Imaging of pancreatic neuroendocrine tumors: recent advances, current status, and controversies

Improvements and future perspective in diagnostic tools for neuroendocrine neoplasms

INTRODUCTION

Neuroendocrine neoplasms (NENs) represent a complex group of tumors arising from neuroendocrine cells, characterized by heterogeneous behavior and challenging diagnostics. Despite advancements in medical technology, NENs present a major challenge in early detection, often leading to delayed diagnosis and variable outcomes. This review aims to provide an in-depth analysis of current diagnostic methods as well as the evolving and future directions of diagnostic strategies for NENs.

AREA COVERED

The review extensively covers the evolution of diagnostic tools for NENs, from traditional imaging and biochemical tests to advanced genomic profiling and next-generation sequencing. The emerging role of technologies such as artificial intelligence, machine learning, and liquid biopsies could improve diagnostic precision, as could the integration of imaging modalities such as positron emission tomography (PET)/magnetic resonance imaging (MRI) hybrids and innovative radiotracers.

EXPERT OPINION

Despite progress, there is still a significant gap in the early diagnosis of NENs. Bridging this diagnostic gap and integrating advanced technologies and precision medicine are crucial to improving patient outcomes. However, challenges such as low clinical awareness, limited possibility of noninvasive diagnostic tools and funding limitations for rare diseases like NENs are acknowledged.

[Imaging of pancreatic neuroendocrine tumors]

BACKGROUND

Neuroendocrine tumors of the pancreas have a broad biological spectrum. The treatment decision is based on an optimal diagnosis with regard to the local findings and possible locoregional and distant metastases. In addition to purely morphologic imaging procedures, functional parameters are playing an increasingly important role in imaging.

OBJECTIVES

Prerequisites for optimal imaging of the pancreas, technical principles are provided, and the advantages and disadvantages of common cross-sectional imaging techniques as well as clinical indications for these special imaging methods are discussed.

MATERIALS AND METHODS

Guidelines, basic and review papers will be analyzed.

RESULTS

Neuroendocrine tumors of the pancreas have a broad imaging spectrum. Therefore, there is a need for multimodality imaging in which morphologic and functional techniques support each other. While positron emission tomography/computed tomography (PET/CT) can determine the presence of one or more lesions and its/their functional status of the tumor, magnetic resonance imaging (MRI) efficiently identifies the location, relationship to the main duct and the presence of liver metastases. CT allows a better vascular evaluation, even in the presence of anatomical variants as well as sensitive detection of lung metastases.

CONCLUSIONS

Knowledge of the optimal combination of imaging modalities including clinical and histopathologic results and dedicated imaging techniques is essential to achieve an accurate diagnosis to optimize treatment decision-making and to assess therapy response.

Diagnostic Anatomic Imaging for Neuroendocrine Neoplasms: Maximizing Strengths and Mitigating Weaknesses

ABSTRACT

Neuroendocrine neoplasms are a heterogeneous group of gastrointestinal and lung tumors. Their diverse clinical manifestations, variable locations, and heterogeneity present notable diagnostic challenges. This article delves into the imaging modalities vital for their detection and characterization. Computed tomography is essential for initial assessment and staging. At the same time, magnetic resonance imaging (MRI) is particularly adept for liver, pancreatic, osseous, and rectal imaging, offering superior soft tissue contrast. The article also highlights the limitations of these imaging techniques, such as MRI's inability to effectively evaluate the cortical bone and the questioned cost-effectiveness of computed tomography and MRI for detecting specific gastric lesions. By emphasizing the strengths and weaknesses of these imaging techniques, the review offers insights into optimizing their utilization for improved diagnosis, staging, and therapeutic management of neuroendocrine neoplasms.

[Neuroendocrine tumors of the pancreas]

CLINICAL/METHODOLOGICAL ISSUE

Neuroendocrine tumors (NET) of the pancreas fall into the group of gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN). The assignment of imaging morphological criteria to this heterogeneous group of complex tumors is often difficult.

STANDARD RADIOLOGICAL METHODS

Diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography-CT (PET/CT) are available for the detection of pancreatic NET (also referred to as NEN) and for the diagnosis of spread and the search for metastases.

METHODOLOGICAL INNOVATIONS

In particular, nuclear medicine examination methods with somatostatin analogues are of high value, since they make tumors visible with high sensitivity via radioactively labeled receptor ligands.

PERFORMANCE

CT and MRI have high detection rates of pancreatic NET. Further developments, such as diffusion imaging, have further improved these traditional cross-sectional imaging diagnostics. However, nuclear medicine methods are an important component in detection and are superior to CT and MRI.

ACHIEVEMENTS

It is important for the radiologist to be familiar with NET of the pancreas, as it is an important differential diagnosis-also with regard to prognosis-of other pancreatic lesions.

PRACTICAL RECOMMENDATIONS

Because NET are often hypervascularized, a biphasic examination technique after contrast administration is mandatory for cross-sectional imaging. PET/CT with somatostatin analogues should be performed for further diagnosis.

Gastroenteropancreatic Neuroendocrine Tumors-Current Status and Advances in Diagnostic Imaging

Gastroenteropancreatic neuroendocrine neoplasia (GEP-NEN) is a heterogeneous and complex group of tumors that are often difficult to classify due to their heterogeneity and varying locations. As standard radiological methods, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT) are available for both localization and staging of NEN. Nuclear medical imaging methods with somatostatin analogs are of great importance since radioactively labeled receptor ligands make tumors visible with high sensitivity. CT and MRI have high detection rates for GEP-NEN and have been further improved by developments such as diffusion-weighted imaging. However, nuclear medical imaging methods are superior in detection, especially in gastrointestinal NEN. It is important for radiologists to be familiar with NEN, as it can occur ubiquitously in the abdomen and should be identified as such. Since GEP-NEN is predominantly hypervascularized, a biphasic examination technique is mandatory for contrast-enhanced cross-sectional imaging. PET/CT with somatostatin analogs should be used as the subsequent method.

Prognostic Implications of PET-Derived Tumor Volume and Uptake in Patients with Neuroendocrine Tumors

Historically, molecular imaging of somatostatin receptor (SSTR) expression in patients with neuroendocrine tumors (NET) was performed using SSTR scintigraphy (SRS). Sustained advances in medical imaging have led to its gradual replacement with SSTR positron-emission tomography (SSTR-PET). The higher sensitivity in comparison to SRS on the one hand and conventional cross-sectional imaging, on the other hand, enables more accurate staging and allows for image quantification. In addition, in recent years, a growing body of evidence has assessed the prognostic implications of SSTR-PET-derived prognostic biomarkers for NET patients, with the aim of risk stratification, outcome prognostication, and prediction of response to peptide receptor radionuclide therapy. In this narrative review, we give an overview of studies examining the prognostic value of advanced SSTR-PET-derived (semi-)quantitative metrics like tumor volume, uptake, and composite metrics. Complementing this analysis, a discussion of the current trends, clinical implications, and future directions is provided.

The Latest Advancements in Diagnostic Role of Endosonography of Pancreatic Lesions

Endosonography, a minimally invasive imaging technique, has revolutionized the diagnosis and management of pancreatic diseases. This comprehensive review highlights the latest advancements in endosonography of the pancreas, focusing on key technological developments, procedural techniques, clinical applications and additional techniques, which include real-time elastography endoscopic ultrasound, contrast-enhanced-EUS, EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy. EUS is well established for T-staging and N-staging of pancreaticobiliary malignancies, for pancreatic cyst discovery, for identifying subepithelial lesions (SEL), for differentiation of benign pancreaticobiliary disorders or for acquisition of tissue by EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy. This review briefly describes principles and application of EUS and its related techniques.

Exploiting the Potential of Photon-Counting CT in Abdominal Imaging

ABSTRACT

Photon-counting computed tomography (PCCT) imaging uses a new detector technology to provide added information beyond what can already be obtained with current CT and MR technologies. This review provides an overview of PCCT of the abdomen and focuses specifically on applications that benefit the most from this new imaging technique. We describe the requirements for a successful abdominal PCCT acquisition and the challenges for clinical translation. The review highlights work done within the last year with an emphasis on new protocols that have been tested in clinical practice. Applications of PCCT include imaging of cystic lesions, sources of bleeding, and cancers. Photon-counting CT is positioned to move beyond detection of disease to better quantitative staging of disease and measurement of treatment response.

A systems biology approach to define mechanisms, phenotypes, and drivers in PanNETs with a personalized perspective

Pancreatic neuroendocrine tumors (PanNETs) are a rare tumor entity with largely unpredictable progression and increasing incidence in developed countries. Molecular pathways involved in PanNETs development are still not elucidated, and specific biomarkers are missing. Moreover, the heterogeneity of PanNETs makes their treatment challenging and most approved targeted therapeutic options for PanNETs lack objective responses. Here, we applied a systems biology approach integrating dynamic modeling strategies, foreign classifier tailored approaches, and patient expression profiles to predict PanNETs progression as well as resistance mechanisms to clinically approved treatments such as the mammalian target of rapamycin complex 1 (mTORC1) inhibitors. We set up a model able to represent frequently reported PanNETs drivers in patient cohorts, such as Menin-1 (MEN1), Death domain associated protein (DAXX), Tuberous Sclerosis (TSC), as well as wild-type tumors. Model-based simulations suggested drivers of cancer progression as both first and second hits after MEN1 loss. In addition, we could predict the benefit of mTORC1 inhibitors on differentially mutated cohorts and hypothesize resistance mechanisms. Our approach sheds light on a more personalized prediction and treatment of PanNET mutant phenotypes.

Fully automated magnetic resonance imaging-based radiomics analysis for differentiating pancreatic adenosquamous carcinoma from pancreatic ductal adenocarcinoma

PURPOSE

To develop and validate an automated magnetic resonance imaging (MRI)-based model to preoperatively differentiate pancreatic adenosquamous carcinoma (PASC) from pancreatic ductal adenocarcinoma (PDAC).

METHODS

This retrospective study included patients with surgically resected, histopathologically confirmed PASC or PDAC who underwent MRI between January 2011 and December 2020. According to time of treatment, they were divided into training and validation sets. Automated deep-learning-based artificial intelligence was used for pancreatic tumor segmentation. Linear discriminant analysis was performed with conventional MRI and radiomic features to develop clinical, radiomics, and mixed models in the training set. The models' performances were determined from their discrimination and clinical utility. Kaplan-Meier and log-rank tests were used for survival analysis.

RESULTS

Overall, 389 and 123 patients with PDAC (age, 61.37 ± 9.47 years; 251 men) and PASC (age, 61.99 ± 9.82 years; 78 men) were included, respectively; they were split into the training (n = 358) and validation (n = 154) sets. The mixed model showed good performance in the training and validation sets (area under the curve: 0.94 and 0.96, respectively). The sensitivity, specificity, and accuracy were 76.74%, 93.38%, and 89.39% for the training set, respectively, and 67.57%, 97.44%, and 90.26% for the validation set, respectively. The mixed model outperformed the clinical (p = 0.001) and radiomics (p = 0.04) models in the validation set. Log-rank test revealed significantly longer survival in the predicted PDAC group than in the predicted PASC group (p = 0.003), according to the mixed model.

CONCLUSION

Our mixed model, which combined MRI and radiomic features, can be used to differentiate PASC from PDAC.

The Role of MRI in the Diagnosis of Solid Pseudopapillary Neoplasm of the Pancreas and Its Mimickers: A Case-Based Review with Emphasis on Differential Diagnosis

Solid pseudopapillary neoplasm (SPN) is rare pancreatic tumor occurring most commonly in young females. The typical imaging appearance of SPN is of well-defined, encapsulated, and large heterogeneous tumors, consisting of solid and cystic components due to various degrees of intralesional hemorrhage and necrosis. However, atypical imaging presentation in the form of small solid tumors or uniformly cystic lesions might also be seen, which can be explained by specific pathological characteristics. Other imaging features such as a round shape, the absence of main pancreatic duct dilatation, and slow growth, in combination with vague symptoms, favor the diagnosis of SPNs. Nevertheless, the radiological findings of SPN might overlap with other solid and cystic pancreatic neoplasms, such as neuroendocrine tumors, serous and mucinous neoplasms, and even small pancreatic adenocarcinomas. In addition, a few benign non-tumorous conditions including walled-of-necrosis, and intrapancreatic accessory spleen may also pose diagnostic dilemmas simulating SPNs on imaging studies. The aim of this manuscript is to provide a comprehensive overview of the typical and atypical imaging features of SPNs and to describe useful tips for differential diagnosis with its potential mimickers.

Report of a Novel Molecular Profile in Malignant Insulinoma

Pancreatic neuroendocrine tumors, or pNETs, represent a rare and clinically heterogenous subset of pancreatic neoplasms. One such pNET, the insulinoma, is found to be malignant in just 4% of all insulinomas. Due to the exceedingly uncommon occurrence of these tumors, there is controversy regarding the optimal evidence-based management for these patients. We therefore report on a 70-year-old male patient admitted with 3 months of episodic confusion with concurrent hypoglycemia. The patient was found to have inappropriately elevated endogenous insulin levels during these episodes, and somatostatin-receptor subtype 2 selective imaging revealed a pancreatic mass metastatic to local lymph nodes, spleen, and the liver. Fine needle aspiration of pancreatic and liver lesions confirmed the diagnosis of a low grade pancreatic neuroendocrine tumor. Molecular analysis of tumor tissue revealed a novel mutational profile consistent with pNET. The patient was initiated on octreotide therapy. However, treatment with octreotide alone demonstrated limited efficacy in controlling the patient's symptoms, prompting consideration of other therapies.

Use of dual-layer spectral detector computed tomography in the diagnosis of pancreatic neuroendocrine neoplasms

PURPOSE

To explore the optimal energy level of dual-layer spectral detector computed tomography (DLCT) images of pancreatic neuroendocrine neoplasms (pNENs) and investigate the value in their detection.

METHODS

This retrospective analysis included 134 pNEN patients with 136 lesions; they underwent contrast-enhanced DLCT scanning with histopathological confirmation of pNENs. Virtual monoenergetic images (VMI) of 40-100 keV, iodine concentration map (IC map), Z-effective atomic number map (Zeff map), and conventional images were analysed. The optimal energy level was obtained by comparing the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). The lesion detection rates of DLCT and conventional images were compared. Subjective image analysis was performed by two readers who assessed the image quality and lesion conspicuity on a 5-point scale.

RESULTS

The SNR of VMIs from 40 to 80 keV (arterial phase, P < 0.001; venous phase, P < 0.05) and CNR from 40 to 60 keV (arterial and venous phases, each P < 0.05) were higher than that of conventional images; VMI_40keV showed the highest SNR and CNR. There was a good inter-reader agreement between the two reviewers (Kappa values > 0.61); the scores of Zeff and IC maps were higher than those of conventional images and VMI_40keV (P < 0.05). The detection performance of DLCT images was better than conventional images.

CONCLUSIONS

The VMI_40keV demonstrated the best CNR and SNR of pNENs compared to other VMIs. Zeff and IC maps improve objective image quality and reader preference compared to conventional images. These findings could possess important clinical implications in formulating treatment strategies.

Differential diagnosis between pancreatic solid pseudopapillary tumors and pancreatic neuroendocrine tumors based on contrast enhanced ultrasound imaging features

PURPOSES

To evaluate the application of contrast enhanced ultrasound (CEUS) in preoperatively differential diagnosis between pancreatic solid pseudopapillary tumors (SPTs) and pancreatic neuroendocrine tumors (pNETs).

PATIENTS AND METHODS

This retrospective study was approved by Institutional Review Board. Patients with surgical resection and histopathological diagnosis as SPTs and pNETs were included. All patients underwent B mode ultrasound (BMUS) and CEUS examinations within one week before surgical operation. On BMUS, the size, location, echogenicity, calcification, and margin of lesions were observed and recorded. On CEUS imaging, enhancement patterns, and enhancement degrees were recorded and analyzed. An independent t-test or Mann-Whitney U test was used for comparison between continuous variables. Chi-square test was used to compare the CEUS patterns.

RESULTS

From February 2017 to Dec 2022, patients diagnosed as SPTs (n = 39) and pNETs (n = 48) were retrospectively included. On BMUS, anechoic cystic changes (19/39, 48.72%) and hyperechoic calcification (14/39, 35.90%) are more commonly detected in SPTs (P = 0.000). On CEUS imaging, the majority of SPTs (27/39, 69.23%) showed hypo-enhancement in the arterial phase, while most of the pNETs (36/48, 75.00%) showed hyper- or iso-enhancement in the arterial phase (P = 0.000). In the venous phase, most of the SPTs (32/39, 82.05%) showed hypo-enhancement, while over half of pNETs (29/48, 60.42%) showed hyper- or iso-enhancement compared to pancreatic parenchyma (P = 0.001).

CONCLUSIONS

CEUS is a valuable and non-invasive imaging method to make preoperatively differential diagnoses between SPTs and pNETs.

Diagnostic work-up and advancement in the diagnosis of gastroenteropancreatic neuroendocrine neoplasms

Neuroendocrine neoplasms (NENs) are a heterogeneous group of neoplasms ranging from well-differentiated, slowly growing tumors to poorly differentiated carcinomas. These tumors are generally characterized by indolent course and quite often absence of specific symptoms, thus eluding diagnosis until at an advanced stage. This underscores the importance of establishing a prompt and accurate diagnosis. The gold-standard remains histopathology. This should contain neuroendocrine-specific markers, such as chromogranin A; and also, an estimate of the proliferation by Ki-67 (or MIB-1), which is pivotal for treatment selection and prognostication. Initial work-up involves assessment of serum Chromogranin A and in selected patients gut peptide hormones. More recently, the measurement of multiple NEN-related transcripts, or the detection of circulating tumor cells enhanced our current diagnostic armamentarium and appears to supersede historical serum markers, such as Chromogranin A. Standard imaging procedures include cross-sectional imaging, either computed tomography or magnetic resonance, and are combined with somatostatin receptor scintigraphy. In particular, the advent of ¹¹¹In-DTPA-octreotide and more recently PET/CT and ⁶⁸Ga-DOTA-Octreotate scans revolutionized the diagnostic landscape of NENs. Likewise, FDG PET represents an invaluable asset in the management of high-grade neuroendocrine carcinomas. Lastly, endoscopy, either conventional, or more advanced modalities such as endoscopic ultrasound, capsule endoscopy and enteroscopy, are essential for the diagnosis and staging of gastroenteropancreatic neuroendocrine neoplasms and are routinely integrated in clinical practice. The complexity and variability of NENs necessitate the deep understanding of the current diagnostic strategies, which in turn assists in offering optimal patient-tailored treatment. The current review article presents the diagnostic work-up of GEP-NENs and all the recent advances in the field.

Screening of an annexin-A2-targeted heptapeptide for pancreatic adenocarcinoma localization

Annexin A2 (ANXA2) encodes an oncoprotein whose expression has been found to correlate with poorer overall survival (OS) of pancreatic adenocarcinoma (PAAD) patients. Although peptides are available for targeting ANXA2, none of these were initially selected to target this protein specifically. Here, we took ANXA2 as a molecular target for PAAD and employed the phage display technique to screen for a new ANXA2-targeted peptide. The resultant heptapeptide, YW7, was firstly labeled with fluorescein isothiocyanate (FITC) to evaluate its selectivity in cellular uptake, and further with the near-infrared fluorescent (NIRF) dye Cy7 to assess in vivo distribution in a mouse model bearing PANC-1 human pancreatic cancer xenografic tumors. We found that both FITC-YW7 and Cy7-YW7 probes showed significantly higher uptake in PANC-1 cells compared to the HPDE6-C7 pancreatic epithelium cells. Mice intravenously injected with Cy7-YW7 showed higher tumor-to-background ratios (TBRs) (~ 2.7-fold) in tumor tissues compared to those injected with Cy7 alone. Our study suggested that YW7 is a novel peptide targeting ANXA2 and Cy7-YW7 is an NIRF probe potentially useful for the early detection of PAAD.

Pancreatic adenocarcinoma and pancreatic high-grade neuroendocrine carcinoma: two sides of the moon

Pancreatic adenocarcinoma is the seventh leading cause of cancer death in the world and the most common type pf pancreatic cancer. Unfortunately, less than 20% of patients are surgically resectable and the great majority of cases are treated with palliative chemotherapy with unsatisfactory results. No targeted agents or personalized approaches have been validated in the last decades. On the other side, neuroendocrine neoplasms of the pancreas are generally considered indolent tumours. However, high-grade neuroendocrine carcinoma is a rare subtype of neuroendocrine neoplasm of the pancreas (accounting up to 10% of the neuroendocrine neoplasms of the pancreas), with particularly aggressive behaviour and poor prognosis. Even in this case, the treatment is represented by palliative chemotherapy with dismal results and no personalized therapies are available, so far. Notably, the quality of life of these patients is disappointingly low and the future perspectives of more personalized diagnostic and therapeutic strategies are scarce. In this review, we discuss relevant and current information on epidemiology, pathology, diagnosis, clinical presentation, treatment and ongoing clinical trials of these two entities, in order to illustrate the two sides of the moon.

[Modern molecular and imaging diagnostics in pancreatic neuroendocrine neoplasms]

BACKGROUND AND OBJECTIVE

New molecular diagnostic and radiologic imaging techniques can be used to assess the extent, risk of recurrence, prognosis and response to treatment of pancreatic neuroendocrine neoplasms (pNENs). They therefore represent a decisive help in setting the indications for surgical treatment, especially in advanced stages.

METHODS

This article presents a narrative assessment of the options and evidence for modern molecular and radiologic imaging diagnostics of pNENs based on the current literature.

RESULTS

While circulating DNA, circulating tumor cells and microRNAs have not yet become established in everyday clinical practice, the current literature suggests a promising role for the so-called NETest. Recent studies demonstrated its possible importance for the surgical management of pNENs. Besides [68Ga]Ga-DOTA-SSA-PET and [18]FDG-PET, which remain the gold standards for imaging NENs, radiomics represent an exciting alternative to biopsies and will possibly play an increasingly important role in the future.

DISCUSSION

There are new promising alternatives to chromogranin A, which has been clinically widespread since the 1970s despite several drawbacks, to map the extent, risk of recurrence, prognosis and response to treatment of pancreatic pNENs. In terms of personalized medicine, modern molecular and radiological diagnostics should play an increasing role for indicating and planning surgical treatment and for follow-up in the future.

Rare Bone Metastasis of Neuroendocrine Tumors of Unknown Origin: A Case Report and Literature Review

BACKGROUND

The neuroendocrine tumor (NET) is rare, accounting for about 0.5% of all tumors. NETs have the characteristics of metastasis, especially lymph nodes, liver, spleen, and bone.

CASE PRESENTATION

We report a 30-year-old man diagnosed with a NET with bone metastasis and presented with waist and leg pain. The imaging findings of this case showed multiple osteosclerosis and no apparent bone destruction. We collected the patient's previous examinations, including laboratory, imaging, and pathological examination to get a precise diagnosis. Given this case, we carried out symptomatic support treatment to relieve the patients' pain symptoms.

CONCLUSION

Bone metastases from NETs of unknown primary site are rare in both clinical and imaging manifestations. The disease is mainly manifested as multiple osteosclerosis, accompanied by muscle soreness and pain. It is recommended to try chemotherapy for this disorder.

Integration of molecular imaging in the personalized approach to neuroendocrine tumors

NETs lesions can be difficult to characterize with conventional anatomic imaging (CT and MRI). Functional imaging techniques, and especially PET imaging, are very useful for detecting small neuroendocrine tumors that would not be seen with other techniques. The role of nuclear medicine in the localization, staging, restaging, treatment and monitoring of neuroendocrine tumors (NETs) has become progressively more relevant due to: the availability of tracers on new targets, tracers for positron emission tomography (PET); the development of cyclotrons and generators that allow this availability; as well as to hybrid systems (SPECT/CT, PET/CT and PET/MRI) that, by joining the functional and anatomical image, improve the quality of the images. Teragnosis, a new emerging therapy, in NET used receptor-mediated or nonreceptor- mediated mechanism to facilitate penetration and high-affinity binding between the radiopharmaceutical and the tumor cell. Teragnosis offers the possibility of personalized targeted radionuclide therapy.

The New Radiolabeled Peptide 99mTcEDDA/HYNIC-TOC: Is It a Feasible Choice for Diagnosing Gastroenteropancreatic NETs?

(1) Background: The aim of our study is to reveal the advantages and limitations of the use of 99mTcEDDA/HYNIC-TOC (Tektrotyd®, Polatom) in the diagnosis of gastroenteropancreatic neuroendocrine tumors and to compare our results with the values obtained for 111In-pentetreotide and 68Ga-DOTA-peptides, routinely used in medical practice. (2) Methods: This retrospective monocentric study included 173 patients with gastroenteropancreatic neuroendocrine tumors who underwent 99mTcEDDA/HYNIC-TOC scans as part of their clinical management. The examination protocol included a whole-body scan acquired 2 h after the radiotracer's administration, with the SPECT/CT performed 4 h post-injection. Physiological and abnormal uptake were established by two experienced physicians and, based on the obtained results, sensitivity, specificity, accuracy, positive predictive value and negative predictive value were calculated. (3) Results: Our method presented a sensitivity of 90.5%, a specificity of 71.9%, and an accuracy of 84.3%, with a positive predictive value of 86.7% and a negative predictive value of 78.8%. (4) Conclusions: 99mTc-EDDA/HYNIC-TOC, a receptor-based radiopharmaceutical, could represent a competitor for 68Ga-labeled peptides in the diagnosis and management of patients with gastroenteropancreatic neuroendocrine tumors. Our results show a lower sensitivity (90.5%) than 68Ga-DOTA-peptides, but with great specificity, accuracy, positive, and negative predictive values.

Nonfunctional pancreatic neuroendocrine tumours misdiagnosed as autoimmune pancreatitis: A case report and review of literature

BACKGROUND

Nonfunctional pancreatic neuroendocrine tumours are difficult to diagnose in the early stage of disease due to a lack of clinical symptoms, but they can rarely manifest as autoimmune pancreatitis. Autoimmune pancreatitis is an uncommon disease that may cause recurrent acute pancreatitis and is therefore often regarded as a special type of chronic pancreatitis.

CASE SUMMARY

We report a case of a 42-year-old female who had nonspecific upper abdominal pain for 4 years and radiological abnormalities of the pancreas that mimicked autoimmune pancreatitis. The symptoms and pancreatic imaging did not improve following 1 year of steroid therapy. Finally, pancreatic biopsy was performed through endoscopic ultrasonography-guided fine-needle aspiration biopsy, and nonfunctional pancreatic neuroendocrine tumours were ultimately diagnosed. Pancreatectomy has resolved her symptoms.

CONCLUSION

Therefore, the differentiation of nonfunctional pancreatic neuroendocrine tumours from autoimmune pancreatitis is very important, although it is rare. We propose that endoscopic ultrasonography-guided fine-needle aspiration biopsy should be performed if imaging characteristics are equivocal or the diagnosis is in question.

Value of lymphadenectomy in patients with surgically resected pancreatic neuroendocrine tumors

BACKGROUND

Although some factors that predict the prognosis in pancreatic neuroendocrine tumor (pNET) have been confirmed, the predictive value of lymph node metastasis (LNM) in the prognosis of pNETs remains conflicting and it is not clear whether regional lymphadenectomy should be performed in all grades of tumors.

METHODS

We included pNET patients undergoing surgery in Shanghai pancreatic cancer institute (SHPCI). The risk factors for survival were investigated by the Kaplan-Meier method and Cox regression model. We evaluated the predictors of LNM using Logistic regression.

RESULTS

For 206 patients in the SHPCI series, LNM was an independent prognostic factor for entire cohort suggested by multivariate Cox regression analysis. LNM (P = 0.002) predicted poorer overall survival (OS) in grade 2/3 cohort, but there is no significant association between LNM and OS in grade 1 cohort. Grade (P < 0.001) and size (P = 0.049) predicted LNM in entire cohort. Grade (P = 0.002) predicted LNM while regardless of size in grade 2/3 cohort.

CONCLUSIONS

Based on our own retrospective data obtained from a single center series, LNM seems to be associated with poorer outcome for patients with grade 2/3 and/or grade 1 > 4 cm tumors. On the other way, LNM was seems to be not associated with prognosis in patients with grade 1 tumors less than 4 cm. Moreover, tumor grade and tumor size seem to act as independent predictors of LNM. Thus, regional lymphadenectomy should be performed in grade 2/3 patients but was not mandatory in grade 1 tumors < 4 cm. It is reasonable to perform functional sparing surgery for grade 1 patients or propose a clinical-radiological monitoring.

Dual-Energy CT in the Pancreas

Dual-energy computed tomography (DECT) is an evolving imaging technology that is gaining popularity, particularly in different abdominopelvic applications. Essentially, DECT uses two energy spectra simultaneously to acquire CT attenuation data which is used to distinguish among structures with different tissue composition. The wide variety of reconstructed image data sets makes DECT especially attractive in pancreatic imaging. This article reviews the current literature on DECT as it applies to imaging the pancreas, focusing on pancreatitis, trauma, pancreatic ductal adenocarcinoma, and other solid and cystic neoplasms. The advantages of DECT over conventional CT are highlighted, including improved lesion detection, radiation dose reduction, and enhanced image contrast. Additionally, data exploring the ideal protocol for pancreatic imaging using DECT is reviewed. Finally, limitations of DECT in pancreatic imaging as well as recommendations for future research are provided.

Predictive Factors for Resistant Disease with Medical/Radiologic/Liver-Directed Anti-Tumor Treatments in Patients with Advanced Pancreatic Neuroendocrine Neoplasms: Recent Advances and Controversies

Simple Summary

Tumor resistance, both primary and acquired, is leading to increased complexity in the nonsurgical treatment of patients with advanced panNENs, which would be greatly helped by reliable prognostic/predictive factors. The importance in identifying resistance is being contributed to by the increased array of possible treatments available for treating resistant advanced disease; the variable clinical course as well as response to any given treatment approach of patients within one staging or grading system, the advances in imaging which are providing increasing promising results/parameters that correlate with grading/outcome/resistance, the increased understanding of the molecular pathogenesis providing promising prognostic markers, all of which can contribute to selecting the best treatment to overcome resistance disease. Several factors have been identified that have prognostic/predictive value for identifying development resistant disease and affecting overall survival (OS)/PFS with various nonsurgical treatments of patients with advanced panNENs. Prognostic factors identified for patients with advanced panNENs for both OS/PFSs include various clinically-related factors (clinical, laboratory/biological markers, imaging, treatment-related factors), pathological factors (histological, classification, grading) and molecular factors. Particularly important prognostic factors for the different treatment modalities studies are the recent grading systems. Most prognostic factors for each treatment modality for OS/PFS are not specific for a given treatment option. These advances have generated several controversies and new unanswered questions, particularly those related to their possible role in predicting the possible sequence of different anti-tumor treatments in patients with different presentations. Each of these areas is reviewed in this paper.

Abstract

Purpose: Recent advances in the diagnosis, management and nonsurgical treatment of patients with advanced pancreatic neuroendocrine neoplasms (panNENs) have led to an emerging need for sensitive and useful prognostic factors for predicting responses/survival. Areas covered: The predictive value of a number of reported prognostic factors including clinically-related factors (clinical/laboratory/imaging/treatment-related factors), pathological factors (histological/classification/grading), and molecular factors, on therapeutic outcomes of anti-tumor medical therapies with molecular targeting agents (everolimus/sunitinib/somatostatin analogues), chemotherapy, radiological therapy with peptide receptor radionuclide therapy, or liver-directed therapies (embolization/chemoembolization/radio-embolization (SIRTs)) are reviewed. Recent findings in each of these areas, as well as remaining controversies and uncertainties, are discussed in detail, particularly from the viewpoint of treatment sequencing. Conclusions: The recent increase in the number of available therapeutic agents for the nonsurgical treatment of patients with advanced panNENs have raised the importance of prognostic factors predictive for therapeutic outcomes of each treatment option. The establishment of sensitive and useful prognostic markers will have a significant impact on optimal treatment selection, as well as in tailoring the therapeutic sequence, and for maximizing the survival benefit of each individual patient. In the paper, the progress in this area, as well as the controversies/uncertainties, are reviewed.

Role of Combined 68Ga DOTA-Peptides and 18F FDG PET/CT in the Evaluation of Gastroenteropancreatic Neuroendocrine Neoplasms

This review article summarizes the role of combined ⁶⁸Ga DOTA-peptides and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the evaluation of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). Patients with GEP-NENs can initially present themselves to a gastroenterologist or endocrinologist rather than cancer specialist; hence, it is vital for a wider group of clinicians to be familiar with the range of tests available for the evaluation of these patients. The role of PET scanning by using ⁶⁸Ga DOTA-peptides has a high sensitivity in the diagnosis of GEP-NENs and to guide patient selection for treatment with somatostatin analogues (SSA) and/or peptide receptor radionuclide therapy (PRRT). The loss of somatostatin receptor (SSTR) expression was found to be associated with an increased glucose metabolism in cells. However, the routine use of SSTR targeted radiotracers in combination with ¹⁸F-FDG to evaluate glucose utilization in GEP-NENs is still debatable. In our opinion, in patients with NENs, ¹⁸F-FDG PET should be performed in the case of a negative or slightly positive ⁶⁸Ga DOTA-peptides PET scan for assessing the dedifferentiation status, to guide correct therapeutic strategy and to evaluate the prognosis. The approach of combined receptor and metabolic imaging can improve diagnostic accuracy, especially considering the heterogeneity of these lesions. Therefore, ⁶⁸Ga DOTA-peptides and ¹⁸F-FDG PET should be considered complementary in patients with GEP-NENs.

Current and New Challenges in the Management of Pancreatic Neuroendocrine Tumors: The Role of miRNA-Based Approaches as New Reliable Biomarkers

Pancreatic neuroendocrine tumors (PanNETs) are rare tumors; however, their incidence greatly increases with age, and they occur more frequently among the elderly. They represent 5% of all pancreatic tumors, and despite the fact that low-grade tumors often have an indolent evolution, they portend a poor prognosis in an advanced stages and undifferentiated tumors. Additionally, functional pancreatic neuroendocrine tumors greatly impact quality of life due to the various clinical syndromes that result from abnormal hormonal secretion. With limited therapeutic and diagnostic options, patient stratification and selection of optimal therapeutic strategies should be the main focus. Modest improvements in the management of pancreatic neuroendocrine tumors have been achieved in the last years. Therefore, it is imperative to find new biomarkers and therapeutic strategies to improve patient survival and quality of life, limiting the disease burden. MicroRNAs (miRNAs) are small endogenous molecules that modulate the expression of thousands of genes and control numerous critical processes involved in tumor development and progression. New data also suggest the implication of miRNAs in treatment resistance and their potential as prognostic or diagnostic biomarkers and therapeutic targets. In this review, we discusses the current and new challenges in the management of PanNETs, including genetic and epigenetic approaches. Furthermore, we summarize the available data on miRNAs as potential prognostic, predictive, or diagnostic biomarkers and discuss their function as future therapeutic targets.

Prognostic Value of Volume-Based Parameters Measured by SSTR PET/CT in Neuroendocrine Tumors: A Systematic Review and Meta-Analysis

Purpose: A meta-analysis was conducted to investigate the value of the volume parameters based on somatostatin receptor (SSTR)-positron emission tomography (PET) in predicting the prognosis in patients with neuroendocrine tumors (NETs). Material: PUBMED, EMBASE, Cochrane library, and Web of Knowledge were searched from January 1990 to May 2021 for studies evaluating prognostic value of volume-based parameters of SSTR PET/CT in NETs. The terms used were "volume," "positron emission tomography," "neuroendocrine tumors," and "somatostatin receptor." Pooled hazard ratio (HR) values were calculated to assess the correlations between volumetric parameters, including total tumor volume (TTV) and total-lesion SSTR expression (TL-SSTR), with progression-free survival (PFS) and overall survival (OS). Heterogeneity and subgroup analysis were performed. Funnel plots, Begg's and Egger's test were used to assess possible underlying publication bias. Results: Eight eligible studies involving 593 patients were included in the meta-analysis. In TTV, the pooled HRs of its prognostic value of PFS and OS were 2.24 (95% CI: 1.73-2.89; P < 0.00001) and 3.54 (95% CI, 1.77-7.09; P = 0.0004), respectively. In TL-SSTR, the pooled HR of the predictive value was 1.61 (95% CI, 0.48-5.44, P = 0.44) for PFS. Conclusion: High TTV was associated with a worse prognosis for PFS and OS in with patients NETs. The TTV of SSTR PET is a potential objective prognosis predictor.

Somatostatin and Somatostatin Receptors: From Signaling to Clinical Applications in Neuroendocrine Neoplasms

Neuroendocrine neoplasms (NENs) are heterogeneous neoplasms which arise from neuroendocrine cells that are distributed widely throughout the body. Although heterogenous, many of them share their ability to overexpress somatostatin receptors (SSTR) on their cell surface. Due to this, SSTR and somatostatin have been a large subject of interest in the discovery of potential biomarkers and treatment options for the disease. The aim of this review is to describe the molecular characteristics of somatostatin and somatostatin receptors and its application in diagnosis and therapy on patients with NENs as well as the use in the near future of somatostatin antagonists.

Plasma Hemoglobin and Red Blood Cell Mass Levels as Dynamic Prognostic Markers for Progression and Survival in Pancreatic Neuroendocrine Tumors

There are scarce data on readily available markers enabling immediate risk stratification and personalized management in patients with advanced pancreatic neuroendocrine tumors. This study explores the association of red blood cells-related parameters as prognostic markers in patients harboring pancreatic neuroendocrine tumors. Retrospective analysis of a tertiary medical center database, acquiring data of patients with pancreatic neuroendocrine tumors including demographics, tumor-related parameters and consecutive imaging results, vital status at last follow-up, and red blood cells parameters at baseline, last follow-up, and dynamics (last/baseline ratio). Univariate and multivariable analyses were performed. Sixty-seven patients were identified (mean age at diagnosis of 63±11 years, 56.7% males). Patients with disease progression had lower hemoglobin, red blood cells mass values and hematocrit at the last evaluation (p<0.001 for all comparisons), with red blood cells mass level<3.9 m/μl and a 6% and 9% relative reduction in hemoglobin and hematocrit levels, respectively, associated with an increased risk for disease progression. Similarly, patients deceased during the study period had lower hemoglobin, red blood cells mass values and hematocrit (p<0.03 for all) than those alive, at last follow-up. Eleven percent reduction in hemoglobin level was noted indicating a higher mortality risk (p=0.04). Negative hemoglobin and hematocrit dynamics were independently associated with increased risk for disease progression (p=0.03 and 0.049, respectively). In conclusion, decrease in red blood cells mass, hemoglobin and/or hematocrit levels are all associated with poor prognosis in patients with pancreatic neuroendocrine tumors. We suggest utilizing these parameters as complementary follow-up prognostic markers to radiologic imaging in this patients population.

Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography for staging of canine insulinoma: 3 cases (2019-2020)

OBJECTIVES

Canine insulinomas are uncommon malignant functional pancreatic neuroendocrine tumours with a high metastatic rate. Diagnostic imaging aids with staging and surgical planning of these tumours; however, identification is unpredictable across modalities. High-grade human pancreatic neuroendocrine tumours display increased avidity on ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT.

MATERIALS AND METHODS

Dogs with clinicopathologic findings consistent with pancreatic insulinoma were prospectively enrolled. Patients underwent ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT and CT angiography, followed by exploratory laparotomy.

RESULTS

Three patients met the inclusion criteria and had histologically confirmed insulinomas. Both metastatic lesions in patient 1 were mildly avid (SUV_max 2.79 and 3.01). In patient 2, the primary pancreatic insulinoma was minimally avid (SUV_max 2.16). The primary pancreatic lesion in patient 3 had similar avidity to normal pancreatic parenchyma (SUV_max 1.54) and was undetected on ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT. Insulinomas demonstrated variable attenuation and contrast enhancement patterns on CT angiography and certain lesions were more conspicuous than on ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT. Two metastatic lesions not visible on either imaging modality were discovered in patient 2 at surgery.

CLINICAL SIGNIFICANCE

Canine insulinomas were inconsistently avid on ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT. This finding is likely attributable to the confounding clinicopathological features and multifaceted transformation of these tumours, in addition to the influence of variable tumour size, composition and vascularity. Unpredictable tumoural avidity limits the value of ¹⁸ F-fluorodeoxyglucose positron emission tomography-CT for staging canine insulinomas.

Diagnostic performance of noninvasive imaging modalities for localization of insulinoma: A meta-analysis

BACKGROUND

Insulinoma is the most common functional neuroendocrine tumor found only in the pancreas. The early detection of insulinoma is of importance. Studies comparing the performance of noninvasive modalities were limited by sample size and heterogeneity between studies. The aim of this meta-analysis was to evaluate the diagnostic performance of PET/CT, SPECT/CT, CT and MRI for the localization of insulinoma, and to provide evidence for clinical practice.

METHODS

PubMed, Embase, Cochrane Library, Wanfang Data and China National Knowledge Infrastructure were searched from inception to May 31, 2021. Pooled sensitivity, specificity, positive Likelihood Ratio (+LR) and negative Likelihood Ratio (-LR), diagnostic odds ratio (DOR), and concordance rate were calculated.

RESULTS

A total of 19 studies including 708 patients of insulinoma reached the inclusion criteria. PET/CT imaging demonstrated a pooled sensitivity of 0.79 (95% CI: 0.54-0.92) and a pooled specificity of 0.84 (95% CI: 0.20-0.99). The pooled sensitivity and specificity of SPECT/CT were 0.77 (95% CI: 0.46-0.93) and 0.45 (95% CI: 0.22-0.70). CT showed an overall sensitivity of 0.54 (95% CI: 0.35-0.72) and specificity of 0.75 (95% CI: 0.54-0.88). The pooled sensitivity and specificity for MRI were 0.54 (95% CI: 0.31-0.75) and 0.65 (95% CI: 0.39-0.84), respectively. The concordance rates of PET, SPECT, CT, and MRI were 78% (95% CI: 66-90%), 74% (95% CI: 52-97%), 56% (95% CI: 41-72%), and 53% (95% CI: 33-73%), respectively.

CONCLUSION

Results of this study indicate that PET/CT demonstrated superior performance than SPECT/CT, CT and MRI for the localization of insulinoma. GLP-1R based PET/CT manifested better diagnostic performance in comparison with SSTR based PET/CT imaging modality.

Current update on imaging for pancreatic neuroendocrine neoplasms

Pancreatic neuroendocrine neoplasms (panNEN) are a heterogeneous group of tumors with differing pathological, genetic, and clinical features. Based on clinical findings, they may be categorized into functioning and nonfunctioning tumors. Adoption of the 2017 World Health Organization classification system, particularly its differentiation between grade 3, well-differentiated pancreatic neuroendocrine tumors (panNET) and grade 3, poorly-differentiated pancreatic neuroendocrine carcinomas (panNEC) has emphasized the role imaging plays in characterizing these lesions. Endoscopic ultrasound can help obtain biopsy specimen and assess tumor margins and local spread. Enhancement patterns on computed tomography (CT) and magnetic resonance imaging (MRI) may be used to classify panNEN. Contrast enhanced MRI and diffusion-weighted imaging have been reported to be useful for characterization of panNEN and quantifying metastatic burden. Current and emerging radiotracers have broadened the utility of functional imaging in evaluating panNEN. Fluorine-18 fluorodeoxyglucose positron emission tomography (PET)/CT and somatostatin receptor imaging such as Gallium-68 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid–octreotate PET/CT may be useful for improved identification of panNEN in comparison to anatomic modalities. These new techniques can also play a direct role in optimizing the selection of treatment for individuals and predicting tumor response based on somatostatin receptor expression. In addition, emerging methods of radiomics such as texture analysis may be a potential tool for staging and outcome prediction in panNEN, however further investigation is required before clinical implementation.

Enhancement patterns in the venous phase of contrast-enhanced ultrasounds: diagnostic value for patients with solid pancreatic lesions

Background

To observe and assess the diagnostic value of the venous phase enhancement patterns of contrast-enhanced ultrasounds (CEUS) in patients with solid pancreatic lesions that show iso- to hyperenhancement in the arterial phase of the CEUS.

Methods

Patients who underwent CEUS for pancreatic lesions in the Peking Union Medical College Hospital between April 2017 and August 2019 were identified from the dynamic CEUS imaging database in the hospital. A total of 57 patients with pathologically or clinically diagnosed pancreatic lesions were retrospectively included in this study, and the CEUS images from these patients were evaluated. The enhancement patterns in each phase were analyzed, and each lesion was classified as malignant or benign using a five-point scale of confidence based on morphology, boundary, vascular invasion, blood flow, and enhancement patterns in ultrasound (US) and CEUS images.

Results

Rapid washout in the venous phase of CEUS images was detected in 30 malignant lesions and 4 benign lesions with malignant potential. The specificity for determining malignancy was 77.8%. Continuous isoenhancement with normal pancreatic tissues in the venous phase achieved a high specificity of 95.0% for determining benign lesions. Early hyperenhancement in the arterial phase followed by slow washout in the venous phase showed high specificity of 98.1% for determining metastasis. The diagnostic confidence improved after reviewing CEUS scans (area under the receiver operating characteristic curve was 0.737 for baseline US and 0.910 for CEUS; P=0.056).

Conclusions

Enhancement patterns in the venous phase of CEUS images were beneficial in the differential diagnosis of solid pancreatic lesions with iso- to hyperenhancement in the arterial phase on CEUS.

Imaging of neuroendocrine tumors: A pictorial review of the clinical value of different imaging modalities

Neuroendocrine tumors (NETs) are multifaceted tumors occurring in a variety of organs and often present as metastatic at the time of diagnosis. Accurate staging is the most significant factor in therapy planning, but it remains a challenge. Imaging is established as the cornerstone for disease detection/diagnosis, staging, and follow up. To accurately assess and monitor tumor burden in patients with NETs, various imaging techniques have been developed and optimized. Current recommendations for the imaging of patients with NETs include a combination of both morphologic (or anatomic) and molecular imaging, but a final choice can be puzzling for clinicians. Recognizing that there is no uniform sequence consensus on the "best" imaging test, and the heterogeneity of technologic availability at different centers, we hope to provide a pictorial review of the different imaging techniques and their role and utility in management of patients with NETs, aimed to provide a practical guide for all clinicians.

Updated Trends in Imaging Practices for Pancreatic Neuroendocrine Tumors (PNETs): A Systematic Review and Meta-Analysis to Pave the Way for Standardization in the New Era of Big Data and Artificial Intelligence

Purpose

Medical imaging plays a central and decisive role in guiding the management of patients with pancreatic neuroendocrine tumors (PNETs). Our aim was to synthesize all recent literature of PNETs, enabling a comparison of all imaging practices.

Methods

based on a systematic review and meta-analysis approach, we collected; using MEDLINE, EMBASE, and Cochrane Library databases; all recent imaging-based studies, published from December 2014 to December 2019. Study quality assessment was performed by QUADAS-2 and MINORS tools.

Results

161 studies consisting of 19852 patients were included. There were 63 ‘imaging’ studies evaluating the accuracy of medical imaging, and 98 ‘clinical’ studies using medical imaging as a tool for response assessment. A wide heterogeneity of practices was demonstrated: imaging modalities were: CT (57.1%, n=92), MR (42.9%, n=69), PET/CT (13.3%, n=31), and SPECT/CT (9.3%, n=15). International imaging guidelines were mentioned in 2.5% (n=4/161) of studies. In clinical studies, imaging protocol was not mentioned in 30.6% (n=30/98) of cases and only mentioned imaging modality without further information in 63.3% (n=62/98), as compared to imaging studies (1.6% (n=1/63) of (p<0.001)). QUADAS-2 and MINORS tools deciphered existing biases in the current literature.

Conclusion

We provide an overview of the updated current trends in use of medical imaging for diagnosis and response assessment in PNETs. The most commonly used imaging modalities are anatomical (CT and MRI), followed by PET/CT and SPECT/CT. Therefore, standardization and homogenization of PNETs imaging practices is needed to aggregate data and leverage a big data approach for Artificial Intelligence purposes.

Pancreatic Hamartoma Difficult to Diagnose Preoperatively

Abdominal ultrasonography in a 70-year-old woman showed a hypoechoic mass, 14 mm in diameter, in the pancreatic body. Computed tomography showed a mass with contrast effect in the pancreatic body. Test results for endocrine factors or tumor markers were normal. The initial consideration was nonfunctional pancreatic neuroendocrine tumor. Over 8 years of monitoring, the tumor diameter increased to 18 mm, until pancreatic tumor enucleation was performed. The postoperative diagnosis was pancreatic hamartoma, a rare type of benign pancreatic tumor. The preoperative diagnosis of pancreatic hamartoma is difficult, but consideration must be given to the possibility of hamartoma when encountering pancreatic tumors.

Radiological Imaging of Gastro-Entero-Pancreatic Neuroendocrine Tumors. The Review of Current Literature Emphasizing the Diagnostic Value of Chosen Imaging Methods

Despite development of radiologic imaging, detection and follow-up of neuroendocrine neoplasms (NENs) still pose a diagnostic challenge, due to the heterogeneity of NEN, their relatively long-term growth, and small size of primary tumor. A set of information obtained by using different radiological imaging tools simplifies a choice of the most appropriate treatment method. Moreover, radiological imaging plays an important role in the assessment of metastatic lesions, especially in the liver, as well as, tumor response to treatment. This article reviews the current, broadly in use imaging modalities which are applied to the diagnosis of GEP-NETs, (the most common type of NENs) and put emphasis on the strengths and limitations of each modality.

[18F]FDG-PET/CT and long-term responses to everolimus in advanced neuroendocrine neoplasia

PURPOSE

This study aims to identify in patients with neuroendocrine neoplasia (NEN) the potential correlation between FDG-PET findings and responses to everolimus therapy to identify predictors of long-term efficacy.

METHODS

Retrospective analysis of patients with sporadic, advanced, progressive NEN treated with everolimus was performed based on the available data on FDG-PET patients obtained before commencing therapy. Data are expressed as the median (25-75th IQR). Risk factor analysis and survival analysis were performed by logistic regression and Cox proportional hazard regression and the determination of Kaplan-Meier curves, as appropriate.

RESULTS

Sixty-six patients were evaluated (NET G1 19.7%, NET G2 75.7%, and NET G3 4.6%), including 45.4% with positive FDG-PET findings. Overall, disease stabilization and a partial response were achieved for 71.2% and 6% of patients, respectively. A long-term response (> 24 months) was observed in 33% of patients. Ki67 was the only predictor of tumor progression (p = 0.03). No significant difference in clinical outcomes was observed between patients with positive or negative FDG-PET findings (median PFS was 24 months and 18 months, respectively, p = 0.337; the disease control rate was 83.3% and 70%, respectively, p = 0.245).

CONCLUSIONS

Everolimus is a valid therapeutic option for advanced, progressive, well-differentiated NEN, even in patients with positive FDG-PET findings.

Role of Somatostatin Receptor in Pancreatic Neuroendocrine Tumor Development, Diagnosis, and Therapy

Pancreatic neuroendocrine tumors (pNETs) are rare and part of the diverse family of neuroendocrine neoplasms (NENs). Somatostatin receptors (SSTRs), which are widely expressed in NENs, are G-protein coupled receptors that can be activated by somatostatins or its synthetic analogs. Therefore, SSTRs have been widely researched as a diagnostic marker and therapeutic target in pNETs. A large number of studies have demonstrated the clinical significance of SSTRs in pNETs. In this review, relevant literature has been appraised to summarize the most recent empirical evidence addressing the clinical significance of SSTRs in pNETs. Overall, these studies have shown that SSTRs have great value in the diagnosis, treatment, and prognostic prediction of pNETs; however, further research is still necessary.

Perspectives on the current pharmacotherapeutic strategies for management of functional neuroendocrine tumor syndromes

Introduction: In the past, controlling the hormone-excess-state was the main determinant of survival in Functional-Neuroendocrine-Neoplasm-syndromes (F-NENs). This was difficult because the pharmacological-armamentarium available was limited. Recently, new therapeutic strategies have increased but it also generated controversies/uncertainties.Areas covered: The authors briefly review: established/proposed F-NENs; the rationale for treatments; the recommended initial-pharmacotherapeutic-approach to controlling F-NENs hormone-excess-state; the secondary-approaches if the initial approach fails or resistance develops; and the approach to deal with the malignant nature of the NEN. Also discussed are controversies/uncertainties related to new treatments.Expert opinion: Unfortunately, except for patients with insulinomas (>90-95%), gastrinomas (<20-40%), a minority with the other F-panNENs and 0-<1% with Carcinoid-syndrome is curative-surgery possible. Except for insulinomas, gastrinomas, and ACTHomas, long-acting somatostatin-analogs are the initial-pharmacological-treatments for hormone-excess-state. For insulinomas prior to surgery/malignancy, diazoxide is the initial drug-treatment; for gastrinomas, oral PPIs; and for ACTHomas, steroidogenesis inhibitors. There are now several secondary pharmacotherapeutic treatments. Surgery and liver-directed therapies also have a role in selected patients. Particularly promising is the recent results with PRRT for the hormone-excess-state, independent of its anti-growth effect. The sequence to use various agents and the approach to syndrome diagnosis while taking various agents remains unclear/controversial in many cases.

Pancreatic Neuroendocrine Neoplasms: 2020 Update on Pathologic and Imaging Findings and Classification

Pancreatic neuroendocrine neoplasms (panNENs) are heterogeneous neoplasms with neuroendocrine differentiation that show characteristic clinical, histomorphologic, and prognostic features; genetic alterations; and biologic behavior. Up to 10% of panNENs develop in patients with syndromes that predispose them to cancer, such as multiple endocrine neoplasia type 1, von Hippel-Lindau disease, tuberous sclerosis complex, neurofibromatosis type 1, and glucagon cell adenomatosis. PanNENs are classified as either functioning tumors, which manifest early because of clinical symptoms related to increased hormone production, or nonfunctioning tumors, which often manifest late because of mass effect. PanNENs are histopathologically classified as well-differentiated pancreatic neuroendocrine tumors (panNETs) or poorly differentiated pancreatic neuroendocrine carcinomas (panNECs) according to the 2010 World Health Organization (WHO) classification system. Recent advances in cytogenetics and molecular biology have shown substantial heterogeneity in panNECs, and a new tumor subtype, well-differentiated, high-grade panNET, has been introduced. High-grade panNETs and panNECs are two distinct entities with different pathogenesis, clinical features, imaging findings, treatment options, and prognoses. The 2017 WHO classification system and the eighth edition of the American Joint Committee on Cancer staging system include substantial changes. Multidetector CT, MRI, and endoscopic US help in anatomic localization of the primary tumor, local-regional spread, and metastases. Somatostatin receptor scintigraphy and fluorine 18-fluorodeoxyglucose PET/CT are helpful for functional and metabolic assessment. Knowledge of recent updates in the pathogenesis, classification, and staging of panNENs and familiarity with their imaging findings allow optimal patient treatment. ^©RSNA, 2020.

Prevention and Management of Hormonal Crisis during Theragnosis with LU-DOTA-TATE in Neuroendocrine Tumors. A Systematic Review and Approach Proposal

Neuroendocrine tumors (NETs) frequently overexpress somatostatin receptors (SSTR) on their cell surface. The first-line pharmacological treatment for inoperable metastatic functioning well-differentiated NETs are somatostatin analogs. On second line, Lu-DOTA-TATE (177Lu-DOTA0 Tyr 3 octreotate) has shown stabilization of the disease and an increase in progression free survival, as well as effectiveness in controlling symptoms and increasing quality of life. The management of functional NETs before and during LU-DOTA-TATE treatment is specially challenging, as several complications such as severe carcinoid and catecholamine crisis have been described. The aim of this review is to establish practical guidance for the management and prevention of the most common hormonal crises during radionuclide treatment with Lu-DOTA-TATE: carcinoid syndrome (CS) and catecholamine hypersecretion, as well as to provide a brief commentary on other infrequent metabolic complications. To establish a practical approach, a systematic review was performed. This systematic review was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and conducted using MEDLINE (accessed from PubMed), Google Scholar and ClinicalTrials.gov. Literature searches found 449 citations, and finally nine were considered for this systematic review.

(Radio)Theranostic Patient Management in Oncology Exemplified by Neuroendocrine Neoplasms, Prostate Cancer, and Breast Cancer

The role of nuclear medicine in the management of oncological patients has expanded during last two decades. The number of radiopharmaceuticals contributing to the realization of theranostics/radiotheranostics in the context of personalized medicine is increasing. This review is focused on the examples of targeted (radio)pharmaceuticals for the imaging and therapy of neuroendocrine neoplasms (NENs), prostate cancer, and breast cancer. These examples strongly demonstrate the tendency of nuclear medicine development towards personalized medicine.

Tumor Contrast-Enhancement for Monitoring of PRRT 177Lu-DOTATATE in Pancreatic Neuroendocrine Tumor Patients

Background: Therapy monitoring of cancer treatment by contrast-enhanced CT (CECT), applying response evaluation criteria in solid tumors criteria version 1. 1 (RECIST 1.1) is less suitable for neuroendocrine tumors (NETs) which, when responding, tend to show stabilization rather than shrinkage. New methods are needed to further classify patients in order to identify non-responders at an early stage and avoid unnecessary adverse effects and costs. Changes in arterial tumor attenuation and contrast-enhancement could be used to identify the effect of therapy, perhaps even in early stages of treatment.

Methods: Patients with metastatic pancreatic NETs (PNETs) receiving peptide receptor radionuclide therapy (PRRT) with ¹⁷⁷Lu-DOTATATE underwent CECT at baseline, mid-treatment (PRRT cycles 3–5) and at follow-up, 3 months after the last PRRT cycle. At baseline CECT, the liver metastasis with the highest arterial attenuation was identified in each patient. The fold changes in arterial tumor attenuation (Hounsfield Units, HU), contrast-enhancement (HU), and transversal tumor area (cm²) between CECT at baseline, mid-treatment and follow-up were calculated. Correlation of the tumor metrics to outcome parameters such as progression-free survival (PFS) and time to best response was performed.

Results: Fifty-two patients were included (27 men, 25 women), median age 60 years (range 29–80), median Ki-67 8% (range 1–30). Six patients had grade 1 PNETs, forty had grade 2 and four had grade 3 tumors. As an internal control, it was first tested and established that the tumor contrast-enhancement was not merely related to that of the abdominal aorta. The mean ± SD arterial attenuation of the liver metastases was similar at baseline, 217 ± 62 HU and at mid-treatment, 238 ± 80 HU and then decreased to 198 ± 62 HU at follow-up, compared to baseline (p = 0.024, n = 52) and mid-treatment (p = 0.0004, n = 43). The transversal tumor area decreased 25% between baseline and follow-up (p = 0.013, n = 52). Tumor contrast-enhancement increased slightly from baseline to mid-treatment and these fold changes correlated with PFS (R² = 0.33, p = 0.0002, n = 37) and with time to best response (R² = 0.34, p < 0.0001, n = 37).

Conclusions: Early changes in contrast-enhancement and arterial attenuation in PNET liver metastases may for CECT monitoring of PRRT yield complementary information to evaluation by RECIST 1.1.

Les nouvelles techniques diagnostiques des tumeurs neuroendocrines pancréatiques

Les tumeurs neuroendocrines pancréatiques (TNEp) sont des tumeurs développées aux dépens du pancréas et nécessitent un bilan diagnostique spécifique. Le bilan d’imagerie d’une TNEp est utile pour le diagnostic ainsi que pour le traitement chirurgical/médical. Récemment, un certain nombre de progrès ont été réalisés dans le domaine de l’imagerie des TNEp, en particulier en ce qui concerne l’imagerie fonctionnelle utilisant des analogues de la somatostatine radiomarqués. Dans cette mise au point, nous abordons les progrès diagnostiques en nous focalisant sur les avancées des dernières années. Ainsi, il est abordé l’intérêt de l’imagerie conventionnelle (scanner, échographie abdominale, imagerie par résonance magnétique), de l’échoendoscopie et la place de l’imagerie fonctionnelle, principalement avec des analogues de la somatostatine radiomarqués.

Prognostic and predictive factors on overall survival and surgical outcomes in pancreatic neuroendocrine tumors: recent advances and controversies

Introduction: Recent advances in diagnostic modalities and therapeutic agents have raised the importance of prognostic factors in predicting overall survival, as well as predictive factors for surgical outcomes, in tailoring therapeutic strategies of patients with pancreatic neuroendocrine neoplasms (panNENs).Areas covered: Numerous recent studies of panNEN patients report the prognostic values of a number of clinically related factors (clinical, laboratory, imaging, treatment-related factors), pathological factors (histological, classification, grading) and molecular factors on long-term survival. In addition, an increasing number of studies showed the usefulness of various factors, specifically biomarkers and molecular makers, in predicting recurrence and mortality related to surgical treatment. Recent findings (from the last 3 years) in each of these areas, as well as recent controversies, are reviewed.Expert commentary: The clinical importance of prognostic and predictive factors for panNENs is markedly increased for both overall outcome and post resection, as a result of recent advances in all aspects of the diagnosis, management and treatment of panNENs. Despite the proven prognostic utility of routinely used tumor grading/classification and staging systems, further studies are required to establish these novel prognostic factors to support their routine clinical use.