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Manoharan J, Albers MB, Bartsch DK. [Individualized approach for MEN1-associated duodenopancreatic neuroendocrine neoplasms]. Chirurgie (Heidelb) 2024; 95:207-215. [PMID: 38180518 DOI: 10.1007/s00104-023-01994-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Multiple endocrine neoplasia type 1 (MEN1)-associated duodenopancreatic neuroendocrine neoplasms (dpNEN) represent the most frequent syndrome-associated cause of death, but the adequate treatment is sometimes considered controversial. OBJECTIVE Presentation of possible diagnostic and therapeutic options for MEN1-associated dpNENs. MATERIAL AND METHODS In this review article retrospective case studies, expert recommendations, national and international guidelines as well as personal experiences were analyzed and evaluated. RESULTS Due to early detection programs and the use of the most modern imaging techniques, dpNEN are nowadays diagnosed much earlier. Nonfunctional pNENs currently represent the most frequent dpNENs with about 70%, followed by gastrinomas and insulinomas. Regardless of their functional activity, dpNENs with a size of > 2 cm are generally an indication for surgery. The choice of the optimal treatment strategy, however, in most cases remains the subject of controversial discussions, although nowadays surgery should always be performed in an organ-preserving and minimally invasive way when feasible. Recurrences or new dpNENs are expected in more than 60% of cases, necessitating a reoperation in up to 40% of these cases. Duodenopancreatic resections and reoperations can be carried out safely by experienced practitioners and with an acceptable level of risk. CONCLUSION The planning of treatment requires careful consideration of the suitable timing, the extent of the operation, the risk of recurrence and potential morbidities. Furthermore, preserving pancreatic function and the quality of life is of utmost importance. In view of the complexity of the disease, MEN1 patients should be treated in specialized centers.
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Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland.
| | - Max B Albers
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
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Kann PH, Scheunemann A, Adelmeyer J, Bergmann S, Goebel JN, Bartsch DK, Holzer K, Albers MB, Manoharan J, Scheunemann LM. Regional Growth Velocity and Incidence of Pancreatic Neuroendocrine Neoplasias in Multiple Endocrine Neoplasia Type 1. Pancreas 2022; 51:1327-1331. [PMID: 37099774 DOI: 10.1097/mpa.0000000000002191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Pancreatic neuroendocrine neoplasias (pNENs) in multiple endocrine neoplasia type 1 are predominantly found in the dorsal anlage. Whether their growth velocity and incidence might be related to their location in the pancreas has not been investigated yet. METHODS We studied 117 patients using endoscopic ultrasound. RESULTS Growth velocity could be calculated for 389 pNENs. Increase of largest tumor diameter (% per month) was 0.67 (standard deviation [SD], 2.04) in the pancreatic tail (n = 138), 1.12 (SD, 3.00) in the pancreatic body (n = 100), 0.58 (SD, 1.19) in the pancreatic head/uncinate process-dorsal anlage (n = 130), and 0.68 (SD, 0.77) in the pancreatic head/uncinate process-ventral anlage (n = 12). Comparing growth velocity of all pNENs in the dorsal (n = 368, 0.76 [SD, 2.13]) versus ventral anlage, no significant difference was detected. Annual tumor incidence rate was 0.21 in the pancreatic tail, 0.13 in the pancreatic body, 0.17 in the pancreatic head/uncinate process-dorsal anlage, 0.51 dorsal anlage together, and 0.02 in the pancreatic head/uncinate process-ventral anlage. CONCLUSIONS Multiple endocrine neoplasia type 1 pNENs are unequally distributed between ventral (low prevalence and incidence) and dorsal anlage. However, there are no regional differences in growth behavior.
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Affiliation(s)
| | - Adrian Scheunemann
- From the Centre for Endocrinology, Diabetology and Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Jan Adelmeyer
- From the Centre for Endocrinology, Diabetology and Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Simona Bergmann
- From the Centre for Endocrinology, Diabetology and Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Joachim Nils Goebel
- From the Centre for Endocrinology, Diabetology and Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Katharina Holzer
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Lisann M Scheunemann
- From the Centre for Endocrinology, Diabetology and Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
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Manoharan J, Anlauf M, Albers MB, Denzer UW, Mintziras I, Wächter S, Di Fazio P, Bollmann C, Bartsch DK. Gastric enterochromaffin-like cell changes in multiple endocrine neoplasia type 1. Clin Endocrinol (Oxf) 2021; 95:439-446. [PMID: 33506527 DOI: 10.1111/cen.14430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 01/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Gastric enterochromaffin-like cell (ECL) tumours can occur in patients with multiple endocrine neoplasia type 1 (MEN1), especially in those affected by Zollinger Ellison syndrome (ZES). Since the prevalence of ECL lesions is not well defined yet, the present study evaluated the presence and extent of ECL lesions in MEN1 patients with and without ZES. METHODS Multiple endocrine neoplasia type 1 patients being part of a regular screening program (2014-2018) underwent gastroduodenoscopies with biopsies of the stomach and determination of serum gastrin and chromogranin A levels. Haematoxylin- and immunostaining with chromogranin A, gastrin and VMAT I and II (vesicular monoamine transporter I and II) of the biopsies were performed. RESULTS Thirty-eight MEN1 patients, of whom 16 (42%) were diagnosed and treated earlier for ZES, were analysed. In ten of 16 (62.5%) ZES patients, a locally scattered, mixed image of diffuse, linear and micronodular mild hyperplasia was present. In addition, two of these patients (13%) showed small (max 1.5 mm in size) intramucosal ECL tumours. Neither ECL changes, nor tumours were found in MEN1 patients without ZES (n = 22). In MEN1/ZES patients, the median serum gastrin level was significantly elevated compared to MEN1 patients without ZES (206 pg/ml vs. 30.5 pg/ml, p < .001). A subgroup analysis of the serum gastrin and chromogranin A levels of MEN1/ZES patients with or without ECL hyperplasia did not show significant differences (gastrin level: p = .302, chromogranin A: p = .464). CONCLUSION Enterochromaffin-like cell hyperplasia and gastric carcinoids occur only in MEN1 patients with ZES, but less frequently than reported.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Martin Anlauf
- Institute of Pathology and Cytology, Wetzlar, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Department of Gastroenterology, Philipps University Marburg, Marburg, Germany
| | - Ioannis Mintziras
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Sabine Wächter
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Pietro Di Fazio
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
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Kann PH, Scheunemann A, Dorzweiler P, Adelmeyer J, Bergmann S, Goebel JN, Mann V, Bartsch DK, Holzer K, Albers MB, Manoharan J, Scheunemann LM. Pancreatic Neuroendocrine Neoplasias in Multiple Endocrine Neoplasia Type 1 Are Predominantly Located in the Dorsal Anlage: An Endoscopic Ultrasound Study. Pancreas 2021; 50:1169-1172. [PMID: 34714280 DOI: 10.1097/mpa.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pancreatic neuroendocrine neoplasias (pNENs) frequently occur in multiple endocrine neoplasia type 1 (MEN1). Their distribution referring to embryology, that is, the pancreatic anlagen, has not been investigated yet. METHODS In the time between 1998 and 2019, we studied the distribution of pNENs in MEN1 concerning the embryologic origin of the pancreas, that is, the dorsal versus ventral anlage using endoscopic ultrasound in 117 MEN1 patients: 56 women, 61 men; aged 40 years (standard deviation, 14 years) at first endoscopic ultrasound. RESULTS In 105 patients, a total of 628 pNENs were detected. They were located in the pancreatic tail: 231; pancreatic body: 177; pancreatic head/uncinate process: 220. Of the latter, 22 were located in the ventral anlage, 176 in the dorsal anlage, and 22 remained undefined. In summary, just 3.5% of all detected pNENs were located in the ventral anlage, 93.0% in the dorsal anlage, and 3.5% could not be assigned. CONCLUSIONS Our study indicates that the vast majority of pNENs in MEN1 is located in the dorsal anlage, whereas the ventral anlage of the pancreas seems to be to a large extend spared from pNENs. Implications for new surgical strategies might be considered.
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Affiliation(s)
| | - Adrian Scheunemann
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Peter Dorzweiler
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Jan Adelmeyer
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Simona Bergmann
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Joachim Nils Goebel
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Verena Mann
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Katharina Holzer
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipp's University and University Hospital, Marburg, Germany
| | - Lisann M Scheunemann
- From the Centre for Endocrinology, Diabetology & Osteology, Endocrine Laboratory, Philipp's University and University Hospital, Marburg
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Najafi N, Mintziras I, Wiese D, Albers MB, Maurer E, Bartsch DK. A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms. Surg Today 2020; 50:872-880. [PMID: 32016613 DOI: 10.1007/s00595-020-01966-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/05/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms. METHODS Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed. RESULTS In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure. CONCLUSION The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.
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Affiliation(s)
- Nawid Najafi
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - I Mintziras
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - D Wiese
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - M B Albers
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - E Maurer
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - D K Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
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Manoharan J, Bollmann C, Kann PH, Di Fazio P, Bartsch DK, Albers MB. Gender Differences in Multiple Endocrine Neoplasia Type 1: Implications for Screening? Visc Med 2020; 36:3-9. [PMID: 32110650 PMCID: PMC7036590 DOI: 10.1159/000505498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/17/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Some gender-related differences have been reported in multiple endocrine neoplasia type 1 (MEN1), although not all reports are conclusive. This systematic review with analysis of the own MEN1 cohort evaluates gender differences and potential consequences for screening. METHODS A systematic review of the literature between 1990 and 2019 with the search terms "MEN1" or "multiple endocrine neoplasia type 1" and "gender" or "sex" was performed. In addition, the prospectively collected data of a genetically confirmed MEN1 cohort of the Philipps University Marburg were retrospectively analyzed. RESULTS Review of the literature identified five retrospective case series with original data of 1,057 MEN1 patients. One series suggested a higher frequency of pancreatic neuroendocrine neoplasms (NEN), especially gastrinomas, in men (61 vs. 54%) and a higher frequency of pituitary tumors in women (47 vs. 30%), but others did not. Only thymic NEN occurred predominantly in men throughout all studies. Women with MEN1 were found to have an increased risk of breast cancer. In the own series consisting of 116 MEN1 patients (male = 58, female = 58), thymic lesions were also more frequently detected in male patients (male = 5, female = 1). No gender difference was found with regard to the other manifestations. CONCLUSION Regarding the typical MEN1 tumor manifestations, gender-adapted diagnostic and therapeutic approaches cannot be recommended. Female MEN1 patients should be encouraged to participate in breast cancer screening programs.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Peter Herbert Kann
- Division of Endocrinology, Philipps University Marburg, Marburg, Germany
| | - Pietro Di Fazio
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Detlef K. Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Max B. Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
- *Dr. Max B. Albers, Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstr., DE–35043 Marburg (Germany), E-Mail
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Manoharan J, Albers MB, Bollmann C, Maurer E, Mintziras I, Wächter S, Bartsch DK. Single gland excision for MEN1-associated primary hyperparathyroidism. Clin Endocrinol (Oxf) 2020; 92:63-70. [PMID: 31626728 DOI: 10.1111/cen.14112] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
IMPORTANCE Guidelines advocate subtotal parathyroidectomy (SPTX) or total parathyroidectomy with autotransplantation (TPTX) with bilateral cervical thymectomy for primary hyperparathyroidism (pHPT) associated with multiple endocrine neoplasia type 1 (MEN1). However, both procedures are associated with a significant risk of permanent hypoparathyroidism. OBJECTIVE The aim of the current study was to compare long-term results of either single gland excision (SGE, 1-2 glands), SPTX and TPTX for the treatment of MEN1-associated pHPT. DESIGN AND SETTING Data of genetically confirmed MEN1 patients who underwent surgery for pHPT between 1987 and 2017 were retrieved from a prospective database and were retrospectively analysed. RESULTS Eighty-nine MEN1 patients underwent either TPTX (n = 38, 42.7%), SPTX (n = 23, 25.8%) or SGE (n = 28, 31.5%). The rate of disease persistence after initial surgery was 2.6%, 0% and 14.2% in the TPTX, SPTX and SGE groups, respectively. After median follow-up of 112 (range 7-411) months, the rate of recurrent pHPT was significantly higher in the SGE group (n = 19, 21.3%) compared with the TPTX (n = 4, 4.4%, P = .001) and the SPTX (n = 9, 10.1%, P = .03) groups. Analysis of the recurrence-free time among the surgical groups revealed a significant difference (P = .036). The median time to recurrence was significantly shorter after SGE (101, range 3-301 months) than after SPTX (139, range 28-278 months, P = .018) and TPTX (204, range 75-396 months, P = .049). Twelve (32%) patients who underwent TPTX developed permanent hypoparathyroidism compared with only 4 (17%, P = .06) in the SPTX and 0 in the SGE group (P = .001). CONCLUSION Given the high rate of postoperative permanent hypoparathyroidism after TPTX and SPTX, SGE is a valid option for the treatment of MEN1-associated pHPT.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Elisabeth Maurer
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Ioannis Mintziras
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Sabine Wächter
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
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Abstract
About 30% of patients with MEN1 develop a Zollinger-Ellison syndrome. Meanwhile it is well established that the causative gastrinomas are almost exclusively localized in the duodenum and not in the pancreas, MEN1 gastrinomas occur multicentric and are associated with hyperplastic gastrin cell lesions and tiny gastrin-producing micro tumors in contrast to sporadic duodenal gastrinomas. Regardless of the high prevalence of early lymphatic metastases, the survival is generally good with an aggressive course of disease in only about 20% of patients. Symptoms can be controlled medically. The indication, timing, type, and extent of surgery are highly controversial and are discussed in detail in this article by a thorough and critical review of literature. More radical procedures, like partial pancreaticoduodenectomy, are weighed against less aggressive local excision of gastrinomas and the pros and cons of both approaches are discussed in terms of long-term morbidity, biochemical cure, and survival.
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Affiliation(s)
- Max B Albers
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany.
| | - Jerena Manoharan
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University Marburg, Baldingerstr, 35037 Marburg, Germany
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Albers MB, Manoharan J, Bollmann C, Chlosta MP, Holzer K, Bartsch DK. Results of Duodenopancreatic Reoperations in Multiple Endocrine Neoplasia Type 1. World J Surg 2019; 43:552-558. [PMID: 30288555 DOI: 10.1007/s00268-018-4809-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND To evaluate the outcome of duodenopancreatic reoperations in patients with multiple endocrine neoplasia type 1 (MEN1). METHODS MEN1 patients who underwent reoperations for duodenopancreatic neuroendocrine neoplasms (dpNENs) were retrieved from a prospective database and retrospectively analyzed. RESULTS Twelve of 101 MEN1 patients underwent up to three reoperations, resulting in a total of 18 reoperations for dpNEN recurrence. Patients initially underwent either formal pancreatic resections (n = 7), enucleations (n = 3), or duodenotomy with lymphadenectomy for either NF-pNEN (seven patients), Zollinger-Ellison syndrome (ZES, three patients), organic hyperinsulinism (one patient) or VIPoma (one patient). Six patients had malignant dpNENs with lymph node (n = 5) and/or liver metastases (n = 2). The indication of reoperations was NF-pNEN (five patients), ZES (five patients), organic hyperinsulinism (one patient), and recurrent VIPoma (one patient). Median time to first reoperation was 67.5 (range 6-251) months. Five patients required a second duodenopancreatic reoperation for 60-384 months after initial surgery, and one patient underwent a third reoperation after 249 months. The rate of complications (Clavien-Dindo ≥3) was 28%. Four patients required completion pancreatectomy. Six patients developed pancreoprivic diabetes. After a median follow-up of 18 (6-34) years after initial surgery, ten of 12 patients are alive, one died of metastatic pancreatic VIPoma, and one died of metastatic thymic NEN. CONCLUSION Reoperations are frequently necessary for dpNEN in MEN1 patients, but are not associated with an increased perioperative morbidity in specialized centers. Organ-sparing resections should be preferred as initial duodenopancreatic procedures to maintain pancreatic function and avoid completion pancreatectomy.
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Affiliation(s)
- Max B Albers
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany.
| | - Jerena Manoharan
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Maximilian P Chlosta
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Katharina Holzer
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University of Marburg, Baldingerstr, 35043, Marburg, Germany
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Polenta V, Slater EP, Kann PH, Albers MB, Manoharan J, Ramaswamy A, Mahnken AH, Bartsch DK. Preoperative Imaging Overestimates the Tumor Size in Pancreatic Neuroendocrine Neoplasms Associated with Multiple Endocrine Neoplasia Type 1. World J Surg 2018; 42:1440-1447. [PMID: 29075857 DOI: 10.1007/s00268-017-4317-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Radiological tumor size of non-functioning pancreatic neuroendocrine neoplasms (Nf-pNENs) associated with multiple endocrine neoplasia type 1 (MEN1) is a crucial parameter to indicate surgery. The aim of this study was to compare radiological size (RS) and pathologic size (PS) of MEN1 associated with pNENs. METHODS Prospectively collected data of MEN1 patients who underwent pancreatic resections for pNENs were retrospectively analyzed. RS was defined as the largest tumor diameter measured on endoscopic ultrasound (EUS), magnetic resonance imaging (MRI) or computed tomography (CT). PS was defined as the largest tumor diameter on pathological analysis. Student's t test and linear regression analysis were used to compare the median RS and PS. p < 0.05 was considered significant. RESULTS Forty-four patients with a median age of 37 (range 10-68) years underwent primary pancreatic resections for pNENs. Overall, the median RS (20 mm, range 3-100 mm) was significantly larger than the PS (13 mm, range 4-110 mm) (p = 0.001). In patients with pNENs < 20 mm (n = 27), the size difference (median RS 15 mm vs PS 12 mm) was also significant (p = 0.003). However, the only modality that significantly overestimated the PS was EUS (median RS 14 mm vs 11 mm; p = 0.0002). RS overestimated the PS in 21 patients (21 of 27 patients, 78%). Five of 11 patients (12%) with a Nf-pNEN and a RS > 20 mm had in reality a PS < 20 mm. MRI was the imaging technique that best correlated with PS in the total cohort (r = 0.8; p < 0.0001), whereas EUS was the best correlating imaging tool in pNENs < 20 mm (r = 0.5; p = 0.0001). CONCLUSION Preoperative imaging, especially EUS, frequently overestimates the size of MEN1-pNENs, especially those with a PS < 20 mm. This should be considered when indicating surgery in MEN1 patients with small Nf-pNENs.
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Affiliation(s)
- V Polenta
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany. .,Department of General Surgery, Ospedali Riuniti Ancona, Conca 71, Torrette, 60020, Ancona, Italy.
| | - E P Slater
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - P H Kann
- Division Endocrinology, Philipps-University Marburg, Marburg, Germany
| | - M B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - J Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
| | - A Ramaswamy
- Institute of Pathology, Philipps-University Marburg, Marburg, Germany
| | - A H Mahnken
- Department of Radiology, Philipps-University Marburg, Marburg, Germany
| | - D K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University Marburg, Marburg, Germany
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Manoharan J, Raue F, Lopez CL, Albers MB, Bollmann C, Fendrich V, Slater EP, Bartsch DK. Is Routine Screening of Young Asymptomatic MEN1 Patients Necessary? World J Surg 2018; 41:2026-2032. [PMID: 28321559 DOI: 10.1007/s00268-017-3992-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent clinical practice guidelines recommend that routine screening of MEN1 mutation carriers should start at the age of 5 years. The occurrence of clinically relevant MEN1 organ manifestations in children (≤18 years) was evaluated. METHODS Two prospective collected databases of MEN1 patients (n = 166) who underwent annual screening were retrospectively analyzed for organ manifestations in MEN1 patients ≤18 years. The follow-up was based on the most recent screening examination until December 2015. RESULTS Twenty [11 females, 9 males, (12%)] of 166 MEN1 patients were diagnosed with at least one organ manifestation at age ≤18 years. The most frequent manifestation was mild asymptomatic pHPT (n = 9, 45%, age range 8-18 years). Eight (40%) young patients had pNENs (three non-functioning pNENs, five insulinomas, age range 9-18 years). All five insulinomas were diagnosed based on hypoglycemic symptoms. The other organ manifestations were asymptomatic pituitary adenomas in six patients (30%, age range 15-18 years) and a bronchial carcinoid in one 15-year-old patient. Only six (30%) patients ≤18 years had clinically relevant organ manifestations. CONCLUSION Symptomatic or severe manifestations in MEN1 patients rarely occur below the age of 16 years. With regard to psychological burden and cost-effectiveness, routine screening of asymptomatic MEN1 patients should be postponed at least until the age of 16 years.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany.
| | - Friedhelm Raue
- Practice and Molecular Laboratory, Brueckenstrasse 21, 69120, Heidelberg, Germany
| | - Caroline L Lopez
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
| | - Volker Fendrich
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
| | - Emily P Slater
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35041, Marburg, Germany
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Manoharan J, Fendrich V, Di Fazio P, Bollmann C, Roth S, Joos B, Mintziras I, Albers MB, Ramaswamy A, Bertolino P, Zhang CX, Slater EP, Bartsch DK, Lopez-Lopez CL. Chemoprevention with Enalapril and Aspirin in Men1(+/T) Knockout Mouse Model. Neuroendocrinology 2018; 107:257-266. [PMID: 30025403 DOI: 10.1159/000492224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/18/2018] [Indexed: 02/05/2023]
Abstract
Pancreatic neuroendocrine neoplasias (pNEN) are the most common cause of death in adult patients with multiple endocrine neoplasia type 1 (MEN1). So far, only few chemopreventive strategies (e.g., with somatostatin analogues) have been evaluated for MEN1 associated pNENs. In this experimental study on 75 Men1(+/T) knockout mice, the effect of aspirin (n = 25) and an inhibitor of angiotensin-I converting enzyme (enalapril, n = 25) compared to controls (n = 25) were evaluated as single chemopreventive strategies for pNENs after 6, 9, 12, 15, and 18 months. After each study period, mice were sacrificed and the resected pancreata were evaluated by histopathological analysis, immunostaining, and real-time PCR. PNEN size and number was measured. Aspirin and enalapril lead to a pNEN size reduction of 80% (167,518 vs. 838,876 µm2, p < 0.001) and 79% (174,758 vs. 838,876 µm2, p < 0.001) compared to controls. Furthermore, aspirin and enalapril treatment resulted in a significant reduction of the number of pNENs by 33%, (p = 0.04) and 41% (p = 0.002) respectively. The apoptosis marker caspase 3 revealed a higher positive expression in pNEN of treated Men1(+/T) mice. Immunostaining of VEGF in pNEN detected a downregulation of its expression in treated Men1(+/T) mice compared to the control group. REL A transcript was significantly downregulated in 18-months treated enalapril Men1(+/T) mice, but not in aspirin-treated Men1(+/T) mice. There was no significant difference in the Ki-67 index. Using a transgenic mouse model that imitates human MEN1, this study provides first evidence that aspirin and enalapril are effective chemopreventive agents that aid in the progression of pNENs.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg,
| | - Volker Fendrich
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Pietro Di Fazio
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Carmen Bollmann
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Silvia Roth
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Barbara Joos
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Ioannis Mintziras
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Annette Ramaswamy
- Department of Pathology, Philipps University Marburg, Marburg, Germany
| | - Philippe Bertolino
- Centre de Recherche en Cancérologie de Lyon, Inserm U1052, CNRS UMR5286, Université Lyon 1, Lyon, France
| | - Chang X Zhang
- Centre de Recherche en Cancérologie de Lyon, Inserm U1052, CNRS UMR5286, Université Lyon 1, Lyon, France
| | - Emily P Slater
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Caroline L Lopez-Lopez
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
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Manoharan J, Albers MB, Bartsch DK. The future: diagnostic and imaging advances in MEN1 therapeutic approaches and management strategies. Endocr Relat Cancer 2017; 24:T209-T225. [PMID: 28790162 DOI: 10.1530/erc-17-0231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 08/08/2017] [Indexed: 12/13/2022]
Abstract
Prospective randomized data are lacking, but current clinical expert guidelines recommend annual screening examinations, including laboratory assessments and various imaging modalities (e.g. CT, MRI, scintigraphy and EUS) for patients with multiple endocrine neoplasia type 1 (MEN1). Routine screening is proposed to detect and localize neuroendocrine manifestations as early as possible. The goal is timely intervention to improve quality of life and to increase life expectancy by preventing the development of life-threatening hormonal syndromes and/or metastatic disease. In recent years, some studies compared different and new imaging methods regarding their sensitivity and utility in MEN1 patients. This present article reviews the proposed diagnostic tools for MEN1 screening as well as potential future perspectives.
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Affiliation(s)
- Jerena Manoharan
- Department of VisceralThoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Max B Albers
- Department of VisceralThoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Detlef K Bartsch
- Department of VisceralThoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
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Manoharan J, Lopez CL, Hackmann K, Albers MB, Pehl A, Kann PH, Slater EP, Schröck E, Bartsch DK. An unusual phenotype of MEN1 syndrome with a SI-NEN associated with a deletion of the MEN1 gene. Endocrinol Diabetes Metab Case Rep 2016; 2016:160011. [PMID: 27076911 PMCID: PMC4828980 DOI: 10.1530/edm-16-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 12/12/2022] Open
Abstract
We report about a young female who developed an unusual and an aggressive phenotype of the MEN1 syndrome characterized by the development of a pHPT, malignant non-functioning pancreatic and duodenal neuroendocrine neoplasias, a pituitary adenoma, a non-functioning adrenal adenoma and also a malignant jejunal NET at the age of 37 years. Initial Sanger sequencing could not detect a germline mutation of the MEN1 gene, but next generation sequencing and MPLA revealed a deletion of the MEN1 gene ranging between 7.6 and 25.9 kb. Small intestine neuroendocrine neoplasias (SI-NENs) are currently not considered to be a part of the phenotype of the MEN1-syndrome. In our patient the SI-NENs were detected during follow-up imaging on Ga68-Dotatoc PET/CT and could be completely resected. Although SI-NENs are extremely rare, these tumors should also be considered in MEN1 patients. Whether an aggressive phenotype or the occurrence of SI-NENs in MEN1 are more likely associated with large deletions of the gene warrants further investigation.
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Affiliation(s)
- Jerena Manoharan
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Caroline L Lopez
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Karl Hackmann
- Faculty of Medicine Carl Gustav Carus, Institute for Clinical Genetics, TU Dresden, Fetscherstrasse 7401307, Dresden, Germany; German Cancer Consortium (DKTK), Dresden, Germany, German Cancer Research Center (DKFZ), Heidelberg, Germany, National Center for Tumor Diseases (NCT), Dresden, Germany
| | - Max B Albers
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Anika Pehl
- Department of Pathology, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Peter H Kann
- Division of Endocrinology and Diabetology, Department of Gastroenterology and Endocrinology, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Emily P Slater
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
| | - Evelin Schröck
- Faculty of Medicine Carl Gustav Carus, Institute for Clinical Genetics, TU Dresden, Fetscherstrasse 7401307, Dresden, Germany; German Cancer Consortium (DKTK), Dresden, Germany, German Cancer Research Center (DKFZ), Heidelberg, Germany, National Center for Tumor Diseases (NCT), Dresden, Germany
| | - Detlef K Bartsch
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg , Baldingerstrasse35043, Marburg , Germany
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Bartsch DK, Albers MB, Lopez CL, Apitzsch JC, Walthers EM, Fink L, Fendrich V, Slater EP, Waldmann J, Anlauf M. Bronchopulmonary Neuroendocrine Neoplasms and Their Precursor Lesions in Multiple Endocrine Neoplasia Type 1. Neuroendocrinology 2016; 103:240-7. [PMID: 26113081 DOI: 10.1159/000435921] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 06/10/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The prevalence and clinical behavior of bronchopulmonary neuroendocrine tumors (bNET) associated with multiple endocrine neoplasia type 1 (MEN1) are not well defined. This study aimed to determine the prevalence, potential precursor lesions and prognosis of bNET in patients with MEN1. METHODS A database of 75 prospectively collected MEN1 cases was retrospectively analyzed for bNET. Patient characteristics, imaging and treatment were evaluated. Resection specimens of operated patients were reassessed by two specialized pathologists. Available CT scans of the whole cohort were reviewed to determine the prevalence of bronchopulmonary nodules. RESULTS Five of the 75 MEN1 patients (6.6%; 2 male, 3 female) developed histologically confirmed bNET after a median follow-up of 134 months. The median age at diagnosis of bNET was 47 years (range 31-67), and all patients were asymptomatic. Four patients underwent anatomic lung resections with lymphadenectomy; the remaining patient with multiple lesions had only a wedge resection of the largest bNET. Tumor sizes ranged from 7 to 32 mm in diameter, and all bNET were well differentiated. Two patients had lymph node metastases. Two of 4 reevaluated resection specimens revealed multifocal bNET, and 3 specimens showed tumorlets (up to 3) associated with multifocal areas of a neuroendocrine cell hyperplasia within the subsegmental bronchi. One bNET-related death (1.3%) occurred during long-term follow-up. Review of the available CT scans of the patients without proven bNET revealed small bronchopulmonary lesions (≥3 mm) in 16 of 53 cases (30.2%). CONCLUSIONS bNET in MEN1 might be more common than previously recognized. Their natural course seems to be rather benign. Multifocal tumorlets and multifocal neuroendocrine cell hyperplasia might represent their precursor lesions.
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Affiliation(s)
- Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-Universitx00E4;t Marburg, Marburg, Germany
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Bartsch DK, Albers MB. Controversies in surgery for multiple endocrine neoplasia type 1-associated Zollinger–Ellison syndrome. International Journal of Endocrine Oncology 2015. [DOI: 10.2217/ije.15.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Zollinger–Ellison syndrome (ZES) is a common manifestation of multiple endocrine neoplasia type 1 (MEN1). At least 90% of MEN1-ZES patients have multiple duodenal gastrinomas, making the duodenum the target organ of ZES. The indication and the timing of surgery in MEN1-ZES is controversial, since there is yet no parameter that indicates an aggressive course of disease and long-term survival is generally good. An imageable, most likely nonfunctioning pancreatic neuroendocrine neoplasm (pNEN) >1–2 cm seems to be a good surrogate parameter to indicate surgery in order to prevent distant metastatic pNEN disease, although some groups indicate surgery at the time of biochemical ZES evidence. The optimal surgical procedure is also controversial. Different strategies encomprise local excision via duodenotomy with or without distal pancreatic resection and regional lymphadenectomy to partial pancreaticoduodenectomy. At present, the timing and type of surgery for MEN1-ZES should be individualized according to patient’s characteristics and preference.
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Affiliation(s)
- Detlef K Bartsch
- Department of Visceral, Thoracic & Vascular Surgery, University Hospital Gießen/Marburg GmbH, Philipps-University Marburg, Baldingerstrasse, 35043 Marburg, Germany
| | - Max B Albers
- Department of Visceral, Thoracic & Vascular Surgery, University Hospital Gießen/Marburg GmbH, Philipps-University Marburg, Baldingerstrasse, 35043 Marburg, Germany
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Sesterhenn AM, Albers MB, Timmesfeld N, Werner JA, Wiegand S. Dermal metastases in squamous cell carcinomas of the head and neck. Head Neck 2012; 35:767-71. [DOI: 10.1002/hed.23025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2012] [Indexed: 11/06/2022] Open
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Belloti JC, Moraes VY, Albers MB, Faloppa F, Dos Santos JBG. Does an ulnar styloid fracture interfere with the results of a distal radius fracture? J Orthop Sci 2010; 15:216-22. [PMID: 20358335 DOI: 10.1007/s00776-009-1443-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 12/01/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND The ulnar styloid is a supportive structure for the capsular ligament complex of the distal radioulnar joint. The relation between fractures of the ulna and distal radius is not clear, especially in regard to whether ulnar fractures predict worse outcomes for distal radius fractures. The objective of this study was to analyze the influence of ulnar styloid fractures in patients with reducible and unstable distal radius fractures. METHODS A total of 100 patients with unstable and reducible distal radius fractures, with or without an ulnar styloid fracture, were randomly assigned to treatment with transarticular bridging external fixation or transulnar percutaneous pinning. Follow-up was obtained for 91 patients. For the secondary data analysis, three patient cohorts were created: a no ulnar styloid fracture group with the radius fracture treated by pinning or external fixation (n = 30); an ulnar styloid fracture with radius fracture group treated by external fixation (n = 31); and an ulnar styloid fracture with radius fracture treated by pinning (n = 30). Functional and radiological outcomes were measured at 6 and 24 months. Functional outcome measures included wrist pain (visual analogue scale) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS At 24 months, patients with both fractures had worse wrist pain and worse scores on the DASH questionnaire than the patients with an isolated distal radius fracture; and those treated by pinning had less wrist pain and showed better scores on the DASH questionnaire than the patients treated by fixation. CONCLUSIONS Ulnar styloid fracture may be a predictive factor of worse functional outcome for distal radius fracture. Pinning and above-the-elbow casting, used to treat ulnar styloid fractures, led to better function than fixation.
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Affiliation(s)
- J C Belloti
- Department of Orthopaedics and Traumatology, Federal University of São Paulo, Escola Paulista de Medicina, Rua Borges Lagoa 783-5 degrees Andar, 04038-031, São Paulo, SP, Brazil
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