1
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Mori H, Tamura M, Ogawa R, Kimata Y, Endo S, Sekine K, Kodama S, Watanabe HH, Ookuma K, Jinzaki M. A Case of Pancreatic Neuroendocrine Tumor with Liver Metastases Demonstrating the Possibility of Enhanced ACTH Production by the SACI Test. Case Rep Endocrinol 2024; 2024:5923680. [PMID: 38681235 PMCID: PMC11055651 DOI: 10.1155/2024/5923680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 05/01/2024] Open
Abstract
Objective ACTH-producing pancreatic NETs have a propensity to metastasize, and in patients with metastases, there is no established method yet to precisely determine if the excess ACTH is produced by the primary or the metastatic tumors. Localizing the source of production of ACTH in such cases is important for devising suitable treatment strategies and evaluating the benefit of local therapies from the viewpoint of control of Cushing's syndrome. Methods We performed the selective arterial calcium injection (SACI) test combined with selective portal and hepatic venous sampling in a 32-year-old female patient with ectopic ACTH-producing pancreatic NET and liver metastases. Results The blood level of ACTH after Ca loading was significantly elevated only in the vessels thought to be directly feeding the pancreatic tumor, and Ca loading from any artery did not significantly increase ACTH concentrations in the hepatic veins compared to the main trunk of the portal vein. Conclusions The present case demonstrates that there might be an ACTH-producing p-NET that responds to Ca loading. Further in vitro studies are required to validate this possibility.
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Affiliation(s)
- Hirozumi Mori
- Department of Radiology, Saitama City Hospital, Saitama, Japan
| | - Masashi Tamura
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Ogawa
- Department of Radiology, Saitama City Hospital, Saitama, Japan
| | - Yuta Kimata
- Department of Medicine, Saitama City Hospital, Saitama, Japan
| | - Sho Endo
- Department of Medicine, Saitama City Hospital, Saitama, Japan
| | | | - Sayuri Kodama
- Department of Radiology, Saitama City Hospital, Saitama, Japan
| | | | - Kiyoshi Ookuma
- Department of Radiology, Saitama City Hospital, Saitama, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
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2
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Hu S, Wang X, Su F, Zhou Q, Li Z, Luo J, Tan H. Effect of mitotane in patients with ectopic adrenocorticotropic hormone syndrome caused by advanced pancreatic neuroendocrine tumors: a case series and review of the literature. J Int Med Res 2024; 52:3000605231220867. [PMID: 38190848 PMCID: PMC10775748 DOI: 10.1177/03000605231220867] [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: 09/13/2023] [Accepted: 11/23/2023] [Indexed: 01/10/2024] Open
Abstract
Ectopic adrenocorticotropic hormone syndrome (EAS) is a rare condition caused by pancreatic neuroendocrine tumors (p-NETs). The severe hypercortisolemia that characterizes EAS is associated with a poor prognosis and survival. Mitotane is the only adrenolytic drug approved by the Food and Drug Administration and is often used to treat adrenocortical carcinoma. Combination therapy with mitotane and other adrenal steroidogenesis inhibitors is common for patients with Cushing's syndrome (CS). Here, we describe three patients who developed EAS secondary to the liver metastasis of p-NETs. All three rapidly developed hypercortisolemia but no typical features of CS. They underwent anti-tumor and mitotane therapy, which rapidly reduced their blood cortisol concentrations and ameliorated their symptoms. Their hypercortisolemia was controlled long term using a low dose of mitotane. The principal adverse effects were a slight loss of appetite and occasional dizziness, and there were no severe adverse effects. Importantly, even when the tumor progressed, the patients' circulating cortisol concentrations remained within the normal range. In summary, the present case series suggests that mitotane could be used to treat hypercortisolemia in patients with EAS caused by advanced p-NETs, in the absence of significant adverse effects.
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Affiliation(s)
- Shaobo Hu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Xianhua Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Fei Su
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Qiong Zhou
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Zhaoqing Li
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Jie Luo
- Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Huangying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, China
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3
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Sulciner ML, Clancy TE. Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2023; 15:cancers15072006. [PMID: 37046665 PMCID: PMC10093271 DOI: 10.3390/cancers15072006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.
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Danda VSR, Srinivas Rao P, Konda C, Lodha P. Acanthosis nigricans in Insulinoma: Reversible experiments of the nature. Med J Armed Forces India 2022; 78:S315-S318. [PMID: 36147425 PMCID: PMC9485756 DOI: 10.1016/j.mjafi.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/11/2019] [Indexed: 10/25/2022] Open
Abstract
Acanthosis Nigricans is considered to be a skin marker of insulin resistance and atherosclerosis. It is rarely reported in cases of insulinoma where there is marked hyperinsulinaemia. We report two cases of insulinoma with acanthosis nigricans which regressed, concomitant with significant weight loss and reduction in blood pressure following surgical resection. This strengthens the hypothesis that hyperinsulinaemia is responsible for Acanthosis nigricans and atherosclerotic risk factors.
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Affiliation(s)
- Vijay Sheker R. Danda
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Hyderabad, Telangana, 500003, India
| | - Paidipally Srinivas Rao
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Hyderabad, Telangana, 500003, India
| | - Chaitanya Konda
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Hyderabad, Telangana, 500003, India
| | - Piyush Lodha
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Hyderabad, Telangana, 500003, India
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5
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Zhang D, Lu L, Zhu HJ, Xiao Y, Han XL, Du SD, Xue HD, Liu QX, Zhu ZH, Hu MM, Zhai X, Xing XP, Lu ZL. Somatostatin Treatment for Ectopic ACTH Syndrome due to Pancreatic Neuroendocrine Tumors: Review of the Literature. Int J Endocrinol 2022; 2022:6283706. [PMID: 35265125 PMCID: PMC8901294 DOI: 10.1155/2022/6283706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/21/2022] [Accepted: 02/01/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To analyze and summarize the effect of SSA treatment on EAS due to p-NETs (EAS-p-NETs). METHODS Thirteen patients with EAS-p-NETs treated with SSAs at our center or described in the literature were included in this study. Clinical characteristics, laboratory data, imaging studies, histopathologic results, the effect of SSA treatment, and the prognosis of these EAS-p-NET patients were evaluated. RESULTS Four males and 9 females with an average age of 42.9 years were included in the study. The mean duration of follow-up was 38.8 ± 28.2 months. As one of the combined treatment measures, SSAs controlled the levels of ACTH and cortisol in 9 of the 13 patients (69.2%). Partial response was observed in 3 patients (23.1%), stable disease in 2 patients (15.4%), and progressive disease in 6 patients (46.2%). The median time to tumor progression was 24 months, and the median overall survival was 61 months. The side effects of SSA treatment included temporary mild abdominal pain, diarrhea, gallstones, and cholecystitis. CONCLUSIONS As a supplemental therapy, SSA treatment led to clinical and biochemical improvement with a good safety profile in patients exhibiting EAS-p-NET with metastasis. However, tumor progression was inhibited by SSA treatment in only a few patients. Combined with other treatments, SSAs may improve the prognosis of patients with EAS-p-NETs.
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Affiliation(s)
- Da Zhang
- Department of Endocrinology, Air Force Medical Center, People's Liberation Army, Beijing 100142, China
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Hui-Juan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Yu Xiao
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xian-Lin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Shun-Da Du
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Hua-Dan Xue
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Qing-Xing Liu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Zhao-Hui Zhu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Ming-Ming Hu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xiao Zhai
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xiao-Ping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Zhao-Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
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6
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Lam AKY, Ishida H. Pancreatic neuroendocrine neoplasms: Clinicopathological features and pathological staging. Histol Histopathol 2021; 36:367-382. [PMID: 33305819 DOI: 10.14670/hh-18-288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The nomenclature and classification of pancreatic neuroendocrine neoplasms has evolved in the last 15 years based on the advances in knowledge of the genomics, clinical behaviour and response to therapies. The current 2019 World Health Organization classification of pancreatic neuroendocrine neoplasms categorises them into three groups; pancreatic neuroendocrine tumours (PanNETs)(grade 1 grade 2, grade 3), pancreatic neuroendocrine carcinomas and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) based on the mitotic rate, Ki-67 index, morphological differentiation and/or co-existing tissue subtype. PanNETs are also classified into non-functional NET, insulinoma, gastrinoma, VIPoma, glucagonoma, somatostatinoma, ACTH-producing NET and serotonin producing NET based on hormone production and clinical manifestations. A portion of the cases were associated with genetic syndromes such as multiple neuroendocrine neoplasia 1 (MEN 1), neurofibromatosis and Von Hippel-Lindau syndrome. In view of the distinctive pathology and clinical behaviour of PanNENs, the current 8th AJCC/UICC staging system has separated prognostic staging grouping for PanNETs from the pancreatic neuroendocrine carcinomas or MiNENs. Pancreatic neuroendocrine carcinomas and MiNENs are staged according to the prognostic stage grouping for exocrine pancreatic carcinoma. The new stage grouping of PanNETs was validated to have survival curves separated between different prognostic groups. This refined histological and staging would lead to appropriate selections of treatment strategies for the patients with pancreatic neuroendocrine neoplasms.
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Affiliation(s)
| | - Hirotaka Ishida
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
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7
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Shayesteh S, Fouladi DF, Fishman EK, Kawamoto S. Ectopic Cushing syndrome caused by a pancreatic neuroendocrine tumor: A case report. Radiol Case Rep 2020; 15:1014-1017. [PMID: 32547669 PMCID: PMC7283937 DOI: 10.1016/j.radcr.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
Cushing syndrome is a disorder that occurs when the body is exposed to a higher than normal level of the hormone cortisol. It is most commonly caused by exogenous glucocorticoids, and less commonly due to endogenous sources. Ectopic adrenocorticotropic hormone (ACTH) syndrome is one of the rare causes of endogenous Cushing syndrome engendered by oversecretion of ACTH from a tumor outside of the pituitary or adrenal glands. We present a case of a 74-year-old male with uncontrolled type 2 diabetes mellitus who was suspected of having Cushing syndrome on chest CT due to increasing mediastinal lipomatosis and enlarging bilateral adrenal glands. Cushing syndrome was confirmed based on clinical features and biochemical tests. Further investigation revealed an ACTH-producing functional neuroendocrine tumor of the pancreas causing ectopic Cushing syndrome.
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Affiliation(s)
- Shahab Shayesteh
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, JHOC 3140E, 601 North Caroline St, Baltimore, MD, USA
| | - Daniel Fadaei Fouladi
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, JHOC 3140E, 601 North Caroline St, Baltimore, MD, USA
| | - Elliot K Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, JHOC 3140E, 601 North Caroline St, Baltimore, MD, USA
| | - Satomi Kawamoto
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, JHOC 3140E, 601 North Caroline St, Baltimore, MD, USA
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8
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Bleicher J, Lombardo S, Carbine S, Kapitonov D, Pletneva MA, Mulvihill SJ. Adrenocorticotropin Hormone Secreting Carcinoma of the Pancreas: A Case Report. J Pancreat Cancer 2019; 5:22-25. [PMID: 31236541 PMCID: PMC6588116 DOI: 10.1089/pancan.2019.0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: Adrenocorticotropin hormone (ACTH) secreting pancreatic neuroendocrine neoplasms (pNENs) are rare. The clinical and biological behavior of pNENs is poorly understood. Patients often present at an advanced stage of disease and outcomes remain poor. This report demonstrates a case of ectopic Cushing's syndrome secondary to an ACTH-producing pancreatic neuroendocrine carcinoma (pNEC). Case report: A 54-year-old woman presented with rapidly progressive Cushing's syndrome complicated by hypertension and acute heart failure. This was ultimately found to be secondary to a metastatic ACTH-producing pNEC. She underwent laparoscopic distal pancreatectomy and splenectomy with hepatic metastasectomy as primary treatment. She had rapid correction of her endocrine abnormalities and associated physiological abnormalities. She had progressive hepatic metastases found on imaging at 3 months, but remained free of significant endocrine abnormalities for 9 months after surgery. Her disease did recur and she died of complications associated with her disease at 1 year after her surgery. Conclusion: ACTH-producing pNEN is a very rare disease with a poor prognosis. Robust evidence to guide treatment decisions is limited. This report suggests that aggressive surgical management of primary and metastatic lesions for management of this disease is reasonable, consistent with prior case reports. Control of endocrine abnormalities offers the best opportunity for prolonged survival, and an aggressive surgical approach can achieve this goal. The patient presented had control of endocrine abnormalities after surgery for 9 months before symptomatic disease recurrence.
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Affiliation(s)
- Josh Bleicher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sarah Lombardo
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stacie Carbine
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.,Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Dmitri Kapitonov
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Maria A Pletneva
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sean J Mulvihill
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.,Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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9
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Herrera-Martínez AD, Feelders RA, de Herder WW, Castaño JP, Gálvez Moreno MÁ, Dogan F, van Dungen R, van Koetsveld P, Hofland LJ. Effects of Ketoconazole on ACTH-Producing and Non-ACTH-Producing Neuroendocrine Tumor Cells. HORMONES & CANCER 2019; 10:107-119. [PMID: 31102172 DOI: 10.1007/s12672-019-00361-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 03/28/2019] [Indexed: 02/08/2023]
Abstract
Prolonged remission of hypercortisolism with steroidogenesis inhibitors has been described in patients with ectopic adrenocorticotropic hormone (ACTH) syndrome. The anti-proliferative and pro-apoptotic effect of ketoconazole in human cancer cells was previously suggested. The aim of this study was to explore the effects of ketoconazole on ACTH-producing and non-ACTH-producing neuroendocrine tumor (NET) cell lines. The effects of ketoconazole alone, and in combination with somatostatin analogs, were evaluated in two human cell lines: DMS-79 (ectopic ACTH-producing small cell lung carcinoma) and BON-1 (human pancreatic NET). Total DNA measurement, apoptosis, cell cycle, chromogranin A (CgA)/proopiomelanocortin (POMC) expression by qRT-PCR, serotonin, CgA, and ACTH secretion assays were performed. In both cell lines, ketoconazole significantly suppressed cell growth and colony formation in a dose and time-dependent manner. The effect in DMS-79 was primarily cytotoxic, while it was more apoptotic in BON-1 cells. Ketoconazole also induced increase in G0/G1 phase in both cell lines and arrest in phase G2/M of BON-1 cells. Ketoconazole did not affect the secretion of serotonin, CgA, ACTH, or the mRNA expression of CgA and POMC. Decreased serotonin secretion was observed after the combination treatment with pasireotide. These results suggest a direct effect of ketoconazole on cell proliferation, apoptosis, and cell cycle in both ACTH- and non-ACTH-producing NET cells.
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Affiliation(s)
- Aura D Herrera-Martínez
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.,Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
| | - Wouter W de Herder
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
| | - Justo P Castaño
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Córdoba, Spain
| | | | - Fadime Dogan
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
| | - Rosanna van Dungen
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
| | - Peter van Koetsveld
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
| | - Leo J Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
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10
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do Amor Divino PH, Marchetti KR, Almeida MQ, Riechelmann RP. Functional pancreatic neuroendocrine tumour causing Cushing's syndrome: the effect of chemotherapy on clinical symptoms. Ecancermedicalscience 2017; 11:773. [PMID: 29104610 PMCID: PMC5659828 DOI: 10.3332/ecancer.2017.773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 01/06/2023] Open
Abstract
Background Neuroendocrine tumours (NETs) are a heterogeneous group of diseases that can originate from any part of the gastrointestinal tract, bronchi, thyroid and pancreas. These tumours may be functioning or not depending on their ability to produce active substances, such as adrenocorticotrophic hormone (ACTH). ACTH-producing pancreatic neuroendocrine tumours are rare, with limited data about effective antitumor therapies. Case Report A 58-year-old man with a history of type-2 diabetes mellitus and arterial hypertension was diagnosed with Cushing’s syndrome (CS) secondary to an ACTH ectopic production from a well-differentiated neuroendocrine tumour of the pancreas metastatic to the liver. The patient underwent initial body-caudal pancreatectomy, splenectomy and hepatic nodulectomy with subsequent recurrence. Hepatic embolisation and somatostatin analogues were used to control CS but without success. Bilateral adrenalectomy led to CS control, while capecitabine and oxaliplatin (CAPOX) was effective in controlling tumour growth and ACTH production. Discussion ACTH-producing pancreatic neuroendocrine tumours are rare, aggressive and difficult to treat with available therapies. In settings of limited resources, such as in developing countries where targeted therapies are not available, cytotoxic chemotherapy with CAPOX represents a good and inexpensive option to control ACTH-producing pancreatic neuroendocrine tumours. Because of its complexity, the management of this tumour should be performed by multidisciplinary teams.
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Affiliation(s)
| | - Katia Regina Marchetti
- Instituto do Câncer do Estado de São Paulo, Av Dr Arnaldo, 251 - Cerqueira César, Sao Paulo, 1246-000, Brazil
| | - Madson Q Almeida
- Instituto do Câncer do Estado de São Paulo, Av Dr Arnaldo, 251 - Cerqueira César, Sao Paulo, 1246-000, Brazil
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11
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Yang F, Jin C, Fu D. A Rare Cause of Severe Hypokalemia and Back Pain. Gastroenterology 2017; 153:e1-e3. [PMID: 28881192 DOI: 10.1053/j.gastro.2017.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/06/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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12
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ElGuindy YM, Javadi S, Menias CO, Jensen CT, Elsamaloty H, Elsayes KM. Imaging of secretory tumors of the gastrointestinal tract. Abdom Radiol (NY) 2017; 42:1113-1131. [PMID: 27878636 DOI: 10.1007/s00261-016-0976-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gastrointestinal secretory tumors, or gastroenteropancreatic neuroendocrine tumors, encompass a wide array of endocrine cell tumors. The significance of these tumors lies in their ability to alter physiology through hormone production as we well as in their malignant potential. Functioning tumors may present earlier due to symptomatology; conversely, non-functioning tumors are often diagnosed late as they reach large sizes, causing symptoms secondary to local mass effect. Imaging aids in the diagnosis, staging, and prognosis and provides key information for presurgical planning. Although most of these tumors are sporadic, some are associated with important syndromes and associations, knowledge of which is critical for patient management. In this article, we provide an overview of secretory and neuroendocrine tumors of the GI tract and pancreas.
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13
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Bansal M, Agarwal A, Govindarajan R. Ectopic Adrenocorticotropic Hormone Syndrome Due to a Pancreatic Neuroendocrine Tumor. J Gastrointest Cancer 2016; 43 Suppl 1:S231-3. [PMID: 22733565 DOI: 10.1007/s12029-012-9400-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Meghana Bansal
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301, West Markham Street, Little Rock, AR, 72205, USA
| | - Abhishek Agarwal
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301, West Markham Street, Little Rock, AR, 72205, USA.
| | - R Govindarajan
- Division of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
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14
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Tadokoro R, Sato S, Otsuka F, Ueno M, Ohkawa S, Katakami H, Taniyama M, Nagasaka S. Metastatic Pancreatic Neuroendocrine Tumor that Progressed to Ectopic Adrenocorticotropic Hormone (ACTH) Syndrome with Growth Hormone-releasing Hormone (GHRH) Production. Intern Med 2016; 55:2979-2983. [PMID: 27746436 PMCID: PMC5109566 DOI: 10.2169/internalmedicine.55.6827] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The patient was a 61-year-old woman who had a well-differentiated pancreatic neuroendocrine tumor (PNET) with lymph node metastasis. After 15 months of octreotide treatment, glucose control deteriorated and pigmentation of the tongue and moon face developed, leading to the diagnosis of ectopic adrenocorticotropic hormone (ACTH) syndrome. An abnormal secretion of growth hormone (GH) was identified, and the plasma growth hormone-releasing hormone (GHRH) level was elevated. A tumor biopsy specimen positively immunostained for ACTH and GHRH. Ectopic hormone secretion seems to have evolved along with the progression of the PNET.
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Affiliation(s)
- Rie Tadokoro
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, Japan
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15
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Isidori AM, Sbardella E, Zatelli MC, Boschetti M, Vitale G, Colao A, Pivonello R. Conventional and Nuclear Medicine Imaging in Ectopic Cushing's Syndrome: A Systematic Review. J Clin Endocrinol Metab 2015; 100:3231-44. [PMID: 26158607 PMCID: PMC4570166 DOI: 10.1210/jc.2015-1589] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CONTEXT Ectopic Cushing's Syndrome (ECS) can be a diagnostic challenge with the hormonal source difficult to find. This study analyzes the accuracy of imaging studies in ECS localization. EVIDENCE ACQUISITION Systematic review of medical literature for ECS case series providing individual patient data on at least one conventional imaging technique (computed tomography [CT]/magnetic resonance imaging) and one of the following: 111In-pentetreotide (OCT), 131I/123I-metaiodobenzylguanidine, 18Ffluoro-2-deoxyglucose-positron emission tomography (FDG-PET), 18F-fluorodopa-PET (F-DOPA-PET), 68Ga- DOTATATE-PET/CT or 68Ga-DOTATOC-PET/CT scan (68Gallium-SSTR-PET/CT). EVIDENCE SUMMARY The analysis comprised 231 patients (females, 50.2%; age, 42.617 y). Overall, 52.4%(121/231) had "overt" ECS,18.6% had "occult" ECS, and 29% had "covert" ECS. Tumors were located in the lung (55.3%), mediastinum-thymus (7.9%), pancreas (8.5%), adrenal glands (6.4%), gastrointestinal tract (5.4%), thyroid (3.7%), and other sites (12.8%), and primary tumors were mostly bronchial neuroendocrine tumors (NETs) (54.8%), pancreatic NETs (8%), mediastinum-thymus NETs (6.9%), gastrointestinal NETs (5.3%), pheochromocytoma (6.4%), neuroblastoma (3.2%), and medullary thyroid carcinoma (3.2%). Tumors were localized byCTin66.2%(137/207), magnetic resonance imaging in 51.5% (53/103), OCT in 48.9% (84/172), FDG-PET in 51.7% (46/89), F-DOPAPET in 57.1% (12/21), 131/123I-metaiodobenzylguanidine in 30.8% (4/13), and 68Gallium-SSTRPET/CT in 81.8% (18/22) of cases. Molecular imaging discovered 79.1% (53/67) of tumors unidentified by conventional radiology, with OCT the most commonly used, revealing the tumor in 64%, followed by FDG-PET in 59.4%. F-DOPA-PET was used in only seven covert cases (sensitivity, 85.7%). Notably, 68Gallium-SSTR-PET/CT had 100% sensitivity among covert cases. CONCLUSIONS Nuclear medicine improves the sensitivity of conventional radiology when tumor site identification is problematic. OCT offers a good availability/reliability ratio, and FDG-PET was proven useful. 68Gallium-SSTR-PET/CT use was infrequent, despite offering the highest sensitivity.
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16
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Shusterman M, Bloomgarden NA, Sotardi ST, Shastri A. Tumor Lysis Syndrome in an Unusual Metastatic Pancreatic Neuroendocrine Tumor with Ectopic ACTH Secretion. J Gastrointest Cancer 2015; 47:423-428. [PMID: 26271662 DOI: 10.1007/s12029-015-9755-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michael Shusterman
- Department of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Noah A Bloomgarden
- Department of Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Susan T Sotardi
- Department of Radiology, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Aditi Shastri
- Department of Oncology, Montefiore Medical Center, 111 East 210th Street, Hofheimer Main, Room 111, Bronx, NY, 10467, USA.
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17
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Vaduganathan M, Nagarur A, Kerr DA, Lauter KB, Padmanabhan A, Raghavan S, Pallais JC, Fenves AZ. Metastatic pancreatic neuroendocrine tumor with ectopic adrenocorticotropic hormone production. Proc (Bayl Univ Med Cent) 2015; 28:46-9. [PMID: 25552797 DOI: 10.1080/08998280.2015.11929184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We describe a 71-year-old man who presented with abdominal pain, lower-extremity edema, recent unintentional weight loss, hypertension, hyperglycemia, hypokalemia, and metabolic alkalosis. Serum cortisol levels remained elevated after overnight high-dose dexamethasone suppression. Magnetic resonance imaging revealed a small mass in the head of the pancreas with scattered liver metastases. Both endoscopic ultrasound-guided pancreatic biopsy and liver biopsy revealed a well-differentiated neuroendocrine tumor. These lesions did not show significant uptake on octreotide scan. Medical management and hepatic artery chemoembolization were attempted. Ultimately, the patient underwent bilateral adrenalectomy, but died within 4 months of symptom onset secondary to postoperative complications.
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amulya Nagarur
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Darcy A Kerr
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kelly B Lauter
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arun Padmanabhan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Srivatsan Raghavan
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Juan C Pallais
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Z Fenves
- Department of Medicine (Vaduganathan, Nagarur, Lauter, Padmanabhan, Raghavan, Pallais, Fenves) and the Department of Pathology (Kerr), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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18
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Abstract
OBJECTIVE Pancreatic cancer continues to have a poor prognosis despite impressive improvements in the outcomes of many other types of cancer, often because most pancreatic neoplasms are found to be unresectable at diagnosis. The purpose of this review is to provide an overview of pancreatic cancer and the role of modern imaging in its diagnosis and management with an emphasis on (18)F-FDG PET/CT fusion imaging. CONCLUSION Multimodality imaging is critical in the diagnosis and management of pancreatic cancer. PET/CT is increasingly viewed as a useful, accurate, and cost-effective modality in diagnosing and managing pancreatic cancer, but further studies are warranted. Early data suggest that contrast-enhanced PET/CT performed with modern PET/CT scanners yields high-resolution anatomic information for surgical and radiotherapeutic planning and functional information for whole-body staging in the care of patients with this disease.
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19
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Chowdry RP, Bhimani C, Delgado MA, Lee DJ, Dayamani P, Sica GL, Owonikoko TK. Unusual suspects: pulmonary opportunistic infections masquerading as tumor metastasis in a patient with adrenocorticotropic hormone-producing pancreatic neuroendocrine cancer. Ther Adv Med Oncol 2012; 4:295-300. [PMID: 23118805 DOI: 10.1177/1758834012456415] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pancreatic neuroendocrine tumors (p-NETs) are a rare group of neoplasms but with increasing incidence. The atypical complications that arise in the setting of functional endocrine tumors are underreported and therefore have not received sufficient attention and the necessary mention in the oncology literature. The clinical implications of these complications pose management challenges starting with the difficulty in establishing diagnosis, accurate staging and optimal treatment of the primary process. We present the case of a middle-aged woman diagnosed with adrenocorticotropic hormone-producing carcinoma arising from the pancreas whose case was complicated by excessive uncontrolled hypercortisolism and reactivation of pulmonary opportunistic infections that confounded her management. We believe that this case illustration will be of value to practicing oncologists and other groups of physicians who are called upon to participate in the multidisciplinary treatment of these relatively rare but highly challenging cases.
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Affiliation(s)
- Rajasree P Chowdry
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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20
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Lin HW, Tseng FY. Ectopic adrenalcorticotropic hormone syndrome improved by transarterial embolization to hepatic metastatic lesions of pancreatic neuroendocrine carcinoma: a case report. J Clin Oncol 2012; 30:e360-3. [PMID: 23071243 DOI: 10.1200/jco.2011.41.4326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hao-Wen Lin
- National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
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21
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Tani Y, Sugiyama T, Hirooka S, Izumiyama H, Hirata Y. Ectopic ACTH syndrome caused by bronchial carcinoid tumor indistinguishable from Cushing's disease. Endocr J 2010; 57:679-86. [PMID: 20558893 DOI: 10.1507/endocrj.k10e-129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 75-year-old woman was admitted to our hospital because of a poor glycemic control. She was found to have Cushingoid feature and dynamic endocrine tests showed elevated plasma ACTH and cortisol levels, lack of their circadian rhythm, non-suppressibility to high-dose dexamethasone, responsiveness to CRH, but not to DDAVP, and suppression to octreotide. Pituitary MRI showed an equivocal small lesion. CT scan of the chest showed two nodular lesions in the right lung (S5, S7), while a mild uptake was noted only in S5 lesion by FDG-PET, but positive uptake was only in S7 lesion by somatostatin receptor scintigraphy (SRS). Inferior petrosal sinus sampling revealed a gradient of plasma ACTH after CRH stimulation, consistent with the diagnosis of Cushing' s disease. She underwent middle and inferior lobectomy of the right lung. The resected tumor in S7 was consistent with the diagnosis of a bronchial carcinoid tumor with positive ACTH immunoreactivity, while that of S5 was cryptococcal granuloma. RT-PCR revealed abundant expressions of POMC and SSTR (-1, -2, -5), but not of CRHR and V1bR. Postoperatively, abnormal endocrine data were normalized along with improvement of hypertension and diabetes. This was a diagnostic challenging case with ectopic ACTH syndrome indistinguishable from Cushing' s disease by various endocrine and imaging tests, among which SRS successfully localized the tumor responsible for ectopic ACTH secretion.
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Affiliation(s)
- Yuji Tani
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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22
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Sugiyama T, Kouyama R, Tani Y, Izumiyama H, Akashi T, Kishimoto S, Arii S, Hirata Y. Giant malignant insulinoma which developed from a non-functioning pancreatic tumor over a long period of time. Intern Med 2010; 49:1573-9. [PMID: 20686293 DOI: 10.2169/internalmedicine.49.3540] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Insulinomas are the most common hormone-producing pancreatic neuroendocrine tumors (NETs), which are usually benign, solitary and small. We describe herein a patient with a giant insulinoma (>10 cm in diameter) with concomitant thyroid tumor as detected by Somatostatin receptor scintigraphy (SRS). A 50-year-old man presented hypoglycemic symptoms 20 years after the first detection of a pancreatic tumor, which was ameliorated by administration of a somatostatin analogue, octreotide. SRS showed abnormal uptake by the insulinoma as well as by the thyroid tumor. RT-PCR and immunohistochemical study revealed abundant expression of somatostatin receptor (SSTR)-1, -2, and -5 in his insulinoma and SSTR-1 and -2 in his thyroid follicular neoplasm. This is a rare case of a slow-growing pancreatic well-differentiated neuroendocrine carcinoma over a long period of time to become a symptomatic giant insulinoma. Furthermore, SRS proves to be a useful tool for localization of insulinoma as well as concomitant thyroid neoplasm with predominant expression of SSTRs.
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Affiliation(s)
- Toru Sugiyama
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School.
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