Carcinoid tumors of the duodenum

Prevalence and risk factors for lymph node metastasis in duodenal neuroendocrine tumors: a systematic review and meta-analysis

BACKGROUND

Although the status of lymph node metastasis (LNM) is crucial in determining treatment strategy for duodenal neuroendocrine tumors (D-NETs), robust evidence for their potential LNM risk remains lacking. This systematic review aimed to summarize the prevalence and risk factors of LNM in D-NETs.

METHODS

This systematic review of electronic databases identified eligible case-control and cohort studies for D-NET resected either endoscopically or surgically, published from 1990 to 2023. The primary outcome was the pooled prevalence of LNM in D-NETs. Secondary outcomes included the pooled prevalence of LNM according to tumor location and functionality, as well as identifying pathological risk factors for LNM. Meta-analysis was performed.

RESULTS

We identified 36 studies that involved 1,396 patients with D-NETs, including 326 with LNM. The pooled prevalence of LNM in D-NETs was 22.7% (95% confidence interval [CI] 17.3-29.2%). The prevalence was high in ampullary/peri-ampullary D-NETs and functional D-NETs (46.8 and 53.3%, respectively), whereas it was low in non-functional, non-ampullary D-NETs (NAD-NETs) (9.5%). Pathological risk factors for LNM in NAD-NETs included tumor size > 10 mm (odds ratio [OR] 7.31 [95% CI 3.28-16.31]), tumor invasion into the muscularis propria or deeper (OR 7.79 [3.65-16.61]), lymphovascular invasion (OR 5.67 [2.29-14.06]), and World Health Organization grading of G2 (OR 2.47 [1.03-5.92]).

CONCLUSION

Approximately one-fourth of the patients with D-NETs had LNM. Endoscopic resection might be acceptable for non-functional NAD-NETs with diameters of 10 mm or less, but additional surgical resection with lymphadenectomy may be recommended for cases exhibiting pathological risk factors.

Surgical and Endoscopic Resection of Duodenal Neuroendocrine Tumors Have Similar Disease-Specific Survival Outcome

BACKGROUND

Duodenal neuroendocrine tumors (dNETs) are rare, and their management is not well-defined. National Comprehensive Cancer Network (NCCN) guidelines recommend surgical resection of large dNETs (> 2 cm) and endoscopic resection of small tumors (< 2 cm). We compared the survival outcomes between surgical and endoscopic resection in various dNET sizes.

METHODS

A retrospective cohort study was conducted using patient data from Surveillance, Epidemiology, and End Results Program (SEER) database. Variables analyzed included age, tumor size, grade, stage, and lymph node status. Disease-specific survival (DSS) was compared for endoscopic and surgical groups in dNET size strata: 0-0.5, 0.5-1, 1-2, 2-3, and > 3 cm. Kaplan-Meier and multivariable Cox proportional hazards models were used for survival analysis.

RESULTS

The study included 465 patients, with 124 (26.7%) undergoing surgical resection. The average age was 61.9 years, and tumor sizes ranged from 0.1 to 10.5 cm. Endoscopic resection had 40.5% of tumors between 0 and 0.5 cm, while surgery had only 21% (p < 0.001). In the surgical cohort, 79.8% had grade 1 tumors compared to 88.3% in the endoscopy group (P = 0.024). Among surgically resected cases, 48.4% (60 patients) had lymph node involvement. Age, tumor size, grade, and stage did not significantly predict survival after surgical resection. Stratified by tumor size, no difference in DSS was observed between surgery and endoscopy groups.

CONCLUSIONS

Endoscopic resection demonstrated similar survival outcomes to surgical resection across dNET sizes in this national analysis. Given the risks and the lack of survival benefits for surgery, endoscopic resection may be beneficial for both small and large tumors. Further studies are warranted to validate the current NCCN guidelines.

Long-term outcomes of endoscopic resection for duodenal neuroendocrine tumors

Duodenal neuroendocrine tumors (d-NETs) ≤ 10 mm in size, confined to the submucosal layer, without lymph node or distant metastasis, can be treated safely and effectively by endoscopic management. However, most results are based on limited data and short follow-up outcomes. Herein, we aimed to evaluate the short-term and long-term outcomes of endoscopic resection for d-NETs. We retrospectively analyzed 63 patients with 68 d-NETs who had undergone endoscopic resection at two hospitals between January 2009 and December 2021. En-bloc resection, endoscopically complete resection, and histopathologically complete resection rates were evaluated as short-term outcomes. Furthermore, long-term outcomes were analyzed in 46 patients with 50 d-NETs with a follow-up period of > 1 year. The overall en-bloc, endoscopically complete, and histopathologically complete resection rates were 92.6% (63/68), 100% (68/68), and 69.1% (47/68), respectively. Tumor size (> 5 mm) was the only predictive factor for histopathologically incomplete resection (p = 0.015). The procedure-related bleeding and perforation rates were 0% and 5.9%, respectively. No recurrences were observed in patients with histopathologically complete resection and those with histopathologically incomplete resection at a median follow-up period of 48 months (range 12-132 months). Endoscopic resection for d-NETs ≤ 10 mm in size, limited to the submucosal layer, and without lymph node or distant metastasis provides favorable long-term outcomes when endoscopically complete resection is achieved.

A Comprehensive Review on Neuroendocrine Neoplasms: Presentation, Pathophysiology and Management

Neuroendocrine neoplasms (NENs) are a group of heterogeneous tumors with neuroendocrine differentiation that can arise from any organ. They account for 2% of all malignancies in the United States. A significant proportion of NEN patients experience endocrine imbalances consequent to increased amine or peptide hormone secretion, impacting their quality of life and prognosis. Over the last decade, pathologic categorization, diagnostic techniques and therapeutic choices for NENs-both well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs)-have appreciably evolved. Diagnosis of NEN mostly follows a suspicion from clinical features or incidental imaging findings. Hormonal or non-hormonal biomarkers (like serum serotonin, urine 5-HIAA, gastrin and VIP) and histology of a suspected NEN is, therefore, critical for both confirmation of the diagnosis and classification as an NET or NEC. Therapy for NENs has progressed recently based on a better molecular understanding, including the involvement of mTOR, VEGF and peptide receptor radionuclide therapy (PRRT), which add to the growing evidence supporting the possibility of treatment beyond complete resection. As the incidence of NENs is on the rise in the United States and several other countries, physicians are more likely to see these cases, and their better understanding may support earlier diagnosis and tailoring treatment to the patient. We have compiled clinically significant evidence for NENs, including relevant changes to clinical practice that have greatly updated our diagnostic and therapeutic approach for NEN patients.

Analysis of Prognostic Risk Factors of Endoscopic Submucosal Dissection (ESD) and Curative Resection of Gastrointestinal Neuroendocrine Neoplasms

Objective

To explore the prognostic risk factors of ESD curative resection of gastrointestinal-neuroendocrine neoplasms (GI-NENs).

Methods

A total of 97 patients treated with ESD successfully in our hospital were selected, their surgical site, size, number of resection lesions, operation time, intraoperative complications (such as bleeding and perforation), and treatment status were recorded, and the number of hemostatic clamps used after the postoperative follow-up results and the independent risk factors for ESD complications were obtained through the comparison between the noncomplication group and the ESD complication group using regression analysis.

Results

A total of 97 patients with gastrointestinal neuroendocrine tumors were treated with ESD. 61 were males, 36 were females, the ratio of male to female was 1.7 : 1, onset age was 20–78 years old, and median onset age was 50 years old. In 81 cases, tumors were located in the stomach, 10 in the duodenum, and 6 in the rectum. A total of 103 lesions were detected by endoscopy, including 1 case with 2 sites in the stomach, 5 cases with 2 sites in the rectum, and the rest were single. The tumor diameter was 0.3 ∼ 2.5 cm, and the median diameter was 0.6 cm; there were 25 sites with a diameter less than 5 cm. There were 57 places with 10 mm, 16 places with 10–15 mm, and 5 places with >15 mm. All ESD operations were performed in one piece, with a total resection rate of 100%; 89.6% (60/67) of postoperative pathology showed negative basal, and 90.3% (56/62) showed negative resection margin, with a complete resection rate of 88.9% (48/54). ESD's operation time is 6 ∼ 66 min, and the median time is 18 min. During the operation, 5 cases had small amount of bleeding, 3 cases were perforated, 2 cases of delayed postoperative bleeding, 1 case of bleeding was caused by the patient's failure to follow the advice of the doctor to eat a large amount of solid food too early, and 1 case of delayed perforation (all recovered and discharged). ESD operation that bled, age, gender, and perforation location, pathological grade, pathological classification, tumor diameter, tumor surface, operation time, number of titanium clips, origin, echo uniformity, and echo level were statistically insignificant (P > 0.05). Postoperative bleeding was related to the operation time (P=0.017), but it was not an independent risk factor for postoperative bleeding (P=0.118; OR, 0.226; 95% CI, 0.035–1.461). 59 cases were followed up by endoscopy after the operation, and recurrence or no new tumors were found.

Conclusion

ESD is an effective and safe treatment method for gastrointestinal neuroendocrine tumors with a diameter of 1-2 cm without invading the muscularis propria. The intraoperative complications seem to have little relationship with the patient; postoperative delayed bleeding is closely related to the ESD operation time but it is not an independent risk factor.

Metastasis Prevalence and Survival of Patients with T1-2 Gastric Neuroendocrine Tumor Treated with Endoscopic Therapy and Surgery

BACKGROUND AND AIM

The selection criteria and long-term outcomes of endoscopic therapy (ET) for gastric neuroendocrine tumors (G-NETs) remain controversial.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER) Program database, we assessed the prevalence of metastasis of early G-NETs and long-term outcomes of ET in G-NET patients with good/moderate differentiation and no muscularis propria (MP) involvement.

RESULTS

A total of 2207 patients with stage T1 and T2 G-NETs were included. The depth of invasion into MP [odds ratio (OR) 4.581, 95% confidence interval (CI) 2.571-8.162; P < 0.001] and size of > 20 mm (OR 5.656, 95% CI 2.002-15.975; P = 0.001) were significantly associated with metastasis. The 5-year overall survival (OS) and cancer-specific survival (CSS) of the ET group were similar to the surgery group (91.11% vs. 91.09%, P = 0.750; 99.26% vs. 99.01%, P = 0.173). In the multivariable Cox proportional hazards regression models adjusting for age, gender, race, year of diagnosis, SEER region, depth of tumor invasion, site of cancer, tumor size, and chemotherapy, procedures employed (ET or surgery) had no significant impact on the OS [hazard ratio (HR) 1.189; 95%CI 0.721-1.961; P = 0.498] and CSS (HR 0.684; 95% CI 0.021-22.727; P = 0.832).

CONCLUSIONS

The long-term outcome of survival did not appear to differ between ET and surgery in G-NETs with good/moderate differentiation, ≤ 20 mm size, and no MP involvement.

Spannungsfeld endoskopische Resektionsverfahren bei GEP-NET // Endoscopic resection for GEP-NET

Neuroendokrine Tumoren des Verdauungstraktes (GEP-NET) sind eine seltene Tumorentität, die häufig als Zufallsbefund diagnostiziert werden. Ein großer Teil dieser Zufallsdiagnosen wird im Rahmen einer endoskopischen Untersuchung gestellt. Während die vollständige Entfernung des Tumors im Sinne einer kurativen chirurgischen Resektion nach onkologischen Kriterien das Standardvorgehen für lokalisierte Tumorerkrankungen ist, kann bei kleinen Tumoren ohne Hinweis und Risiko für eine lymphogene Metastasierung eine endoskopische Abtragung in gleicher Intention erfolgen. Während dies für Magen-, Duodenum- und Rektum-NET der Standard ist, sollten NET des Jejunums und Ileums aufgrund der hohen Metastasierungsrate trotz geringer Tumorgröße regelhaft nicht endoskopisch angegangen werden. Die Grenze für eine endoskopische Resektion ergibt sich sowohl durch die technische Machbarkeit im Sinne des Erreichens einer R0-Resektion, der erwarteten Komplikationen im Sinne von Blutung und Perforationen als auch durch das vermutete Risiko für eine lymphogene Metastasierung. Generell wird eine endoskopische Resektion bei Befunden < 1 cm regelhaft empfohlen, da sowohl die gute technische Machbarkeit als auch das geringe Metastasierungsrisiko für eine endoskopische Resektion sprechen. Bei allen Befunden über 2 cm Größe sind sowohl die technischen Erfolgsaussichten so niedrig als auch das Metastasierungsrisiko so hoch, dass in dieser Situation regelhaft ein chirurgisches Vorgehen erfolgen sollte. Es bleibt somit ein Graubereich bei der Tumorgröße zwischen 1 und 2 cm, wo sowohl endoskopische, aber auch chirurgische Resektionsverfahren sinnvoll eingesetzt werden können. Zunehmend kommen auch gemeinsame Eingriffe im Sinne eines endoskopisch-laparoskopischen Rendezvous-Verfahrens zum Einsatz – insbesondere im Duodenum bieten sich diese Eingriffe an, um eine minimale Resektion mit größtmöglicher R0-Erfolgsrate und niedriger Perforationsrate zu erreichen.

Management of Duodenal Neuroendocrine Tumors: Surgical versus Endoscopic Mucosal Resection

BACKGROUND

Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller lesions (< 1-2 cm) generally treated by endoscopic mucosal resection (EMR) and larger DNETs by surgical resection (SR). This study reviewed how patients were selected for treatment and compared outcomes.

PATIENTS AND METHODS

Patients with DNETs undergoing resection were identified through institutional databases, and clinicopathologic data recorded. χ² and Wilcoxon tests compared variables. Survival was determined by Kaplan-Meier, and Cox regression tested association with survival.

RESULTS

Among 104 patients, 64 underwent EMR and 40 had SR. Patients selected for SR had larger tumor size, younger age, and higher T, N, and M stage. There was no difference in progression-free (PFS) or overall survival (OS) between SR and EMR. In 1-2 cm DNETs, there was no difference in PFS between SR and EMR [median not reached (NR), P = 0.1]; however, longer OS was seen in SR (median NR versus 112 months, P = 0.03). In 1-2 cm DNETs, SR patients were more likely to be node-positive and younger. After adjustment for age, resection method did not correlate with survival. Comparison of surgically resected DNETs versus jejunoileal NETs revealed longer PFS (median NR versus 73 months, P < 0.001) and OS (median NR versus 119 months, P = 0.004) DISCUSSION: In 1-2 cm DNETs, there was no difference in survival between EMR and SR after adjustment for age. Recurrences could be salvaged, suggesting that EMR is a reasonable strategy. Compared with jejunoileal NETs, DNETs treated by SR had improved PFS and OS.

Incidence of Lymph Node Metastases and Impact of Radical Surgery for Duodenal Neuroendocrine Tumors

BACKGROUND

Despite the high frequency of regional lymph node (LN) metastases associated with duodenal neuroendocrine tumors (D-NETs), the impact of these metastases on survival and the ideal extent of LN dissection are unknown. We used the National Cancer Database (NCDB) to investigate factors associated with survival, including LN metastases and types of surgery, in patients with D-NETs.

METHODS

All patients with D-NETs recorded in the NCDB between 2004 and 2016 were included in the study. We applied a multivariate Cox regression model to assess the relationship between the clinicopathological characteristics and overall survival (OS).

RESULTS

We identified 7613 patients, among whom 4886 local excisions and 233 radical surgeries had been performed. Among patients with at least 1 LN pathologically examined, the overall incidence of LN metastasis was 41.2%. For all patients, the median OS was 10.6 years. Univariate analyses showed equivalent OS in N0 and N1 groups (HR,0.83; 95% CI,0.64-1.09) and diminished OS in those who had undergone radical surgery compared with those who had undergone local resection (HR,1.35; 95% CI,1.02-1.8). In multivariable analyses, tumor size >50 mm and having more than 9 positive LNs were associated with diminished OS (HR,1.64 and 5.2; 95% CI,1.25-2.16 and 1.91-14.18), whereas the type of surgery did not remain in the model.

CONCLUSION

Our study revealed that the presence of regional LN metastases and extent of surgery did not affect OS among patients with D-NETs. Radical resection to clear occult LN metastases for nonfunctioning, sporadic D-NETs was not supported by the current study.

Survival and Disease Recurrence in Patients with Duodenal Neuroendocrine Tumours-A Single Centre Cohort

Simple Summary

Neuroendocrine tumours of the upper part of the small intestine are rare. They are slow growing but may spread to lymph nodes or other organs already when the tumours are small. Such tumours may be treated by endoscopic removal or by an operation. In the current study we present the treatment results of 32 patients with this rare tumour. We found that the long-term survival was long, and patients more often died from other diseases. The survival was associated with the growth rate of the tumours and whether all the tumour tissue could be removed. Endoscopic removal was sufficient for smaller tumours <10 mm, whereas a high proportion of tumours 10–20 mm have lymph node metastases that must be removed by an operation to make patients tumour free. None of the tumours that were perceived as cured after removal recurred after an average follow-up time of 4.8 years.

Abstract

Background: Duodenal neuroendocrine tumours (D-NETs) are rare but increasingly diagnosed. This study aimed to assess the overall survival and recurrence rate among patients treated for D-NETs. Methods: Patients with D-NETs were retrospectively reviewed with a median follow-up time of 4.8 years (range 0.0–17.2 years). Results: A total of 32 patients with median age 68.0 years were identified. Fifteen patients underwent surgery while ten patients underwent endoscopic treatment. Mean estimated overall survival for the entire population was 12.1 years (95% CI 9.5–14.7 years), while 5-year overall survival was 81.3%. Tumour grade G1 was associated with longer mean estimated survival compared to G2 tumours (13.2 years versus 4.4 years, p = 0.010). None of the 23 patients who underwent presumed radical endoscopic or surgical resection had disease recurrence during follow-up. Tumours <10 mm could be treated endoscopically whereas a high proportion of patients with tumours 10–20 mm should be considered for surgery. Conclusion: Patients with D-NETs had long overall survival, and mortality was more influenced by other diseases. Both endoscopic and surgical resections were effective as no recurrences were diagnosed during follow-up.

Optimal surgery and lymph node metastasis of duodenal bulbar neuroendocrine neoplasms

BACKGROUND

There is no consensus on the extent of nodal dissection for duodenal bulbar NENs (neuroendocrine neoplasms).

MATERIALS AND METHODS

We constructed and analyzed a combined dataset consisting of the patients who received surgery in our hospital and the patients from the literature based on a systematic review. The incidence, risk factors and location of nodal metastases were examined.

RESULTS

Fifty-nine cases including 11 cases managed at our hospital and 48 cases identified from the literature search were examined. Nodal metastasis was observed in 24 patients (40.7%). The 5-year overall survival rate was 100%, regardless of nodal metastasis. Risk factors for lymph node metastasis were tumor size ≥15 mm and muscularis propria or deeper invasion. Stomach-related lymph node metastasis was found in >20% of patients who were positive for at least one risk factor and 15.4% when patients were negative for both risk factors, while pancreas-related lymph node metastasis was observed in 45.5% of patients who were positive for both risk factors, 7.7% who were only positive for one risk factor, and 0% who were negative for both risk factors.

CONCLUSIONS

Tumor size and depth of invasion would determine whether the optimal surgery for duodenal bulbar NENs is distal gastrectomy or pancreatico-duodenectomy.

Risk factors for lymph node metastasis and survival of patients with nonampullary duodenal carcinoid tumors treated with endoscopic therapy versus surgical resection: analysis of the Surveillance, Epidemiology, and End Results program

BACKGROUND AND AIMS

Endoscopic therapy (ET) has been used to treat nonampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in size, but data on long-term outcomes are limited. In addition, management of 11- to 19-mm NAD-NETs is not well defined because of variable estimates of risk of metastasis. We aimed to determine the prevalence and risk factors of metastasis of NAD-NETs ≤19 mm and evaluate the long-term survival of patients after ET as compared with radical surgery.

METHODS

The Surveillance Epidemiology and End Result database was used to identify 1243 patients with T1-2 histologically confirmed NAD-NETs ≤19 mm in size. Cancer-specific survival (CSS) and overall survival (OS) were calculated.

RESULTS

Overall, 4.8% of cases had metastasis at the time of diagnosis, with lower prevalence in ≤10-mm lesions (3.1%) versus 11- to 19-mm lesions (11.7%, P < .001). The risk factors for metastases included invasion to the muscularis propria (odds ratio, 25.95; 95% confidence interval, 9.01-76.70), age <65 years (odds ratio, 1.93), submucosal involvement (odds ratio, 3.1), and 11 to 19 mm in size (vs ≤10 mm). In patients with well- to moderately differentiated T1-2N0M0 NAD-NETs ≤19 mm confined to the mucosa/submucosa who underwent ET or surgery, the 5-year CSS was 100%. The 5-year OS was similar between the ≤10-mm and 11- to 19-mm groups (86.6% vs 91.0%, P = .31) and the ET and surgery groups (87.4% vs 87.5%, P = .823).

CONCLUSIONS

In NAD-NETs, invasion to the muscularis propria is the strongest risk factor for metastasis. In the absence of metastasis, in lesions with well/moderate differentiation and without muscle invasion, ET is adequate for NAD-NETs ≤10 mm and is a viable option for 11- to 19-mm lesions.

Endoscopic Management of Diminutive Duodenal Neuroendocrine Tumors

INTRODUCTION

Although duodenal neuroendocrine tumors (dNETs) are rare, the incidence, particularly for lesions ≤ 10 mm, continues to rise with the advent of widely available, high-quality endoscopy. Given their rarity and controversy regarding prognostication factors, limited guidelines exist for resection of well-differentiated, ≤ 20-mm dNETs. Importantly, lesions ≤ 10 mm in a duodenal location are ideal for consideration of endoscopic management given both morbidity and technical challenges associated with surgery and their accessibility to a wide range of endoscopic techniques.

OBJECTIVES

The primary objective of this study was to demonstrate the safety and efficacy of the endoscopic resection of dNETs <10 mm in a case series and literature review.

METHODS

We performed a literature review and present a series of nine cases to demonstrate the viability of endoscopic resection for diminutive dNETs as an alternative to surgery.

RESULTS

Our case series included nine well-differentiated diminutive dNETs in seven patients, the majority resected using endoscopic mucosal resection (EMR), 67%, and there was no residual disease at follow-up. The literature review of 178 patients demonstrated that EMR was the most used method of resection of diminutive dNETs, 81%, compared to endoscopic submucosal dissection, 19%. The most common complication was intraoperative bleeding in 9.55%, and only 2.25% of patients had recurrence.

CONCLUSION

While complications may arise with endoscopic resection of diminutive dNETs, they are usually managed endoscopically and compare favorably with the literature on surgical complication rates and typically result in shorter hospitalizations.

Management and Prognosis of Localized Duodenal Neuroendocrine Neoplasms

INTRODUCTION

The characteristics, prognostic factors, and management of duodenal neuroendocrine neoplasms (dNEN) are ill-defined, given their rarity. Whether nonsurgical management might be appropriate for patients with nonmetastatic dNEN and a good prognosis, as is the case for pancreatic NEN (pNEN), is unknown. We aimed to describe the management and prognosis of nonmetastatic dNEN patients.

METHODS

All consecutive patients with nonmetastatic dNEN managed between 1981 and 2018 in 2 expert centers were included. Recurrence-free survival (RFS) and factors associated with recurrence were estimated.

RESULTS

A total of 145 patients with dNEN were included. Twenty-eight patients with sporadic, nonfunctioning, small (median 7 mm) dNEN underwent endoscopic resection, with a 5-year RFS rate of 89.4%. Local recurrence occurred in 2 patients, who underwent surgery with no new events. The 5-year RFS rate was 87.9% in patients who underwent surgery. Upon univariate analysis, age, size, Ki67 index, and lymph node involvement (LN+) were significantly associated with worse RFS for all dNEN treated (endoscopy/surgery); multivariate analysis found that age, size, and LN+ were associated with worse RFS.

CONCLUSION

Selected nonmetastatic dNEN had a favorable outcome, and a less invasive therapeutic strategy appeared more suitable than oncological surgery.

The role of autofluorescence, photodynamic diagnosis and Photodynamic therapy in malignant tumors of the duodenum

This article presents the current state of knowledge and a review of the literature in terms of the prevalence, etiopathogenesis, differential diagnosis, management, prognosis, and treatment of malignant tumors of the duodenum. The role of autofluorescence and photodynamic diagnosis as an emerging treatment method for rarely o ccurring duodenal malignant neoplasms .. We selected publications which can be found in databases such as The National Center for Biotechnology Information, U.S. National Library of Medicine (PubMed), The American Chemical Society, The American Association of Pharmaceutical Sciences and The American Society for Photobiology and The Canada Institute for Scientific and Technical Information.

A Modified Duodenal Neuroendocrine Tumor Staging Schema Better Defines the Risk of Lymph Node Metastasis and Disease-free Survival

Duodenal neuroendocrine tumors are rare but increasing in incidence and optimal management is hindered by lack of duodenum-specific staging. Duodenal carcinoids were identified in the Surveillance, Epidemiology and End Results tumor registry. Depth of invasion was defined as limited to lamina propria (LP), invading muscularis propria (MP), through muscularis propria (TMP), and through serosa (S). Nine hundred forty-nine patients were identified with majorities being male (57%), white (70%), and node-negative (87%). Tumor size (cm) was less than 1, 47 per cent; 1 to 2, 35 per cent; and greater than 2, 8 per cent with 76 per cent LP. Lymph node (LN) involvement was associated with age, depth of invasion (LP 4%, MP 28%, TMP 54%, and S 57%) and size (less than 1 cm, 3%; 1 to 2 cm, 13%; and greater than 2 cm, 40%). Using the current T staging, LN involvement was: T1 (LP) 2 per cent, T2 (MP or greater than 1 cm) 13 per cent, T3 (TMP) 54 per cent, and T4 (S) 57 per cent. We reclassified current T1 to T1a and current T2 stage to T1b (1 to 2 cm and LP) and T2 (MP or greater than 2 cm). LN metastasis for T1b tumors was 4.7 per cent compared with 20.8 per cent for T2. The resulting TNM classification better defines 5-year disease-specific survival. Our modified staging schema identifies a low-risk group (T1a and T1b) that may be considered for local therapy.

Surgical outcomes of patients with duodenal vs pancreatic neuroendocrine tumors following pancreatoduodenectomy

BACKGROUND

To investigate the short- and long-term outcomes of patients undergoing pancreaticoduodenectomy (PD) for duodenal neuroendocrine tumors (dNETs) vs pancreatic neuroendocrine tumors (pNETs).

METHOD

Patients undergoing PD for dNETs or pNETs between 1997 and 2016 were identified from a multi-institutional database. Overall survival (OS) and recurrence-free survival (RFS) were evaluated.

RESULTS

Among 276 patients who underwent PD, 244 (88.4%) patients had a primary pNET, whereas 32 (11.6%) patients had a dNET. Following PD, postoperative morbidity and mortality were comparable. While the total number of lymph nodes examined was similar between the two groups (median, dNETs 15.0 vs pNETs 13.0; P= .648), patients with dNETs had a higher incidence of lymph node metastasis (LNM) (60.0% vs 38.2%; P = .022) and a larger number of metastatic nodes (median, 3.5 vs 2.0; P = .039). No differences in OS or RFS were noted among patients with dNETs vs pNETs in both unadjusted and adjusted analyses. Among patients who recurred after PD, patients with dNETs were more likely to recur early (within 2 years, 100% vs 49.2%; P = .029) and at an extrahepatic site (intrahepatic-only recurrence, 20.0% vs 54.1%; P = 0.142) vs patients with pNETs.

CONCLUSIONS

Patients with dNETs and pNETs had a similar prognosis following PD. Data on differences in the incidence of LNM, as well as in recurrence time and patterns may help to inform the treatment of these patients.

Surgical resection for duodenal neuroendocrine neoplasia: Outcome, prognostic factors and risk of metastases

BACKGROUND

Clinical management of duodenal neuroendocrine neoplasms (dNEN) is controversial. The aim of this study was to assess the outcome of surgical management and to identify risk factors for metastatic disease.

METHODS

Patients undergoing surgery for dNEN were retrospectively analysed. Clinicopathologic features, perioperative outcome and survival were assessed. A literature review with focus on risk factors for metastatic disease was additionally performed.

RESULTS

24 patients were identified. Out of 22 patients presenting with their primary tumour, 20 patients underwent curative resection and 18 patients received curative resection with systematic lymphadenectomy. 17 patients underwent formal oncological resection. Surgical mortality was 1 out of 24 patients. The 5-year overall survival rate was 67% in the entire cohort, 71% in patients undergoing resection for their primary tumour, 72% for patients undergoing curative resection with systematic lymphadenectomy, 75% for pN0 and 70% for pN1 tumours. Lymph node metastases were identified in 15 patients undergoing systematic lymphadenectomy, including 9 of 14 patients with tumours smaller than 2 cm, and 6 of 10 patients with G1 tumours. Literature review confirmed a high risk of metastases in small (58%) or G1 (24%) tumours. Tumour grade and angioinvasion were significantly associated with overall and disease-free survival.

CONCLUSION

Even well differentiated or small dNEN harbour a considerable risk of metastases. These data challenge the concepts of surveillance, local resection and endoscopic management for dNEN based on size and grading. Angioinvasion was identified as a strong negative predictor of overall and disease-free survival in dNEN.

Duodenal neuroendocrine tumors: Somewhere between the pancreas and small bowel?

BACKGROUND

While sub-2 cm pancreatic neuroendocrine tumors (NETs) are often observed, small bowel-NETs undergo resection and lymphadenectomy regardless of size. Aim was to define the natural history of duodenal (D-NETs), determine the role of resection, and define the factors associated with overall survival (OS) after resection.

METHODS

National Cancer Database (2004-2014) was queried for the patients with nonmetastatic/nonfunctional D-NETs. Local resection (LR): local excision/polypectomy/excisional biopsy. Anatomic resection (AR): radical surgery. Tumor size was divided into less than 1 cm, 1 to 2 cm, and ≥2 cm. Propensity score weighting was used to create balanced resection and no-resection cohorts. The primary endpoint was OS.

RESULTS

Among 5502 patient, the median age was 65 years. The median follow-up was 49 months. The median tumor size was 0.8 cm. Resection was performed in 72% (n = 3954; LR: 61%, AR: 39%). Lymph node (LN) resection was performed in 26% (43% had metastasis). A total of 74% had negative margins. Resection and no-resection cohorts were propensity score weighted for age/sex/race/Charlson-Deyo score/tumor grade (all independently associated with OS on multivariable analysis). Resection was associated with improved median OS compared to no resection in all sizes (<1 cm: median not reached vs 194 months; 1-2 cm: median not reached vs 56 months; >2 cm: median not reached vs 90 months; all P < .01). Subset analysis of each resection size cohort demonstrated that neither type of resection, LN retrieval, LN positivity, or margin status was associated with OS (all P > .05).

CONCLUSION

Patients with nonmetastatic and nonfunctional D-NETS should be considered for resection regardless of tumor size. Given the lack of prognostic value, the resection type and extent of LN retrieval should be tailored to each patient's clinical picture and safety profile.

[Duodenal neuroendocrine tumors]

Significant augmentation of the incidence of duodenal neuroendocrine tumors duodenum has been observed in recent decades. There are 5 histological types of these tumors: gastrinoma (50-60%), somatostatin-producing tumor (15%), inactive serotonin-containing tumors (20%), poorly differentiated neuroendocrine carcinoma (<3%) and gangliocytic paraganglioma (<2%). The majority of tumors are localized within the bulb and postbulbar part of duodenum, 20% are found in periampular area. Treatment strategy depends on dimensions, localization, histological class, stage and type of tumor. It is believed that endoscopic resection is permissible for small inactive tumors (G1) located above major duodenal papilla. The majority of other neoplasms requires surgical resection. Personal experience of various surgeons is limited by small group of patients. Therefore, it is necessary to summarize results for selection of optimal treatment.

Risk factors for lymph node metastasis in duodenal neuroendocrine tumors: A retrospective, single-center study

Duodenal neuroendocrine tumors (NETs) are rare, and risk factors associated with lymph node (LN) metastasis are still not well defined. The aim of this study was to investigate risk factors of LN metastasis in duodenal NETs based on the final histopathologic results and clinical follow-up data.This study included a total of 44 duodenal NETs in 38 patients who underwent endoscopic or surgical resection between January 2008 and December 2015. Diagnosis of duodenal NETs was confirmed based on immunohistochemical staining of chromogranin A, synaptophysin, and CD56; the clinicopathologic records were collected at the time of the initial diagnosis of duodenal NETs.Most duodenal NETs were small (≤1 cm in 33 tumors), World Health Organization (WHO) grade G1 (in 32 tumors), limited to the mucosa and/or submucosa (in 40 tumors), and located at the duodenal bulb (in 32 tumors). Of 44 tumors, lymphovascular invasion was present in 4 (9.1%), and among 38 patients, LN metastasis was detected in 4 (10.5%). LN metastases were significantly associated with the non-bulb location, tumor size >10 mm, tumor invasion into the muscularis propria or deeper, WHO grade G2, and lymphovascular invasion. During the mean follow-up period of 54.5 months (range, 24-123 months), recurrence occurred in 1 patient.Non-bulb location, tumor size >10 mm, invasion beyond the submucosa, WHO grade G2, and lymphovascular invasion are risk factors of LN metastasis in duodenal NETs. These findings can help clinicians choose the appropriate therapeutic modality for duodenal NETs.

Duodenal somatostatinoma presenting as obstructive jaundice with the coexistence of a gastrointestinal stromal tumour in neurofibromatosis type 1: a case with review of the literature

Somatostatinomas are rare neuroendocrine tumours, mostly located in the pancreas or duodenum, with an estimated incidence of 1 in 40 million. Duodenal somatostatinomas (DSs) are usually found in association with neurofibromatosis type 1 (NF1), tuberous sclerosis and Von Hippel-Lindau syndrome. Gastrointestinal stromal tumours (GIST) have also been described in NF1, but the association with somatostatinoma is very uncommon. We report the case of a patient with NF1 who presented with obstructive jaundice due to multiple firm nodules around the ampulla of Vater. A pancreaticoduodenectomy was performed and revealed a 1 cm duodenal/ampullary mass which stained positive for somatostatin, together with a GIST also found on the duodenal wall. Despite its rarity, ampullary somatostatinomas should be considered in the differential diagnosis of biliary tract dilation in patients with NF1.

Laparoscopic resection of duodenal carcinoid: A feasible method: Single institute case series

Background

Duodenal carcinoids (neuroendocrine tumour) are rare tumour, but recently, increase in incidence has been noted. Various techniques for excision of tumour have been described in literature, but very few case reports and case series have mentioned about laparoscopic management of carcinoid tumour. We describe a case series of seven cases of duodenal non-periampullary carcinoids which was managed by laparoscopic method.

Aims

The aim of the study was to check feasibility of laparoscopic management of duodenal carcinoid and technique of surgery.

Settings and Design

This study design was a case series and prospective data were retrospectively collected.

Materials and Methods

A total of 7 patients were operated for carcinoid tumour of duodenum mainly involving first part by laparoscopic method from February 2016 to January 2017. All patients were followed up for minimum 1-year period and various pre-operative, intra-operative findings and post-operative outcome were noted.

Results

Out of seven patients, 6 patient were managed by laparoscopic duodenotomy and transduodenal excision whereas one patient required duodenectomy of first part. Mean operative time was 99 min, mean intraoperative blood loss was 55.7, mean hospital stay was 99.7 and no recurrence in a 1-year follow-up.

Conclusions

Laparoscopic excision of carcinoid tumour is safe, technically reproducible and feasible method.

Well-Differentiated, Non-Functional, Non-Ampullary Duodenal Neuroendocrine Tumors: Toward Defining Evaluation and Management

INTRODUCTION

Nonfunctional, non-ampullary duodenal neuroendocrine tumors (dNETs) are rare neoplasms, and specific treatment recommendations are less clear than for other NETs.

MATERIALS AND METHODS

We performed a retrospective review of patients (pts) with a diagnosis of dNET, excluding hormonally functional, ampullary, and high-grade tumors. Clinical data were evaluated to identify factors that might impact clinical staging and predictors of metastases.

RESULTS

Thirty-six pts were identified. Surgical resection was performed in 28 and endoscopic resection in 8. LNs were included in specimens of 19/28 (68 %) pts who underwent surgical resection (median #LNs 5, range 1-12). Of these 19 pts, 5 (26 %) were found to be LN+. Of LN+ pts, all had tumors ≤2 cm. When compared to LN- pts, LN+ pts were more likely to have muscularis propria (MP) invasion (80 vs. 23 %, p = 0.04). Tumor size, tumor grade, lymphovascular invasion, and multifocality were similar between LN+ and LN- patients. No pt was found to have distant metastases. Heterogeneity in clinical staging modalities and small number of pts evaluated prohibited meaningful analysis of most appropriate preoperative imaging. At a median follow-up of 25 months (range 9-139), no patient developed recurrence or experienced disease-specific death.

CONCLUSIONS

Non-functional, non-ampullary dNETs, particularly those with MP invasion, have a propensity to metastasize to regional LNs. However, these neoplasms appear to have a favorable prognosis. Further evaluation of preoperative imaging is required to better determine most appropriate clinical staging. A suggested workup and management strategy for prospective evaluation is proposed.

Medical Therapy of Gastrointestinal Neuroendocrine Tumors

Intestinal neuroendocrine tumors (NETs) constitute a heterogeneous group with duodenal, small intestinal, colonic and rectal NETs. They constitute more than half of all NETs, with the highest frequencies in the rectum, small intestine, and colon. The tumor biology varies with the location of the primary tumor as well as with the grade and staging of the tumor. Small intestinal NETs usually present low proliferation and are treated in the first line with somatostatin analogs according to current guidelines. If progression occurs, one can add interferon alpha or change the treatment to everolimus. Peptide receptor radionuclide therapy (PRRT) with Lutetium¹⁷⁷-DOTATATE can be an option in the future after registration of the compound. Rectal tumors are usually small when they metastasize; they can be treated with somatostatin analogs but more so with PRRT, while another option is of course everolimus. Colonic NETs are more aggressive than the rest of intestinal NETs and will be treated with everolimus, sometimes in combination with somatostatin analogs based on positive scintigraphy. Another option is a cytotoxic agent such as streptozotocin plus 5-fluorouracil (5-FU) or temozolomide plus capecitabine. The most aggressive tumors, i.e. neuroendocrine carcinoma G3, are treated with a platin-based therapy plus etoposide; if they present with a lower proliferation, i.e. <50%, temozolomide plus capecitabine plus bevacizumab can also be attempted. Duodenal NETs are mostly treated similar to pancreatic NETs, either with cytotoxic agents, streptozotocin plus 5-FU, or temozolomide plus capecitabine, or with targeted agents such as everolimus.

Duodenal and Ampullary Carcinoid Tumors: Size Predicts Necessity for Lymphadenectomy

BACKGROUND

Unlike other neuroendocrine tumors of the gastrointestinal tract, management of duodenal and periampullary carcinoids remains controversial. We aimed to determine the metastatic potential and optimal choice of therapy for these neoplasms.

METHODS

A retrospective review of all patients treated at the Johns Hopkins Hospital between 1996 and 2012 was conducted. Clinicopathologic factors associated with lymph nodal involvement and clinical outcomes were evaluated.

RESULTS

A total of 101 patients were identified. Eighty (79.2%) tumors arose from the duodenum and 21 (20.8%) from the periampullary area. Thirty-five (34.7%) patients underwent pancreaticoduodenectomy (PD), 12 (11.9%) local resection, 38 (37.6%) endoscopic excision, and 16 (15.8%) patients harbored incidental tumors identified in the specimen after PD for another indication. Lymph node (LN) pathologic evaluation was done in 56 patients, among which 27 (48%) had positive LN. Specifically, LN positivity (LN+) for tumors <1 cm in size was 4.5% (1/22), for tumors 1-2 cm 72% (13/18), and for tumors >2 cm 81% (13/16). Tumor size was the only factor associated with LN+ (p = 0.029).

CONCLUSION

Lymph nodal involvement is common for duodenal and periampullary carcinoid tumors, particularly among those >1 cm in size; therefore, resection with lymphadenectomyfor these larger tumors is recommended.

The Risk Factors for Metastasis in Non-Ampullary Duodenal Neuroendocrine Tumors Measuring 20 mm or Less in Diameter

BACKGROUND/AIMS

The treatment strategy for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤20 mm in diameter has not been established. In this study, we aimed to evaluate the detailed characteristics of NAD-NETs ≤20 mm in diameter to clarify the risk factors of subsequent metastasis.

METHODS

The patients with NAD-NETs ≤20 mm in diameter who had been treated at 12 institutions between 1992 and 2013 were enrolled. Clinical records were retrieved, and histopathological findings of all cases were centrally reviewed by 2 pathologists.

RESULTS

We studied 49 patients with a mean follow-up period of 66.5 months. Thirty-five patients were initially treated with endoscopic resection (ER), and 14 with surgery. A univariate analysis revealed the ORs and 95% CIs of the risk factors for metastasis were lymphovascular invasion (12.5 [2.01-77.9]), multiple tumors (9.75 [1.46-65.4]), a tumor size of 11-20 mm (6.67 [1.21-36.6]), and World Health Organization grade G2 (7.13 [1.16-43.9]). Five-year overall and disease-specific survival rates were 86.1 and 97.2%, respectively.

CONCLUSION

This is the first study to demonstrate the risk factors of metastasis in NAD-NETs ≤20 mm in diameter. These findings may be helpful for determining the appropriate therapeutic approach and the clinical strategy of treatment following ER.

Management of gastric and duodenal neuroendocrine tumors

Gastrointestinal neuroendocrine tumors (GI-NETs) are rare neoplasms, like all NETs. However, the incidence of GI-NETS has been increasing in recent years. Gastric NETs (G-NETs) and duodenal NETs (D-NETs) are the common types of upper GI-NETs based on tumor location. G-NETs are classified into three distinct subgroups: type I, II, and III. Type I G-NETs, which are the most common subtype (70%-80% of all G-NETs), are associated with chronic atrophic gastritis, including autoimmune gastritis and Helicobacter pylori associated atrophic gastritis. Type II G-NETs (5%-6%) are associated with multiple endocrine neoplasia type 1 and Zollinger-Ellison syndrome (MEN1-ZES). Both type I and II G-NETs are related to hypergastrinemia, are small in size, occur in multiple numbers, and are generally benign. In contrast, type III G-NETs (10%-15%) are not associated with hypergastrinemia, are large-sized single tumors, and are usually malignant. Therefore, surgical resection and chemotherapy are generally necessary for type III G-NETs, while endoscopic resection and follow-up, which are acceptable for the treatment of most type I and II G-NETs, are only acceptable for small and well differentiated type III G-NETs. D-NETs include gastrinomas (50%-60%), somatostatin-producing tumors (15%), nonfunctional serotonin-containing tumors (20%), poorly differentiated neuroendocrine carcinomas (< 3%), and gangliocytic paragangliomas (< 2%). Most D-NETs are located in the first or second part of the duodenum, with 20% occurring in the periampullary region. Therapy for D-NETs is based on tumor size, location, histological grade, stage, and tumor type. While endoscopic resection may be considered for small nonfunctional D-NETs (G1) located in the higher papilla region, surgical resection is necessary for most other D-NETs. However, there is no consensus regarding the ideal treatment of D-NETs.

Efficacy of Endoscopic Mucosal Resection for Management of Small Duodenal Neuroendocrine Tumors

BACKGROUND

Endoscopic mucosal resection (EMR) for small (<20 mm) duodenal neuroendocrine tumors (NETs) remains controversial because of their rarity.

MATERIALS AND METHODS

This is a retrospective cohort study of patients with surgically or endoscopically resected duodenal NETs from 2001 to 2011. The primary outcome is the rate of disease-free status following resection. A secondary outcome is the sensitivity of endoscopic ultrasound (EUS) in determining NET appropriateness for EMR.

RESULTS

Thirty patients underwent resection of duodenal NETs (EMR 20, surgery 10). Tumor was present at the margins in 40% of EMR-resected NETs and 10% of surgically resected NETs. Five patients who underwent EMR had residual disease treated with repeat EMR (3) and surgery (2). EUS demonstrated 96% sensitivity in determining lesions limited to the submucosa.

CONCLUSIONS

EMR for small duodenal NETs can be a safe and effective alternative to surgery in carefully selected patients. EUS is a useful adjunct in determining depth of invasion for duodenal NETs.

Neuroendocrine tumor of the ampulla of Vater with distant cystic lymph node metastasis: a case report

Background

Neuroendocrine tumors (NETs) of the ampulla of Vater are rare and difficult to diagnose. We report a rare case of a small NET of the ampulla of Vater with metastasis to distant lymph nodes.

Case presentation

The patient was a 54-year-old man complaining of epigastric pain and melena. Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding, which was diagnosed as a well-differentiated NET of the ampulla of Vater. An approximately 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm cyst adjacent to the wall of the jejunum were revealed by abdominal computed tomography. We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater and a 52-mm cyst adjacent to the wall of the jejunum. Histological examination revealed that the cyst was a lymph node metastasis. The final diagnosis was non-functional NET G1 of the ampulla of Vater, designated T1N1M0 stage IIIB. Postoperatively, the patient underwent no treatment and has had no recurrence for 4 years.

Conclusions

This case demonstrates that sporadic NETs of Vater’s papilla have aggressive metastatic potential even with a small primary lesion, and radical resection with lymphadenectomy is recommended for all cases.

A Multi-institutional Analysis of Duodenal Neuroendocrine Tumors: Tumor Biology Rather than Extent of Resection Dictates Prognosis

INTRODUCTION

Duodenal neuroendocrine tumors (NETs) are rare neoplasms with poorly defined management. We sought to evaluate the outcomes of patients undergoing resection of duodenal NETs.

METHODS

Using a multi-institutional database, 146 patients who underwent resection for duodenal NETs between 1993 and 2015 were identified. Data on clinicopathologic characteristics and outcomes were collected and analyzed.

RESULTS

Local surgical resection (LR) was performed in 57 (39.0 %) patients, while 50 (34.3 %) patients underwent pancreaticoduodenectomy (PD) and 39 (26.7 %) patients an endoscopic resection (ER). Factors associated with worse RFS included advanced tumor grade and metastasis at diagnosis (both P < 0.05) but not procedure type (P > 0.05). Among patients who had at least one lymph node examined (n = 85), 50 (58.8 %) had a metastatic lymph node; lymph node metastasis (P = 0.04) and advanced tumor grade (P = 0.04) were more common among patients with tumors >1.5 cm. Median length-of-stay was longer for PD versus LR (P < 0.001). PD patients were at increased risk for severe postoperative complications (P = 0.01).

CONCLUSION

Recurrence of duodenal NETs was dependent on tumor biology rather than procedure type. PD was associated with a longer hospital stay and higher risk of perioperative complications. For patients with tumors ≤1.5 cm, LR or ER may be appropriate with PD reserved for larger lesions and those not amenable to a more local approach.

Duodenal Neuroendocrine Tumors: Location Matters!

Duodenal neuroendocrine tumors (NETs) are rare. Historically, when feasible a less aggressive surgical approach is considered. The aim of this study was to identify factors associated with prognosis and the necessity for more aggressive surgical procedures. All patients who underwent surgery for duodenal NETs between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Eighteen patients underwent surgical management for duodenal NETs. Two patients underwent transduodenal excision (11%), two patients had partial duodenal resection (11%), two patients had antrectomy including 1st part of duodenum (D1) resection (33%), and eight underwent pancreaticoduodenectomy [PD (44%)]. On analysis, 2nd part of duodenum (D2) location was the most common site of duodenal NETs (n = 9, 50%). The odds of having a PD were 10 times higher when the lesion was in D2 location. The odds of having a positive lymph node are nine times higher when the lesion is in D2 region. The odds of having a positive lymph node are three times higher when lesion is greater than T1. D2 location of NETs is associated with higher odds of lymph node positivity and need for more extensive procedures like PD.

Duodenal neuroendocrine tumors: retrospective evaluation of CT imaging features and pattern of metastatic disease on dual-phase MDCT with pathologic correlation

PURPOSE

The purpose of the study is to evaluate the CT appearance and pattern of metastatic disease of patients with surgically resected well-differentiated duodenal neuroendocrine tumors who underwent pre-operative dual-phase CT.

METHODS

Clinical and pathologic records and CT images of 28 patients (average age 58.0 years) following Whipple procedure were retrospectively reviewed. The size, morphology (polypoid, intraluminal mass or wall thickening, intramural mass), location, CT attenuation in the arterial and venous phases, and the presence of lymph node or liver metastases were recorded.

RESULTS

On CT, 19 patients (67.8%) had neuroendocrine tumors manifested as polypoid or intraluminal masses (38 lesions, multiple tumors in 3 patients), 4 patients (14.3%) had tumors manifested as wall thickening or intramural masses, and in 5 patients (17.9%), the primary tumor was not visualized. Lesions not seen at CT were less than 0.8 cm on pathologic diagnosis. The mean size of polypoid tumors on CT was 1.2 cm (range 0.3-3.8 cm); 24 tumors were 1.0 cm or smaller, and 14 tumors were larger than 1.0 cm. Most lesions were hypervascular in the arterial phase (19/23 patients) with an increase in tumor enhancement in the venous phase in 14 patients (60.9%), decrease in enhancement in 7 patients (30.4%), and no change in enhancement in 2 patients (8.7%). Thirteen patients (46.4%) had metastatic disease from carcinoid tumor, most commonly regional enhancing lymphadenopathy.

CONCLUSION

Duodenal carcinoid tumors commonly appear as an enhancing mass in either the arterial or venous phases. If a primary tumor is not seen in the duodenum, adjacent enhancing lymphadenopathy can be a clue to the presence of a duodenal carcinoid tumor.

Duodenal neuroendocrine tumor and the onset of severe diabetes mellitus in a US veteran

Objective:

Neuroendocrine tumors are neoplasms derived from endocrine cells, most commonly occurring in the gastrointestinal tract. Duodenal neuroendocrine tumors are rare tumors averaging 1.2–1.5 cm, and most are asymptomatic. Common presentation is abdominal pain, upper gastrointestinal bleed, constipation, anemia, and jaundice.

Methods:

An adult, Black, male patient with newly diagnosed diabetes mellitus presented to the emergency department with elevated liver function test and fatigue.

Results:

Magnetic resonance cholangiopancreatography demonstrated a large obstructing mass (3.6 cm × 4.4 cm × 3 cm) within the second and third portions of the duodenum at the ampulla. Esophagogastroduodenoscopy demonstrated an ulcerated duodenal mass that was biopsied. Immunohistochemical stains were positive for synaptophysin, chromogranin B, and CK7. Chromogranin A was in normal range. Post-Whipple procedure demonstrated a 5.5 cm × 4.1 cm × 2.9 cm duodenal mass with invasion of the subserosal tissue of the small intestine, a mitotic rate of 2 per high-power field, and antigen Ki-67 of 2%–5%.

Conclusion:

This case raises the question as to if the patient developed diabetes mellitus due to the tumor size and location or if the new onset of diabetes was coincidental. This case also demonstrates the importance of a proficient history and physical.

Surgical management of neuroendocrine tumors

During the last decades an increase in the incidence of neuroendocrine tumors (NETs) was observed. Gastroenteropancreatic NETs represent the majority of NETs. Compared with their epithelial counterpart they usually have a more indolent behaviour and surgical resection improves survival. Tumor diameter is one of the main parameter in the decision making process for nonfunctioning forms. Generally, small lesions can be treated conservatively whereas larger tumors should be treated with standard surgical resection and lymphadenectomy. Functioning tumors should be resected regardless the dimension of the lesion. Locally advanced and metastatic disease should be also treated with extended resections, keeping in consideration the grading, size, Ki67, and presence of extra-abdominal disease. In the case of metastases the panel of operative treatment includes resection, ablation, up to liver transplantation.

Elevated Plasma Pancreastatin, but Not Chromogranin A, Predicts Survival in Neuroendocrine Tumors of the Duodenum

BACKGROUND

Neuroendocrine tumors (NETs) of the duodenum are rare, heterogeneous, and often indolent neoplasms. We hypothesized that elevated pancreastatin levels are an indicator of a poor prognosis in well-differentiated duodenal NETs.

STUDY DESIGN

Data from patients diagnosed with a primary duodenal NET were analyzed. Patients that underwent esophogogastroduodenoscopy, endoscopic ultrasound, or exploratory surgery to localize their neoplasm and whose tumors were confirmed histologically were included.

RESULTS

Eighty-four patients were diagnosed with duodenal NETs from January 1991 to January 2014. Seventy-five percent and 21% of patients had their tumor localized by esophogogastroduodenoscopy and endoscopic ultrasound, respectively. The remaining 4% were localized during exploratory surgery. The 5-year Kaplan-Meier survival rate for the entire cohort (N = 84) was 80%. Survival sorted by normal vs abnormal pancreastatin level was statistically significant (p < 0.0001). Five-year survival rates were 94% and 37% for normal and abnormal pancreastatin, respectively. In contrast, survival sorted by normal vs abnormal plasma chromogranin A level was not statistically significant (p = 0.24).

CONCLUSIONS

Patients with primary duodenal NETs have high 5-year survival rates. Serial monitoring of plasma pancreastatin levels can identify patients who have a poor prognosis.

Increasing incidence of duodenal neuroendocrine tumors: Incidental discovery of indolent disease?

BACKGROUND

There has been a marked increase in the recognized incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Studies have often combined duodenal neuroendocrine tumors (D-NETs) with other small bowel GEP-NETs. As a result, the natural history and clinical ramifications of these D-NETs is poorly understood.

METHODS

Patients diagnosed with duodenal "carcinoid" tumors from 1983 to 2010 were identified in the Surveillance Epidemiology and End Results tumor registry.

RESULTS

A total of 1,258 patients were identified. The mean age was 64 years. The majority of patients were male (55.6%), white (55.6%), and had stage I disease (66.2%). Patients meeting inclusion criteria were divided into 2 cohorts: (i) era 1 patients diagnosed with GEP-NETs from 1983 to 2005, and (ii) era 2 those diagnosed from 2005 to 2010. There was a clear increase in the incidence rate of D-NETs from 0.27 per 100,000 in 1983 to 1.1 per 100,000 in 2010 (P < .001). Comparison of patients from the different eras revealed that those in era 2 were more likely than era 1 to present with stage I disease (69.9 vs 57.5%; P < .01) and less likely to present with late-stage disease. The 5-year, disease-specific survival improved for era 2 patients compared with era 1 (89.3 vs 85.2%; P = .05); however, multivariate analysis demonstrated that stage but not era was associated with disease-specific survival.

CONCLUSION

Prognosis for D-NETs, in contrast with other small bowel NETs, is excellent. There has been a steady increase in the recognized incidence of D-NETs, coincident with the migration to earlier disease stage and improved disease-specific survival.

Neuroendocrine Neoplasms of the Major Duodenal Papilla With Focus on Histopathological Features and Prognosis

Neuroendocrine neoplasms (NENs) are generally indolent and progress slowly. However, NENs of major duodenal papilla are uncommon. We retrospectively assessed relevant clinicopathological findings in 9 consecutive patients treated for major duodenal papilla NENs by pancreaticoduodenectomy in our hospital from 2009 to 2013. Eight of the 9 patients (89%) presented with painless obstructive jaundice and one with intermittent fever, attributable to pancreatitis, without jaundice. The diagnostic accuracy was 75% (6/8) for biopsies obtained under duodenoscope guidance. Enhanced multidetector computed tomography detected 89% (8/9) of tumors. Patients with uncertain preoperative diagnoses all underwent intraoperative frozen section pathological diagnosis. Tumor cells extended to at least the muscularis propria in all patients. There were 5 neuroendocrine tumors, 2 neuroendocrine carcinomas, and 2 mixed adenoneuroendocrine carcinomas. Two, 4, and 3 cases were grades 1, 2, and 3, respectively. Grade 3 tumor patients had poor prognoses with tumor recurrence or metastasis within 2 months and all died within 1 year. The overall survival rate (1 year) of grade 3 was lower than in grades 1 and 2 (P < .05). Patients with grade 1 tumors had a similar prognosis to grade 2 (P > .05). To date, only 4 cases of this tumor have been reported in the Chinese literature. The prognosis can be predicted accurately by histopathological features accordingly to the World Health Organization 2010 classification. Multiple imaging techniques and pathological examination should be carried out appropriately to diagnose the disease early.

Suitable closure for post-duodenal endoscopic resection taking medical costs into consideration

AIM: To compare closure methods, closure times and medical costs between two groups of patients who had post-endoscopic resection (ER) artificial ulcer floor closures.

METHODS: Nineteen patients with duodenal adenoma, early duodenal cancer, and subepithelial tumors that received ER between September 2009 and September 2014 at Kagawa University Hospital and Ehime Rosai Hospital, an affiliated hospital of Kagawa University, were included in the study. We retrospectively compared two groups of patients who received post-ER artificial ulcer floor closure: the conventional clip group vs the over-the-scope clip (OTSC) group. Delayed bleeding, procedure time of closure, delayed perforation, total number of conventional clips and OTSCs and medical costs were analyzed.

RESULTS: Although we observed delayed bleeding in three patients in the conventional clip group, we observed no delayed bleeding in the OTSC group (P = 0.049). We did not observe perforation in either group. The mean procedure times for ulcer closure were 33.26 ± 12.57 min and 9.71 ± 2.92 min, respectively (P = 0.0001). The resection diameters were 18.8 ± 1.30 mm and 22.9 ± 1.21 mm for the conventional clip group and the OTSC group, respectively, with significant difference (P = 0.039). As for medical costs, the costs of all conventional clips were USD $1257 and the costs of OTSCs were $7850 (P = 0.005). If the post-ER ulcer is under 20 mm in diameter, a conventional clip closure may be more suitable with regard to the prevention of delayed perforation and to medical costs.

CONCLUSION: If the post-ER ulcer is over 20 mm, the OTSC closure should be selected with regard to safety and reliable closure even if there are high medical costs.

Small duodenal carcinoids: a case series comparing endoscopic resection and autoamputation with band ligation

GOALS

We sought to compare the efficacy and safety of endoscopic ultrasound-guided endoscopic resection (ER) and endoscopic band ligation (EBL) for autoamputation of small duodenal carcinoids.

BACKGROUND

The ideal management of small duodenal carcinoid tumors remains unclear.

STUDY

A retrospective review of duodenal carcinoids over a 10-year period (2002 to 2012) was performed at our tertiary-care teaching hospital. All patients with duodenal carcinoids ≤10 mm in size treated with either ER or EBL were included. The main outcome measurements were the efficacy and safety of endotherapy.

RESULTS

A total of 37 patients with 39 subcentimeter duodenal carcinoids were identified. In the EBL group, the mean (SD) tumor size was 6.7±2.1 mm compared with 6.7±1.7 mm in the ER group (P=0.943). The mean Ki-67 index was ≤2% in specimens available for histologic analysis in both groups (16/23 EBL and 15/16 ER). The positive deep margin rate in the ER group was 68.8%. Residual carcinoid tumor cells were detected on follow-up biopsies in 1 patient after EBL, and 2 patients after ER. All underwent subsequent successful endotherapy. No adverse events occurred in the EBL group compared with an 18.8% adverse event rate in the ER group (P=0.066).

CONCLUSIONS

Endoscopic ultrasound-guided EBL is a safe, effective method for removal of small superficial duodenal carcinoids and seems to be a lower risk alternative to conventional ER with cautery.

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review

Neuroendocrine tumors (NET) previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome. The annual incidence of patients with NET is 8.4 per 100000; yet many NET remain asymptomatic and clinically undetected. A majority of NET follows a benign course; however, some will display malignant characteristics. NET most commonly occur in the gastrointestinal tract (67%) and bronchopulmonary system (25%). Gastrointestinal NET occur within the stomach, small intestine, liver, and rectum. We report a retrospective study of 11 subjects: Eight with benign carcinoid tumors: duodenal bulb (n = 2), terminal ileum (n = 1), sigmoid colon (n = 2), and rectum (n = 3); three with malignant carcinoid: liver (n = 1) and intra-abdominal site (n = 2). The diagnosis, endoscopic images, outcome, treatment and review of the literature are presented.

Surgical management of superficial non-ampullary duodenal tumors

BACKGROUND AND AIM

We present our experiences with the so-called 'limited resections' such as transduodenal excision and local full-thickness resection for superficial non-ampullary duodenal tumors (SNADT). The optimal surgical management for SNADT is also discussed.

METHODS

Six patients with SNADT (adenoma, n=1; mucosal carcinomas, n=2; submucosal carcinoma, n=1; carcinoids, n=2) were included in this study. Four patients underwent transduodenal excision, one local full-thickness resection, and one laparoscopy-assisted endoscopic full-thickness resection as a modification of local full-thickness resection.

RESULTS

All patients were successfully treated by these limited resections without any adverse events.

CONCLUSIONS

Surgical resection is the treatment of choice for SNADT not amenable to endoscopic resection in terms of technical and/or oncological reasons. However, the optimal surgical management for SNADT remains controversial because of the complexity of the relevant anatomy of the duodenum, its rarity, the not well-known incidence of nodal metastasis, and the wide spectrum of pathologies that can be encountered.

Management strategy for small duodenal carcinoid tumors: does conservative management with close follow-up represent an alternative to endoscopic treatment?

BACKGROUND/AIMS

Limited data exist regarding the natural history of duodenal carcinoid tumors and the efficacy of endoscopic treatment.

METHODS

A total of 27 patients with duodenal carcinoid tumors were enrolled. All tumors were located outside the periampullary region and were ≤10 mm in size. 11 patients underwent endoscopic mucosal resection (EMR) and argon plasma coagulation (APC). 13 patients did not undergo any specific procedure for tumor removal and were followed clinically.

RESULTS

Of 13 patients not undergoing treatment, tumors disappeared in 5 cases during follow-up with diagnostic forceps biopsy. Endoscopically visible lesions remained in the last follow-up endoscopy in 8 patients (61.5%). No lymph node or distant metastases or tumor-related deaths occurred during a median follow-up of 37 months. Of 11 cases treated with EMR, tumor-free resection margins were achieved in 10 cases and no local recurrence occurred after treatment. Two perforations occurred during EMR. Of the 3 cases treated with APC, local recurrence occurred in 1 case.

CONCLUSIONS

Given the risks associated with EMR and the likely favorable natural history of small duodenal carcinoid tumors, conservative management with close follow-up may represent a viable alternative to endoscopic treatment, especially in patients with a high risk of perioperative complications.

Pathologic grade and tumor size are associated with recurrence-free survival in patients with duodenal neuroendocrine tumors

BACKGROUND

Duodenal neuroendocrine tumors are rare and few studies exist to guide surgical management. This study identifies factors associated with recurrence after resection.

METHODS

A retrospective, single institution review was performed between 1983 and 2011 on patients with a pathologic diagnosis of duodenal neuroendocrine tumor. Tumor grade was assigned based on WHO 2010 criteria (Ki-67 and mitotic rate).

RESULTS

Seventy-five patients were identified that underwent curative resection. This included 12 patients with endoscopic mucosal resection, 34 that had local resection, and 29 that underwent pancreaticoduodenectomy. Two-year and 5-year recurrence-free survival was 84 and 81%, respectively. There were 11 tumor recurrences (either local or distant), and four patients died of their disease (3/4 had high-grade lesions) with an overall median follow-up of 27 months. On univariate analysis, tumor size and tumor grade were identified as being associated with recurrence, but not intervention type, lymph node metastases, ampullary location, or margin status.

CONCLUSIONS

Tumor grade and size are associated with recurrence-free survival in duodenal neuroendocrine tumors. When feasible, a less aggressive surgical approach to treat low-grade and low-stage duodenal NETs should be considered.

Endoscopic resection for duodenal carcinoid tumors: a multicenter, retrospective study

BACKGROUND AND AIM

Gastrointestinal carcinoid tumors < 10 mm in diameter and limited to the submucosal layer demonstrate a low frequency of lymph node and distant metastasis, and are suitable for endoscopic treatment. The aim of this study was to assess the efficacy, safety, and long-term prognosis of endoscopic resections for the treatment of duodenal carcinoid tumors.

METHODS

This study included a total of 41 duodenal carcinoid tumors in 38 patients between January 2006 and December 2011. The indications for endoscopic resection were lesions ≤ 10 mm in diameter, confined to the submucosal layer, and without lymph node or distant metastasis. Endoscopic resection was accomplished using endoscopic mucosal resection (EMR), EMR with a ligation device (EMR-L), EMR after circumferential precutting, or endoscopic submucosal dissection (ESD).

RESULTS

EMR was performed in 18 tumors, EMR-L in 16, EMR after circumferential precutting in 3, and ESD in 4. En-bloc resection was performed in 39 tumors (95%), and endoscopic complete resection was achieved in 40 (98%); pathological complete resection was achieved in 17 tumors (41%). The endoscopic complete resection rate did not differ according to the resection method, but the pathological complete resection rate was higher for ESD than for EMR and EMR-L. Intraprocedural bleeding was noted in five cases, with no occurrence of perforation. Recurrence was not observed during the mean follow-up period of 17 months (range 1-53 months).

CONCLUSION

Endoscopic resection appears to be a safe and effective treatment for duodenal carcinoid tumors measuring ≤ 10 mm in diameter and confined to the submucosal layer.