1
|
Manoharan J, Albers MB, Bartsch DK. [Individualized approach for MEN1-associated duodenopancreatic neuroendocrine neoplasms]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:207-215. [PMID: 38180518 DOI: 10.1007/s00104-023-01994-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Multiple endocrine neoplasia type 1 (MEN1)-associated duodenopancreatic neuroendocrine neoplasms (dpNEN) represent the most frequent syndrome-associated cause of death, but the adequate treatment is sometimes considered controversial. OBJECTIVE Presentation of possible diagnostic and therapeutic options for MEN1-associated dpNENs. MATERIAL AND METHODS In this review article retrospective case studies, expert recommendations, national and international guidelines as well as personal experiences were analyzed and evaluated. RESULTS Due to early detection programs and the use of the most modern imaging techniques, dpNEN are nowadays diagnosed much earlier. Nonfunctional pNENs currently represent the most frequent dpNENs with about 70%, followed by gastrinomas and insulinomas. Regardless of their functional activity, dpNENs with a size of > 2 cm are generally an indication for surgery. The choice of the optimal treatment strategy, however, in most cases remains the subject of controversial discussions, although nowadays surgery should always be performed in an organ-preserving and minimally invasive way when feasible. Recurrences or new dpNENs are expected in more than 60% of cases, necessitating a reoperation in up to 40% of these cases. Duodenopancreatic resections and reoperations can be carried out safely by experienced practitioners and with an acceptable level of risk. CONCLUSION The planning of treatment requires careful consideration of the suitable timing, the extent of the operation, the risk of recurrence and potential morbidities. Furthermore, preserving pancreatic function and the quality of life is of utmost importance. In view of the complexity of the disease, MEN1 patients should be treated in specialized centers.
Collapse
Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland.
| | - Max B Albers
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
| |
Collapse
|
2
|
Manoharan J, Albers M, Bartsch DK. [Indication and Surgical Procedures for MEN1-associated Duodenopancreatic Neuroendocrine Neoplasms]. Zentralbl Chir 2023; 148:483-491. [PMID: 37604166 DOI: 10.1055/a-2103-3525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The optimal therapy of duodenopancreatic neuroendocrine neoplasia (dpNEN), which occurs in the context of multiple endocrine neoplasia type 1, is still a major challenge and is controversial. Due to the rarity of the disease, there is a lack of prospective randomised studies, so that most recommendations regarding the surgical indication and procedure are based on retrospective case series. In summary, surgical therapy is indicated for non-functional dpNEN > 2 cm, suspected malignancy and functionally active dpNEN. Enucleation or formal pancreatic resections with or without lymphadenectomy may be considered. The aim of therapy should be to eliminate hormone-associated symptoms and prevent an aggressive metastatic disease. At the same time, pancreatic function and quality of life should be preserved in the mostly young patients by resections that save as much parenchyma as possible.
Collapse
Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Max Albers
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| |
Collapse
|
3
|
Jha S, Simonds WF. Molecular and Clinical Spectrum of Primary Hyperparathyroidism. Endocr Rev 2023; 44:779-818. [PMID: 36961765 PMCID: PMC10502601 DOI: 10.1210/endrev/bnad009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/09/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
Recent data suggest an increase in the overall incidence of parathyroid disorders, with primary hyperparathyroidism (PHPT) being the most prevalent parathyroid disorder. PHPT is associated with morbidities (fractures, kidney stones, chronic kidney disease) and increased risk of death. The symptoms of PHPT can be nonspecific, potentially delaying the diagnosis. Approximately 15% of patients with PHPT have an underlying heritable form of PHPT that may be associated with extraparathyroidal manifestations, requiring active surveillance for these manifestations as seen in multiple endocrine neoplasia type 1 and 2A. Genetic testing for heritable forms should be offered to patients with multiglandular disease, recurrent PHPT, young onset PHPT (age ≤40 years), and those with a family history of parathyroid tumors. However, the underlying genetic cause for the majority of patients with heritable forms of PHPT remains unknown. Distinction between sporadic and heritable forms of PHPT is useful in surgical planning for parathyroidectomy and has implications for the family. The genes currently known to be associated with heritable forms of PHPT account for approximately half of sporadic parathyroid tumors. But the genetic cause in approximately half of the sporadic parathyroid tumors remains unknown. Furthermore, there is no systemic therapy for parathyroid carcinoma, a rare but potentially fatal cause of PHPT. Improved understanding of the molecular characteristics of parathyroid tumors will allow us to identify biomarkers for diagnosis and novel targets for therapy.
Collapse
Affiliation(s)
- Smita Jha
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-1752, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-1752, USA
| |
Collapse
|
4
|
van Beek DJ, Verschuur AVD, Brosens LAA, Valk GD, Pieterman CRC, Vriens MR. Status of Surveillance and Nonsurgical Therapy for Small Nonfunctioning Pancreatic Neuroendocrine Tumors. Surg Oncol Clin N Am 2023; 32:343-371. [PMID: 36925190 DOI: 10.1016/j.soc.2022.10.010] [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: 03/16/2023]
Abstract
Pancreatic neuroendocrine tumors (PNETs) occur in < 1/100,000 patients and most are nonfunctioning (NF). Approximately 5% occur as part of multiple endocrine neoplasia type 1. Anatomic and molecular imaging have a pivotal role in the diagnosis, staging and active surveillance. Surgery is generally recommended for nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) >2 cm to prevent metastases. For tumors ≤2 cm, active surveillance is a viable alternative. Tumor size and grade are important factors to guide management. Assessment of death domain-associated protein 6/alpha-thalassemia/mental retardation X-linked and alternative lengthening of telomeres are promising novel prognostic markers. This review summarizes the status of surveillance and nonsurgical management for small NF-PNETs, including factors that can guide management.
Collapse
Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Internal Mail Number G.04.228, PO Box 85500, Utrecht 3508 GA, the Netherlands
| | - Anna Vera D Verschuur
- Department of Pathology, University Medical Center Utrecht, Internal Mail Number G02.5.26, PO Box 85500, Utrecht 3508 GA, the Netherlands. https://twitter.com/annaveraverschu
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Internal Mail Number G4.02.06, PO Box 85500, Utrecht 3508 GA, the Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Internal Mail Number Q.05.4.300, PO Box 85500, Utrecht 3508 GA, the Netherlands
| | - Carolina R C Pieterman
- Department of Endocrine Oncology, University Medical Center Utrecht, Internal Mail Number Q.05.4.300, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Internal Mail Number G.04.228, PO Box 85500, Utrecht 3508 GA, the Netherlands
| |
Collapse
|
5
|
Frey S, Mirallié E, Le Bras M, Regenet N. What Are the Place and Modalities of Surgical Management for Pancreatic Neuroendocrine Neoplasms? A Narrative Review. Cancers (Basel) 2021; 13:5954. [PMID: 34885063 PMCID: PMC8656750 DOI: 10.3390/cancers13235954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are a heterogeneous group of tumors derived from cells with neuroendocrine differentiation. They are considered malignant by default. However, their outcomes are variable depending on their presentation in the onset of hereditary syndromes, hormonal secretion, grading, and extension. Therefore, although surgical treatment has long been suggested as the only treatment of pancreatic neuroendocrine neoplasms, its modalities are an evolving landscape. For selected patients (small, localized, non-functional panNENs), a "wait and see" strategy is suggested, as it is in the setting of multiple neuroendocrine neoplasia type 1, but the accurate size cut-off remains to be established. Parenchyma-sparring pancreatectomy, aiming to limit pancreatic insufficiency, are also emerging procedures, which place beyond the treatment of insulinomas and small non-functional panNENs (in association with lymph node picking) remains to be clarified. Furthermore, giving the fact that the liver is generally the only metastatic site, surgery keeps a place of choice alongside medical therapies in the treatment of metastatic disease, but its modalities and extensions are still a matter of debate. This narrative review aims to describe the current recommended surgical management for pancreatic NENs and controversies in light of the actual recommendations and recent literature.
Collapse
Affiliation(s)
- Samuel Frey
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- L’institut du Thorax, Université de Nantes, CNRS, INSERM, CHU de Nantes, 44000 Nantes, France
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Eric Mirallié
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Maëlle Le Bras
- Endocrinologie, Diabétologie et Nutrition, L’institut du Thorax, CHU Nantes, 44000 Nantes, France;
| | - Nicolas Regenet
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| |
Collapse
|
6
|
Tacelli M, Petrone MC, Capurso G, Muffatti F, Andreasi V, Partelli S, Doglioni C, Falconi M, Arcidiacono PG. Diagnostic accuracy of EUS-FNA in the evaluation of pancreatic neuroendocrine neoplasms grading: Possible clinical impact of misclassification. Endosc Ultrasound 2021; 10:372-380. [PMID: 34677159 PMCID: PMC8544016 DOI: 10.4103/eus-d-20-00261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background and Objectives Prognosis of pancreatic neuroendocrine neoplasms (PanNENs) mostly depend on tumor stage and grade, determined by Ki-67 labeling index. EUS-FNA is considered the gold-standard technique to obtain it. The aims of our study were to establish diagnostic accuracy of preoperative EUS-FNA Ki-67 evaluation considering final pathological assessment on surgical specimen as gold standard and to investigate the possible impact on prognosis of misclassification. Methods This is a retrospective study from a prospectively collected database. EUS-FNA grading (eG) and surgical one (sG) measured according to Ki-67 proliferative index values, according to 2017 WHO classification, were compared. eG-sG correlation was evaluated by Spearman index. Logistic regression investigated factors associated with misclassification. Prognostic difference in terms of progression-free survival was evaluated by Kaplan Meier method. Results One hundred and twelve PanNENs patients enrolled. In 13.4% of patients (15/112) EUS-FNA "undergraded" patients (eG1 vs. sG2), while in 12.5% (n = 14) it "overgraded" PanNENs (eG2 to sG1). No misclassifications in G3 patients. In patients with tumors <20 mm (n = 44), 2 (4.5%) eG1 and 10 (22.7%) eG2 were finally classified respectively as G2 and G1 at surgical histology. No factors, as i.e. the lesions' size or their morphological aspect, were associated with misclassification. In overgraded PanNENs, no progression occurred, while in patients correctly classified/undergraded the progression rate was 14.3%. Conclusions This is the largest cohort of surgical PanNENs with preoperative EUS-FNA grading evaluation. Despite an acceptable eG-sG correlation, about 25% of patients are misclassified. Clinical impact of misclassification should be carefully considered especially in small tumors undergoing observation.
Collapse
Affiliation(s)
- Matteo Tacelli
- Division of Pancreato-Biliary Endoscopy and EUS, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Maria Chiara Petrone
- Division of Pancreato-Biliary Endoscopy and EUS, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Gabriele Capurso
- Division of Pancreato-Biliary Endoscopy and EUS, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Francesca Muffatti
- Division of Pancreato-Biliary Endoscopy and EUS, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Valentina Andreasi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Claudio Doglioni
- Department of Pathology, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Paolo Giorgio Arcidiacono
- Division of Pancreato-Biliary Endoscopy and EUS, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| |
Collapse
|
7
|
Crippa S, Belfiori G, Tamburrino D, Partelli S, Falconi M. Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground. Updates Surg 2021; 73:1219-1229. [PMID: 34331677 DOI: 10.1007/s13304-021-01141-0] [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: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 12/23/2022]
Abstract
The extension of a partial pancreatectomy up to total pancreatectomy because of positive neck margin examined at intraoperative frozen section (IFS) analysis is an accepted procedure in modern pancreatic surgery with good accuracy. The goal of this practice is to improve the rate of radical (R0) resection in malignant tumors, mainly pancreatic ductal adenocarcinoma (PDAC), and to completely resect pre-invasive neoplasms such as intraductal papillary mucinous neoplasms (IPMNs). In the setting of IPMNs there is a consensus for pancreatic re-resection when high-grade dysplasia and invasive cancer are present at the neck margin. The presence of denudation is another indication for further resection in IPMNs. The role of IFS analysis in the management of pancreatic cancer is more debated. The presence of a positive intraoperative transection margin can be considered the surrogate of a biologically aggressive disease associated with a poorer prognosis. There are conflicting data regarding possible advantages of pancreatic re-resection up to total pancreatectomy, and the lack of randomized trials comparing different strategies does not offer a definitive answer. The goal of this review is to provide an up-to-date overview of the role IFS analysis of pancreatic margin and of pancreatic re-resection up to total pancreatectomy considering different pancreatic tumors.
Collapse
Affiliation(s)
- Stefano Crippa
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giulio Belfiori
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Stefano Partelli
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy. .,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy. .,Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| |
Collapse
|
8
|
Brandi ML, Agarwal SK, Perrier ND, Lines KE, Valk GD, Thakker RV. Multiple Endocrine Neoplasia Type 1: Latest Insights. Endocr Rev 2021; 42:133-170. [PMID: 33249439 PMCID: PMC7958143 DOI: 10.1210/endrev/bnaa031] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 02/06/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1), a rare tumor syndrome that is inherited in an autosomal dominant pattern, is continuing to raise great interest for endocrinology, gastroenterology, surgery, radiology, genetics, and molecular biology specialists. There have been 2 major clinical practice guidance papers published in the past 2 decades, with the most recent published 8 years ago. Since then, several new insights on the basic biology and clinical features of MEN1 have appeared in the literature, and those data are discussed in this review. The genetic and molecular interactions of the MEN1-encoded protein menin with transcription factors and chromatin-modifying proteins in cell signaling pathways mediated by transforming growth factor β/bone morphogenetic protein, a few nuclear receptors, Wnt/β-catenin, and Hedgehog, and preclinical studies in mouse models have facilitated the understanding of the pathogenesis of MEN1-associated tumors and potential pharmacological interventions. The advancements in genetic diagnosis have offered a chance to recognize MEN1-related conditions in germline MEN1 mutation-negative patients. There is rapidly accumulating knowledge about clinical presentation in children, adolescents, and pregnancy that is translatable into the management of these very fragile patients. The discoveries about the genetic and molecular signatures of sporadic neuroendocrine tumors support the development of clinical trials with novel targeted therapies, along with advancements in diagnostic tools and surgical approaches. Finally, quality of life studies in patients affected by MEN1 and related conditions represent an effort necessary to develop a pharmacoeconomic interpretation of the problem. Because advances are being made both broadly and in focused areas, this timely review presents and discusses those studies collectively.
Collapse
Affiliation(s)
| | | | - Nancy D Perrier
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Gerlof D Valk
- University Medical Center Utrecht, CX Utrecht, the Netherlands
| | | |
Collapse
|
9
|
Luo Y, Chen X. Imaging of Insulinoma by Targeting Glucagonlike Peptide-1 Receptor. PET Clin 2021; 16:205-217. [PMID: 33589387 DOI: 10.1016/j.cpet.2020.12.008] [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: 11/19/2022]
Abstract
"Glucagonlike peptide-1 (GLP-1) receptor imaging, using radiolabeled exendin-4, was recently established for detecting insulinoma in patients with hyperinsulinemic hypoglycemia. It has proven to be a sensitive and specific method for preoperative localization of insulinoma. This review introduces the development, clinical research, and perspective of GLP-1 receptor imaging mainly in insulinoma.
Collapse
Affiliation(s)
- Yaping Luo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, #1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing 100730, P. R. China; Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine
| | - Xiaoyuan Chen
- Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore 117597, Singapore.
| |
Collapse
|
10
|
Tanaka M, Heckler M, Mihaljevic AL, Probst P, Klaiber U, Heger U, Schimmack S, Büchler MW, Hackert T. Systematic Review and Metaanalysis of Lymph Node Metastases of Resected Pancreatic Neuroendocrine Tumors. Ann Surg Oncol 2020; 28:1614-1624. [PMID: 32720049 DOI: 10.1245/s10434-020-08850-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The optimal surgical strategy for pancreatic neuroendocrine tumors (PNETs) is unknown. However, current guidelines recommend a watch-and-wait strategy for small nonfunctional PNETs (NF-PNETs). The aim of this study is to investigate the risk stratification and prognostic significance of lymph node metastasis (LNM) of PNETs to guide decision-making for lymphadenectomy. PATIENTS AND METHODS The MEDLINE and Web of Science databases were systematically searched for studies reporting either risk factors of LNM in resected PNETs or survival of patients with LNM. The weighted average incidence of LNM was calculated according to tumor characteristics. Random-effects metaanalyses were performed, and pooled hazard ratios (HR) and their 95% confidence intervals (CI) were calculated to determine the impact of LNM on overall survival (OS). In subgroup analyses, NF-PNETs were assessed. RESULTS From a total of 5883 articles, 98 retrospective studies with 13,374 patients undergoing resection for PNET were included. In all PNETs, the weighted median rates of LNM were 11.5% for small (≤ 2 cm) PNETs and 15.8% for G1 PNETs. In NF-PNETs, the rates were 11.2% for small PNETs and 10.3% for G1 PNETs. LNM of all PNETs (HR 3.87, 95% CI 3.00-4.99, P < 0.001) and NF-PNETs (HR 4.98, 95% CI 2.81-8.83, P < 0.001) was associated with worse OS. CONCLUSIONS LNM is potentially prevalent even in small and well-differentiated PNETs and is associated with worse prognosis. A watch-and-wait strategy for small NF-PNETs should be reappraised, and oncologic resection with lymphadenectomy can be considered. Prospective and controlled studies are needed in the future.
Collapse
Affiliation(s)
- Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Surgery, Keio University, School of Medicine, Tokyo, Japan
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Simon Schimmack
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| |
Collapse
|
11
|
Sadowski SM, Pieterman CRC, Perrier ND, Triponez F, Valk GD. Prognostic factors for the outcome of nonfunctioning pancreatic neuroendocrine tumors in MEN1: a systematic review of literature. Endocr Relat Cancer 2020; 27:R145-R161. [PMID: 32229700 PMCID: PMC7304521 DOI: 10.1530/erc-19-0372] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Metastatic duodenopancreatic neuro-endocrine tumors (dpNETs) are the most important disease-related cause of death in patients with multiple endocrine neoplasia type 1 (MEN1). Nonfunctioning pNETs (NF-pNETs) are highly prevalent in MEN1 and clinically heterogeneous. Therefore, management is controversial. Data on prognostic factors for risk stratification are limited. This systematic review aims to establish the current state of evidence regarding prognostic factors in MEN1-related NF-pNETs. We systematically searched four databases for studies assessing prognostic value of any factor on NF-pNET progression, development of distant metastases, and/or overall survival. In- and exclusion, critical appraisal and data-extraction were performed independently by two authors according to pre-defined criteria. Thirteen studies (370 unique patients) were included. Prognostic factors investigated were tumor size, timing of surgical resection, WHO grade, methylation, p27/p18 expression by immunohistochemistry (IHC), ARX/PDX1 IHC and alternative lengthening of telomeres. Results were complemented with evidence from studies in MEN1-related pNET for which data could not be separately extracted for NF-pNET and data from sporadic NF-pNET. We found that the most important prognostic factors used in clinical decision making in MEN1-related NF-pNETs are tumor size and grade. NF-pNETs <2 cm may be managed with watchful waiting, while surgical resection is advised for NF-pNETs ≥2 cm. Grade 2 NF-pNETs should be considered high risk. The most promising and MEN1-relevant avenues of prognostic research are multi-analyte circulating biomarkers, tissue-based molecular factors and imaging-based prognostication. Multi-institutional collaboration between clinical, translation and basic scientists with uniform data and biospecimen collection in prospective cohorts should advance the field.
Collapse
Affiliation(s)
- S M Sadowski
- Endocrine Surgery, Surgical Oncology Program, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - C R C Pieterman
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - F Triponez
- Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - G D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
12
|
Abstract
OPINION STATEMENT Pancreatic neuroendocrine neoplasms (PanNENs) are increasingly recognized entities, whose incidence has dramatically grown during the last two decades. Surgery plays a pivotal role in their management as it represents the only chance of cure. Since PanNENs display a wide range of aggressiveness, their surgical management needs to be tailored on tumor's and patient's characteristics. Currently, there are several open questions and burning issues in the field of PanNEN, such as the management of asymptomatic nonfunctioning pancreatic neuroendocrine tumors (NF-PanNET) ≤ 2 cm. An active surveillance of these small lesions has been demonstrated to be safe although the available evidences are only based on retrospective studies. On the other hand, formal pancreatic resection associated with lymphadenectomy represents the gold standard for patients with localized NF-PanNEN > 2 cm or NF-PanNEN ≤ 2 cm in the presence of symptoms, dilation of the main pancreatic duct or suspicion of nodal metastases. Surgery plays also an important role in the setting of metastatic disease. In particular, surgery is generally recommended in the presence of low-grade, resectable, metastatic disease, but several series have reported also a survival benefit of palliative primary tumor resection in patients with unresectable liver metastases. The role of surgery in PanNEN G3 is still controversial. Indeed, surgery is associated with an improved survival in patients with well-differentiated PanNET G3, whereas there is almost no survival benefit in case of poorly differentiated lesions.
Collapse
|
13
|
Christ E, Antwi K, Fani M, Wild D. Innovative imaging of insulinoma: the end of sampling? A review. Endocr Relat Cancer 2020; 27:R79-R92. [PMID: 31951592 PMCID: PMC7040495 DOI: 10.1530/erc-19-0476] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/17/2020] [Indexed: 12/16/2022]
Abstract
Receptors for the incretin glucagon-like peptide-1 (GLP-1R) have been found overexpressed in selected types of human tumors and may, therefore, play an increasingly important role in endocrine gastrointestinal tumor management. In particular, virtually all benign insulinomas express GLP-1R in high density. Targeting GLP-1R with indium-111, technetium-99m or gallium-68-labeled exendin-4 offers a new approach that permits the successful localization of small benign insulinomas. It is likely that this new non-invasive technique has the potential to replace the invasive localization of insulinomas by selective arterial stimulation and venous sampling. In contrast to benign insulinomas, malignant insulin-secreting neuroendocrine tumors express GLP-1R in only one-third of the cases, while they more often express the somatostatin subtype 2 receptors. Importantly, one of the two receptors appears to be always overexpressed. In special cases of endogenous hyperinsulinemic hypoglycemia (EHH), that is, in the context of MEN-1 or adult nesidioblastosis GLP-1R imaging is useful whereas in postprandial hypoglycemia in the context of bariatric surgery, GLP-1R imaging is probably not helpful. This review focuses on the potential use of GLP-1R imaging in the differential diagnosis of EHH.
Collapse
Affiliation(s)
- Emanuel Christ
- Division of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, University of Basel, Basel, Switzerland
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel Switzerland
| | - Kwadwo Antwi
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| | - Melpomeni Fani
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| | - Damian Wild
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel Switzerland
- Clinic of Radiology and Nuclear Medicine, University Hospital, Basel, Switzerland
| |
Collapse
|
14
|
La néoplasie endocrinienne multiple de type 1 : mise au point après le congrès de l’ENETS 2019. ANNALES D'ENDOCRINOLOGIE 2020; 80 Suppl 1:S19-S28. [PMID: 31606058 DOI: 10.1016/s0003-4266(19)30113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple Endocrine Neoplasia Type 1 (NEM1) is related to mutations of the menin gene. It is an autosomal dominant disease. Its prevalence is about 1/30 000 with a hugh penetrance. There is no genotype-phenotype correlation. This hereditary syndrome is characterized by the presence of tumors of the endocrine system (parathyroid, endocrine pancreas, pituitary and adrenal gland). Other disorders have also been described (bronchial and thymic carcinoid tumor, breast cancer, skin lesions). Management must take into account the specificities of these pathologies in NEM1 compared to sporadic forms (young age at diagnosis, multiple lesions within the same gland, multi-focal disease). © 2019 Published by Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Les Must de l'Endocrinologie 2019 réalisé avec le soutien institutionnel de Ipsen-Pharma.
Collapse
|
15
|
Dong DH, Zhang XF, Lopez-Aguiar AG, Poultsides G, Makris E, Rocha F, Kanji Z, Weber S, Fisher A, Fields R, Krasnick BA, Idrees K, Smith PM, Cho C, Beems M, Dillhoff M, Maithel SK, Pawlik TM. Resection of pancreatic neuroendocrine tumors: defining patterns and time course of recurrence. HPB (Oxford) 2020; 22:215-223. [PMID: 31235429 PMCID: PMC10182895 DOI: 10.1016/j.hpb.2019.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND To define recurrence patterns and time course, as well as risk factors associated with recurrence following curative resection of pNETs. METHOD Patients who underwent curative-intent resection for pNET between 1997 and 2016 were identified from the US Neuroendocrine Tumor Study Group. Data on baseline and tumor-specific characteristics, overall survival (OS), timing and first-site of recurrence, predictors and recurrence management were analyzed. RESULTS Among 1020 patients, 154 (15.1%) patients developed recurrence. Among patients who experienced recurrence, 76 (49.4%) had liver-only recurrence, while 35 (22.7%) had pancreas-only recurrence. The proportion of liver-only recurrence increased from 54.3% within one-year after surgery to 61.5% from four-to-six years after surgery; whereas the proportion of pancreas-only recurrence decreased from 26.1% to 7.7% over these time periods. While liver-only recurrence was associated with tumor characteristics, pancreas-only recurrence was only associated with surgical margin status. Patients undergoing curative resection of recurrence had comparable OS with patients who had no recurrence (median OS, pancreas-only recurrence, 133.9 months; liver-only recurrence, not attained; no recurrence, 143.0 months, p = 0.499) CONCLUSIONS: Different recurrence patterns and timing course, as well as risk factors suggest biological heterogeneity of pNET recurrence. A personalized approach to postoperative surveillance and treatment of recurrence disease should be considered.
Collapse
Affiliation(s)
- Ding-Hui Dong
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China; Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | | | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Zaheer Kanji
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander Fisher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, WI, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, WI, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Paula M Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Cliff Cho
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
| |
Collapse
|
16
|
Antwi K, Nicolas G, Fani M, Heye T, Pattou F, Grossman A, Chanson P, Reubi JC, Perren A, Gloor B, Vogt DR, Wild D, Christ E. 68Ga-Exendin-4 PET/CT Detects Insulinomas in Patients With Endogenous Hyperinsulinemic Hypoglycemia in MEN-1. J Clin Endocrinol Metab 2019; 104:5843-5852. [PMID: 31298706 DOI: 10.1210/jc.2018-02754] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 01/15/2023]
Abstract
CONTEXT Surgical intervention is advised in patients with multiple endocrine neoplasia type-1 (MEN-1) and nonfunctioning pancreatic neuroendocrine tumors (PanNETs) with a size ≥20 mm. Functioning PanNETs, such as in patients with endogenous hyperinsulinemic hypoglycemia (EHH) due to (one or multiple) insulinomas, should be treated surgically independent of size. Preoperative localization of insulinomas is critical for surgery. OBJECTIVE To evaluate the feasibility and sensitivity of 68Ga-DOTA-exendin-4 positron emission tomography (PET)/CT in the detection of clinically relevant lesions in patients with MEN-1 and EHH in combination with MRI. DESIGN Post hoc subgroup analysis of a larger prospective imaging study with 52 patients with EHH. PATIENTS Six of 52 consecutive patients with EHH and genetically proven MEN-1 mutation were included. INTERVENTIONS All patients received one 68Ga-DOTA-exendin-4 PET/CT and one MRI scan within 3 to 4 days. Thereafter, surgery was performed based on all imaging results. MAIN OUTCOME MEASURES Lesion-based sensitivity of PET/CT and MRI for detection of clinically relevant lesions was calculated. Readers were unaware of other results. The reference standard was surgery with histology and treatment outcome. True positive (i.e., clinically relevant lesions) was defined as PanNETs ≥20 mm or insulinoma. RESULTS In six patients, 37 PanNETs were confirmed by histopathology. Sensitivity (95% CI) in the detection of clinically relevant lesions for combined PET/CT plus MRI, MRI, and PET/CT was 92.3% (64% to 99.8%), 38.5% (13.9% to 68.4%), and 84.6% (54.6% to 98.1%), respectively (P = 0.014 for the comparison of PET/CT plus MRI vs MRI). Postsurgery, EHH resolved in all patients. CONCLUSION 68Ga-DOTA-exendin-4 PET/CT is feasible in patients with MEN-1 and EHH. The combination with MRI is superior to MRI alone in the detection of insulinomas and may guide the surgical strategy.
Collapse
Affiliation(s)
- Kwadwo Antwi
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Guillaume Nicolas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
| | - Melpomeni Fani
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Heye
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Francois Pattou
- Department of General and Endocrine Surgery, Lille University Hospital, Lille France
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
- Neuroendocrine Unit, Royal Free Hospital, London, United Kingdom
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- UMR S-1185, Université Paris Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Aurel Perren
- Department of Pathology, University of Bern, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Deborah R Vogt
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Damian Wild
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
| | - Emanuel Christ
- Center for Neuroendocrine and Endocrine Tumors, University Hospital Basel, Basel, Switzerland
- Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
17
|
Albers MB, Manoharan J, Bartsch DK. Contemporary surgical management of the Zollinger-Ellison syndrome in multiple endocrine neoplasia type 1. Best Pract Res Clin Endocrinol Metab 2019; 33:101318. [PMID: 31521501 DOI: 10.1016/j.beem.2019.101318] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
About 30% of patients with MEN1 develop a Zollinger-Ellison syndrome. Meanwhile it is well established that the causative gastrinomas are almost exclusively localized in the duodenum and not in the pancreas, MEN1 gastrinomas occur multicentric and are associated with hyperplastic gastrin cell lesions and tiny gastrin-producing micro tumors in contrast to sporadic duodenal gastrinomas. Regardless of the high prevalence of early lymphatic metastases, the survival is generally good with an aggressive course of disease in only about 20% of patients. Symptoms can be controlled medically. The indication, timing, type, and extent of surgery are highly controversial and are discussed in detail in this article by a thorough and critical review of literature. More radical procedures, like partial pancreaticoduodenectomy, are weighed against less aggressive local excision of gastrinomas and the pros and cons of both approaches are discussed in terms of long-term morbidity, biochemical cure, and survival.
Collapse
Affiliation(s)
- Max B Albers
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany.
| | - Jerena Manoharan
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
| |
Collapse
|
18
|
Long-term Follow-up of MEN1 Patients Who Do Not Have Initial Surgery for Small ≤2 cm Nonfunctioning Pancreatic Neuroendocrine Tumors, an AFCE and GTE Study: Association Francophone de Chirurgie Endocrinienne & Groupe d'Etude des Tumeurs Endocrines. Ann Surg 2019; 268:158-164. [PMID: 28263205 PMCID: PMC6012055 DOI: 10.1097/sla.0000000000002191] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: To report long-term follow-up of patients with multiple endocrine neoplasia type 1 (MEN1) and nonfunctioning pancreatic neuroendocrine tumors (NF-PET). Background: Pancreaticoduodenal tumors occur in almost all patients with MEN1 and are a major cause of death. The natural history and clinical outcome are poorly defined, and management is still controversial for small NF-PET. Methods: Clinical outcome and tumor progression were analyzed in 46 patients with MEN1 with 2 cm or smaller NF-PET who did not have surgery at the time of initial diagnosis. Survival data were analyzed using the Kaplan-Meier method. Results: Forty-six patients with MEN1 were followed prospectively for 10.7 ± 4.2 (mean ± standard deviation) years. One patient was lost to follow-up and 1 died from a cause unrelated to MEN1. Twenty-eight patients had stable disease and 16 showed significant progression of pancreaticoduodenal involvement, indicated by increase in size or number of tumors, development of a hypersecretion syndrome, need for surgery (7 patients), and death from metastatic NF-PET (1 patient). The mean event-free survival was 13.9 ± 1.1 years after NF-PET diagnosis. At last follow-up, none of the living patients who had undergone surgery or follow-up had evidence of metastases on imaging studies. Conclusions: Our study shows that conservative management for patients with MEN1 with NF-PET of 2 cm or smaller is associated with a low risk of disease-specific mortality. The decision to recommend surgery to prevent tumor spread should be balanced with operative mortality and morbidity, and patients should be informed about the risk-benefit ratio of conservative versus aggressive management when the NF-PET represents an intermediate risk.
Collapse
|
19
|
Oleinikov K, Dancour A, Epshtein J, Benson A, Mazeh H, Tal I, Matalon S, Benbassat CA, Livovsky DM, Goldin E, Gross DJ, Jacob H, Grozinsky-Glasberg S. Endoscopic Ultrasound-Guided Radiofrequency Ablation: A New Therapeutic Approach for Pancreatic Neuroendocrine Tumors. J Clin Endocrinol Metab 2019; 104:2637-2647. [PMID: 31102458 DOI: 10.1210/jc.2019-00282] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is rapidly emerging as feasible therapy for patients with pancreatic neuroendocrine tumors (pNETs) in selected cases, as a result of its favorable safety profile. OBJECTIVE To assess the feasibility, safety, and efficacy of EUS-RFA in a cohort of patients with functional and nonfunctional pNETs (NF-pNETs). DESIGN Data on pNET patients treated with EUS-RFA between March 2017 and October 2018 at two tertiary centers was retrospectively analyzed. RESULTS The cohort included 18 adults (eight women, 10 men), aged 60.4 ± 14.4 years (mean ± SD), seven insulinoma patients, and 11 patients with NF-pNETs. Twenty-seven lesions with a mean diameter of 14.3 ± 7.3 mm (range 4.5 to 30) were treated. Technical success defined as typical postablative changes on a surveillance imaging was achieved in 26 out of 27 lesions. Clinical response with normalization of glucose levels was observed in all (seven of seven) insulinoma cases within 24 hours of treatment. Overall, there were no major complications 48 hours postprocedure. No clinically significant recurrences were observed during mean follow-up of 8.7 ± 4.6 months (range 2 to 21 months). CONCLUSIONS EUS-guided RFA of pNETs is a minimally invasive, safe, and technically feasible procedure for selected patients.
Collapse
Affiliation(s)
- Kira Oleinikov
- Neuroendocrine Tumor Unit, Endocrinology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Alain Dancour
- Gastroenterology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Julia Epshtein
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel Benson
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Haggi Mazeh
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ilanit Tal
- Neuroendocrine Tumor Unit, Endocrinology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shay Matalon
- Institute of Gastroenterology, Assaf Harofeh Medical Center, Zrifin, Israel
| | - Carlos A Benbassat
- Institute of Endocrinology, Assaf Harofeh Medical Center, Zrifin, Israel
| | - Dan M Livovsky
- Gastroenterology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eran Goldin
- Gastroenterology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, Endocrinology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
20
|
Albers MB, Manoharan J, Bollmann C, Chlosta MP, Holzer K, Bartsch DK. Results of Duodenopancreatic Reoperations in Multiple Endocrine Neoplasia Type 1. World J Surg 2019; 43:552-558. [PMID: 30288555 DOI: 10.1007/s00268-018-4809-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND To evaluate the outcome of duodenopancreatic reoperations in patients with multiple endocrine neoplasia type 1 (MEN1). METHODS MEN1 patients who underwent reoperations for duodenopancreatic neuroendocrine neoplasms (dpNENs) were retrieved from a prospective database and retrospectively analyzed. RESULTS Twelve of 101 MEN1 patients underwent up to three reoperations, resulting in a total of 18 reoperations for dpNEN recurrence. Patients initially underwent either formal pancreatic resections (n = 7), enucleations (n = 3), or duodenotomy with lymphadenectomy for either NF-pNEN (seven patients), Zollinger-Ellison syndrome (ZES, three patients), organic hyperinsulinism (one patient) or VIPoma (one patient). Six patients had malignant dpNENs with lymph node (n = 5) and/or liver metastases (n = 2). The indication of reoperations was NF-pNEN (five patients), ZES (five patients), organic hyperinsulinism (one patient), and recurrent VIPoma (one patient). Median time to first reoperation was 67.5 (range 6-251) months. Five patients required a second duodenopancreatic reoperation for 60-384 months after initial surgery, and one patient underwent a third reoperation after 249 months. The rate of complications (Clavien-Dindo ≥3) was 28%. Four patients required completion pancreatectomy. Six patients developed pancreoprivic diabetes. After a median follow-up of 18 (6-34) years after initial surgery, ten of 12 patients are alive, one died of metastatic pancreatic VIPoma, and one died of metastatic thymic NEN. CONCLUSION Reoperations are frequently necessary for dpNEN in MEN1 patients, but are not associated with an increased perioperative morbidity in specialized centers. Organ-sparing resections should be preferred as initial duodenopancreatic procedures to maintain pancreatic function and avoid completion pancreatectomy.
Collapse
Affiliation(s)
- Max B Albers
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany.
| | - Jerena Manoharan
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Maximilian P Chlosta
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Katharina Holzer
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| |
Collapse
|
21
|
Concomitant pancreatic neuroendocrine tumors in hereditary tumor syndromes: who, when and how to operate? JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
22
|
Ratnayake CBB, Loveday BP, Windsor JA, Lawrence B, Pandanaboyana S. Patient characteristics and clinical outcomes following initial surgical intervention for MEN1 associated pancreatic neuroendocrine tumours: A systematic review and exploratory meta-analysis of the literature. Pancreatology 2019; 19:462-471. [PMID: 30894303 DOI: 10.1016/j.pan.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND This systematic review aimed to define the outcomes of different pancreatic resection procedures for multiple endocrine neoplasia type 1 (MEN1) associated pancreatic neuroendocrine neoplasms (pNENs). METHODS A search of PubMed, MEDLINE and SCOPUS databases were performed in accordance with PRISMA guidelines. RESULTS Twenty-seven studies including 533 patients undergoing initial pancreatic resection for MEN1 associated pNENs were included in this systematic review. Three hundred and sixty-six (68.7%) distal pancreatectomies (DP), 120 (22.5%) sole enucleations (SE) and 47 (8.8%) pancreaticoduodenectomies (PD) were identified. SE was associated with a higher rate of recurrence than DP (25/67, 37% vs 40/190, 21% respectively, P = 0.008) but a lower rate of endocrine insufficiency than PD (1/20, 5% vs 8/21, 38% respectively, P = 0.010). A meta-analysis of major pancreatic resections (PD or DP) vs SE in 15 studies showed that SE is associated with an increased rate of recurrence (Major resection 42/184, 23% vs SE 20/53, 38% RR 0.65 CI 0.43-0.96 P = 0.032) but reduced rate of postoperative endocrine insufficiency (Resection 37/93, 40% vs SE 0/24, 0% RR 7.37 CI 1.57-34.64 P = 0.008). Similarly, insulinomas and functional pNENs overall had lower rates of recurrence and reoperation with major resection. There was no difference in the reoperation rates or survival outcomes after SE compared with major pancreatic resections at follow-up (pooled overall mean duration: 85 months). CONCLUSION Major pancreatic resections for MEN1 associated pNENs have a lower risk of recurrence and a higher risk of postoperative endocrine insufficiency when compared to sole enucleation, but a similar rate of reoperation and survival.
Collapse
Affiliation(s)
| | - Benjamin Pt Loveday
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HPB Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - John Albert Windsor
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HPB Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Benjamin Lawrence
- Regional Cancer and Blood Service, Auckland City Hospital, Auckland, New Zealand; Discipline of Oncology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HPB Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand.
| |
Collapse
|
23
|
Selberherr A, Koperek O, Riss P, Scheuba C, Niederle MB, Kaderli R, Perren A, Niederle B. Intertumor heterogeneity in 60 pancreatic neuroendocrine tumors associated with multiple endocrine neoplasia type 1. Orphanet J Rare Dis 2019; 14:54. [PMID: 30795813 PMCID: PMC6387504 DOI: 10.1186/s13023-019-1034-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 02/17/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with multiple endocrine neoplasia type 1 (MEN-1) develop multiple pancreatic neuroendocrine neoplasias (PNENs). Size at diagnosis and growth during follow-up are crucial parameters. According to the WHO 2017, grading is another important parameter. The impact of grading compared to size (WHO 2000) on the clinical course needs to be evaluated. METHODS Sixty PNENs of six patients with MEN-1 were retrospectively evaluated. RESULTS Fifty-one tumors with a diameter of < 20 mm were graded as G1. Two of 9 tumors with diameters of ≥20 mm were graded as G2. Tumor size of ≥20 mm correlated significantly with higher proliferation (p = 0.000617). Lymph node metastases were documented in two patients with a total of 19 tumors. In one patient, all 13 tumors (diameter: 0.4 to 100 mm) were classified as G1. However, metastases were documented in 9/29 lymph nodes. In the other patient, 5 tumors (3.5 to 20 mm) were classified as G1. The sixth tumor (30 mm) was classified as G2 (Ki-67: 8%). Metastases were revealed in 2/20 lymph nodes. CONCLUSIONS Tumor size of ≥20 mm seems to correlate with more aggressive MEN-1 related pancreatic disease, regardless of individual proliferation. Tumors ≥20 mm and tumors graded as G2 should be treated surgically regardless of their size.
Collapse
Affiliation(s)
- Andreas Selberherr
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
| | - Oskar Koperek
- Department of Pathology, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Philipp Riss
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Christian Scheuba
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Martin B Niederle
- Department of Anesthesiology, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Reto Kaderli
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Aurel Perren
- Institute of Pathology, University of Bern, Murtenstrasse 31, CH-3012, Bern, Switzerland
| | - Bruno Niederle
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| |
Collapse
|
24
|
Polenta V, Slater EP, Kann PH, Albers MB, Manoharan J, Ramaswamy A, Mahnken AH, Bartsch DK. Preoperative Imaging Overestimates the Tumor Size in Pancreatic Neuroendocrine Neoplasms Associated with Multiple Endocrine Neoplasia Type 1. World J Surg 2018; 42:1440-1447. [PMID: 29075857 DOI: 10.1007/s00268-017-4317-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Radiological tumor size of non-functioning pancreatic neuroendocrine neoplasms (Nf-pNENs) associated with multiple endocrine neoplasia type 1 (MEN1) is a crucial parameter to indicate surgery. The aim of this study was to compare radiological size (RS) and pathologic size (PS) of MEN1 associated with pNENs. METHODS Prospectively collected data of MEN1 patients who underwent pancreatic resections for pNENs were retrospectively analyzed. RS was defined as the largest tumor diameter measured on endoscopic ultrasound (EUS), magnetic resonance imaging (MRI) or computed tomography (CT). PS was defined as the largest tumor diameter on pathological analysis. Student's t test and linear regression analysis were used to compare the median RS and PS. p < 0.05 was considered significant. RESULTS Forty-four patients with a median age of 37 (range 10-68) years underwent primary pancreatic resections for pNENs. Overall, the median RS (20 mm, range 3-100 mm) was significantly larger than the PS (13 mm, range 4-110 mm) (p = 0.001). In patients with pNENs < 20 mm (n = 27), the size difference (median RS 15 mm vs PS 12 mm) was also significant (p = 0.003). However, the only modality that significantly overestimated the PS was EUS (median RS 14 mm vs 11 mm; p = 0.0002). RS overestimated the PS in 21 patients (21 of 27 patients, 78%). Five of 11 patients (12%) with a Nf-pNEN and a RS > 20 mm had in reality a PS < 20 mm. MRI was the imaging technique that best correlated with PS in the total cohort (r = 0.8; p < 0.0001), whereas EUS was the best correlating imaging tool in pNENs < 20 mm (r = 0.5; p = 0.0001). CONCLUSION Preoperative imaging, especially EUS, frequently overestimates the size of MEN1-pNENs, especially those with a PS < 20 mm. This should be considered when indicating surgery in MEN1 patients with small Nf-pNENs.
Collapse
Affiliation(s)
- V Polenta
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany. .,Department of General Surgery, Ospedali Riuniti Ancona, Conca 71, Torrette, 60020, Ancona, Italy.
| | - E P Slater
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - P H Kann
- Division Endocrinology, Philipps-University Marburg, Marburg, Germany
| | - M B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - J Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - A Ramaswamy
- Institute of Pathology, Philipps-University Marburg, Marburg, Germany
| | - A H Mahnken
- Department of Radiology, Philipps-University Marburg, Marburg, Germany
| | - D K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| |
Collapse
|
25
|
Exploring the surgical landscape of pancreatic neuroendocrine neoplasia in Austria: Results from the ASSO pNEN study group. Eur J Surg Oncol 2018; 45:198-206. [PMID: 30262324 DOI: 10.1016/j.ejso.2018.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Pancreatic neuroendocrine neoplasia (pNEN) show increasing incidence and management is complex due to biological heterogeneity. Most publications report isolated high-volume single-centre data. This Austrian multi-centre study on surgical management of pNENs provides a comprehensive real-life picture of quality indicators, recurrence-patterns, survival factors and systemic treatments. METHODS Retrospective, national cohort-study from 7 medium-/high-volume centres in Austria, coordinated under the auspices of the Austrian Society of Surgical Oncology (ASSO). RESULTS Two-hundred patients underwent resection for pNEN, 177 had non-functioning tumours and 31 showed stage 4 disease. Participating centres were responsible for 2/3 of pNEN resections in Austria within the last years. The mean rate of completeness of variables was 98.6%. Ninety-days mortality was 3.5%, overall rate of complications was 42.5%. Morbidity did not influence long-term survival. The 5-year overall-survival (OS) was 81.3%, 10-year-OS 52.5% and 5-year recurrence-free-survival (RFS) 69.8%. Recurrence was most common in the liver (68.1%). Four out of five patients with recurrence underwent further treatment, most commonly with medical therapy or chemotherapy. Multivariable analysis revealed grading (HR:2.7) and metastasis (HR:2.5) as significant factors for relapse. Tumours-size ≥2 cm (HR:5.9), age ≥60 years (HR:3.1), metastasis (HR:2.3) and grading (HR:2.0) were associated with OS. Tumours <2 cm showed 93.9% 10-year-OS, but 33% had G2/G3 grading, 12.5% positive lymph-nodes and 4.7% metastasis at diagnosis, each associated with significant worse survival. CONCLUSION Resection of pNENs in Austria is performed with internationally comparable safety. Analysed factors allow for risk-stratification in clinical treatment and future prospective trials. A watch-and-wait strategy purely based on tumour-size cannot be recommended.
Collapse
|
26
|
Ariotti R, Partelli S, Muffatti F, Andreasi V, Della Sala F, Falconi M. How should incidental NEN of the pancreas and gastrointestinal tract be followed? Rev Endocr Metab Disord 2018. [PMID: 29527619 DOI: 10.1007/s11154-018-9445-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neuroendocrine gastro-entero-pancreatic neoplasms (GEP-NENs) constitute a heterogeneous group of tumors, whose incidence has increased over the years. The most frequent site for primary disease is the stomach followed by small and large intestine, and pancreas. In the last decade, a dramatic growing in the incidence of small, incidental GEP-NENs has been recorded. In parallel, an increasing attitude toward more conservative approaches instead of surgical management has being widely spreading. This is particularly true for small, asymptomatic, pancreatic NEN as for these tumor forms an active surveillance has proven to be safe and feasible. Primary site and biological features of the neoplasms lead to different strategies and indications for surveillance and follow-up. This review focuses on the current evidence on modality and timing of surveillance and conservative treatment of incidentally discovered lesions.
Collapse
Affiliation(s)
- Riccardo Ariotti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Della Sala
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Via Olgettina 60, 20132, Milan, Italy.
| |
Collapse
|
27
|
Limited Value of Ga-68-DOTATOC-PET-CT in Routine Screening of Patients with Multiple Endocrine Neoplasia Type 1. World J Surg 2018; 41:1521-1527. [PMID: 28138732 DOI: 10.1007/s00268-017-3907-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Routine screening is recommended for patients with multiple endocrine neoplasia type 1 (MEN1) to enable early detection and treatment of associated neuroendocrine neoplasms (NEN). Gallium68-DOTATOC-Positron emission tomography combined with computed tomography (Ga-68-DOTATOC-PET-CT) is a very sensitive and specific imaging technique for the detection of sporadic neuroendocrine tumors. The present study evaluated the value of Ga-68-DOTATOC-PET-CT in routine screening of patients with MEN1. METHODS Between January 2014 and March 2016, all MEN1 patients underwent Ga-68-DOTATOC-PET-CT in addition to conventional imaging (computed tomography of the thorax, magnetic resonance imaging of the abdomen and pituitary, endoscopic ultrasonography). The diagnostic yield of conventional imaging and Ga-68-DOTATOC-PET-CT was prospectively documented and compared, and treatment changes caused by the addition of Ga-68-DOTATOC-PET-CT were recorded. RESULTS Conventional imaging detected 145 NENs, mainly pancreaticoduodenal NENs (n = 117, 81%), in 31 of 33 MEN1 patients. Ga-68-DOTATOC-PET-CT detected 55 NENs in 23 of the 33 patients (p = 0.0001). Ninety (62%) NENs detected by conventional imaging were missed by DOTATOC-PET-CT. The majority of missed lesions were pNEN (n = 68; 74%). The sensitivity of Ga-68-DOTATOC-PET-CT for NENs <5, 5-9, 10-19 and ≥20 mm was 0, 29, 81 and 100%, respectively. However, Ga-68-DOTATOC-PET-CT detected more liver and lymph node metastases in patients with known metastatic disease, which did not lead to a change of patients' management. In one patient (3%), Ga-68-DOTATOC-PET-CT was the only imaging modality that detected a small intestine NEN and led to potentially curative surgery. CONCLUSION Ga-68-DOTATOC-PET-CT cannot be recommended for routine screening of MEN1 patients. It might provide important additional information in patients with suspected or known metastatic disease.
Collapse
|
28
|
Thomaschewski M, Neeff H, Keck T, Neumann HPH, Strate T, von Dobschuetz E. Is there any role for minimally invasive surgery in NET? Rev Endocr Metab Disord 2017; 18:443-457. [PMID: 29127554 DOI: 10.1007/s11154-017-9436-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.
Collapse
Affiliation(s)
- M Thomaschewski
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H Neeff
- Department of Visceral and General Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - T Keck
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H P H Neumann
- Section for Preventive Medicine, Department of Nephrology and General Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - T Strate
- Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany
| | - E von Dobschuetz
- Section of Endocrine Surgery, Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany.
| |
Collapse
|
29
|
Sadowski SM, Cadiot G, Dansin E, Goudet P, Triponez F. The future: surgical advances in MEN1 therapeutic approaches and management strategies. Endocr Relat Cancer 2017; 24:T243-T260. [PMID: 28811298 DOI: 10.1530/erc-17-0285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/16/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a hereditary autosomal dominant disorder associated with numerous neuroendocrine tumors (NETs). Recent advances in the management of MEN1 have led to a decrease in mortality due to excess hormones; however, they have also led to an increase in mortality from malignancy, particularly NETs. The main challenges are to localize these tumors, to select those that need therapy because of the risk of aggressive behavior and to select the appropriate therapy associated with minimal morbidity. This must be applied to a hereditary disease with a high risk of recurrence. The overall aim of management in MEN1 is to ensure that the patient remains disease- and symptom-free for as long as possible and maintains a good quality of life. Herein, we review the changes that occurred in the last 20 years in the surgical management of MEN1-associated functional and non-functional pancreatico-duodenal NETs and thymic and bronchial NETs.
Collapse
Affiliation(s)
- S M Sadowski
- Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of Geneva, Geneva, Switzerland
| | - G Cadiot
- Gastroenterology and HepatologyUniversity Hospital of Reims, Reims, France
| | - E Dansin
- OncologyOscar Lambret Cancer Center, University of Lille, Lille, France
| | - P Goudet
- Endocrine SurgeryUniversity Hospital of Dijon, and INSERM, U866, Epidemiology and Clinical Research in Digestive Oncology Team, and INSERM, CIC1432, Clinical Epidemiology Unit, University Hospital of Dijon, Clinical Investigation Centre, Clinical Epidemiology/Clinical Trials Unit, Dijon, France
| | - F Triponez
- Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of Geneva, Geneva, Switzerland
| |
Collapse
|
30
|
Canellas R, Lo G, Bhowmik S, Ferrone C, Sahani D. Pancreatic neuroendocrine tumor: Correlations between MRI features, tumor biology, and clinical outcome after surgery. J Magn Reson Imaging 2017; 47:425-432. [PMID: 28480609 DOI: 10.1002/jmri.25756] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/19/2017] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To assess which magnetic resonance imaging (MRI) features are associated with pNETs (pancreatic neuroendocrine tumors) grade based on the WHO classification, as well as identify MRI features related to disease progression after surgery. MATERIALS AND METHODS In this Institutional Review Board (IRB)-approved study, 1.5T and 3.0T MRI scans of 80 patients with surgically verified pNETs were assessed. The images were evaluated for tumor location; size; pattern; predominant signal intensity on precontrast T1 - and T2 -weighted images, as well as on postcontrast arterial and portal venous phase T1 -weighted sequences; presence of pancreatic duct dilatation; pancreatic atrophy; restricted diffusion; vascular involvement by the tumor; extrapancreatic tumor spread; and synchronous liver metastases. Tumors were graded based on the WHO classification and patients were followed-up with computed tomography (CT) or MRI after surgical resection. Data were analyzed with Student's t and chi-square tests, logistic regression, and Kaplan-Meier curves. RESULTS The MRI features that were associated with aggressive tumors were: size >2.0 cm (odds ratio [OR] = 4.8, P = 0.002), "T2 nonbright lesions" on T2 -weighted images (OR = 4.6, P = 0.008), presence of pancreatic ductal dilatation (OR = 4.9, P = 0.024), and restricted diffusion within the lesion (OR = 4.9, P = 0.013). Differences in progression-free survival distribution were found for patients whose pNETs were associated with the following MRI features: size >2.0 cm (χ2 (1) = 6.0, P = 0.014), "nonbright lesions" on T2 -weighted images (χ2 (1) = 6.8, P = 0.009), and presence of pancreatic duct dilatation (χ2 (1) = 10.9, P = 0.001). CONCLUSION MRI features can be used to assess pNETs aggressiveness and identify patients at risk for early disease progression after surgical resection. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:425-432.
Collapse
Affiliation(s)
- Rodrigo Canellas
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Grace Lo
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sreejita Bhowmik
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dushyant Sahani
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
31
|
Cioppi F, Cianferotti L, Masi L, Giusti F, Brandi ML. The LARO-MEN1 study: a longitudinal clinical experience with octreotide Long-Acting Release in patients with Multiple Endocrine Neoplasia type 1 Syndrome. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2017; 14:123-130. [PMID: 29263719 PMCID: PMC5726195 DOI: 10.11138/ccmbm/2017.14.1.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a rare hereditary tumoral syndrome, featured by a combination of neoplasms of various endocrine and nonendocrine tissues. Approximately 33% of MEN1-related deaths are due to the malignant behaviour of well-differentiated neuroendocrine tumors (NETs), for which a preventive surgical treatment is not feasible. Somatostatin analogues (SSA) have been employed in the treatment of NETs in the stage of advanced or metastatic disease, in order to control the growth and secretion of tumor lesions. A longitudinal, open label study named "LARO-MEN1" was undertaken in order to assess whether early medical treatment with long-acting SSA could act as a preventive approach in small MEN1-related gastroenteropancreatic (GEP) NETs. Thirty consecutive patients affected by MEN1 were screened and 8 patients with small (<2 cm) NETs and abnormal laboratory values of at least one of the GEP hormones were administered octreotide acetate slow-release formulation (LAR) (10 mg i.m. every 28 days). Octreotide LAR was effective in decreasing GEP hormones and overall safe in the majority of patients up to six years of treatment, maintaining the disease stable also in terms of tumor size. The positive outcomes of this study in MEN1 patients reinforce the results obtained in advanced NETs on the use of SSA, opening to the opportunity for preventive use of octreotide LAR, aimed to delay or even avoid surgery in these patients.
Collapse
Affiliation(s)
- Federica Cioppi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Luisella Cianferotti
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Laura Masi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Francesca Giusti
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Bone and Mineral Metabolism Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| |
Collapse
|
32
|
Li Y, Simonds WF. Recent advances in the management of endocrine malignancies associated with hereditary hyperparathyroidism syndromes. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017. [DOI: 10.2217/ije-2016-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hereditary hyperparathyroidism syndromes, such as multiple endocrine neoplasm type 1, type 2A and the hyperparathyroidism-jaw tumor syndrome, are associated with an increased incidence of malignancies involving the neuroendocrine tissue of the pancreas and thymus, parathyroid and thyroid glands. The natural history of these endocrine tumors can differ from nonhereditary malignancies. The surgical approach, the only potentially curative treatment option for these endocrine malignancies, has evolved considerably in recent years. Newer targeted therapies, such as small molecule kinase inhibitors, somatostatin analogs and peptide receptor radionuclide therapy, are being developed. We provide here a comprehensive review of the current standards of treatment and emerging novel therapies for the endocrine malignancies commonly associated with hereditary hyperparathyroidism syndromes.
Collapse
Affiliation(s)
- Yulong Li
- Metabolic Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, MD 20892, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, MD 20892, USA
| |
Collapse
|
33
|
Surveillance strategy for small asymptomatic non-functional pancreatic neuroendocrine tumors - a systematic review and meta-analysis. HPB (Oxford) 2017; 19:310-320. [PMID: 28254159 DOI: 10.1016/j.hpb.2016.12.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/11/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-functional pancreatic neuroendocrine tumors (NF-PNET) are rare neoplasms being increasingly diagnosed. Surgical treatment or expectant management are both suggested for small NF-PNETs. The aim of this study was to evaluate the outcome of surveillance strategy for small NF-PNETs. METHODS A systematic search was performed up to March 2016 in MEDLINE, EMBASE and the Cochrane Library according to the PRISMA guidelines. Data was pooled using the random-effects model. RESULTS Nine articles including 344 patients with sporadic and 64 patients with MEN1 related NF-PNET were selected. Tumor growth was observed in 22% and 52%, development of metastases were reported on 0% and 9%, and rate of secondary surgical resection was 12% and 25% in patients with sporadic or MEN1 related NF-PNETs, respectively. All metastases (1 distant, 4 nodal) were reported by a single study in patients with MEN1. Reason for secondary surgery was tumor growth in half of patients undergoing surgery. DISCUSSION Expectant management of small asymptomatic, sporadic, NF-PNETs could be a reasonable option in highly selected patients. However, the level of evidence is low and longer follow-up is needed to identify patients could benefit from upfront surgery instead of expectant treatment.
Collapse
|
34
|
Matsubayashi H, Kawata N, Kakushima N, Tanaka M, Takizawa K, Kiyozumi Y, Horiuchi Y, Sasaki K, Sugiura T, Uesaka K, Ono H. A case of type 1 multiple endocrine neoplasia with esophageal stricture successfully treated with endoscopic balloon dilation and local steroid injection combined with surgical resection of gastrinomas. BMC Gastroenterol 2017; 17:37. [PMID: 28270118 PMCID: PMC5341352 DOI: 10.1186/s12876-017-0597-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 03/01/2017] [Indexed: 01/08/2023] Open
Abstract
Background In type 1 multiple endocrine neoplasia (MEN1), esophageal diseases association with excessive gastrin secretion in Zollinger-Ellison syndrome (ZES) sometimes develop. Here, we reported a case of MEN1/ZES, who developed dysphagia due to reflux esophagitis with severe esophageal stricture. Treatment for his esophageal stricture and ZES was discussed. Case presentation A 43-year-old man with progressive dysphagia and diarrhea was referred to the teaching hospital. He had a history of recurrent duodenojejunal perforations despite the anti-secretory medication. Blood examinations revealed elevated serum gastrin, calcium, and parathyroid hormone. Upper gastrointestinal endoscopy demonstrated a severe esophageal stricture, multiple gastroduodenal ulcer scars, and a duodenal submucosal tumor. Enhanced computed tomography showed multiple hypervascular tumors within the pancreas and duodenum, suggestive of MEN1. Genetic examination demonstrated a pathogenic MEN1 mutation. Repetitive endoscopic esophageal dilatation with intralesional corticosteroid injection, coupled with pancreatoduodenectomy were performed to improve the patient’s symptoms and to treat pancreatic tumors. The histology of multiple tumors in the duodenum and pancreas were all consistent with neuroendocrine tumors. His hypergastrinemia subsided and he remained asymptomatic in his gastrointestinal tract after these treatments. Conclusion For esophageal stenosis in case of MEN1/ZES, anti-secretory therapy and endoscopic dilatation with corticosteroid injection could be recommended. However, in refractory cases with repetitive and/or severe complications due to high acid secretion, surgical treatment could be considered as an option.
Collapse
Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan. .,Clinic of Genetic Medicine, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan.
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Yoshimi Kiyozumi
- Clinic of Genetic Medicine, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Yasue Horiuchi
- Clinic of Genetic Medicine, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Teiichi Sugiura
- Division of Hepato-biliary-pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-biliary-pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| |
Collapse
|
35
|
Treatment of Pancreatic Neuroendocrine Tumors in Multiple Endocrine Neoplasia Type 1: Some Clarity But Continued Controversy. Pancreas 2017; 46:589-594. [PMID: 28426491 PMCID: PMC5407310 DOI: 10.1097/mpa.0000000000000825] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
36
|
Partelli S, Cirocchi R, Crippa S, Cardinali L, Fendrich V, Bartsch DK, Falconi M. Systematic review of active surveillance versus surgical management of asymptomatic small non-functioning pancreatic neuroendocrine neoplasms. Br J Surg 2016; 104:34-41. [PMID: 27706803 DOI: 10.1002/bjs.10312] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of asymptomatic, sporadic, small non-functioning pancreatic neuroendocrine neoplasms (NF-PNENs) has increased in recent decades. Conservative treatment has been advocated for these tumours. The aim of this study was systematically to evaluate the literature on active surveillance and to compare this with surgical management for asymptomatic sporadic small NF-PNENs. METHODS PubMed, Embase and the Cochrane Library were searched systematically for studies that compared the active surveillance of asymptomatic, sporadic, small NF-PNENs with surgical management. PRISMA guidelines for systematic reviews were followed. RESULTS After screening 3915 records, five retrospective studies with a total of 540 patients were included. Of these, 327 patients (60·6 per cent) underwent active surveillance and 213 (39·4 per cent) had surgery. There was wide variation in the tumour diameter threshold considered as inclusion criterion (2 cm to any size). The median length of follow-up ranged from 28 to 45 months. Measurable tumour growth was observed in 0-51·0 per cent of patients. Overall, 46 patients (14·1 per cent) underwent pancreatic resection after initial conservative treatment. In most patients the reason was an increase in tumour size (19 of 46). There were no disease-related deaths in the active surveillance group in any of the studies. CONCLUSION This systematic review suggests that active surveillance of patients affected by sporadic, small, asymptomatic NF-PNENs may be a good alternative to surgical treatment.
Collapse
Affiliation(s)
- S Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - R Cirocchi
- Department of Digestive and Liver Surgery Unit, St Maria Hospital, Terni, Italy
| | - S Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - L Cardinali
- Department of Surgery, Polytechnic University of Marche Region, Ancona, Italy
| | - V Fendrich
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - D K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - M Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| |
Collapse
|