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Yan Z, Zhu C, Wu X, Zhu H, Yuan T, Luo Y, Feng Y, Wang Q, Zhang S, Xue H, Zheng Z, Yang A. A single-center experience on endoscopic ultrasonography-guided ethanol ablation of insulinomas. Pancreatology 2023; 23:98-104. [PMID: 36577553 DOI: 10.1016/j.pan.2022.12.007] [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: 06/21/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES As the most frequent functional pancreatic neuroendocrine tumor, insulinomas may cause a plethora of symptoms and severe impairment in the living of patients by endogenous hyperinsulinemia and subsequent hypoglycemia. Surgery has been regarded as the first choice although a high risk of complications. Ethanol ablation is a promising non-surgical option that could achieve tumor shrinking in a short-term period. But the impact of symptom control and the long-term efficacy lack sufficient and good-quality evidence. METHODS A total number of 14 endoscopic ultrasonography-guided ethanol ablations were performed in 9 patients between September 2016 and September 2018 in Peking Union Medical College Hospital. The data were collected and prospectively analyzed. RESULTS The follow-up duration ranged from 21 to 1567 days in 9 patients, with a median of 994 days. 4 patients were free from relapse during a median follow-up of 1108 days (range: 994-1567 days). In 5 patients who suffered relapses, the median duration with symptom relief after the first ablation was 128 days (range: 13-393 days). If only repeated ablation was taken into consideration, the median duration with symptom relief was 26 days (range: 1-516 days). No complications happened during the procedures. The severe complication rate after the first ablation was 0.0% (0/9), compared to 7.14% (1/14) if each procedure was counted separately. The only severe complication documented was acute pancreatitis which was completely relieved after symptomatic treatment. CONCLUSIONS For patients who are not suitable for surgical resections, endoscopic ultrasonography-guided ethanol ablation of insulinomas could be an effective and safe alternative to relieve symptoms of hypoglycemia.
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Affiliation(s)
- Zhiyu Yan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China; Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, China
| | - Cheng Zhu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xi Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Tao Yuan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yaping Luo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yunlu Feng
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qiang Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shengyu Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Zehui Zheng
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
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El Sayed G, Frim L, Franklin J, McCrudden R, Gordon C, Al-Shamma S, Kiss S, Hegyi P, Erőss B, Hegyi PJ. Endoscopic ultrasound-guided ethanol and radiofrequency ablation of pancreatic insulinomas: a systematic literature review. Therap Adv Gastroenterol 2021; 14:17562848211042171. [PMID: 34819995 PMCID: PMC8606734 DOI: 10.1177/17562848211042171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/15/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Insulinoma is the most common neuroendocrine neoplasm of the pancreas, characterised by hypoglycaemic symptoms. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and ethanol ablation (EUS-EA) are novel methods for treating insulinoma.We aimed to perform a systematic review to assess the efficacy and safety of EUS-guided ablation techniques for pancreatic insulinomas. METHODS We systematically searched for articles detailing EUS-guided ablations of insulinomas. We performed a qualitative analysis and summarised data on the efficacy and safety of EUS-RFA and EUS-EA techniques. RESULTS In total, we identified 35 case reports and case series describing 75 patients with insulinomas treatment with EUS-guided ablation. Twenty-seven patients were treated with EUS-RFA, 47 patients with EUS-EA, and 1 patient received EUS-EA and EUS-RFA in the same session. In total, 84 insulinomas were ablated (EUS-RFA: 31, EUS-EA: 53). Most insulinomas were in the head of the pancreas (40%). The clinical success rate for EUS-guided ablation techniques was 98.5%. The median glucose level was 1.95 (Q1-Q3: 1.69-2.13) mmol/L before ablation compared to 6.20 (Q1-Q3: 5.30-7.05) mmol/L after treatment. The median insulin and C-peptide levels before and after RFA/EA were 230 (Q1-Q2: 120-257) pmol/L and 41 (Q1-Q2 35-42) pmol/L; 2077 (Q1-Q2 1644-2459) pmol/L and 819 (Q1-Q2 696-1072) pmol/L, respectively. There were eleven adverse events: seven abdominal pain, two mild acute pancreatitis, one necrotising acute pancreatitis and one local hematoma. All patients recovered, and there were no periprocedural deaths. CONCLUSIONS EUS-guided ablation of insulinoma seems to be a safe and effective treatment and is an alternative to surgical resection in selected cases.
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Affiliation(s)
- Ghassan El Sayed
- The Royal Bournemouth Hospital, University Hospital Dorset, Bournemouth, UK
| | - Levente Frim
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Jamie Franklin
- The Royal Bournemouth Hospital, University Hospital Dorset, Institute of Medical Imaging and Visualisation, Bournemouth, UKLevente Frim
| | - Raymond McCrudden
- The Royal Bournemouth Hospital, University Hospital Dorset, Bournemouth, UK
| | - Charles Gordon
- The Royal Bournemouth Hospital, University Hospital Dorset, Bournemouth, UK
| | - Safa Al-Shamma
- The Royal Bournemouth Hospital, University Hospital Dorset, Bournemouth, UK
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary,Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary,Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary,Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
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Abstract
Ablative therapies for locoregional treatment of pancreatic neoplastic lesions developed over the last decade to be applied during surgery are now becoming also available to be utilized under endoscopic ultrasound (EUS) guidance. The advantage of this approach is clear because of the close proximity of the EUS transducer to the target lesion, coupled with developments of specifically designed ablation devices, making the procedure minimally invasive, and potentially sparing patients from the morbidity of this method when performed surgically. EUS-guided ablative techniques that have been applied to pancreatic neoplastic cysts, pancreatic functional and non-functional neuroendocrine neoplasms and pancreatic ductal adenocarcinoma include ethanol injection, radiofrequency ablation (RFA), a combination of bipolar RFA and cryoablation, laser therapy (LT) and photodynamic therapy (PDT). Up to now, most of these procedures have been applied to patients at high surgical risk or who refused surgery. However, more studies evaluating some of these treatments also in selected patients not at surgical risk are becoming available. These studies will pave the road to apply this therapeutic approach to a more extensive number of patients, alone or in association with other therapies, such as immunomodulating drugs. The present manuscript will critically review the available evidence in the field of EUS-guided local ablative treatment of solid and cystic pancreatic neoplasms.
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Affiliation(s)
- Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania.,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy - .,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Larghi A, Rimbaș M, Rizzatti G, Carbone C, Gasbarrini A, Costamagna G, Alfieri S, Tortora G. Endoscopic ultrasound-guided therapies for pancreatic solid tumors: An overview. Semin Oncol 2021; 48:95-105. [PMID: 33608132 DOI: 10.1053/j.seminoncol.2021.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
The close proximity of the endoscopic ultrasound (EUS) probe to the pancreas, coupled with the ease with which a needle can be inserted into a pancreatic lesion, have contributed to the development of EUS-guided therapies for both adenocarcinoma and neuroendocrine pancreatic neoplasms. EUS-guided fine needle injection of different types of drugs, implantation of fiducial markers to facilitate stereotactic body radiation therapy or of radioactive seeds to perform brachytherapy, and the use of different thermal and nonthermal ablation devices and techniques have all been tested in preliminary human studies. This manuscript will present the available evidence accumulated thus far in the field of EUS-guided oncological treatment of pancreatic solid tumors, along with a look into possible future applications.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Carmine Carbone
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy; IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Giampaolo Tortora
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
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5
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Niederle B, Selberherr A, Bartsch DK, Brandi ML, Doherty GM, Falconi M, Goudet P, Halfdanarson TR, Ito T, Jensen RT, Larghi A, Lee L, Öberg K, Pavel M, Perren A, Sadowski SM, Tonelli F, Triponez F, Valk GD, O'Toole D, Scott-Coombes D, Thakker RV, Thompson GB, Treglia G, Wiedenmann B. Multiple Endocrine Neoplasia Type 1 and the Pancreas: Diagnosis and Treatment of Functioning and Non-Functioning Pancreatic and Duodenal Neuroendocrine Neoplasia within the MEN1 Syndrome - An International Consensus Statement. Neuroendocrinology 2021; 111:609-630. [PMID: 32971521 DOI: 10.1159/000511791] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
The better understanding of the biological behavior of multiple endocrine neoplasia type 1 (MEN1) organ manifestations and the increase in clinical experience warrant a revision of previously published guidelines. Duodenopancreatic neuroendocrine neoplasias (DP-NENs) are still the second most common manifestation in MEN1 and, besides NENs of the thymus, remain a leading cause of death. DP-NENs are thus of main interest in the effort to reevaluate recommendations for their diagnosis and treatment. Especially over the last 2 years, more clinical experience has documented the follow-up of treated and untreated (natural-course) DP-NENs. It was the aim of the international consortium of experts in endocrinology, genetics, radiology, surgery, gastroenterology, and oncology to systematically review the literature and to present a consensus statement based on the highest levels of evidence. Reviewing the literature published over the past decade, the focus was on the diagnosis of F- and NF-DP-NENs within the MEN1 syndrome in an effort to further standardize and improve treatment and follow-up, as well as to establish a "logbook" for the diagnosis and treatment of DP-NENs. This shall help further reduce complications and improve long-term treatment results in these rare tumors. The following international consensus statement builds upon the previously published guidelines of 2001 and 2012 and attempts to supplement the recommendations issued by various national and international societies.
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Affiliation(s)
- Bruno Niederle
- Department of Surgery, Medical University of Vienna, Vienna, Austria,
| | | | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Maria L Brandi
- Firmo Lab, Fondazione F.I.R.M.O. and University Florence, Florence, Italy
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Pierre Goudet
- Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Universitaire François Mitterand, Dijon, France
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital and Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Sawara-ku, Fukuoka, Japan
| | - Robert T Jensen
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS and Center for Endoscopic Research, Therapeutics and Training, Catholic University, Rome, Italy
| | - Lingaku Lee
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kjell Öberg
- Endocrine Oncology, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Marianne Pavel
- Endocrinology and Diabetology, Department of Medicine 1, University Clinic of Erlangen, Erlangen, Germany
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dermot O'Toole
- Department of Clinical Medicine, St. James's Hospital and St Vincent's University Hospital and Trinity College, Dublin, Ireland
| | - David Scott-Coombes
- Department of Endocrine Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Geoffrey B Thompson
- Section of Endocrine Surgery, Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giorgio Treglia
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Bertram Wiedenmann
- Department of Gastroenterology and Hepatology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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6
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Rimbaş M, Horumbă M, Rizzatti G, Crinò SF, Gasbarrini A, Costamagna G, Larghi A. Interventional endoscopic ultrasound for pancreatic neuroendocrine neoplasms. Dig Endosc 2020; 32:1031-1041. [PMID: 31995848 DOI: 10.1111/den.13635] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/25/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023]
Abstract
The proximity of the endoscopic ultrasound (EUS) transducer to the pancreas and the possibility to place needles or other accessories into a target located adjacent to the wall of the GI tract have encouraged researchers to develop various EUS-guided local treatments directed towards pancreatic neuroendocrine neoplasms (PanNENs). The use of pre-operative EUS-guided tattooing or fiducial marker placement to facilitate intraoperative tumor localization has proven effective in reducing operative time of laparoscopic surgeries. To reduce the mortality and morbidity rates of surgical resection, which is presently the mainstay treatment of PanNENs. EUS-guided loco-regional treatments, such as injection of alcohol and radiofrequency ablation have been proposed and results are hitherto promising. The present paper summarizes currently available data in the field of EUS-guided interventions to pancreatic neuroendocrine tumors, as well as possible future applications.
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Affiliation(s)
- Mihai Rimbaş
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Mihaela Horumbă
- Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Guido Costamagna
- and, Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy.,IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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7
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Yao C, Wang X, Zhang Y, Kong J, Gao J, Ke S, Ding X, Xin Z, Xu W, Wang S, Sun W. Treatment of Insulinomas by Laparoscopic Radiofrequency Ablation: Case Reports and Literature Review. Open Med (Wars) 2020; 15:84-91. [PMID: 32104725 PMCID: PMC7029651 DOI: 10.1515/med-2020-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022] Open
Abstract
Despite its rarity, insulinoma is the most common type of pancreatic endocrine neoplasm, with an occurrence of 1 to 5 per million per year in the population. Surgical resection or enucleation is the first line of curative treatment choice for insulinoma. Eight patients with symptomatic insulinomas treated by radiofrequency ablation have been described since 2009. In the past two years, we treated two patients with symptomatic insulinomas (one in the pancreatic tail and the other in the pancreatic neck) successfully using laparoscopic radiofrequency ablation. Both patients achieved complete elimination without any significant complications. Our study suggests laparoscopic radiofrequency ablation could be developed as a safe and effective alternative treatment to surgery for the patients with insulinomas who refuse or are not eligible for surgery.
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Affiliation(s)
- Changyu Yao
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Xiangtao Wang
- Department of General Surgery, Zhanhua People's Hospital, Shandong Province, China
| | - Yongli Zhang
- Department of General Surgery, Zhanhua People's Hospital, Shandong Province, China
| | - Jian Kong
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Jun Gao
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Shan Ke
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Xuemei Ding
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Zonghai Xin
- Department of General Surgery, Zhanhua People's Hospital, Shandong Province, China
| | - Wenlei Xu
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Shaohong Wang
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
| | - Wenbing Sun
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University, No. 5, Jingyuan Street, Beijing 100043, China
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Egorov AV, Vasilyev IA, Musayev GH, Mironova AV. The role of microwave ablation in management of functioning pancreatic neuroendocrine tumors. Gland Surg 2019; 8:766-772. [PMID: 32042685 DOI: 10.21037/gs.2019.12.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Surgical resection is considered to be the only potentially curative option for patients with pancreatic neuroendocrine tumors (pNETs). High risk rates of perioperative complications make minimally invasive ablative techniques a novel perspective and alternative treatment option for pancreatic neuroendocrine tumors. This study aims to present the first experience of using a microwave ablation in management of pNETs. Methods Sechenov University has an experience of treating more than 400 patients with hormone-producing tumors of the pancreas, 7 of which were treated by microwave ablation (MWA). Results In all patients that underwent MWA, a regression of hormonal symptomatic was achieved. Two patients required readmission a month later for draining of pseudocyst and abscess. Conclusions The exact role of microwave ablation in the treatment of non-metastatic pancreatic neuroendocrine tumors has not been defined yet. There is a lack of large prospective randomized studies and the reason for this is that local tumor destruction is indicated in selected cases only, thus making it difficult to analyze a large group of patients and assess long-term results of the treatment. However, microwave ablation allows to take a better control of symptoms in patients with hormone overproduction and in those with high risk of postoperative complications.
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Affiliation(s)
- Alexey Victorovich Egorov
- Abdominal Surgery Department, University Clinical Hospital Nº1 of Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Ivan Alekseevich Vasilyev
- Abdominal Surgery Department, University Clinical Hospital Nº1 of Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Gaziyav Hadisovich Musayev
- General Surgery, University Clinical Hospital Nº1 of Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Anna Victorovna Mironova
- Faculty Surgery, University Clinical Hospital Nº1 of Sechenov First Moscow State Medical University, Moscow, Russian Federation
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9
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Dugarova RS, Berelavichus SV, Kaldarov AR, Gorin DS. [Physical minimally invasive treatment of pancreatic insulinoma]. Khirurgiia (Mosk) 2018:94-97. [PMID: 29697692 DOI: 10.17116/hirurgia2018494-97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R S Dugarova
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - S V Berelavichus
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A R Kaldarov
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - D S Gorin
- Vishnevsky Institute of Surgery of Healthcare Ministry of the Russian Federation, Moscow, Russia
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10
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Mele C, Brunani A, Damascelli B, Tichà V, Castello L, Aimaretti G, Scacchi M, Marzullo P. Non-surgical ablative therapies for inoperable benign insulinoma. J Endocrinol Invest 2018; 41:153-162. [PMID: 28755102 DOI: 10.1007/s40618-017-0738-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 07/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Benign insulinoma is the most common functioning neuroendocrine tumor of the pancreas. The gold-standard therapeutic approach for insulinoma is surgery, which allows for tumor removal, histology and immunochemical analyses. If surgery is not feasible, minimally invasive ablative procedures performed by interventional radiology can lead to partial or complete remission of hormone hypersecretion and tumor control in insulinoma patients. METHODS We performed a review of existing literature on non-chemotherapeutic/radioactive ablative techniques employed for the treatment of benign, otherwise inoperable, pancreatic insulinoma. For this purpose, feasibility, effectiveness and safety of ablative treatments for pancreatic insulinoma were reviewed from literature data published from 1982 to date. RESULTS A total of 44 insulinoma cases treated with non-surgical ablative techniques were desumed, and divided as follows: 7 cases of tumor embolization, 26 ethanol ablations, 7 radiofrequency ablations, 2 high intensity focused ultrasound ablation, 1 irreversible electroporation and 1 percutaneous microwave ablation. Most cases involved single insulinoma, predominantly located in the pancreas head and body. In the majority of patients, ablation was chosen instead of surgery due to severe comorbidities. After an average follow-up of 16 months, the overall success rate of non-surgical ablative treatments of insulinoma was 84%, the recurrence/persistence rate was 16%, and transient adverse events were noted in 23% of cases. Adverse events were usually self-limiting and medically manageable. CONCLUSIONS Non-surgical ablation is a feasible, safe and repeatable procedure in patients with pancreatic insulinoma, who are not candidate to surgery or refuse it. Partial or complete control of symptoms and tumor growth is experienced by the majority of patients.
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Affiliation(s)
- C Mele
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - A Brunani
- Division of Rehabilitation Medicine, Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - B Damascelli
- Department of Interventional Radiology, EMO GVM Centro Cuore Columbus, Via Buonarroti 48, 20145, Milan, Italy
| | - V Tichà
- Radiology and Interventional Radiology Unit, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Via Pio II 3, 20153, Milan, Italy
| | - L Castello
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - G Aimaretti
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - M Scacchi
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy
| | - P Marzullo
- Division of General Medicine, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Via Cadorna 90, 28824, Piancavallo, VB, Italy.
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy.
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11
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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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12
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Ito T, Lee L, Jensen RT. Treatment of symptomatic neuroendocrine tumor syndromes: recent advances and controversies. Expert Opin Pharmacother 2016; 17:2191-2205. [PMID: 27635672 DOI: 10.1080/14656566.2016.1236916] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Neuroendocrine tumors(NETs), once thought rare, are increasing in frequency in most countries and receiving increasing-attention. NETs present two-treatment problems. A proportion is aggressive and a proportion has a functional, hormone-excess-state(F-NET), each of which must be treated. Recently, there have been many advances, well-covered in reviews/consensus papers on imaging-NETs; new, novel anti-tumor treatments and understanding their pathogenesis. However, little attention has been paid to advances in the treatment of the hormone-excess-state. These advances are usually reported in case-series, and case-reports with few large studies. In this paper these advances are reviewed. Areas covered: Advances in the last 5-years are concentrated on, but a review of literature from the last 10-years was performed. PubMed and other databases (Cochrane, etc.) were searched for F-NET-syndromes including carcinoid-syndrome, as well as meeting-abstracts on NETs. All advances that controlled hormone-excess-states or facilitated-control were covered. These include new medical-therapies [serotonin-synthesis inhibitors(telotristat), Pasireotide, new agents for treating ACTHomas], increased dosing with conventional therapies (octreotide-LAR, Lanreotide-Autogel), mTor inhibitors(everolimus), Tyrosine-kinase inhibitors(sunitinib),cytoreductive surgery, liver-directed therapies (embolization, chemoembolization, radioembolization, RFA), peptide radio-receptor-therapy(PRRT) and 131I-MIBG, ablation of primary F-NETs. Expert opinion: Although many of the newer therapies controlling the hormone-excess-states in F-NETs are reported in relatively few patients, all the approaches show promise. Their description also generates some controversies/unresolved areas,such as the order of these new treatments, their longterm-efficacy, and effectiveness of combinations which may require large,controlled studies.
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Affiliation(s)
- Tetsuhide Ito
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Lingaku Lee
- a Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences , Kyushu University , Fukuoka , Japan
| | - Robert T Jensen
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
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13
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Trikudanathan G, Mallery SJ, Amateau SK. Successful Endoscopic Ultrasound-Guided Alcohol Ablation of Sporadic Insulinoma Using Three-Dimensional Targeting (with Video). Clin Endosc 2016; 49:399-401. [PMID: 27000426 PMCID: PMC4977744 DOI: 10.5946/ce.2015.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/27/2016] [Indexed: 12/15/2022] Open
Abstract
Surgical resection is considered the standard of care in the management of symptomatic insulinoma. In this video, we describe the successful management of a symptomatic insulinoma by using linear array endoscopic ultrasound (EUS)-guided ethanol ablation in a poor surgical candidate. EUS-guided ethanol ablation of insulinoma offers a safer, effective, and less invasive alternative to surgery.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Shawn J Mallery
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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14
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Al-Hawary MM, Francis IR, Anderson MA. Pancreatic Solid and Cystic Neoplasms: Diagnostic Evaluation and Intervention. Radiol Clin North Am 2015; 53:1037-48. [PMID: 26321452 DOI: 10.1016/j.rcl.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
High-resolution imaging modalities, such as multi-detector computed tomography, MR imaging, and endoscopic ultrasound, are frequently used alone or in combination to characterize focal solid and cystic pancreatic neoplasms. Imaging in solid pancreatic neoplasms, typically adenocarcinoma and neuroendocrine tumors, is primarily used to detect and stage the extent of the tumor and to determine if complete surgical resection for cure is feasible. In cystic pancreatic masses, imaging aims to differentiate benign nonmucinous cystic lesions from potentially or frankly malignant mucin-producing cysts. Several noninvasive and invasive treatment options can be performed if surgical resection is not possible or contraindicated.
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Affiliation(s)
- Mahmoud M Al-Hawary
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Hospitals, 1500 East Medical Center Drive, Room B1 D502, Ann Arbor, MI 48109, USA.
| | - Isaac R Francis
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Hospitals, 1500 East Medical Center Drive, Room B1 D540, Ann Arbor, MI 48109, USA
| | - Michelle A Anderson
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospitals, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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15
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Morales-Oyarvide V, Yoon WJ, Ingkakul T, Forcione DG, Casey BW, Brugge WR, Fernández-del Castillo C, Pitman MB. Cystic pancreatic neuroendocrine tumors: the value of cytology in preoperative diagnosis. Cancer Cytopathol 2014; 122:435-44. [PMID: 24591417 DOI: 10.1002/cncy.21403] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/13/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine-needle aspiration (FNA). METHODS Cytopathology records between 1992 and 2013 were searched for all reports of cysts interpreted as PanNET. Patient demographics, clinical and radiologic information, CFA, histopathology, and cytopathology findings were recorded. Performance characteristics of cytology and EUS for the accurate diagnosis of cPanNET were calculated. RESULTS In total, 35 FNAs from 33 patients with cPanNETs were identified, and 34 EUS were performed. Cytology made a specific diagnosis of a cPanNET in 71% of the biopsies compared with a specific diagnosis by EUS in 38% of cases. An interpretation of suspicious for cPanNET was given in 77% of cases by cytology and in 47% by EUS. Cytology identified 86% of the lesions as high-risk pancreatic cysts compared with 56% by EUS. Diagnostic morphology was present on both cytology and cell block preparations in 60% of aspirates, on cytology only in 20%, and on cell block only in 20%. CFA was performed on 51% cyst fluids. All cysts but 1 revealed low carcinoembryonic antigen levels (range, 0.2 to >500 ng/mL; mean, 29.5 ng/mL), and amylase levels were <500 U/L in all but 2 cases (range, 16-1493 U/L; mean, 205 U/L). CONCLUSIONS Cytology is the most accurate test for preoperative diagnosis of cPanNETs. EUS is insufficiently accurate for independent diagnosis, and carcinoembryonic antigen and amylase analyses are noncontributory.
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Affiliation(s)
- Vicente Morales-Oyarvide
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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