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Xiang JX, Nan YL, He J, Lopez-Aguiar AG, Poultsides G, Rocha F, Weber S, Fields R, Idrees K, Cho C, Maithel SK, Lv Y, Zhang XF, Pawlik TM. Preoperative anemia: impact on short- and long-term outcomes following curative-intent resection of gastroenteropancreatic neuroendocrine tumors. J Gastrointest Surg 2024; 28:852-859. [PMID: 38538480 DOI: 10.1016/j.gassur.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/10/2024] [Accepted: 03/09/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The effect of preoperative anemia on clinical outcomes of patients undergoing resection of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has not been previously investigated. This study aimed to characterize how preoperative anemia affected short- and long-term outcomes of patients undergoing curative-intent resection of GEP-NETs. METHODS Patients who underwent curative-intent resection for GEP-NETs between January 1990 and December 2020 were identified from 8 major institutions. The last preoperative hemoglobin level was recorded; anemia was defined as <13.5 g/dL in males or <12.0 g/dL in females based on the guides of the American Society of Hematology. The effect of anemia on postoperative outcomes was assessed on uni- and multivariate analyses. RESULTS Among 1559 patients, the median age was 58 years (IQR, 48-66), and roughly one-half of the cohort was male (796 [51.1%]). Most patients had a pancreatic tumor (1040 [66.7%]), followed by small bowel (259 [16.6%]), duodenum (103 [6.6%]), stomach (66 [4.2%]), appendix (53 [3.4%]), and other locations (38 [2.6%]). The median preoperative hemoglobin level was 13.4 g/dL (IQR, 12.2-14.5). Overall, 101 (6.7%) and 119 (8.5%) patients received an intra- or postoperative packed red blood cell (pRBC) transfusion, respectively. A total of 972 patients (44.5%) experienced a postoperative complication. Although the overall incidence of complications was no different among patients who did (anemic: 48.7%) vs patients who did not (nonanemic: 47.3%) have anemia (P = .597), patients with preoperative anemia were more likely to develop a major (Clavien-Dindo grade ≥IIIa: 48.9% [anemic] vs 38.0% [nonanemic]; P = .006) and multiple (≥3 types of complications: 32.2% [anemic] vs 19.7% [anemic]; P < .001) complications. Of note, 1-, 3-, and 5-year overall survival (OS) rates were 96.7%, 90.5%, and 86.6%, respectively. On multivariable analysis, anemia (hazard ratio, 2.0; 95% CI, 1.2-3.2; P = .006) remained associated with worse OS; postoperative pRBC transfusion was associated with an OS (5-year OS: 75.0% vs 87.7%; P = .017) and recurrence-free survival (RFS; 5-year RFS: 66.9% vs 76.5%; P = .047). CONCLUSION Preoperative anemia was commonly identified in roughly 1 in 3 patients who underwent curative-intent resection for GEP-NETs. Preoperative anemia was strongly associated with a higher risk of postoperative morbidity and worse long-term outcomes.
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Affiliation(s)
- Jun-Xi Xiang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang-Long Nan
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, United States
| | - George Poultsides
- Department of Surgery, Stanford University, Palo Alto, California, United States
| | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Sharon Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Ryan Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Wisconsin, United States
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee, United States
| | - Cliff Cho
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, United States
| | - Yi Lv
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China; Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
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Dhara FT, Fayshal MA. Waste Sludge: Entirely Waste or a Sustainable Source of Biocrude? A Review. Appl Biochem Biotechnol 2024:10.1007/s12010-023-04846-7. [PMID: 38236434 DOI: 10.1007/s12010-023-04846-7] [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: 12/19/2023] [Indexed: 01/19/2024]
Abstract
Biomass-derived biocrude is gaining greater recognition from people in general as an alternative fuel source to traditional fossil fuels. Worldwide, a great deal of research is being done to develop fuels made from sustainable biomass in order to replace the current conventional energy sources. Waste sludge has been thought of as a viable raw biomass source because of its accessibility, affordability, high lignin content, and higher heating value. Additionally, considering sludge contains a high proportion of moisture and water acts as a catalyst during the hydrothermal liquefaction (HTL) process, it is the best choice for thermochemical conversion. From the ultimate component value ranges obtained from elemental analysis, it can be demonstrated that the C, H, and higher heating value (HHV) of petrocrude are approximately 8.78%, 23.5%, and 10.66% higher than those of biofuel. According to the overall analysis, co-liquefaction of waste vegetable oil and swine manure can result in 87.97% bio-oil at 340 °C. The temperature, retention period, inclusion of catalysts, and use of solvents, however, can all affect this proportion. To support this illustration, it has been assessed from the study that municipal wet sewage sludge can produce an HHV of 28.52 MJ/kg when water is used as the solvent. However, 34.14 MJ/kg, or 16.5% more than the previous one, can be produced for the same amount of biomass, when the mixture of water and methanol serves as the solvents. This review article highlights an array of waste sludge categories, their chemical properties, and their conversion through the HTL process. It also features a Van Krevlen diagram with a graphical representation of essential operating parameters. This review research illustrates one of the best strategies for producing biofuel in which waste sludge can be used as raw material through the HTL conversion process, considering the prospective mass commercial production of biocrude oil.
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Affiliation(s)
- Farin Tasnuva Dhara
- Department of Civil Engineering, Khulna University of Engineering & Technology (KUET), Khulna, 9203, Bangladesh
| | - Md Atik Fayshal
- Department of Civil Engineering, Khulna University of Engineering & Technology (KUET), Khulna, 9203, Bangladesh.
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Ewang-Emukowhate M, Subramaniam K, Lam F, Hayes A, Mandair D, Toumpanakis C, Grossman A, Nair D, Caplin M. Plasma or serum 5-hydroxyindoleacetic acid can be used interchangeably in patients with neuroendocrine tumours. Scand J Clin Lab Invest 2023; 83:576-581. [PMID: 38112030 DOI: 10.1080/00365513.2023.2286645] [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: 08/07/2023] [Accepted: 11/05/2023] [Indexed: 12/20/2023]
Abstract
5-hydroxyindole acetic acid, a metabolite of serotonin, is used in the diagnosis and monitoring of patients with neuroendocrine tumours, in particular patients with small intestinal neuroendocrine tumours associated with the carcinoid syndrome. Analysis of 5-hydroxyindole acetic acid was commonly performed in urine, but blood-based assays are now becoming available. The objective of this study was to assess how 5-hydroxyindole acetic acid compares in plasma and serum as a biochemical marker of neuroendocrine tumours. Twenty-four-hour urine, plasma and serum samples were obtained from 80 patients with neuroendocrine tumours and 30 healthy volunteers. We developed a liquid chromatography tandem mass spectrometry assay for plasma and serum 5-hydroxyindole acetic acid. Comparison was made between them, and their cut-off was determined using a receiver-operating characteristic curve. A close correlation was shown between plasma and serum 5-hydroxyindole acetic acid. At a cut-off of 135 nmol/l, a sensitivity of 91.2% with a specificity of 61.9% was obtained for both compared to the urinary assay. A statistically significant agreement was shown when plasma and serum 5-hydroxyindole acetic acid were compared with the currently used urine assay in patients with neuroendocrine tumours; κ = 0.675 (95% CI 0.49 to 0.86), p < 0.001 and healthy volunteers; 0.967 (95% CI 0.828 to 0.999), p = <0.001. In conclusion, 5-hydroxyindole acetic acid in plasma and serum were comparable, hence either sample type can be used interchangeably.
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Affiliation(s)
- Mfon Ewang-Emukowhate
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, UK
- Department of Clinical Biochemistry, Royal Free Hospital, London, UK
| | | | | | - Aimee Hayes
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, UK
| | | | | | | | - Devaki Nair
- Department of Clinical Biochemistry, Royal Free Hospital, London, UK
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, UK
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Belei O, Basaca DG, Heredea ER, Iacob ER, Olariu L, Folescu R, Motoc AGM, Nanu AM, Mărginean O. Chronic Diarrhea Caused by Vasoactive Intestinal Peptide-Secreting Tumor. Life (Basel) 2023; 13:1974. [PMID: 37895355 PMCID: PMC10608053 DOI: 10.3390/life13101974] [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: 08/31/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
VIPomas are a type of neuroendocrine tumor that independently produces vasoactive intestinal peptide (VIP). VIPomas causing watery diarrhea, hypokalemia, and achlorhydria (WDHA) syndrome are not frequently observed in adult patients without pancreatic ailments. However, in children, the occurrence of a VIPoma originating in the pancreas is exceedingly uncommon. Instead, WDHA syndrome is more commonly associated with neurogenic tumors that secrete VIP, often located in the retroperitoneum or mediastinum. Among infants, chronic diarrhea is a prevalent issue that often necessitates the attention of pediatric gastroenterologists. The underlying causes are diverse, and delays in arriving at a definitive diagnosis can give rise to complications affecting the overall well-being of the child. The authors present the case of an infant with chronic watery diarrhea, subocclusion manifestations, mild hypokalemia, and metabolic hyperchloremic acidosis secondary to a VIPoma in the retroperitoneum that was diagnosed via abdominal ultrasound and tomography. The laboratory results revealed lowered potassium levels and an excessive secretion of VIP. Following the surgical removal of the tumor, the diarrhea resolved, and both electrolyte levels and the imbalanced hormone levels returned to normal. Immunohistochemical examination confirmed the diagnosis of ganglioneuroblastoma, with N-MYC negative on molecular biology tests. We present the clinical and histo-genetic aspects of this rare clinical entity, with a literature review.
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Affiliation(s)
- Oana Belei
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (O.M.)
- Third Pediatric Clinic, “Louis Țurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania; (L.O.); (A.-M.N.)
| | - Diana-Georgiana Basaca
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (O.M.)
- Third Pediatric Clinic, “Louis Țurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania; (L.O.); (A.-M.N.)
| | - Elena Rodica Heredea
- Department of Pathology, “Louis Ţurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania;
- Department of Clinical Practical Skills, “Victor Babeş” University of Medicine and Pharmacy, 300041 Timişoara, Romania
| | - Emil Radu Iacob
- Department of Pediatric Surgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Laura Olariu
- Third Pediatric Clinic, “Louis Țurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania; (L.O.); (A.-M.N.)
- First Pediatric Clinic, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Roxana Folescu
- Department of Balneology, Medical Recovery, and Rheumatology, Family Medicine Discipline, Center for Preventive Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Andrei Gheorghe Marius Motoc
- Department of Anatomy and Embryology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Anda-Maria Nanu
- Third Pediatric Clinic, “Louis Țurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania; (L.O.); (A.-M.N.)
| | - Otilia Mărginean
- First Pediatric Clinic, Disturbances of Growth and Development on Children Research Center, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (O.B.); (O.M.)
- Third Pediatric Clinic, “Louis Țurcanu” Emergency Hospital for Children, 300011 Timișoara, Romania; (L.O.); (A.-M.N.)
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Brown G, Monaghan AM, Fristedt R, Ramsey E, Al-Mrayat M, Rajak R, Armstrong T, Takhar A. Metastatic mixed VIPoma/PPoma-induced diarrhoea causing renal failure. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0231. [PMID: 36001009 PMCID: PMC9422256 DOI: 10.1530/edm-22-0231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022] Open
Abstract
Summary Vasoactive intestinal peptide-secreting tumours (VIPomas) are an extremely rare form of functional pancreatic neuroendocrine tumour with an estimated annual incidence of 1 in 10 million. Associated tumour hypersecretion of other peptides, including pancreatic polypeptide (PPomas), may also be seen. These malignancies classically present with a defined triad of refractory diarrhoea, hypokalaemia and metabolic acidosis known as Verner-Morrison syndrome. Diagnosis is frequently delayed, and the majority of patients will have metastatic disease at presentation. Symptoms are usually well controlled with somatostatin analogue administration. Here we report a case of metastatic mixed VIPoma/PPoma-induced diarrhoea causing renal failure so severe that ultrafiltration was required to recover adequate renal function. Learning points Profuse, watery diarrhoea is a common presenting complaint with a multitude of aetiologies. This, combined with the rarity of these tumours, makes diagnosis difficult and frequently delayed. A functional neuroendocrine tumour should be suspected when diarrhoea is unusually extreme, prolonged and common causes have been promptly excluded. These patients are likely to be profoundly unwell on presentation. They are extremely hypovolaemic with dangerous electrolyte and metabolic abnormalities. Aggressive initial rehydration and electrolyte replacement are imperative. A somatostatin analogue should be commenced as soon as the diagnosis is suspected. This is an extreme example of Verner-Morrison syndrome. We are unaware of another case where renal failure secondary to diarrhoea and dehydration was so severe that renal replacement therapy was required to restore adequate renal function, further emphasising how critically unwell these patients can be. Both the primary tumour and metastases showed a remarkably good and rapid response to somatostatin analogue administration. Cystic change and involution were noted on repeat imaging within days. Prior to his illness, this patient was extremely high functioning with no medical history. His diagnosis was an enormous psychological shock, and the consideration and care for his psychological well-being were a crucial part of his overall management. It highlights the importance of a holistic approach to cancer care and the role of the clinical nurse specialist within the cancer multidisciplinary team.
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Affiliation(s)
- George Brown
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
| | - Anthony Mark Monaghan
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
| | - Richard Fristedt
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
| | - Emma Ramsey
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
| | - Ma’en Al-Mrayat
- Department of Endocrinology, University Hospital Southampton, Southampton, UK
| | - Rushda Rajak
- Department of Cellular Pathology, University Hospital Southampton, Southampton, UK
| | - Thomas Armstrong
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
| | - Arjun Takhar
- Department of Hepatobiliary & Pancreatic Surgery, University Hospital Southampton, Southampton, UK
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Koumarianou A, Daskalakis K, Tsoli M, Kaltsas G, Pavel M. Efficacy, safety and unmet needs of evolving medical treatments for carcinoid syndrome. J Neuroendocrinol 2022; 34:e13174. [PMID: 35794780 DOI: 10.1111/jne.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/06/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
This review reports on the currently available medical treatment options for the control of symptoms due to carcinoid syndrome in patients with neuroendocrine tumors. The efficacy and adverse events (AEs) of approved drugs such as somatostatin analogues (SSA), telotristat ethyl (TE) and interferon-alpha, are reviewed. Somatostatin analogues remain the standard treatment of carcinoid syndrome based on the high expression of somatostatin receptors and the resulting inhibition of secretion of bioactive compounds; their use is associated with relatively mild AEs, involving mainly the gastrointestinal system, and being usually transient. Although dose escalation of SSA remains an unapproved option, it is clinically implemented to alleviate symptoms in refractory carcinoid syndrome and supported by the most recent guidelines. The side effects associated with the increased dose are in general mild and consistent with standard dose of SSA. Telotristat ethyl, an oral inhibitor of tryptophan hydroxylase, the rate-limiting enzyme in serotonin biosynthesis, represents a rather novel innovative treatment option in patients with carcinoid syndrome suffering from diarrhea and complements the standard therapy of SSA. Given the low toxicity profile, TE may be considered an early add-on treatment to SSA in patients with uncontrolled carcinoid syndrome. However, further prolonged follow-up of patients treated with TE may be needed to exclude potential AEs, such as liver toxicity or depressed mood, in patients with long-term treatment. Interferon alpha is a cytokine with direct inhibitory effect on hormone secretion and tumor cell proliferation and an approved therapy in carcinoid syndrome but is associated with significant AEs in the majority of the patients requiring frequently dose reduction. The finding of a more favorable tolerability of pegylated interferon needs to be confirmed in a prospective study.
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Affiliation(s)
- Anna Koumarianou
- Hematology-Oncology Unit, Fourth Department of Internal Medicine, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Kosmas Daskalakis
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- 2nd Department of Surgery, "Korgialenio-Benakio", Red Cross General Hospital, Athens, Greece
| | - Marina Tsoli
- 1st Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- 1st Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianne Pavel
- Department of Endocrinology, Universitatsklinikum Erlangen, Erlangen, Germany
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Diagnosis in Neuroendocrine Neoplasms: From Molecular Biology to Molecular Imaging. Cancers (Basel) 2022; 14:cancers14102514. [PMID: 35626118 PMCID: PMC9139608 DOI: 10.3390/cancers14102514] [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: 03/24/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Neuroendocrine neoplasms are a small group of malignancies with a diverse prognosis and behaviour. In order to offer an adequate treatment, physicians need to perform a proper diagnosis, staging and stratification. This review aims to help to integrate the information from pathology, immunohistochemistry, molecular biology and imaging to guide this process. Abstract Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumours with a diverse behaviour, biology and prognosis, whose incidence is gradually increasing. Their diagnosis is challenging and a multidisciplinary approach is often required. The combination of pathology, molecular biomarkers, and the use of novel imaging techniques leads to an accurate diagnosis and a better treatment approach. To determine the functionality of the tumour, somatostatin receptor expression, differentiation, and primary tumour origin are the main determining tumour-dependent factors to guide treatment, both in local and metastatic stages. Until recently, little was known about the biological behaviour of these tumours. However, in recent years, many advances have been achieved in the molecular characterization and diagnosis of NENs. The incorporation of novel radiotracer-based imaging techniques, such as 68Gallium-DOTATATE PET-CT, has significantly increased diagnostic sensitivity, while introducing the theragnosis concept, offering new treatment strategies. Here, we will review current knowledge and novelties in the diagnosis of NENs, including molecular biology, pathology, and new radiotracers.
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Gilliaux Q, Bertrand C, Hanon F, Donckier JE. Preoperative treatment of benign insulinoma: diazoxide or somatostatin analogues? Acta Chir Belg 2022; 122:136-139. [PMID: 32375590 DOI: 10.1080/00015458.2020.1765676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Surgery is the ideal treatment of insulinoma. However, systemic therapy may be required to prevent severe preoperative hypoglycaemia, when surgery is contraindicated, delayed or refused and in case of unresectable metastatic disease. Diazoxide is commonly used but is not always effective and can cause serious side effects. Somatostatin analogues (octreotide and lanreotide) may be an alternative option. We report the case of a 27-year-old patient with insulinoma in whom diazoxide was compared with lanreotide before operation. A diagnosis of insulinoma was made on the basis of a fasting test and a 2 cm tumour confirmed in the body of the pancreas, with a high uptake of 111-In-pentreotide. Diazoxide was initiated and increased to a maximal tolerated dose of 450 mg/day. Because of dyspnoea and persisting hypoglycaemia, diazoxide was shifted to lanreotide 120 mg. All symptoms resolved without hypoglycaemia. According to the EORTC quality score of life, the score without treatment, under diazoxide, under lanreotide and after surgery were respectively 84.7, 73.3, 90.9 and 99.1. Thus, providing a positive Octreoscan, somatostatin analogues may be a safe, effective and well-tolerated option in patients with insulinoma refractory and/or intolerant to diazoxide or with a high risk of fluid retention.
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Affiliation(s)
- Quentin Gilliaux
- Department of Endocrinology, CHU UCL Namur (Site Godinne), Université Catholique de Louvain, Yvoir, Belgium
| | - Claude Bertrand
- Department of Digestive, Endocrine and General Surgery, CHU UCL Namur – (Site Godinne), Université Catholique de Louvain, Yvoir, Belgium
| | - François Hanon
- Department of Endocrinology, CHU UCL Namur (Site Godinne), Université Catholique de Louvain, Yvoir, Belgium
| | - Julian E. Donckier
- Department of Endocrinology, CHU UCL Namur (Site Godinne), Université Catholique de Louvain, Yvoir, Belgium
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Perez K, Chan J. Medical management of gastrointestinal neuroendocrine tumors. Curr Opin Endocrinol Diabetes Obes 2022; 29:219-224. [PMID: 35045527 DOI: 10.1097/med.0000000000000711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarize the recent developments in the medical treatment of gastrointestinal neuroendocrine neoplasms. RECENT FINDINGS The medical management of gastrointestinal neuroendocrine tumors (GI-NETs) continues to evolve with advances in the management of symptoms related to hormone hypersecretion and therapeutic control of disease progression. Systemic therapy options include somatostatin analogs (SSAs), radiolabeled SSAs, molecularly targeted agents, and cytotoxic therapy. Recent progress has focused on new targeted therapies, the sequencing of therapy and the role of immunotherapy. SUMMARY This review will focus on treatment of GI-NETs and highlight new developments published over the last year.
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Affiliation(s)
- Kimberly Perez
- Harvard Medical School, Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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10
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Mejia A, Vivian E, Nwogu C, Shah J, Longoria R, Vo A, Shahin I, Verma J, Bageac A. Peptide receptor radionuclide therapy implementation and results in a predominantly gastrointestinal neuroendocrine tumor population: A two-year experience in a nonuniversity setting. Medicine (Baltimore) 2022; 101:e28970. [PMID: 35244064 PMCID: PMC8896579 DOI: 10.1097/md.0000000000028970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/10/2022] [Indexed: 01/04/2023] Open
Abstract
Neuroendocrine tumors (NETs) are rare, but the incidence and prevalence of NETs are increasing in the United States. While surgery is the preferred treatment for NETs, it is not a viable option for metastatic disease. Lutathera (177Lu-DOTATATE) is approved by the United States Food and Drug Administration and the European Medicines Agency for the treatment of gastroenteropancreatic (GEP)-NETs in adults. There is limited information on GEP-NET treatment responses to Lutathera.Our institution launched a peptide receptor radionuclide therapy (PRRT) service line using Lutathera with involvement from a multidisciplinary team and complete collaboration between hospital administration and clinical providers. A prospective registry study was also established in order to collect patient demographics and clinical data regarding the treatment of GEP primary NETs with Lutathera.Between August 2018 and July 2020, 35 GEP-NET patients were treated with Lutathera, of which 65.71% received 4 complete cycles and 25.71% received 3 cycles; 5.71% and 2.86% received 2 and 1 cycles of PRRT, respectively. Most adverse events during the course of our study were low grade using the common terminology criteria for adverse events system. Of the patients who completed all 4 cycles: 22% showed partial response to Lutathera, 44% showed stable disease, and 13% showed disease progression based on a qualitative assessment of positron emission tomography/computed tomography imaging.From our experience, Lutathera was well tolerated in patients with GEP-NET. Additional studies are needed to examine long-term clinical and patient-reported outcomes associated with GEP-NET treatment as well as financial considerations for hospitals embarking on a PRRT program.
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Affiliation(s)
- Alejandro Mejia
- The Liver Institute, Methodist Dallas Medical Center, Dallas, TX
| | - Elaina Vivian
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX
| | - Christiana Nwogu
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX
| | - Jimmy Shah
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX
| | - Raquel Longoria
- Cancer Program Administration, Methodist Dallas Medical Center, Dallas, TX
| | - Allison Vo
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX
- Cancer Program Administration, Methodist Dallas Medical Center, Dallas, TX
| | - Islam Shahin
- Radiology Associates of North Texas, Fort Worth, TX
| | - Jonathan Verma
- Texas Oncology – Methodist Dallas Medical Center, Dallas, TX
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Fijalkowski R, Reher D, Rinke A, Gress TM, Schrader J, Baum RP, Kaemmerer D, Hörsch D. Clinical Features and Prognosis of Patients with Carcinoid Syndrome and Carcinoid Heart Disease: A Retrospective Multicentric Study of 276 Patients. Neuroendocrinology 2022; 112:547-554. [PMID: 34348326 DOI: 10.1159/000518651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Carcinoid syndrome is the most frequent functional syndrome of neuroendocrine neoplasia. It is characterized by flushing, diarrhea, wheezing, hypotension, and exanthema and may cause carcinoid heart disease. METHODS We assessed clinical characteristics and prognosis of patients with carcinoid syndrome and carcinoid heart disease in 276 patients from 3 referral centers. RESULTS Carcinoid syndrome patients had a mean age of 57 years (range 21-84) and a normal BMI of 24.9 (SD 4.5; range 13.8-39.6). Most primaries were of small bowel or unknown primaries with distant metastasis in 94.6%. Flushing was the most frequent symptom in 74.3% of patients, followed by diarrhea in 68.8%, and wheezing in 40.9%. Pain was described by 45.3%, weakness by 23.5%, and weight loss of >10% in 6 months by 30.1% of patients. Carcinoid heart disease was diagnosed in 37.3% of patients (n = 104) by echocardiography and involved predominantly in the tricuspid valve. Combinations with other valve defects were common. Somatostatin analogs were taken by 80.4% of patients and 17% needed additional loperamide/opium tincture. Surgery and peptide receptor radiotherapy were most frequent treatments. The median survival of patients with carcinoid syndrome after diagnosis was 9 years. Prognosis was significantly impaired by male sex and diagnosis of carcinoid heart disease but surprisingly significantly increased by the presence of symptoms flushing and weakness. DISCUSSION/CONCLUSION Carcinoid syndrome is associated with extensive disease and primaries in small bowels or of unknown primary. Weight loss, weakness, and pain are frequent, and carcinoid heart disease is diagnosed in more than one-third of patients.
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Affiliation(s)
- Robert Fijalkowski
- ENETS Center of Excellence Bad Berka, Internal Medicine/Gastroenterology and Endocrinology, Bad Berka, Germany
| | - Dominik Reher
- I. Department of Medicine, ENETS Center of Excellence, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Rinke
- ENETS Center of Excellence, Internal Medicine, Philipps-University Marburg, Marburg, Germany
| | - Thomas M Gress
- ENETS Center of Excellence, Internal Medicine, Philipps-University Marburg, Marburg, Germany
| | - Jörg Schrader
- I. Department of Medicine, ENETS Center of Excellence, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard P Baum
- ENETS Center of Excellence Bad Berka, Molecular Radiotherapy, Bad Berka, Germany
- CURANOSTICUM Wiesbaden-Frankfurt, DKD Helios Clinic, Wiesbaden, Germany
| | - Daniel Kaemmerer
- ENETS Center of Excellence Bad Berka, General and Visceral Surgery, Bad Berka, Germany
| | - Dieter Hörsch
- ENETS Center of Excellence Bad Berka, Internal Medicine/Gastroenterology and Endocrinology, Bad Berka, Germany
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Simonsen JK, Rejnmark L. Endocrine Disorders with Parathyroid Hormone-Independent Hypercalcemia. Endocrinol Metab Clin North Am 2021; 50:711-720. [PMID: 34774242 DOI: 10.1016/j.ecl.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The most common causes of hypercalcemia are primary hyperparathyroidism and malignancy, constituting 80% to 90% of all cases. Although less common, several nonparathyroid endocrine disorders are associated with hypercalcemia. The most well described is hyperthyroidism, although the reported prevalence of hypercalcemia in hyperthyroid patients varies depending on applied method for measuring serum calcium levels. Also, adrenal insufficiency, pheochromocytoma, and vasoactive intestinal polypeptide are associated with hypercalcemia. These are differential diagnoses when assessing the hypercalcemic patient for whom common causes have been excluded. Further investigation is needed regarding hypothyroidism; acromegaly, hyperprolactinemia, gonadal dysfunction, and diabetes are not associated with hyperthyroidism.
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Affiliation(s)
- Jo Krogsgaard Simonsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Aarhus N 8200, Denmark.
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Aarhus N 8200, Denmark
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Sánchez-Salazar SM, Torres-Alzate S, Muñoz-Cortés VM, Builes-Barrera CA, Gutiérrez-Montoya JI, Román-González A. VIPoma: a rare cause of diarrhea. A case report. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v69n3.81603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction: Vasoactive intestinal peptide-secreting tumor (VIPoma) is a rare functional pancreatic neuroendocrine tumor (F-PNET) characterized by secretory diarrhea, hypokalemia, and hypochlorhydria. Its low incidence and high risk of malignancy pose a clinical challenge that requires a high degree of clinical suspicion.
Case presentation: A 61-year-old woman visited the emergency department of a tertiary care hospital in Medellín, Colombia, due to chronic diarrhea (7 months) that led to dehydration, renal failure, metabolic acidosis, and hypokalemia. As a result, a treatment based on loperamide, intravenous fluids and broad-spectrum antibiotics was started. In addition, chromogranin A levels of 477 ug/L (<100) were reported, while an abdominal MRI showed a 33x30mm mass in the head and uncinate process of the pancreas, so outpatient surgical management was decided. However, three days after discharge, and due to the persistence of clinical signs, the patient was admitted to another hospital (also a tertiary care hospital), where, given the high suspicion of VIPoma, and once the diarrhea was solved, the mass was removed (Whipple procedure) without any complication. Finally, the diagnosis was confirmed based on serum vasoactive intestinal peptide levels (930 pg/mL (RV<75)) and the pathology report (PNET tumor grade 2). Two years after the surgery, the patient was asymptomatic, and no residual lesions or metastases were evident in a control MRI.
Conclusion: Late diagnosis of VIPoma is associated with worsened quality of life, severe complications, and high prevalence of metastasis. Therefore, it should be suspected in patients with chronic secretory diarrhea that is not caused by an infection, since early diagnosis and timely treatment can contribute to achieving better survival rates in these patients.
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14
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Cella D, Evans J, Feuilly M, Neggers S, Van Genechten D, Herman J, Khan MS. Patient and Healthcare Provider Perspectives of First-Generation Somatostatin Analogs in the Management of Neuroendocrine Tumors and Acromegaly: A Systematic Literature Review. Adv Ther 2021; 38:969-993. [PMID: 33432541 PMCID: PMC7799425 DOI: 10.1007/s12325-020-01600-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
Introduction Somatostatin analogs (SSAs) are used to treat neuroendocrine tumors (NETs) and acromegaly. Two first-generation SSAs, octreotide long-acting release (OCT LAR) and lanreotide autogel/depot (LAN), are available. A systematic literature review (SLR) was conducted to investigate which characteristics beyond efficacy are most important in patient and healthcare practitioner (HCP) experience of LAN and OCT when used to treat acromegaly and NETs. Methods MEDLINE, Embase, the Cochrane Library, and Database of Abstracts of Reviews of Effect were searched from database inception to January 2019 with terms for first-generation SSAs, NETs, acromegaly, preferences, decision-making, and human factors. Key congresses in 2016–2018 and SLR bibliographies were hand-searched. Two independent reviewers screened articles at title/abstract and full-text stage. Publications fulfilling pre-specified inclusion criteria reported patient or HCP perspectives of LAN or OCT, or any factors affecting treatment perspectives for NETs or acromegaly. Results A total of 1110 unique records were screened, of which 21 studies were included, reporting from the perspectives of patients (n = 18) and/or HCPs (n = 9). Perspectives were collected using shared decision-making frameworks, questionnaires, informal patient opinion, and a Delphi panel. Where patient preference was specifically reported, LAN was preferred in 4/5 studies and OCT LAR in 1/5. Common factors underlying treatment experience included technical problems with injections and associated pain, emotional quality/anxiety of injections, time and convenience of treatment administration, and independence. Immediate aspects of injections appeared most important to patients, though the possibilities of extended dosing intervals and self-/partner-injection with LAN were also notable factors. Conclusions Study outcomes favored LAN in this SLR, with factors surrounding injection administration most influential in treatment experience. The findings of this SLR provide a basis that could inform development of decision-making criteria, with patient and HCP treatment perspectives considered. Future studies should utilize a common method to report preference and associated drivers. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-020-01600-x.
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Affiliation(s)
- David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | | | - Sebastian Neggers
- Department of Medicine, Section Endocrinology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dirk Van Genechten
- Belgian Neuroendocrine Tumour (NET) and Multiple Endocrine Neoplasia (MEN) Association, Blankenberge, Belgium
- International Neuroendocrine Cancer Alliance (INCA), Boston, MA, USA
| | - Jackie Herman
- Canadian Neuroendocrine Tumour Society, Cornwall, ON, Canada
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15
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Ito T, Jensen RT. Perspectives on the current pharmacotherapeutic strategies for management of functional neuroendocrine tumor syndromes. Expert Opin Pharmacother 2020; 22:685-693. [PMID: 33131345 DOI: 10.1080/14656566.2020.1845651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: In the past, controlling the hormone-excess-state was the main determinant of survival in Functional-Neuroendocrine-Neoplasm-syndromes (F-NENs). This was difficult because the pharmacological-armamentarium available was limited. Recently, new therapeutic strategies have increased but it also generated controversies/uncertainties.Areas covered: The authors briefly review: established/proposed F-NENs; the rationale for treatments; the recommended initial-pharmacotherapeutic-approach to controlling F-NENs hormone-excess-state; the secondary-approaches if the initial approach fails or resistance develops; and the approach to deal with the malignant nature of the NEN. Also discussed are controversies/uncertainties related to new treatments.Expert opinion: Unfortunately, except for patients with insulinomas (>90-95%), gastrinomas (<20-40%), a minority with the other F-panNENs and 0-<1% with Carcinoid-syndrome is curative-surgery possible. Except for insulinomas, gastrinomas, and ACTHomas, long-acting somatostatin-analogs are the initial-pharmacological-treatments for hormone-excess-state. For insulinomas prior to surgery/malignancy, diazoxide is the initial drug-treatment; for gastrinomas, oral PPIs; and for ACTHomas, steroidogenesis inhibitors. There are now several secondary pharmacotherapeutic treatments. Surgery and liver-directed therapies also have a role in selected patients. Particularly promising is the recent results with PRRT for the hormone-excess-state, independent of its anti-growth effect. The sequence to use various agents and the approach to syndrome diagnosis while taking various agents remains unclear/controversial in many cases.
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Affiliation(s)
- Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, International University of Health and Welfare, Fukuoka, Japan
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16
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Sandru F, Carsote M, Albu SE, Valea A, Petca A, Dumitrascu MC. Glucagonoma: From skin lesions to the neuroendocrine component (Review). Exp Ther Med 2020; 20:3389-3393. [PMID: 32905095 PMCID: PMC7465236 DOI: 10.3892/etm.2020.8966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023] Open
Abstract
Glucagonoma is a hormonally active rare pancreatic neuroendocrine tumour causing an excess of glucagon. This is a narrative review based on a multidisciplinary approach of the tumour. Typically associated dermatosis is necrolytic migratory erythema (NME) which is most frequently seen at disease onset. Insulin-dependent diabetes mellitus, depression, diarrhoea, deep vein thrombosis are also identified, as parts of so-called 'D' syndrome. Early diagnosis is life saving due to potential aggressive profile and high risk of liver metastasis. NME as paraneoplastic syndrome may be present for months and even years until adequate recognition and therapy; it is remitted after successful pancreatic surgery. Thus the level of practitioners' awareness is essential. If surgery is not curative, debulking techniques may improve the clinical aspects and even the outcome in association with other procedures such as embolization of hepatic metastasis; ablation of radiofrequency type; medical therapy including chemotherapy, targeted therapy with mTOR inhibitors such as everolimus, PRRT (peptide receptor radiotherapy), and somatostatin analogues (including combinations of medical treatments). Increased awareness of the condition involves multidisciplinary practitioners.
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Affiliation(s)
- Florica Sandru
- Department of Dermatology, ‘Elias’ Emergency University Hospital, 125100 Bucharest, Romania
- Department of Dermatology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology,‘C.I. Parhon’ National Institute of Endocrinology, 011863 Bucharest, Romania
- Department of Endocrinology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Simona Elena Albu
- Department of Gynecology, Emergency University Hospital, 050098 Bucharest, Romania
- Department of Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ana Valea
- Department of Endocrinology, Clinical County Hospital, 400000 Cluj-Napoca, Romania
- Department of Endocrinology, ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Aida Petca
- Department of Dermatology, ‘Elias’ Emergency University Hospital, 125100 Bucharest, Romania
| | - Mihai Cristian Dumitrascu
- Department of Gynecology, Emergency University Hospital, 050098 Bucharest, Romania
- Department of Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
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17
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Eads JR, Reidy-Lagunes D, Soares HP, Chan JA, Anthony LB, Halfdanarson TR, Naraev BG, Wolin EM, Halperin DM, Li D, Pommier RF, Zacks JS, Morse MA, Metz DC. Differential Diagnosis of Diarrhea in Patients With Neuroendocrine Tumors. Pancreas 2020; 49:1123-1130. [PMID: 32991344 DOI: 10.1097/mpa.0000000000001658] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with neuroendocrine tumors (NETs) and carcinoid syndrome experience diarrhea that can have a debilitating effect on quality of life. Diarrhea also may develop in response to other hormonal syndromes associated with NETs, surgical complications, medical comorbidities, medications, or food sensitivities. Limited guidance on the practical approach to the differential diagnosis of diarrhea in these patients can lead to delays in appropriate treatment. This clinical review and commentary underscore the complexity in identifying the etiology of diarrhea in patients with NETs. Based on our collective experience and expertise, we offer a practical algorithm to guide medical oncologists and other care providers to expedite effective management of diarrhea and related symptoms in patients with NETs.
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Affiliation(s)
- Jennifer R Eads
- From the Department of Medicine, Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Diane Reidy-Lagunes
- Department of Medicine, Division of Solid Tumor, Gastrointestinal Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Heloisa P Soares
- Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jennifer A Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Lowell B Anthony
- Division of Medical Oncology, University of Kentucky Medical Center, Markey Cancer Center, Lexington, KY
| | | | - Boris G Naraev
- Division of Cancer Medicine, Banner MD Anderson Cancer Center, The University of Texas MD Anderson Cancer Center, Gilbert, AZ
| | - Edward M Wolin
- Department of Medicine, Division of Hematology/Oncology, Icahn School of Medicine, Center for Carcinoid and Neuroendocrine Tumors, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY
| | - Daniel M Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daneng Li
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center and Beckman Research Institute, Duarte, CA
| | - Rodney F Pommier
- Division of Surgical Oncology, Oregon Health & Science University, Portland, OR
| | - Jerome S Zacks
- Department of Medicine (Cardiology), The Mount Sinai School of Medicine, The Carcinoid Heart Center, New York, NY
| | - Michael A Morse
- Department of Medical Oncology, Duke University Medical Center, Durham, NC
| | - David C Metz
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tsoli M, Alexandraki K, Xanthopoulos C, Kassi E, Kaltsas G. Medical Treatment of Gastrointestinal Neuroendocrine Neoplasms. Horm Metab Res 2020; 52:614-620. [PMID: 32108932 DOI: 10.1055/a-1110-7251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Neuroendocrine neoplasms (NENs) are rare tumours that arise mainly in the gastrointestinal or pulmonary system. Most NENs are well-differentiated and may obtain prolonged survival besides the presence of metastatic disease; however, a subset (poorly differentiated NENs) may display a truly aggressive behaviour exhibiting a poor prognosis. The recently developed classification systems along with advances in functional imaging have helped stratify patients to the administration of appropriate therapeutic options. Surgery is the mainstay of treatment of NENs, but in recent decades there has been a considerable evolution of medical treatments that are used for locally advanced or metastatic disease not amenable to surgical resection. Long acting somatostatin analogues are the main therapeutic modality for patients with functioning and well-differentiated low grade NENs exhibiting symptomatic control and mainly stabilisation of tumour growth. Other systemic treatments include chemotherapy, molecular targeted agents, interferon-α, peptide receptor radionuclide therapy (PRRT), and immunotherapy. In addition, new agents such as telotristat may be used for the control of symptoms of carcinoid syndrome. The choice and/or sequence of therapeutic agents should be individualized according to tumour origin and differentiation, disease burden, presence of clinical symptoms and patients' performance status in the context of a multidisciplinary approach. Recent advances in the molecular pathogenesis of NENs set the field for a more personalised treatment approach.
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Affiliation(s)
- Marina Tsoli
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia Alexandraki
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Xanthopoulos
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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19
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Alvarez M, Almanzar A, Sanabria F, Meneses G, Velasquez L, Zarate L. MANIFESTATIONS OF GLUCAGONOMA SYNDROME. AACE Clin Case Rep 2020; 6:e46-e49. [PMID: 32524009 DOI: 10.4158/accr-2019-0211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 10/21/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Glucagonoma is a rare neuroendocrine tumor of the pancreas. We present the case of a young female patient who presented with the major clinical manifestations of glucagonoma syndrome. Methods The major clinical manifestations of glucagonoma syndrome are described in a 44-year-old, female patient. Beyond glucagonoma, the patient also displayed deep venous thrombosis, depression, diabetes, and necrolytic migratory erythema. We discuss the difficulty of treatment of patients with glucagonoma due to the low prevalence of the disorder, scarcity of medical evidence, lateness of diagnosis with liver metastases in most cases, and poor response to chemotherapy with high rates of relapse after surgery. In this case, pancreatectomy and hepatic lobectomy followed by somatostatin analogue therapy was the chosen treatment strategy. Results The clinical findings were pancreatic and hepatic masses, proximal deep venous thrombosis, depression, diabetes, and necrolytic migratory erythema. The patient also had elevated levels of glucagon. Pancreatectomy and right hepatic lobectomy were performed and confirmed the glucagonoma. Conclusion Our case adds new knowledge about glucagonoma which is important due to the low incidence of the disease and the particular characteristics of the syndrome.
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20
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Fust K, Maschio M, Kohli M, Singh S, Pritchard DM, Marteau F, Myrenfors P, Feuilly M. A Budget Impact Model of the Addition of Telotristat Ethyl Treatment to the Standard of Care in Patients with Uncontrolled Carcinoid Syndrome. PHARMACOECONOMICS 2020; 38:607-618. [PMID: 32157590 DOI: 10.1007/s40273-020-00896-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Carcinoid syndrome, a rare condition in patients with neuroendocrine tumours, characterised by flushing and diarrhoea, severely affects patients' quality of life. The current carcinoid syndrome standard of care includes somatostatin analogues, but some patients experience uncontrolled symptoms despite somatostatin analogue therapy. Telotristat ethyl is a novel treatment approved by the European Medicines Agency (EMA) and US FDA that significantly reduces bowel movement frequency in patients with uncontrolled carcinoid syndrome. OBJECTIVE We developed a model to evaluate the 5-year budget impact of introducing telotristat ethyl to standard care in Swedish patients with uncontrolled carcinoid syndrome. METHODS Treatment response in the 12-week phase III TELESTAR trial (NCT01677910) informed telotristat ethyl efficacy; subsequently, health states were captured by a Markov model using 4-week cycles. TELESTAR open-label extension data informed telotristat ethyl discontinuation. The number of treatment-eligible patients was estimated from literature reviews reporting the prevalence, incidence and mortality of carcinoid syndrome. A Swedish database study informed real-world costs related to carcinoid syndrome and carcinoid heart disease costs. Telotristat ethyl market share was assumed to increase annually from 24% (year 1) to 70% (year 5). RESULTS Over the 5-year model horizon, 44 patients were expected to initiate telotristat ethyl treatment. The cumulative net budget impact of adding telotristat ethyl to current standard of care was €172,346; per-year costs decreased from €66,495 (year 1) to €29,818 (year 5). Increased drug costs from adding telotristat ethyl were offset by reduced costs elsewhere. CONCLUSIONS The expected budget impact of adding telotristat ethyl to the standard of care in Sweden was relatively low, largely because of the rarity of carcinoid syndrome.
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Affiliation(s)
- Kelly Fust
- Optum, 1325 Boylston Street, Boston, MA, 02215, USA
| | - Michael Maschio
- Formerly affiliated with Optum, 5500 North Service Road, Suite 501, Burlington, ON, L7L 6W6, Canada
| | - Michele Kohli
- Formerly affiliated with Optum, 5500 North Service Road, Suite 501, Burlington, ON, L7L 6W6, Canada
| | - Simron Singh
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - D Mark Pritchard
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L69 3BX, UK
| | - Florence Marteau
- Ipsen Pharma, 65 Quai Georges Gorse, 92100, Boulogne-Billancourt, France
| | | | - Marion Feuilly
- Ipsen Pharma, 65 Quai Georges Gorse, 92100, Boulogne-Billancourt, France.
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Ishida H, Lam AKY. Pancreatic neuroendocrine neoplasms: The latest surgical and medical treatment strategies based on the current World Health Organization classification. Crit Rev Oncol Hematol 2020; 145:102835. [DOI: 10.1016/j.critrevonc.2019.102835] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022] Open
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Shen C, He J, Le X, Zheng L, Cao D. Application of Somatostatin, Chemotherapy Combined with TAE in Heterogeneous Glucagonoma Presented with Necrolytic Migratory Erythema. Onco Targets Ther 2019; 12:11339-11344. [PMID: 31920326 PMCID: PMC6929939 DOI: 10.2147/ott.s237634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/07/2019] [Indexed: 02/05/2023] Open
Abstract
Glucagonoma, a rare neuroendocrine tumor of the pancreas, which is often misdiagnosed because of non-characteristic clinical manifestations. In addition, the treatment has not been well established for this disease so far. We here report a case of glucagonoma previous misdiagnosed as recurrent erythema. In this case, necrolytic migratory erythema was the main clinical manifestation, and he received surgical resection after admission although with liver metastasis. Postoperative pathological results showed that the heterogeneity of proliferative index in primary (Ki-67: 5~10%) and metastatic (Ki-67: 25~30%) tumors were obviously observed. One month postoperatively, abdominal CT and MRI showed multiple liver metastasis (type III) again. Interestingly, the skin rash was obviously improved after treatment with somatostatin combined with chemotherapy (octreotide, temozolomide and capecitabine). Subsequently, the patient received transarterial embolization (TAE). Up to now, no progression was noted for liver metastasis. Due to its rarity, clinical diagnosis is challenging; thus, further understanding of the disease by clinicians is helpful for early diagnosis and treatment, so as to improve the prognosis of patients.
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Affiliation(s)
- Chaoyong Shen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
| | - Jiaoxue He
- Department of Oncology, Wenjiang District People's Hospital, Chengdu, Sichuan, People's Republic of China
| | - Xiaoyan Le
- Department of Oncology, Wenjiang District People's Hospital, Chengdu, Sichuan, People's Republic of China
| | - Linmao Zheng
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
| | - Dan Cao
- Department of Abdominal Oncology, Cancer Center of West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
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Abstract
Neuroendocrine tumors (NETs) represent a group of biologically and clinically heterogeneous neoplasms arising from the diffuse neuroendocrine system. Although NETs may develop in almost any organ, they commonly arise in the gastrointestinal tract and pancreas and are referred to as gastroenteropancreatic (GEP)-NETs when they arise from these sites. In recent years, advances in understanding of the biology of NETs have resulted in an expansion in treatment options and improved survival for patients. This review focuses on treatment of GEP-NETS and highlights factors that govern the therapeutic approach.
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Affiliation(s)
- Kimberly Perez
- Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA.
| | - Jennifer Chan
- Program in Carcinoid and Neuroendocrine Tumors, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
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Naraev BG, Halland M, Halperin DM, Purvis AJ, O'Dorisio TM, Halfdanarson TR. Management of Diarrhea in Patients With Carcinoid Syndrome. Pancreas 2019; 48:961-972. [PMID: 31425482 PMCID: PMC6867674 DOI: 10.1097/mpa.0000000000001384] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/10/2019] [Indexed: 02/06/2023]
Abstract
Neuroendocrine tumors (NETs) arise from enterochromaffin cells found in neuroendocrine tissues, with most occurring in the gastrointestinal tract. The global incidence of NETs has increased in the past 15 years, likely due to better diagnostic methods. Small-bowel NETs are frequently associated with carcinoid syndrome (CS). Carcinoid syndrome diarrhea occurs in 80% of CS patients and poses a substantial symptomatic and economic burden. Patients with CS diarrhea frequently suffer from diarrhea and flushing and report corresponding impairment in quality of life, requiring substantial changes in daily activities and lifestyle. Treatment paradigms range from surgical debulking to liver-directed therapies to treatment with somatostatin analogs, nonspecific anti-diarrheal agents, and a tryptophan hydroxylase inhibitor. Other causes of diarrhea, including steatorrhea, short bowel syndrome, and bile acid malabsorption, should be considered in NET patients with refractory diarrhea. More therapeutic options are needed for symptomatic management of patients with NETs, and better understanding of the pathophysiology can empower clinicians with improved patient care.
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Affiliation(s)
| | - Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Daniel M. Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amy J. Purvis
- University of Arizona Cancer Center (UACC), Phoenix, AZ
| | - Thomas M. O'Dorisio
- Neuroendocrine Cancer Program, University of Iowa Health Care, Iowa City, IA
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Anthony LB, Kulke MH, Caplin ME, Bergsland E, Öberg K, Pavel M, Hörsch D, Warner RRP, O'Dorisio TM, Dillon JS, Lapuerta P, Kassler-Taub K, Jiang W. Long-Term Safety Experience with Telotristat Ethyl Across Five Clinical Studies in Patients with Carcinoid Syndrome. Oncologist 2019; 24:e662-e670. [PMID: 30651397 PMCID: PMC6693702 DOI: 10.1634/theoncologist.2018-0236] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 11/20/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients with neuroendocrine tumors (NETs) and carcinoid syndrome experience considerable morbidity and mortality; carcinoid syndrome may be associated with shorter survival. Carcinoid syndrome is linked to tumoral secretion of serotonin and other bioactive substances. The subsequent debilitating diarrhea and urgency to defecate pose significant health risks. In previous studies, telotristat ethyl, a tryptophan hydroxylase inhibitor, was effective and well tolerated in treating carcinoid syndrome diarrhea. We present pooled safety data from five clinical trials with telotristat ethyl in patients with carcinoid syndrome. SUBJECTS, MATERIALS, AND METHODS Adverse events reported during telotristat ethyl treatment were pooled from two phase II and three phase III clinical trials in 239 patients with carcinoid syndrome. Long-term safety of telotristat ethyl and causes of hospitalization and death were reviewed; overall survival was estimated. RESULTS Mean (median; range) duration of exposure and follow-up was 1.3 years (1.1 years; 1 week to 5.7 years), with 309 total patient-years of exposure. Leading causes of hospitalization were gastrointestinal disorders or were related to the underlying tumor and related treatment. Survival estimates at 1, 2, and 3 years were 93%, 88%, and 77%. Nearly all deaths were due to progression or complication of the underlying disease; none were attributable to telotristat ethyl. There was one death in year 4. CONCLUSION Based on long-term safety data, telotristat ethyl is well tolerated and has a favorable long-term safety profile in patients with carcinoid syndrome. IMPLICATIONS FOR PRACTICE Carcinoid syndrome can cause persistent diarrhea, even in patients treated with somatostatin analogs. Across five clinical trials in patients with carcinoid syndrome, telotristat ethyl has been well tolerated and efficacious, providing clinicians with a new approach to help control carcinoid syndrome diarrhea, in addition to somatostatin analog therapy. By reducing the stool frequency in patients with carcinoid syndrome whose diarrhea is refractory to anticholinergics, such as loperamide and atropine/diphenoxylate, and somatostatin analog dose escalation, improvement in quality of life becomes an achievable goal.
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Affiliation(s)
- Lowell B Anthony
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Matthew H Kulke
- Boston University Medical Center, Boston, Massachusetts, USA
| | - Martyn E Caplin
- Neuroendocrine Tumor Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
| | - Emily Bergsland
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kjell Öberg
- Department of Endocrine Oncology, Uppsala University, Uppsala, Sweden
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin, Berlin, Germany
| | - Dieter Hörsch
- Department of Gastroenterology/Endocrinology, Center for Neuroendocrine Tumors, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Richard R P Warner
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Thomas M O'Dorisio
- Department of Internal Medicine - Endocrinology and Metabolism, University of Iowa, Iowa City, Iowa, USA
| | - Joseph S Dillon
- Department of Internal Medicine - Endocrinology and Metabolism, University of Iowa, Iowa City, Iowa, USA
| | - Pablo Lapuerta
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
| | | | - Wenjun Jiang
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
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Abstract
OPINION STATEMENT Carcinoid syndrome (CS) is a complex disorder caused by functional neuroendocrine tumors (NETs). This debilitating disease is characterized by hyper-secretion of biologically active substances eliciting major hormonal symptoms burden and fibrotic changes that are often challenging for management. There have been a number of insights that have substantially advanced treatments since the introduction of somatostatin analogs (SSAs). Second-line treatments are needed in a substantial proportion of patients with advanced disease that have uncontrolled hormone secretion on the highest labeled doses of SSAs. International guidelines suggest several available options including dose escalation of SSAs, interferon alpha, everolimus, radionuclide therapy, liver-directed therapies, and the novel tryptophan hydroxylase 1 inhibitor, telotristat ethyl. The clear preference of one second-line therapy over the other is not stated since their relative and long-term efficacy are largely unknown, and standardized approach of hormonal response assessment is lacking in the literature. In the clinical setting, the treatment of CS is guided in conjunction with patients' performance status, tumor origin, grade, stage, and growth rate, with regard to both anti-hormonal, as well as anti-proliferative effect. There is an unmet need for further well-designed randomized placebo-controlled and head-to-head studies that systematically assess CS symptom control and biochemical response following a specific intervention.
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Mitchell E, Ciccone M, Zhang B, Tsai A, Brunette LL. Paraneoplastic Cushing's syndrome and hypercalcemia arising from metastatic endometrioid endometrial adenocarcinoma: A case report. Gynecol Oncol Rep 2019; 29:58-60. [PMID: 31334321 PMCID: PMC6620411 DOI: 10.1016/j.gore.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/12/2019] [Indexed: 01/22/2023] Open
Abstract
Paraneoplastic Cushing's syndrome is rarely seen in gynecologic cancers, appearing only in case reports It almost universally results in acute decompensation and portends a poor prognosis We describe a patient with metastatic endometrial carcinoma with both paraneoplastic Cushing's syndrome and hypercalcemia High clinical suspicion for malignancy is essential, as these syndromes improve with treatment of the underlying malignancy
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Affiliation(s)
- Evelyn Mitchell
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, USA
| | - Marcia Ciccone
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, USA
| | - Bing Zhang
- Department of Medicine, Keck School of Medicine, University of Southern California, USA
| | - Arnold Tsai
- Department of Medicine, Keck School of Medicine, University of Southern California, USA
| | - Laurie L Brunette
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, USA
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28
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Clement DSVM, Tesselaar MET, van Leerdam ME, Srirajaskanthan R, Ramage JK. Nutritional and vitamin status in patients with neuroendocrine neoplasms. World J Gastroenterol 2019; 25:1171-1184. [PMID: 30886501 PMCID: PMC6421241 DOI: 10.3748/wjg.v25.i10.1171] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023] Open
Abstract
Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.
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Affiliation(s)
- Dominique SVM Clement
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
| | - Margot ET Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute ENETS Centre of Excellence, Amsterdam 1066 CX, Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Rajaventhan Srirajaskanthan
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
- Department of Gastroenterology, King’s College Hospital, London SE5 9RS, United Kingdom
| | - John K Ramage
- Neuroendocrine Tumour Unit, King’s College Hospital ENETS Centre of Excellence, London SE5 9RS, United Kingdom
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29
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Tsoli M, Chatzellis E, Koumarianou A, Kolomodi D, Kaltsas G. Current best practice in the management of neuroendocrine tumors. Ther Adv Endocrinol Metab 2019; 10:2042018818804698. [PMID: 30800264 PMCID: PMC6378464 DOI: 10.1177/2042018818804698] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/05/2018] [Indexed: 12/13/2022] Open
Abstract
Neuroendocrine neoplasms are rare tumors that display marked heterogeneity with varying natural history, biological behavior, response to therapy and prognosis. Their management is complex, particularly as a number of them may be associated with a secretory syndrome and involve a variety of options. A number of factors such as proliferation rate, degree of differentiation, functionality and extent of the disease are mostly utilized to tailor treatment accordingly, ideally in the context of a multidisciplinary team. In addition, a number of relevant scientific societies have published therapeutic guidelines in an attempt to direct and promote evidence-based treatment. Surgery remains the treatment of choice with an intention to cure while it may also be recommended in some cases of metastatic disease and difficult to control secretory syndromes. Long-acting somatostatin analogs constitute the main treatment for the majority of functioning tumors, whereas specific evolving agents such as telotristat may be used for the control of carcinoid syndrome and related sequelae. In patients with advanced disease not amenable to surgical resection, treatment options include locoregional therapies, long-acting somatostatin analogs, molecular targeted agents, radionuclides, chemotherapy and recently immunotherapy, alone or in combination. However, the ideal time of treatment initiation, sequence of administration of different therapies and identification of robust prognostic markers to select the most appropriate treatment for each individual patient still need to be defined.
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Affiliation(s)
| | - Eleftherios Chatzellis
- First Department of Propaedeutic Internal
Medicine, Laiko General Hospital, National and Kapodistrian University of
Athens, Athens, Greece
| | - Anna Koumarianou
- Fourth Department of Internal Medicine, Attikon
University General Hospital, Athens, Greece
| | - Dionysia Kolomodi
- First Department of Propaedeutic Internal
Medicine, Laiko General Hospital, National and Kapodistrian University of
Athens, Athens, Greece
| | - Gregory Kaltsas
- First Department of Propaedeutic Internal
Medicine, Laiko General Hospital, National and Kapodistrian University of
Athens, Athens, Greece
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Lesén E, Björstad Å, Björholt I, Marlow T, Bollano E, Feuilly M, Marteau F, Welin S, Elf AK, Johanson V. Real-world treatment patterns, resource use and costs of treating uncontrolled carcinoid syndrome and carcinoid heart disease: a retrospective Swedish study. Scand J Gastroenterol 2018; 53:1509-1518. [PMID: 30449217 DOI: 10.1080/00365521.2018.1531653] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To quantify healthcare resource use (HRU) and costs in relation to carcinoid syndrome (CS) and carcinoid heart disease (CHD) in a real-world setting, and to provide perspective on treatment patterns. MATERIALS AND METHODS Patient data and HRU were collected retrospectively from three Swedish healthcare registers. Adult patients diagnosed with metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) grade 1 or 2 and CS who purchased somatostatin analogs (SSAs), and experienced controlled (defined by SSAs use) and uncontrolled (defined by SSAs dose escalation) CS for ≥8 months during the study period were included. Patients diagnosed with CHD from the date of the GEP-NET diagnosis were included in the CHD study group. RESULTS Overall, total HRU cost increased with uncontrolled CS and CHD. Total resource cost was 15,500€/patient during controlled CS (8 months), rising to 21,700€/patient during uncontrolled CS (8 months), representing an increase of ∼40% (6200€/patient). Costs/patient were driven mainly by SSA use, tumor-related medical interventions and examinations. The total mean cost/year of disease was 1100€/patient without CHD, compared to 4600€/patient with CHD, a difference of 3500€/patient. Excluding SSA cost burden, the main drivers of increased cost in CHD patients were surgical interventions and echocardiography. CONCLUSIONS This study provides a comprehensive overview of the treatment patterns and burden of uncontrolled CS symptoms and CHD using Swedish national register data. Increases in medical interventions and examinations HRU and increased SSA use suggest that SSA dose escalation alone may not effectively control the symptoms associated with uncontrolled CS, highlighting an unmet treatment need in this patient group.
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Affiliation(s)
- Eva Lesén
- a PharmaLex, formerly Nordic Health Economics AB , Gothenburg , Sweden
| | - Åse Björstad
- a PharmaLex, formerly Nordic Health Economics AB , Gothenburg , Sweden
| | - Ingela Björholt
- a PharmaLex, formerly Nordic Health Economics AB , Gothenburg , Sweden
| | - Tom Marlow
- a PharmaLex, formerly Nordic Health Economics AB , Gothenburg , Sweden
| | - Entela Bollano
- b Department of Cardiology , Sahlgrenska University Hospital , Gothenburg , Sweden
| | | | | | - Staffan Welin
- d Department of Endocrine Oncology , Uppsala University Hospital , Uppsala , Sweden
| | - Anna-Karin Elf
- e Department of Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Viktor Johanson
- e Department of Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
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Zaidi MY, Lopez-Aguiar AG, Poultsides GA, Dillhoff M, Rocha FG, Idrees K, Nathan H, Winslow ER, Fields RC, Cardona K, Maithel SK. The impact of failure to achieve symptom control after resection of functional neuroendocrine tumors: An 8-institution study from the US Neuroendocrine Tumor Study Group. J Surg Oncol 2018; 119:5-11. [PMID: 30481383 PMCID: PMC10181271 DOI: 10.1002/jso.25306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The goals of resection of functional neuroendocrine tumors (NETs) are two-fold: Oncological benefit and symptom control. The interaction between the two is not well understood. METHODS All patients with functional NETs of the pancreas, duodenum, and ampulla who underwent curative-intent resection between 2000 and 2016 were identified. Using Cox regression analysis, factors associated with reduced recurrence-free survival (RFS) were identified. RESULTS Two-hundred and thirty patients underwent curative-intent resection. Fifty-three percent were insulinomas, 35% gastrinomas, and 12% were other types. Twenty-one percent had a known genetic syndrome, 23% had lymph node (LN) positivity, 80% underwent an R0 resection, and 14% had no postoperative symptom improvement (SI). Factors associated with reduced RFS included noninsulinoma histology, the presence of a known genetic syndrome, LN positivity, R1 margin, and lack of SI. On multivariable analysis, only the failure to achieve SI following resection was associated with reduced RFS. Considering only those patients with an R0 resection, failure to achieve SI was associated with worse 3-year RFS compared with patients having SI (36% vs 80%; P = 0.006). CONCLUSIONS Failure to achieve symptomatic improvement after resection of functional NETs is associated with worse RFS. These patients may benefit from short-interval surveillance imaging postoperatively to assess for earlier radiographical disease recurrence.
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Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Flavio G Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Hu X, Cao W, Zhao M. Octreotide reverses shock due to vasoactive intestinal peptide-secreting adrenal pheochromocytoma: A case report and review of literature. World J Clin Cases 2018; 6:862-868. [PMID: 30510956 PMCID: PMC6264997 DOI: 10.12998/wjcc.v6.i14.862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 02/05/2023] Open
Abstract
Vasoactive intestinal peptide-producing tumors (VIPoma) usually originate in the pancreas and are characterized by diarrhea, hypokalemia, and achlorhydria (WDHA syndrome). In adults, nonpancreatic VIPoma is very rare. Herein, we report an unusual case of VIP-producing pheochromocytoma marked by persistent shock, flushing, and watery diarrhea and high sensitivity to octreotide. A 53-year-old woman was hospitalized for sudden-onset hypertension with convulsions, which then rapidly evolved to persistent shock, flushing, and watery diarrhea. Abdominal computed tomography indicated a left adrenal mass, accompanied by bleeding; and marked elevations of both plasma catecholamine and VIP concentrations were documented via laboratory testing. Surprisingly, all clinical symptoms responded swiftly to octreotide treatment. Once surgically treated, hormonal levels normalized in this patient, and the clinical symptoms dissipated. Postoperative pathological and immunohistopathological studies confirmed a VIP-secreting pheochromocytoma with strong, diffuse positivity for somatostatin receptor type 2. During a 6-mo follow-up period, she seemed in good health and was symptom-free.
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Affiliation(s)
- Xiao Hu
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wei Cao
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Min Zhao
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Cella D, Beaumont JL, Hudgens S, Marteau F, Feuilly M, Houchard A, Lapuerta P, Ramage J, Pavel M, Hörsch D, Kulke MH. Relationship Between Symptoms and Health-related Quality-of-life Benefits in Patients With Carcinoid Syndrome: Post Hoc Analyses From TELESTAR. Clin Ther 2018; 40:2006-2020.e2. [PMID: 30477789 DOI: 10.1016/j.clinthera.2018.10.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/12/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with metastatic neuroendocrine tumors and carcinoid syndrome (CS) may experience chronic, recurring symptoms despite somatostatin analogue therapy. Little is known about the relationship between bowel movement (BM) frequency, patient-reported symptoms and health-related quality of life (QoL). Data from the TELESTAR study were used in exploratory, post hoc analyses to understand the relationship between durable reductions in BM frequency, symptom relief, and health-related QoL. METHODS Patients with metastatic neuroendocrine tumors and CS in the Phase III TELESTAR study were randomized (1:1:1) to receive telotristat ethyl (TE) 250 mg, TE 500 mg, or placebo three times daily (TID) during a 12-week double-blind treatment period (DBTP). All patients received TE 500 mg TID in an open-label extension (OLE) to Week 48. Durable response was predefined. Analyses compared durable responders (DRs) and non-durable responders (NDRs), irrespective of treatment group, at Weeks 12, 24, and 48. FINDINGS At the start of the DBTP, 135 patients were randomized, 45 patients each to TE 250 mg, TE 500 mg, and placebo. After the 12-week DBTP, 48 of 135 patients were DRs (TE 250 mg, n = 20; TE 500 mg, n = 19; placebo, n = 9). Of the 115 patients who entered the OLE, 35 were DRs initially randomized to TE 250 mg (n = 18) or 500 mg (n = 17), 29 of whom maintained a durable response throughout the OLE. Of the 71 DBTP-NDRs (inclusive of patients initially randomized to placebo), 28 became OLE-DRs. There were 29 NDRs initially randomized to placebo who entered the OLE, 16 of whom became DRs when switched to TE 500 mg. DRs during the DBTP had greater symptom improvements in the DBTP; these improvements continued over the OLE. DBTP-DRs also maintained more meaningful QoL improvements in EORTC QLQ-C30 global health status, nausea and vomiting, pain, diarrhea, and EORTC QLQ-GINET21 gastrointestinal symptoms over the DBTP and OLE periods than DBTP-NDRs. IMPLICATIONS These results suggest that sustained improvements in BM frequency in patients with CS may have multifaceted, long-term effects on a patient's well-being. ClinicalTrials.gov identifiers: NCT01677910.
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Affiliation(s)
- David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Jennifer L Beaumont
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Terasaki Research Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - John Ramage
- Hampshire Hospitals, Basingstoke, United Kingdom
| | - Marianne Pavel
- Universitatsklinikum Erlangen, Erlangen, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany
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34
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Abstract
Neuroendocrine tumors, including carcinoids, are rare and insidiously growing tumors. Related to their site of origin, tumors can be functional, causing various forms of the carcinoid syndrome, owing to the overproduction of serotonin, histamine, or other bioactive substances. They often invade adjacent structures or metastasize to the liver and elsewhere. Treatment includes multimodal approaches, including cytoreductive surgery, locoregional embolization, cytotoxic therapy, peptide receptor radionuclide therapy, and various targeted therapies with goals of symptom relief and control of tumor growth. This article summarizes current and emerging approaches to management and reviews several promising future therapies.
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Affiliation(s)
- Paul Benjamin Loughrey
- Department of Ophthalmology, Royal Victoria Hospital, Belfast Trust, Grosvenor Road, Belfast, BT12 6BA, UK; Department of Endocrinology and Diabetes, Royal Victoria Hospital, Belfast Trust, Grosvenor Road, Belfast, BT12 6BA, UK
| | - Dongyun Zhang
- Department of Medicine, David Geffen School of Medicine, University of California, 700 Tiverton Avenue, Los Angeles, CA 90095, USA
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, 700 Tiverton Avenue, Los Angeles, CA 90095, USA; Department of Neurosurgery, David Geffen School of Medicine, University of California, 700 Tiverton Avenue, Los Angeles, CA 90095, USA.
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35
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Li TN, Liu Z, Zhang Y, Wang F. Ectopic insulinomas in the pelvis secondary to rectum neuroendocrine tumour. BMJ Case Rep 2018; 2018:bcr-2018-224281. [PMID: 29960958 PMCID: PMC6040560 DOI: 10.1136/bcr-2018-224281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We describe a middle-aged woman with recurrent hypoglycaemia, who confirmed with rectum G1 neuroendocrine tumour (NET) 6 years ago. Biochemical assay showed high concentration of serum insulin and C-peptide associated with hypoglycaemia. Because of recurrent hypoglycaemia in June 2015, she underwent a resection of the tail of the pancreas. However, hypoglycaemia attack happened more frequently and severely. 68Ga-DOTA-NOC positron emission tomography/CT revealed five foci in the pelvis with intense uptake. Immediately after excision of the pelvic lesions, insulin and C-peptide decreased to normal levels promptly, and therefore, serum glucose increased significantly. Hypoglycaemia was disappeared, and insulin and C-peptide were normal at 2 years follow-up after surgery. Immunohistochemistry validated the primary rectum NET and pelvic tumours expressed with higher insulin, somatostatin receptor and glucagon-like peptide-1. This is the first reported ectopic pelvic insulinomas secondary to rectum NET, which may originate both from neuroendocrine cells in the rectum and pelvic tissues.
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Affiliation(s)
- Tian-Nv Li
- Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical Univerity, Nanjing, Jiangsu, China
| | - Zijun Liu
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yingdong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Wang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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36
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Jin XF, Spampatti MP, Spitzweg C, Auernhammer CJ. Supportive therapy in gastroenteropancreatic neuroendocrine tumors: Often forgotten but important. Rev Endocr Metab Disord 2018; 19:145-158. [PMID: 29464446 DOI: 10.1007/s11154-018-9443-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Neuroendocrine tumors (NETs) are a group of rare and heterogeneous malignancies that can develop in various organs. A significant number of gastroenteropancreatic neuroendocrine tumours (GEP-NETs) is functionally active and presents with symptoms related to the secretion of biologically active substances, leading to the development of distinct clinical syndromes. There are various therapeutic approaches for GEP-NETs, including curative surgery, palliative surgery, local-ablative and loco-regional therapies as well as systemic therapeutic options including peptide receptor radionuclide therapy, cytotoxic therapy, and molecularly targeted therapies. Specific supportive therapy of patients with NETs includes management or prevention of hormone-related clinical syndromes and paraneoplastic states. Supportive therapy plays a key role in NET treatment. Supportive therapy includes debulking surgery and interventional radiologic techniques to reduce tumour bulk or load, as well as systemic medical treatment options to manage or prevent hypersecretion syndromes and treatment-related side effects. Supportive therapies are a type of of comprehensive treatment addressing the patient as a whole person throughout the process of NET treatment. Therefore, supportive therapy also encompasses psychosocial support, expert nursing, nutritional support and management of cancer related pain.
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Affiliation(s)
- Xi-Feng Jin
- Department of Internal Medicine IV, University-Hospital Campus Grosshadern, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Matilde P Spampatti
- Department of Internal Medicine II, University-Hospital Campus Grosshadern, Ludwig-Maximilian University of Munich, Munich, Germany
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System (GEPNET-KUM), Klinikum der Universitaet Muenchen, Ludwig-Maximilians-University of Munich, Campus Grosshadern, Marchioninistr, 15, 81377, Munich, Germany
| | - Christine Spitzweg
- Department of Internal Medicine IV, University-Hospital Campus Grosshadern, Ludwig-Maximilian University of Munich, Munich, Germany
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System (GEPNET-KUM), Klinikum der Universitaet Muenchen, Ludwig-Maximilians-University of Munich, Campus Grosshadern, Marchioninistr, 15, 81377, Munich, Germany
| | - Christoph J Auernhammer
- Department of Internal Medicine IV, University-Hospital Campus Grosshadern, Ludwig-Maximilian University of Munich, Munich, Germany.
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System (GEPNET-KUM), Klinikum der Universitaet Muenchen, Ludwig-Maximilians-University of Munich, Campus Grosshadern, Marchioninistr, 15, 81377, Munich, Germany.
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Pedraza-Arévalo S, Gahete MD, Alors-Pérez E, Luque RM, Castaño JP. Multilayered heterogeneity as an intrinsic hallmark of neuroendocrine tumors. Rev Endocr Metab Disord 2018; 19:179-192. [PMID: 30293213 DOI: 10.1007/s11154-018-9465-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neuroendocrine tumors (NETs) comprise a complex and highly heterogeneous group of neoplasms that can arise all over the body, originating from neuroendocrine cells. NETs are characterized by a general lack of symptoms until they are in advanced phase, and early biomarkers are not as available and useful as required. Heterogeneity is an intrinsic, pivotal feature of NETs that derives from diverse causes and ultimately shapes tumor fate. The different layers that conform NET heterogeneity include a wide range of distinct characteristics, from the mere location of the tumor to its clinical and functional features, and from its cellular properties, to the core signaling and (epi)genetic components defining the molecular signature of the tumor. The importance of this heterogeneity resides in that it translates into a high variability among tumors and, hence, patients, which hinders a more precise diagnosis and prognosis and more efficacious treatment of these diseases. In this review, we highlight the significance of this heterogeneity as an intrinsic hallmark of NETs, its repercussion on clinical approaches and tumor management, and some of the possible factors associated to such heterogeneity, including epigenetic and genetic elements, post-transcriptional regulation, or splicing alterations. Notwithstanding, heterogeneity can also represent a valuable and actionable feature, towards improving medical approaches based on personalized medicine. We conclude that NETs can no longer be viewed as a single disease entity and that their diagnosis, prognosis and treatment must reflect and incorporate this heterogeneity.
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Affiliation(s)
- Sergio Pedraza-Arévalo
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Avenida Menéndez Pidal s/n, Edificio IMIBIC, 14004, Córdoba, Spain
- Department of Cell Biology, Physiology, and Immunology, Universidad de Córdoba, Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Agrifood Campus of International Excellence (ceiA3), Córdoba, Spain
| | - Manuel D Gahete
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Avenida Menéndez Pidal s/n, Edificio IMIBIC, 14004, Córdoba, Spain
- Department of Cell Biology, Physiology, and Immunology, Universidad de Córdoba, Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Agrifood Campus of International Excellence (ceiA3), Córdoba, Spain
| | - Emilia Alors-Pérez
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Avenida Menéndez Pidal s/n, Edificio IMIBIC, 14004, Córdoba, Spain
- Department of Cell Biology, Physiology, and Immunology, Universidad de Córdoba, Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Agrifood Campus of International Excellence (ceiA3), Córdoba, Spain
| | - Raúl M Luque
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Avenida Menéndez Pidal s/n, Edificio IMIBIC, 14004, Córdoba, Spain.
- Department of Cell Biology, Physiology, and Immunology, Universidad de Córdoba, Córdoba, Spain.
- Reina Sofia University Hospital, Córdoba, Spain.
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain.
- Agrifood Campus of International Excellence (ceiA3), Córdoba, Spain.
| | - Justo P Castaño
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Avenida Menéndez Pidal s/n, Edificio IMIBIC, 14004, Córdoba, Spain.
- Department of Cell Biology, Physiology, and Immunology, Universidad de Córdoba, Córdoba, Spain.
- Reina Sofia University Hospital, Córdoba, Spain.
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain.
- Agrifood Campus of International Excellence (ceiA3), Córdoba, Spain.
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Changes in Weight Associated With Telotristat Ethyl in the Treatment of Carcinoid Syndrome. Clin Ther 2018; 40:952-962.e2. [DOI: 10.1016/j.clinthera.2018.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/16/2022]
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Auernhammer CJ, Spitzweg C, Angele MK, Boeck S, Grossman A, Nölting S, Ilhan H, Knösel T, Mayerle J, Reincke M, Bartenstein P. Advanced neuroendocrine tumours of the small intestine and pancreas: clinical developments, controversies, and future strategies. Lancet Diabetes Endocrinol 2018; 6:404-415. [PMID: 29229497 DOI: 10.1016/s2213-8587(17)30401-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/14/2017] [Accepted: 10/18/2017] [Indexed: 12/18/2022]
Abstract
In this Review, we discuss clinical developments and controversies in the treatment of neuroendocrine tumours (NETs) that are relevant for clinicians and clinical researchers. We describe advances in genetics, blood-based biomarkers, functional imaging, and systemic therapy of advanced NETs and discuss results of recent phase 3 studies, systemic treatment of advanced disease with peptide receptor radionuclide therapy, biotherapy, chemotherapy, and molecularly targeted therapy, and the potential role of immunotherapy in the treatment of NETs. Suggested treatment algorithms for NETs of ileal or jejunal origin and of pancreatic origin are presented.
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Affiliation(s)
- Christoph J Auernhammer
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 4, Ludwig-Maximilians-University of Munich, Munich, Germany.
| | - Christine Spitzweg
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 4, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Martin K Angele
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Stefan Boeck
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 3, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Ashley Grossman
- Neuroendocrine Tumour Centre, Royal Free Hospital, London, UK
| | - Svenja Nölting
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 4, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Harun Ilhan
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Thomas Knösel
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Institute of Pathology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Julia Mayerle
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 2, Klinikum der Universitaet Muenchen, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Martin Reincke
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Internal Medicine 4, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Peter Bartenstein
- Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
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Carlini M, Spoletini D, Grieco M, Apa D, Appetecchia M, Lauretta R, Palazzo S, Minardi S, Severi S, lanniello A. Management of Ileal, Appendiceal and Colorectal Neuroendocrine Tumors. Updates Surg 2018. [DOI: 10.1007/978-88-470-3955-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Neuroendocrine tumours (NETs) are a heterogenous group of tumours arising from neuroendocrine cells in several sites around the body. They include tumours of the gastroenteropancreatic system, phaeochromocytoma and paraganglioma and medullary thyroid cancer. In recent years, it has become increasingly apparent that a number of these tumours arise as a result of germline genetic mutations and are inherited in an autosomal dominant pattern. The number of genes implicated is increasing rapidly. Identifying which patients are likely to have a germline mutation enables clinicians to counsel patients adequately about their future disease risk, and allows for earlier detection of at-risk patients through family screening. The institution of screening and surveillance programmes may in turn lead to a major shift in presentation patterns for some of these tumours. In this review, we examine the features which may lead a clinician to suspect that a patient may have an inherited cause of a NET and we outline which underlying conditions should be suspected. We also discuss what type of screening may be appropriate in a variety of situations.
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Affiliation(s)
- Triona O'Shea
- Centre of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Maralyn Druce
- Centre of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
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Rastogi A, Priya V, Haldar R, Riaz R. Paediatric VIPoma: A Jamboree of Electrolytes. Turk J Anaesthesiol Reanim 2017; 46:158-160. [PMID: 29744252 DOI: 10.5152/tjar.2017.22220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
Vasoactive intestinal peptide secreting tumour (VIPoma) is a rare type of neuroendocrine tumour (NET), primarily located in the tail of pancreas. This type of tumour presents with myriad of metabolic and electrolyte misbalances in the preoperative period, mainly due to increased vasoactive intestinal peptide (VIP) levels. Perioperative management of patients with VIPoma is challenging, especially when dealing with paediatric patients. The anaesthetic management of a two-year-old girl who was selected for VIPoma resection is hereby presented.
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Affiliation(s)
- Amit Rastogi
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vansh Priya
- T.S Misra Medical College, Amausi, Lucknow, India
| | - Rudrashish Haldar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rameez Riaz
- Sher-I-Kashmir Institute of Medical Sciences and Associated Hospitals, Srinagar, India
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Advances and Current Concepts in the Medical Management of Gastroenteropancreatic Neuroendocrine Neoplasms. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9856140. [PMID: 29349087 PMCID: PMC5733630 DOI: 10.1155/2017/9856140] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023]
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare and heterogeneous group of tumors presenting as localised or metastatic disease and in a subset with distinct clinical syndromes. Treatment is aimed at controlling the functional syndrome, eradicating the tumor, and/or preventing further tumor growth. Surgery is the treatment of choice in removing the primary tumor and/or reducing tumor burden but cannot be applied to all patients. Somatostatin analogs (SS-analogs) obtain control of functional syndromes in the majority of GEP-neuroendocrine tumors (NETs); phase III trials have shown that SS-analogs can be used as first-line antiproliferative treatment in patients with slow-growing GEP-NETs. The role of the recently approved serotonin inhibitor, telotristat ethyl, and gastrin receptor antagonist, netazepide, is evolving. Streptozotocin-based chemotherapy has been used for inoperable or progressing pancreatic NENs but the orally administered combination of capecitabine/temozolomide is becoming more popular due to its better tolerability and potential effect in other GEP-NENs. Phase III trials have shown efficacy of molecular targeted therapies in GEP-NETs and of radionuclide treatment in patients with midgut carcinoid tumors expressing somatostatin receptors. Most patients will develop disease progression necessitating further therapeutic options. A combination of currently available treatments along with the molecular signature of each tumor will guide future treatment.
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Anthony L, Ervin C, Lapuerta P, Kulke MH, Kunz P, Bergsland E, Hörsch D, Metz DC, Pasieka J, Pavlakis N, Pavel M, Caplin M, Öberg K, Ramage J, Evans E, Yang QM, Jackson S, Arnold K, Law L, DiBenedetti DB. Understanding the Patient Experience with Carcinoid Syndrome: Exit Interviews from a Randomized, Placebo-controlled Study of Telotristat Ethyl. Clin Ther 2017; 39:2158-2168. [PMID: 29074312 DOI: 10.1016/j.clinthera.2017.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Telotristat ethyl, an oral tryptophan hydroxylase inhibitor, is intended to treat carcinoid syndrome by reducing serotonin production. Telotristat ethyl was evaluated in TELESTAR, a Phase III study for patients who had carcinoid syndrome with at least 4 bowel movements (BMs) per day and who were receiving somatostatin analogue therapy. This interview substudy was conducted to provide insight into the patient experience in TELESTAR and to help understand whether reductions in BM frequency (the primary end point) and other symptoms were clinically meaningful. METHODS Participating sites were asked to invite (before randomization) all eligible patients to telephone interviews scheduled at the end of the double-blind treatment period. Patients and interviewers were blinded to treatment. FINDINGS All 35 interviewed participants reported diarrhea and/or excessive BMs at baseline. Patients reported that these symptoms negatively affected emotional, social, physical, and occupational well-being. Prespecified criteria for treatment response (achieving ≥30% reduction in BM frequency for at least 50% of the days) were met by 8 of 26 patients taking telotristat ethyl and 1 of 9 patients taking placebo. All 8 patients taking telotristat ethyl described clinically meaningful reductions in BM frequency and were very satisfied with the ability of the study drug to control their carcinoid syndrome symptoms. Overall, reports of being very satisfied were observed in 12 patients taking telotristat ethyl and 0 taking placebo. IMPLICATIONS Patient interviews revealed that TELESTAR patients, at baseline, were significantly affected by their high BM frequency. Patient reports of their clinical trial experience supported the significance of the primary end point and clinical responder analysis in TELESTAR, helping identify and understand clinically meaningful change produced by telotristat ethyl.
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Affiliation(s)
- Lowell Anthony
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Claire Ervin
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | | | - Pamela Kunz
- Stanford Cancer Center, Standford, California
| | - Emily Bergsland
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Dieter Hörsch
- Zentralklinik Bad Berka GmbH, Klinik fur Innerre, Medizin/Gastroenterologie und Endokrinologie, Bad Berka, Germany
| | - David C Metz
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Nick Pavlakis
- Royal North Shore Hospital, New South Wales, Australia
| | | | | | | | - John Ramage
- Hampshire Hospitals NHS Trust, Basingstoke and North Hampshire Hospital, Basingstoke-Hampshire, United Kingdom
| | - Emily Evans
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | | | - Karie Arnold
- Lexicon Pharmaceuticals Inc, The Woodlands, Texas
| | - Linda Law
- Lexicon Pharmaceuticals Inc, The Woodlands, Texas
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Dimitriadis GK, Angelousi A, Weickert MO, Randeva HS, Kaltsas G, Grossman A. Paraneoplastic endocrine syndromes. Endocr Relat Cancer 2017; 24:R173-R190. [PMID: 28341725 DOI: 10.1530/erc-17-0036] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 12/13/2022]
Abstract
The majority of neoplasms are responsible for symptoms caused by mass effects to surrounding tissues and/or through the development of metastases. However, occasionally neoplasms, with or without endocrine differentiation, acquire the ability to secrete a variety of bioactive substances or induce immune cross-reactivity with the normal tissues that can lead to the development of characteristic clinical syndromes. These syndromes are named endocrine paraneoplastic syndromes when the specific secretory components (hormones, peptides or cytokines) are unrelated to the anticipated tissue or organ of origin. Endocrine paraneoplastic syndromes can complicate the patient's clinical course, response to treatment, impact prognosis and even be confused as metastatic spread. These syndromes can precede, occur concomitantly or present at a later stage of tumour development, and along with the secreted substances constitute the biological 'fingerprint' of the tumour. Their detection can facilitate early diagnosis of the underlying neoplasia, monitor response to treatment and/or detect early recurrences following successful initial management. Although when associated with tumours of low malignant potential they usually do not affect long-term outcome, in cases of highly malignant tumours, endocrine paraneoplastic syndromes are usually associated with poorer survival outcomes. Recent medical advances have not only improved our understanding of paraneoplastic syndrome pathogenesis in general but also enhanced their diagnosis and treatment. Yet, given the rarity of endocrine paraneoplastic syndromes, there is a paucity of prospective clinical trials to guide management. The development of well-designed prospective multicentre trials remains a priority in the field in order to fully characterise these syndromes and provide evidence-based diagnostic and therapeutic protocols.
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Affiliation(s)
- Georgios K Dimitriadis
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Anna Angelousi
- Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Martin O Weickert
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Harpal S Randeva
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Gregory Kaltsas
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
- Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece
- Oxford Centre for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Oxford Centre for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
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