1
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Ail DA, Paulose RR. A relook at gastroenteropancreatic neuroendocrine tumours as per 2019 WHO classification-A tertiary centre experience. Ir J Med Sci 2023; 192:2065-2070. [PMID: 36409421 DOI: 10.1007/s11845-022-03217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Neuroendocrine neoplasm of GIT (gastrointestinal tract) and pancreas is heterogenous with variable clinical features and disease outcomes. Despite multiple attempts of risk stratification by grading and staging, some have unpredictable clinical courses. Well-differentiated grade 3 neuroendocrine tumour (G3NET) is a recent subcategory introduced in the 2019 WHO classification based on morphology, molecular profile and prognosis distinguishing it from neuroendocrine carcinoma(NEC). This study aimed at describing the spectrum of NENs encountered in a tertiary centre with focus on reclassifying previously reported G3 tumours into G3 NET and NEC and comparing the survival between them. METHODOLOGY This is an 8-year retrospective study of all gastro-entero-pancreatic neuroendocrine neoplasms reclassified according to the 2019 WHO classification based on morphology and Ki-67 index with analysis of the survival rates between the categories. Minimum follow-up period was 20 months. RESULTS Eighty-six patients with NENs of gastro-entero-pancreas were included, with median age group of 40-60 years (age range 9 to 79 years) and male:female ratio of 1.7:1. The tumour grade correlated with the TNM staging and most of the syndromic NETs were low grade. Eleven percent of the tumours were reclassified as well-differentiated G3NETs. The survival of G3 NETs was higher than NEC. CONCLUSION Grading of NEN is vital for therapeutic decisions and for prognostication. Currently, morphology is the key to recognise the well-differentiated G3 NETs, but can be subject to interobserver variability. Molecular surrogates may play a role in accurately identifying these entities, the validity of which is warranted.
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Affiliation(s)
- Divya Achutha Ail
- GI and Liver Pathology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
- Department of Pathology, Yenepoya Medical College, Mangalore, India
| | - Roopa Rachel Paulose
- Department of Pathology, Amrita Institute of Medical Sciences, Kochi, Kerala, India.
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2
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Cuny T, Fargette C, Taïeb D. Imaging of multiple endocrine neoplasia type 1 patients in the era of somatostatin receptor positron emission tomography–computed tomography: “no place to hide for neuroendocrine tumours”. Eur J Endocrinol 2023; 188:C9-C10. [PMID: 37220756 DOI: 10.1093/ejendo/lvad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/22/2023] [Accepted: 05/10/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Thomas Cuny
- APHM, Marseille Medical Genetics, Inserm U1251, Conception Hospital, Endocrinology Department, Aix Marseille University , Marseille , France
| | - Christelle Fargette
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix-Marseille University , Marseille , France
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix-Marseille University , Marseille , France
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3
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Graf A, Welch J, Bansal R, Mandl A, Parekh VI, Cochran C, Levy E, Nilubol N, Patel D, Sadowski S, Jha S, Agarwal SK, Millo C, Blau JE, Simonds WF, Weinstein LS, Del Rivero J. Metastatic Grade 3 Neuroendocrine Tumor in Multiple Endocrine Neoplasia Type 1 (MEN1) Expressing Somatostatin Receptors. J Endocr Soc 2022; 6:bvac122. [DOI: 10.1210/jendso/bvac122] [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] [Received: 03/17/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) can occur in 30-90% of patients with Multiple Endocrine Neoplasia Type 1 (MEN1). However, only 1% of GEP-NETs are Grade 3 (G3). Given the rarity of these aggressive tumors, treatment of advanced G3 GEP-NETs in MEN1 is based on the treatment guidelines for sporadic GEP-NETs. We report a 43-year-old male with germline MEN1 followed at our institution with clinical features including hyperparathyroidism, a non-functional pancreatic NET, and Zollinger-Ellison Syndrome. On routine surveillances imaging, at age 40, computer tomography (CT/ positron emission tomography (PET)) imaging showed two arterially enhancing intraluminal masses on the medial aspect of the gastric wall. Anatomical imaging confirmed two enhancing masses within the pancreas and a rounded mass-like thickening along the lesser curvature of the stomach. The gastric mass was resected, and pathology reported a well-differentiated G3 NET with a Ki-67 >20%. The patient continued active surveillance. Eighteen months later cross-sectional imaging studies showed findings consistent with metastatic disease within the right hepatic lobe and bland embolization was done. On follow-up scans, including 68Ga-DOTATATE (68Ga-DOTA(0)-Tyr(3)-octreotate) imaging, interval increase in number and avidity of metastatic lesions were compatible with disease progression. Given a paucity of treatment recommendations for G3 tumors in MEN1, the patient was counseled based on standard NET treatment guidelines and recommended 177Lu-DOTATATE treatment. PRRT (peptide receptor radionuclide therapy) with 177Lu-DOTATATE ( 177Lu-tetraazacyclododecanetetraacetic acid-octreotide) is an important therapeutic modality for patients with somatostatin receptor-positive (SSTR) NETs. However, prospective studies are needed to understand the role of PRRT in G3 NETs.
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Affiliation(s)
- Akua Graf
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - James Welch
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Rashika Bansal
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Adel Mandl
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Vaishali I Parekh
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Craig Cochran
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Elliot Levy
- Radiology and Imaging Sciences, Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, MD
| | - Naris Nilubol
- Endocrine Surgery Section, Surgical Oncology Program, National Cancer Institute , Bethesda, MD
| | - Dhaval Patel
- Endocrine Surgery Section, Surgical Oncology Program, National Cancer Institute , Bethesda, MD
| | - Samira Sadowski
- Endocrine Surgery Section, Surgical Oncology Program, National Cancer Institute , Bethesda, MD
| | - Smita Jha
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Sunita K Agarwal
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Corina Millo
- Radiology and Imaging Sciences, Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, MD
| | - Jenny E Blau
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
- Presently employed full-time at Astra-Zeneca , Gaithersburg, MD
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Lee S Weinstein
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health , Bethesda, MD
| | - Jaydira Del Rivero
- Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, Maryland
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4
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Luchini C, Pantanowitz L, Adsay V, Asa SL, Antonini P, Girolami I, Veronese N, Nottegar A, Cingarlini S, Landoni L, Brosens LA, Verschuur AV, Mattiolo P, Pea A, Mafficini A, Milella M, Niazi MK, Gurcan MN, Eccher A, Cree IA, Scarpa A. Ki-67 assessment of pancreatic neuroendocrine neoplasms: Systematic review and meta-analysis of manual vs. digital pathology scoring. Mod Pathol 2022; 35:712-720. [PMID: 35249100 PMCID: PMC9174054 DOI: 10.1038/s41379-022-01055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 12/18/2022]
Abstract
Ki-67 assessment is a key step in the diagnosis of neuroendocrine neoplasms (NENs) from all anatomic locations. Several challenges exist related to quantifying the Ki-67 proliferation index due to lack of method standardization and inter-reader variability. The application of digital pathology coupled with machine learning has been shown to be highly accurate and reproducible for the evaluation of Ki-67 in NENs. We systematically reviewed all published studies on the subject of Ki-67 assessment in pancreatic NENs (PanNENs) employing digital image analysis (DIA). The most common advantages of DIA were improvement in the standardization and reliability of Ki-67 evaluation, as well as its speed and practicality, compared to the current gold standard approach of manual counts from captured images, which is cumbersome and time consuming. The main limitations were attributed to higher costs, lack of widespread availability (as of yet), operator qualification and training issues (if it is not done by pathologists), and most importantly, the drawback of image algorithms counting contaminating non-neoplastic cells and other signals like hemosiderin. However, solutions are rapidly developing for all of these challenging issues. A comparative meta-analysis for DIA versus manual counting shows very high concordance (global coefficient of concordance: 0.94, 95% CI: 0.83-0.98) between these two modalities. These findings support the widespread adoption of validated DIA methods for Ki-67 assessment in PanNENs, provided that measures are in place to ensure counting of only tumor cells either by software modifications or education of non-pathologist operators, as well as selection of standard regions of interest for analysis. NENs, being cellular and monotonous neoplasms, are naturally more amenable to Ki-67 assessment. However, lessons of this review may be applicable to other neoplasms where proliferation activity has become an integral part of theranostic evaluation including breast, brain, and hematolymphoid neoplasms.
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Affiliation(s)
- Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy.
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy.
| | - Liron Pantanowitz
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, MI, USA
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Sylvia L Asa
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Pietro Antonini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Ilaria Girolami
- Division of Pathology, San Maurizio Central Hospital, Bolzano, Italy
| | - Nicola Veronese
- Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Alessia Nottegar
- Pathology Unit, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Sara Cingarlini
- Department of Medicine, Section of Oncology, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Lodewijk A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna V Verschuur
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Antonio Pea
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Andrea Mafficini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Michele Milella
- Department of Medicine, Section of Oncology, University and Hospital Trust of Verona, Verona, Italy
| | - Muhammad K Niazi
- Center for Biomedical Informatics, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Metin N Gurcan
- Center for Biomedical Informatics, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Albino Eccher
- Pathology Unit, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Ian A Cree
- International Agency for Research on Cancer, IARC, Lyon, France
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy.
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy.
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5
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Hackeng WM, van Beek DJ, Kok ASM, van Emst M, Morsink FHM, van Treijen MJC, Borel Rinkes IHM, Dreijerink KMA, Offerhaus GJA, Valk GD, Vriens MR, Brosens LAA. Metastatic Patterns of Duodenopancreatic Neuroendocrine Tumors in Patients With Multiple Endocrine Neoplasia Type 1. Am J Surg Pathol 2022; 46:159-168. [PMID: 34560682 DOI: 10.1097/pas.0000000000001811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with multiple endocrine neoplasia 1 syndrome (MEN1) often develop multifocal duodenopancreatic neuroendocrine tumors (dpNETs). Nonfunctional pancreatic neuroendocrine tumors (PanNETs) and duodenal gastrinomas are the most frequent origins of metastasis. Current guidelines recommend surgery based on tumor functionality, size ≥2 cm, grade or presence of lymph node metastases. However, in case of multiple primary tumors it is often unknown which specific tumor metastasized. This study aims to unravel the relationship between primary dpNETs and metastases in patients with MEN1 by studying endocrine differentiation. First, it was shown that expression of the endocrine differentiation markers ARX and PDX1 was concordant in 18 unifocal sporadic neuroendocrine tumors (NETs) and matched metastases. Thereafter, ARX, PDX1, Ki67 and gastrin expression, and the presence of alternative lengthening of telomeres were determined in 137 microscopic and macroscopic dpNETs and 36 matched metastases in 10 patients with MEN1. ARX and PDX1 H-score clustering was performed to infer relatedness. For patients with multiple metastases, similar intrametastases transcription factor expression suggests that most metastases (29/32) originated from a single NET of origin, while few patients may have multiple metastatic primary NETs. In 6 patients with MEN1 and hypergastrinemia, periduodenopancreatic lymph node metastases expressed gastrin, and clustered with minute duodenal gastrinomas, not with larger PanNETs. PanNET metastases often clustered with high grade or alternative lengthening of telomeres-positive primary tumors. In conclusion, for patients with MEN1-related hypergastrinemia and PanNETs, a duodenal origin of periduodenopancreatic lymph node metastases should be considered, even when current conventional and functional imaging studies do not reveal duodenal tumors preoperatively.
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Affiliation(s)
- Wenzel M Hackeng
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht
| | - Aranxa S M Kok
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Madelon van Emst
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Folkert H M Morsink
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Mark J C van Treijen
- Department of Endocrine Oncology, University Medical Center Utrecht Cancer Center, Utrecht
| | | | - Koen M A Dreijerink
- Department of Endocrinology and Internal Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht University
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht Cancer Center, Utrecht
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht
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6
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Marini F, Giusti F, Tonelli F, Brandi ML. Pancreatic Neuroendocrine Neoplasms in Multiple Endocrine Neoplasia Type 1. Int J Mol Sci 2021; 22:4041. [PMID: 33919851 PMCID: PMC8070788 DOI: 10.3390/ijms22084041] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are a rare group of cancers accounting for about 1-2% of all pancreatic neoplasms. About 10% of pNETs arise within endocrine tumor syndromes, such as Multiple Endocrine Neoplasia type 1 (MEN1). pNETs affect 30-80% of MEN1 patients, manifesting prevalently as multiple microadenomas. pNETs in patients with MEN1 are particularly difficult to treat due to differences in their growth potential, their multiplicity, the frequent requirement of extensive surgery, the high rate of post-operative recurrences, and the concomitant development of other tumors. MEN1 syndrome is caused by germinal heterozygote inactivating mutation of the MEN1 gene, encoding the menin tumor suppressor protein. MEN1-related pNETs develop following the complete loss of function of wild-type menin. Menin is a key regulator of endocrine cell plasticity and its loss in these cells is sufficient for tumor initiation. Somatic biallelic loss of wild-type menin in the neuroendocrine pancreas presumably alters the epigenetic control of gene expression, mediated by histone modifications and DNA hypermethylation, as a driver of MEN1-associated pNET tumorigenesis. In this light, epigenetic-based therapies aimed to correct the altered DNA methylation, and/or histone modifications might be a possible therapeutic strategy for MEN1 pNETs, for whom standard treatments fail.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
| | - Francesco Tonelli
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
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7
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Calissendorff J, Bjellerup-Calissendorff F, Bränström R, Juhlin CC, Falhammar H. Characteristics, Treatment, Outcomes, and Survival in Neuroendocrine G1 and G2 Pancreatic Tumors: Experiences From a Single Tertiary Referral Center. Front Endocrinol (Lausanne) 2021; 12:657698. [PMID: 33927695 PMCID: PMC8076901 DOI: 10.3389/fendo.2021.657698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/22/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Neuroendocrine tumors of the pancreas (Pan-NETs) are usually hormonally inactive with a capacity to metastasize. Since Pan-NETs are rare, more knowledge is needed. Methods We reviewed all patients' medical files with Pan-NET treated at a tertiary center (2006-2019). Grade 1 (G1) and grade 2 (G2) tumors were compared. The latter group was subdivided arbitrarily based on proliferation index into G2a (3-9.9%) and G2b (10-19.9%). Results We found 137 patients (76 females, 61 males; G1 n=66, G2 n=42), the median age at diagnosis 61 years (interquartile range (IQR) 50-71), and tumor size 2 cm (1.3-5 cm). The initial surgery was performed in 101 patients. The remaining (n=36) were followed conservatively. Metastatic disease was evident in 22 patients (16%) at diagnosis while new lesions developed in 13 out of 22 patients (59%). In patients without previous metastatic disease, progressive disease was discovered in 29% of G1 vs. 55% of G2 patients (P=0.009), 47% of G2a vs. 75% of G2b patients (NS). Survival was poorer in patients with metastasis at diagnosis vs. those with local disease (P<0.001). During follow-up of 74 months, Pan-NET related death was found in 10 patients. Survival was not different between G1 vs. G2 or G2a vs. G2b, or if tumors were functional. Size ≤2 cm was associated with a better outcome (P=0.004). During the follow-up of small tumors (≤2 cm, n=36) two were resected. Conclusion In small non-functional Pan-NETs, active surveillance is reasonable. Progressive disease was more common in G2, but survival was similar in G1, G2 and between G2 subgroups. Survival was poorer in patients with metastasis at diagnosis.
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Affiliation(s)
- Jan Calissendorff
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Freja Bjellerup-Calissendorff
- Department of Pathology, Västmanland County Hospital, Västerås, Sweden
- Center for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - Robert Bränström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine and Sarcoma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - C. Christofer Juhlin
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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8
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Brandi ML, Agarwal SK, Perrier ND, Lines KE, Valk GD, Thakker RV. Multiple Endocrine Neoplasia Type 1: Latest Insights. Endocr Rev 2021; 42:133-170. [PMID: 33249439 PMCID: PMC7958143 DOI: 10.1210/endrev/bnaa031] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 02/06/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1), a rare tumor syndrome that is inherited in an autosomal dominant pattern, is continuing to raise great interest for endocrinology, gastroenterology, surgery, radiology, genetics, and molecular biology specialists. There have been 2 major clinical practice guidance papers published in the past 2 decades, with the most recent published 8 years ago. Since then, several new insights on the basic biology and clinical features of MEN1 have appeared in the literature, and those data are discussed in this review. The genetic and molecular interactions of the MEN1-encoded protein menin with transcription factors and chromatin-modifying proteins in cell signaling pathways mediated by transforming growth factor β/bone morphogenetic protein, a few nuclear receptors, Wnt/β-catenin, and Hedgehog, and preclinical studies in mouse models have facilitated the understanding of the pathogenesis of MEN1-associated tumors and potential pharmacological interventions. The advancements in genetic diagnosis have offered a chance to recognize MEN1-related conditions in germline MEN1 mutation-negative patients. There is rapidly accumulating knowledge about clinical presentation in children, adolescents, and pregnancy that is translatable into the management of these very fragile patients. The discoveries about the genetic and molecular signatures of sporadic neuroendocrine tumors support the development of clinical trials with novel targeted therapies, along with advancements in diagnostic tools and surgical approaches. Finally, quality of life studies in patients affected by MEN1 and related conditions represent an effort necessary to develop a pharmacoeconomic interpretation of the problem. Because advances are being made both broadly and in focused areas, this timely review presents and discusses those studies collectively.
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Affiliation(s)
| | | | - Nancy D Perrier
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Gerlof D Valk
- University Medical Center Utrecht, CX Utrecht, the Netherlands
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9
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van Beek DJ, Nell S, Vorselaars WMCM, Bonsing BA, van Eijck CHJ, van Goor H, Nieveen van Dijkum EJ, Dejong CHC, Valk GD, Borel Rinkes IHM, Vriens MR. Complications After Major Surgery for Duodenopancreatic Neuroendocrine Tumors in Patients with MEN1: Results from a Nationwide Cohort. Ann Surg Oncol 2021; 28:4387-4399. [PMID: 33521900 PMCID: PMC8253708 DOI: 10.1245/s10434-020-09496-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/01/2020] [Indexed: 12/16/2022]
Abstract
Background Little is known about complications after major duodenopancreatic surgery for duodenopancreatic neuroendocrine tumors (dpNETs) in multiple endocrine neoplasia type 1 (MEN1). Therefore, the incidence and severity of complications after major surgery for MEN1-related dpNETs were assessed. Methods Patients were selected from the population-based Dutch MEN1 database if they had undergone a Whipple procedure or total pancreatectomy from 2003 to 2017. Complications were graded according to the Clavien–Dindo classification (grade III or higher complications were considered a severe complication) and definitions from the International Study Group of Pancreatic Surgery. The Cumulative Complication Index (CCI®) was calculated as the sum of all complications weighted for their severity. Univariable logistic regression was performed to assess potential associations between predictor candidates and a severe complication. Results Twenty-seven patients (median age 43 years) underwent a major duodenopancreatic resection, including 14 Whipple procedures and 13 total pancreatectomies. Morbidity and mortality were 100% (27/27) and 4% (1/27), respectively. A severe complication occurred in 17/27 (63%) patients. The median CCI® was 47.8 [range 8.7–100]. Grade B/C pancreatic fistulas, delayed gastric emptying, bile leakage, hemorrhage, and chyle leakage occurred in 7/14 (50%), 10/27 (37%), 1/27 (4%), 7/27 (26%), 3/27 (11%) patients, respectively. Patients with a severe complication had longer operative time and higher blood loss. After Whipple, new-onset endocrine and exocrine insufficiency occurred in 1/13 and 9/14 patients, respectively. Conclusions Major duodenopancreatic surgery in MEN1 is associated with a very high risk of severe complications and cumulative burden of complications and should therefore be reserved for a select subgroup of patients with MEN1-related dpNETs. Supplementary Information The online version of this article (10.1245/s10434-020-09496-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd Nell
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wessel M C M Vorselaars
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Niederle B, Selberherr A, Bartsch DK, Brandi ML, Doherty GM, Falconi M, Goudet P, Halfdanarson TR, Ito T, Jensen RT, Larghi A, Lee L, Öberg K, Pavel M, Perren A, Sadowski SM, Tonelli F, Triponez F, Valk GD, O'Toole D, Scott-Coombes D, Thakker RV, Thompson GB, Treglia G, Wiedenmann B. Multiple Endocrine Neoplasia Type 1 and the Pancreas: Diagnosis and Treatment of Functioning and Non-Functioning Pancreatic and Duodenal Neuroendocrine Neoplasia within the MEN1 Syndrome - An International Consensus Statement. Neuroendocrinology 2021; 111:609-630. [PMID: 32971521 DOI: 10.1159/000511791] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
The better understanding of the biological behavior of multiple endocrine neoplasia type 1 (MEN1) organ manifestations and the increase in clinical experience warrant a revision of previously published guidelines. Duodenopancreatic neuroendocrine neoplasias (DP-NENs) are still the second most common manifestation in MEN1 and, besides NENs of the thymus, remain a leading cause of death. DP-NENs are thus of main interest in the effort to reevaluate recommendations for their diagnosis and treatment. Especially over the last 2 years, more clinical experience has documented the follow-up of treated and untreated (natural-course) DP-NENs. It was the aim of the international consortium of experts in endocrinology, genetics, radiology, surgery, gastroenterology, and oncology to systematically review the literature and to present a consensus statement based on the highest levels of evidence. Reviewing the literature published over the past decade, the focus was on the diagnosis of F- and NF-DP-NENs within the MEN1 syndrome in an effort to further standardize and improve treatment and follow-up, as well as to establish a "logbook" for the diagnosis and treatment of DP-NENs. This shall help further reduce complications and improve long-term treatment results in these rare tumors. The following international consensus statement builds upon the previously published guidelines of 2001 and 2012 and attempts to supplement the recommendations issued by various national and international societies.
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Affiliation(s)
- Bruno Niederle
- Department of Surgery, Medical University of Vienna, Vienna, Austria,
| | | | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Maria L Brandi
- Firmo Lab, Fondazione F.I.R.M.O. and University Florence, Florence, Italy
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Pierre Goudet
- Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Universitaire François Mitterand, Dijon, France
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital and Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Sawara-ku, Fukuoka, Japan
| | - Robert T Jensen
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS and Center for Endoscopic Research, Therapeutics and Training, Catholic University, Rome, Italy
| | - Lingaku Lee
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kjell Öberg
- Endocrine Oncology, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Marianne Pavel
- Endocrinology and Diabetology, Department of Medicine 1, University Clinic of Erlangen, Erlangen, Germany
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dermot O'Toole
- Department of Clinical Medicine, St. James's Hospital and St Vincent's University Hospital and Trinity College, Dublin, Ireland
| | - David Scott-Coombes
- Department of Endocrine Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Geoffrey B Thompson
- Section of Endocrine Surgery, Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giorgio Treglia
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Bertram Wiedenmann
- Department of Gastroenterology and Hepatology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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11
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van Beek DJ, Verkooijen HM, Nell S, Bonsing BA, van Eijck CH, van Goor H, Hoogwater FJH, Nieveen van Dijkum EJM, Kazemier G, Dejong CHC, Brosens LAA, Wessels FJ, Borel Rinkes IHM, Valk GD, Vriens MR. Reliability and Agreement of Radiological and Pathological Tumor Size in Patients with Multiple Endocrine Neoplasia Type 1-Related Pancreatic Neuroendocrine Tumors: Results from a Population-Based Cohort. Neuroendocrinology 2021; 111:705-717. [PMID: 32721974 PMCID: PMC8491507 DOI: 10.1159/000510514] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/07/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (pNETs) have a high prevalence in patients with multiple endocrine neoplasia type 1 (MEN1) and are the leading cause of death. Tumor size is still regarded as the main prognostic factor and therefore used for surgical decision-making. We assessed reliability and agreement of radiological and pathological tumor size in a population-based cohort of patients with MEN1-related pNETs. METHODS Patients were selected from the Dutch MEN1 database if they had undergone a resection for a pNET between 2003 and 2018. Radiological (MRI, CT, and endoscopic ultrasonography [EUS]) and pathological tumor size were collected from patient records. Measures of agreement (Bland-Altman plots with limits of agreement [LoA] and absolute agreement) and reliability (intraclass correlation coefficients [ICC] and unweighted kappa) were calculated for continuous and categorized (< or ≥2 cm) pNET size. RESULTS In 73 included patients, the median radiological and pathological tumor sizes measured were 22 (3-160) and 21 (4-200) mm, respectively. Mean bias between radiological and pathological tumor size was -0.2 mm and LoA ranged from -12.9 to 12.6 mm. For the subgroups of MRI, CT, and EUS, LoA of radiological and pathological tumor size ranged from -9.6 to 10.9, -15.9 to 15.8, and -13.9 to 11.0, respectively. ICCs for the overall cohort, MRI, CT, and EUS were 0.80, 0.86, 0.75, and 0.76, respectively. Based on the 2 cm criterion, agreement was 81.5%; hence, 12 patients (18.5%) were classified differently between imaging and pathology. Absolute agreement and kappa values of MRI, CT, and EUS were 88.6, 85.7, and 75.0%, and 0.77, 0.71, and 0.50, respectively. CONCLUSION Within a population-based cohort, MEN1-related pNET size was not systematically over- or underestimated on preoperative imaging. Based on agreement and reliability measures, MRI is the preferred imaging modality.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd Nell
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederik J H Hoogwater
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center location Academic Medical Center, Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center location VUmc University Medical Center, Amsterdam, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
- Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands,
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12
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Metastatic Potential and Survival of Duodenal and Pancreatic Tumors in Multiple Endocrine Neoplasia Type 1: A GTE and AFCE Cohort Study (Groupe d'étude des Tumeurs Endocrines and Association Francophone de Chirurgie Endocrinienne). Ann Surg 2020; 272:1094-1101. [PMID: 30585820 DOI: 10.1097/sla.0000000000003162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the distant metastatic potential of duodeno-pancreatic neuroendocrine tumors (DP-NETs) in patients with MEN1, according to functional status and size. SUMMARY BACKGROUND DATA DP-NETs, with their numerous lesions and endocrine secretion-related symptoms, continue to be a medical challenge; unfortunately they can become aggressive tumors associated with distant metastasis, shortening survival. The survival of patients with large nonfunctional DP-NETs is known to be poor, but the overall contribution of DP-NETs to metastatic spread is poorly known. METHODS The study population included patients with DP-NETs diagnosed after 1990 and followed in the MEN1 cohort of the Groupe d'étude des Tumeurs Endocrines (GTE). A multistate Markov piecewise constant intensities model was applied to separate the effects of prognostic factors on 1) metastasis, and 2) metastasis-free death or 3) death after appearance of metastases. RESULTS Among the 603 patients included, 39 had metastasis at diagnosis of DP-NET, 50 developed metastases during follow-up, and 69 died. The Markov model showed that Zollinger-Ellison-related tumors (regardless of tumor size and thymic tumor pejorative impact), large tumors over 2 cm, and age over 40 years were independently associated with an increased risk of metastases. Men, patients over 40 years old and patients with tumors larger than 2 cm, also had an increased risk of death once metastasis appeared. CONCLUSIONS DP-NETs of 2 cm in size or more, regardless of the associated secretion, should be removed to prevent metastasis and increase survival. Surgery for gastrinoma remains debatable.
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13
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Prognosis after surgery for multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors: Functionality matters. Surgery 2020; 169:963-973. [PMID: 33220975 DOI: 10.1016/j.surg.2020.09.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/06/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Metastasized pancreatic neuroendocrine tumors are the leading cause of death in patients with multiple endocrine neoplasia type 1. Aside from tumor size, prognostic factors of pancreatic neuroendocrine tumors are largely unknown. The present study aimed to assess whether the prognosis of patients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors differs from those with resected multiple endocrine neoplasia type 1-related insulinomas and assessed factors associated with prognosis. METHODS Patients who underwent resection of a multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors between 1990 and 2016 were identified in 2 databases: the DutchMEN Study Group and the International MEN1 Insulinoma Study Group databases. Cox regression was performed to compare liver metastases-free survival of patients with a nonfunctioning pancreatic neuroendocrine tumors versus those with an insulinoma and to identify factors associated with liver metastases-free survival. RESULTS Out of 153 patients with multiple endocrine neoplasia type 1, 61 underwent resection for a nonfunctioning pancreatic neuroendocrine tumor and 92 for an insulinoma. Of the patients with resected lymph nodes, 56% (18/32) of nonfunctioning pancreatic neuroendocrine tumors had lymph node metastases compared to 10% (4/41) of insulinomas (P = .001). Estimated 10-year liver metastases-free survival was 63% (95% confidence interval 42%-76%) for nonfunctioning pancreatic neuroendocrine tumors and 87% (72%-91%) for insulinomas. After adjustment for size, World Health Organization tumor grade, and age, nonfunctioning pancreatic neuroendocrine tumors had an increased risk for liver metastases or death (hazard ratio 3.04 [1.47-6.30]). In pancreatic neuroendocrine tumors ≥2 cm, nonfunctioning pancreatic neuroendocrine tumors (2.99 [1.22-7.33]) and World Health Organization grade 2 (2.95 [1.02-8.50]) were associated with liver metastases-free survival. CONCLUSION Patients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors had a significantly lower liver metastases-free survival than patients with insulinomas. Postoperative counseling and follow-up regimens should be tumor type specific and at least consider size and World Health Organization grade.
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Sadowski SM, Pieterman CRC, Perrier ND, Triponez F, Valk GD. Prognostic factors for the outcome of nonfunctioning pancreatic neuroendocrine tumors in MEN1: a systematic review of literature. Endocr Relat Cancer 2020; 27:R145-R161. [PMID: 32229700 PMCID: PMC7304521 DOI: 10.1530/erc-19-0372] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Metastatic duodenopancreatic neuro-endocrine tumors (dpNETs) are the most important disease-related cause of death in patients with multiple endocrine neoplasia type 1 (MEN1). Nonfunctioning pNETs (NF-pNETs) are highly prevalent in MEN1 and clinically heterogeneous. Therefore, management is controversial. Data on prognostic factors for risk stratification are limited. This systematic review aims to establish the current state of evidence regarding prognostic factors in MEN1-related NF-pNETs. We systematically searched four databases for studies assessing prognostic value of any factor on NF-pNET progression, development of distant metastases, and/or overall survival. In- and exclusion, critical appraisal and data-extraction were performed independently by two authors according to pre-defined criteria. Thirteen studies (370 unique patients) were included. Prognostic factors investigated were tumor size, timing of surgical resection, WHO grade, methylation, p27/p18 expression by immunohistochemistry (IHC), ARX/PDX1 IHC and alternative lengthening of telomeres. Results were complemented with evidence from studies in MEN1-related pNET for which data could not be separately extracted for NF-pNET and data from sporadic NF-pNET. We found that the most important prognostic factors used in clinical decision making in MEN1-related NF-pNETs are tumor size and grade. NF-pNETs <2 cm may be managed with watchful waiting, while surgical resection is advised for NF-pNETs ≥2 cm. Grade 2 NF-pNETs should be considered high risk. The most promising and MEN1-relevant avenues of prognostic research are multi-analyte circulating biomarkers, tissue-based molecular factors and imaging-based prognostication. Multi-institutional collaboration between clinical, translation and basic scientists with uniform data and biospecimen collection in prospective cohorts should advance the field.
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Affiliation(s)
- S M Sadowski
- Endocrine Surgery, Surgical Oncology Program, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - C R C Pieterman
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - F Triponez
- Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - G D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Hackeng WM, Schelhaas W, Morsink FHM, Heidsma CM, van Eeden S, Valk GD, Vriens MR, Heaphy CM, Nieveen van Dijkum EJM, Offerhaus GJA, Dreijerink KMA, Brosens LAA. Alternative Lengthening of Telomeres and Differential Expression of Endocrine Transcription Factors Distinguish Metastatic and Non-metastatic Insulinomas. Endocr Pathol 2020; 31:108-118. [PMID: 32103422 PMCID: PMC7250793 DOI: 10.1007/s12022-020-09611-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Insulin-producing pancreatic neuroendocrine tumors (PanNETs)/insulinomas are generally considered to be indolent tumors with an excellent prognosis after complete resection. However, some insulinomas have a poor prognosis due to relapses and metastatic disease. Recently, studies in non-functional PanNETs indicated that behavior can be stratified according to alpha- and beta-cell differentiation, as defined by expression of the transcription factors ARX and PDX1, respectively. It is unknown whether similar mechanisms play a role in insulinomas. Therefore, we determined ARX and PDX1 expression in a cohort of 35 sporadic primary insulinomas and two liver metastases of inoperable primary insulinomas. In addition, WHO grade and loss of ATRX or DAXX were determined by immunohistochemistry, and alternative lengthening of telomeres (ALT) and CDKN2A status by fluorescence in situ hybridization. These findings were correlated with tumor characteristics and clinical follow-up data. In total, five out of 37 insulinoma patients developed metastatic disease. Metastatic insulinomas were all larger than 3 cm, whereas the indolent insulinomas were smaller (p value < 0.05). All three primary insulinomas that metastasized showed ARX expression, 2/3 showed ALT, and 1/3 had a homozygous deletion of CDKN2A as opposed to absence of ARX expression, ALT, or CDKN2A deletions in the 32 non-metastatic cases. The two liver metastases also showed ARX expression and ALT (2/2). The presence of ARX expression, which is usually absent in beta-cells, and genetic alterations not seen in indolent insulinomas strongly suggest a distinct tumorigenic mechanism in malignant insulinomas, with similarities to non-functional PanNETs. These observations may inform future follow-up strategies after insulinoma surgery.
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Affiliation(s)
- Wenzel M Hackeng
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Willemien Schelhaas
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Folkert H M Morsink
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Charlotte M Heidsma
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Susanne van Eeden
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gerlof D Valk
- Department of Endocrinology and Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology and Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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16
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Hackeng WM, Morsink FHM, Moons LMG, Heaphy CM, Offerhaus GJA, Dreijerink KMA, Brosens LAA. Assessment of ARX expression, a novel biomarker for metastatic risk in pancreatic neuroendocrine tumors, in endoscopic ultrasound fine-needle aspiration. Diagn Cytopathol 2019; 48:308-315. [PMID: 31846235 PMCID: PMC7079001 DOI: 10.1002/dc.24368] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The transcription factors ARX and PDX1, and alternative lengthening of telomeres (ALT) were recently described as prognostic markers for resected non-functional pancreatic neuroendocrine tumors (PanNETs). ALT positive tumors with ARX expression relapse most often. Currently, tumor size is the only preoperative marker used to decide whether or not to operate, thus additional preoperative prognostic markers are needed. Therefore, it is critical to assess the performance of these biomarkers on preoperative cytologic specimens. METHODS Endoscopic fine-needle aspiration cellblock material and corresponding surgical specimens of 13 patients with PanNETs were assessed for histology, immunohistochemical staining of ARX, PDX1, Synaptophysin, Ki67, and telomere-specific fluorescence in situ hybridization to detect ALT, and then associated with clinicopathological features. Scoring for ARX and PDX1 was performed blinded by two independent observers. RESULTS Of the 13 surgical specimens, 8 were ARX+/PDX1-, 2 ARX-/PDX1+, and 3 ARX+/PDX1+. Concordance between cytologic and surgical specimens for ARX protein expression was 100%, whereas concordance for PDX1, ALT, and WHO tumor grade was 85%, 91%, and 73%, respectively. There was a perfect inter-observer agreement in ARX and PDX1 scoring. CONCLUSION ARX can reliably be determined in cytologic specimens and has low inter-observer variability. For cytology, false-positive PDX1 expression was observed, possibly due to contamination or sampling, while ALT had a false-negative case due to incomplete sampling. As previously observed, tumor grade is underestimated in cytologic specimens. Thus, ARX and ALT are the most promising markers to predict metastatic behavior in PanNETs, thereby warranting further validation in larger studies.
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Affiliation(s)
- Wenzel M Hackeng
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Folkert H M Morsink
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher M Heaphy
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology and Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Challis BG, Casey RT, Grossman A, Newell-Price J, Newey P, Thakker RV. What is the appropriate management of nonfunctioning pancreatic neuroendocrine tumours disclosed on screening in adult patients with multiple endocrine neoplasia type 1? Clin Endocrinol (Oxf) 2019; 91:708-715. [PMID: 31505044 DOI: 10.1111/cen.14094] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is an inherited tumour syndrome characterised by a predisposition to the development of endocrine tumours of the parathyroid glands, pituitary and pancreas: 30%-80% of patients with MEN1 develop pancreatic neuroendocrine tumours (pNETs), with metastatic tumours and/or their sequelae contributing to increased morbidity and early mortality. The optimal management of nonfunctioning (NF) pNETs in MEN1 remains controversial. Whilst pancreatic resection is widely recommended for tumours >2 cm, for smaller tumours (≤2 cm) a well-established consensus guiding the indications for surgical intervention does not exist. Although total pancreatectomy may be curative for some patients, both short- and long-term complications make this an unsatisfactory option for many patients. For small (<2 cm) MEN1 NF-pNETs, some clinicians advocate surveillance based largely on retrospective data that suggest 50%-80% of these lesions are stable over time and infrequently exhibit accelerated growth rates. It is increasingly recognised, however, that NF-pNETs exhibit unpredictable malignant behaviour that is not determined by tumour size alone, thereby prompting other clinicians to advocate surgery for all MEN1 NF-pNETs, irrespective of size. Such uncertainty poses clinical management challenges with regards to the timing and extent of surgery, which is further hindered by the inability to stratify patients based on predicted tumour behaviour. It is therefore critical that future MEN1 research initiatives include: (a) the discovery of biomarkers that better predict tumour behaviour; (b) the evaluation of medical therapies that may delay, or even prevent, the need for pancreatic surgery; and, ultimately, (c) improvement in the quality of life for individuals with MEN1. Here, based on the published literature, we address the Clinical Question, 'What is the management of NF-pNETs disclosed on screening in adult patients with MEN1?'.
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Affiliation(s)
- Benjamin G Challis
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Translational Science & Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Ruth T Casey
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Medical Genetics, Cambridge University, Cambridge, UK
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Royal Free Hospital ENETS Centre of Excellence, London, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - Paul Newey
- Division of Molecular & Clinical Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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18
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Valk G. Update on phenotypes of MEN1 mutation carriers. ANNALES D'ENDOCRINOLOGIE 2019; 80:193-194. [DOI: 10.1016/j.ando.2019.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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19
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Kamilaris CDC, Stratakis CA. Multiple Endocrine Neoplasia Type 1 (MEN1): An Update and the Significance of Early Genetic and Clinical Diagnosis. Front Endocrinol (Lausanne) 2019; 10:339. [PMID: 31263451 PMCID: PMC6584804 DOI: 10.3389/fendo.2019.00339] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 05/10/2019] [Indexed: 12/21/2022] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a rare hereditary tumor syndrome inherited in an autosomal dominant manner and characterized by a predisposition to a multitude of endocrine neoplasms primarily of parathyroid, enteropancreatic, and anterior pituitary origin, as well as nonendocrine neoplasms. Other endocrine tumors in MEN1 include foregut carcinoid tumors, adrenocortical tumors, and rarely pheochromocytoma. Nonendocrine manifestations include meningiomas and ependymomas, lipomas, angiofibromas, collagenomas, and leiomyomas. MEN1 is caused by inactivating mutations of the tumor suppressor gene MEN1 which encodes the protein menin. This syndrome can affect all age groups, with 17% of patients developing MEN1-associated tumors before 21 years of age. Despite advances in the diagnosis and treatment of MEN1-associated tumors, patients with MEN1 continue to have decreased life expectancy primarily due to malignant neuroendocrine tumors. The most recent clinical practice guidelines for MEN1, published in 2012, highlight the need for early genetic and clinical diagnosis of MEN1 and recommend an intensive surveillance approach for both patients with this syndrome and asymptomatic carriers starting at the age of 5 years with the goal of timely detection and management of MEN1-associated neoplasms and ultimately decreased disease-specific morbidity and mortality. Unfortunately, there is no clear genotype-phenotype correlation and individual mutation-dependent surveillance is not possible currently.
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Neoplasms of the Neuroendocrine Pancreas: An Update in the Classification, Definition, and Molecular Genetic Advances. Adv Anat Pathol 2019; 26:13-30. [PMID: 29912000 DOI: 10.1097/pap.0000000000000201] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This review focuses on discussing the main modifications of the recently published 2017 WHO Classification of Neoplasms of the Neuroendocrine Pancreas (panNEN). Recent updates separate pancreatic neuroendocrine tumors into 2 broad categories: well-differentiated pancreatic neuroendocrine tumors (panNET) and poorly differentiated pancreatic neuroendocrine carcinoma (panNEC), and incorporates a new subcategory of "well-differentiated high-grade NET (G3)" to the well-differentiated NET category. This new classification algorithm aims to improve the prediction of clinical outcomes and survival and help clinicians select better therapeutic strategies for patient care and management. In addition, these neuroendocrine neoplasms are capable of producing large quantity of hormones leading to clinical hormone hypersecretion syndromes. These functioning tumors include, insulinomas, glucagonomas, somatostatinomas, gastrinomas, VIPomas, serotonin-producing tumors, and ACTH-producing tumors. Although most panNENs arise as sporadic diseases, a subset of these heterogeneous tumors present as parts on inherited genetic syndromes, such as multiple endocrine neoplasia type 1, von Hippel-Lindau, neurofibromatosis type 1, tuberous sclerosis, and glucagon cell hyperplasia and neoplasia syndromes. Characteristic clinical and morphologic findings for certain functioning and syndromic panNENs should alert both pathologists and clinicians as appropriate patient management and possible genetic counseling may be necessary.
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Abstract
This article reviews the role of surgical and medical management in patients with Zollinger-Ellison syndrome (ZES) due to a gastrin-secreting neuroendocrine tumor (gastrinoma). It concentrates on the status at present but also briefly reviews the changes over time in treatment approaches. Generally, surgical and medical therapy are complementary today; however, in some cases, such as patients with ZES and multiple endocrine neoplasia type 1, the treatment approach remains controversial.
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Affiliation(s)
- Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, 291 campus Drive, Stanford, CA 94305-5101, USA
| | - Deshka S Foster
- Department of Surgery, Stanford University School of Medicine, 291 campus Drive, Stanford, CA 94305-5101, USA
| | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare, 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, National Institutes of Health, Building 10, Room 9C-103, Bethesda, MD 20892-1804, USA.
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Conemans EB, Lodewijk L, Moelans CB, Offerhaus GJA, Pieterman CRC, Morsink FH, Dekkers OM, de Herder WW, Hermus AR, van der Horst-Schrivers AN, Drent ML, Bisschop PH, Havekes B, Brosens LAA, Dreijerink KMA, Borel Rinkes IHM, Timmers HTM, Valk GD, Vriens MR. DNA methylation profiling in MEN1-related pancreatic neuroendocrine tumors reveals a potential epigenetic target for treatment. Eur J Endocrinol 2018; 179:153-160. [PMID: 29903750 DOI: 10.1530/eje-18-0195] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/14/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Epigenetic changes contribute to pancreatic neuroendocrine tumor (PanNET) development. Hypermethylation of promoter DNA as a cause of tumor suppressor gene silencing is a well-established oncogenic mechanism that is potentially reversible and therefore an interesting therapeutic target. Multiple endocrine neoplasia type 1 (MEN1) is the most frequent cause of inherited PanNETs. The aim of this study was to determine promoter methylation profiles in MEN1-related PanNETs. DESIGN AND METHODS Methylation-specific multiplex ligation-dependent probe amplification was used to assess promoter methylation of 56 tumor suppressor genes in MEN1-related (n = 61) and sporadic (n = 34) PanNETs. Differences in cumulative methylation index (CMI), individual methylation percentages and frequency of promoter hypermethylation between subgroups were analyzed. RESULTS We found promoter methylation of a large number of potential tumor suppressor genes. CMI (median CMI: 912 vs 876, P = 0.207) was the same in MEN1-related and sporadic PanNETs. We found higher methylation percentages of CASP8 in MEN1-related PanNETs (median: 59% vs 16.5%, P = 0.002). In MEN1-related non-functioning PanNETs, the CMI was higher in larger PanNETs (>2 cm) (median: 969.5 vs 838.5; P = 0.021) and in PanNETs with liver metastases (median: 1036 vs 869; P = 0.013). Hypermethylation of MGMT2 was more frequent in non-functioning PanNETs compared to insulinomas (median: 44.7% vs 8.3%; P = 0.022). Hypermethylation of the Von Hippel-Lindau gene promoter was observed in one MEN1-related PanNET and was associated with loss of protein expression. CONCLUSION Promoter hypermethylation is a frequent event in MEN1-related and sporadic PanNETs. Targeting DNA methylation could be of therapeutic value in MEN1 patients with advanced PanNETs.
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Affiliation(s)
- E B Conemans
- Departments of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Departments of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Departments of Section Endocrinology, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - L Lodewijk
- Departments of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C B Moelans
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C R C Pieterman
- Departments of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F H Morsink
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O M Dekkers
- Departments of Endocrinology and Metabolism and Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - W W de Herder
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A R Hermus
- Department of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - M L Drent
- Departments of Section Endocrinology, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - P H Bisschop
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - B Havekes
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K M A Dreijerink
- Departments of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Departments of Section Endocrinology, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - I H M Borel Rinkes
- Departments of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Th M Timmers
- Regenerative Medicine Center and Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ) and Department of Urology, Medical Center-University of Freiburg, Freiburg, Germany
| | - G D Valk
- Departments of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M R Vriens
- Departments of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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van Beek DJ, van Leeuwaarde RS, Pieterman CRC, Vriens MR, Valk GD. 'Quality in, quality out', a stepwise approach to EBM for rare diseases promoted by MEN1. Endocr Connect 2018; 7:/journals/ec/aop/ec-18-0359.xml. [PMID: 30352412 PMCID: PMC6215791 DOI: 10.1530/ec-18-0359] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/13/2018] [Indexed: 12/20/2022]
Abstract
Rare diseases pose specific challenges in the field of medical research to provide physicians with evidence based guidelines derived from studies with sufficient quality. An example of these rare diseases is multiple endocrine neoplasia type 1 (MEN1), which is an autosomal dominant endocrine tumor syndrome with an estimated occurrence rate of 2-3 per 100.000. For this complex disease, characterized by multiple endocrine tumors, it proves difficult to perform both adequate and feasible studies. The opinion of patients themselves is of utmost importance to identify the gaps in the evidence based medicine regarding clinical care. In the search for scientific answers to clinical research questions, the aim for best available evidence is obvious. Observational studies within patient cohorts, although prone to bias, seem the most feasible study design regarding the disease prevalence. Knowledge and adaptation to all types of bias is demanded in the strive for answers. Guided by our research on MEN1 patients, we elaborate on strategies to identify sufficient patients, to maximize and maintain patient enrollment and to standardize the data collection process. Preferably, data collection is performed prospectively, however, under certain conditions data storage in a longitudinal retrospective database with a disease-specific framework is suitable. Considering the global challenges on observational research on rare diseases, we propose a stepwise approach from clinical research questions to scientific answers.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Carolina R C Pieterman
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
- Parelsnoer InstituteUtrecht, The Netherlands
| | - the DutchMEN Study Group
- Department of Endocrine Surgical OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
- Department of Endocrine OncologyUniversity Medical Center Utrecht, Utrecht, The Netherlands
- Parelsnoer InstituteUtrecht, The Netherlands
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