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Emile SH, Horesh N, Garoufalia Z, Gefen R, Wignakumar A, Wexner SD. Predictors of lymph node metastasis and survival in radically resected rectal neuroendocrine tumors: A Surveillance, Epidemiology, and End Results (SEER) database analysis. Surgery 2024:S0039-6060(24)00330-1. [PMID: 38918107 DOI: 10.1016/j.surg.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Rectal neuroendocrine tumors are uncommon tumor types. Lymph node metastases may occur in up to 40%, potentially impacting decision-making. We aimed to assess risk factors for lymph node metastases of rectal neuroendocrine tumors and their association with overall and cancer-specific survival. METHODS This retrospective case-control study involved patients with stage I to III rectal neuroendocrine tumors who underwent radical resection. Data were derived from the Surveillance, Epidemiology, and End Results database (2000-2020). Patients with pathologic evidence of lymph node metastases were compared to those without lymph node metastases for baseline patient and tumor characteristics. The main outcomes were lymph node metastases, overall survival, and cancer-specific survival. RESULTS In total, 580 patients (50.9% male; mean age: 58.9 years) were included. The lymph node metastases rate was 37.1%. Independent predictors of lymph node metastases were Grade 2 neuroendocrine tumors (odds ratio: 8.06; P = .001), neuroendocrine carcinoma (odds ratio: 2.59, P = .006), large-cell neuroendocrine carcinoma (odds ratio: 4.89; P = .017), T2 tumors (odds ratio: 6.44; P < .001), T3 tumors (odds ratio: 27.5; P < .001), and T4 tumors (odds ratio: 17.3; P < .001). Lymph node metastases were associated with shorter restricted mean overall survival (40.8 vs 52.7 months; P < .001) and cancer-specific survival (41.3 vs 54.8 months; P < .001). When adjusted for other confounders, the nodal status of rectal neuroendocrine tumors was not independently associated with overall (hazard ratio = 1.56; P = .165) or cancer-specific survival (hazard ratio = 1.69; P = .158). Significant factors associated with worse overall survival and cancer-specific survival were age, tumor size, neuroendocrine carcinomas, large-cell neuroendocrine carcinomas, and the number of positive lymph nodes. CONCLUSIONS Lymph node metastases of rectal neuroendocrine tumors were more likely associated with high-grade, large-sized, and T2 to T4 tumors. The number of involved lymph nodes was an independent predictor of overall and cancer-specific survival. Other independent survival predictors were tumor grade, size, and T stage.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Egypt. https://twitter.com/dr_samehhany81
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel. https://twitter.com/nirhoresh
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel. https://twitter.com/Rachellgefen
| | - Anjelli Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Impellizzeri G, Donato G, De Angelis C, Pagano N. Diagnostic Endoscopic Ultrasound (EUS) of the Luminal Gastrointestinal Tract. Diagnostics (Basel) 2024; 14:996. [PMID: 38786295 PMCID: PMC11120241 DOI: 10.3390/diagnostics14100996] [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: 04/10/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
The purpose of this review is to focus on the diagnostic endoscopic ultrasound of the gastrointestinal tract. In the last decades, EUS has gained a central role in the staging of epithelial and sub-epithelial lesions of the gastrointestinal tract. With the evolution of imaging, the position of EUS in the diagnostic work-up and the staging flow-chart has continuously changed with two extreme positions: some gastroenterologists think that EUS is absolutely indispensable, and some think it is utterly useless. The truth is, as always, somewhere in between the two extremes. Analyzing the most up-to-date and strong evidence, we will try to give EUS the correct position in our daily practice.
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Affiliation(s)
| | | | | | - Nico Pagano
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (G.I.); (C.D.A.)
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Weng J, Chen YF, Li SH, Lv YH, Chen RB, Xu GL, Lin SY, Bai KH. Endoscopic ultrasonography-related diagnostic accuracy and clinical significance on small rectal neuroendocrine neoplasms. World J Gastroenterol 2024; 30:774-778. [PMID: 38515953 PMCID: PMC10950619 DOI: 10.3748/wjg.v30.i7.774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/19/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024] Open
Abstract
This research aimed to examine the diagnostic accuracy and clinical significance of endoscopic ultrasonography (EUS) in the context of small rectal neuroendocrine neoplasms (NENs). A total of 108 patients with rectal subepithelial lesions (SELs) with a diameter of < 20 mm were included in the analysis. The diagnosis and depth assessment of EUS was compared to the histology findings. The prevalence of NENs in rectal SELs was 78.7% (85/108). The sensitivity of EUS in detecting rectal NENs was 98.9% (84/85), while the specificity was 52.2% (12/23). Overall, the diagnostic accuracy of EUS in identifying rectal NENs was 88.9% (96/108). The overall accuracy rate for EUS in assessing the depth of invasion in rectal NENs was 92.9% (78/84). Therefore, EUS demonstrates reasonable diagnostic accuracy in detecting small rectal NENs, with good sensitivity but inferior specificity. EUS may also assist physicians in assessing the depth of invasion in small rectal NENs before endoscopic excision.
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Affiliation(s)
- Jun Weng
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou 510060, Guangdong Province, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510060, Guangdong Province, China
| | - Yu-Fan Chen
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou 510060, Guangdong Province, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510060, Guangdong Province, China
| | - Shu-Han Li
- Department of Management, Clinical Medical College of Tianjin Medical University, Tianjin 300000, China
| | - Yan-Hua Lv
- Cancer Prevention Center, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Ruo-Bing Chen
- Cancer Prevention Center, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Guo-Liang Xu
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou 510060, Guangdong Province, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510060, Guangdong Province, China
| | - Shi-Yong Lin
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou 510060, Guangdong Province, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510060, Guangdong Province, China
| | - Kun-Hao Bai
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou 510060, Guangdong Province, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510060, Guangdong Province, China
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Chen X, Zhou J, Wang P, Wang P, Wang L, Mu L, Lang C, Mu Y, Wang X, Shang R, Li Q, Lv H, Wu K, Shi N, Jia X, Lai Y, Zhang Y, Li Z, Zhong N. Endoscopic ultrasound-based application system for predicting endoscopic resection-related outcomes and diagnosing subepithelial lesions: Multicenter prospective study. Dig Endosc 2024; 36:141-151. [PMID: 37059698 DOI: 10.1111/den.14568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/13/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES Subepithelial lesions (SELs) are associated with various endoscopic resection (ER) outcomes and diagnostic challenges. We aimed to establish a tool for predicting ER-related outcomes and diagnosing SELs and to investigate the predictive value of endoscopic ultrasound (EUS). METHODS Phase 1 (system development) was performed in a retrospective cohort (n = 837) who underwent EUS before ER for SELs at eight hospitals. Prediction models for five key outcomes were developed using logistic regression. Models with satisfactory internal validation performance were included in a mobile application system, SEL endoscopic resection predictor (SELERP). In Phase 2, the models were externally validated in a prospective cohort of 200 patients. RESULTS An SELERP was developed using EUS characteristics, which included 10 models for five key outcomes: post-ER ulcer management, short procedure time, long hospital stay, high medication costs, and diagnosis of SELs. In Phase 1, 10 models were derived and validated (C-statistics, 0.67-0.99; calibration-in-the-large, -0.14-0.10; calibration slopes, 0.92-1.08). In Phase 2, the derived risk prediction models showed convincing discrimination (C-statistics, 0.64-0.73) and calibration (calibration-in-the-large, -0.02-0.05; calibration slopes, 1.01-1.09) in the prospective cohort. The sensitivities and specificities of the five diagnostic models were 68.3-95.7% and 64.1-83.3%, respectively. CONCLUSION We developed and prospectively validated an application system for the prediction of ER outcomes and diagnosis of SELs, which could aid clinical decision-making and facilitate patient-physician consultation. EUS features significantly contributed to the prediction. TRIAL REGISTRATION Chinese Clinical Trial Registry, http://www.chictr.org.cn (ChiCTR2000040118).
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Affiliation(s)
- Xinyu Chen
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Digestive Disease, Qilu Hospital of Shandong University, Jinan, China
| | - Jiawei Zhou
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Digestive Disease, Qilu Hospital of Shandong University, Jinan, China
| | - Peizhu Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Digestive Disease, Qilu Hospital of Shandong University, Jinan, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Limei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Linjun Mu
- Department of Gastroenterology, Weifang People's Hospital, Weifang, China
| | - Cuicui Lang
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Ying Mu
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Xiaohong Wang
- Department of Gastroenterology, The Affiliated Taian City Centeral Hospital of Qingdao University, Taian, China
| | - Ruilian Shang
- Department of Gastroenterology, The 960th Hospital of the PLA Joint Logistics Support Force, Jinan, China
| | - Qun Li
- Department of Gastroenterology, The 960th Hospital of the PLA Joint Logistics Support Force, Jinan, China
| | - Hongna Lv
- Department of Gastroenterology and Hepatology, Binzhou People's Hospital, Binzhou, China
| | - Kangkang Wu
- Department of Gastroenterology, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Ning Shi
- Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou, China
| | - Xingfang Jia
- Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou, China
| | - Yonghang Lai
- Qingdao Medicon Digital Engineering Co., Ltd., Qingdao, China
| | - Yiyan Zhang
- Qingdao Medicon Digital Engineering Co., Ltd., Qingdao, China
| | - Zhen Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
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He H, Tang T, Wang X, Zhou L, Wang L. Comparing endoscopic ultrasonography and double contrast-enhanced ultrasonography in the preoperative diagnosis of gastric stromal tumor. Cancer Imaging 2023; 23:122. [PMID: 38102702 PMCID: PMC10724945 DOI: 10.1186/s40644-023-00646-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This study was designed to perform a comparative analysis between endoscopic ultrasonography (EUS) and double contrast-enhanced ultrasonography (DCEUS) for the preoperative diagnosis of gastric stromal tumors (GSTs). METHODS A retrospective study was conducted involving 139 patients with histologically confirmed GSTs. All patients preoperatively underwent DCEUS and EUS. The pathology reports were treated as the baseline and were retrospectively compared with the findings of EUS and DCEUS. RESULTS Of the 139 lesions, 120 and 113 were correctly identified by DCEUS and EUS, respectively, with an accuracy of 86.3% and 81.3%. The results revealed an insignificant difference between these two methods (p = 0.189). CONCLUSIONS DCEUS can display not only the locations, sizes, shapes, borders, internal echoes, but also show the blood perfusion patterns of GSTs. It is a highly accurate, noninvasive, and convenient method to be used at the pre-treatment stage.
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Affiliation(s)
- Huiliao He
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou, Zhejiang, 325027, China
| | - Tingting Tang
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou, Zhejiang, 325027, China
| | - Xiaohua Wang
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou, Zhejiang, 325027, China
| | - Lingling Zhou
- Department of Pathology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou, Zhejiang, 325027, China
| | - Liang Wang
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou, Zhejiang, 325027, China.
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Hamada Y, Tanaka K, Mukai K, Baba Y, Kobayashi M, Tominaga S, Kawabata H, Sawai S, Kaneko M, Sugimoto S, Inoue H, Mimuro M, Tamaru S, Nakagawa H. Efficacy of Endoscopic Resection for Rectal Neuroendocrine Tumors Smaller than 15 mm. Dig Dis Sci 2023:10.1007/s10620-023-07914-4. [PMID: 37024740 DOI: 10.1007/s10620-023-07914-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Local resection, including endoscopic resection, is recommended for rectal neuroendocrine tumors (NETs) < 15 mm in patients without risk factors for metastasis, though the short- and long-term outcomes are unclear. AIMS This study investigates the efficacy of endoscopic resection for rectal NETs < 15 mm. METHODS The short- and long-term outcomes of patients with rectal NETs < 15 mm who underwent endoscopic resection and the outcomes of each endoscopic technique were analyzed. The tumors were stratified as < 10 mm (small-size group, SSG) and 10-14 mm (intermediate-size group, IMG). RESULTS Overall, 139 lesions (SSG, n = 118; IMG, n = 21) were analyzed. All tumors were classified as G1 (n = 135) or G2 (n = 4) according to the 2019 World Health Organization grading criteria. The complete resection rate was not different between the groups (P = 0.151). Endoscopic submucosal dissection (ESD) and endoscopic submucosal resection with a ligation device (ESMR-L) achieved complete resection rates > 90% in the SSG. The ESMR-L procedure time (P < 0.001) and hospitalized period (P < 0.001) were significantly shorter than those of ESD. ESD achieved a complete resection rate of 80.0% in the IMG. The tumor size did not affect the overall survival or rate of lymph node/distant metastases. CONCLUSIONS Endoscopic resection is a feasible and effective treatment for patients with rectal NETs < 15 mm without the risk factors of metastasis. ESMR-L and ESD are optimal techniques for resecting tumors smaller than 10 mm and 10-14 mm, respectively.
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Affiliation(s)
- Yasuhiko Hamada
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kyosuke Tanaka
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
- Department of Endoscopy, Mie University Hospital, Tsu, Japan.
| | - Katsumi Mukai
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Japan
| | - Youichirou Baba
- Department of Pathology, Suzuka General Hospital, Suzuka, Japan
| | - Makoto Kobayashi
- Department of Gastroenterology, Municipal Yokkaichi Hospital, Yokkaichi, Japan
| | - Shintaro Tominaga
- Department of Gastroenterology, Municipal Yokkaichi Hospital, Yokkaichi, Japan
| | - Hiroyuki Kawabata
- Department of Gastroenterology, Saiseikai Mastusaka General Hospital, Matsusaka, Japan
| | - Shoma Sawai
- Department of Gastroenterology, Saiseikai Mastusaka General Hospital, Matsusaka, Japan
| | - Masabumi Kaneko
- Department of Gastroenterology, Matsusaka General Hospital, Matsusaka, Japan
| | - Shinya Sugimoto
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Japan
| | - Hidekazu Inoue
- Department of Gastroenterology, Mie Prefectural Medical Center, Yokkaichi, Japan
| | - Maya Mimuro
- Department of Oncologic Pathology, Mie University Hospital, Tsu, Japan
| | - Satoshi Tamaru
- Department of Clinical Research Center, Mie University Hospital, Tsu, Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Correlation of four-phase CT findings of rectal neuroendocrine neoplasms with different World Health Organization grades. Abdom Radiol (NY) 2023; 48:855-864. [PMID: 36576516 DOI: 10.1007/s00261-022-03771-3] [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: 10/08/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE To investigate the four-phase computed tomography (CT) features of rectal neuroendocrine neoplasms (R-NENs) as they relate to different World Health Organization pathological grades. METHODS A total of 42 patients who underwent pre-operative four-phase CT for evaluation of neoplasms confirmed as different pathological grades of R-NENs by surgery were included. The CT features were retrospectively analyzed by two radiologists in consensus including the tumor location, shape, long diameter, necrosis, boundary, transmural invasion, CT attenuation values of noncontrast and different enhancement phases, intra mesenteric metastasis, lateral lymph node metastasis, and distant metastasis. The differences among R-NENs of different pathological grades were analyzed using T-test, analysis of variance, and non-parametric rank sum test. RESULTS Among 42 cases (23 males, 19 females, aged 57 ± 10.48 years) of R-NENs, neuroendocrine tumors G1, G2, and G3 (NET G1, NET G2, NET G3) and neuroendocrine carcinoma (NEC) were 13, 13, 3 and 13 cases, respectively. There were statistically significant differences in tumor long diameter, shape, necrosis, boundary, transmural invasion, CT values in delayed phase, intra mesenteric metastasis, lateral lymph node metastasis, and liver metastasis of different pathological grades (P < 0.001, P = 0.014, P = 0.004, P < 0.001, P < 0.001, P = 0.038, P = 0.006, P = 0.022, and P = 0.020, respectively). CONCLUSION Features on four-phase CT can correlate with WHO pathological grades of R-NENs; this may be helpful for preoperative diagnosis and prognosis evaluation.
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Multiple ligation-assisted endoscopic submucosal resection combined with endoscopic ultrasonography: a novel method to treat rectal neuroendocrine tumors. Eur J Gastroenterol Hepatol 2023; 35:174-180. [PMID: 36574308 DOI: 10.1097/meg.0000000000002486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The first choice of treatment for rectal neuroendocrine tumors (R-NETs) 10 mm in size is endoscopic resection, there is still controversy concerning the optimal endoscopic treatment for resecting R-NETs. This study evaluated the efficacy and safety of multiple ligation-assisted endoscopic submucosal resection combined with endoscopic ultrasonography (EMR-MLUS) for R-NETs. METHODS We retrospectively analyzed the data of 62 patients with R-NETs ≤10 mm in size who underwent EMR-MLUS or ligation-assisted endoscopic submucosal resection combined with endoscopic ultrasonography (EMR-LUS) between May 2019 and April 2022, including tumor characteristics, endoscopic complete resection, pathological complete resection, the procedure time, adverse events, and follow-up were compared between the two groups of patients. RESULTS Of the 62 patients, 19 underwent EMR-MLUS and 43 underwent EMR-LUS. The endoscopic morphology of lesions was statistically different between group EMR-MLUS and group EMR-LUS ( P = 0.015), and most of them were flat and slightly raised lesions in group EMR-MLUS. Although the pathological complete resection rate was slightly higher in the EMR-MLUS group than in the EMR-LUS group (94.74% vs. 90.70%; P = 0.290), the endoscopic complete resection rate was high in both groups. Involvement of the lateral resection margin was found four cases in the ESMR-LUS group; one case of deep resection margin involvement in the EMR-MLUS group. The mean procedure time was longer in the EMR-MLUS group than in the EMR-LUS group (12.79 ± 1.01 min vs. 11.08 ± 1.89 min; P = 0.041). In group EMR-LUS, there were two cases of immediate bleeding; in group EMR-MLUS, one case of perforation, all of them were successfully treated by endoscopy. No recurrence, progression, or metastasis was found in all patients. CONCLUSION EMR-MLUS is a safe and effective technique that could be considered when removing small rectal NETs, especially flat and slightly raised lesions.
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Sadeghi A, Zali MR, Tayefeh Norooz M, Pishgahi M, Ketabi Moghadam P. Management of gastrointestinal subepithelial lesions: an answer to the conflicting opinions. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:378-385. [PMID: 38313357 PMCID: PMC10835092 DOI: 10.22037/ghfbb.v16i4.2690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/10/2023] [Indexed: 02/06/2024]
Abstract
Subepithelial lesions, formerly known as subepithelial tumors, are incidentally discovered protrusions throughout the gastrointestinal tract with normal overlying mucosa. Studies related to the diagnosis and therapy methods are limited due to the low incidence and malignant potential of these lesions. They commonly originating from the second, third, and fourth layers (muscularis mucosa, submucosa, and muscularis propria) of the gastrointestinal wall. They are reported to be more prevalent in the stomach and esophagus than small intestine and colon. Subepithelial lesions in the stomach and duodenum are more prone to malignancy than the lesions in the esophagus. Despite different strategies in the management of subepithelial lesions based on their size and location, there is still not a unique consensus on the issue. In this review, we have attempted to introduce the most practical approach to managing gastrointestinal subepithelial lesions based on current guidelines.
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Affiliation(s)
- Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Pishgahi
- Department of Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pardis Ketabi Moghadam
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Rectal neuroendocrine neoplasms: what the radiologists should know. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:4016-4031. [PMID: 35288791 DOI: 10.1007/s00261-022-03474-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023]
Abstract
Neuroendocrine neoplasms of the rectum (R-NENs) are rare; however, their incidence has increased almost threefold in the last few decades. Imaging of R-NENs includes two primary categories: anatomic/morphologic imaging comprised of endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), and functional/molecular imaging comprising of planar scintigraphy, single-photon emission computed tomography (SPECT), and positron emission tomography (PET). The management depends on stage, dimension, atypical features, histological grade, and lymphovascular invasion (LVI). Low-risk local R-NENs can be resected endoscopically, and high-risk or locally advanced neoplasms can be treated with radical surgery and lymphadenectomy and/or chemoradiation. The review article focuses on imaging illustrations and discusses applications of different imaging modalities in diagnosing and managing R-NENs.
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Iabichino G, Di Leo M, Arena M, Rubis Passoni GG, Morandi E, Turpini F, Viaggi P, Luigiano C, De Luca L. Diagnosis, treatment, and current concepts in the endoscopic management of gastroenteropancreatic neuroendocrine neoplasms. World J Gastroenterol 2022; 28:4943-4958. [PMID: 36160644 PMCID: PMC9494936 DOI: 10.3748/wjg.v28.i34.4943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/29/2022] [Accepted: 08/22/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare tumors derived from the neuroendocrine cell system, which that have increased in incidence and prevalence in recent years. Despite improvements in radiological and metabolic imaging, endoscopy still plays a pivotal role in the number of GEP-NENs. Tumor detection, characterization, and staging are essential in management and treatment planning. Upper and lower gastrointestinal (GI) endoscopy is essential for correct localization of the primary tumor site of GI NENs. Endoscopic ultrasonography (EUS) has an important role in the imaging and tissue acquisition of pancreatic NENs and locoregional staging of GI neuroendocrine tumors. Correct staging and histological diagnosis have important prognostic implications. Endoscopic operating techniques allow the removal of small GI NENs in the early stage of mucosal or submucosal invasion of the intestinal wall. Preoperative EUS-guided techniques may help the surgeon locate small and deep tumors, thus avoiding formal pancreatic resections in favor of parenchymal-sparing surgery. Finally, locoregional ablative treatments have been proposed in recent studies with promising results in selected patients.
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Affiliation(s)
| | - Milena Di Leo
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Monica Arena
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | | | | | - Francesca Turpini
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Paolo Viaggi
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
| | - Carmelo Luigiano
- Gastroenterology Section, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria 89124, Italy
| | - Luca De Luca
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milano 20144, Italy
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12
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Deprez PH, Moons LMG, OʼToole D, Gincul R, Seicean A, Pimentel-Nunes P, Fernández-Esparrach G, Polkowski M, Vieth M, Borbath I, Moreels TG, Nieveen van Dijkum E, Blay JY, van Hooft JE. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:412-429. [PMID: 35180797 DOI: 10.1055/a-1751-5742] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
1: ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.Strong recommendation, moderate quality evidence. 2: ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.Weak recommendation, very low quality evidence. 3: ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.Strong recommendation, moderate quality evidence. 4: ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.Strong recommendation, moderate quality evidence. 5: ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3-6 months, and then at 2-3-year intervals for lesions < 10 mm in size, and at 1-2-year intervals for lesions 10-20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6-12-month intervals.Weak recommendation, very low quality evidence. 6: ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.Strong recommendation, low quality evidence. 7: ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.Weak recommendation, very low quality evidence. 8: ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.Weak recommendation, very low quality evidence. 9: ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1-2 years is advised.Strong recommendation, low quality evidence. 10: For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3-6 months and another attempt at endoscopic resection in the case of residual disease.Strong recommendation, low quality evidence.
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Affiliation(s)
- Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Leon M G Moons
- Divisie Interne Geneeskunde en Dermatologie, Maag-, Darm- en Leverziekten, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Dermot OʼToole
- Neuroendocrine Tumor Service, ENETS Centre of Excellence, St. Vincent's University Hospital and Department of Clinical Medicine, Trinity College Dublin, University of Dublin St. James's Hospital, Dublin, Ireland
| | - Rodica Gincul
- Service de Gastroentérologie et Endoscopie Digestive, Hôpital Privé Jean Mermoz, Lyon, France
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto; Department of Surgery and Physiology, Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Portugal
| | | | - Marcin Polkowski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center for Postgraduate Medical Education, and Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michael Vieth
- Institut of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Ivan Borbath
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Tom G Moreels
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Els Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, The Netherlands
| | - Jean-Yves Blay
- Centre Léon Bérard, Université Claude Bernard Lyon 1, Lyon, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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13
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Gallo C, Rossi RE, Cavalcoli F, Barbaro F, Boškoski I, Invernizzi P, Massironi S. Rectal neuroendocrine tumors: Current advances in management, treatment, and surveillance. World J Gastroenterol 2022; 28:1123-1138. [PMID: 35431507 PMCID: PMC8985485 DOI: 10.3748/wjg.v28.i11.1123] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/24/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
Rectal neuroendocrine neoplasms (r-NENs) are considered among the most frequent digestive NENs, together with small bowel NENs. Their incidence has increased over the past few years, and this is probably due to the widespread use of endoscopic screening for colorectal cancer and the advanced endoscopic procedures available nowadays. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, well-differentiated r-NENs smaller than 10 mm should be endoscopically removed in view of their low risk of local and distant invasion. R-NENs larger than 20 mm are candidates for surgical resection because of their high risk of distant spreading and the involvement of the muscularis propria. There is an area of uncertainty regarding tumors between 10 and 20 mm, in which the metastatic risk is intermediate and the endoscopic treatment can be challenging. Once removed, the indications for surveillance are scarce and poorly codified by international guidelines, therefore in this paper, a possible algorithm is proposed.
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Affiliation(s)
- Camilla Gallo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Roberta Elisa Rossi
- Division of HPB Surgery, Hepatology and Liver Transplantation, Department of Pathophysiology and Transplantation, University of Milan, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute), Milan 20133, Italy
| | - Federica Cavalcoli
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan 20133, Italy
| | - Federico Barbaro
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
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14
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Fang JM, Li J, Shi J. An update on the diagnosis of gastroenteropancreatic neuroendocrine neoplasms. World J Gastroenterol 2022; 28:1009-1023. [PMID: 35431496 PMCID: PMC8968521 DOI: 10.3748/wjg.v28.i10.1009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/26/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) arise from neuroendocrine cells found throughout the gastrointestinal tract and islet cells of the pancreas. The incidence and prevalence of GEP-NENs have been increasing each year due to higher awareness, improved diagnostic modalities, and increased incidental detection on cross-sectional imaging and endoscopy for cancer screening and other conditions and symptoms. GEP-NENs are a heterogeneous group of tumors and have a wide range in clinical presentation, histopathologic features, and molecular biology. Clinical presentation most commonly depends on whether the GEP-NEN secretes an active hormone. The World Health Organization recently updated the classification of GEP-NENs to introduce a distinction between high-grade neuroendocrine tumors and neuroendocrine carcinomas, which can be identified using histology and molecular studies and are more aggressive with a worse prognosis compared to high-grade neuroendocrine tumors. As our understanding of the biology of GEP-NENs has grown, new and improved diagnostic modalities can be developed and optimized. Here, we discuss clinical features and updates in diagnosis, including histopathological analysis, biomarkers, molecular techniques, and radiology of GEP-NENs. We review established diagnostic tests and discuss promising novel diagnostic tests that are currently in development or require further investigation and validation prior to broad utilization in patient care.
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Affiliation(s)
- Jiayun M Fang
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, MI 48109, United States
| | - Jay Li
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI 48109, United States
| | - Jiaqi Shi
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, MI 48109, United States
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15
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Waked B, De Maeyer F, Carton S, Pieter-Jan CUYLE, Vandamme T, Verslype C, Demetter P, Borbath I, Van Eycken L, Hoorens A, Geboes K, Van Damme N, Ribeiro S. Quality of pathology reporting and adherence to guidelines in rectal neuroendocrine neoplasms: a Belgian national study. Acta Clin Belg 2021; 77:823-831. [PMID: 34607538 DOI: 10.1080/17843286.2021.1985806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The incidence of neuroendocrine neoplasms (NEN) in the rectum is rising since the introduction of colonoscopy screening programs. Guidelines, such as the European NeuroEndocrine Tumor Society (ENETS) algorithm, are mainly based on expert opinion. The goal of this nationwide study is to gain a better insight into the evolution in pathology reporting and adherence to the ENETS guidelines in Belgium. In Belgium, all NENs have to be reported to the Belgian Cancer Registry. We thoroughly reviewed all available pathology reports, coded as rectal NEN between 2004 and 2015, and reclassified according to World Health Organisation (WHO) classification 2019. To evaluate the adherence to the ENETS guidelines, population-based cancer registry data were linked with the medical procedures of the Belgian Health Insurance database. A total of 670 rectal NEN were retained and 16% of the cases needed reclassification. Annual incidence between 2004 and 2015 tripled from 0,20 to 0,61 per 100.000 inhabitants. Reporting of Ki67 proliferation index ameliorated most, while reporting of tumor size, lymphovascular and perineural invasion remained disappointing. Endoscopic ultrasound was performed in only 36.6% of the cases, while the mostly recommended mode of treatment (endoscopic/surgical/no resection) was followed in the majority of the cases. Incidence of rectal NEN in Belgium increased throughout the years and quality of pathology reporting improved especially after the WHO classification update in 2010. The growing awareness and knowledge among clinicians and pathologists in the community counters the need for centralization.
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Affiliation(s)
- Bruno Waked
- Ghent University Hospital, Department of Gastroenterology. Ghent, Belgium
| | - Filip De Maeyer
- Az Sint-Elisabeth Zottegem, Department of Gastroenterology. Godveerdegemstraat 69, Zottegem, Belgium
| | - Saskia Carton
- Imeldaziekenhuis, Bonheiden, Department of Gastroenterology. Bonheiden, Belgium
| | - CUYLE Pieter-Jan
- Imeldaziekenhuis, Bonheiden, Department of Gastroenterology. Bonheiden, Belgium
| | - Timon Vandamme
- Ziekenhuis Netwerk Antwerpen, Department of Gastroenterology. Antwerp, Belgium
| | - Chris Verslype
- University Hospital Gasthuisberg Leuven, Department of Gastroenterology. Leuven, Belgium
| | - Pieter Demetter
- Institute Jules Bordet, Department of Gastroenterology. Brussels, Belgium
| | - Ivan Borbath
- Cliniques Universitaires Saint-Luc, Department of Gastro-enterology. Brussels, Belgium
| | | | - Anne Hoorens
- Ghent University Hospital, Department of Pathology. Ghent, Belgium
| | - Karen Geboes
- Ghent University Hospital, Department of Gastroenterology. Ghent, Belgium
| | | | - Suzane Ribeiro
- Ghent University Hospital, Department of Gastroenterology. Ghent, Belgium
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16
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Maione F, Chini A, Milone M, Gennarelli N, Manigrasso M, Maione R, Cassese G, Pagano G, Tropeano FP, Luglio G, De Palma GD. Diagnosis and Management of Rectal Neuroendocrine Tumors (NETs). Diagnostics (Basel) 2021; 11:diagnostics11050771. [PMID: 33923121 PMCID: PMC8145857 DOI: 10.3390/diagnostics11050771] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 12/15/2022] Open
Abstract
Rectal neuroendocrine tumors (NETs) are rare, with an incidence of 0.17%, but they represent 12% to 27% of all NETs and 20% of gastrointestinal NETs. Although rectal NETs are uncommon tumors, their incidence has increased over the past few years, and this is probably due to the improvement in detection rates made by advanced endoscopic procedures. The biological behavior of rectal NETs may be different: factors predicting the risk of metastases have been identified, such as size and grade of differentiation. The tendency for metastatic diffusion generally depends on the tumor size, muscular and lymphovascular infiltration, and histopathological differentiation. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, tumors that are smaller than 10 mm and well differentiated are thought to have a low risk of lymphovascular invasion, and they should be completely removed endoscopically. Rectal NETs larger than 20 mm have a higher risk of involvement of muscularis propria and high metastatic risk and are candidates for surgical resection. There is controversy over rectal NETs of intermediate size, 10–19 mm, where the metastatic risk is considered to be 10–15%: assessment of tumors endoscopically and by endoanal ultrasound should guide treatment in these cases towards endoscopic, transanal, or surgical resection.
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17
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Clinical utility of endoscopic submucosal dissection using the pocket-creation method with a HookKnife and preoperative evaluation by endoscopic ultrasonography for the treatment of rectal neuroendocrine tumors. Surg Endosc 2021; 36:375-384. [DOI: 10.1007/s00464-021-08292-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
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18
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de Mestier L, Lorenzo D, Fine C, Cros J, Hentic O, Walter T, Panis Y, Couvelard A, Cadiot G, Ruszniewski P. Endoscopic, transanal, laparoscopic, and transabdominal management of rectal neuroendocrine tumors. Best Pract Res Clin Endocrinol Metab 2019; 33:101293. [PMID: 31326374 DOI: 10.1016/j.beem.2019.101293] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rectal neuroendocrine tumors (RNET) are rare tumors but their prevalence is constantly increasing due to a prolonged survival and rising incidence related to a growing number of colonoscopies and improved knowledge. Their main prognostic determinant is tumor stage. While most RNET are localized, their management should be tailored depending on the presence or absence of the factors predictive of lymph-node metastases including tumor size, endoscopic aspect, T stage, grade and lymphovascular invasion. Endoscopic ultrasonography is the most relevant technique for locoregional assessment. Low-risk RNET can be treated using advanced endoscopic resection techniques or transanal endoscopic microsurgery, in expert centers because they require technicity and experience. Conversely, radical surgery with lymphadenectomy should be proposed in the presence of any pejorative factor. The long-term evolution of RNET remains to be specified, and prospective studies should be conducted in order to determine the relevance of the current management strategies.
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Affiliation(s)
- Louis de Mestier
- Department of Pancreatology and Gastroenterology, ENETS Centre of Excellence, AP-HP, Beaujon Hospital, Clichy, France; Université de Paris, France; INSERM UMR1149, Paris, France.
| | - Diane Lorenzo
- Department of Pancreatology and Gastroenterology, ENETS Centre of Excellence, AP-HP, Beaujon Hospital, Clichy, France; Université de Paris, France
| | - Caroline Fine
- Department of Digestive Oncology, ENETS Centre of Excellence, Edouard Herriot University Hospital, Lyon, France
| | - Jérôme Cros
- Université de Paris, France; INSERM UMR1149, Paris, France; Department of Pathology, ENETS Centre of Excellence, AP-HP, Bichat/Beaujon Hospital, Clichy, France
| | - Olivia Hentic
- Department of Pancreatology and Gastroenterology, ENETS Centre of Excellence, AP-HP, Beaujon Hospital, Clichy, France
| | - Thomas Walter
- Department of Digestive Oncology, ENETS Centre of Excellence, Edouard Herriot University Hospital, Lyon, France
| | - Yves Panis
- Université de Paris, France; Department of Colorectal Surgery, ENETS Centre of Excellence, AP-HP, Beaujon Hospital, Clichy, France
| | - Anne Couvelard
- Université de Paris, France; INSERM UMR1149, Paris, France; Department of Pathology, ENETS Centre of Excellence, AP-HP, Bichat/Beaujon Hospital, Clichy, France
| | - Guillaume Cadiot
- Department of Hepato-Gastroenterology and Digestive Oncology, Robert Debré Hospital and Reims-Champagne-Ardennes University, Reims, France
| | - Philippe Ruszniewski
- Department of Pancreatology and Gastroenterology, ENETS Centre of Excellence, AP-HP, Beaujon Hospital, Clichy, France; Université de Paris, France; INSERM UMR1149, Paris, France
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19
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Abstract
PURPOSE OF REVIEW Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS. RECENT FINDINGS Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.
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Affiliation(s)
- Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8124, Saint Louis, MO, 63110, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8124, Saint Louis, MO, 63110, USA.
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20
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Lee JW, Choi SH, Chon HJ, Kim DJ, Kim G, Kwon CI, Ko KH. Robotic transduodenal ampullectomy: A novel minimally invasive approach for ampullary neoplasms. Int J Med Robot 2019; 15:e1979. [PMID: 30578741 DOI: 10.1002/rcs.1979] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/03/2018] [Accepted: 12/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The adoption of minimally invasive surgery for transduodenal ampullectomy has been slow because of special characteristics and complexity of this procedure. METHODS Six patients underwent robotic transduodenal ampullectomy. We employed novel methods to facilitate exposure of the ampulla. RESULTS All patients completed robotic transduodenal ampullectomy, but one patient was immediately converted to robotic pancreaticoduodenectomy because of presence of invasive carcinoma on frozen biopsy. The final pathologic report revealed high-grade dysplasia in four patients, low-grade dyplasia in one, and T2N0 in one patient who converted to pancreaticoduodenectomy. There was no immediate postoperative complication or mortality. One patient was readmitted after 3 months because of stricture of the bile duct outlet. There was no recurrence over a median follow-up period of 20 months. CONCLUSION An appropriate combination of patient positioning and retraction method helps the robot surgical system to provide competent performance for sophisticated and precise manipulation of ampullary lesions.
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Affiliation(s)
- Jin Woo Lee
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Sung Hoon Choi
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Hong Jae Chon
- Medical oncology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Dae Jung Kim
- Radiolgy, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Gwangil Kim
- Pathology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Chang Il Kwon
- Gastroenterology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Kwang Hyun Ko
- Gastroenterology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
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21
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Ramage JK, Valle JW, Nieveen van Dijkum EJM, Sundin A, Pascher A, Couvelard A, Kloeppel G. Colorectal Neuroendocrine Neoplasms: Areas of Unmet Need. Neuroendocrinology 2019; 108:45-53. [PMID: 30219817 DOI: 10.1159/000493767] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 09/14/2018] [Indexed: 12/15/2022]
Abstract
The subject of colorectal neuroendocrine neoplasms (NENs), subdivided into well-differentiated NENs, termed neuroendocrine tumours (NETs; grade (G) 1 and 2), and poorly differentiated NENs, termed neuroendocrine carcinomas (NECs; G3) according to the 2010 World Health Organisation (WHO) classification, has arguably not had as much attention or study as NENs occurring in other sites. Colorectal NETs and NECs are however easier to study than many others since they are usually not difficult to remove and are increasingly detected because of intensified colorectal cancer screening and surveillance programmes. Colorectal NETs and NECs show site-specific heterogeneity with variable behaviour and different therapeutic options; these various aspects provide unique challenges. Because of bowel cancer screening programmes, colorectal NENs, like conventional adenocarcinomas, may be diagnosed at a stage that is associated with improved survival. In this article we intend to describe and define areas of unmet needs relating to the epidemiology, classification, pathology, diagnosis and therapy of colorectal NETs (including NETs G3), colorectal NECs, and finally, mixed adeno-neuroendocrine carcinomas (MANECs) by reviewing and discussing the relevant literature.
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Affiliation(s)
- John K Ramage
- Department Gastroenterology, Hampshire Hospitals NHS Trust, Kings College Hospital ENETS centre of Excellence, Basingstoke, United
| | - Juan W Valle
- Department of Medical Oncology, University of Manchester, The Christie ENETS Centre of Excellence, Manchester, United Kingdom
| | | | - Anders Sundin
- Department of Radiology, Institution Surgical Sciences, Uppsala University and ENETS centre of excellence, Uppsala University Hopsital, Uppsala, Sweden
| | - Andreas Pascher
- Department of Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Visceral and Transplant Surgery, University of Muenster, Muenster, Germany
| | - Anne Couvelard
- Department of Pathology, Bichat Hospital AP-HP and University of Paris Diderot, Paris, France
| | - Guenter Kloeppel
- Department of Pathology, Technical University Munich, Munich, Germany
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22
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Chayanupatkul M, Gould Suarez M, Sealock RJ. Colonic Schwannoma Diagnosed by Endoscopic Ultrasound With Fine-Needle Aspiration. Clin Gastroenterol Hepatol 2018; 16:A29-A30. [PMID: 28342954 DOI: 10.1016/j.cgh.2017.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Maneerat Chayanupatkul
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Milena Gould Suarez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Robert Jay Sealock
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Zilli A, Arcidiacono PG, Conte D, Massironi S. Clinical impact of endoscopic ultrasonography on the management of neuroendocrine tumors: lights and shadows. Dig Liver Dis 2018; 50:6-14. [PMID: 29102525 DOI: 10.1016/j.dld.2017.10.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/04/2017] [Accepted: 10/09/2017] [Indexed: 02/07/2023]
Abstract
The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades. An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms. Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities. Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.
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Affiliation(s)
- Alessandra Zilli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Postgraduate School of Gastroenterology, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- PancreatoBiliary Endoscopy and Endosonography Division, Pancreas Translatiinal and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Massironi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
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24
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The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85:1117-1132. [PMID: 28385194 DOI: 10.1016/j.gie.2017.02.022] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/21/2017] [Indexed: 02/06/2023]
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Park SB, Kim DJ, Kim HW, Choi CW, Kang DH, Kim SJ, Nam HS. Is endoscopic ultrasonography essential for endoscopic resection of small rectal neuroendocrine tumors? World J Gastroenterol 2017; 23:2037-2043. [PMID: 28373770 PMCID: PMC5360645 DOI: 10.3748/wjg.v23.i11.2037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/24/2017] [Accepted: 02/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the importance of endoscopic ultrasonography (EUS) for small (≤ 10 mm) rectal neuroendocrine tumor (NET) treatment.
METHODS Patients in whom rectal NETs were diagnosed by endoscopic resection (ER) at the Pusan National University Yangsan Hospital between 2008 and 2014 were included in this study. A total of 120 small rectal NETs in 118 patients were included in this study. Histologic features and clinical outcomes were analyzed, and the findings of endoscopy, EUS and histology were compared.
RESULTS The size measured by endoscopy was not significantly different from that measured by EUS and histology (r = 0.914 and r = 0.727 respectively). Accuracy for the depth of invasion was 92.5% with EUS. No patients showed invasion of the muscularis propria or metastasis to the regional lymph nodes. All rectal NETs were classified as grade 1 and demonstrated an L-cell phenotype. Mean follow-up duration was 407.54 ± 374.16 d. No patients had local or distant metastasis during the follow-up periods.
CONCLUSION EUS is not essential for ER in the patient with small rectal NETs because of the prominent morphology and benign behavior.
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Ishikawa M, Ota Y, Nagai M, Kusaka G, Tanaka Y, Naritaka H. Ultrasonography Monitoring with Superb Microvascular Imaging Technique in Brain Tumor Surgery. World Neurosurg 2017; 97:749.e11-749.e20. [DOI: 10.1016/j.wneu.2016.10.111] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 10/21/2016] [Accepted: 10/22/2016] [Indexed: 01/16/2023]
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27
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Li P, Wu F, Zhao H, Dou L, Wang Y, Guo C, Wang G, Zhao D. Analysis of the factors affecting lymph node metastasis and the prognosis of rectal neuroendocrine tumors. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:13331-13338. [PMID: 26722537 PMCID: PMC4680482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/22/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To analyze the factors affecting lymph node metastasis and the prognosis of rectal neuroendocrine tumors after surgical treatment. METHODS A retrospective analysis was conducted using the clinical data from 156 cases of rectal neuroendocrine tumors during the period of January 1999 to December 2013. The Kaplan-Meier method was used to calculate the survival time, Cox regression analysis was performed for statistical analysis of clinicopathological factors that may be associated with lymph node metastasis and prognosis, and correlation analysis was carried out using binary logistic regression. RESULTS The overall 5-year survival rate of the entire group was 95.7%. Multivariate analysis showed that the depth of invasion was an independent prognostic factor (P < 0.001). The incidence of lymph node metastasis was 7.7% (12/156), and logistic regression analysis showed that lymph node metastasis was related to the depth of invasion (P = 0.003) and tumor diameter (P = 0.006). CONCLUSION The surgical approach of rectal neuroendocrine tumors should be selected based on a comprehensive consideration of factors such as tumor size, depth of invasion and lymph node metastasis.
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Affiliation(s)
- Peng Li
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Fan Wu
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Hong Zhao
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Lizhou Dou
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Yang Wang
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Chunguang Guo
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Guiqi Wang
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
| | - Dongbing Zhao
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing 100021, China
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Wen B, Zhang L, Wang C, Huang R, Peng H, Zhang T, Dong J, Xiao W, Zeng Z, Liu M, Gao Y. Prognostic significance of clinical and pathological stages on locally advanced rectal carcinoma after neoadjuvant chemoradiotherapy. Radiat Oncol 2015; 10:124. [PMID: 26040453 PMCID: PMC4490617 DOI: 10.1186/s13014-015-0425-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 05/21/2015] [Indexed: 02/06/2023] Open
Abstract
Objective To investigate prognostic significance of clinical and pathological stages in patients with locally advanced rectal carcinoma treated with neoadjuvant chemoradiotherapy (neo-CRT) and total mesorectal excision. Patients and methods 210 patients with locally advanced rectal carcinoma (cT3-4 or cN+) treated with neo-CRT followed by total mesorectal excision. Treatment outcomes were compared according to clinical and pathological stage. Overall survival (OS), disease free survival (DFS) among patients with different clinical stage and pathological stage after neo-CRT. Results The median follow-up time was 47 months (range, 14–98 months). Clinical T stage was associated with 5 year OS (p = 0.042) and 5 year DFS (p = 0.014) while clinical N stage was not associated with 5 year OS (p = 0.440), 5 year DFS (p = 0.711). Pathological T stage was associate with 5 year OS (p = 0.001) and 5 year DFS (p = 0.046); and N stage was associated with 5 year OS (p = 0.001), 5 year DFS (p = 0.002). The pathological stage was further classified into three groups: ypT0–2N0 in 91 patients (43.3 %), ypT3–4N0 in 69 patients (32.9 %) and ypT0–4N+ in 50 patients (23.8 %). While pathological stage (ypT0–2 vs ypT3–4N0 vs ypT0–4N+) was associated with 5 year OS (87.9 %, 75.5 %, 56.7 %, p = 0.000), 5 year DFS (74.5 %, 77.4 %, 50.5 %, p = 0.003). Multivariate analysis showed that ypN stage was an independent prognostic factor for patients 5 year DFS. Conclusions Pathological stage is strongly associated with treatment outcomes in patients with locally advanced rectal carcinoma treated with neo-CRT followed by total mesorectal excision, which may be used as guidance for further individualized treatment.
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Affiliation(s)
- Bixiu Wen
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Luning Zhang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Chengtao Wang
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Rong Huang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Haihua Peng
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Tian Zhang
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Jun Dong
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Weiwei Xiao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Zhifan Zeng
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Mengzhong Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Yuanhong Gao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
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