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Kunte AR, Yadav N, Bhandare MS, Puranik A, Bal M, Chaudhari VA, Shrikhande SV. Observation for localized, low-grade duodenal neuroendocrine tumors: Equivalent outcomes to resection. J Gastrointest Surg 2024:S1091-255X(24)00462-1. [PMID: 38782087 DOI: 10.1016/j.gassur.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/24/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Aditya R Kunte
- Department of Surgical Oncology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Nishant Yadav
- Department of Surgical Oncology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Manish S Bhandare
- Department of Surgical Oncology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Ameya Puranik
- Department of Nuclear Medicine, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Vikram A Chaudhari
- Department of Surgical Oncology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India
| | - Shailesh V Shrikhande
- Department of Surgical Oncology, Tata Memorial Centre (Mumbai), Homi Bhabha National Institute, Mumbai, India.
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2
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Gupta S, Kumar P, Chacchi R, Murino A, Despott EJ, Lemmers A, Pioche M, Bourke MJ. Duodenal neuroendocrine tumors: Short-term outcomes of endoscopic submucosal dissection performed in the Western setting. Endosc Int Open 2023; 11:E1099-E1107. [PMID: 38026782 PMCID: PMC10681807 DOI: 10.1055/a-2181-0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 09/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background and study aims Endoscopic resection (ER) is recommended for the management of duodenal neuroendocrine tumors (D-NETs) confined to the submucosal layer, without lymph node or distant metastasis. While this is accepted practice for lesions < 10 mm, consensus for larger lesions remains unclear. Although endoscopic submucosal dissection (ESD) has been proposed as the preferred ER technique for DNETs ≥10 mm, there are limited data on efficacy and safety, particularly in the Western setting. Patients and methods We performed a retrospective analysis of patients with D-NETs who underwent ESD between 2012 and 2022 in three tertiary referral centers in Australia, France, and Belgium. Results Fourteen patients with 15 D-NETs were evaluated. Median patient age was 64 years (interquartile range [IQR] 58-70 years). All D-NETs were confined to the duodenal bulb. Median D-NET size was 10 mm (IQR 7-12 mm) and specimen size was 15 mm (IQR 15-20 mm). Median procedure time was 60 minutes (IQR 25-90 minutes). The rate of en bloc resection was 100%. Intra-procedural perforation occurred in four patients (26.7%), with all closed endoscopically without long-term sequelae. There were no episodes of clinically significant bleeding. No local recurrence, lymph node or distant metastasis was observed at a median follow-up of 19.9 months (IQR 10.3-49.3 months). Conclusions In experienced hands, ESD for D-NETs can achieve a 100% en bloc resection rate. There were no cases of local recurrence or distant metastatic spread, indicating that ESD may be a viable option for patients with D-NETs 10 to 15 mm that are not surgical candidates.
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Affiliation(s)
- Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Puja Kumar
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Division of Gastroenterology and Hepatology, University of Calgary Faculty of Medicine, Calgary, Canada
| | - Rocio Chacchi
- Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Arnaud Lemmers
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Mathieu Pioche
- Endoscopy Unit, Digestive Disease Department, Hôpital Edouard Herriot, Lyon, France
| | - Michael J. Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
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3
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Esposito G, Dell'Unto E, Ligato I, Marasco M, Panzuto F. The meaning of R1 resection after endoscopic removal of gastric, duodenal and rectal neuroendocrine tumors. Expert Rev Gastroenterol Hepatol 2023; 17:785-793. [PMID: 37497604 DOI: 10.1080/17474124.2023.2242261] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/26/2023] [Accepted: 07/25/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Well-differentiated gastric, duodenal, and rectal neuroendocrine neoplasms (NETs) are rare diseases usually managed by endoscopic treatment. Although several endoscopic techniques are available, the number of patients with incomplete (R1) resection is significant. AREAS COVERED This review focuses on the meaning of incomplete R1 findings after endoscopic resection in type I gastric NETs; nonfunctioning, non-ampullary duodenal NETs; and small rectal NETs. Data were identified by MEDLINE database search without publication date limitation. EXPERT OPINION An incomplete R1 finding may have no significant impact on a patient's clinical outcome, particularly in small G1 type I gastric NETs, which have an indolent course. A 'stepwise approach,' which uses more advanced endoscopic techniques, or minimally invasive surgery may be justified to achieve complete margin-free resection. This approach must balance the tumor features and the procedure-related risk of complications, particularly in the duodenum, where the role of deep endoscopic resections is limited due to the thin duodenal wall. Gastric and rectal NETs that are incompletely removed after initial resection are more easily amenable to deep endoscopic techniques. However, this might not be necessary for patients with comorbidities, elderly, or both due to the uncertainty of how R1 finding impacts a patient's clinical outcome.
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Affiliation(s)
- Gianluca Esposito
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Elisabetta Dell'Unto
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Irene Ligato
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Matteo Marasco
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
| | - Francesco Panzuto
- ENETS Center of ExcellenceDepartment of Medical-Surgical Sciences, Translational Medicine Sapienza University of Rome, Digestive Disease Unit - Sant'andrea University Hospital, Rome, Italy
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Papaefthymiou A, Laskaratos FM, Koffas A, Manolakis A, Gkolfakis P, Coda S, Sodergren M, Suzuki N, Toumpanakis C. State of the Art in Endoscopic Therapy for the Management of Gastroenteropancreatic Neuroendocrine Tumors. Curr Treat Options Oncol 2022; 23:1014-1034. [PMID: 35511346 DOI: 10.1007/s11864-022-00986-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT Gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) comprise a heterogeneous group of slow growing tumors arising from the neuroendocrine cells of the gastrointestinal (GI) tract. Although they are considered relatively rare, their incidence is rising and it is believed that the more frequent use of endoscopy and imaging studies have at least in part contributed to the increased diagnosis especially of localized neoplasms. The management of these neoplasms should be guided by a multidisciplinary NEN team following appropriate staging investigations. Localized neoplasms of the GI tract may be suitable for endoscopic therapy, while patients with pancreatic NENs, unsuitable for surgery, should be considered for endoscopic ultrasound (EUS)-guided ablation. In this review, we discuss the evidence regarding endoscopic resection of luminal NENs and EUS-guided therapy of pancreatic NENs. The efficacy, safety, and other longer-term outcomes of these techniques are summarized. In conclusion, this review of endoscopic therapies for localized NENs may be a useful guide for NEN clinicians and endoscopists who are considering these therapeutic options for the management of focal GEP NENs.
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Affiliation(s)
- Apostolis Papaefthymiou
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece.,First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Macedonia, Greece
| | | | - Apostolos Koffas
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece
| | - Anastasios Manolakis
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, 1070, Brussels, Belgium
| | - Sergio Coda
- Digestive Diseases Centre, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Mikael Sodergren
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, UK
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit (ENETS Centre of Excellence) Centre for Gastroenterology, Royal Free Hospital, London, UK
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5
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Ratnayake GM, Srirajaskanthan R, Luong T, Gnanasegaran G, Toumpanakis C. Duodenal neuroendocrine neoplasms with unexpectedly aggressive behaviour: Challenging the "watch and wait" approach. J Neuroendocrinol 2022; 34:e13067. [PMID: 34914146 DOI: 10.1111/jne.13067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
The incidence of duodenal neuroendocrine neoplasms has risen over the past decades as a result of the wide availability of endoscopy and associated expertise. Although it is considered that tumour size greater than 10 mm, higher tumour grade and/or location in relation to the ampulla of Vater represent the main risk factors for local or distant metastases, we describe two cases of well differentiated grade 1 and grade 2 neuroendocrine tumours, which measured < 10 mm at the time of diagnosis but had an aggressive course during follow-up. Furthermore, we also summarise the available therapeutic strategies for the management of small, low grade, non-functioning, non-ampullary duodenal neuroendocrine neoplasms.
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Affiliation(s)
- Gowri M Ratnayake
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Raj Srirajaskanthan
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence Department of Gastroenterology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - TuVinh Luong
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Gopinath Gnanasegaran
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
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Yozgat A, Kekilli M, Altay M. Time to give up traditional methods for the management of gastrointestinal neuroendocrine tumours. World J Clin Cases 2021; 9:8627-8646. [PMID: 34734042 PMCID: PMC8546836 DOI: 10.12998/wjcc.v9.i29.8627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
Neuroendocrine tumors (NETs) are a rare and heterogeneous disease group and constitute 0.5% of all malignancies. The annual incidence of NETs is increasing worldwide. The reason for the increase in the incidence of NETs is the detection of benign lesions, incidental detection due to the highest use of endoscopic and imaging procedures, and higher recognition rates of pathologists. There have been exciting developments regarding NET biology in recent years. Among these, first of all, somatostatin receptors and downstream pathways in neuroendocrine cells have been found to be important regulatory mechanisms for protein synthesis, hormone secretion, and proliferation. Subsequently, activation of the mammalian target of rapamycin pathway was found to be an important mechanism in angiogenesis and tumor survival and cell metabolism. Finally, the importance of proangiogenic factors (platelet-derived growth factor, vascular endothelial growth factor, fibroblastic growth factor, angiopoietin, and semaphorins) in the progression of NET has been determined. Using the combination of biomarkers and imaging methods allows early evaluation of the appropriateness of treatment and response to treatment.
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Affiliation(s)
- Ahmet Yozgat
- Department of Gastroenterology, Ufuk University, Ankara, 06510, Turkey
| | - Murat Kekilli
- Department of Gastroenterology, Gazi University, Ankara 06560, Turkey
| | - Mustafa Altay
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Keçiören Health Administration and Research Center, Ankara 06190, Turkey
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7
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Brito HP, Torres IT, Turke KC, Parada AA, Waisberg J, Botelho RV. Comparison of endoscopic resection techniques for duodenal neuroendocrine tumors: systematic review. Endosc Int Open 2021; 9:E1214-E1221. [PMID: 34447867 PMCID: PMC8383086 DOI: 10.1055/a-1487-5594] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Regardless of size, duodenal neuroendocrine tumors (dNETs) should be considered potentially malignant. A complete resection without complications is essential to increase safety procedures. The aim of this review was to describe effectiveness and possible complications of endoscopic techniques resection for resectioning dNETs in patients with tumors ≤ 20 mm in diameter. Methods An electronic bibliographic search was conducted using MEDLINE (via PubMed), Embase, Cochrane Central, and Google Scholar virtual databases. The types of intervention were endoscopic mucosal resection alone (EMR) or with cap (EMR-C), with a ligation device (EMR-L), with previous elevation of the tumor (EMR-I) or with endoscopic submucosal dissection (ESD); argon plasm coagulation (APC), and polypectomy. The outcome measures adopted were presence of free margin associated with tumor resection, tumor recurrence, complications (bleeding and perforation), and length of the procedure. Results Ten publications were included with the result of 224 dNET resections. EMR alone and polypectomy resulted in the most significantly compromised margin. The most frequent complication was bleeding (n = 21), followed by perforation (n = 8). Recurrence occurred in 13 cases, the majority of those under EMR or EMR-I. Conclusions EMR-C or EMR-I should be preferred for resectioning of dNETs. Polypectomy should not be indicated for resection of dNETs due to the high occurrence of incomplete resections. EMR alone must be avoided due a higher frequency of compromised margin and recurrent surgery. ESD was associated with no recurrence, however, but an increased occurrence of bleeding and perforation.
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Affiliation(s)
| | | | | | | | - Jaques Waisberg
- Department of Surgery, ABC Medical School, Santo André, São Paulo, Brazil,Department of Surgery, Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil
| | - Ricardo Vieira Botelho
- Department of Surgery, Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil
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8
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Exarchou K, Moore AR, Smart HL, Duckworth CA, Howes N, Pritchard DM. A "Watch and Wait" Strategy Involving Regular Endoscopic Surveillance Is Safe for Many Patients with Small, Sporadic, Grade 1, Non-Ampullary, Non-Functioning Duodenal Neuroendocrine Tumours. Neuroendocrinology 2021; 111:764-774. [PMID: 32937631 DOI: 10.1159/000511613] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Duodenal neuroendocrine tumours (d-NETs) are rare but are increasing in incidence. Current ENETS guidelines advocate resection of all localized d-NETs. However, "watch and wait" may be appropriate for some localized, small, grade 1, non-functioning, non-ampullary d-NETs. We evaluated whether patients with such d-NETs who chose "watch and wait" involving regular endoscopic surveillance had equivalent disease-related outcomes to patients undergoing endoscopic or surgical resection. METHODS Retrospective review of patients with histologically confirmed d-NETs at Liverpool ENETS Centre of Excellence 2007-2020. RESULTS Sixty-nine patients were diagnosed with d-NET of which 50 were sporadic, non-functioning, non-ampullary tumours. Patient treatment groups were similar in terms of age, gender, and tumour location and grade, but unsurprisingly, larger tumours (median diameter 17 mm [p < 0.0001]) were found in the surgically treated group. Five patients underwent surgical resection with no evidence of tumour recurrence or disease-related death. Twelve patients underwent endoscopic resection (ER), with 1 local recurrence detected during follow-up. Thirty patients (28 with d-NETs ≤10 mm) underwent "watch and wait" with resection only if tumours increased in size. The d-NETs in 28/30 patients remained stable or decreased in size over a median 27 months (IQR: 15-48, R: 3-98). In 7 patients, the d-NET was completely removed by avulsion during diagnostic biopsy and was not seen at subsequent endoscopies. Only 2 patients showed increased d-NET size during surveillance, of whom only one was fit for ER. No NET-related deaths were documented during follow-up. CONCLUSIONS All of the localized, ≤10 mm, grade 1, non-functioning, non-ampullary d-NETs in this cohort behaved indolently with very low risks of progression and no tumour-related deaths. "Watch and wait," therefore, appears to be a safe alternative management strategy for selected d-NETs.
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Affiliation(s)
- Klaire Exarchou
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Andrew R Moore
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Howard L Smart
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Carrie A Duckworth
- Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Nathan Howes
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - D Mark Pritchard
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom,
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom,
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9
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Gay-Chevallier S, de Mestier L, Perinel J, Forestier J, Hervieu V, Ruszniewski P, Millot I, Valette PJ, Pioche M, Lombard-Bohas C, Subtil F, Adham M, Walter T. Management and Prognosis of Localized Duodenal Neuroendocrine Neoplasms. Neuroendocrinology 2021; 111:718-727. [PMID: 32335556 DOI: 10.1159/000508102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The characteristics, prognostic factors, and management of duodenal neuroendocrine neoplasms (dNEN) are ill-defined, given their rarity. Whether nonsurgical management might be appropriate for patients with nonmetastatic dNEN and a good prognosis, as is the case for pancreatic NEN (pNEN), is unknown. We aimed to describe the management and prognosis of nonmetastatic dNEN patients. METHODS All consecutive patients with nonmetastatic dNEN managed between 1981 and 2018 in 2 expert centers were included. Recurrence-free survival (RFS) and factors associated with recurrence were estimated. RESULTS A total of 145 patients with dNEN were included. Twenty-eight patients with sporadic, nonfunctioning, small (median 7 mm) dNEN underwent endoscopic resection, with a 5-year RFS rate of 89.4%. Local recurrence occurred in 2 patients, who underwent surgery with no new events. The 5-year RFS rate was 87.9% in patients who underwent surgery. Upon univariate analysis, age, size, Ki67 index, and lymph node involvement (LN+) were significantly associated with worse RFS for all dNEN treated (endoscopy/surgery); multivariate analysis found that age, size, and LN+ were associated with worse RFS. CONCLUSION Selected nonmetastatic dNEN had a favorable outcome, and a less invasive therapeutic strategy appeared more suitable than oncological surgery.
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Affiliation(s)
- Servane Gay-Chevallier
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Gastroentérologie et d'Oncologie Médicale, Lyon, France
| | - Louis de Mestier
- Service de Gastroentérologie et Pancréatologie, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Julie Perinel
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Julien Forestier
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Gastroentérologie et d'Oncologie Médicale, Lyon, France
| | - Valérie Hervieu
- Université Lyon 1, Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Service de Pathologie Multisite, Site EST, Centre de Biologie et de Pathologie Est, Bron, France
| | - Philippe Ruszniewski
- Service de Gastroentérologie et Pancréatologie, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Ingrid Millot
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d'anesthésie-Réanimation, Lyon, France
| | - Pierre-Jean Valette
- Université Lyon 1, Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Radiologie, Lyon, France
| | - Mathieu Pioche
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Gastroentérologie et d'Oncologie Médicale, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Catherine Lombard-Bohas
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Gastroentérologie et d'Oncologie Médicale, Lyon, France
| | - Fabien Subtil
- Université Lyon 1, Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
- CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Mustapha Adham
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Thomas Walter
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Gastroentérologie et d'Oncologie Médicale, Lyon, France,
- Université Lyon 1, Université de Lyon, Lyon, France,
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10
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Exarchou K, Howes N, Pritchard DM. Systematic review: management of localised low-grade upper gastrointestinal neuroendocrine tumours. Aliment Pharmacol Ther 2020; 51:1247-1267. [PMID: 32390152 DOI: 10.1111/apt.15765] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/24/2020] [Accepted: 04/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neuroendocrine tumours (NETs) of the stomach and duodenum are rare, but are increasing in incidence. Optimal management of localised, low-grade gastric and duodenal NETs remains controversial. AIMS To systematically review recent literature that has evaluated the management of localised low-grade gastric and duodenal NETs. METHODS A systematic literature search was conducted. Articles were screened and eligible articles fully assessed. Additional articles were identified through the included articles' reference lists. RESULTS Several relevant retrospective case series were identified, but there was considerable heterogeneity between studies and they reported a variety of parameters. Type I gastric NETs had an excellent prognosis and conservative management approaches such as endoscopic surveillance/resection were appropriate in most cases. Many type III gastric NETs were low grade and appeared to have a better prognosis than has previously been appreciated. Endoscopic rather than surgical resection was therefore effective in some patients who had small, low-grade tumours. Duodenal NETs were more heterogenous. Endoscopic resection was generally safe and effective in patients who had small, low-grade, nonfunctional, non-ampullary tumours. However, some patients, especially those with larger or ampullary duodenal NETs, required surgical resection. CONCLUSIONS Most type I gastric NETs behave indolently and surgical resection is only rarely indicated. Some type III gastric and duodenal NETs have a worse prognosis, but selected patients who have small, localised, nonfunctional, low-grade tumours are adequately and safely treated by endoscopic resection. Due to the complexity of this area, a multidisciplinary approach to management is strongly recommended.
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Affiliation(s)
- Klaire Exarchou
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Nathan Howes
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - David Mark Pritchard
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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11
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Nishio M, Hirasawa K, Ozeki Y, Sawada A, Ikeda R, Fukuchi T, Kobayashi R, Makazu M, Sato C, Maeda S. Short- and long-term outcomes of endoscopic submucosal dissection for non-ampullary duodenal neuroendocrine tumors. Ann Gastroenterol 2020; 33:265-271. [PMID: 32382229 PMCID: PMC7196614 DOI: 10.20524/aog.2020.0477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/11/2020] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic resection is recommended for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in diameter and confined to the submucosal layer, without lymph node or distant metastasis. However, the efficacy and safety of endoscopic submucosal dissection (ESD) for NAD-NET remains unclear. The aim of this study was to assess the short-term efficacy and safety and the long-term outcomes of ESD for NAD-NET. Methods Eight patients with 8 NAD-NETs who underwent ESD between 2015 and 2018 were included. The indications for ESD were: i) tumor ≤10 mm in diameter; ii) NET G1; iii) confined to the submucosal layer; and iv) without lymph node or distant metastasis. We retrospectively assessed the short- and long-term outcomes and safety. Results The median patient age was 69 (48-76) years. All tumors were located in the duodenal bulb and showed 0-Is morphology. The median size was 6.4 (3-9.3) mm. The rates of en bloc resection, histologically free horizontal and vertical margins, and curative resection were 100%, 88%, and 88%, respectively. Intraoperative and postoperative perforation each occurred in 13% of patients, all of whom were treated conservatively and avoided emergent surgery. Delayed bleeding was not observed. No local, lymph node or distant recurrence was observed during a median follow-up period of 34 (18.5-62.5) months. Conclusions The rates of en bloc and curative resection, and histologically free margins were sufficiently high. Although intraoperative and postoperative perforations occurred, emergency surgery was not needed. The results show that ESD is an efficacious and safe treatment for NAD-NET.
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Affiliation(s)
- Masafumi Nishio
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Yuichiro Ozeki
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Atsushi Sawada
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Ryosuke Ikeda
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Takehide Fukuchi
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Ryosuke Kobayashi
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Makomo Makazu
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Chiko Sato
- Division of Endoscopy, Yokohama City University Medical Center (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato)
| | - Shin Maeda
- Department of Gastoenterology, Yokohama City University Guraduate School of Medicine (Shin Maeda), Japan
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12
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Nießen A, Bergmann F, Hinz U, Schimmack S, Hackert T, Büchler MW, Strobel O. Surgical resection for duodenal neuroendocrine neoplasia: Outcome, prognostic factors and risk of metastases. Eur J Surg Oncol 2020; 46:1088-1096. [PMID: 32088004 DOI: 10.1016/j.ejso.2020.01.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/18/2019] [Accepted: 01/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clinical management of duodenal neuroendocrine neoplasms (dNEN) is controversial. The aim of this study was to assess the outcome of surgical management and to identify risk factors for metastatic disease. METHODS Patients undergoing surgery for dNEN were retrospectively analysed. Clinicopathologic features, perioperative outcome and survival were assessed. A literature review with focus on risk factors for metastatic disease was additionally performed. RESULTS 24 patients were identified. Out of 22 patients presenting with their primary tumour, 20 patients underwent curative resection and 18 patients received curative resection with systematic lymphadenectomy. 17 patients underwent formal oncological resection. Surgical mortality was 1 out of 24 patients. The 5-year overall survival rate was 67% in the entire cohort, 71% in patients undergoing resection for their primary tumour, 72% for patients undergoing curative resection with systematic lymphadenectomy, 75% for pN0 and 70% for pN1 tumours. Lymph node metastases were identified in 15 patients undergoing systematic lymphadenectomy, including 9 of 14 patients with tumours smaller than 2 cm, and 6 of 10 patients with G1 tumours. Literature review confirmed a high risk of metastases in small (58%) or G1 (24%) tumours. Tumour grade and angioinvasion were significantly associated with overall and disease-free survival. CONCLUSION Even well differentiated or small dNEN harbour a considerable risk of metastases. These data challenge the concepts of surveillance, local resection and endoscopic management for dNEN based on size and grading. Angioinvasion was identified as a strong negative predictor of overall and disease-free survival in dNEN.
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Affiliation(s)
- Anna Nießen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Simon Schimmack
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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13
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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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14
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Khara HS, Shovlin GJ, Johal AS, Diehl DL. Endoscopic banding without resection (BWR) technique for treatment of diminutive neuroendocrine tumors in the duodenum. Endosc Int Open 2019; 7:E302-E307. [PMID: 30746433 PMCID: PMC6368483 DOI: 10.1055/a-0684-9563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/17/2018] [Indexed: 12/20/2022] Open
Abstract
Endoscopic treatment of diminutive (less than 10 mm) duodenal neuroendocrine tumors (NETs) is recommended because of the risk of metastatic potential. Endoscopic mucosal resection and endoscopic submucosal dissection are alternatives to surgical management but have significant adverse event rates. We evaluated the effectiveness, feasibility, and safety of the 'banding without resection' (BWR) technique and assessed outcomes for the treatment of diminutive duodenal NETs. Our study included eight patients referred for endoscopic treatment of incidentally discovered, biopsy proven, diminutive duodenal bulb NETs. Endoscopic ultrasound (EUS) in all patients showed duodenal bulb NETs located in the deep mucosa and submucosal layers without any nodal metastasis. The BWR technique was successfully performed in all patients with technical feasibility, with the assistance of submucosal saline lift in three patients when the lesion was smaller than 5 mm in size, without any immediate or delayed adverse events. Complete resection with no residual lesion was confirmed at short-term (median 2.3 months) and long-term (median 4.2 years) follow-up intervals by repeat endoscopy, biopsy, and EUS exam. The BWR technique appears to be a safe, feasible, and effective therapy for endoscopic treatment of diminutive duodenal bulb NETs in the absence of local and distant metastasis.
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Affiliation(s)
- Harshit S. Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA 17822, USA,Corresponding author Harshit S. Khara, MD Center for Advanced Therapeutic EndoscopyDepartment of Gastroenterology & NutritionGeisinger Medical Center100 N. Academy Avenue21-11DanvillePA 17822USA+1-570-271-6852
| | - Gerald J. Shovlin
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA 17822, USA
| | - Amitpal S. Johal
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA 17822, USA
| | - David L. Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA 17822, USA
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15
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Abstract
For the management of diminutive duodenal neuroendocrine tumors (d-NETs), Harshit et al. have proposed - in the work accompanying this editorial - an interesting approach, the endoscopic banding without resection (BWR) technique. Given the risks associated with classic endoscopic resections and surgical procedures, and the likely favorable natural history of diminutive d-NETs, BWR may be an option for these selected patients with a very low risk of LN + and recurrence. However, a close follow-up (endoscopic, EUS and thoraco-abdominal CT scan) is then required to guarantee the safety of this policy.
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Affiliation(s)
- Thomas Walter
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Department d’Oncologie Médicale, Lyon, France
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16
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Outcomes of Surgical and Endoscopic Resection of Duodenal Neuroendocrine Tumours (NETs): a Systematic Review of the Literature. J Gastrointest Surg 2018; 22:1652-1658. [PMID: 29869091 DOI: 10.1007/s11605-018-3825-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/17/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Duodenal neuroendocrine tumours (dNETs) comprise about 2% of all the NETs. Treatment of dNETs involves resection of the tumour either by endoscopic or surgical resection. Surgical or endoscopic local resection of the lesion is usually a more conservative and less morbid option compared with a more radical pancreaticoduodenectomy. However, inadequate clearance by local resection might result in recurrent disease with reduced overall survival. METHODS The current systematic review compared the differences in outcomes of endoscopic resection (ER), local resection (LR) and pancreaticoduodenectomy (PD) in the management of dNETs. Searches were performed on MEDLINE, PubMed, Embase and Cochrane databases using MeSH keyword combinations: 'duodenal', AND, 'neuroendocrine tumours'. All relevant articles published up to 2016 were included. Post-operative morbidity, R0 resection status and recurrence rates were the outcomes assessed. RESULTS Eight non-randomised retrospective studies with 335 participants were included (LR = 122; PD = 118; ER = 64). While PD was associated with higher morbidity compared with LR (27/64 vs. 10/74; P = 0.002), PD was associated with a higher incidence of an R0 resection (3/97 vs. 15/97; P = 0.007) as well as lower recurrence rates (3/51 vs. 6/46; P = 0.21). ER was associated with a higher positive resection margin status versus LR (22/51 vs. 14/91; P = 0.0002). Recurrence at follow-up was not different among patients with dNETs who underwent PD versus LR. CONCLUSIONS Radical surgical resection in the form of PD was associated with higher post-operative morbidity among patients with dNETs yet provided better margin clearance. Patients with dNETs need systematic evaluation with a view to obtain most of the information about the prognostic factors in order to tailor the treatment options.
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17
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Weatherall T, Denbo J, Sharpe J, Martin M, O'Brien T, Gupta R, Groshart K, Behrman S, Dickson P. Well-Differentiated, Non-Functional, Non-Ampullary Duodenal Neuroendocrine Tumors: Toward Defining Evaluation and Management. World J Surg 2017; 41:844-850. [PMID: 27743074 DOI: 10.1007/s00268-016-3770-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Nonfunctional, non-ampullary duodenal neuroendocrine tumors (dNETs) are rare neoplasms, and specific treatment recommendations are less clear than for other NETs. MATERIALS AND METHODS We performed a retrospective review of patients (pts) with a diagnosis of dNET, excluding hormonally functional, ampullary, and high-grade tumors. Clinical data were evaluated to identify factors that might impact clinical staging and predictors of metastases. RESULTS Thirty-six pts were identified. Surgical resection was performed in 28 and endoscopic resection in 8. LNs were included in specimens of 19/28 (68 %) pts who underwent surgical resection (median #LNs 5, range 1-12). Of these 19 pts, 5 (26 %) were found to be LN+. Of LN+ pts, all had tumors ≤2 cm. When compared to LN- pts, LN+ pts were more likely to have muscularis propria (MP) invasion (80 vs. 23 %, p = 0.04). Tumor size, tumor grade, lymphovascular invasion, and multifocality were similar between LN+ and LN- patients. No pt was found to have distant metastases. Heterogeneity in clinical staging modalities and small number of pts evaluated prohibited meaningful analysis of most appropriate preoperative imaging. At a median follow-up of 25 months (range 9-139), no patient developed recurrence or experienced disease-specific death. CONCLUSIONS Non-functional, non-ampullary dNETs, particularly those with MP invasion, have a propensity to metastasize to regional LNs. However, these neoplasms appear to have a favorable prognosis. Further evaluation of preoperative imaging is required to better determine most appropriate clinical staging. A suggested workup and management strategy for prospective evaluation is proposed.
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Affiliation(s)
- Timothy Weatherall
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, 3rd Floor, Memphis, TN, 38163, USA
| | - Jason Denbo
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, 3rd Floor, Memphis, TN, 38163, USA
| | - John Sharpe
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, 3rd Floor, Memphis, TN, 38163, USA
| | - Michael Martin
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN, USA.,West Cancer Center, 7945 Wolf River Blvd, Germantown, TN, 38138, USA
| | - Thomas O'Brien
- Memphis Pathology Group, 1211 Union Avenue, Suite 300, Memphis, TN, 38104, USA
| | - Rajib Gupta
- Department of Pathology, University of Tennessee Health Science Center, 930 Madison Ave, 5th Floor, Memphis, TN, 38163, USA
| | - Kenneth Groshart
- Pathology Group of the Midsouth, 6019 Walnut Grove Rd, Memphis, TN, 38120, USA
| | - Stephen Behrman
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, 3rd Floor, Memphis, TN, 38163, USA
| | - Paxton Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, 3rd Floor, Memphis, TN, 38163, USA.
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18
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Scherübl H, Cadiot G. Early Gastroenteropancreatic Neuroendocrine Tumors: Endoscopic Therapy and Surveillance. Visc Med 2017; 33:332-338. [PMID: 29177161 DOI: 10.1159/000459404] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neuroendocrine neoplasias (NEN) of the stomach, duodenum, pancreas, appendix, or rectum that are ≤1 cm in size as well as well-differentiated with World Health Organization grade 1 (G1) can be considered 'early' neuroendocrine tumors; they have a very good prognosis. Regarding prognosis, neuroendocrine tumors (NET) G1 must be distinguished from well-differentiated NET G2 and poorly differentiated neuroendocrine carcinomas (NEC) G3. NET are increasing, with a rise in the age-adjusted incidence in the USA by about 700% in the last 40 years. Earlier diagnosis of NET is one of the main epidemiological changes of clinically detected NEN. The general availability of high-resolution endoscopy and advanced radiological imaging techniques has contributed to a shift in the discovery to smaller-sized (≤10 mm) gastrointestinal and pancreatic NET and earlier tumor stages at diagnosis. Thus, screening colonoscopy is effective in the early diagnosis not only of colorectal adenomas and adenocarcinomas but also of rectal NET. Endoscopic resection is the treatment of choice in NET G1 of the stomach, duodenum (despite gastrinoma), and rectum that are ≤10 mm in size, do not infiltrate the muscularis propria (T1), and do not show angioinvasion (V0, L0). Similarly, histologically proven, early pancreatic NET G1 (≤10 mm) may be managed conservatively by regular surveillance. In contrast, small (≤1 cm) NET G1 of the jejunum or ileum are not 'early' tumors and have to be resected surgically with lymph node dissection.
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Affiliation(s)
- Hans Scherübl
- Department of Gastroenterology, Gastrointestinal Oncology and Infectious Diseases, Vivantes Klinikum Am Urban, Berlin, Germany
| | - Guillaume Cadiot
- Service d'Hépato-Gastroentérologie, Hôpital Robert Debré, Reims, France
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Takahashi K, Hatta W, Koike T, Kanno T, Ara N, Asanuma K, Asano N, Imatani A, Fujishima F, Sasano H, Shimosegawa T. The slow progressive nature of duodenal neuroendocrine tumor: a case report of long-term observation over 14 years. Clin J Gastroenterol 2017; 10:469-473. [PMID: 28664383 DOI: 10.1007/s12328-017-0758-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 06/13/2017] [Indexed: 11/28/2022]
Abstract
The number of duodenal neuroendocrine tumors has recently increased, but their natural history has not been well characterized. Here we report the case of a 59-year-old female undergoing complete resection by endoscopic mucosal resection after monitoring endoscopic morphologic changes and the size increment of a duodenal neuroendocrine tumor over the longest follow-up duration. An elevated lesion was initially detected on the duodenal bulb. Endoscopic biopsy from this lesion was performed three times during the follow-up, but all of the specimens simply demonstrated the presence of gastric metaplasia. Thereafter, in the esophagogastroduodenoscopy performed 14 years after the initial examination, a slight depression was detected in the center of the lesion together with an incremental change of its size. The histopathologic diagnosis of neuroendocrine tumor was made by deeper tissue sampling, and the patient subsequently underwent endoscopic mucosal resection for this tumor and was finally diagnosed with a G1 duodenal neuroendocrine tumor with pT2 cN0, cM0, stage IIa in the TNM classification. This is the first case demonstrating the slowly progressive nature of such a tumor with the longest follow-up of a duodenal neuroendocrine tumor ever reported, which could provide important information regarding the natural history and management of such tumors.
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Affiliation(s)
- Kiichi Takahashi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan.
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Nobuyuki Ara
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Kiyotaka Asanuma
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Fumiyoshi Fujishima
- Department of Pathology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
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20
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Bisschops R, Areia M, Coron E, Dobru D, Kaskas B, Kuvaev R, Pech O, Ragunath K, Weusten B, Familiari P, Domagk D, Valori R, Kaminski MF, Spada C, Bretthauer M, Bennett C, Senore C, Dinis-Ribeiro M, Rutter MD. Performance measures for upper gastrointestinal endoscopy: A European Society of Gastrointestinal Endoscopy quality improvement initiative. United European Gastroenterol J 2016; 4:629-656. [PMID: 27733906 DOI: 10.1177/2050640616664843] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 12/14/2022] Open
Affiliation(s)
- Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Miguel Areia
- Gastroenterology Department, Portuguese Oncology Institute, Coimbra, Portugal; Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Nantes, France
| | - Daniela Dobru
- Gastroenterology Department, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Bernd Kaskas
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roman Kuvaev
- Endoscopy, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation
| | - Oliver Pech
- Klinik für Gastroenterologie und interventionelle Endoskopie, Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Dirk Domagk
- Department of Internal Medicine, Joseph's Hospital, Warendorf, Germany
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Michal F Kaminski
- Department of Health Management and Health Economy and KG Jebsen Centre for Colorectal Cancer, University of Oslo, Oslo, Norway; Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, and Medical Center for Postgraduate Education, Warsaw, Poland
| | - Cristiano Spada
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Michael Bretthauer
- Department of Health Management and Health Economy and KG Jebsen Centre for Colorectal Cancer, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Cathy Bennett
- Centre for Technology Enabled Research, Coventry University, Coventry, UK
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Mário Dinis-Ribeiro
- Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal; Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK; School of Medicine, Durham University, Durham, UK
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Fendrich V, Bartsch DK. Chirurgische Therapie gastroduodenaler neuroendokriner Neoplasien. Chirurg 2016; 87:280-7. [DOI: 10.1007/s00104-015-0138-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Zollinger-Ellison syndrome (ZES) is an endocrinopathy characterized by gastrin-secreting tumors, responsible for causing the formation of multiple, refractory, and recurrent peptic ulcers in the distal duodenum and proximal jejunum. Two main variants have been described, sporadic and those found in association with parathyroid and pituitary tumors, a genetic disorder known as multiple endocrine neoplasia-1 (MEN-1). Biochemical serum evaluation for elevated gastrin, followed by radiological or nuclear localization of the primary lesion, is mandated for establishing diagnosis. The mainstays of treatment include management of hypersecretory state with medical suppression of gastric acid production and surgical resection of primary tumor for the prevention of malignant transformation and metastatic complications. Medical therapy with proton pump inhibitors has virtually eliminated the need for acid-reducing surgical procedures. Surgical approach to sporadic and MEN-1-associated ZES varies based on our understanding of the natural history of the condition and the probability of cure; however, resection to a negative microscopic margin is indicated in both cases. Postoperative surveillance involves measurement of gastrin level, followed by imaging if elevation is detected. Re-excision of recurrent or resection of metastatic disease is a subject of controversy; however, at the present time aggressive cytoreductive approach is favored.
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Affiliation(s)
- Irene Epelboym
- Department of Surgery, Columbia University Medical Center, New York, New York, USA; Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
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