Current practice in approaching controversial diagnostic and therapeutic topics in gastroenteropancreatic neuroendocrine neoplasm management. Belgian multidisciplinary expert discussion based on a modified Delphi method

BACKGROUND AND STUDY AIMS

Neuroendocrine neoplasms (NENs) are relatively rare, with marked clinical and biological heterogeneity. Consequently, many controversial areas remain in diagnosis and optimal treatment stratification for NEN patients. We wanted to describe current clinical practice regarding controversial NEN topics and stimulate critical thinking and mutual learning among a Belgian multidisciplinary expert panel.

PATIENTS AND METHODS

A 3-round, Delphi method based project, coordinated by a steering committee (SC), was applied to a predefined multidisciplinary NEN expert panel studying the following controversial topics : factors guiding therapeutic decision making, the use of somatostatin analogues (SSA) in adjuvant setting, the interference between non-radioactive and radioactive SSAs, challenging small intestine neuroendocrine tumor (NET) cases, the approach of the carcinoid syndrome, the role of chemotherapy in well differentiated NET, the relevance of NET G3 and neuroendocrine carcinoma subclassification and the role of imaging techniques in NEN management.

RESULTS

A high level of consensus exists regarding the necessary diagnostic work-up, use of imaging techniques and interference between non-radioactive and radioactive SSAs. However, the prognostic impact of tumor functionality might be overrated and adequate diarrhea differential diagnostic work-up in these patients is underused. Significant differences are seen between individual experts and centers regarding treatment preferences both on the treatment modality level, as well as the choice of specific drugs (e.g. chemotherapy regimen).

CONCLUSIONS

A Delphi-like multi-round expert discussion proves useful to boost critical thinking and discussion among experts of different background, as well as to describe current clinical practice and stimulate mutual learning in the absence of high-level scientific guidance.

Surveillance recommendations for patients with Lynch syndrome and FAP : a monocentric study

BACKGROUND AND STUDY AIMS

The most important causes of hereditary colorectal cancer are Lynch syndrome (LS) and the adenomatous polyposis syndromes (familial adenomatous poly- posis syndrome or FAP, attenuated FAP or AFAP and MUTYH associated polyposis syndrome or MAP). The aim of this study was to investigate whether all patients with a hereditary syndrome within one center receive uniform advice regarding surveillance and treatment.

PATIENTS AND METHODS

A retrospective analysis was performed of all electronic patient health records of patients with LS, FAP, AFAP and MAP who received genetic counselling or were followed by a health care specialist at the University Hospital in Ghent.

RESULTS

Data from 122 patients were collected. For all patients, recommendations from the medical genetics department were highly consistent. Adherence to their recommendations was good within the center for the management of colon polyps. There was a lack of consistency in the screening and surveillance advice for other tumors in departments other than gastroenterology. Only 33 patients had systematic follow-up consultations to check results and organize surveillance.

CONCLUSION

Previously, small studies have suggested that patients with hereditary gastrointestinal cancer syndromes infrequently have surveillance as specified in the guidelines. This study shows almost uniform recommendations and good adherence for surveillance of the colon, but incomplete or contradictory advice for surveillance of other organs. The need for an integrated approach from a multidisciplinary team will only increase in the future, because more families with hereditary cancer are likely to be found due to the increased use of next generation sequencing in cancer diagnostics.

Update on liver transplantation for cholangiocarcinoma : a review of the recent literature

Cholangiocarcinoma (CC) represent 3% of all gastrointestinal tumours and can be classified anatomically in 3 types: intrahepatic (ICC), perihilar (PCC) and distal (DCC) cholangiocarcinomas. Resection is the treatment of choice but is only achieved in a few cases (<20%) because of invasion of the biliary tract and/or vascular structures. The outcome of advanced CC is poor with an overall survival (OS) of maximum 15 months with chemotherapy. In the 1990s, CC was regarded as a contraindication for liver transplantation (LT). LT has recently been proposed as potentially curative option for ICC and PCC. Careful patient selection has changed OS. This article provides an update on current status of LT for patients with unresectable CC.

Second primary malignancies in patients with a gastrointestinal neuroendocrine tumour: a case report and review of the literature

A second primary malignancy (SPM) is frequently reported in patients with a gastrointestinal neuroendocrine tumour (NET). The majority of SPM are located in the gastrointestinal tract, but malignancies at other sites are described as well. This phenomenon might just be coincidental due to high incidence rates of asymptomatic NET lesions in patients who are operated or who undergo autopsy for another primary malignancy. However, other theories have been developed since the observed incidences rates seem to be double as high as expected. Some authors suggest a common genetic predisposition, while others report tumourigenic properties of various neuroendocrine peptides, including secretin, gastrin and cholecystokinin. This review is illustrated by a case report of a patient in whom the radiological diagnosis of a diffuse liver metastasized adenocarcinoma of the rectum changed dramatically after positron emission tomography and explorative laparoscopy to a curable adenocarcinoma of the rectum with a simultaneous well-differentiated neuroendocrine carcinoma.

Endoscopic treatment of a perforated duodenal diverticulum

We describe a case of a perforated duodenal diverticulum, which was managed by a combined percutaneous and endoscopic approach. In combination with conservative treatment, this technique can be a challenging alternative to surgery.

Aortic pressure pain: clinical significance. Any relationship to the irritable bowel syndrome?

Pressure pain over the abdominal aorta is a clinical sign of undetermined significance. Ultrasonographic criteria were used to define and further evaluate this variety of epigastric tenderness. The incidence of aortic pressure pain, aortic characteristics, and gastrointestinal symptoms were scored in 250 consecutive patients. The incidence was approximately 7%. All the patients with aortic pressure pain had gastrointestinal symptoms, with a significantly higher mean symptom score. The occurrence of pressure pain was independent of any of the examined aortic characteristics, age, or body mass index. We further compared the incidence of aortic pressure pain between 25 patients with irritable bowel syndrome and 25 patients without apparent functional gastrointestinal disease. It was present in approximately 50% of the patients with irritable bowel syndrome. We found pressure pain over the abdominal aorta to be associated with significant gastrointestinal discomfort. A causal relationship is possible but not proven. Aortic pressure pain can be provoked in a significant subgroup of patients with the irritable bowel syndrome.

A case of Peutz-Jeghers syndrome with nasal polyposis, extreme iron deficiency anemia, and hamartoma-adenoma transformation: management by combined surgical and endoscopic approach

We report a rare variant of Peutz-Jeghers syndrome identified by the presence of nasal polyposis and extreme anemia. Multiple hamartomatous polyps were found throughout the upper and lower gastrointestinal tract. We conducted a combined surgical-endoscopic approach to prevent the development of a short-bowel syndrome. The polyps removed by snare and surgical polypectomy showed features typical of harmartomas. Three colonic polyps and two nasal polyps showed histological evidence of adenomatous change. This adenomatous change seems to fit into the pathogenic sequence of hamartoma-adenoma.

Infectious gastroenteritis: are they all the same?

Campylobacter jejuni and Salmonella spp are the most frequently cultured micro-organisms in infectious gastroenteritis among patients hospitalized at the departments of gastroenterology and geriatrics. As a whole, the hospitalized patient population with Campylobacter gastroenteritis is a younger one, compared to the Salmonella-infected group. Both pathogens can be associated with a biochemical pancreatitis, which is usually without clinical importance. However, serious complications can occur, with a predominance of visceritis for C. jejuni, and renal function impairment for Salmonella spp. Finally, an asymptomatic carrier state is well known in the Salmonella infection spectrum, whereas C. jejuni might cause a recurrent disease in some patients.

Combined percutaneous balloon dilation and extracorporeal shock wave lithotripsy for treatment of biliary stricture and common bile duct stones

We report a case of cholangitis, liver abscess, and common bile duct stones in a patient with a benign stricture at a choledochojejunal anastomosis, 3 yr after a complicated duodenohemipancreatectomy. Because surgical reintervention seemed inappropriate, a percutaneous transhepatic balloon dilation was performed after temporary internal-external biliary drainage. Extracorporeal shockwave lithotripsy (ESWL) was successfully applied to fragment all common bile duct stones, with subsequent spontaneous evacuation of all stone fragments through the dilated bilioenteric anastomosis. Only one similar case report has been published before (1), though with a different sequence of therapeutic modalities. Moreover, according to our literature review, this is the first report of ESWL of common bile duct stones by means of the Dornier Compact Lithotriptor (Dornier, Germany) with electromagnetic shockwave source.

Endoscopic drainage of pancreatic pseudocysts

Endoscopic drainage is a recent method in the management of pancreatic pseudocysts. It has been developed as an alternative to surgical treatment in high risk patients. Our experience with this technique is illustrated by a well documented case report which is followed by a brief review of the literature.

Endoscopic sclerotherapy: the value of balloon tamponade and the importance of disinfection

Endoscopic sclerotherapy in active variceal bleeding stopped bleeding in 48 out of 67 patients (72%). Survival of the acute bleeding episode was related to liver function: 6% mortality in Child A patients vs. 48% mortality in Child C. Comparing two treatment modalities: 24 h Linton balloon tamponade followed by sclerotherapy vs. sclerotherapy alone, our results in comparable groups slightly, although not significantly, favor tamponade-sclerotherapy treatment: 75% survival vs. 71%. As this treatment modality is more convenient and helps to avoid dangerous aspiration pneumonia, we advocate balloon tamponade prior to sclerotherapy in acute variceal bleeding. In maintenance treatment 65 patients were treated until eradication of varices. The rebleeding risk was 0.034% per patient per month, with 64% of the rebleeding within the 2 first months before complete eradication of the varices. The long-term survival depends largely on liver function: one year survival of 88% in Child A vs. 30% in Child C. Using Aethoxysklerol 1% in intravariceal injection, no stricture occurred. Using a sterile injection needle and a glutaraldehyde-disinfected endoscope, no infectious complications directly related to the procedure occurred, and all hemocultures remained negative.