Peritoneal metastases in patients with neuroendocrine neoplasms: a challenging site of metastases with clinical and prognostic implications

PURPOSE

Peritoneal metastases (PM) of neuroendocrine neoplasm (NEN) origin are identified with increasing frequency and exert a significant effect on quality of life and clinical status of the patients. The aim of this study was to identify the characteristics and the prognostic significance of PM in patients with NENs.

METHODS

A retrospective analysis of the data of patients from two tertiary referral centers was performed. We defined a control group of age- and gender-matched NEN patients with comparable stage IV disease but no PM.

RESULTS

We analysed 70 patients (41 females) with PM. Small intestine was the most common primary NEN site (87.1%). PM prevalence was 10.3%. Forty-four patients presented with synchronous PM, whereas 26 developed metachronous PM. The majority of patients had other concomitant metastases (50 hepatic, 6 lung and 12 bone metastases). Twelve patients developed intestinal obstruction. After PM diagnosis, 76% of patients received treatment with somatostatin analogues while six patients (8.6%) were treated with peptide receptor radionuclide therapy (PRRT). The median progression-free survival (PFS) in the PRRT-treated group was 15 months (95% CI 2-28). Median overall survival (OS) in the PM group was 142 months [95% CI 71-213] while it was not reached in the control group.

CONCLUSION

Peritoneal metastases show low prevalence among NEN patients and are most likely to develop in patients with small intestinal NENs and advanced metastatic disease. The presence of PM does seem to be associated with a negative prognostic impact on OS of NEN patients and their identification and prompt treatment is of major importance.

Increasing oxygen prescribing during the COVID-19 pandemic

Valid oxygen prescriptions for hospital inpatients have been a long-standing problem and have been described extensively in BMJ Open Quality with numerous quality improvement projects (QIPs) with the aim of improving compliance with oxygen prescribing.The British Thoracic Society recommends that all inpatients should have oxygen target saturation set on admission: this is motivated by risks of both undertreatment and overtreatment with oxygen. The discrepancy between the recommendation and the reality produced a number of interventions studied in QIPs over the past years, all aiming at bringing the local ward teams closer to the target. This has become even more important during the COVID-19 pandemic, where non-standard oxygen saturation targets and oxygen scarcity led hospital systems to rethink their internal guidelines on the subject.We propose three novel interventions to improve compliance: a remote, personally directed email communication to a ward pharmacist, a similar communication to ward nurses, and a remote, personally directed WhatsApp communication to junior ward doctors. We undertake a QIP which compares novel interventions developed in-house with the most successful interventions from oxygen prescribing initiatives that have previously been published by BMJ Open Quality The main outcome measure was the proportion of patients with valid oxygen prescription on a ward.The series of novel interventions in three plan, do study, act cycles led to improvement in the outcome measure from 0% at baseline to 70% at the end of the QIP. The successful interventions from previous QIPs were ran in parallel on a similar ward and achieved improvement from 17.9% at baseline to 55.6% at the end of the QIP.This QIP demonstrates adapted interventions performed in context of social distancing aimed at members of multidisciplinary team which achieve superiority in increasing proportion of patients with a valid oxygen prescription, when compared with previously described methods from BMJ Open Quality.

Is local excision sufficient in selected grade 1 or 2 type III gastric neuroendocrine neoplasms?

PURPOSE

Type III gastric neuroendocrine neoplasms (g-NENs) have historically been regarded as aggressive tumours, hence current guidelines advocate radical surgery with lymph node dissection. Data on the roles of endoscopic or less extensive surgical resections are more limited. The aim of our study is to evaluate the clinicopathological features and long-term outcomes of patients undergoing endoscopic or limited surgical resection for localised grade 1 or 2 type III g-NENs when compared to radical surgery.

METHODS

Retrospective analysis of all patients diagnosed with a localised grade 1 or 2 type III g-NENs across six tertiary NEN centers between 2006 and 2019.

RESULTS

Forty-five patients were diagnosed with a potentially resectable grade 1 or 2 type III g-NEN of whom 36 underwent either endoscopic or surgical resection. No statistically significant differences were found between the three resection groups in terms of patient age, tumour location, grade or size. Only tumour size was found to be significantly associated with poor clinical outcome (p = 0.012) and ROC curve analysis identified tumour size >10 mm as a negative predictor (AUC:0.8030, p = 0.0021). Tumours >10 mm were also more likely to be associated with lymph node metastases on imaging and histology (p = 0.039 and p = 0.026 respectively).

CONCLUSIONS

Localised grade 1 or 2 type III g-NENs had a good prognosis in this series. Tumour size >10 mm was the most significant prognostic factor affecting patient outcome. Endoscopic resection or limited surgical resection is feasible and safe in small type III g-NENs which demonstrate favourable grade 1/2, well differentiated histology.

Monitoring the skin NADH changes during ischaemia and reperfusion in humans

Nicotinamide adenine dinucleotide (NADH/NAD+) is involved in many important biochemical reactions in human metabolism, including participation in energy production by mitochondria. Flow Mediated Skin Fluorescence (FMSF) is a non-invasive method to study dynamic changes in the content of the reduced form of NADH by measuring the optical properties of NADH related to the emission of the autofluorescent light (460 nm) after an earlier excitation by ultraviolet light. This review summarises the available studies using this method to describe its potential and limitations.

Orbital metastases from neuroendocrine neoplasms: clinical implications and outcomes

PURPOSE

Neuroendocrine neoplasms (NENs) may rarely metastasise to the orbit. Published data on epidemiology, incidence and preferred treatment is limited. We present the largest cohort of symptomatic and asymptomatic NEN patients with orbital metastases and data on epidemiological parameters, symptoms as well as diagnostic/treatment modalities used.

METHODS

We identified patients from our internal NEN database of patients who had also undergone Gallium⁶⁸-DOTATATE PET (Ga⁶⁸-DOTA). The diagnosis of orbital metastatic NEN was made on somatostatin receptor imaging and confirmed on a dedicated MRI of orbits.

RESULTS

We identified 27 patients of 994 patients evaluated with Ga⁶⁸-DOTATATE PET imaging during their surveillance monitoring in our department; 15 female, average age at NEN diagnosis 53 years and orbital metastatic NEN diagnosis 59 years. The majority of NEN primaries originated from small bowel (18/27, 66.4%) or pancreas 4/27 (4/27, 14.8%). Hepatic with or without concomitant skeletal metastases were present in 23/27 (85%) of patients. Ocular symptoms and/or signs were evident in 11/27 (41%) of patients. 5/11 symptomatic patients underwent external beam radiotherapy (EBRT) resulting in complete symptoms resolution. The 5-year survival was estimated at 84.1%.

CONCLUSIONS

Orbital metastases of NEN have a relatively low prevalence, more commonly associated with small bowel primary. Extraocular muscles are primarily affected, irrespectively of liver disease burden. Survival does not seem to be affected. EBRT is an efficacious treatment modality for both symptom relief and tumour growth control. Administration of peptide receptor radionuclide therapy may occasionally induce temporary ocular symptoms, which resolve following treatment with a short course of steroids.

Predictors of antiproliferative effect of lanreotide autogel in advanced gastroenteropancreatic neuroendocrine neoplasms

PURPOSE

The antiproliferative properties of lanreotide autogel (LAN) in gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) were demonstrated in the CLARINET study. However, there is limited literature regarding factors that affect progression-free survival (PFS) in patients with GEP NENs treated with LAN.

METHODS

We identified a total of 191 treatment-naive patients with advanced GEP NENs and positive SSTR uptake on imaging (Octreoscan or ⁶⁸Gallium DOTATATE Positron Emission Tomography [⁶⁸GaPET]) who received first-line LAN monotherapy, albeit at various starting doses (60, 90 or 120 mg/month). A group of 102 patients who initiated treatment at the standard dose of 120 mg/month were included in the study and further evaluated by univariate and multivariate analyses to identify predictors of PFS.

RESULTS

The location of tumour primary was in the small bowel in 63 (62%), pancreas in 31 (30%) and colon/rectum in 8 patients (8%). The tumours were well-differentiated, and the majority were grade 1 (52%), or 2 (38%). About 60% of cases had progressive disease at the time of treatment initiation. Most patients with available pretreatment nuclear medicine imaging (Octreoscan or ⁶⁸Ga PET) had a Krenning score of 3 (44%) or 4 (50%). The median PFS for the entire cohort was 19 months (95% CI 12, 26 months). The univariate analysis demonstrated that grade 2 tumours, progressive disease at baseline and metastatic liver disease were associated with a significantly shorter PFS, while other evaluated variables did not affect PFS at a statistically significant level. However, at multivariate analysis only the tumour grade remained statistically significant.

CONCLUSIONS

The current study showed that, of many evaluated variables, only the tumour grade was predictive of PFS duration and this should be considered during patient selection for treatment.