Management of nonfunctioning islet cell tumors

Solid pseudopapillary tumor of the pancreas: E-cadherin, β-catenin, CD99 new useful markers with characteristic expression (about two case reports)

Solid pseudopapillary neoplasm of the pancreas is a rare tumor that has favorable prognosis. It poses frequently diagnostic challenges. We describe two cases of solid pseudopapillary tumor of the pancreas managed in our department between 2007 and 2011. Two females have mean age of 36.5 years. Clinical presentation include: abdominal pain, bloating and palpable abdominal mass. Tumor is localized in the head of the pancreas in one case and in the tail in the other case. The mean size of the mass was 6 cm (range: 5 to 7 cm). Surgical treatment was performed in two cases. Histological examination confirms the diagnosis of solid pseudopapillary tumor of the pancreas. Immunohistochemical analysis was concordant to the literature data especially concerning CD99 which positivity was in dot, loss of positivity of E-cadherin and nuclear staining of β-catenin. CD10 and α-1-antitrypsin were also positive. One patient was dead 3 days postoperative and neither cancer recurrence nor distant metastases were detected on the follow up of the other. However, solid pseudo-papillary tumor of the pancreas has a distinctive histological appearance; some cases are problematic requiring the use of immunohistochemistry to distinguish it from other pancreatic neoplasm which prognosis is different.

Minimally Invasive Techniques for Resection of Pancreatic Neuroendocrine Tumors

Surgical resection remains the treatment of choice for primary pancreatic neuroendocrine tumors (PNETs), because it is associated with increased survival. Minimally invasive procedures are a safe modality for the surgical treatment of PNETs. In malignant PNETs, laparoscopy is not associated with a compromise in terms of oncologic resection, and provides the benefits of decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. Further prospective, multicenter, randomized trials are required for the analysis of these minimally invasive surgical techniques for the treatment of PNETs and their comparison with traditional open pancreatic surgery.

Antitumor activity of mHSP65-TTL enhanced by administration of low dose cyclophosphamide in pancreatic cancer-bearing mice

Pancreatic cancer remains a lethal malignancy. Despite chemotherapy or/and radiotherapy after the surgery, the improvement on the overall survival of the patients has still been minimal. To develop novel therapeutic approaches, we tried to prepare mHSP65-TTL, a candidate vaccine prepared by mixing the recombinant mycobacterial heat shock protein 65 (mHSP65) with tumor tissue lysate (TTL) of Panc02 pancreatic cancer tissue. The mHSP65-TTL were used to immune the C57BL/6 mice implanted with the Panc02 cancer cells, in combination with or without low dose cyclophosphamide (CY). The results showed that mHSP65-TTL significantly prolonged the survival of the pancreatic cancer bearing mice and low dose CY enhanced the efficacy of the mHSP65-TTL. In addition, we detected mRNA expression of RORγt and IL-17A in spleen cells of mice received mHSP65-TTL or mHSP65-TTL plus CY, and found that mHSP65-TTL up-regulated mRNA expressions of RORγt and IL-17A, CY alone or mHSP65-TTL plus CY up-regulated mRNA expressions of RORγt. The work could provide an insight into a combinational approach for the immunotherapy of pancreatic cancer.

Surgical treatment of sporadic pancreatic neuroendocrine tumors: a state of the art review

Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms. They are clinically diverse and divided into functioning and nonfunctioning disease, depending on their ability to produce symptoms due to hormone production. Surgical resection is the only curative treatment and remains the cornerstone therapy for this patient group, even in patients with advanced disease. Over the last decade there has been a noticeable trend towards more aggressive surgery as well as more minimally invasive surgery in patients with PNETs. This has resulted in improved long-term survival in patients with locally advanced and metastatic disease treated aggressively, as well as shorter hospital stays and comparable long-term outcomes in patients with limited disease treated minimally invasively. There are still controversies related to issues of surgical treatment of PNETs, such as to what extent enucleation, lymph node sampling, and vascular reconstruction are beneficial for the oncologic outcome. Histopathologic tumor classification is of high clinical importance for treatment planning and prognostic evaluation of patients with PNETs. A constant challenge, which relates to the treatment of PNETs, is the lack of an internationally accepted histopathological classification system. This paper reviews current issues on the surgical treatment of sporadic PNETs with specific focus on surgical approaches and tumor classification.

TNM stage and grade in predicting the prognosis of operated, non-functioning neuroendocrine carcinoma of the pancreas--a single-institution experience

OBJECTIVE

To evaluate the prognostic significance of TNM and grading categories in curatively resected non-functioning neuroendocrine pancreatic carcinoma (nfnepC).

METHOD

Eighteen nfnepC were retrospectively analyzed for differences in survival.

RESULTS

(1) There was a correlation between pT (P = 0.026), respectively pM categories (P = 0.016) and survival. (2) G categories and length of survival were closely correlated (P = 0.0036). (3) Disease stages I-IV had a significant effect on survival (P = 0.051). (4) The WHO classification in well and poorly differentiated carcinomas proved to be the most conclusive predictive factor (P = 0.0009). (5) Subgroups with significantly different prognoses determined by histological grade were present within disease stage II.

CONCLUSIONS

The retrospective analysis showed a good correlation between survival and pT, pM, tumor stage, G categories, and WHO classification in well and poorly differentiated carcinomas. Including histological differentiation in the staging system or carrying it out separately in well and poorly differentiated carcinomas, could enhance the predictive potential of TNM-based disease stages.

Surgical resection and multidisciplinary care for primary and metastatic pancreatic islet cell carcinomas

INTRODUCTION

The role of multidisciplinary management of islet cell cancers (ICC) has not been fully investigated in a population-based setting.

METHODS

The Los Angeles County Cancer Surveillance Program was assessed for patients with ICC between the years 1982 to 2006. Patients were stratified by treatment received and clinicopathologic characteristics and survival were compared.

RESULTS

We identified 236 patients with ICC; 86 patients underwent curative-intent surgery with median survival for local, regional, and distant disease of 17.3, 12.2, and 4.0 years, respectively. In comparison, 102 patients underwent medical management alone; survival was significantly shorter when compared to the surgical cohort for local, regional, and distant disease (p < 0.05). To determine whether adjuvant chemotherapy was associated with improved survival, we compared patients who underwent surgery alone compared to patients who underwent surgery followed by adjuvant chemotherapy. Although patients with metastatic disease had 3-year longer survival with adjuvant chemotherapy, these improvements in survival were not statistically significant.

CONCLUSION

Surgical resection was associated with improved survival compared to medical management for any extent of disease in patients with ICC. Furthermore, adjuvant chemotherapy was not associated with survival but does warrant further examination in patients with metastatic disease.

Pathological differential diagnosis of solid-pseudopapillary neoplasm and endocrine tumors of the pancreas

AIM: To investigate differential points of solid-pseudopapillary neoplasm (SPN) of the pancreas and pancreatic endocrine tumor (PET).

METHODS: Ten cases of SPN and fourteen cases of PET were studied in this retrospective study. Clinical and pathologic features, immunostaining reactions and β-catenin gene mutations were analyzed.

RESULTS: The mean age of SPN patients was 25.6 years and these patients had no specific symptoms. The mean diameter of the tumors was 11.0 cm, 9/10 cases were cystic or a mixture of solid and cystic structures, and there was hemorrhage and necrosis on the cut surface in 8/10 (80%) cases. Characteristic pseudopapillary structure and discohesive appearance of the neoplastic cells were observed in all 10 (100%) cases. The results of immunostaining showed that nuclear expression of β-catenin and loss of E-cadherin in all the cases, was only seen in SPN. Molecular studies discovered that 9/10 (90%) cases harbored a point mutation of exon 3 in β-catenin gene. On the other hand, the mean age of PET patients was 43.1 years. Eight of 14 cases presented with symptoms caused by hypoglycemia, and the other 6 cases presented with symptoms similar to those of SPN. The mean size of the tumors was 2.9 cm, most of the tumors were solid, only 3/14 (21%) were a mixture of solid and cystic structures, and macroscopic hemorrhage and necrosis were much less common (3/14, 21%). Histologically, tumor cells were arranged in trabecular, acinar or solid patterns and demonstrated no pseudopapillary structure and discohesive appearance in all 14 (100%) cases. The results of immunostaining and mutation detection were completely different with SPN that membrane and cytoplastic expression of β-catenin without loss of E-cadherin, as well as no mutation in β-catenin gene in all the cases.

CONCLUSION: Both macroscopic and microscopic features of SPN are quite characteristic. It is not difficult to distinguish it from PET. If necessary, immunostaining of β-catenin and E-cadherin is quite helpful to make the differential diagnosis.

Pancreatic endocrine neoplasms: epidemiology and prognosis of pancreatic endocrine tumors

Pancreatic endocrine tumors (PETs) are uncommon tumors with an annual incidence <1 per 100 000 person-years in the general population. The PETs that produce hormones resulting in symptoms are designated as functional. The majority of PETs are non-functional. Of the functional tumors, insulinomas are the most common, followed by gastrinomas. The clinical course of patients with PETs is variable and depends on the extent of the disease and the treatment rendered. Patients with completely resected tumors generally have a good prognosis, and aggressive surgical therapy in patients with advanced disease may also prolong survival. The epidemiology, prognosis, and established and novel prognostic markers of PETs are reviewed.

Clinicopathologic features and treatment trends of pancreatic neuroendocrine tumors: analysis of 9,821 patients

The natural history of pancreatic neuroendocrine tumors (PNET) remains poorly defined. Our objectives were to examine the clinicopathologic features of PNETs, to assess treatment trends over time, and to identify factors associated with undergoing resection. From the National Cancer Data Base (1985-2004), 9,821 patients were identified with PNETs. Clinicopathologic features and treatment trends were examined. Multivariable logistic regression was used to assess factors associated with undergoing resection. Of 9,821 patients with PNETs, 85% were nonfunctional, 7.1% were functional, and 7.9% were carcinoid tumors. Of the 3,851 (39.0%) patients who underwent pancreatectomy, 449 (11.7%) received adjuvant chemotherapy, and 254 (6.6%) received adjuvant radiation. From 1985 to 2004, utilization of pancreatectomy increased from 39.4 to 44.3% (P < 0.0001). Patients were less likely to undergo resection if they were > 55 years old, had tumors in the head of the pancreas, tumors > or = 4 cm, or had distant metastases (P < 0.0001). Patients treated at NCCN/NCI, academic, or high-volume hospitals were more likely to undergo resection. There are disparities in the utilization of pancreatectomy for PNETs. As PNETs have a better prognosis than adenocarcinoma, concerns regarding the morbidity and mortality of pancreatic surgery and neoplasms should not preclude resection.

Well or poorly differentiated nonfunctioning neuroendocrine carcinoma of the pancreas: a single institution experience with 17 cases

AIM

To evaluate the influence of distinguishing between well and poorly differentiated nonfunctioning neuroendocrine pancreatic carcinomas (PC).

METHOD

Six well differentiated and 11 poorly differentiated nonfunctioning neuroendocrine PC were retrospectively analyzed for differences and compared with 340 ductal PC.

RESULTS

1. There was no difference in pT categories between well differentiated and, poorly differentiated nonfunctioning neuroendocrine PC and ductal PC. 2. The rate of the pN1 category was lower in well differentiated lesions (20%) than in poorly differentiated lesions (66%) and in the ductal PC group (75%). 3. The outcome of patients with R0 resections was significantly better for well differentiated neuroendocrine PC with all patients alive than for poorly differentiated ones and for ductal PC (5-year survival rate 0% and 18%, respectively). 4. The outcome following R1/R2 resections for poorly differentiated neuroendocrine PC tended to be similar than for ductal PC (1-year survival rate 20% vs. 33%). 5. There was no difference in mean survival time (9 months) between poorly differentiated lesions and ductal PC after palliative procedures.

CONCLUSIONS

The better outcome of surgical treatment of nonfunctioning neuroendocrine PC vs. that of ductal PC was confined to well differentiated neuroendocrine lesions. For poorly differentiated lesions the outcome was as poor as for ductal PC. These results underscore the importance to distinguish between well and poorly differentiated nonfunctioning neuroendocrine PC.

Surgical treatment of pancreatic endocrine neoplasms

BACKGROUND

Pancreatic endocrine neoplasia (PEN) is an entity with an indolent course and prolonged survival. The aim of the current study was to review the prognostic factors and outcome of patients with PEN at 1 institution.

METHODS

Records of patients with the diagnosis of PEN in the period of 1980 to 2001 were reviewed. Descriptive statistics and log-rank test were used; significance was defined as P < .05.

RESULTS

Of 49 patients, 25 had functional and 24 nonfunctional tumors. Surgery was performed in 43 patients, 36 with curative intent. With a median follow-up of 31 months, there were 5 deaths. Symptoms were controlled with surgical resection in 86%. Median disease-free survival (DFS) was 46 months; actuarial 5-year disease-specific (DSS) was 72%. Factors associated with better DFS and DSS were absence of liver involvement (P = .02) and resection of the primary tumor (P = .04).

CONCLUSIONS

Surgical resection and absence of liver metastases are associated with better DFS and DSS in patients with PEN.

Gastrointestinal manifestations of endocrine disease

The hormonal interactions among the systems throughout the body are not fully understood; many vague clinical symptoms may in fact be manifestations of underlying endocrine diseases. The aim of the following review is to discuss gastrointestinal manifestations of surgically correctable endocrine diseases, focusing on abnormalities of thyroid function, cancer and finally autoimmune diseases. We also review manifestations of pancreatic endocrine tumors, and multiple endocrine neoplasia.

Surgical treatment of non-functioning pancreatic islet cell tumors

Pancreatic endocrine tumors (PETs) are rare neoplasms originating from the amine precursor uptake and decarboxylation (APUD) stem cells. Although the majority of PETs are sporadic, they frequently occur in familial syndromes. PETs may cause a variety of functional syndromes or symptoms of local progression if they are non-functional. General neuroendocrine tumor markers are highly sensitive in the diagnostic assessment of a PET. Imaging studies for tumor localization and staging include computer tomography (CT) scan, magnetic resonance imaging (MRI), In(111)-octreotide scan, MIBG, and endoscopic ultrasonography (EUS). Treatment of PETs often requires a multi-modality approach; however, surgical resection remains the only curative therapy for localized (non-metastatic) disease. Treatment of metastatic disease includes biologic agents, cytotoxic chemotherapy, and liver-directed therapies.