ, Jensen RT. Causes of death and prognostic factors in multiple endocrine neoplasia type 1: a prospective study: comparison of 106 MEN1/Zollinger-Ellison syndrome patients with 1613 literature MEN1 patients with or without pancreatic endocrine tumors. Medicine (Baltimore) 2013; 92:135-181. [PMID: 23645327 PMCID: PMC3727638 DOI: 10.1097/md.0b013e3182954af1] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is classically characterized by the development of functional or nonfunctional hyperplasia or tumors in endocrine tissues (parathyroid, pancreas, pituitary, adrenal). Because effective treatments have been developed for the hormone excess state, which was a major cause of death in these patients in the past, coupled with the recognition that nonendocrine tumors increasingly develop late in the disease course, the natural history of the disease has changed. An understanding of the current causes of death is important to tailor treatment for these patients and to help identify prognostic factors; however, it is generally lacking.To add to our understanding, we conducted a detailed analysis of the causes of death and prognostic factors from a prospective long-term National Institutes of Health (NIH) study of 106 MEN1 patients with pancreatic endocrine tumors with Zollinger-Ellison syndrome (MEN1/ZES patients) and compared our results to those from the pooled literature data of 227 patients with MEN1 with pancreatic endocrine tumors (MEN1/PET patients) reported in case reports or small series, and to 1386 patients reported in large MEN1 literature series. In the NIH series over a mean follow-up of 24.5 years, 24 (23%) patients died (14 MEN1-related and 10 non-MEN1-related deaths). Comparing the causes of death with the results from the 227 patients in the pooled literature series, we found that no patients died of acute complications due to acid hypersecretion, and 8%-14% died of other hormone excess causes, which is similar to the results in 10 large MEN1 literature series published since 1995. In the 2 series (the NIH and pooled literature series), two-thirds of patients died from an MEN1-related cause and one-third from a non-MEN1-related cause, which agrees with the mean values reported in 10 large MEN1 series in the literature, although in the literature the causes of death varied widely. In the NIH and pooled literature series, the main causes of MEN1-related deaths were due to the malignant nature of the PETs, followed by the malignant nature of thymic carcinoid tumors. These results differ from the results of a number of the literature series, especially those reported before the 1990s. The causes of non-MEN1-related death for the 2 series, in decreasing frequency, were cardiovascular disease, other nonendocrine tumors > lung diseases, cerebrovascular diseases. The most frequent non-MEN1-related tumor deaths were colorectal, renal > lung > breast, oropharyngeal. Although both overall and disease-related survival are better than in the past (30-yr survival of NIH series: 82% overall, 88% disease-related), the mean age at death was 55 years, which is younger than expected for the general population.Detailed analysis of causes of death correlated with clinical, laboratory, and tumor characteristics of patients in the 2 series allowed identification of a number of prognostic factors. Poor prognostic factors included higher fasting gastrin levels, presence of other functional hormonal syndromes, need for >3 parathyroidectomies, presence of liver metastases or distant metastases, aggressive PET growth, large PETs, or the development of new lesions.The results of this study have helped define the causes of death of MEN1 patients at present, and have enabled us to identify a number of prognostic factors that should be helpful in tailoring treatment for these patients for both short- and long-term management, as well as in directing research efforts to better define the natural history of the disease and the most important factors determining long-term survival at present.
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Affiliation(s)
- Tetsuhide Ito
- From the Department of Medicine and Bioregulatory Science (TI, HI), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Digestive Diseases Branch (TI, HI, HU, MJB, RTJ), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; and Hôpital Kirchberg (MJB), Luxembourg, Luxembourg
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Partial pancreaticoduodenectomy can provide cure for duodenal gastrinoma associated with multiple endocrine neoplasia type 1. Ann Surg 2013; 257:308-14. [PMID: 22580937 DOI: 10.1097/sla.0b013e3182536339] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the outcome of pancreaticoduodenectomy (PD) versus non-PD resections for the treatment of gastrinoma in multiple endocrine neoplasia type 1. BACKGROUND Gastrinoma in MEN1 is considered a rarely curable disease and its management is highly controversial both for timing and extent of surgery. METHODS Clinical characteristics, complications and outcomes of 27 prospectively collected MEN1 patients with biochemically proven gastrinoma, who underwent surgery, were analyzed with special regard to the gastrinoma type and the initial operative procedure. RESULTS Twenty-two (81%) patients with gastrinoma in MEN1 had duodenal gastrinomas and 5 patients (19%) had pancreatic gastrinomas. At the time of diagnosis, 21 (77%) gastrinomas were malignant (18 duodenal, 3 pancreatic), but distant metastases were only present in 4 (15%) patients. Patients with pancreatic gastrinomas underwent either distal pancreatic resections or gastrinoma enucleation with lymphadenectomy, 2 patients also had synchronous resections of liver metastases. One of these patients was biochemically cured after a median of 136 (77-312) months. Thirteen patients with duodenal gastrinomas underwent PD resections (group 1, partial PD [n = 11], total PD [n = 2]), whereas 9 patients had no-PD resections (group 2) as initial operative procedure. Perioperative morbidity and mortality, including postoperative diabetes, differed not significantly between groups (P > 0.5). All patients of group 1 and 5 of 9 (55%) patients of group 2 had a negative secretin test at hospital discharge. However, after a median follow-up of 136 (3-276) months, 12 (92%) patients of group 1 were still normogastrinemic compared to only 3 of 9 (33%) patients of group 2 (P = 0.023). Three (33%) patients of group 2 had to undergo up to 3 reoperations for recurrent or metastatic disease compared to none of group 1. CONCLUSIONS Duodenal gastrinoma in MEN1 should be considered a surgically curable disease. PD seems to be the adequate approach to this disease, providing a high cure rate and acceptable morbidity compared to non-PD resections.
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Abstract
We report 2 cases of familial multiple endocrine neoplasia type 1 syndrome (MEN 1) in related Malaysian Chinese individuals: the son had simultaneous primary lesions in the pancreatic tail, parathyroid, adrenal gland, and hypophysis, with metastatic tumors in the left lung, mediastinum and spine; his mother had simultaneous primary lesions in the pancreatic head, parathyroid, and hypophysis, with metastatic tumors in the liver, spine, ilium, chest wall, and rib. Genetic testing of the 2 patients showed the same mutation in exon 9 of MEN1 (c.1288G>T, Glu430, encoding a stop codon). The tumors with the poorest prognosis and clinical sequelae were in the pancreas of both patients, and these were treated by percutaneous cryoablation. The number of hypoglycemic episodes in the son improved for more than 120 days, and the abdominal space occupying lesion resolved in his mother.
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Bartsch DK, Albers M, Knoop R, Kann PH, Fendrich V, Waldmann J. Enucleation and limited pancreatic resection provide long-term cure for insulinoma in multiple endocrine neoplasia type 1. Neuroendocrinology 2013; 98:290-8. [PMID: 24356648 DOI: 10.1159/000357779] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/06/2013] [Indexed: 12/25/2022]
Abstract
AIM To assess the characteristics and long-term outcome after surgery in patients with multiple endocrine neoplasia type 1 (MEN1)-associated insulinoma. METHODS Retrospective analysis of prospectively collected data of MEN1 patients with organic hyperinsulinism at a tertiary referral center. RESULTS Thirteen (17%) of 74 patients with MEN1 had organic hyperinsulinism. The median age at diagnosis was 27 (range 9-48) years. In 7 patients insulinoma was the first manifestation of the syndrome. All patients had at least one pancreatic neuroendocrine neoplasm (pNEN) upon imaging, including CT, MRI or endoscopic ultrasonography. Seven patients had solitary lesions upon imaging, 4 patients had one dominant tumor with coexisting multiple small pNENs, and 2 patients had multiple lesions without dominance. Eight patients had limited resections (1 segmental resection, 7 enucleations), 4 subtotal distal pancreatectomies, and 1 patient a partial duodenopancreatectomy. There was no postoperative mortality. Six patients experienced complications, including pancreatic fistula in 5 patients. Pathological examination revealed median three (range 1-14) macro-pNENs sized between 6 and 40 mm, and a total of 14 potentially benign insulinomas were detected in the 13 patients. After median follow-up of 156 months, only 1 patient developed recurrent hyperinsulinism after initial enucleation. Twelve patients developed new pNENs in the pancreatic remnant and 4 patients underwent reoperations (3 for metastatic ZES, 1 for recurrent hyperinsulinism). One of 5 patients with an initial extended pancreatic resection developed insulin-dependent diabetes mellitus. CONCLUSION Enucleation and limited resection provide long-term cure for MEN1 insulinoma in patients with solitary or dominant tumors. Subtotal distal pancreatectomy should thus be preserved for patients with multiple pNENs without dominance given the risk of exocrine and endocrine pancreas insufficiency in the mostly young patients.
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Affiliation(s)
- Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
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Singh MH, Fraker DL, Metz DC. Importance of surveillance for multiple endocrine neoplasia-1 and surgery in patients with sporadic Zollinger-Ellison syndrome. Clin Gastroenterol Hepatol 2012; 10:1262-9. [PMID: 22902777 DOI: 10.1016/j.cgh.2012.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 07/09/2012] [Accepted: 08/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Zollinger-Ellison syndrome (ZES) is a rare disorder characterized by gastrin-secreting tumors of the gastrointestinal tract and gastric acid hypersecretion. There is controversy over the best way to manage these patients; we investigated outcomes of patients with different forms of the disease, who did and did not undergo surgery. METHODS We performed a retrospective chart review of patients with ZES associated with multiple endocrine neoplasia type 1 (MEN-1) (n = 16) and those with sporadic ZES (n = 33) seen at a tertiary care center from August 1994 to January 2012. Cox proportional hazards modeling was used to compare survival times among groups, based on treatment with surgery (n = 34) and the presence of MEN-1 (n = 9 with surgery; n = 7 without surgery). Differences were compared using the unpaired Student t test and the Fisher exact test. RESULTS Patients with MEN-1 syndrome-associated ZES presented at a younger age than patients with sporadic ZES (34.9 vs 45.7 y, respectively; P < .05) and were diagnosed at a younger age (39.3 vs 49.7 y, respectively; P < .01), yet lived a similar number of years (55.9 vs 55.1 y, respectively; P = .91). None of the patients with MEN-1-associated ZES died of progressive disease, compared with 86% of deaths among patients with sporadic ZES (P < .05). Lymph node involvement, detected during surgery, increased the risk of metastasis to liver (P = .13) and lack of cure by surgery (P = .01). Surgery reduced all-cause mortality (hazard ratio, 0.11; 95% confidence interval, 0.2-0.6; P = .011) and disease-related mortality (hazard ratio, 0.14; 95% confidence interval, 0.2-0.84; P = .032) of patients with sporadic, but not MEN-1 syndrome-associated, ZES. CONCLUSIONS The presence of MEN-1 is associated with earlier onset and diagnosis of ZES, but a benign clinical course that rarely results in disease-related death; surgery therefore can be deferred for these patients. However, 86% of deaths among patients with sporadic ZES are attributed to disease-related causes, and mortality is reduced by early surgical intervention. Patients with sporadic ZES should undergo surgery soon after diagnosis.
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Affiliation(s)
- Maneesh H Singh
- Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Frilling A, Akerström G, Falconi M, Pavel M, Ramos J, Kidd M, Modlin IM. Neuroendocrine tumor disease: an evolving landscape. Endocr Relat Cancer 2012; 19:R163-85. [PMID: 22645227 DOI: 10.1530/erc-12-0024] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) represent a heterogenous group of tumors arising from a variety of neuroendocrine cell types. The incidence and prevalence of GEP-NENs have markedly increased over the last three decades. Symptoms are often absent in early disease, or vague and nonspecific even in advanced disease. Delayed diagnosis is thus common. Chromogranin A is the most commonly used biomarker but has limitations as does the proliferative marker Ki-67%, which is often used for tumor grading and determination of therapy. The development of a multidimensional prognostic nomogram may be valuable in predicting tumor behavior and guiding therapy but requires validation. Identification of NENs that express somatostatin receptors (SSTR) allows for SSTR scintigraphy and positron emission tomography imaging using novel radiolabeled compounds. Complete surgical resection of limited disease or endoscopic ablation of small lesions localized in stomach or rectum can provide cure; however, the majority of GEP-NENs are metastatic (most frequently the liver and/or mesenteric lymph nodes) at diagnosis. Selected patients with metastatic disease may benefit from advanced surgical techniques including hepatic resection or liver transplantation. Somatostatin analogs are effective for symptomatic treatment and exhibit some degree of antiproliferative activity in small intestinal NENs. There is a place for streptozotocin, temozolomide, and capecitabine in the management of pancreatic NENs, while new agents targeting either mTOR (everolimus) or angiogenic (sunitinib) pathways have shown efficacy in these lesions.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, London, UK
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