1
|
Behi H, Omry A, Dallagi R, Changuel A, Troudi D, Khalifa MB. Diagnosing and managing small bowel neuroendocrine tumors presenting as acute obstruction in an elderly patient: A case report and comprehensive management overview. Int J Surg Case Rep 2024; 122:110126. [PMID: 39126932 PMCID: PMC11363995 DOI: 10.1016/j.ijscr.2024.110126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Neuroendocrine tumors (NETs) of the small bowel are rare but clinically significant due to their challenging diagnostic pathways and potential for insidious progression. Early identification is critical for effective management and improved prognosis in these cases. CLINICAL PRESENTATION Here, we present a case of a 75-year-old patient with no significant medical history who presented acutely with diffuse abdominal pain, vomiting, and signs of bowel obstruction. Diagnostic workup, including CT imaging, revealed a distal ileal neuroendocrine mass with mesenteric lymphadenopathy, necessitating urgent surgical intervention. DISCUSSION This case underscores the diagnostic complexities and therapeutic challenges associated with small bowel NETs. Surgical resection with meticulous lymph node dissection remains the cornerstone of treatment, aimed at achieving complete tumor excision and optimal disease control. The role of imaging modalities and biochemical markers in guiding clinical decisions and postoperative management strategies is discussed considering the patient's clinical course. CONCLUSION Timely recognition and intervention are crucial in the management of small bowel NETs, given their potential for late presentation and nonspecific symptoms. Despite diagnostic and procedural challenges highlighted in this case, early surgical intervention and comprehensive follow-up are essential for achieving favorable outcomes and minimizing recurrence risks in patients with small bowel NETs.
Collapse
Affiliation(s)
- Hager Behi
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia
| | - Ahmed Omry
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia.
| | - Rania Dallagi
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia
| | - Amel Changuel
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia
| | - Dholkefl Troudi
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia
| | - Med Bachir Khalifa
- General Surgery Department, Military Hospital of Tunis, Mont Fleury-1008, Tunis, Tunisia; Faculty of Medicine of Tunis, 15, Djebel Lakhdhar Street - 1007 Bab Saadoun, Tunis, Tunisia
| |
Collapse
|
2
|
Gustafson A, Sadowski SM. Invited Editorial: Long-Term Survival Outcomes After Minimally Invasive Surgery for Ileal Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:5487-5488. [PMID: 38839670 DOI: 10.1245/s10434-024-15563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Alexandra Gustafson
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Samira M Sadowski
- Neuroendocrine Cancer Therapy Section, Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
3
|
Patel SM, Venkatesan V, Barras AA, Pacheco LL. Ileo-Ileal Intussusception Secondary to Neuroendocrine Tumor in Adult Patient. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e944872. [PMID: 39097769 PMCID: PMC11318702 DOI: 10.12659/ajcr.944872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/02/2024] [Accepted: 06/16/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Intussusception occurs when a proximal region of the intestine telescopes into a distal region. It is more common in the pediatric population, with only 5% of cases occurring in adults. The most frequent causes of adult intussusception are malignancy, polyps, or diverticula. A very rare cause is neuroendocrine tumor (NET). NETs are a diverse group of neoplasms that arise from endocrine cells throughout the body. Here, we present a case of a patient who presented with ileo-ileal intussusception due to a T3N1 NET, grade 1. CASE REPORT A 60-year-old man with a medical history of peptic ulcer disease presented for evaluation of lower abdominal pain, dark "maroon" colored stools, and hematemesis for the past 2 days. Computed tomography (CT) of the abdomen and pelvis showed ileo-ileal intussusception. Exploratory laparotomy revealed a small bowel mass approximately 30 cm from the ileocecal valve. After removal of 15 cm of small bowel and 13 lymph nodes, pathology confirmed the diagnosis of a T3N1 NET, grade 1. He was subsequently referred to the Oncology Department, where he was cleared, with no need for additional surveillance. CONCLUSIONS In adult patients presenting with nonspecific abdominal pain and concern for small bowel obstruction, a CT scan can be helpful in diagnosing intussusception. When dealing with adult intussusception, the etiology needs to be carefully investigated to search for an underlying malignancy. In rare occasions, small bowel NETs can be the cause of intussusception and can therefore be identified early, before they metastasize and present with carcinoid syndrome.
Collapse
|
4
|
Sarioglu AG, Akgun E, Uysal M, Osman M, Berber E. The utility of fluorescence imaging in detecting primary and metastatic small bowel carcinoid tumors. Am J Surg 2024; 232:3-7. [PMID: 37945469 DOI: 10.1016/j.amjsurg.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Our aim was to investigate utility of indocyanine green (ICG) and autofluorescence (AF) imaging in detection of small bowel primary and metastatic carcinoids. METHODS Using Institutional Review Board approval, ICG and AF imaging of small bowel carcinoids was performed. Imaging findings were prospectively recorded in operating room and compared with conventional imaging, surgical exploration and pathologic findings. RESULTS There were 16 patients with 23 primary small bowel tumors, 27 mesenteric lymph nodes, 36 liver metastases and 2 peritoneal nodules. Carcinoid tumors exhibited brighter AF signals compared to background. AF imaging was superior to both DOTATATE PET and surgeon inspection/palpation in demonstrating small bowel primaries. Utility for metastatic lymph nodes and peritoneal metastases was limited. Superficial liver metastases exhibited brighter fluorescence compared to background on both ICG and AF imaging. CONCLUSIONS This is the largest study assessing utility of near-infrared fluorescence imaging in detection of small bowel carcinoids. Our results show promise in the utilization fluorescence imaging to detect occult primary tumors and superficial liver metastases.
Collapse
Affiliation(s)
| | - Ege Akgun
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Melis Uysal
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammed Osman
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA; Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
5
|
Gonzalez RS, La Rosa S, Ma C, Polydorides AD, Shi C, Yang Z, Cox B, Karamchandani DM. Debating Deposits, Redux: Substantial Interobserver Agreement Exists in Distinguishing Tumor Deposits From Nodal Metastases in Small Bowel Neuroendocrine Tumors. Arch Pathol Lab Med 2024; 148:581-587. [PMID: 37639446 DOI: 10.5858/arpa.2023-0169-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Recent data suggest mesenteric tumor deposits (MTDs) indicate poor prognosis in small bowel well-differentiated neuroendocrine tumors (SB-NETs), including compared to positive lymph nodes, making their distinction crucial. OBJECTIVE To study interobserver agreement in distinguishing SB-NET MTDs from positive nodes. DESIGN Virtual slides from 36 locally metastatic SB-NET foci were shared among 7 gastrointestinal pathologists, who interpreted each as an MTD or a positive node. Observers ranked their 5 preferred choices among a supplied list of potentially useful histologic features, for both options. Diagnostic opinions were compared using Fleiss multirater and Cohen weighted κ analyses. RESULTS Preferred criteria for MTD included irregular shape (n = 7, top choice for 5), perineural invasion/nerve entrapment (n = 7, top choice for 2), encased thick-walled vessels (n = 7), and prominent fibrosis (n = 6). Preferred criteria for positive nodes included peripheral lymphoid follicles (n = 6, top choice for 4), round shape (n = 7, top choice for 2), peripheral lymphocyte rim (n = 7, top choice for 1), subcapsular sinuses (n = 7), and a capsule (n = 6). Among 36 foci, 10 (28%) each were unanimously diagnosed as MTD or positive node. For 13 foci (36%), there was a diagnosis favored by most observers (5 or 6 of 7): positive node in 8, MTD in 5. Only 3 cases (8%) had a near-even (4:3) split. Overall agreement was substantial (κ = .64, P < .001). CONCLUSIONS Substantial interobserver agreement exists for distinguishing SB-NET MTDs from lymph node metastases. Favored histologic criteria in making the distinction include irregular shape and nerve/vessel entrapment for MTD, and peripheral lymphocytes/lymphoid follicles and round shape for positive nodes.
Collapse
Affiliation(s)
- Raul S Gonzalez
- From the Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia (Gonzalez)
| | - Stefano La Rosa
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy (La Rosa)
| | - Changqing Ma
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri (Ma)
| | - Alexandros D Polydorides
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (Polydorides)
| | - Chanjuan Shi
- Department of Pathology, Duke University Medical Center, Durham, North Carolina (Shi)
| | - Zhaohai Yang
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (Yang)
| | - Brian Cox
- Pacific Rim Pathology, San Diego, California (Cox)
| | - Dipti M Karamchandani
- the Department of Pathology, UT Southwestern Medical Center, Dallas, Texas (Karamchandani)
| |
Collapse
|
6
|
Nigam A, Li JWY, Fiasconaro M, Lin S, Capanu M, Kleiman DA, Memeh K, Raj N, Reidy-Lagunes DL, Untch BR. Morbidity and Outcomes of Primary Tumor Management in Patients with Widely Metastatic Well-Differentiated Small Bowel Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:2337-2348. [PMID: 38036927 DOI: 10.1245/s10434-023-14637-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The benefit of primary tumor resection in distant metastatic small bowel neuroendocrine tumors (SBNETs) is controversial, with treatment-based morbidity not well-defined. We aimed to determine the impact of primary tumor resection on development of disease-specific complications in patients with metastatic well-differentiated SBNETs. PATIENTS AND METHODS A retrospective analysis was performed of patients diagnosed with metastatic well-differentiated jejunal/ileal SBNETs at a single tertiary care cancer center from 1980 to 2016. Outcomes were compared on the basis of treatment selected at diagnosis between patients who underwent initial medical treatment or primary tumor resection. RESULTS Among 180 patients, 71 underwent medical management and 109 primary tumor resection. Median follow-up was 116 months. Median event-free survival did not differ between treatment approaches (log-rank p = 0.2). In patients medically managed first, 16/71 (23%) required surgery due to obstruction, perforation, or bleeding. These same complications led to resection at presentation in 31/109 (28%) surgically treated patients. Development of an obstruction from the primary tumor was not associated with disease progression/recurrence (HR 1.14, 95% CI 0.75-1.75) with all patients recovering postoperatively. Ongoing tumor progression requiring secondary laparotomy was associated with worse mortality (HR 7.51, 95% CI 3.3-16.9; p < 0.001) and occurred in 20/109 (18%) primary tumor resection and 7/16 (44%) initially medically treated patients. CONCLUSIONS Rates of event-free survival among patients with metastatic SBNETs do not differ on the basis of primary tumor management. The development of an obstruction from the primary tumor was not associated with worse outcomes with all patients salvaged. Regardless of initial treatment selected, patients with metastatic SBNET should be closely followed for early signs of primary tumor complications.
Collapse
Affiliation(s)
- Aradhya Nigam
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Janet W Y Li
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Fiasconaro
- Department of Epidemiology and Statistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sabrina Lin
- Department of Epidemiology and Statistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marinela Capanu
- Department of Epidemiology and Statistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David A Kleiman
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Kelvin Memeh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nitya Raj
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Brian R Untch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
7
|
Nigam A, Untch BR. ASO Author Reflections: Morbidity and Outcomes of Primary Tumor Management in Patients with Widely Metastatic Well-Differentiated Small Bowel Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:2359-2360. [PMID: 38252266 DOI: 10.1245/s10434-023-14823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Aradhya Nigam
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | - Brian R Untch
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
8
|
Søreide K, Stättner S, Hallet J. Surgery as a Principle and Technical Consideration for Primary Tumor Resection of Small Bowel Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:1125-1137. [PMID: 38006527 PMCID: PMC10761444 DOI: 10.1245/s10434-023-14610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/27/2023]
Abstract
Small bowel neuroendocrine tumors (SB-NETs) are increasingly identified and have become the most frequent entity among small bowel tumors. An increasing incidence, a high prevalence, and a prolonged survival with optimal modern multidisciplinary management makes SB-NETs a unique set of tumors to consider for surgical oncologists. The major goals of surgical treatment in the setting of SB-NET include control of tumor volume, control of endocrine secretion, and prevention of locoregional complications. Key considerations include assessment of multifocality and resection of mesenteric nodal masses with the use of mesenteric-sparing approaches and acceptance of R1 margins if necessary to clear disease while avoiding short bowel syndrome. A description through eight steps for consideration is presented to allow for systematic surgical planning and execution of resection. Moreover, some controversies and evolving considerations to the surgical principles and technical procedures remain. The role of primary tumor resection in the presence of (unresectable) liver metastasis is still unclear. Reports of feasibility of minimally invasive surgery are emerging, with undetermined selection criteria for appropriateness or long-term outcomes. Resection of SB-NETs should be considered in all patients fit for surgery and should follow principles to achieve surgical oncological control that is appropriate for the stage and tumor burden, considering the age and comorbidity of the individual patient.
Collapse
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Vöcklabruck, Austria
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
9
|
Eneholm J, Beka E, Kotán R, Gimm O. A retrospective study comparing minimally invasive versus open surgical resection of small intestinal neuroendocrine neoplasms at a tertiary referral center. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107936. [PMID: 38176259 DOI: 10.1016/j.ejso.2023.107936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/07/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Neuroendocrine neoplasms (SI-NEN) are the commonest malignancies of the small intestine. Traditionally, surgical treatment for SI-NEN has been open surgery. PURPOSE The purpose of this study was to compare minimally invasive surgery (MIS) with the traditional open surgery approach for treating SI-NEN in a Swedish population. METHODS Patients with histopathological confirmed SI-NEN who underwent open surgery or MIS resection within 2009-2021 were extracted from the hospital's medical records. RESULTS 65 patients were included in this study, with 35 (54 %) undergoing MIS and 30 (46 %) undergoing open surgery. We found no statistically significant difference (p = 0.173) in the frequency of R0 resections (MIS group n = 34 (97 %), open surgery group n = 26 (87 %)). Nor was there a significant difference (p = 0.101) when comparing the median number of resected lymph nodes (MIS group n = 13.5, open surgery group n = 10). A post-operative paralytic ileus was more often reported (p = 0.052) in the MIS group (n = 9, 26 %) compared to the open surgery group (n = 2, 7 %). In light of this, the days of hospital stay did not differ significantly (MIS group median = 6, IQR (5-8), open surgery group median = 6, IQR (5-9)). The Kaplan-Meier analysis did not reveal differences concerning cancer-related deaths (p = 0.109). CONCLUSION The results from this study support that a MIS approach for the treatment of SI-NEN may not be inferior to open surgery. The higher number of resected lymph nodes and R0 resections may even speak in favor for a MIS approach. More studies with a longer time of observation are needed to further support this conclusion.
Collapse
Affiliation(s)
- Johan Eneholm
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58185, Linköping, Sweden
| | - Ervin Beka
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58185, Linköping, Sweden
| | - Róbert Kotán
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58185, Linköping, Sweden
| | - Oliver Gimm
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58185, Linköping, Sweden.
| |
Collapse
|
10
|
Alsalman J, Alqourain A, Alyousef M, Aldandan O, Alzahrani I. Obstructive Jaundice Caused by Metastatic Neuroendocrine Tumor of the Ampulla of Vater in a Young Adult: A Case Report. Case Rep Gastroenterol 2024; 18:204-213. [PMID: 38590835 PMCID: PMC11001288 DOI: 10.1159/000538260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction Ampullary neuroendocrine tumors (NETs) are usually diagnosed in the 5th-6th decades of life, and no cases were reported in <20 years of age. We report a rare case, presenting at a very young age, of well-differentiated NET involving the ampulla of Vater with lymph node metastasis. Case Presentation An 18-year-old man presented with a 3-month history of upper abdominal pain and jaundice. Abdominal ultrasound showed a dilated common bile duct, and endoscopic retrograde cholangiopancreatography revealed two duodenal polypoid lesions, one of them overlying the ampulla of Vater, with an erythematous and ulcerated surface. Histopathological examination confirmed the diagnosis of NET grade 1. Octreotide scan revealed 2 para-aortic lymph nodes with intense radiotracer uptake. The patient had undergone Whipple surgery with para-aortic lymph node dissection. Histopathological examination of the surgical specimens was confirmatory of NET grade 2 and paraganglioma in a few of the dissected lymph nodes. Postoperatively, the patient was kept on monthly intramuscular octreotide. Follow-up gallium-68 DOTATATE is unremarkable apart from an avid left para-aortic lymph node which is showing stability over 12 months of follow-up. Conclusion This case demonstrates that NETs of the ampulla of Vater can present at a very young age. Radical surgical excision with extended lymph node dissection and postoperative octreotide is associated with better patient outcomes and survival.
Collapse
Affiliation(s)
- Jaafar Alsalman
- Department of Internal Medicine, Division of Gastroenterology, Dammam Medial Complex, Dammam, Saudi Arabia
| | - Abdulaziz Alqourain
- Department of Internal Medicine, Division of Gastroenterology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed Alyousef
- Department of Pathology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Omran Aldandan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ibrahim Alzahrani
- Department of Internal Medicine, Division of Gastroenterology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
11
|
Shin SY, Shen TC, Wank SA, Summers RM. Fully-automated detection of small bowel carcinoid tumors in CT scans using deep learning. Med Phys 2023; 50:7865-7878. [PMID: 36988164 PMCID: PMC10539477 DOI: 10.1002/mp.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/20/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Small bowel carcinoid tumor is a rare neoplasm and increasing in incidence. Patients with small bowel carcinoid tumors often experience long delays in diagnosis due to the vague symptoms, slow growth of tumors, and lack of clinician awareness. Computed tomography (CT) is the most common imaging study for diagnosis of small bowel carcinoid tumor. It is often used with positron emission tomography (PET) to capture anatomical and functional aspects of carcinoid tumors and thus to increase the sensitivity. PURPOSE We compared three different kinds of methods for the automatic detection of small bowel carcinoid tumors on CT scans, which is the first to the best of our knowledge. METHODS Thirty-three preoperative CT scans of 33 unique patients with surgically-proven carcinoid tumors within the small bowel were collected. Ground-truth segmentation of tumors was drawn on CT scans by referring to available 18 F-DOPA PET scans and the corresponding radiology report. These scans were split into the trainval set (n = 24) and the test positive set (n= 9). Additionally, 22 CT scans of 22 unique patients who had no evidence of the tumor were collected to comprise the test negative set. We compared three different kinds of detection methods, which are detection network, patch-based classification, and segmentation-based methods. We also investigated the usefulness of small bowel segmentation for reduction of false positives (FPs) for each method. Free-response receiver operating characteristic (FROC) curves and receiver operating characteristic (ROC) curves were used for lesion- and patient-level evaluations, respectively. Statistical analyses comparing the FROC and ROC curves were also performed. RESULTS The detection network method performed the best among the compared methods. For lesion-level detection, the detection network method, without the small bowel segmentation-based filtering, achieved sensitivity values of (60.8%, 81.1%, 82.4%, 86.5%) at per-scan FP rates of (1, 2, 4 ,8), respectively. The use of the small bowel segmentation did not improve the performance (p = 0.742 $p=0.742$ ). For patient-level detection, again the detection network method, but with the small bowel segmentation-based filtering, achieved the highest AUC of 0.86 with a sensitivity of 78% and specificity of 82% at the Youden point. CONCLUSIONS The carcinoid tumors in this patient population were very small and potentially difficult to diagnose. The presented method showed reasonable sensitivity at small numbers of FPs for lesion-level detection. It also achieved a promising AUC for patient-level detection. The method may have clinical application in patients with this rare and difficult to detect disease.
Collapse
Affiliation(s)
- Seung Yeon Shin
- Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas C Shen
- Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Stephen A Wank
- Digestive Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ronald M Summers
- Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
12
|
Zhang C, Gudmundsdottir H, Takahashi H, Day C, Glasgow A, Wasif N, Starlinger P, Warner S, Grotz T, Smoot R, Truty M, Cleary S, Kendrick M, Nagorney D, Navin P, Halfdanarson TR, Thiels C. Accuracy of DOTATATE PET imaging in the preoperative planning of small bowel neuroendocrine tumor resection. J Surg Oncol 2023; 128:1072-1079. [PMID: 37529970 DOI: 10.1002/jso.27413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND AND OBJECTIVES We assessed the accuracy of preoperative gallium-68 DOTA-Tyr3-octreotate (DOTATATE) positron emission tomography (PET) imaging in estimating multifocality and nodal metastases of small bowel neuroendocrine tumors (sbNETs). METHODS A multicenter analysis was performed on patients with sbNETs who underwent preoperative DOTATATE PET imaging and surgical resection, with manual palpation of the entire length of the small bowel, between January 2016 and August 2022. Preoperative imaging reports and blinded secondary imaging reviews were compared to the final postoperative pathology reports. Descriptive statistics were applied. RESULTS One-hundred and four patients met inclusion criteria. Pathology showed 53 (51%) patients had multifocal sbNETs and 96 (92%) had nodal metastases. The original preoperative DOTATATE PET imaging identified multifocal sbNET in 28 (27%) patients and lymph node (LN) metastases in 80 (77%) patients. Based on original radiology reports, sensitivity for multifocal sbNET identification was 45%, specificity was 92%, positive predictive value (PPV) was 86%, and negative predictive value (NPV) was 62%. For the identification of LN metastases, sensitivity was 82%, specificity was 88%, PPV was 99%, and NPV was 29%. CONCLUSIONS Although DOTATATE PET imaging is specific and relatively accurate, sensitivity and NPV are insufficient to guide surgical planning. Preoperative use should not replace open palpation to identify additional synchronous lesions or to omit regional lymphadenectomy.
Collapse
Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Hallbera Gudmundsdottir
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Courtney Day
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Amy Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Susanne Warner
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis Grotz
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rory Smoot
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David Nagorney
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick Navin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Cornelius Thiels
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
13
|
Kmiotek E, Lakda S, Borakati A, Ogunbiyi O, Mandair D, Caplin M, Toumpanakis C, Mirnezami R. Management Strategies and Outcomes for Small Intestinal Neuroendocrine Tumours with Involvement of the Superior Mesenteric Vessels: A Systematic Review. Curr Oncol 2023; 30:9192-9204. [PMID: 37887564 PMCID: PMC10605700 DOI: 10.3390/curroncol30100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/26/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
Small intestinal neuroendocrine tumours (SI-NETs) are the most common small intestinal tumours. A particularly challenging subset of these tumours is those that involve the superior mesenteric artery or vein for which the role and feasibility of surgery are often questioned. This systematic review aimed to identify and evaluate the management strategies used for these complex SI-NETs. The identified studies showed positive outcomes with surgery and multimodality therapy.
Collapse
Affiliation(s)
- Elizabeth Kmiotek
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
| | - Sakina Lakda
- University College London Medical School, 74 Huntley Street, London WC1E 6DE, UK;
| | - Aditya Borakati
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital Campus, 9th Floor, Pond Street, Hampstead, London NW3 2QG, UK;
| | - Olagunju Ogunbiyi
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Dalvinder Mandair
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| | - Reza Mirnezami
- Department of Colorectal Surgery, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK (O.O.)
- Neuroendocrine Tumour Unit, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK; (D.M.); (M.C.); (C.T.)
| |
Collapse
|
14
|
Draskacheva N, Saljamovski D, Gošić V, Trajkovski G, Ristovski G, Misimi S, Nikolovski A. When is surgery indicated in metastatic small intestine neuroendocrine tumor? J Surg Case Rep 2023; 2023:rjad580. [PMID: 37873052 PMCID: PMC10590655 DOI: 10.1093/jscr/rjad580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/06/2023] [Indexed: 10/25/2023] Open
Abstract
Small intestine neuroendocrine tumors are predominantly small but with high potential for distant metastases development. Diagnosis establishment in early-stage is often difficult and challenging. Small intestine neuroendocrine tumors often initially present with liver metastases. According to the Consensus Guidelines of the North American Neuroendocrine Tumor Society, in patients with liver metastases from unknown origin of primary neuroendocrine tumor, surgical exploration should be performed in order to identify the primary location, prevent small intestine obstruction, and treat one if already present. We present a case of a 69-year-old male patient diagnosed with liver and peritoneal metastases due to small bowel neuroendocrine tumor treated with surgery due to the presence of small intestine obstruction.
Collapse
Affiliation(s)
- Nadica Draskacheva
- Faculty of Medical Sciences, Goce Delčev University of Štip, Štip 2000, North Macedonia
| | - Darko Saljamovski
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
| | - Violeta Gošić
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
| | - Gjorgji Trajkovski
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
- University Clinic for Digestive Surgery, Skopje 1000, North Macedonia
| | - Gligor Ristovski
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
- Institute of Pathology, Medical Faculty in Skopje, Skopje 1000, North Macedonia
| | - Shqipe Misimi
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
| | - Andrej Nikolovski
- Medical Faculty in Skopje, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
- Department of Visceral Surgery, University Surgery Hospital “St. Naum Ohridski”, Bul. 11 Oktomvri 53, 1000 Skopje, North Macedonia
| |
Collapse
|
15
|
Søreide K, Hallet J, Jamieson NB, Stättner S. Optimal surgical approach for digestive neuroendocrine neoplasia primaries: Oncological benefits versus short and long-term complications. Best Pract Res Clin Endocrinol Metab 2023; 37:101786. [PMID: 37328324 DOI: 10.1016/j.beem.2023.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The rising incidence and the accumulating prevalence of neuroendocrine neoplasia (NEN) in the population makes this a common, prevalent and a clinically relevant disease group. Surgical resection represents the only potentially curative treatment for digestive NENs. Thus, resection should in principle be considered for all patients with NEN, although taking the patients age, relevant comorbidity, and performance status into account for operability. Patients with insulinomas, NEN of the appendix and rectal NENs are usually cured by surgery alone. However, less than a third of patients are amendable to curative surgery alone at time of diagnosis. Furthermore, recurrence is common and may occur years after primary surgery, hence the long follow-up time recommended in most NENs (>10 years). As many patients with NENs present with locoregional or metastatic disease, there is considerable debate regarding the role of debulking surgery in these settings. However, good long-term survival can be achieved in a considerable proportion of patients, with 50-70% alive up to 10 years after surgery. Location and grade are the main determinants of long-term survival. Here we present considerations to surgery for primary neuroendocrine tumors in the digestive tract.
Collapse
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
| |
Collapse
|
16
|
Madishetty V, Starr AJ, Chu QD, Starr PACB. Evaluating the Presence of a Stage IV Low-Grade Well-Differentiated Neuroendocrine Tumor of the Ileocecum: A Case Report with Evaluation of Staging Protocol of Neuroendocrine Tumors and Treatment Options Based on Current Available Evidence. Case Rep Surg 2023; 2023:2919223. [PMID: 37637014 PMCID: PMC10449591 DOI: 10.1155/2023/2919223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Neuroendocrine tumors (NET) are rare neoplasms that can originate throughout the human body. An initial treatment option includes upfront surgical resection of the primary tumor (pT) if the tumor can be localized. Current systemic therapy options following resection of the pT or with evidence of metastatic disease include somatostatin analogs, evorlimus, peptide receptor radionuclide therapy, cytotoxic chemotherapy, and interferon alpha among other less common therapy options. We present a case of a patient with a NET that originated in the ileocecal region. The patient underwent upfront surgical resection with a right hemicolectomy due to the location of the tumor. The pT was notable for extensive invasion into the visceral peritoneum and metastasis to nearby lymph nodes. However, despite being diagnosed as a stage IV NET, the Ki67 index was less than 1%, categorizing it as a low-grade well-differentiated tumor. Following resection of the tumor, there was no evidence of metastasis to the liver on the follow-up magnetic resonance imaging and recurrent somatostatin receptor overexpressing neoplasm on the Gallium-68 DOTATE PET/CT scan. Due to the juxtaposition of the low grade of the tumor and the high staging, several different treatment options were discussed with the main distinction being whether to base these options off of the stage or the grade of the tumor in the case. Low-grade well-differentiated NET have a good prognosis. On the other hand, stage IV NET and tumors that have metastasized to nearby lymph nodes and organs have an increased likelihood to reoccur and worse outcomes. Recommendations for NET based on current evidence have a lack of clarity in terms of when to undergo observation versus systemic therapy.
Collapse
Affiliation(s)
| | | | - Quyen D. Chu
- Surgical Oncology, Orlando Health Institute, Orlando, FL, USA
| | | |
Collapse
|
17
|
Daraghmeh L, Shbaita S, Nassef O, Melhem L, Maqboul I. Non-specific Symptoms of Small Bowel Neuroendocrine Tumor and the Diagnostic Challenges: A Case Report. Cureus 2023; 15:e41080. [PMID: 37519565 PMCID: PMC10375939 DOI: 10.7759/cureus.41080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Neuroendocrine tumors (NETs) are considered the most frequent tumors that affect the small bowels. Despite diagnostic modalities, the diagnosis of small bowel NETs is not straightforward and poses a high challenge to most physicians, due to poor accessibility to this area and the patient's non-specific presentations. We reported a case of a 60-year-old male patient, who presented with severe postprandial epigastric pain of one-month duration, loss of appetite, and weight loss. Investigations revealed no definite diagnosis. Therefore, exploratory laparoscopy was attempted along with multiple biopsies that led to the diagnosis of small bowel NET. We conclude that NETs require a high index of suspicion in patients with recurrent abdominal pain.
Collapse
Affiliation(s)
- Laith Daraghmeh
- Department of General Surgery, An-Najah National University Hospital, Nablus, PSE
| | - Sara Shbaita
- Faculty of Medicine, An-Najah National University, Nablus, PSE
| | - Omar Nassef
- Department of Radiology, An-Najah National University Hospital, Nablus, PSE
| | - Layan Melhem
- Department of Pathology, An-Najah National University Hospital, Nablus, PSE
| | - Iyad Maqboul
- Department of General Surgery, An-Najah National University Hospital, An-Najah National University, Nablus, PSE
| |
Collapse
|
18
|
Kupietzky A, Dover R, Mazeh H. Surgical aspects of small intestinal neuroendocrine tumors. World J Gastrointest Surg 2023; 15:566-577. [PMID: 37206065 PMCID: PMC10190731 DOI: 10.4240/wjgs.v15.i4.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/25/2023] [Accepted: 03/27/2023] [Indexed: 04/22/2023] Open
Abstract
Small intestinal neuroendocrine tumors (NETs) are a heterogeneous group of epithelial tumors with a predominant neuroendocrine differentiation. Although NETs are usually considered rare neoplasms, small intestinal NETs are the most common primary malignancy of the small bowel, with an increasing prevalence worldwide during the course of the past few decades. The indolent nature of these tumors often leads to a delayed diagnosis, resulting in over one-third of patients presenting with synchronous metastases. Primary tumor resection remains the only curative option for this type of tumor. In this review article, the various surgical aspects for the excision of small intestinal NETs are discussed.
Collapse
Affiliation(s)
- Amram Kupietzky
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
| | - Roi Dover
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
| | - Haggi Mazeh
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
| |
Collapse
|
19
|
Kroepfl V, Bellotti R, Gasser E, Esswein K, Esser H, Kafka-Ritsch R, Öfner D, Perathoner A. Small bowel neuroendocrine tumors: An analysis of clinical presentation, diagnostic workup and surgical approach—A single center retrospective study. Front Surg 2023; 10:1072435. [PMID: 37077861 PMCID: PMC10106623 DOI: 10.3389/fsurg.2023.1072435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundNeurocrine neoplasms (NEN) of the small bowel (SBNEN) are a rare entity and mostly asymptomatic. The aim of this study was to explore trends in the clinical presentation, diagnostic workup, surgical approach and oncological outcome in patients with SBNEN at our surgical department.Materials and methodsAll patients who underwent surgical resection for SBNEN from 2004 to 2020 at our department were enrolled in this single center retrospective study.ResultsA total of 32 patients were included in this study. In most cases, the diagnosis was based on incidental findings during endoscopy or radiographic imaging (n = 23; 72%). Twenty cases had a G1 tumor and 12 cases a G2 tumor. The 1-, 3- and 5-year overall survival (OS) were 96%, 86% and 81%, respectively. Patients with a tumor more than 30 mm had a significantly lower OS (p = 0.01). For G1 tumors, the estimated disease-free survival (DFS) was 109 months. Again, the DFS was significantly lower when the tumor had more than 30 mm in diameter (p = 0.013).ConclusionDue to the mostly asymptomatic presentation, the diagnostic workup can be difficult. An aggressive approach and a strict follow-up seem to be important for the oncological outcome.
Collapse
|
20
|
Lee S, Jyala A, Ghazanfar H, Shin D, Patel H. Diagnostic Challenge of Small Bowel Neuroendocrine Tumor in a Young Female Patient. Cureus 2023; 15:e37925. [PMID: 37220442 PMCID: PMC10200070 DOI: 10.7759/cureus.37925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/25/2023] Open
Abstract
Neuroendocrine tumors (NETs) are rare cancers arising from neuroendocrine cells and are characterized by their ability to secrete functional hormones causing distinctive hormonal syndromes. The incidence of NET has increased over the years, and small bowel neuroendocrine tumor (SBNET) is one of the most challenging to detect due to its varied presentation and poor accessibility with traditional endoscopic methods. Patients with SBNET present with variable hormonal symptoms, such as diarrhea, flushing, and nonspecific abdominal pain, which often delay the diagnosis. We present the case of a young patient who underwent multidisciplinary workups leading to a successful diagnosis of SBNET promptly. The patient was a 31-year-old female who presented to the emergency department with complaints of nausea, vomiting, and sudden-onset, severe, sharp abdominal pain. CT scan of her abdomen showed an area of irregular intraluminal soft tissue density suspicious for a mass in the mid-small bowel. The patient's initial enteroscopy was normal. A video capsule endoscopy showed a small bowel mass, which was consistent with SBNET confirmed by pathology later. This case emphasizes the importance of considering SBNET as a differential diagnosis in young patients with nonspecific symptoms of abdominal pain and highlights the role of multidisciplinary approaches in achieving prompt diagnosis and treatment.
Collapse
Affiliation(s)
- Somin Lee
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | - Dongmin Shin
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Harish Patel
- Gastroenterology, BronxCare Health System, Bronx, USA
| |
Collapse
|
21
|
Reccia I, Pai M, Kumar J, Spalding D, Frilling A. Tumour Heterogeneity and the Consequent Practical Challenges in the Management of Gastroenteropancreatic Neuroendocrine Neoplasms. Cancers (Basel) 2023; 15:1861. [PMID: 36980746 PMCID: PMC10047148 DOI: 10.3390/cancers15061861] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/10/2023] [Accepted: 03/18/2023] [Indexed: 03/22/2023] Open
Abstract
Tumour heterogeneity is a common phenomenon in neuroendocrine neoplasms (NENs) and a significant cause of treatment failure and disease progression. Genetic and epigenetic instability, along with proliferation of cancer stem cells and alterations in the tumour microenvironment, manifest as intra-tumoural variability in tumour biology in primary tumours and metastases. This may change over time, especially under selective pressure during treatment. The gastroenteropancreatic (GEP) tract is the most common site for NENs, and their diagnosis and treatment depends on the specific characteristics of the disease, in particular proliferation activity, expression of somatostatin receptors and grading. Somatostatin receptor expression has a major role in the diagnosis and treatment of GEP-NENs, while Ki-67 is also a valuable prognostic marker. Intra- and inter-tumour heterogeneity in GEP-NENS, however, may lead to inaccurate assessment of the disease and affect the reliability of the available diagnostic, prognostic and predictive tests. In this review, we summarise the current available evidence of the impact of tumour heterogeneity on tumour diagnosis and treatment of GEP-NENs. Understanding and accurately measuring tumour heterogeneity could better inform clinical decision making in NENs.
Collapse
Affiliation(s)
- Isabella Reccia
- General Surgical and Oncology Unit, Policlinico San Pietro, Via Carlo Forlanini, 24036 Ponte San Pietro, Italy
| | - Madhava Pai
- Division of Surgery, Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Jayant Kumar
- Division of Surgery, Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Duncan Spalding
- Division of Surgery, Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Andrea Frilling
- Division of Surgery, Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| |
Collapse
|
22
|
Watanabe A, Mckendry G, Yip L, Loree JM, Stuart HC. Association between surveillance imaging and survival outcomes in small bowel neuroendocrine tumors. J Surg Oncol 2023; 127:578-586. [PMID: 36537012 DOI: 10.1002/jso.27176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surveillance guidelines following the resection of small bowel neuroendocrine tumors (SB-NETs) are inconsistent. We evaluated the impact of surveillance imaging on SB-NET recurrence and overall survival (OS). METHODS Patients with completely resected SB-NETs referred to a provincial cancer center (2004-2015) were reviewed. Associations between imaging frequency, recurrence, post-recurrence treatment, and OS were determined using univariate and Cox-regression analyses. RESULTS Among 195 completely resected SB-NET patients, 31% were ≥70 years, 43% were female, and 80% had grade 1 disease. Imaging frequency was predictive of recurrence (hazard ratio 2.52, 95% confidence interval 1.84-3.46, p < 0.001). 72% underwent interventions for recurrent disease. Patients who were treated for the recurrent disease had comparable OS to those who did not recur (median 152 vs. 164 months; p = 0.25). Imaging frequency was not associated with OS in those with treated recurrent disease (p = 0.65). Patients who recurred underwent more computerized tomography (CT) scans than those who did not recur (CT: 1.47 ± 0.89 vs. 1.02 ± 0.81 scans/year, p < 0.001). Detection of disease recurrence was 5%-7% per year during the first 6 years of surveillance and peaked at 17% in Year 9. CONCLUSION Less frequent imaging over a longer duration should be emphasized to capture clinically relevant recurrences that can be treated to improve OS.
Collapse
Affiliation(s)
- Akie Watanabe
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey Mckendry
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lily Yip
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan M Loree
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Heather C Stuart
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
23
|
Kahveci AS, Mubarak MF, Perveze I, Daglilar ES. Differential to Terminal Ileitis: Terminal Ileum Neuroendocrine Tumor Identified on Screening Colonoscopy. Ochsner J 2023; 23:67-71. [PMID: 36936484 PMCID: PMC10016213 DOI: 10.31486/toj.22.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Asymptomatic patients at average risk of developing colorectal cancer are encouraged to undergo screening colonoscopy beginning at age 45 years. While ileal intubation is often considered the gold standard for a complete colonoscopy, the relatively low diagnostic yield has prevented widespread adoption. Small bowel cancers, including neuroendocrine tumors, may present incidentally as terminal ileitis on routine colonoscopy with terminal ileum intubation. Neuroendocrine tumors, the most common primary neoplasm of the small intestine, are often asymptomatic or present as nonspecific abdominal pain in the sixth or seventh decade of life. Case Report: A 51-year-old asymptomatic male with unremarkable physical examination underwent screening colonoscopy that revealed scattered ulcerations of the terminal ileum. Immunohistochemistry of the lesion was consistent with well-differentiated neuroendocrine tumor, World Health Organization Grade I. DOTATATE positron emission tomography/computed tomography demonstrated avid adjacent right mesenteric lymph node and avid focal pancreatic body lesion. Fine-needle biopsy and immunohistochemistry of the pancreatic lesion confirmed neuroendocrine tumor, while the mesenteric lymph node was found to be benign. The patient underwent robotic-assisted ileocolic resection and has ongoing surveillance of the pancreatic lesion. Conclusion: Terminal ileitis encompasses a host of pathologic processes, including inflammatory states, infectious disease, malignancy, and vasculitis. Importantly, small bowel cancer is an increasing cause of terminal ileitis. Screening colonoscopy with ileal intubation can be a valuable tool for early detection of these lesions.
Collapse
Affiliation(s)
- Alp S. Kahveci
- School of Medicine, University of Missouri, Columbia, MO
| | | | - Isma Perveze
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO
| | | |
Collapse
|
24
|
Mohamed A, Wu S, Hamid M, Mahipal A, Cjakrabarti S, Bajor D, Selfridge JE, Asa SL. Management of Appendix Neuroendocrine Neoplasms: Insights on the Current Guidelines. Cancers (Basel) 2022; 15:295. [PMID: 36612291 PMCID: PMC9818268 DOI: 10.3390/cancers15010295] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023] Open
Abstract
Appendiceal neuroendocrine neoplasms (ANENs) usually present as incidental findings at the time of appendectomy for acute appendicitis. They are rare, accounting for only 0.5-1% of intestinal neoplasms; they are found in 0.3-0.9% of all appendectomy specimens. They are usually sporadic tumors. There are several histological types including well-differentiated neuroendocrine tumors (NETs), poorly differentiated neuroendocrine carcinomas (NECs), and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs). Histologic differentiation and the grade of well-differentiated NETs correlate with clinical behavior and prognosis. Management varies based on differentiation, aggressiveness, and metastatic potential. There is debate about the optimal surgical management for localized appendiceal NETs that are impacted by many factors including the tumor size, the extent of mesoappendiceal spread, lymphovascular invasion and perineural involvement. In addition, the data to guide therapy in metastatic disease are limited due to the paucity of these tumors. Here, we review the current advances in the management of ANENs within the context of a multidisciplinary approach to these tumors.
Collapse
Affiliation(s)
- Amr Mohamed
- Division of Hematology and Medical Oncology, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sulin Wu
- Department of Internal Medicine, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
- Department of Medical Genetics, Center for Human Genetics, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Mohamed Hamid
- Department of Stem Cell Biology and Regenerative Medicine, City of Hope Beckman Research Institute, Duarte, CA 91010, USA
| | - Amit Mahipal
- Division of Hematology and Medical Oncology, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sakti Cjakrabarti
- Division of Hematology and Medical Oncology, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - David Bajor
- Division of Hematology and Medical Oncology, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - J. Eva Selfridge
- Division of Hematology and Medical Oncology, UH Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sylvia L. Asa
- Department of Pathology, UH Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH 44106, USA
| |
Collapse
|
25
|
Gastrointestinal Neuroendocrine Tumours: A Single-Centre Experience. FORUM OF CLINICAL ONCOLOGY 2022. [DOI: 10.2478/fco-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objectives
Gastrointestinal neuroendocrine tumours (GI-NETs) are actually malignant tumours, and their most common location of metastasis is the liver. In this study, we define the epidemiologic features of NETs and investigate the demographic factors, clinicopathologic features, survival, and the oncologic results related to GI-NETs.
Materials and Methods
In this 10-year study (2009–2019), all GI and liver NETs were taken out from the pathology records. When classification based on the WHO classification criteria, patients were categorized based on their location, sex, age, and proliferative index. After studying clinical charts of GI-NET cases, a complete panel of IHC markers such as Chromogranin A, ‘Ki67’ and synaptophysin were used. Results: Based on published data, the liver is not a common primary site for NETs; most liver lesions are most likely to have been metastases. The mean age of patients at diagnosis was 52.72 years. In this research, 27.78% of patients had colon NETs and 27.78 liver. Two (11.11%) patients were classified as stage II, seven (38.89%) as stage III, and one (5.56%) as stage IV. After a 120-month follow-up, 13 (72.22%) patients with colorectal NETs were alive, and 5 (27.78%) of the patients had died.
Conclusion
Treatment of colon and rectal NETs is difficult because it affects the patient's initial site of involvement, and this often makes treatment difficult for the patient. With suitable management, the prognosis can be positive with long survival, but it is related to the tumour variation grade, the efficiency of the selected treatment, and also to the patient's adherence to the follow-up.
Collapse
|
26
|
Gonzáles-Yovera JG, Roseboom PJ, Concepción-Zavaleta M, Gutiérrez-Córdova I, Plasencia-Dueñas E, Quispe-Flores M, Ramos-Yataco A, Alcalde-Loyola C, Massucco-Revoredo F, Paz-Ibarra J, Concepción-Urteaga L. Diagnosis and management of small bowel neuroendocrine tumors: A state-of-the-art. World J Methodol 2022; 12:381-391. [PMID: 36186753 PMCID: PMC9516545 DOI: 10.5662/wjm.v12.i5.381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/22/2022] [Accepted: 08/05/2022] [Indexed: 02/08/2023] Open
Abstract
This review provides an update on the epidemiology, pathophysiology, symptoms, diagnosis and treatment of neuroendocrine neoplasms (NENs) of the small bowel (SB). These NENs are defined as a group of neoplasms deriving from neuroendocrine cells. NENs are currently the most common primary tumors of the SB, mainly involving the ileum, making the SB the most frequently affected part of the gastrointestinal tract. SB NENs by definition are located between the ligament of Treitz and the ileocecal valve. They are characterized by small size and induce an extensive fibrotic reaction in the small intestine including the mesentery, resulting in narrowing or twisting of the intestine. Clinical manifestations of bowel functionality are related to the precise location of the primary tumor. The majority of them are non-functional NENs and generally asymptomatic; in an advanced stage, NENs present symptoms of mass effect by non-specific abdominal pain or carcinoid syndrome which appears in patients with liver metastasis (around 10%). The main manifestations of the carcinoid syndrome are facial flushing (94%), diarrhea (78%), abdominal cramps (50%), heart valve disease (50%), telangiectasia (25%), wheezing (15%) and edema (19%). Diagnosis is made by imaging or biochemical tests, and the order of request will depend on the initial diagnostic hypothesis, while confirmation will always be histological. All patients with a localized SB NEN with or without near metastasis in the mesentery are recommended for curative resection. Locoregional and distant spread may be susceptible to several therapeutic strategies, such as chemotherapy, somatostatin analogs and palliative resection.
Collapse
Affiliation(s)
| | - Pela J Roseboom
- Division of Emergency Medicine, Regional Academic Hospital of Trujillo, Trujillo 13011, Peru
| | | | | | | | - María Quispe-Flores
- Division of Endocrinology, Guillermo Almenara Irigoyen National Hospital, Lima 12590, Peru
| | - Anthony Ramos-Yataco
- Division of Internal Medicine, Ricardo Cruzado Rivarola Hospital, Ica 110301, Peru
| | | | | | - José Paz-Ibarra
- Department of Medicine, School of Medicine, National University of San Marcos, Lima 15001, Peru
| | - Luis Concepción-Urteaga
- Division of Internal Medicine, School of Medicine, National University of Trujillo, Trujillo 13011, Peru
| |
Collapse
|
27
|
Iabichino G, Di Leo M, Arena M, Rubis Passoni GG, Morandi E, Turpini F, Viaggi P, Luigiano C, De Luca L. Diagnosis, treatment, and current concepts in the endoscopic management of gastroenteropancreatic neuroendocrine neoplasms. World J Gastroenterol 2022; 28:4943-4958. [PMID: 36160644 PMCID: PMC9494936 DOI: 10.3748/wjg.v28.i34.4943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/29/2022] [Accepted: 08/22/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare tumors derived from the neuroendocrine cell system, which that have increased in incidence and prevalence in recent years. Despite improvements in radiological and metabolic imaging, endoscopy still plays a pivotal role in the number of GEP-NENs. Tumor detection, characterization, and staging are essential in management and treatment planning. Upper and lower gastrointestinal (GI) endoscopy is essential for correct localization of the primary tumor site of GI NENs. Endoscopic ultrasonography (EUS) has an important role in the imaging and tissue acquisition of pancreatic NENs and locoregional staging of GI neuroendocrine tumors. Correct staging and histological diagnosis have important prognostic implications. Endoscopic operating techniques allow the removal of small GI NENs in the early stage of mucosal or submucosal invasion of the intestinal wall. Preoperative EUS-guided techniques may help the surgeon locate small and deep tumors, thus avoiding formal pancreatic resections in favor of parenchymal-sparing surgery. Finally, locoregional ablative treatments have been proposed in recent studies with promising results in selected patients.
Collapse
Affiliation(s)
| | - Milena Di Leo
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Monica Arena
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | | | | | - Francesca Turpini
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Paolo Viaggi
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Carmelo Luigiano
- Gastroenterology Section, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria 89124, Italy
| | - Luca De Luca
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| |
Collapse
|
28
|
Nagy GA, Neag MA, Drasovean R, Crisan D, Chira RI. Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report. Int J Mol Sci 2022; 23:ijms231810351. [PMID: 36142264 PMCID: PMC9499482 DOI: 10.3390/ijms231810351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/29/2022] Open
Abstract
Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors.
Collapse
Affiliation(s)
- Georgiana Anca Nagy
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Gastroenterology, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
| | - Maria Adriana Neag
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- Correspondence:
| | - Radu Drasovean
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Doinita Crisan
- Department of Pathology, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Romeo Ioan Chira
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Gastroenterology, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
| |
Collapse
|
29
|
Agarwal P, Mohamed A. Systemic Therapy of Advanced Well-differentiated Small Bowel Neuroendocrine Tumors Progressive on Somatostatin Analogues. Curr Treat Options Oncol 2022; 23:1233-1246. [PMID: 35939200 DOI: 10.1007/s11864-022-00998-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
OPINION STATEMENT Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors whose management requires a nuanced and multi-disciplinary approach in order to control symptoms, halt tumor growth, and improve survival outcomes. Of late, the treatment landscape of NENs has advanced considerably as a result of several pivotal clinical trials, which have established somatostatin analogues as first-line therapy for advanced, metastatic, well-differentiated neuroendocrine tumors (NETs). However, an evolving classification system as well as an increased understanding of distinct clinical, molecular, and biologic features contribute to complexity in management. In particular, there remains limited randomized prospective data in the somatostatin analogue (SSA)-refractory setting for patients with primary tumors that originate in the small bowel. For well-differentiated small bowel neuroendocrine tumors (SBNETs), treatment beyond SSAs includes radionuclide therapy, targeted agents, liver-directed therapy, and to a lesser extent, cytotoxic chemotherapy. In the current era, selection of these agents is largely based on expert opinion in the context of patient and tumor characteristics without definitive data on the preferred order of agents to administer. In this review, we aim to describe the treatment landscape of metastatic SBNETs beyond SSAs and provide an overview of novel treatments which are currently under clinical evaluation.
Collapse
Affiliation(s)
- Parul Agarwal
- Hematology/Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PCAM 10 South Pavilion, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Amr Mohamed
- Department of Medical Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, 11100 Euclid Avenue, Lakeside, Cleveland, OH, 44106, USA.
| |
Collapse
|
30
|
McGuinness MJ, Woodhouse B, Harmston C, Parker K, Kramer N, Findlay M, Print C, Merrie A, Lawrence B. Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand. ANZ J Surg 2022; 92:1748-1753. [PMID: 35762209 PMCID: PMC9541869 DOI: 10.1111/ans.17851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Background Small intestinal Neuroendocrine Neoplasms (SI‐NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI‐NEN in Auckland, Aotearoa New Zealand (AoNZ). Methods A retrospective study of all patients diagnosed with a jejunal or ileal SI‐NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data. Results One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10‐year disease‐specific survival for all patients was 66.1% (95% CI 56.5–75.7%) and 61.8% (95% CI 51.8–71.8%), respectively. Ten‐year disease‐specific survival was 100% for stage I and II, 74% (95%CI 61.7–84.4%) for stage III and 33.9% (95%CI 16.9–35.6%) for stage IV SI‐NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92–5.5) nor distant resection (HR 1.72, 95% CI 0.63–4.7) were significantly associated with a disease‐specific or overall survival benefit. Conclusion This study demonstrates that stage at SI‐NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.
Collapse
Affiliation(s)
- Matthew J. McGuinness
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Whangārei Hospital, Northland District Health Board Whangārei New Zealand
| | - Braden Woodhouse
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Christopher Harmston
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Whangārei Hospital, Northland District Health Board Whangārei New Zealand
| | - Kate Parker
- Planning, Funding and Outcomes Waitematā District Health Board Waitakere New Zealand
| | - Nicole Kramer
- Department of Pathology North Shore Hospital, Waitematā District Health Board Waitakere New Zealand
| | - Michael Findlay
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Cristin Print
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Arend Merrie
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Auckland City Hospital, Auckland District Health Board Auckland New Zealand
| | - Ben Lawrence
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Auckland City Hospital, Auckland District Health Board Auckland New Zealand
| |
Collapse
|
31
|
Yao H, Sokas C, Welch HG. Rising Incidence of Cancer of the Small Intestine: Overdiagnosis and Better Diagnosis of Low-lethality Disease. Gastroenterology 2022; 162:1749-1751.e2. [PMID: 35031298 DOI: 10.1053/j.gastro.2022.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 12/02/2022]
Affiliation(s)
| | - Claire Sokas
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - H Gilbert Welch
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
32
|
Helderman NC, Elsayed FA, van Wezel T, Terlouw D, Langers AM, van Egmond D, Kilinç G, Hristova ( H, Sarasqueta AF, Morreau H, Nielsen M, Suerink M. Mismatch Repair Deficiency and MUTYH Variants in Small Intestine-Neuroendocrine Tumors. Hum Pathol 2022; 125:11-17. [DOI: 10.1016/j.humpath.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/25/2022]
|
33
|
Yozgat A, Kekilli M, Altay M. Time to give up traditional methods for the management of gastrointestinal neuroendocrine tumours. World J Clin Cases 2021; 9:8627-8646. [PMID: 34734042 PMCID: PMC8546836 DOI: 10.12998/wjcc.v9.i29.8627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
Neuroendocrine tumors (NETs) are a rare and heterogeneous disease group and constitute 0.5% of all malignancies. The annual incidence of NETs is increasing worldwide. The reason for the increase in the incidence of NETs is the detection of benign lesions, incidental detection due to the highest use of endoscopic and imaging procedures, and higher recognition rates of pathologists. There have been exciting developments regarding NET biology in recent years. Among these, first of all, somatostatin receptors and downstream pathways in neuroendocrine cells have been found to be important regulatory mechanisms for protein synthesis, hormone secretion, and proliferation. Subsequently, activation of the mammalian target of rapamycin pathway was found to be an important mechanism in angiogenesis and tumor survival and cell metabolism. Finally, the importance of proangiogenic factors (platelet-derived growth factor, vascular endothelial growth factor, fibroblastic growth factor, angiopoietin, and semaphorins) in the progression of NET has been determined. Using the combination of biomarkers and imaging methods allows early evaluation of the appropriateness of treatment and response to treatment.
Collapse
Affiliation(s)
- Ahmet Yozgat
- Department of Gastroenterology, Ufuk University, Ankara, 06510, Turkey
| | - Murat Kekilli
- Department of Gastroenterology, Gazi University, Ankara 06560, Turkey
| | - Mustafa Altay
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Keçiören Health Administration and Research Center, Ankara 06190, Turkey
| |
Collapse
|
34
|
Carpizo DR, Harris CR. Genetic Drivers of Ileal Neuroendocrine Tumors. Cancers (Basel) 2021; 13:cancers13205070. [PMID: 34680217 PMCID: PMC8533727 DOI: 10.3390/cancers13205070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Although ileal neuroendocrine tumors are the most common tumors of the small intestine, they are not well-defined at the genetic level. Unlike most cancers, they have an unusually low number of mutations, and also lack recurrently mutated genes. Moreover ileal NETs have been difficult to study in the laboratory because there were no animal models and because cell lines were generally unavailable. But recent advances, including the first ileal NET mouse model as well as methods for culturing patient tumor samples, have been described and have already helped to identify IGF2 and CDK4 as two of the genetic drivers for this tumor type. These advances may help in the development of new treatments for patients. Abstract The genetic causes of ileal neuroendocrine tumors (ileal NETs, or I-NETs) have been a mystery. For most types of tumors, key genes were revealed by large scale genomic sequencing that demonstrated recurrent mutations of specific oncogenes or tumor suppressors. In contrast, genomic sequencing of ileal NETs demonstrated a distinct lack of recurrently mutated genes, suggesting that the mechanisms that drive the formation of I-NETs may be quite different than the cell-intrinsic mutations that drive the formation of other tumor types. However, recent mouse studies have identified the IGF2 and RB1 pathways in the formation of ileal NETs, which is supported by the subsequent analysis of patient samples. Thus, ileal NETs no longer appear to be a cancer without genetic causes.
Collapse
|
35
|
Ganguly T, Do J, Hoh SM, Foster Smith E, Eteuati J. Baker's dozen of small bowel neuroendocrine tumours: case report and review of the significance and management of multifocal neuroendocrine tumours. ANZ J Surg 2021; 92:1215-1217. [PMID: 34550637 DOI: 10.1111/ans.17223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Timothy Ganguly
- Colorectal Unit, Lyell McEwin Hospital - SA Health, Adelaide, South Australia, Australia.,Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Surgical Department, University Hospital Geelong, Geelong, Victoria, Australia
| | - Jee Do
- Colorectal Unit, Lyell McEwin Hospital - SA Health, Adelaide, South Australia, Australia.,Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Surgical Department, University Hospital Geelong, Geelong, Victoria, Australia
| | - Su Mei Hoh
- Colorectal Unit, Lyell McEwin Hospital - SA Health, Adelaide, South Australia, Australia.,Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Surgical Department, University Hospital Geelong, Geelong, Victoria, Australia
| | - Erwin Foster Smith
- Colorectal Unit, Lyell McEwin Hospital - SA Health, Adelaide, South Australia, Australia.,Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Surgical Department, University Hospital Geelong, Geelong, Victoria, Australia
| | - Jimmy Eteuati
- Colorectal Unit, Lyell McEwin Hospital - SA Health, Adelaide, South Australia, Australia.,Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Surgical Department, University Hospital Geelong, Geelong, Victoria, Australia
| |
Collapse
|
36
|
Abstract
Consensus guidelines acknowledge the role of gallium Ga-68 (68Ga) 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic (DOTA) somatostatin receptor (SSTR) positron emission tomography/computed tomography (PET/CT) in management of neuroendocrine tumor (NET) patients. 68Ga-DOTA-SSTR PET/CT demonstrates superior performance to conventional imaging in initial detection, staging, detection of recurrent tumor, and detection of unknown primary in known metastatic disease. 68Ga-DOTA-SSTR PET/CT is low yield for NET detection in the setting of symptoms or elevated biomarkers when conventional imaging is negative, but may still guide management. The role of 68Ga-DOTA-SSTR PET/CT is not established in monitoring response to systemic therapy but may identify progression through detection of new metastases.
Collapse
Affiliation(s)
- Janet Pollard
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Parren McNeely
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Yusuf Menda
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
| |
Collapse
|
37
|
Mazlom H, Teuwen LA, Peeters M. Management of small bowel adenocarcinoma: making the most of the available evidence to inform routine practice. Curr Opin Oncol 2021; 33:368-371. [PMID: 33882527 DOI: 10.1097/cco.0000000000000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Small bowel adenocarcinoma (SBA) is a rare disease, for which few studies have been conducted so far. Therefore, most treatment recommendations have been extrapolated from trials in colorectal cancer. In this review, we revise available data that could improve the management of SBA, with a particular focus on systemic therapy. RECENT FINDINGS For advanced/irresectable disease, first-line doublet chemotherapy remains standard of care. It is uncertain whether extending treatment to triplet chemotherapy brings added benefit. Pembrolizumab is an accepted treatment modality for mismatch repair-deficient tumors, yet might also be active in microsatellite stable tumors. More trials with immunotherapy are underway. Although there is no place for anti-EGFR monotherapy, the addition of cetuximab to chemotherapy should be investigated further. Two trials suggest an added value of bevacizumab to chemotherapy, yet larger trials are needed to confirm these data. For localized disease, the role of (neo)adjuvant chemotherapy is under investigation. SUMMARY For decades, patients with SBA have probably been treated suboptimal by basing treatment recommendations on data from colorectal cancer. An effort for SBA-specific trials and/or inclusion of SBA patients in basket trials is of utmost importance in order to improve outcome for these patients.
Collapse
Affiliation(s)
| | | | - Marc Peeters
- University Hospital Antwerp, Edegem
- Antwerp University, Antwerp, Belgium
| |
Collapse
|
38
|
Dawod M, Gordoa TA, Cives M, De Mestier L, Crona J, Spada F, Oberg K, Pavel M, Lamarca A. Antiproliferative Systemic Therapies for Metastatic Small Bowel Neuroendocrine Tumours. Curr Treat Options Oncol 2021; 22:73. [PMID: 34185197 DOI: 10.1007/s11864-021-00863-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT Neuroendocrine neoplasms (NENs) are a heterogeneous group of malignancies with rising incidence and prevalence. Outcome and therapy of small bowel neuroendocrine tumours (SBNETs) is variable, depending on the grade, differentiation, tumour burden, as well as the site of the tumour origin. Because of this, multidisciplinary approach is essential. Large randomized clinical trials, with somatostatin analogues (PROMID, CLARINET) or with peptide receptor radionuclide therapy (PRRT) with 177-lutetium (NETTER-1 trial) as well as the mammalian target of rapamycin inhibitor (mTOR) everolimus (RADIANT trials), represent milestones for the medical management of unresectable grade 1 and 2 SBNETS over the last decade. Novel therapies, such as tyrosine kinase inhibitors (TKI), are on the cutting edge. However, multiple unsolved questions remain. This review provides a comprehensive review of the main systemic therapeutic options for advanced SBNETs and discusses the latest guideline recommendations for palliative treatment.
Collapse
Affiliation(s)
- Mohammed Dawod
- Department of Medical Oncology, ENETs, Centre of Excellence, The Christie NHS Foundation Trust, Manchester, UK
| | - Teresa Alonso Gordoa
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Mauro Cives
- Department of Medical Oncology, University of Bari, Bari, Italy
| | - Louis De Mestier
- Department of Gastroenterology, Beaujon Hospital, Université de Paris, Clichy, France
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Francesca Spada
- Gastrointestinal Medical Oncology and Neuroendocrine Tumors Unit, European Institute of Oncology, Milan, Italy
| | - Kjel Oberg
- Department of Endocrinology, Universitatsklinikum Erlangen, Erlangen, Germany
| | - Marianne Pavel
- Department of Medical Oncology, ENETs, Centre of Excellence, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Angela Lamarca
- The Christie NHS Foundation Trust, Wilmslow Road, M20 4BX, Manchester, UK.
| |
Collapse
|
39
|
Jeon Y, Leung D, Lis CA, Wang HL, Deurdulian C, Mandelkern M, Kaunitz JD. Casting a Wider NET: Is It Crohn's or Is It Neuroendocrine Tumor? Dig Dis Sci 2021; 66:1802-1806. [PMID: 33783690 DOI: 10.1007/s10620-021-06952-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Yejoo Jeon
- Department of Medicine, UCLA Medical Center, David Geffen School of Medicine At UCLA, 757 Westwood Plaza, Suite 7501, Los Angeles, CA, 90095, USA.
| | - David Leung
- Department of Medicine, Scripps Mercy Hospital, San Diego, CA, USA
| | - Claire A Lis
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Corinne Deurdulian
- Department of Radiology, West Los Angeles VA Medical Center, Los Angeles, CA, USA
| | - Mark Mandelkern
- Department of Nuclear Medicine, West Los Angeles VA Medical Center, Los Angeles, CA, USA
| | - Jonathan D Kaunitz
- Department of Medicine, UCLA Medical Center, David Geffen School of Medicine At UCLA, 757 Westwood Plaza, Suite 7501, Los Angeles, CA, 90095, USA.,Department of Internal Medicine Services, West Los Angeles VA Medical Center, Los Angeles, CA, USA.,Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
40
|
Lamarca A, Cives M, de Mestier L, Crona J, Spada F, Öberg K, Pavel M, Alonso-Gordoa T. Advanced small-bowel well-differentiated neuroendocrine tumours: An international survey of practice on 3 rd-line treatment. World J Gastroenterol 2021; 27:976-989. [PMID: 33776367 PMCID: PMC7968134 DOI: 10.3748/wjg.v27.i10.976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Somatostatin analogues are an established first-line therapy for well differentiated small bowel neuroendocrine tumours (Wd-SBNETs), while and peptide receptor radionuclide therapy (PRRT) is frequently used as a second-line therapy. Adequate treatment selection of third-line treatment remains challenging due to the limited prospective data currently available on the best therapeutic sequence.
AIM To understand current practice and rationale for decision-making by physicians in the 3rd-line setting by building an online survey.
METHODS Weighted average (WA) of likelihood of usage between responders (1 very unlikely; 4 very likely) was used to reflect the relevance of factors explored.
RESULTS Replies from representatives of 28 centers were received (5/8/2020-21/9/2020); medical oncologist (53.6%), gastroenterologist (17.9%); United Kingdom (21.4%), Spain (17.9%), Italy (14.3%). Majority from European Neuroendocrine Tumor Society (ENETS) Centres of Excellence (57.1%), who followed ENETS guidelines (82.1%). Generally speaking, 3rd-line treatment for Wd-SBNETs was: everolimus (EVE) (66.7%), PRRT (18.5%), liver embolization (LE) (7.4%) and interferon-alpha (IFN) (3.7%); chemotherapy (0%); decision was based on clinical trial data (59.3%), or personal experience (22.2%). EVE was most likely used if Ki-67 < 10% (WA 3.27/4) or age < 70 years (WA 3.23/4), in the 3rd-line setting (WA 3.23/4); regardless of presence/absence of carcinoid syndrome (CS), rate of progression or extent of disease. Chemotherapy was mainly utilised only if rapid progression (within 6 mo) (WA 3.35/4), Ki-67 10%-20% (WA 2.77/4), negative somatostatin receptor imaging (WA 2.65/4) or high tumour burden (WA 2.77/4); temozolomide or streptozocin was used with capecitabine or 5-fluorouracil (5-FU) (57.7%), FOLFOX (5-FU combined with oxaliplatin) (23.1%). LE was selected if presence of CS (WA 3.24/4) or Ki-67 < 10% (WA 2.8/4), after progression to other treatments (WA 2.8/4). IFN was rarely used (WA 1.3/4).
CONCLUSION Everolimus was the most frequently used therapeutic option in the third-line setting. The most important factors for decision-making included Ki-67, rate of progression, functionality and tumour burden; since this decision is based on multiple factors, it highlights the need for a multidisciplinary assessment.
Collapse
Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, European Neuroendocrine Tumor Society Centre of Excellence, The Christie NHS Foundation Trust, University of Manchester, Manchester M20 4BX, United Kingdom
| | - Mauro Cives
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari 70121, Italy
| | - Louis de Mestier
- Department of Gastroenterology and Pancreatology, European Neuroendocrine Tumor Society Center of Excellence, Paris-Diderot University, Clichy 75006, France
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, Uppsala SE-751 85, Sweden
| | - Francesca Spada
- Gastrointestinal Medical Oncology and Neuroendocrine Tumors Unit, European Institute of Oncology, Milan 20141, Italy
| | - Kjell Öberg
- Department of Endocrine Oncology, Uppsala University Hospital, Uppsala SE-751 85, Sweden
| | - Marianne Pavel
- Department of Endocrinology, Universitatsklinikum Erlangen, Erlangen 91054, Germany
| | - Teresa Alonso-Gordoa
- Medical Oncology Department, The Ramón y Cajal Health Research Institute, Alcalá University, University Hospital Ramon y Cajal, Madrid 28034, Spain
| |
Collapse
|
41
|
Kipnis ST, Hung M, Kumar S, Heckert JM, Lee H, Bennett B, Soulen MC, Pryma DA, Mankoff DA, Metz DC, Eads JR, Katona BW. Laboratory, Clinical, and Survival Outcomes Associated With Peptide Receptor Radionuclide Therapy in Patients With Gastroenteropancreatic Neuroendocrine Tumors. JAMA Netw Open 2021; 4:e212274. [PMID: 33755166 PMCID: PMC7988364 DOI: 10.1001/jamanetworkopen.2021.2274] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Peptide receptor radionuclide therapy (PRRT) is approved in the US for treatment of gastroenteropancreatic neuroendocrine tumors (NETs), but data on PRRT outcomes within US populations remain scarce. OBJECTIVE To analyze the first 2 years of PRRT implementation at a US-based NET referral center. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using medical records of patients with metastatic NET receiving PRRT from 2018 through 2020 in a NET program at a tertiary referral center. Included patients were those at the center with metastatic NETs who received at least 1 dose of PRRT over the study period. Laboratory toxic effects were assessed using Common Terminology Criteria for Adverse Events version 5.0. Tumor response was determined using Response Evaluation Criteria in Solid Tumors 1.1. Survival analysis was conducted to identify factors associated with progression-free survival (PFS) and overall survival. Data were analyzed from August 2018 through August 2020. EXPOSURES Receiving 4 cycles of lutetium-177-dotatate infusion, separated by 8-week intervals targeted to 7.4 GBq (200 mCi) per dose. MAIN OUTCOMES AND MEASURES Data were compared from before and after PRRT to determine hematologic, liver, and kidney toxic effects and to assess tumor progression and patient survival. RESULTS Among 78 patients receiving at least 1 dose of PRRT, median (interquartile range) age at PRRT initiation was 59.8 (53.5-69.2) years and 39 (50.0%) were men. The most common primary NET sites included small bowel, occurring in 34 patients (43.6%), and pancreas, occurring in 22 patients (28.2%). World Health Organization grade 1 or 2 tumors occurred in 62 patients (79.5%). Among all patients, 56 patients underwent pretreatment with tumor resection (71.8%), 49 patients received nonsomatostatin analogue systemic therapy (62.8%), and 49 patients received liver-directed therapy (62.8%). At least 1 grade 2 or greater toxic effect was found in 47 patients (60.3%). Median PFS was 21.6 months for the study group, was not reached by 22 months for patients with small bowel primary tumors, and was 13.3 months for patients with pancreatic primary tumors. Having a small bowel primary tumor was associated with a lower rate of progression compared with having a pancreatic primary tumor (hazard ratio, 0.19; 95% CI, 0.07-0.55; P = .01). Median overall survival was not reached. CONCLUSIONS AND RELEVANCE This cohort study of patients with metastatic NETs found that PRRT was associated with laboratory-measured toxic effects during treatment for most patients and an overall median PFS of 21.6 months. Patients with small bowel NETs had longer PFS after PRRT compared with patients with pancreatic NETs.
Collapse
Affiliation(s)
- Sarit T. Kipnis
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Matthew Hung
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shria Kumar
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jason M. Heckert
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Hwan Lee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bonita Bennett
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michael C. Soulen
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel A. Pryma
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David A. Mankoff
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David C. Metz
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jennifer R. Eads
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bryson W. Katona
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
42
|
Bauci G, Kolb W, Janczak J. Is the Meckel diverticulum still a bad boy in general surgery? Case report of an intestinal obstruction managed through a single-port access and review of the literature. J Surg Case Rep 2021; 2021:rjaa584. [PMID: 33532050 PMCID: PMC7837361 DOI: 10.1093/jscr/rjaa584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/28/2020] [Indexed: 11/14/2022] Open
Abstract
In our institution single-port diagnostic laparoscopy is the routine procedure for patients with acute abdominal emergencies. Here, we present a case of intestinal obstruction due to a torqued Meckel diverticulum successfully managed through a single-port incision.
Collapse
Affiliation(s)
- Gabriele Bauci
- Department of General, Visceral, Endocrine, and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Walter Kolb
- Department of General, Visceral, Endocrine, and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Joanna Janczak
- Department of General, Visceral, Endocrine, and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
43
|
Hernandez Vargas S, Lin C, Voss J, Ghosh SC, Halperin DM, AghaAmiri S, Cao HST, Ikoma N, Uselmann AJ, Azhdarinia A. Development of a drug-device combination for fluorescence-guided surgery in neuroendocrine tumors. JOURNAL OF BIOMEDICAL OPTICS 2020; 25:JBO-200129R. [PMID: 33300316 PMCID: PMC7725236 DOI: 10.1117/1.jbo.25.12.126002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/06/2020] [Indexed: 05/13/2023]
Abstract
SIGNIFICANCE The use of cancer-targeted contrast agents in fluorescence-guided surgery (FGS) has the potential to improve intraoperative visualization of tumors and surgical margins. However, evaluation of their translational potential is challenging. AIM We examined the utility of a somatostatin receptor subtype-2 (SSTR2)-targeted fluorescent agent in combination with a benchtop near-infrared fluorescence (NIRF) imaging system to visualize mouse xenografts under conditions that simulate the clinical FGS workflow for open surgical procedures. APPROACH The dual-labeled somatostatin analog, Ga67-MMC(IR800)-TOC, was injected into mice (n = 24) implanted with SSTR2-expressing tumors and imaged with the customized OnLume NIRF imaging system (Madison, Wisconsin). In vivo and ex vivo imaging were performed under ambient light. The optimal dose (0.2, 0.5, and 2 nmol) and imaging time point (3, 24, 48, and 72 h) were determined using contrast-to-noise ratio (CNR) as the image quality parameter. Video captures of tumor resections were obtained to provide an FGS readout that is representative of clinical utility. Finally, a log-transformed linear regression model was fitted to assess congruence between fluorescence readouts and the underlying drug distribution. RESULTS The drug-device combination provided high in vivo and ex vivo contrast (CNRs > 3, except lung at 3 h) at all time points with the optimal dose of 2 nmol. The optimal imaging time point was 24-h post-injection, where CNRs > 6.5 were achieved in tissues of interest (i.e., pancreas, small intestine, stomach, and lung). Intraoperative FGS showed excellent utility for examination of the tumor cavity pre- and post-resection. The relationship between fluorescence readouts and gamma counts was linear and strongly correlated (n = 334, R2 = 0.71; r = 0.84; P < 0.0001). CONCLUSION The innovative OnLume NIRF imaging system enhanced the evaluation of Ga67-MMC(IR800)-TOC in tumor models. These components comprise a promising drug-device combination for FGS in patients with SSTR2-expressing tumors.
Collapse
Affiliation(s)
- Servando Hernandez Vargas
- The University of Texas Health Science Center at Houston, The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, Houston, Texas, United States
| | | | - Julie Voss
- The University of Texas Health Science Center at Houston, The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, Houston, Texas, United States
| | - Sukhen C. Ghosh
- The University of Texas Health Science Center at Houston, The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, Houston, Texas, United States
| | - Daniel M. Halperin
- The University of Texas MD Anderson Cancer Center, Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, Houston, Texas, United States
| | - Solmaz AghaAmiri
- The University of Texas Health Science Center at Houston, The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, Houston, Texas, United States
| | - Hop S. Tran Cao
- The University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Division of Surgery, Houston, Texas, United States
| | - Naruhiko Ikoma
- The University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Division of Surgery, Houston, Texas, United States
| | | | - Ali Azhdarinia
- The University of Texas Health Science Center at Houston, The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, Houston, Texas, United States
| |
Collapse
|
44
|
Liu M, Laskaratos FM, Bennell J, Chen J, Toumpanakis C, Mandair D, Caplin M. Home Total Parenteral Nutrition for Intestinal Failure in Patients with Advanced Small Intestinal Neuroendocrine Neoplasms. Nutr Cancer 2020; 73:1638-1643. [PMID: 32865033 DOI: 10.1080/01635581.2020.1810713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The role of total parenteral nutrition (TPN) in cancer patients is controversial, but it may be a treatment option for some patients with indolent but advanced small intestinal neuroendocrine neoplasms (SI-NENs). The aim of this study is to investigate whether home TPN was associated with long-term survival and to assess the indications, duration and complications of TPN in patients with advanced SI-NENs. Patients with advanced SI-NENs who received home TPN were retrospectively included. Electronic records were reviewed for clinical information. Five patients receiving home TPN were identified out of 1011 patients with SI-NENs in our center. The median duration of TPN administration was 12 mo. Small bowel obstruction was the most common reason for TPN initiation. TPN-related complications included two catheter infections, one thrombosis and one episode of TPN-related transaminitis. At the last follow-up, three patients had died and two were alive. The median survival was 12 mo. Overall estimated 1-yr probability of survival on home TPN by Kaplan-Meier analysis was 40%. In conclusion, home TPN may be a treatment option in highly selected advanced SI-NEN patients with severe gastrointestinal tract dysfunction. The initiation of home TPN is associated with long-term survival (≥1 yr), and complication rates appear acceptable.
Collapse
Affiliation(s)
- Man Liu
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK.,Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Faidon-Marios Laskaratos
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Jose Bennell
- Royal Free London NHS Foundation Trust, London, UK
| | - Jie Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Dalvinder Mandair
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
45
|
Role of Primary Tumor Resection for Metastatic Small Bowel Neuroendocrine Tumors. World J Surg 2020; 45:213-218. [PMID: 32797281 DOI: 10.1007/s00268-020-05727-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 12/21/2022]
Abstract
While small bowel resection is well established as standard of care for curative-intent management of localized and loco-regional small bowel neuroendocrine tumors (SB-NETs), resection of the primary tumor in the setting of metastatic disease is debated. This review addresses the role of primary tumor resection for stage IV well-differentiated grade 1 and 2 SB-NETs. While survival benefits have been reported for primary tumor resection in the setting of metastatic disease, these studies are limited by selection bias and thus controversial. The main clinical benefits of primary tumor resection for stage IV disease involve the prevention of potentially debilitating complications associated with mesenteric fibrosis, including intestinal obstruction, mesenteric ischemia and angina, venous congestion, malabsorption, and malnutrition. Patients with metastases undergoing initial resection of the primary SB-NETs appear to have fewer episodes of care and re-intervention for loco-regional complications than those who do not undergo resection. As recommended by the NANETS and ENETS guidelines, resection of the primary tumor for stage IV SB-NETs should be strongly considered to avoid future loco-regional complications and potentially to improve survival. All patients with stage IV SB-NETs should be assessed by a surgeon experienced in the management of NETs to consider surgical therapies, including resection of the primary tumor despite metastatic disease.
Collapse
|
46
|
Laskaratos FM, Liu M, Malczewska A, Ogunbiyi O, Watkins J, Luong TV, Mandair D, Caplin M, Toumpanakis C. Evaluation of circulating transcript analysis (NETest) in small intestinal neuroendocrine neoplasms after surgical resection. Endocrine 2020; 69:430-440. [PMID: 32291735 PMCID: PMC7392928 DOI: 10.1007/s12020-020-02289-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/25/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Surgical resection is the only effective curative strategy for small intestinal neuroendocrine neoplasms (SINENs). Nevertheless, the evaluation of residual disease and prediction of disease recurrence/progression remains a problematic issue. METHODS We evaluated 13 SINENs that underwent surgical resection of the primary tumour and/or mesenteric mass. Patients were divided in three groups: (a) Group 1: SINENs that underwent resection with curative intent, (b) Group 2: SINENs treated with resection in the setting of metastatic disease, which remained stable and (c) Group 3: SINENs treated with resection in the setting of metastatic disease, with evidence of any progression at follow-up. NETest and chromogranin A were measured pre-operatively and post-operatively during a 22-month median follow-up period and compared with imaging studies. NETest score <20% was determined as normal, 20-40% low, 41-79% intermediate and ≥80% high score. RESULTS NETest score was raised in all (100%) SINENs pre-operatively. Surgery with curative intent resulted in NETest score reduction from 78.25 ± 15.32 to 25.25 ± 1.75 (p < 0.05). Low NETest scores post-operatively were evident in all cases without clinical evidence of residual disease (Group 1). However, the low disease activity score suggested the presence of microscopic residual disease. In three cases (75%) with stable disease (Group 2) the NETest score was low consistent with indolent disease. In the progressive disease group (Group 3), a high NETest score was present in three cases (60%) and an intermediate NETest score in the remainder (40%). CONCLUSIONS Blood NETest scores accurately identified SINENs and were significantly decreased by curative surgery. Monitoring NETest post-operatively may facilitate management by identifying the presence of residual/progressive disease.
Collapse
Affiliation(s)
- Faidon-Marios Laskaratos
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK.
| | - Man Liu
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Anna Malczewska
- Department of Endocrinology and Neuroendocrine Tumors, Medical University of Silesia, Katowice, Poland
| | | | | | - Tu Vinh Luong
- Histopathology Department, Royal Free Hospital, London, UK
| | - Dalvinder Mandair
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Martyn Caplin
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Christos Toumpanakis
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| |
Collapse
|
47
|
Extent of Lymph Node Dissection for Small Bowel Neuroendocrine Tumors. World J Surg 2020; 45:197-202. [PMID: 32737557 DOI: 10.1007/s00268-020-05710-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 12/22/2022]
Abstract
The management of nodal disease remains controversial for small bowel neuroendocrine tumors (SB-NETs). Debates remain regarding the therapeutic role and extent of routine lymph node dissection (LND) for localized SB-NETs, as well as the need for aggressive resection of advanced loco-regional SB-NETs with mesenteric nodal masses. This review will address these questions regarding lymph node dissection for well-differentiated WHO grade 1 and 2 SB-NETs. In general, the aggressiveness and radicality of resection should be balanced against the length of bowel resected and post-operative functional outcomes. In localized SB-NETs with clinically negative lymph nodes, a nodal harvest of ≥ 8 lymph nodes provides accurate staging, but has not been shown to confer survival benefit. For loco-regional SB-NETs with clinically positive lymph nodes identified on imaging, 4 stages of nodal extent have been described: stage 1 nodes are located near to the intestinal border, stage 2 on arterial branches close to the origin of the SMA, stage 3 along the SMA itself, and stage 4 extend in the retroperitoneum under the pancreatic neck. In SB-NETs, every attempt should be made at resection of the primary tumor and the nodal mesenteric mass for curative-intent management and to prevent debilitating complications from mesenteric fibrosis. A mesenteric-sparing approach is favored to allow for resection for complex proximal nodal masses while preserving intestinal length and function. All patients with SB-NETs with nodal mesenteric mass should be assessed by a surgeon for resection; if deemed unresectable, consideration should be given to assessment in high-volume NETs centres to confirm proximal mesenteric-sparing resection is not feasible.
Collapse
|
48
|
Howe JR. Carcinoid Tumors: Past, Present, and Future. Indian J Surg Oncol 2020; 11:182-187. [DOI: 10.1007/s13193-020-01079-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/07/2020] [Indexed: 01/25/2023] Open
|
49
|
Tran CG, Sherman SK, Howe JR. Small Bowel Neuroendocrine Tumors. Curr Probl Surg 2020; 57:100823. [PMID: 33234227 DOI: 10.1016/j.cpsurg.2020.100823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Affiliation(s)
| | - Scott K Sherman
- Division of Surgical Oncology and Endocrine Surgery, University of lowa Carver College of Medicine, lowa City, lowa
| | - James R Howe
- Division of Surgical Oncology and Endocrine Surgery, University of lowa Carver College of Medicine, lowa City, lowa.
| |
Collapse
|
50
|
Khetan P, Oyewole F, Wolin E, Kim MK, Divino CM. Prognostic Factors Associated With Progression for Advanced-Stage/G1 and G2 Small-Bowel Neuroendocrine Tumors After Multimodal Therapy: Experience From a Tertiary Referral Center. Pancreas 2020; 49:509-513. [PMID: 32224719 DOI: 10.1097/mpa.0000000000001520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Neuroendocrine tumors represent approximately 40% of primary small bowel malignancies. However, factors predictive of progression after multimodal surgical therapy have not been well described. We evaluated the characteristics of small bowel neuroendocrine tumor patients associated with progression after multimodal surgical resection. METHODS A retrospective chart review identified 99 stage III and stage IV small bowel neuroendocrine tumor patients at Mount Sinai diagnosed and treated with surgery between 2005 and 2019. Progression-free survival (PFS) was defined as time from surgery until progression in surveillance radiologic imaging. Kaplan-Meier method was used to calculate PFS. Cox proportional hazard models were used to study the prognostic factors for PFS. RESULTS Of 99 patients, 48 had tumor progression during the follow-up period. Median PFS was 5.7 years (95% confidence interval [CI], 3.73-8.66) for the entire cohort. Prognostic factors for PFS were age at diagnosis (hazard ratio [HR], 1.04; 95% CI, 1.01-1.07), perineural invasion (HR, 2.19; 95% CI, 1.13-4.23), and elevated preoperative chromogranin level (HR, 2.31; 95% CI, 1.01-5.27). CONCLUSIONS Age at diagnosis, perineural invasion, and elevated preoperative chromogranin level may play a prognostic role in PFS.
Collapse
Affiliation(s)
- Prerna Khetan
- From the Departments of Surgery, Icahn School of Medicine
| | - Femi Oyewole
- From the Departments of Surgery, Icahn School of Medicine
| | | | | | | |
Collapse
|