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Acher AW, Hallet J. Advances in Management of Nonfunctional Pancreas Neuroendocrine Tumors. Surg Clin North Am 2024; 104:1095-1111. [PMID: 39237166 DOI: 10.1016/j.suc.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
This article presents updates in the surgical management of non-functional sporadic pancreas neuroendocrine tumors NET, including considerations for assessment of biologic behavior to support decision-making, indications for surgery, and surgical approaches tailored to the unique nature of neuroendocrine tumors.
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Affiliation(s)
- Alexandra W Acher
- Department of Surgery, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada, M4N 3M5
| | - Julie Hallet
- Department of Surgery, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada, M4N 3M5; Susan Leslie Clinic for Neuroendocrine Tumors, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Uccella S. Molecular Classification of Gastrointestinal and Pancreatic Neuroendocrine Neoplasms: Are We Ready for That? Endocr Pathol 2024; 35:91-106. [PMID: 38470548 PMCID: PMC11176254 DOI: 10.1007/s12022-024-09807-2] [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] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
In the last two decades, the increasing availability of technologies for molecular analyses has allowed an insight in the genomic alterations of neuroendocrine neoplasms (NEN) of the gastrointestinal tract and pancreas. This knowledge has confirmed, supported, and informed the pathological classification of NEN, clarifying the differences between neuroendocrine carcinomas (NEC) and neuroendocrine tumors (NET) and helping to define the G3 NET category. At the same time, the identification genomic alterations, in terms of gene mutation, structural abnormalities, and epigenetic changes differentially involved in the pathogenesis of NEC and NET has identified potential molecular targets for precision therapy. This review critically recapitulates the available molecular features of digestive NEC and NET, highlighting their correlates with pathological aspects and clinical characteristics of these neoplasms and revising their role as predictive biomarkers for targeted therapy. In this context, the feasibility and applicability of a molecular classification of gastrointestinal and pancreatic NEN will be explored.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
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Chi Y, Liu S, Zhang J, Li H, Yang L, Zhang X, Li H, Li Q, Wang N, Lu M, Zhuo M. Epidemiological characteristics of neuroendocrine neoplasms in Beijing: a population-based retrospective study. BMC Public Health 2024; 24:1396. [PMID: 38789981 PMCID: PMC11127419 DOI: 10.1186/s12889-024-18845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The incidence of neuroendocrine neoplasms (NENs) is rising rapidly worldwide. However, there are few reports on these heterogeneous diseases in China. Our study aimed to explore the epidemiological characteristics of NENs in Beijing. METHODS We conducted a retrospective cohort study using population-based cancer surveillance data in Beijing, China. All data were extracted from the Beijing Cancer Registry with incidence dates from 1 January 1998 to 31 December 2018; the follow-up period was through 31 December 2021. Segi's world standard population was used to estimate the age-standardized rate. Survival was estimated using the Kaplan-Meier method. RESULTS From 1998 to 2018, the incidence of NENs in Beijing initially showed a significant increasing trend, from 1.07/100,000 to 3.53/100,000; this began to plateau after 2013. The age-specific incidence rate increased with age and peaked in the age group 70-74 years. The incidence in men was significantly higher than that in women (4.41/100,000 vs. 1.69/100,000). The most common sites of NENs were the lung (2.38/100,000) and rectum (0.14/100,000). Most NENs were diagnosed at a late stage. We found that NENs originating from the lung had worse overall survival than extrapulmonary NENs, and male patients had worse survival than female patients. CONCLUSIONS This study retrospectively analyzed the epidemiological characteristics of NENs in Beijing from 1998 to 2018. Our findings provide a reference regarding the epidemiological statistics of NENs in Beijing to contribute to the prevention, diagnosis, and treatment of these specific tumors.
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Affiliation(s)
- Yujia Chi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department I of Thoracic Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China
| | - Shuo Liu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Jianwei Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China
| | - Huichao Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Lei Yang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Xi Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Haoxin Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Qingyu Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ning Wang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ming Lu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China.
| | - Minglei Zhuo
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department I of Thoracic Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China.
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Søreide K, Stättner S, Hallet J. Surgery as a Principle and Technical Consideration for Primary Tumor Resection of Small Bowel Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:1125-1137. [PMID: 38006527 PMCID: PMC10761444 DOI: 10.1245/s10434-023-14610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/27/2023]
Abstract
Small bowel neuroendocrine tumors (SB-NETs) are increasingly identified and have become the most frequent entity among small bowel tumors. An increasing incidence, a high prevalence, and a prolonged survival with optimal modern multidisciplinary management makes SB-NETs a unique set of tumors to consider for surgical oncologists. The major goals of surgical treatment in the setting of SB-NET include control of tumor volume, control of endocrine secretion, and prevention of locoregional complications. Key considerations include assessment of multifocality and resection of mesenteric nodal masses with the use of mesenteric-sparing approaches and acceptance of R1 margins if necessary to clear disease while avoiding short bowel syndrome. A description through eight steps for consideration is presented to allow for systematic surgical planning and execution of resection. Moreover, some controversies and evolving considerations to the surgical principles and technical procedures remain. The role of primary tumor resection in the presence of (unresectable) liver metastasis is still unclear. Reports of feasibility of minimally invasive surgery are emerging, with undetermined selection criteria for appropriateness or long-term outcomes. Resection of SB-NETs should be considered in all patients fit for surgery and should follow principles to achieve surgical oncological control that is appropriate for the stage and tumor burden, considering the age and comorbidity of the individual patient.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Vöcklabruck, Austria
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Søreide K, Hallet J, Jamieson NB, Stättner S. Optimal surgical approach for digestive neuroendocrine neoplasia primaries: Oncological benefits versus short and long-term complications. Best Pract Res Clin Endocrinol Metab 2023; 37:101786. [PMID: 37328324 DOI: 10.1016/j.beem.2023.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The rising incidence and the accumulating prevalence of neuroendocrine neoplasia (NEN) in the population makes this a common, prevalent and a clinically relevant disease group. Surgical resection represents the only potentially curative treatment for digestive NENs. Thus, resection should in principle be considered for all patients with NEN, although taking the patients age, relevant comorbidity, and performance status into account for operability. Patients with insulinomas, NEN of the appendix and rectal NENs are usually cured by surgery alone. However, less than a third of patients are amendable to curative surgery alone at time of diagnosis. Furthermore, recurrence is common and may occur years after primary surgery, hence the long follow-up time recommended in most NENs (>10 years). As many patients with NENs present with locoregional or metastatic disease, there is considerable debate regarding the role of debulking surgery in these settings. However, good long-term survival can be achieved in a considerable proportion of patients, with 50-70% alive up to 10 years after surgery. Location and grade are the main determinants of long-term survival. Here we present considerations to surgery for primary neuroendocrine tumors in the digestive tract.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
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Alfagih A, AlJassim A, Alqahtani N, Vickers M, Goodwin R, Asmis T. Small Bowel Neuroendocrine Tumors-10-Year Experience of the Ottawa Hospital (TOH). Curr Oncol 2023; 30:7508-7519. [PMID: 37623025 PMCID: PMC10453717 DOI: 10.3390/curroncol30080544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Aim: The prevalence and incidence of small bowel NETs have increased significantly over the past two decades. This study aims to report the 10-year experience of SB-NET management at a regional cancer center in Canada. (2) Materials and methods: We conducted a retrospective study of the clinical and pathological data of patients diagnosed with biopsy-proven SB-NET at The Ottawa Hospital (TOH), Ottawa, Canada between 2011 and 2021. We report the clinicopathological characteristics of these patients, as well as their outcomes data, including survival rates. (3) Results: Between 2011 and 2021, a total of 177 SB-NET cases were identified with 51% (n = 91) of cases being males. The most common sites of the tumors were the ileum 53% (n = 94), followed by the duodenum 9% (n = 16) and jejunum 7% (n = 12). Approximately 24% (n = 42) of the patients had symptoms for over six months prior to diagnosis and 18% (n = 32) had functioning SB-NET during the course of the disease. The majority of patients had locally advanced or metastatic disease at the time of presentation with stage III, and stage IV representing 42% (n = 75), and 41% (n = 73) respectively. The majority of patients 84% (n = 148) had well-differentiated histology. One hundred twenty patients underwent surgical resection of the primary tumor including 28 patients (16%) with limited metastatic disease. A total of 21 patients (18%) had recurrence after curative surgery. A total of 62 patients (35%) received first-line somatostatin analog (SSA) therapy for unresectable disease and seven patients had PRRT after progression on SSA. Five years OS was 100%, 91%, 97%, and 73% for stages I, II, III, and IV respectively. In univariate analysis, carcinoid symptoms, T stage, and differentiation were significant predictors for worse overall survival, but not RFS. (4) Conclusions: Compared to published historical controls, our study suggests improvement in the 5-year survival rate of SB-NETs over the last 10 years.
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Affiliation(s)
- Abdulhameed Alfagih
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
- Medical Oncology Department, Comprehensive Cancer Center, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Abdulaziz AlJassim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
- Kuwait Cancer Control Center, Kuwait City 42262, Kuwait
| | - Nasser Alqahtani
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
- King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Al Ahsa 11426, Saudi Arabia
| | - Michael Vickers
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
| | - Rachel Goodwin
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
| | - Timothy Asmis
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON K1N 6N5, Canada; (A.A.); (A.A.); (N.A.); (M.V.); (R.G.)
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Reinhard L, Mogl MT, Benz F, Dukaczewska A, Butz F, Dobrindt EM, Tacke F, Pratschke J, Goretzki PE, Jann H. Prognostic differences in grading and metastatic lymph node pattern in patients with small bowel neuroendocrine tumors. Langenbecks Arch Surg 2023; 408:237. [PMID: 37332044 PMCID: PMC10277262 DOI: 10.1007/s00423-023-02956-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
PURPOSE Neuroendocrine tumors of the small intestine (si-NET) describe a heterogenous group of neoplasms. Based on the Ki67 proliferation index si-NET are divided into G1 (Ki67 < 2%), G2 (Ki67 3-20%) and rarely G3 (Ki67 > 20%) tumors. However, few studies evaluate the impact of tumor grading on prognosis in si-NET. Moreover, si-NET can form distinct lymphatic spread patterns to the mesenteric root, aortocaval lymph nodes, and distant organs. This study aims to identify prognostic factors within the lymphatic spread patterns and grading. METHODS Demographic, pathological, and surgical data of 208 (90 male, 118 female) individuals with si-NETs treated at Charité University Medicine Berlin between 2010 and 2020 were analyzed retrospectively. RESULTS A total of 113 (54.5%) specimens were defined as G1 and 93 (44.7%) as G2 tumors. Interestingly, splitting the G2 group in two subgroups: G2 low (Ki67 3-9%) and G2 high (Ki67 10-20%), displayed significant differences in overall survival (OS) (p = 0.008) and progression free survival (PFS) (p = 0.004) between these subgroups. Remission after surgery was less often achieved in patients with higher Ki67 index (> 10%). Lymph node metastases (N +) were present in 174 (83.6%) patients. Patients with isolated locoregional disease showed better PFS and OS in comparison to patients with additional aortocaval and distant lymph node metastases. CONCLUSION Lymphatic spread pattern influences patient outcome. In G2 tumors, low and high grading shows heterogenous outcome in OS and PFS. Differentiation within this group might impact follow-up, adjuvant treatment, and surgical strategy.
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Affiliation(s)
- Lisa Reinhard
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martina T Mogl
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Fabian Benz
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Agata Dukaczewska
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frederike Butz
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eva Maria Dobrindt
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter E Goretzki
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Henning Jann
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Noh JH, Kim DH, Park K, Na HK, Ahn JY, Lee JH, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY. Conventional endoscopic mucosal resection versus modified endoscopic mucosal resection for duodenal neuroendocrine tumor. Surg Endosc 2023; 37:3884-3892. [PMID: 36717428 DOI: 10.1007/s00464-023-09885-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/08/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS As the incidence of duodenal neuroendocrine tumors (DNET) is steadily increasing, the role of endoscopic treatment for appropriate lesions is becoming more significant. We aimed to compare the outcomes according to lesion size and endoscopic mucosal resection (EMR) techniques for DNET treatment. PATIENTS AND METHODS Patients who underwent endoscopic treatment for DNET between June 2000 and December 2019 were included. The clinicopathologic features and treatment outcomes were investigated by reviewing medical records. RESULTS Overall, 104 cases underwent endoscopic resection for nonampullary DNET, including conventional EMR (n = 57), cap-assisted EMR (EMR-C, n = 19), and precut EMR (EMR-P, n = 28). The en bloc resection rates (100% vs. 94.7% vs. 96.4%) and histologic complete resection rates (45.6% vs. 52.6% vs. 57.1%) were not significantly different between the EMR, EMR-C, and EMR-P groups. The histologic complete resection rates were significantly higher in lesions < 10 mm than in lesions ≥ 10 mm (69.8% vs. 38.9%, P = 0.013). In lesions < 10 mm, perforation occurred more frequently in the modified EMR group than in the conventional EMR group (13.2% vs. 0.0%, P = 0.007). During the median follow-up period of 88.0 months, the recurrence-free survival (92.2% vs. 94.4% vs. 92.1%) and overall survival (98.0% vs. 88.1% vs. 100.0%) rates did not show significant differences between the EMR, EMR-C, and EMR-P groups. CONCLUSION Conventional EMR and modified EMR are feasible and effective for the treatment of nonampullary DNET sized < 10 mm and limited to mucosal and submucosal layer. Additionally, endoscopists should be aware of the high risk of perforation in modified EMR.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Kwangbeom Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Mäkinen N, Zhou M, Zhang Z, Kasai Y, Perez E, Kim GE, Thirlwell C, Nakakura E, Meyerson M. Whole genome sequencing reveals the independent clonal origin of multifocal ileal neuroendocrine tumors. Genome Med 2022; 14:82. [PMID: 35922826 PMCID: PMC9351068 DOI: 10.1186/s13073-022-01083-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Small intestinal neuroendocrine tumors (SI-NETs) are the most common neoplasms of the small bowel. The majority of tumors are located in the distal ileum with a high incidence of multiple synchronous primary tumors. Even though up to 50% of SI-NET patients are diagnosed with multifocal disease, the mechanisms underlying multiple synchronous lesions remain elusive. METHODS We performed whole genome sequencing of 75 de-identified synchronous primary tumors, 15 metastases, and corresponding normal samples from 13 patients with multifocal ileal NETs to identify recurrent somatic genomic alterations, frequently affected signaling pathways, and shared mutation signatures among multifocal SI-NETs. Additionally, we carried out chromosome mapping of the most recurrent copy-number alterations identified to determine which parental allele had been affected in each tumor and assessed the clonal relationships of the tumors within each patient. RESULTS Absence of shared somatic variation between the synchronous primary tumors within each patient was observed, indicating that these tumors develop independently. Although recurrent copy-number alterations were identified, additional chromosome mapping revealed that tumors from the same patient can gain or lose different parental alleles. In addition to the previously reported CDKN1B loss-of-function mutations, we observed potential loss-of-function gene alterations in TNRC6B, a candidate tumor suppressor gene in a small subset of ileal NETs. Furthermore, we show that multiple metastases in the same patient can originate from either one or several primary tumors. CONCLUSIONS Our study demonstrates major genomic diversity among multifocal ileal NETs, highlighting the need to identify and remove all primary tumors, which have the potential to metastasize, and the need for optimized targeted treatments.
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Affiliation(s)
- Netta Mäkinen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 USA
- Cancer Program, Broad Institute of Harvard and MIT, Cambridge, MA USA
| | - Meng Zhou
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 USA
- Cancer Program, Broad Institute of Harvard and MIT, Cambridge, MA USA
| | - Zhouwei Zhang
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 USA
- Cancer Program, Broad Institute of Harvard and MIT, Cambridge, MA USA
| | - Yosuke Kasai
- Department of Surgery, University of California, San Francisco, CA USA
| | - Elizabeth Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 USA
| | - Grace E. Kim
- Department of Pathology, University of California, San Francisco, CA USA
| | - Chrissie Thirlwell
- Research Department of Oncology, UCL Cancer Institute, London, UK
- School of Medicine and Health, University of Exeter, RILD Building, Exeter, UK
| | - Eric Nakakura
- Department of Surgery, University of California, San Francisco, CA USA
| | - Matthew Meyerson
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 USA
- Cancer Program, Broad Institute of Harvard and MIT, Cambridge, MA USA
- Departments of Genetics and Medicine, Harvard Medical School, Boston, MA USA
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de Jorge Huerta L, Solares Fernández I, Sánchez-Moreno B, Males Maldonado D, de Ibarrola Andrés C, Díaz-Simón R. Sporadic, non-functional, gastrin-producing duodenal neuroendocrine tumors: A retrospective study of an infrequent disease. J Dig Dis 2022; 23:455-461. [PMID: 36168962 PMCID: PMC10099524 DOI: 10.1111/1751-2980.13129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/19/2022] [Accepted: 09/25/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Non-functioning gastrin-producing neuroendocrine neoplasms (NEN) of the duodenum are rare gastrointestinal tumors without a clinical syndrome due to gastrin production. Their incidence has significantly increased as an incidental finding during endoscopic studies. The aim of this study was to describe the characteristics and prognostic factors of this emergent and infrequent neoplasm. METHODS We performed a retrospective observational study based on the duodenal NENs samples with positive staining for gastrin at the Department of Pathology, University Hospital 12-de-Octubre (Madrid, Spain) between 2000 and 2017. Patients with clinically functional tumors ([Zollinger-Ellison syndrome] or gastrin >1000 pg/mL), with previously diagnosed multiple endocrine neoplasia (MEN) syndrome or synchronous neoplasia were excluded. Clinicopathological and therapeutic variables, follow-up, recurrence, and mortality data were collected. RESULTS In all, 21 patients were included. Most of the tumors were diagnosed incidentally as a single small polypoid lesion limited to mucosa/submucosa and with a low histological grade. Four (19.0%) patients presented with metastatic involvement at diagnosis (lymphatic and/or hepatic). These four patients also had a high or intermediate mitotic grade and infiltration further than submucosa. Local resection was applied in most cases as curative treatment. There were two cases of tumor recurrence and two tumor-related deaths with a 5-year disease-free survival of 81.0%. CONCLUSIONS The majority of these tumors were diagnosed at a localized stage and had a good prognosis with treatment. Nevertheless, given the potential metastatic risk, a close follow-up is necessary, especially in those with aggressive pathological factors such as deep infiltration or high histological grade.
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Affiliation(s)
- Lucía de Jorge Huerta
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
| | - Isabel Solares Fernández
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
| | - Beatriz Sánchez-Moreno
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
| | - David Males Maldonado
- Department of Endocrinology and Metabolism, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
| | - Carolina de Ibarrola Andrés
- Department of Anatomical Pathology, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
| | - Raquel Díaz-Simón
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación i + 12, Madrid, Spain
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11
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Polydorides AD, Liu Q. Evaluation of Pathologic Prognostic Factors in Neuroendocrine Tumors of the Small Intestine. Am J Surg Pathol 2022; 46:547-556. [PMID: 35192293 DOI: 10.1097/pas.0000000000001808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The precise contributions of histopathologic features in the determination of stage and prognosis in small intestinal neuroendocrine tumors (NETs) are still under debate, particularly as they pertain to primary tumor size, mesenteric tumor deposits (TDs), and number of regional lymph nodes with metastatic disease. This single-institution series reviewed 162 patients with small bowel NETs (84 females, mean age: 60.3±12.0 y). All cases examined (100%) were immunoreactive for both chromogranin A and synaptophysin. Primary tumor size >1 cm (P=0.048; odds ratio [OR]=3.06, 95% confidence interval [CI]: 1.01-9.24) and lymphovascular invasion (P=0.007; OR=4.85, 95% CI: 1.53-15.40) were associated with the presence of lymph node metastasis. Conversely, TDs (P=0.041; OR=2.73, 95% CI: 1.04-7.17) and higher pT stage (P=0.006; OR=4.33, 95% CI: 1.53-12.28) were associated with the presence of distant metastasis (pM). A cutoff of ≥7 positive lymph nodes was associated with pM (P=0.041), and a thusly defined modified pN stage (pNmod) significantly predicted pM (P=0.024), compared with the prototypical pN (cutoff of ≥12 positive lymph nodes), which did not. Over a median follow-up of 35.7 months, higher pNmod (P=0.014; OR=2.15, 95% CI: 1.16-3.96) and pM (P<0.001; OR=11.00, 95% CI: 4.14-29.20) were associated with disease progression. Proportional hazards regression showed that higher pNmod (P=0.020; hazard ratio=1.51, 95% CI: 1.07-2.15) and pM (P<0.001; hazard ratio=5.48, 95% CI: 2.90-10.37) were associated with worse progression-free survival. Finally, Kaplan-Meier survival analysis demonstrated that higher pNmod (P=0.003), pM (P<0.001), and overall stage group (P<0.001) were associated with worse progression-free survival, while higher pM also predicted worse disease-specific survival (P=0.025). These data support requiring either chromogranin or synaptophysin, but not both, for small bowel NET diagnosis, the current inclusion of a 1 cm cutoff in primary tumor size and the presence of TDs in staging guidelines, and would further suggest lowering the cutoff number of positive lymph nodes qualifying for pN2 to 7 (from 12).
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Affiliation(s)
- Alexandros D Polydorides
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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12
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Kulkarni R, Kabir I, Hodson J, Raza S, Shah T, Pandanaboyana S, Dasari BVM. Impact of the extent of resection of neuroendocrine tumor liver metastases on survival: A systematic review and meta-analysis. Ann Hepatobiliary Pancreat Surg 2022; 26:31-39. [PMID: 34980681 PMCID: PMC8901984 DOI: 10.14701/ahbps.21-101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
In patients with neuroendocrine tumors with liver metastases (NETLMs), complete resection of both the primary and liver metastases is a potentially curative option. When complete resection is not possible, debulking of the tumour burden has been proposed to prolong survival. The objective of this systematic review was to evaluate the effect of curative surgery (R0-R1) and debulking surgery (R2) on overall survival (OS) in NETLMs. For the subgroup of R2 resections, outcomes were compared by the degree of hepatic debulking (≥ 90% or ≥ 70%). A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines using PubMed, Medline, CINAHL, Cochrane, and Embase databases. Hazard ratios (HRs) were estimated for each study and pooled using a random-effects inverse-variance meta-analysis model. Of 538 articles retrieved, 11 studies (1,729 patients) reported comparisons between curative and debulking surgeries. After pooling these studies, OS was found to be significantly shorter in debulking resections, with an HR of 3.49 (95% confidence interval, 2.70–4.51; p < 0.001). Five studies (654 patients) compared outcomes between ≥ 90% and ≥ 70% hepatic debulking approaches. Whilst these studies reported a tendency for OS and progression-free survival to be shorter in those with a lower degree of debulking, they did not report sufficient data for this to be assessed in a formal meta-analysis. In patients with NETLM, OS following surgical resection is the best to achieve R0-R1 resection. There is also evidence for a progressive reduction in survival benefit with lesser debulking of tumour load.
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Affiliation(s)
- Rugved Kulkarni
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Irfan Kabir
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Syed Raza
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Tahir Shah
- Department of Neuroendocrine Medicine and Hepatology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Sanjay Pandanaboyana
- HPB and Liver Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
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13
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Tran CG, Sherman SK, Suraju MO, Nayyar A, Gerke H, El Abiad RG, Chandrasekharan C, Ear PH, O’Dorisio TM, Dillon JS, Bellizzi AM, Howe JR. Management of Duodenal Neuroendocrine Tumors: Surgical versus Endoscopic Mucosal Resection. Ann Surg Oncol 2022; 29:75-84. [PMID: 34515889 PMCID: PMC8688294 DOI: 10.1245/s10434-021-10774-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/22/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller lesions (< 1-2 cm) generally treated by endoscopic mucosal resection (EMR) and larger DNETs by surgical resection (SR). This study reviewed how patients were selected for treatment and compared outcomes. PATIENTS AND METHODS Patients with DNETs undergoing resection were identified through institutional databases, and clinicopathologic data recorded. χ2 and Wilcoxon tests compared variables. Survival was determined by Kaplan-Meier, and Cox regression tested association with survival. RESULTS Among 104 patients, 64 underwent EMR and 40 had SR. Patients selected for SR had larger tumor size, younger age, and higher T, N, and M stage. There was no difference in progression-free (PFS) or overall survival (OS) between SR and EMR. In 1-2 cm DNETs, there was no difference in PFS between SR and EMR [median not reached (NR), P = 0.1]; however, longer OS was seen in SR (median NR versus 112 months, P = 0.03). In 1-2 cm DNETs, SR patients were more likely to be node-positive and younger. After adjustment for age, resection method did not correlate with survival. Comparison of surgically resected DNETs versus jejunoileal NETs revealed longer PFS (median NR versus 73 months, P < 0.001) and OS (median NR versus 119 months, P = 0.004) DISCUSSION: In 1-2 cm DNETs, there was no difference in survival between EMR and SR after adjustment for age. Recurrences could be salvaged, suggesting that EMR is a reasonable strategy. Compared with jejunoileal NETs, DNETs treated by SR had improved PFS and OS.
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Affiliation(s)
- Catherine G. Tran
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Scott K. Sherman
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mohammed O. Suraju
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Apoorve Nayyar
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Henning Gerke
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Rami G. El Abiad
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Po Hien Ear
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Thomas M. O’Dorisio
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Joseph S. Dillon
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Andrew M. Bellizzi
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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14
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Michael M, Thursfield V, Te Marvelde L, Kong G, Hicks RJ. Incidence, prevalence, and survival trends for neuroendocrine neoplasms in Victoria, Australia, from 1982 to 2019: Based on site, grade, and region. Asia Pac J Clin Oncol 2021; 18:e306-e317. [PMID: 34821050 DOI: 10.1111/ajco.13671] [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: 07/29/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
AIMS Neuroendorcine neoplasms (NENs) are rare tumors characterised by variable biology and delayed diagnosis. Several population studies have reported a marked increased incidence over time. The objectives of this analysis were to describe within Victoria (the second largest Australian state, 6.4 Million) the trends for NENs incidence/survival over nearly 38 years (1982-2019), and regional differences in survival. METHODS All NEN cases were identified from the Victorian Cancer Registry over four time periods: 1982-1989, 1990-1999, 2000-2009, and 2010-2019. Data collected included primary tumor site, histological grade, gender, overall survival (OS), and place of residence. Incidence data were analyzed with the generation of annual standardized rates (ASR). OS was assessed for the entire cohort and between geographical regions. RESULTS The overall NEN population (1982-2019) included 8,106 patients: over 60% grade 1/2 NENs, especially small bowel and colorectal. The number of new diagnoses increased over three-fold over time for the overall cohort and by tumoral categories. The ASR increased similarly, especially pancreatic NENs (4.3-fold) and differed between genders. The 5-year OS rates and median OS increased over time for the overall cohort: from 52% to 67% (p < 0.001). OS was greater for NEN patients residing in major cities relative to regional/remote areas (p = 0.01). CONCLUSION This population-wide analysis with over 38 years of data has confirmed the international trends of the increased incidence, prevalence, and OS of NEN patients regardless of primary site or histological grade. The analysis also observed a difference in survival outcome in rural/remote versus urban areas.
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Affiliation(s)
- M Michael
- Neuroendocrine Tumour Service, a European Neuroendocrine Tumor Society Centre of Excellence, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - V Thursfield
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, Australia
| | - L Te Marvelde
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, Australia
| | - G Kong
- Neuroendocrine Tumour Service, a European Neuroendocrine Tumor Society Centre of Excellence, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - R J Hicks
- Neuroendocrine Tumour Service, a European Neuroendocrine Tumor Society Centre of Excellence, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia
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15
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Rossi RE, Milanetto AC, Andreasi V, Campana D, Coppa J, Nappo G, Rinzivillo M, Invernizzi P, Modica R, David A, Partelli S, Lamberti G, Mazzaferro V, Zerbi A, Panzuto F, Pasquali C, Falconi M, Massironi S. Risk of preoperative understaging of duodenal neuroendocrine neoplasms: a plea for caution in the treatment strategy. J Endocrinol Invest 2021; 44:2227-2234. [PMID: 33651317 DOI: 10.1007/s40618-021-01528-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/04/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Pretreatment staging is the milestone for planning either surgical or endoscopic treatment in duodenal neuroendocrine neoplasms (dNENs). Herein, a series of surgically treated dNEN patients was evaluated to assess the concordance between the pre- and postsurgical staging. METHODS Retrospective analysis of patients with a histologically confirmed diagnosis of dNENs, who underwent surgical resection observed at eight Italian tertiary referral centers. The presurgical TNM stage, based on the radiological and functional imaging, was compared with the pathological TNM stage, after surgery. RESULTS From 2000 to 2019, 109 patients were included. Sixty-six patients had G1, 26 a G2, 7 a G3 dNEN (Ki-67 not available in 10 patients). In 46/109 patients (42%) there was disagreement between the pre- and postsurgical staging, being it understaged in 42 patients (38%), overstaged in 4 (3%). As regards understaging, in 25 patients (22.9%), metastatic loco-regional nodes (N) resulted undetected at both radiological and functional imaging. Understaging due to the presence of distal micrometastases (M) was observed in 2 cases (1.8%). Underestimation of tumor extent (T) was observed in 12 patients (11%); in three cases the tumor was understaged both in T and N extent. CONCLUSIONS Conventional imaging has a poor detection rate for loco-regional nodes and micrometastases in the presurgical setting of the dNENs. These results represent important advice when local conservative approaches, such as endoscopy or local surgical excision are considered and it represents a strong recommendation to include endoscopic ultrasound in the preoperative tools for a more accurate local staging.
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Affiliation(s)
- R E Rossi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
- HBP Surgery, Hepatology and Liver Transplantation Unit, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute), Milan, Italy.
| | - A C Milanetto
- Pancreatic and Endocrine Digestive Surgical Unit, Department of Surgery, Oncology and Gastroenterology, Università degli Studi di Padova, Padua, Italy
| | - V Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - D Campana
- Department of Experimental, Diagnostic and Specialty Medicine, ENETS Center of Excellence, Bologna University, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - J Coppa
- HBP Surgery, Hepatology and Liver Transplantation Unit, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute), Milan, Italy
| | - G Nappo
- Pancreatic Surgery, Humanitas Clinical, and Research Center-IRCCS, ENETS Center of Excellence, Humanitas University, Milan, Rozzano, Italy
| | - M Rinzivillo
- Digestive Disease Unit, ENETS Center of Excellence, Sant'Andrea University Hospital, Rome, Italy
| | - P Invernizzi
- Division of Gastroenterology, San Gerardo Hospital, Bicocca School of Medicine, University of Milano, Monza, Italy
| | - R Modica
- Division of Endocrinology, Department of Clinical Medicine and Surgery, ENETS Center of Excellence, University "Federico II" of Naples, Naples, Italy
| | - A David
- Pancreatic and Endocrine Digestive Surgical Unit, Department of Surgery, Oncology and Gastroenterology, Università degli Studi di Padova, Padua, Italy
| | - S Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - G Lamberti
- Department of Experimental, Diagnostic and Specialty Medicine, ENETS Center of Excellence, Bologna University, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - V Mazzaferro
- HBP Surgery, Hepatology and Liver Transplantation Unit, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute), Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - A Zerbi
- Pancreatic Surgery, Humanitas Clinical, and Research Center-IRCCS, ENETS Center of Excellence, Humanitas University, Milan, Rozzano, Italy
| | - F Panzuto
- Digestive Disease Unit, ENETS Center of Excellence, Sant'Andrea University Hospital, Rome, Italy
| | - C Pasquali
- Pancreatic and Endocrine Digestive Surgical Unit, Department of Surgery, Oncology and Gastroenterology, Università degli Studi di Padova, Padua, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - S Massironi
- Division of Gastroenterology, San Gerardo Hospital, Bicocca School of Medicine, University of Milano, Monza, Italy
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16
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Sakaray Y, Abuji K, Chatterjee D, Irrinki S. Giant retroperitoneal lymph node-an uncommon presentation of duodenal neuroendocrine tumour. BMJ Case Rep 2021; 14:14/7/e243048. [PMID: 34290018 DOI: 10.1136/bcr-2021-243048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary retroperitoneal neuroendocrine tumours (NETs) are extremely rare, and many a times, these are metastatic lesions with known or unknown primary location, most commonly arising from the stomach, duodenum, small intestine and rectum. NETs arising from the duodenum are more commonly seen in the first part of the duodenum followed by the second part. The incidence is increasing because of easy accessibility to endoscopies and cross-sectional imaging. In NETs, lymph node (LN) metastasis occurs commonly when the tumour size is more than 2 cm. In contrast, LN metastasis occurs even with subcentimetric lesions, especially the ampullary variant of NETs. A patient presented to us with mild abdominal pain and found to have retroduodenal mass. On evaluation found to be a metastatic LN deposit of NET with the primary arising from the first part and supra-ampullary part of duodenum.
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Affiliation(s)
- Yashwant Sakaray
- General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kishore Abuji
- General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Debajyoti Chatterjee
- Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Santhosh Irrinki
- General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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17
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Wang R, Mohapatra S, Jovani M, Akshintala VS, Kamal A, Brewer OG, Kumbhari V, Shin EJ, Canto MI, Khashab MA, Singh VK, Lennon AM, Kalloo AN, Ngamruengphong S. Risk factors for lymph node metastasis and survival of patients with nonampullary duodenal carcinoid tumors treated with endoscopic therapy versus surgical resection: analysis of the Surveillance, Epidemiology, and End Results program. Gastrointest Endosc 2021; 93:1384-1392. [PMID: 33347833 DOI: 10.1016/j.gie.2020.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic therapy (ET) has been used to treat nonampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in size, but data on long-term outcomes are limited. In addition, management of 11- to 19-mm NAD-NETs is not well defined because of variable estimates of risk of metastasis. We aimed to determine the prevalence and risk factors of metastasis of NAD-NETs ≤19 mm and evaluate the long-term survival of patients after ET as compared with radical surgery. METHODS The Surveillance Epidemiology and End Result database was used to identify 1243 patients with T1-2 histologically confirmed NAD-NETs ≤19 mm in size. Cancer-specific survival (CSS) and overall survival (OS) were calculated. RESULTS Overall, 4.8% of cases had metastasis at the time of diagnosis, with lower prevalence in ≤10-mm lesions (3.1%) versus 11- to 19-mm lesions (11.7%, P < .001). The risk factors for metastases included invasion to the muscularis propria (odds ratio, 25.95; 95% confidence interval, 9.01-76.70), age <65 years (odds ratio, 1.93), submucosal involvement (odds ratio, 3.1), and 11 to 19 mm in size (vs ≤10 mm). In patients with well- to moderately differentiated T1-2N0M0 NAD-NETs ≤19 mm confined to the mucosa/submucosa who underwent ET or surgery, the 5-year CSS was 100%. The 5-year OS was similar between the ≤10-mm and 11- to 19-mm groups (86.6% vs 91.0%, P = .31) and the ET and surgery groups (87.4% vs 87.5%, P = .823). CONCLUSIONS In NAD-NETs, invasion to the muscularis propria is the strongest risk factor for metastasis. In the absence of metastasis, in lesions with well/moderate differentiation and without muscle invasion, ET is adequate for NAD-NETs ≤10 mm and is a viable option for 11- to 19-mm lesions.
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Affiliation(s)
- Rui Wang
- Gastroenterology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Venkata S Akshintala
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olaya Gutierrez Brewer
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcia I Canto
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anthony Nicholas Kalloo
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
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18
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Kaçmaz E, Sarasqueta AF, van Eeden S, Dreijerink KMA, Klümpen HJ, Tanis PJ, van Dijkum EJMN, Engelsman AF. Update on Incidence, Prevalence, Treatment and Survival of Patients with Small Bowel Neuroendocrine Neoplasms in the Netherlands. World J Surg 2021; 45:2482-2491. [PMID: 33895862 PMCID: PMC8236032 DOI: 10.1007/s00268-021-06119-y] [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] [Accepted: 04/03/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Small bowel neuroendocrine neoplasms (SB-NEN) are rare cancers, population-based studies are needed to study this rare indolent disease. The aim of this study was to explore trends in epidemiology, treatment and survival outcomes of patients with SB-NEN based on Dutch nationwide data. PATIENTS AND METHODS Patients with grade 1 or 2 SB-NEN diagnosed between 2005 and 2015 were retrieved from the Netherlands Cancer Registry and linked to The Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands. Age-adjusted incidence rates were calculated based using the direct standardization method. Survival analyses were performed with the Kaplan-Meier method. RESULTS A total of 1132 patients were included for epidemiological analyses. The age-adjusted incidence rate of SB-NEN increased from 0.52 to 0.81 per 100.000 person-years between 2005 and 2015. Incidence was higher for males than females (0.93 vs. 0.69 in 2015). Most patients had grade 1 tumours (83%). Surgery was performed in 86% of patients, with resection of the primary tumour in 99%. During the study period, administration of somatostatin analogues (SSAs) increased from 5 to 22% for stage III and from 27 to 63% for stage IV disease. Mean follow-up was 61 (standard deviation 38) months. Survival data were complete for 975/1132 patients and five-year overall survival was 75% for stage I-II, 75% for stage III and 57% for stage IV. CONCLUSIONS This study shows an increase in the incidence of SB-NEN in the Netherlands. A predominant role of surgery was found in all disease stages. Use of SSAs has increased over time.
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Affiliation(s)
- Enes Kaçmaz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Arantza Farina Sarasqueta
- Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne van Eeden
- Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Koen M A Dreijerink
- Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands.,Department of Endocrinology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Heinz-Josef Klümpen
- Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands.,Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Els J M Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Anton F Engelsman
- Amsterdam Center for Endocrine and Neuroendocrine Tumours (ACcENT), Cancer Center Amsterdam, ENETS Center of Excellence, Amsterdam, The Netherlands. .,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081HV, Amsterdam, The Netherlands.
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19
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Stankard M, Soule E, Matteo J. Inferior Vena Cava Syndrome as a Manifestation of Metastatic Carcinoid Tumor. Gastrointest Tumors 2021; 8:138-143. [PMID: 34307313 DOI: 10.1159/000514113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/29/2020] [Indexed: 11/19/2022] Open
Abstract
Small bowel-origin carcinoid tumor is indolent but may metastasize relentlessly to various sites, including the liver. Over the past 9 years, we have treated a 69-year-old woman who has undergone 5 percutaneous liver ablations, 5 hepatic intra-arterial chemoembolizations, an ovarian cryoablation, and a trans-ventral hernia mesenteric cryoablation. These interventions are all related to her inoperable carcinoid malignancy. After the patient presented with swelling of the abdomen and both lower extremities, computed tomography (CT) angiography was performed, revealing a circumferential hepatic metastatic mass encasing the intrahepatic inferior vena cava (IVC) and extensive third spacing of fluids specific to the IVC distribution below the diaphragm. A venogram of the intrahepatic IVC revealed extrinsic compression causing 95% narrowing of the vessel. A balloon was advanced to the level of the lesion and inflated, increasing the caliber of the vessel. Subsequently, 2 covered aortic stent graft cuffs were deployed in an overlapping fashion within the lumen of the IVC, traversing the area of narrowing. Next, an open-cell aortic dissection stent was placed across both overlapping aortic stents from the renal veins to the hepatic veins. Following this, three 17-gauge cryoablation probes were inserted into the segment 1 intrahepatic lesions encasing the newly stented IVC via an anterior percutaneous approach. Two 10-min freeze cycles were performed with intraoperative CT imaging, demonstrating circumferential coverage of the lesions. Posttreatment venogram revealed patent stent grafts within the intrahepatic IVC, and restoration of vessel patency. No immediate postoperative complications were noted. The patient's abdominal and lower extremity swelling resolved completely within 1 week after procedure. Two-month follow-up CT demonstrated markedly decreased size of the metastatic lesions and no adverse effects. Six- and 9-month PET-CT scans demonstrated maintained patency of the IVC stent. This palliative procedure allowed the patient to maintain good performance status and alleviated her symptoms of IVC syndrome. The radial force generated by the multiple aortic stents will ostensibly maintain the patency of the intrahepatic IVC. Cryoablation of the encasing metastatic lesion was performed with markedly decreased size of the tumor on the 2-month follow-up.
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Affiliation(s)
- Matthew Stankard
- Department of Radiology, Florida Atlantic University College of Medicine, Boca Raton, Florida, USA
| | - Erik Soule
- Department of Interventional Radiology, UF Health Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Jerry Matteo
- Department of Interventional Radiology, UF Health Jacksonville, University of Florida, Jacksonville, Florida, USA
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20
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Expression profiling of small intestinal neuroendocrine tumors identified pathways and gene networks linked to tumorigenesis and metastasis. Biosci Rep 2021; 40:225160. [PMID: 32496505 PMCID: PMC7298166 DOI: 10.1042/bsr20193860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 11/17/2022] Open
Abstract
Small intestinal neuroendocrine tumors (SI-NETs) remain the most common subset in gastrointestinal neuroendocrine tumors and featured by aggressiveness. However, the molecular feature of SI-NETs remains largely unclear with key genes and pathways yet to be identified. The gene expression profile GSE65286 was retrieved for analysis. Artificial neural networks (ANNs) were constructed for the hub genes network models. A total of 613 differentially expressed genes (DEGs) were identified between normal (N) and primary tumor (T) groups, whereas 61 DEGs were identified between T and liver metastases (LM) groups. The top Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways for the DEGs of N versus T were fat digestion and absorption pathway. For T versus LM the top KEGG pathways were complement and coagulation. In gene set enrichment analysis (GSEA), five gene sets, including Notch signaling, inflammatory response, coagulation, KRAS signaling, and allograft rejection were significantly enriched in the T group. The hub genes in the DEGs of T versus LM included albumin, fibrinogen gamma chain, alpha 2-HS glycoprotein, transferrin and GC, vitamin D binding protein. A distinct correlational alteration of hub genes was observed between T and LM groups. In ANN analysis, ALB and TF were the top predictors of metastasis. Moreover, the expression of ALB≤ showed the highest support to T whereas ALB>15.97 supports LM. TF≤7.54 showed the highest negative correlation to the T. This bioinformatics analysis provided insights on potential key pathways and genes networks involved in SI-NETs and established an ANN-based hub gene model for metastatic prediction.
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21
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Wyld D, Moore J, Tran N, Youl P. Incidence, survival and stage at diagnosis of small intestinal neuroendocrine tumours in Queensland, Australia, 2001-2015. Asia Pac J Clin Oncol 2021; 17:350-358. [PMID: 33567164 DOI: 10.1111/ajco.13503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
AIM Multiple studies have observed increasing incidence of small intestinal (SI) neuroendocrine tumours (NETs). The aim of this study was to describe incidence, mortality and survival of SI NETs by sub-site and stage at diagnosis. METHODS Data on patients diagnosed with SI NETs between 2001 and 2015 were sourced from the Queensland Oncology Repository. Staging algorithms utilising several data sources were used to calculate stage at diagnosis (localised, regional or metastatic disease). RESULTS We identified 778 SI NETs and of those 716 (92%) had either a documented or derived stage. Incidence doubled from 0.68 per 100 000 to 1.42 per 100 000 over the 15-year period. Most common site was ileum (49.1%) and 84.2% were of carcinoid morphology type. Stage at diagnosis was calculated for 91.7% of patients with 28.3% presenting with regional involvement and 23.9% with distant metastasis. Risk factors associated with metastatic disease were jejunal and SI site not otherwise specified, neuroendocrine carcinoma histology and residing in a rural area. Increasing incidence of localised disease and a corresponding reduction in metastatic disease was observed over time. Five-year cause-specific survival for patients diagnosed between 2001 and 2005 was 82.5%, increasing to 93.8% from 2011 to 2015. Survival was lowest for those with metastatic disease (74.2%). Survival increased between 2001 to 2005 and 2011 to 2015 for each disease stage. CONCLUSIONS SI NET incidence in Queensland doubled between 2001 and 2015. Survival was high and improved over time.
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Affiliation(s)
- David Wyld
- Department of Medical Oncology, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Julie Moore
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Nancy Tran
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Philippa Youl
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
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22
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Lancellotti F, Solinas L, Telesco D, Sagnotta A, Belardi A, Balsamo G, Mancini S. A rare case of metachronous neuroendocrine tumor after a colorectal adenocarcinoma: qualitative critical review of synchronous and metachronous gastrointestinal NET. Clin J Gastroenterol 2021; 14:115-122. [PMID: 33044637 PMCID: PMC7886727 DOI: 10.1007/s12328-020-01255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/19/2020] [Indexed: 01/17/2023]
Abstract
Gastrointestinal neuroendocrine tumor (NET) associated with a metachronous intestinal adenocarcinoma is rare. We report the case of a 71-year-old man with an ileal NET. Patient has previously undergone a left colectomy for sigmoid cancer. We report a complete review both of the metachronous and synchronous NET. A comprehensive systematic literature search in PubMed, EMBASE, and MEDLINE identified a total of 35 relevant studies. This study includes an analysis of review articles, case reports, case series, retrospective studies and population-based studies. In the English literature to date, there are 21 case reports (19 synchronous cases and 2 metachronous cases), 3 case series and 3 review articles, and less than 10 retrospective studies or population-based studies. A total of 31 patients in 24 articles were included in the study: 28 patients with a synchronous gastrointestinal NET and colorectal adenocarcinoma and 3 patients with metachronous gastrointestinal NET and colorectal adenocarcinoma. The incidence of synchronous cancer (particularly for colorectal and gastric cancer) with a gastrointestinal NET ranges from 10 to 50%, while for the metachronous ones it is still unclear. This is the third metachronous case report and the first descriptive case of gastrointestinal NET diagnosed 2 years after a colorectal adenocarcinoma. An endoscopic follow-up program for gastrointestinal NET patients and/or for first-degree relatives of NET patients appears recommendable.
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Affiliation(s)
| | - Luigi Solinas
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy
| | - Davide Telesco
- Department of General Surgery, Surgical Specialities “Paride Stefanini”, Sapienza University of Rome, Rome, Italy
| | - Andrea Sagnotta
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy
| | - Augusto Belardi
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy
| | - Giuseppina Balsamo
- Department of Clinical Pathology, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Mancini
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy
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23
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Landerholm K. Time trends in incidence and survival of small intestinal cancer in Sweden. BJS Open 2021; 5:6070826. [PMID: 33609370 PMCID: PMC7893462 DOI: 10.1093/bjsopen/zraa044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Small intestinal cancer is less common than some other gastrointestinal malignancies. Tumours of different histological types and anatomical sites of origin have therefore often been described together. The aim of this study was to investigate the epidemiology for each of the four main subtypes: duodenal adenocarcinoma (D-AC), duodenal neuroendocrine tumour (D-NET), jejunoileal adenocarcinoma (J/I-AC), and jejunoileal neuroendocrine tumour (J/I-NET). METHODS All patients with small intestinal cancer diagnosed between 1960 and 2015 were identified from the Swedish Cancer Register. The age-adjusted incidence rate with incidence rate ratios, as well as overall (OS) and net (NS) survival, were determined and temporal trends were analysed. RESULTS The incidence rate was highest for J/I-NET, with 9.98 clinical diagnoses per million in 2010-2015. Clinical diagnosis of D-AC increased more than 10-fold and surpassed J/I-AC as the second most common subtype. D-NET was by far the least common subtype. Diagnosis at autopsy became less common over time, whereas clinical diagnoses increased significantly for all four subtypes. All subtypes except J/I-AC affected men more often than women. The age distribution was similar between subtypes, although patients with adenocarcinomas were slightly older. Survival was generally much better for patients with NET than for those with adenocarcinoma. Both OS and NS showed a negative association with advancing age. Survival improved only for J/I-NET from a 5-year NS of 0.69 in the 1960s to 0.81 in 2010-2015. CONCLUSION The incidence of small intestinal cancer is increasing, particularly for D-AC and in the elderly. Survival of patients with small intestinal cancer has improved only for J/I-NET over the last decades.
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Affiliation(s)
- K Landerholm
- Department of Surgery, Ryhov County Hospital, Jönköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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24
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Sonbol MB, Saad AM, Gonzalez-Velez M, Starr J, Halfdanarson TR. Causes of Death After Neuroendocrine Tumors Diagnosis: A US Population-Based Analysis. Pancreas 2021; 50:47-53. [PMID: 33370022 DOI: 10.1097/mpa.0000000000001723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In this study, we aimed to determine the cause of death (COD) after the diagnosis of neuroendocrine tumors (NET). METHODS We used the Surveillance, Epidemiology and End Results (SEER) Program to review patients diagnosed with NET during 2000 to 2016. Patients were followed until death, and different CODs were determined. RESULTS Of 94,399 patients with NETs, 40.9% died during the study period. During the first year of diagnosis, most deaths were from NETs (73%), followed by other cancers (11.2%) and cardiac diseases (4.6%). After more than 10 years, NET deaths decreased to 24.3%, whereas other cancers and cardiac disease became more common. Neuroendocrine tumors were responsible for 42.8%, 63.4%, and 81.2% of deaths in grade I, grade II, and grade III, respectively. For grade I localized NET, other cancers (22.2%) were the most common COD followed by NET (19.7%), whereas in grade 2 localized NET, NET was COD in 31.1% of cases followed by other cancers (22.4%). In metastatic disease, NET was the most common COD regardless of grade. CONCLUSIONS For low-grade localized NET, deaths were mostly secondary to non-NET causes. In contrast, NET is responsible for most of deaths in metastatic NET regardless of grade.
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Affiliation(s)
| | - Anas M Saad
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Jason Starr
- Department of Medicine, Mayo Clinic Cancer Center, Jacksonville, FL
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25
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Diagnosis and prognostic significance of extramural venous invasion in neuroendocrine tumors of the small intestine. Mod Pathol 2020; 33:2318-2329. [PMID: 32514164 DOI: 10.1038/s41379-020-0585-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022]
Abstract
Extramural venous invasion (EMVI) is an established independent prognostic factor in colorectal carcinoma where it is linked to hematogenous spread (i.e., liver metastases), influencing the decision for adjuvant chemotherapy. However, its prognostic significance in small intestinal neuroendocrine tumors (NETs) has not been studied, nor is it routinely assessed or reported. We reviewed primary small bowel NETs (14 jejunum, 82 ileum, 8 not specified) from 104 patients (52 women; median age 60.5, range: 24-84). EMVI was identified in 58 cases (55.8%), including in 13 of 21 equivocal cases using an elastin stain. In univariate analysis, EMVI was associated with lymphovascular and perineural invasion, tumor stage, and lymph node and distant metastases, whereas in multivariate analysis, only distant metastases remained significant (p < 0.001). Liver metastases were present in 55 cases (52.9%) and were significantly associated in univariate analysis with lymphovascular and perineural invasion, tumor stage, lymph node metastases, and EMVI, whereas in multivariate analysis, only EMVI remained significant (p < 0.001; odds ratio (OR) = 59.42). Eight patients developed metachronous liver metastases during follow-up (mean 22.9 ± 22.0 months, range: 4.7-73.2) and all (100%) were positive for EMVI. In contrast, of 49 patients who never developed liver metastases over significantly longer follow-up (mean 71.0 ± 32.4 months, range: 6.6-150.4; p < 0.001), only 7 (14.3%) had EMVI (p < 0.001). In Kaplan-Meier analysis, 8 of 15 patients with EMVI (53.3%) developed metachronous liver metastases, compared with 0 of 42 patients without EMVI (p < 0.001). In contrast, nonhepatic distant metastases, seen in 26 (25.0%) patients, were not associated with EMVI in multivariate or Kaplan-Meier analyses. Our data demonstrate that EMVI is common in small bowel NETs and strongly correlates with development of liver metastases. Therefore, its evaluation is critical and should be assessed in combination with adjuvant techniques such as elastin staining, if necessary. Moreover, inclusion of EMVI in pathology reporting guidelines should be considered.
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26
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Sitani K, Parghane RV, Talole S, Basu S. Long-term outcome of indigenous 177Lu-DOTATATE PRRT in patients with Metastatic Advanced Neuroendocrine Tumours: a single institutional observation in a large tertiary care setting. Br J Radiol 2020; 94:20201041. [PMID: 33095671 DOI: 10.1259/bjr.20201041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Assessment of long-term outcome and toxicity of indigenous 177Lu-DOTATATE PRRT in patients of metastatic/advanced NETs in a large tertiary-care PRRT setting. METHODS A total of 468 metastatic/advanced NET patients (wide range of primary sites including CUP-NETs), who underwent at least two cycles of 177Lu-DOTATATE PRRT with available follow-up information, were included and analysed retrospectively in this study. In-house labelling of DOTATATE with 177Lu (direct route produced) was carried out in the hospital radiopharmacy and treatment administered in cycles (dose: 5.55 to 7.4 GBq per patient), at 10-12 weeks interval. The assessment of long-term outcome was undertaken under three broad headings: (a) Therapeutic response, (b) Survival outcome and (c) Toxicity assessment. The median point estimate with 95% CI for progression free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier method. Prognostic covariates for association with PFS and OS was investigated by Cox proportional hazards model (univariate and multivariate Hazard Ratios) and with disease control rate (DCR) by Chi-square test, with significant P value defined as <0.05. RESULTS Long-term outcome (follow-up ranging from 4 to 97.6 months; median period:46 months following first 177Lu-DOTATATE PRRT) results showed, (i) on symptomatic response evaluation scale, complete response (CR) in 214 patients (45.7%), partial response (PR) in 108 (23.1%), stable disease (SD) in 118 (25.2%), progressive disease (PD) in 28 (6%). (ii) Biochemical response evaluation showed CR in 52 (12%), PR in 172 (40%), SD in 161 (38%), and PD in 42 patients (10%). (iii) Molecular imaging response (by PERCIST criteria) showed CR in 29 (6%), PR in 116 (25%), SD in 267 (57%) and PD in 56 (12%) patients. (iv) On RECIST 1.1 criteria, CR was observed in 14 patients (3%), PR in 126 patients (27%), SD in 282 patients (60%) and PD in 46 patients (10%). The median PFS and OS were not reached at a median follow-up of 46 months. Observed PFS and OS at 7 years were 71.1% 95% CI (62.4-79.7%) and 79.4% 95% CI (71.4-86.9%) respectively. PFS was dependent on previous history of chemotherapy, baseline 68Ga-DOTATATE and 18F-FDG uptake, site of primary tumour, total cumulative dose and number of PRRT cycles on univariate analysis, whereas multivariate analysis showed significant association for previous history of chemotherapy, baseline 68Ga-DOTATATE and 18F-FDG uptake and number of PRRT cycles. The OS was dependent on baseline 68Ga-DOTATATE uptake, site of primary tumour, presence of bony metastatic disease, total cumulative dose and number of PRRT cycles on univariate analysis, whereas multivariate analysis showed significant association for bony metastatic disease and number of PRRT cycles. Transient haematological toxicity of Grade 1, Grade 2, and Grade 3 was found in 8 (1.7%), 1 (0.2%) and one patient (0.2%), respectively. Nephrotoxicity of Grade 1, Grade 2, Grade 3, and Grade 4 were seen in 16 (3.5%), 3 (0.6%), 2 (0.4%) and one patient (0.2%), respectively. On a separate sub-analysis of 322 NET patients with progressive disease at the initiation point of PRRT, overall response rates (CR + PR + SD) were 93.5%, 88.5%, 89.1 and 87.9% on symptomatic, biochemical, RECIST 1.1 and PERCIST criteria and PFS and OS at 7 years 68.3% and 79.2%, respectively. CONCLUSIONS The present results demonstrate that 177Lu-DOTATATE PRRT improved symptoms and biochemical markers substantially in most of the NET patients, with disease stabilisation on both anatomical and molecular imaging in majority and response in a sizeable fraction. Additionally, the therapeutic protocol with lesser dose per cycle (mean 5.92 GBq/cycle) and prolonged duration (over 5 cycles and 1.5 years) in a metastatic NET setting proved equally efficacious (with superior PFS and OS rates) and relatively better tolerated with minimal toxicity. ADVANCES IN KNOWLEDGE The present work critically examines the long-term results, survival outcome and toxicity profile of the indigenous 177Lu-DOTATATE (produced through direct neutron activation of enriched 176Lu) in metastatic progressive NETs across a wide range of primary sites and malignancies. Such long-term outcome data establishes the favourable impact of PRRT in a wide patient base and also the therapeutic efficacy of the product.
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Affiliation(s)
- Keerti Sitani
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Rahul V Parghane
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Sanjay Talole
- Homi Bhabha National Institute, Mumbai, India.,Section of Biostatistics, Centre for Cancer Epidemiology, Tata Memorial Centre, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
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Extent of Lymph Node Dissection for Small Bowel Neuroendocrine Tumors. World J Surg 2020; 45:197-202. [PMID: 32737557 DOI: 10.1007/s00268-020-05710-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 12/22/2022]
Abstract
The management of nodal disease remains controversial for small bowel neuroendocrine tumors (SB-NETs). Debates remain regarding the therapeutic role and extent of routine lymph node dissection (LND) for localized SB-NETs, as well as the need for aggressive resection of advanced loco-regional SB-NETs with mesenteric nodal masses. This review will address these questions regarding lymph node dissection for well-differentiated WHO grade 1 and 2 SB-NETs. In general, the aggressiveness and radicality of resection should be balanced against the length of bowel resected and post-operative functional outcomes. In localized SB-NETs with clinically negative lymph nodes, a nodal harvest of ≥ 8 lymph nodes provides accurate staging, but has not been shown to confer survival benefit. For loco-regional SB-NETs with clinically positive lymph nodes identified on imaging, 4 stages of nodal extent have been described: stage 1 nodes are located near to the intestinal border, stage 2 on arterial branches close to the origin of the SMA, stage 3 along the SMA itself, and stage 4 extend in the retroperitoneum under the pancreatic neck. In SB-NETs, every attempt should be made at resection of the primary tumor and the nodal mesenteric mass for curative-intent management and to prevent debilitating complications from mesenteric fibrosis. A mesenteric-sparing approach is favored to allow for resection for complex proximal nodal masses while preserving intestinal length and function. All patients with SB-NETs with nodal mesenteric mass should be assessed by a surgeon for resection; if deemed unresectable, consideration should be given to assessment in high-volume NETs centres to confirm proximal mesenteric-sparing resection is not feasible.
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Abstract
Neuroendocrine neoplasms (NENs) of the gastrointestinal (GI) tract and pancreas are a rare and heterogeneous group of neoplasms characterized by common cellular features as well as unique site-specific traits. GI and pancreatic NENs are much rarer than the more common adenocarcinomas arising at these sites. However, the incidences of GI and pancreatic NENs have increased significantly, particularly in the stomach and common site, followed by rectum, appendix, colon, and stomach. Pancreatic NENs are also uncommon, with fewer than 1 per 100,000, accounting for 1% to 2% of all pancreatic neoplasms.
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Pobłocki J, Jasińska A, Syrenicz A, Andrysiak-Mamos E, Szczuko M. The Neuroendocrine Neoplasms of the Digestive Tract: Diagnosis, Treatment and Nutrition. Nutrients 2020; 12:E1437. [PMID: 32429294 PMCID: PMC7284837 DOI: 10.3390/nu12051437] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/04/2020] [Accepted: 05/13/2020] [Indexed: 12/18/2022] Open
Abstract
Nuroendocrine neoplasms (NENs) are a group of rare neoplasms originating from dispersed neuroendocrine cells, mainly of the digestive and respiratory tract, showing characteristic histology and immunoprofile contributing to classification of NENs. Some NENs have the ability to produce biogenic amines and peptide hormones, which may be associated with clinical syndromes like, e.g., the carcinoid syndrome caused by unmetabolized overproduced serotonin, hypoglycemic syndrome in case of insulinoma, or Zollinger-Ellison syndrome accompanying gastrinoma. Diagnostics for these include ultrasound with endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography/computed tomography (PET/CT). Different nuclear medicine procedures can also be used, like somatostatin analogues scintigraphy (SRS) and 68Ga-Dota-Peptide PET/CT, as well as biochemical methods to determine the level of general neuroendocrine markers, such as chromogranin A (CgA), 5-hydroxyindolacetic acid (5-HIAA), synaptopfysin and cell type-specific peptide hormones, and neurotransmitters like gastrin, insulin, serotonin, and histamine. NENs influence the whole organism by modulating metabolism. The treatment options for neuroendocrine neoplasms include surgery, somatostatin analogue therapy, radionuclide therapy, chemotherapy, molecular targeted therapies, alpha-interferon therapy, and inhibitors of serotonin production. In the case of hypersensitivity to biogenic amines, a diet that limits the main sources of amines should be used. The symptoms are usually connected with histamine, tyramine and putrescine. Exogenic sources of histamine are products that take a long time to mature and ferment. Patients with a genetic insufficiency of the diamine oxidase enzyme (DAO), and those that take medicine belonging to the group of monoamine oxidases (MAO), are particularly susceptible to the negative effects of amines. Diet plays an important role in the initiation, promotion, and progression of cancers. As a result of the illness, the consumption of some nutrients can be reduced, leading to nutritional deficiencies and resulting in malnutrition. Changes in metabolism may lead to cachexia in some patients suffering from NENs. The aim of this narrative review was to advance the knowledge in this area, and to determine possibilities related to dietary support. The authors also paid attention to role of biogenic amines in the treatment of patients with NENs. We can use this information to better understand nutritional issues faced by patients with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs), and to help inform the development of screening tools and clinical practice guidelines.
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Affiliation(s)
- Jakub Pobłocki
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1str, 70-252 Szczecin, Poland; (J.P.); (A.S.); (E.A.-M.)
| | - Anna Jasińska
- Department of Human Nutrition and Metabolomic, Pomeranian Medical University in Szczecin, Broniewskiego 24 str, 71-460 Szczecin, Poland;
| | - Anhelli Syrenicz
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1str, 70-252 Szczecin, Poland; (J.P.); (A.S.); (E.A.-M.)
| | - Elżbieta Andrysiak-Mamos
- Department of Endocrinology, Metabolic Diseases and Internal Diseases, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1str, 70-252 Szczecin, Poland; (J.P.); (A.S.); (E.A.-M.)
| | - Małgorzata Szczuko
- Department of Human Nutrition and Metabolomic, Pomeranian Medical University in Szczecin, Broniewskiego 24 str, 71-460 Szczecin, Poland;
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Gangi A, Manguso N, Gong J, Crystal JS, Paski SC, Hendifar AE, Tuli R. Midgut Neuroendocrine Tumors with Liver-only Metastases: Benefit of Primary Tumor Resection. Ann Surg Oncol 2020; 27:4525-4532. [PMID: 32394299 DOI: 10.1245/s10434-020-08510-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Management of metastatic midgut neuroendocrine tumors (MNET) remains controversial. The benefits of resecting the primary tumor are not clear and advocated only for select patients. This study aimed to determine whether resection of the primary MNET in patients with untreated liver-only metastases has an impact on survival. METHODS This retrospective study reviewed data of the National Cancer Database from 2004 to 2015 for patients with liver-only metastatic MNETs and compared those who received resection of their primary MNET with those who did not. Patient demographics, tumor characteristics, and clinical outcomes were compared between the groups. The primary outcome was overall survival (OS) after adjustment for patient, demographic, and tumor-related factors. RESULTS The study identified 1952 patients with a median age of 63 years (range, 18-90 years). The median primary tumor size was 2.4 cm (range, 0.1-20 cm). Of these patients, 1295 (66%) underwent resection of the primary tumor and 667 (34%) did not. The patients who underwent resection were younger (median age, 63 vs 65 years; p < 0.001) and had smaller primary tumors (median, 2.3 vs 3.0 cm; p < 0.001). The patients with clinical T1 or T2 tumors were significantly less likely to undergo resection than those with stage T3 or T4 tumors (58.5% vs 89.7%; p < 0.001). The median follow-up period was 43 months (range, 1-83 months). In the entire cohort, 483 deaths occurred, with a 5-year OS of 61%. The 5-year OS rate was 49% for the patients who underwent resection and 66% for those who did not (p < 0.001). When the patients were grouped according to T stage, no OS difference between resection and no resection for stages T1 (p = 0.07) and T2 (p = 0.40) was identified. However, the 5-year OS rate was significantly better for the resected patient cohort with T3 (67.5% vs 37.2%; p < 0.001) or T4 (59.8% vs 21.5%; p < 0.001) tumors. CONCLUSIONS The patients with treatment-naïve liver-only metastatic MNET had improved OS when the primary tumor was resected, particularly those with clinical stage T3 or T4 tumors. These patients may benefit from surgical resection of their primary tumor.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicholas Manguso
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jun Gong
- Department of Gastrointestinal Malignancies, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jessica S Crystal
- Division of Surgical Oncology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shirley C Paski
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew E Hendifar
- Department of Gastrointestinal Malignancies, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Bongiovanni A, Liverani C, Recine F, Fausti V, Mercatali L, Vagheggini A, Spadazzi C, Miserocchi G, Cocchi C, Di Menna G, De Vita A, Severi S, Nicolini S, Ibrahim T. Phase-II Trials of Pazopanib in Metastatic Neuroendocrine Neoplasia (mNEN): A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:414. [PMID: 32318336 PMCID: PMC7154093 DOI: 10.3389/fonc.2020.00414] [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: 10/23/2019] [Accepted: 03/10/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Several phase-II trials have been designed to evaluate tyrosine kinase inhibitors (TKIs), in particular, pazopanib in neuroendocrine neoplasia (NEN), but its efficacy has not yet been demonstrated in a randomised-controlled Phase III trial. A systematic review of the published clinical trials of metastatic NEN patients could reduce the possible bias of single phase II studies. The present systematic review focuses on the efficacy and safety of pazopanib in patients with metastatic and locally advanced NEN. Methods: A systematic search in the major databases Medline/PubMed, Cochrane and Embase and in supplementary material from important international Meetings was performed to identify publications on pazopanib for the treatment of neuroendocrine neoplasia. English language was defined as a restriction. Four authors of the present review independently performed the study selection, assessed the risk of bias and extracted study data. Four published clinical trials and 2 abstracts were identified. One trial was excluded because the topic was Von-Hippel Landau disease and one abstract was eliminated because of the lack of information on meeting proceedings. Results: In all of the trials pazopanib was orally administered at a dose of 800 mg daily continuously with a 28-day cycle. The intention-to-treat population for efficacy was composed of 230 patients with a median age of 62 years. The partial response rate was 10.7% (95% confidence interval 2.6-20.5). The rate for stable disease was 79.6% (range: 61.7-92.1%) with a disease control rate (DCR) of 90.3%. Progressive disease was reported in 9.7% (range 5.2-17.6) of patients. No complete responses were observed. Median progression-free survival was 11.6 months (95% CI: 9.2-13.9). Overall survival from all the trials was 24.6 (95% CI: 18.7-40.8) months. Severe adverse events (grade III-IV) included hypertension 31%, 16% increase in AST/ALT, diarrhoea 10% and fatigue 10%. Conclusions: Pazopanib monotherapy achieved a DCR of 90.3% in patients with locally advanced and/or metastatic neuroendocrine neoplasia, with an overall response rate comparable to other TKIs and mTOR inhibitors and a safety profile similar to that of drugs of the same class.
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Affiliation(s)
- Alberto Bongiovanni
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Chiara Liverani
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Federica Recine
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Valentina Fausti
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Laura Mercatali
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Alessandro Vagheggini
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Chiara Spadazzi
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giacomo Miserocchi
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Claudia Cocchi
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giandomenico Di Menna
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Alessandro De Vita
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Stefano Severi
- Nuclear Medicine Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Silvia Nicolini
- Nuclear Medicine Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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Loss of copy of MIR1-2 increases CDK4 expression in ileal neuroendocrine tumors. Oncogenesis 2020; 9:37. [PMID: 32198354 PMCID: PMC7083839 DOI: 10.1038/s41389-020-0221-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 12/19/2022] Open
Abstract
Ileal neuroendocrine tumors (I-NETs) are the most common tumors of the small intestine. Although I-NETs are known for a lack of recurrently mutated genes, a majority of tumors do show loss of one copy of chromosome 18. Among the genes on chromosome 18 is MIR1-2, which encodes a microRNA, MIR1-3p, with high complementarity to the mRNA of CDK4. Here we show that transfection of neuroendocrine cell lines with MIR1-3p lowered CDK4 expression and activity, and arrested growth at the G1 stage of the cell cycle. Loss of copy of MIR1-2 in ileal neuroendocrine tumors associated with increased expression of CDK4. Genetic events that attenuated RB activity, including loss of copy of MIR1-2 as well as loss of copy of CDKN1B and CDKN2A, were more frequent in tumors from patients with metastatic I-NETs. These data suggest that inhibitors of CDK4/CDK6 may benefit patients whose I-NETs show loss of copy of MIR1-2, particularly patients with metastatic disease.
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Impact of Peritoneal Metastasis on Survival of Patients With Small Intestinal Neuroendocrine Tumor. Am J Surg Pathol 2020; 43:559-563. [PMID: 30702499 DOI: 10.1097/pas.0000000000001225] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The liver and peritoneum are the 2 most common distant metastatic sites for small intestinal neuroendocrine tumors (SI-NET). In this study, we evaluated the differential impact of hepatic and/or peritoneal metastasis on prognosis of SI-NET patients. Surgical Pathology archives were searched for SI-NET resections performed between January 1, 1994 and August 31, 2017. Two hundred nineteen cases with clinical follow-up data were identified. Pathology reports and electronic medical records were reviewed. The 219 patients included 104 females and 115 males with a median age of 59 years (range, 19 to 85 y). There were 71 (33%) cases without hepatic or peritoneal metastasis, 80 (37%) with hepatic metastasis only, 14 (6%) with peritoneal metastasis only, and 53 (24%) with both hepatic and peritoneal metastasis at the time of surgery or during follow-up. The number of primary tumors, largest tumor size, lymph node metastasis, pT category, and sex were not significant independent prognostic factors in multivariate Cox proportional hazard regression. Age was the only variable other than presence of metastatic disease that was associated with worse prognosis (5% increase in risk/year of age; 95% confidence interval, 1.7%-8.2%; P=0.003). After controlling for patient age, pairwise comparisons of marginal linear predictions showed increased risk with peritoneal metastasis, with or without associated hepatic metastasis, compared to hepatic metastasis only. In conclusion, although limited by the number of patients with peritoneal metastasis only, these results support substratifying patients with metastatic SI-NET by anatomic site of metastasis.
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34
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Zanini S, Renzi S, Giovinazzo F, Bermano G. mTOR Pathway in Gastroenteropancreatic Neuroendocrine Tumor (GEP-NETs). Front Endocrinol (Lausanne) 2020; 11:562505. [PMID: 33304317 PMCID: PMC7701056 DOI: 10.3389/fendo.2020.562505] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) originate from neuroendocrine cells in the gastrointestinal tract. They are heterogeneous, and though initially considered rare tumors, the incidence of GEP-NENs has increased in the last few decades. Therapeutic approaches for the metastatic disease include surgery, radiological intervention by chemoembolisation, radiofrequency ablation, biological therapy in addition to somatostatin analogs, and PRRT therapy (177Lu-DOTATATE). The PI3K-AKT-mTOR pathway is essential in the regulation of protein translation, cell growth, and metabolism. Evidence suggests that the mTOR pathway is involved in malignant progression and resistance to treatment through over-activation of several mechanisms. PI3K, one of the main downstream of the Akt-mTOR axis, is mainly involved in the neoplastic process. This pathway is frequently deregulated in human tumors, making it a central target in the development of new anti-cancer treatments. Recent molecular studies identify potential targets within the PI3K/Akt/mTOR pathway in GEP-NENs. However, the use of target therapy has been known to lead to resistance due to several mechanisms such as feedback activation of alternative pathways, inactivation of protein kinases, and deregulation of the downstream mTOR components. Therefore, the specific role of targeted drugs for the management of GEP-NENs is yet to be well-defined. The variable clinical presentation of advanced neuroendocrine tumors is a significant challenge for designing studies. This review aims to highlight the role of the PI3K/Akt/mTOR pathway in the development of neuroendocrine tumors and further specify its potential as a therapeutic target in advanced stages.
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Affiliation(s)
- Sara Zanini
- Centre for Obesity Research and Education (CORE), School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom
| | - Serena Renzi
- School of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Francesco Giovinazzo
- Fondazione Policlinico Universitario A. Gemelli Istituto di ricovero e cura a carattere scientifico (IRCCS), Department of Surgery -Transplantation Service, Rome, Italy
- *Correspondence: Francesco Giovinazzo
| | - Giovanna Bermano
- Centre for Obesity Research and Education (CORE), School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom
- Giovanna Bermano
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35
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Eriksson J, Norlén O, Ögren M, Garmo H, Ihre-Lundgren C, Hellman P. Primary small intestinal neuroendocrine tumors are highly prevalent and often multiple before metastatic disease develops. Scand J Surg 2019; 110:44-50. [PMID: 31587594 DOI: 10.1177/1457496919874484] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Small intestinal neuroendocrine tumors are the most common of small bowel malignancies with a clinical incidence of about 1 per 100,000 persons per year. There has been a threefold increase in the incidence of small intestinal neuroendocrine tumor during later decades, but there are no studies that clarify whether this is due to a true higher incidence or if the rise is a mere product of, for instance, improved diagnostic modalities. The aim of this study was to investigate the incidence of clinical as well as subclinical small intestinal neuroendocrine tumors found at autopsy as well as describing the frequency of concomitant malignancies in patients with small intestinal neuroendocrine tumor. MATERIALS AND METHODS An autopsy registry from the Malmö county population from 1970 to 1982 with an 87% autopsy rate was used. The clinical autopsy reports for patients coded for the existence of "carcinoid tumor" were scrutinized for the presence of small intestinal neuroendocrine tumor, metastatic disease, and concomitant malignancies. Details of patients with clinically diagnosed small intestinal neuroendocrine tumor during this time period were gathered from the Swedish Cancer Registry. RESULTS The mean annual incidence of small intestinal neuroendocrine tumor during this period was 5.33 per 100,000 individuals, and the mean annual prevalence was 581 per 100,000. The cause of death in the majority of cases was not due to small intestinal neuroendocrine tumor. In total, 48% of the people with small intestinal neuroendocrine tumor had at least one other malignancy, most commonly colorectal cancer. CONCLUSION Most small intestinal neuroendocrine tumors are subclinical, and persons living with them will often die due to other causes. There was a high rate of multiple primary tumors (40%), suggesting that multiple tumors seem to arise before the advent of metastatic disease. Moreover, a comparably high rate of associated colorectal carcinoma was found.
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Affiliation(s)
- J Eriksson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - O Norlén
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - M Ögren
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - H Garmo
- Division of Cancer Studies, Cancer Epidemiology Group, Research Oncology, King's College London, London, UK.,Regional Oncologic Centre, Uppsala University, Uppsala, Sweden
| | - C Ihre-Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P Hellman
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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36
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Alekberzade AV, Krylov NN, Garmanova TN, Shahbazov R, Azari F, Zuykova KS, Litovchenko ED. [Duodenal neuroendocrine tumors]. Khirurgiia (Mosk) 2019:87-95. [PMID: 31355821 DOI: 10.17116/hirurgia201907187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Significant augmentation of the incidence of duodenal neuroendocrine tumors duodenum has been observed in recent decades. There are 5 histological types of these tumors: gastrinoma (50-60%), somatostatin-producing tumor (15%), inactive serotonin-containing tumors (20%), poorly differentiated neuroendocrine carcinoma (<3%) and gangliocytic paraganglioma (<2%). The majority of tumors are localized within the bulb and postbulbar part of duodenum, 20% are found in periampular area. Treatment strategy depends on dimensions, localization, histological class, stage and type of tumor. It is believed that endoscopic resection is permissible for small inactive tumors (G1) located above major duodenal papilla. The majority of other neoplasms requires surgical resection. Personal experience of various surgeons is limited by small group of patients. Therefore, it is necessary to summarize results for selection of optimal treatment.
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Affiliation(s)
- A V Alekberzade
- Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow, Russia
| | - N N Krylov
- Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow, Russia
| | - T N Garmanova
- Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow, Russia
| | - R Shahbazov
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - F Azari
- Department of Surgery, University of Pennsylvania, Philadelphia PA, USA
| | - K S Zuykova
- Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow, Russia
| | - E D Litovchenko
- Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow, Russia
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Local treatment of liver metastases by administration of 177Lu-octreotate via isolated hepatic perfusion - A preclinical simulation of a novel treatment strategy. Surg Oncol 2019; 29:148-156. [PMID: 31196481 DOI: 10.1016/j.suronc.2019.05.002] [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: 11/09/2018] [Revised: 04/17/2019] [Accepted: 05/10/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Systemic 177Lu-octreotate treatment for metastatic neuroendocrine tumours is restricted by organs at risk. By administering 177Lu-octreotate during isolated hepatic perfusion (IHP), the uptake in organs at risk might be strongly reduced. The aim of this study was to investigate the feasibility to use the combination of IHP and radionuclide therapy. METHODS To simulate IHP, the liver of a pig was prepared for ex vivo perfusion. Blood containing 490 MBq 177Lu-octreotate was circulated through the liver for 60 min, after which the liver was rinsed. After IHP, the liver was examined by SPECT/CT. Lastly, an intraoperative gamma detector (IGD) was used to determine 177Lu activity concentration in the liver and results were compared with the activity concentration in corresponding liver biopsies. RESULTS Detector measurements over the liver during the IHP showed a fast increase with a maximum after approximately 10-15 min. After IHP, about 75% of the 177Lu in the liver could be washed out. The SPECT/CT images revealed a relatively inhomogeneous distribution. Nevertheless, the IGD values of 177Lu activity concentration showed acceptable agreement with the biopsy values. CONCLUSIONS Our results in pig show that it could be feasible to treat patients with liver metastases from NETs with 177Lu-octreotate via IHP 177. However, an inhomogeneous distribution of 177Lu-octreotate in normal liver tissue is expected, and in order to determine the activity concentration with satisfactory accuracy using an IGD, measurements need to be performed at several positions over the liver.
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Lee SW, Sung JK, Cho YS, Bang KB, Kang SH, Kim KB, Kim SH, Moon HS, Song KH, Kim SM, Chung IK, Lee DS, Jeong HY, Youn SJ. Comparisons of therapeutic outcomes in patients with nonampullary duodenal neuroendocrine tumors (NADNETs): A multicenter retrospective study. Medicine (Baltimore) 2019; 98:e16154. [PMID: 31261543 PMCID: PMC6617016 DOI: 10.1097/md.0000000000016154] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Duodenal neuroendocrine tumors (DNETs) are rare tumors that are occasionally found during upper endoscopies. The incidence of DNETs is increasing, although the data regarding treatment outcomes are insufficient. The aim of this study was to evaluate the treatment outcomes in patients with nonampullary DNETs who underwent endoscopic resection or surgery. We evaluated the medical records of patients who were diagnosed with nonampullary DNETs from 2004 to 2017 in 7 university hospitals. We retrospectively analyzed clinical characteristics and compared therapeutic outcomes based on the endoscopic lesion size and treatment method. We ultimately enrolled 60 patients with nonampullary DNETs who underwent endoscopic and surgical treatments. In the endoscopic treatment group, the en bloc resection, endoscopic complete resection (CR) and pathologic CR rates were 88%, 92%, and 50%, respectively. The endoscopic treatment group was divided into 3 subgroups based on the lesion size (1-5 mm, 6-10 mm, and ≥11 mm). The pathologic CR rate was significantly lower in the subgroup with a lesion size ≥11 mm (0%, P = .003) than those in the other 2 subgroups. Lymphovascular invasion occurred significantly more frequently (33.3%, P = .043) among those with a lesion size ≥11 mm. The pathologic CR rate in the surgical treatment group was higher (90.9%) than that in the endoscopic treatment group (50%, P = .017). Surgical treatment appears to be a more appropriate choice because of the risks of incomplete resection and lymphovascular invasion after endoscopic treatment for lesions larger than 11 mm.
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Affiliation(s)
- Seung Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea
| | - Jae Kyu Sung
- Department of Internal Medicine, Chungnam National University, College of Medicine
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan
| | - Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine
| | - Sun Hyung Kang
- Department of Internal Medicine, Chungnam National University, College of Medicine
| | - Ki Bae Kim
- Department of Internal Medicine, Chungbuk National University School of Medicine
| | - Sae Hee Kim
- Department of Internal Medicine, College of Medicine, Eulji University
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University, College of Medicine
| | - Kyung Ho Song
- Department of Internal Medicine, College of Medicine, Konyang University, Republic of Korea
| | - Sun Moon Kim
- Department of Internal Medicine, College of Medicine, Konyang University, Republic of Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan
| | - Dong Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea
| | - Hyun Yong Jeong
- Department of Internal Medicine, Chungnam National University, College of Medicine
| | - Sei Jin Youn
- Department of Internal Medicine, Chungbuk National University School of Medicine
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Numbere N, Huber AR, Shi C, Cates JMM, Gonzalez RS. Should Ki67 immunohistochemistry be performed on all lesions in multifocal small intestinal neuroendocrine tumours? Histopathology 2018; 74:424-429. [PMID: 30326145 DOI: 10.1111/his.13771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/12/2018] [Indexed: 02/06/2023]
Abstract
AIMS Well-differentiated small intestinal neuroendocrine tumours (SI-NETs) are often multifocal, and this has been suggested to impart worse disease-free survival. Practice guidelines have not been established for World Health Organisation (WHO) grading of multiple primary lesions. METHODS AND RESULTS We identified 68 patients with ileal/jejunal SI-NET for a combined total of 207 primary lesions. Each case was evaluated for patient age and sex; size of all tumours; presence of lymph node metastases, mesenteric tumour deposits or distant metastases; and disease-specific outcome. Ki67 staining was performed on all 207 primary lesions. The relationship between multifocality and clinicopathological factors was compared using Fisher's exact test. Outcome was tested using Cox proportional hazard regression. Forty-two patients had unifocal disease, and 26 had multifocal disease (median five lesions, range = 2-32). Most tumours were WHO grade 1 (201 of 207, 97%). Of the five patients with grades 2/3 tumours, three patients had unifocal disease, one patient had two subcentimetre grade 2 lesions (including the largest) and eight subcentimetre grade 1 lesions, and one patient had one 1.6-cm grade 3 lesion and one subcentimetre grade 1 lesion. There was a positive correlation between tumour size and Ki67 index (coefficient 0.28; 95% confidence interval 0.05-0.52, P = 0.017). There was no significant association between multifocality and nodal metastases, mesenteric tumour deposits, distant metastases or disease-specific survival. CONCLUSIONS In patients with multifocal SI-NET, unless a particular lesion has a high mitotic rate, only staining the largest lesion for Ki67 should serve to grade almost all cases accurately. Multifocality does not appear to significantly impact patient survival.
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Affiliation(s)
- Numbereye Numbere
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Aaron R Huber
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Chanjuan Shi
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin M M Cates
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raul S Gonzalez
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Massironi S, Campana D, Partelli S, Panzuto F, Rossi RE, Faggiano A, Brighi N, Falconi M, Rinzivillo M, Delle Fave G, Colao AM, Conte D. Heterogeneity of Duodenal Neuroendocrine Tumors: An Italian Multi-center Experience. Ann Surg Oncol 2018; 25:3200-3206. [PMID: 30054824 DOI: 10.1245/s10434-018-6673-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Sara Massironi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
| | - Davide Campana
- Department of Medical and Surgical Sciences, Bologna University St. Orsola-Malpighi Polyclinic Hospital, Bologna, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Francesco Panzuto
- Digestive and Liver Diseases Department, University "La Sapienza" of Rome Sant'Andrea Hospital, Rome, Italy
| | - Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Antongiulio Faggiano
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Nicole Brighi
- Department of Medical and Surgical Sciences, Bologna University St. Orsola-Malpighi Polyclinic Hospital, Bologna, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Maria Rinzivillo
- Digestive and Liver Diseases Department, University "La Sapienza" of Rome Sant'Andrea Hospital, Rome, Italy
| | - Gianfranco Delle Fave
- Digestive and Liver Diseases Department, University "La Sapienza" of Rome Sant'Andrea Hospital, Rome, Italy
| | - Anna Maria Colao
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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41
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Eriksson J, Garmo JEH, Ihre-Lundgren C, Hellman P. Prognostic factors for death after surgery for small intestinal neuroendocrine tumours. BJS Open 2018; 2:345-352. [PMID: 30263986 PMCID: PMC6156160 DOI: 10.1002/bjs5.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/23/2018] [Indexed: 01/01/2023] Open
Abstract
Background Neuroendocrine tumours of the small intestine (SI-NETs) are rare gastrointestinal neoplasms with an annual incidence of about one per 100 000. Patients with apparently similar tumours have variable outcomes. The aim of this study was to identify postoperative prognostic factors identifiable after initial surgery. Methods This was a nested case-control study of patients with SI-NETs who were treated between 1961 and 2001. Data were retrieved from the Swedish Cancer Registry. Patients who died from the SI-NET and corresponding controls (who outlived cases by at least 1 month), matched by age at diagnosis and calendar period, were included. Sex, postoperative symptoms, postoperative 5-hydroxyindoleacetic acid (5-HIAA) values, European Neuroendocrine Tumor Society (ENETS) stage, insufficiency of the tricuspid valve, radical secondary surgery and secondary malignancy were studied as potential prognostic factors. Results In total, 1122 patients were included (561 cases, 561 controls). Postoperative factors of prognostic importance included hormone-related symptoms, stage IV disease, raised levels of 5-HIAA, insufficiency of the tricuspid valve, secondary surgery not being macroscopically radical and a second malignancy. Conclusion Stage and symptomatic disease are important prognostic factors in SI-NET.
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Affiliation(s)
- J Eriksson
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - J E H Garmo
- Regional Oncological Centre Uppsala University Uppsala Sweden.,Cancer Epidemiology Unit, Division of Cancer Studies King's College London London UK
| | - C Ihre-Lundgren
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - P Hellman
- Department of Surgical Sciences Uppsala University Uppsala Sweden
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42
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Gibson WE, Gonzalez RS, Cates JMM, Liu E, Shi C. Hepatic micrometastases are associated with poor prognosis in patients with liver metastases from neuroendocrine tumors of the digestive tract. Hum Pathol 2018; 79:109-115. [PMID: 29763717 DOI: 10.1016/j.humpath.2018.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/25/2018] [Accepted: 05/04/2018] [Indexed: 01/29/2023]
Abstract
Pathologic examination of hepatic metastasectomies from patients with metastatic small intestinal or pancreatic neuroendocrine tumor frequently reveals micrometastases undetectable by radiologic or macroscopic gross examination. This finding raises the possibility that undetectable micrometastases remain in these patients after metastasectomy. Here we examined liver resections for micrometastases and assessed their impact on prognosis. Hepatic metastasectomies from 65 patients with neuroendocrine tumor of the small intestine (N = 43) or pancreas (N = 22) were reviewed for the presence of micrometastases, which were defined as microscopic tumor foci ≤1 mm in greatest dimension. Medical records were also reviewed for patient demographics, clinical history, and follow-up data. Micrometastasis was identified in 36 (55%) of 65 hepatic resection specimens. More hepatic micrometastases were seen in small intestinal cases than in pancreatic cases (29/43, 67%, versus 7/22, 32%; P < .01). They were typically present within portal tracts, sometimes with extension into the periportal region or sinusoidal spaces away from the portal tracts. Patients without hepatic micrometastases had fewer macrometastases or more R0 hepatic resections than those with micrometastases. The presence of hepatic micrometastases was associated with poor overall survival both before (hazard ratio [HR] 3.43; 95% CI 1.14-10.30; P = .03) and after accounting for confounding variables in stratified Cox regression (HR 4.82; 95% CI 1.0621.79; P = .04). In conclusion, hepatic micrometastases are common in patients with metastatic small intestinal or pancreatic neuroendocrine tumor and are independently associated with poor prognosis. These data suggest that surgical resection of hepatic metastases is likely not curative in these patients.
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Affiliation(s)
- William E Gibson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027
| | - Raul S Gonzalez
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY 14642
| | - Justin M M Cates
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027
| | - Eric Liu
- Department of Surgery, Rocky Mountain Cancer Centers, Denver, CO 80218
| | - Chanjuan Shi
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027.
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43
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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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Chauhan A, Yu Q, Ray N, Farooqui Z, Huang B, Durbin EB, Tucker T, Evers M, Arnold S, Anthony LB. Global burden of neuroendocrine tumors and changing incidence in Kentucky. Oncotarget 2018; 9:19245-19254. [PMID: 29721198 PMCID: PMC5922392 DOI: 10.18632/oncotarget.24983] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/15/2018] [Indexed: 12/31/2022] Open
Abstract
Background Neuroendocrine tumors (NETs) have a low incidence but relatively high prevalence. Over the last three decades, the incidence of NETs has risen 6-fold in the United States. We conducted an observational study to compare the incidence of NETs reported to the Kentucky Cancer Registry (KCR) versus that reported to Surveillance, Epidemiology, and End Results Program (SEER). We also provide a systematic review of the state of neuroendocrine tumors worldwide, and compare the available global and local published data. Methods KCR and SEER databases were queried for NET cases between 1995 and 2015. A detailed literature review of epidemiological data for various nations worldwide summarize epidemiological data from various countries. Results KCR recorded 6179 individuals with newly diagnosed NETs between 1995 and 2015. Between 1995-2012, the incidence of NETs in KCR increased from 3.1 to 7.1 per 100,000 cases, while it increased from 3.96 to 6.61 in the SEER database. The incidence rates in both KCR and SEER databases were linear. 90.57% were Caucasians with 54.74% females. 27.67% of the Kentucky population was from the Appalachian region. Patients aged 50-64 years had the highest prevalence (38%). Lung NET (30.60%) formed the bulk of cases, followed by small intestine (16.82%), rectum/anus (11.35%) and colon (9.71%). Conclusions NETs incidence between 1995 and 2015 show a linear increase in both KCR and SEER databases. Because of this increased incidence it is imperative for community oncologists to familiarize themselves with this entity, which until recently was under-studied and with few viable treatment options.
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Affiliation(s)
- Aman Chauhan
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Qian Yu
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Neha Ray
- University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Zainab Farooqui
- University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Bin Huang
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Eric B Durbin
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Thomas Tucker
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Kentucky Cancer Registry, Lexington, KY, USA
| | - Mark Evers
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Surgery University of Kentucky, Lexington, KY, USA
| | - Susanne Arnold
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Lowell B Anthony
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
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45
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Bodei L, Ambrosini V, Herrmann K, Modlin I. Current Concepts in 68Ga-DOTATATE Imaging of Neuroendocrine Neoplasms: Interpretation, Biodistribution, Dosimetry, and Molecular Strategies. J Nucl Med 2017; 58:1718-1726. [DOI: 10.2967/jnumed.116.186361] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/27/2017] [Indexed: 12/19/2022] Open
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Mesenteric Tumor Deposits in Midgut Small Intestinal Neuroendocrine Tumors Are a Stronger Indicator Than Lymph Node Metastasis for Liver Metastasis and Poor Prognosis. Am J Surg Pathol 2017; 41:128-133. [PMID: 27684993 DOI: 10.1097/pas.0000000000000751] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Mesenteric tumor deposits (MTDs) are not included in the American Joint Committee on Cancer (AJCC) staging system for midgut small intestinal neuroendocrine tumors (NETs). We examined the prognostic significance of MTDs associated with midgut NETs. Hematoxylin and eosin slides from 132 resected jejunal/ileal NETs were reviewed for AJCC tumor stage, lymph node (LN) metastasis, MTDs, and hepatic metastases. MTDs were defined as discrete irregular mesenteric tumor nodules discontinuous from the primary tumor. Clinical or pathologic evidence of metastases and survival data were abstracted from electronic medical records. The cohort included 72 male and 60 female patients with a median age of 60 years. LN metastasis, MTDs, and liver metastasis were present in 80%, 68%, and 58% of patients, respectively. Female sex and presence of MTDs were independent predictors of liver metastasis. The odds ratio for hepatic metastasis in the presence of MTDs was 16.68 (95% confidence interval [CI], 4.66-59.73) and 0.81 (95% CI, 0.20-3.26) for LN metastasis. Age, MTDs, and hepatic metastasis were associated with disease-specific survival (DSS) in univariate analysis. Primary tumor histologic grade, pT3/T4 stage, and LN metastasis were not associated with DSS. Multivariate analysis of liver metastasis-free survival stratified by tumor grade showed that MTDs were associated with adverse outcomes. The hazard ratio for MTDs was 4.58 (95% CI, 1.89-11.11), compared with 0.98 (95% CI, 0.47-2.05) for LN metastasis. MTDs, but not LN metastasis, in midgut NETs are a strong predictor for hepatic metastasis and are associated with poor DSS.
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47
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Recent updates on grading and classification of neuroendocrine tumors. Ann Diagn Pathol 2017; 29:11-16. [PMID: 28807335 DOI: 10.1016/j.anndiagpath.2017.04.005] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/12/2017] [Indexed: 12/24/2022]
Abstract
Neuroendocrine tumors (NETs) are originating from neuroendocrine cells in diffuse endocrine systems. NETs are diagnosed by characteristic histologic features and immunoprofiles. Recent 2010 WHO classification for gastroenteropancreatic NETs introduced grading system based on mitotic count and Ki-67 proliferation index. Gastroenteropancreatic NETs are classified as NET grade 1, NET grade 2, and neuroendocrine carcinoma (NET grade 3). However, the carcinoid is still used in classification of NETs of the lung and uterine cervix. Some issues with grading system such as methodologies for evaluation of Ki-67 index and subclassification of neuroendocrine carcinoma (NET grade 3) are arising. The importance of Ki-67 labeling index is emerging in differential diagnosis of lung carcinoids. In this review, we focus on recent grading and classification of NETs and related issues in various organs, including gastrointestinal tract, pancreas, lung, and female reproductive organs.
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48
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Dedinská I, Laca L, Miklušica J, Palkoci B, Skálová P, Lauková S, Osinová D, Strmeňová S, Janík J, Mokáň M. Complications of liver resection in geriatric patients. Ann Hepatol 2017; 16:149-156. [PMID: 28051804 DOI: 10.5604/16652681.1226934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Introduction and aims. Liver resection is the treatment of choice for many primary and secondary liver diseases. Most studies in the elderly have reported resection of primary and secondary liver tumors, especially hepatocellular carcinoma and colorectal metastatic cancer. However, over the last two decades, hepatectomy has become safe and is now performed in the older population, implying a paradigm shift in the approach to these patients. MATERIAL AND METHODS We retrospectively evaluated the risk factors for postoperative complications in patients over 65 years of age in comparison with those under 65 years of age after liver resection (n = 360). The set comprised 127 patients older than 65 years (35%) and 233 patients younger than 65 years (65%). RESULTS In patients younger than 65 years, there was a significantly higher incidence of benign liver tumors (P = 0.0073); in those older than 65 years, there was a significantly higher incidence of metastasis of colorectal carcinoma to the liver (0.0058). In patients older than 65 years, there were significantly more postoperative cardiovascular complications (P = 0.0028). Applying multivariate analysis, we did not identify any independent risk factors for postoperative complications. The 12-month survival was not significantly different (younger versus older patients), and the 5-year survival was significantly worse in older patients (P = 0.0454). CONCLUSION In the case of liver resection, age should not be a contraindication. An individualized approach to the patient and multidisciplinary postoperative care are the important issues.
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Affiliation(s)
- Ivana Dedinská
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Ludovít Laca
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Juraj Miklušica
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Blazej Palkoci
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Petra Skálová
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Slavomíra Lauková
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Denisa Osinová
- Clinic of Anesthesiology and Intensive Medicine, University Hospital Martin and Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Simona Strmeňová
- Clinic of Internal Medicine I, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Ján Janík
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
| | - Marián Mokáň
- Clinic of Internal Medicine I, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia
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Landau M, Wisniewski S, Davison J. Jejunoileal Neuroendocrine Tumors Complicated by Intestinal Ischemic Necrosis Are Associated With Worse Overall Survival. Arch Pathol Lab Med 2017; 140:461-6. [PMID: 27128303 DOI: 10.5858/arpa.2015-0105-oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Jejunoileal neuroendocrine tumors (JINETs) are slow-growing, malignant tumors that are often associated with protracted survival, despite their frequent presentation at an advanced stage. A subset of JINETs is complicated by intestinal ischemic necrosis (IIN), which leads to their initial clinical presentation. OBJECTIVE -To assess the effect of IIN on overall survival in patients with JINETs. DESIGN -Ten JINETs with IIN during a 14-year period and a control group of 52 JINETs without IIN were identified retrospectively. The hematoxylin-eosin slides and gross descriptions were reviewed, and pathologic features were assessed. Overall survival was compared between the 2 groups using the Kaplan Meier method and Cox proportional hazards model. RESULTS -At 1 year postresection, only 40% (4 of 10) of the patients with IIN were alive, whereas 94% (49 of 52) of those without IIN were alive (P < .001). Patients with IIN were significantly older than those without IIN (median, 83 years versus 65.5 years, P = .001). By univariate Cox proportional hazards regression, IIN was associated with a 4.30-fold increased risk of death (95% confidence interval 1.75-10.56; P = .001). When controlling for age, advanced stage (stage III or IV), tumor grade, and synchronous carcinoma in a multivariate analysis, IIN showed a trend toward prognostic significance (2.31-fold increased risk of death; 95% confidence interval, 0.85-6.27; P = .10). CONCLUSIONS -The pathologic identification of tumor-associated IIN portends a worse overall survival among patients with JINETs.
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Affiliation(s)
| | | | - Jon Davison
- From the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Drs Landau and Davison); and the Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh (Dr Wisniewski)
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50
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Kim JY, Hong SM. Recent Updates on Neuroendocrine Tumors From the Gastrointestinal and Pancreatobiliary Tracts. Arch Pathol Lab Med 2017; 140:437-48. [PMID: 27128301 DOI: 10.5858/arpa.2015-0314-ra] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT -Gastrointestinal (GI) and pancreatobiliary tracts contain a variety of neuroendocrine cells that constitute a diffuse endocrine system. Neuroendocrine tumors (NETs) from these organs are heterogeneous tumors with diverse clinical behaviors. Recent improvements in the understanding of NETs from the GI and pancreatobiliary tracts have led to more-refined definitions of the clinicopathologic characteristics of these tumors. Under the 2010 World Health Organization classification scheme, NETs are classified as grade (G) 1 NETs, G2 NETs, neuroendocrine carcinomas, and mixed adenoneuroendocrine carcinomas. Histologic grades are dependent on mitotic counts and the Ki-67 labeling index. Several new issues arose after implementation of the 2010 World Health Organization classification scheme, such as issues with well-differentiated NETs with G3 Ki-67 labeling index and the evaluation of mitotic counts and Ki-67 labeling. Hereditary syndromes, including multiple endocrine neoplasia type 1 syndrome, von Hippel-Lindau syndrome, neurofibromatosis 1, and tuberous sclerosis, are related to NETs of the GI and pancreatobiliary tracts. Several prognostic markers of GI and pancreatobiliary tract NETs have been introduced, but many of them require further validation. OBJECTIVE -To understand clinicopathologic characteristics of NETs from the GI and pancreatobiliary tracts. DATA SOURCES -PubMed (US National Library of Medicine) reports were reviewed. CONCLUSIONS -In this review, we briefly summarize recent developments and issues related to NETs of the GI and pancreatobiliary tracts.
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Affiliation(s)
| | - Seung-Mo Hong
- From the Department of Pathology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea (Dr Kim); and the Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (Dr Hong)
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