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Exarchou K, Hu H, Stephens NA, Moore AR, Kelly M, Lamarca A, Mansoor W, Hubner R, McNamara MG, Smart H, Howes NR, Valle JW, Pritchard DM. OGC O08 Endoscopic surveillance alone is feasible and safe in type I gastric neuroendocrine neoplasms less than 10mm in diameter. Br J Surg 2022. [DOI: 10.1093/bjs/znac404.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Type I gastric neuroendocrine neoplasms (g-NENs) have a low risk of metastasis and a generally favourable prognosis. Patients with small type I g-NENs (≤10mm) frequently require no treatment, whereas those with larger polyps usually undergo resection. We evaluated the safety and outcomes of endoscopic surveillance after no initial treatment in selected patients with type I g-NENs.
Methods
Retrospective analysis of type I g-NEN patients across two European Neuroendocrine Tumour Society Centers of Excellence 2003–2019.
Results
Following initial assessment, 87 of 115 patients with type I g-NEN (75 with polyps ≤10mm) received no initial treatment and underwent endoscopic surveillance. 79/87 (91%) demonstrated no clinically meaningful change in tumour size or grade over a median 62 month follow up. Only two patients developed NEN progression that required a change in management and two other patients developed gastric adenocarcinoma/high grade dysplasia; all four initially had ≥11mm g-NENs.
Conclusions
Patients with ≤10mm type I g-NENs were unlikely to develop clinically significant tumour progression and in most cases, resection was not needed. The endoscopic surveillance interval could therefore potentially be safely increased to every 2–3 years in such patients. However, lifelong surveillance is still advocated due to the additional risk of developing gastric adenocarcinoma.
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Affiliation(s)
- Klaire Exarchou
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool , Liverpool , United Kingdom
| | - Haiyi Hu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University; National Clinical Research Center for Digestive Diseases , Beijing , China
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool , Liverpool , United Kingdom
| | - Nathan A Stephens
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
| | - Andrew R Moore
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
| | - Mark Kelly
- Department of Gastroenterology, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - Angela Lamarca
- Department of Oncology , The Christie NHS Foundation Trust, Manchester , United Kingdom
- Division of Cancer Sciences, University of Manchester , Manchester , United Kingdom
| | - Wasat Mansoor
- Department of Oncology , The Christie NHS Foundation Trust, Manchester , United Kingdom
- Division of Cancer Sciences, University of Manchester , Manchester , United Kingdom
| | - Richard Hubner
- Department of Oncology , The Christie NHS Foundation Trust, Manchester , United Kingdom
- Division of Cancer Sciences, University of Manchester , Manchester , United Kingdom
| | - Mairead G McNamara
- Department of Oncology , The Christie NHS Foundation Trust, Manchester , United Kingdom
- Division of Cancer Sciences, University of Manchester , Manchester , United Kingdom
| | - Howard Smart
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
| | - Nathan R Howes
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
| | - Juan W Valle
- Department of Oncology , The Christie NHS Foundation Trust, Manchester , United Kingdom
- Division of Cancer Sciences, University of Manchester , Manchester , United Kingdom
| | - D Mark Pritchard
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust , Liverpool , United Kingdom
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool , Liverpool , United Kingdom
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Exarchou K, Hu H, Stephens NA, Moore AR, Kelly M, Lamarca A, Mansoor W, Hubner R, McNamara MG, Smart H, Howes NR, Valle JW, Pritchard DM. Endoscopic surveillance alone is feasible and safe in type I gastric neuroendocrine neoplasms less than 10 mm in diameter. Endocrine 2022; 78:186-196. [PMID: 35895180 PMCID: PMC9474380 DOI: 10.1007/s12020-022-03143-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 07/09/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Type I gastric neuroendocrine neoplasms (g-NENs) have a low risk of metastasis and a generally favourable prognosis. Patients with small type I g-NENs (≤10 mm) frequently require no treatment, whereas those with larger polyps usually undergo resection. We evaluated the safety and outcomes of endoscopic surveillance after no initial treatment in selected patients with type I g-NENs. METHODS Retrospective analysis of type I g-NEN patients across two European Neuroendocrine Tumour Society Centers of Excellence 2003-2019. RESULTS Following initial assessment, 87 of 115 patients with type I g-NEN (75 with polyps ≤10 mm) received no initial treatment and underwent endoscopic surveillance. 79/87 (91%) demonstrated no clinically meaningful change in tumour size or grade over a median 62 month follow up. Only two patients developed NEN progression that required a change in management and two other patients developed gastric adenocarcinoma/high grade dysplasia; all four initially had ≥11 mm g-NENs. CONCLUSIONS Patients with ≤10 mm type I g-NENs were unlikely to develop clinically significant tumour progression and in most cases, resection was not needed. The endoscopic surveillance interval could therefore potentially be safely increased to every 2-3 years in such patients. However, lifelong surveillance is still advocated due to the additional risk of developing gastric adenocarcinoma.
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Affiliation(s)
- Klaire Exarchou
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Haiyi Hu
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Nathan A Stephens
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Andrew R Moore
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Mark Kelly
- Department of Gastroenterology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, UK
| | - Wasat Mansoor
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, UK
| | - Richard Hubner
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, UK
| | - Mairéad G McNamara
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, UK
| | - Howard Smart
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Nathan R Howes
- Department of Upper Gastrointestinal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Juan W Valle
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, UK
| | - D Mark Pritchard
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Nevins EJ, Rao R, Nicholson J, Murphy KD, Moore A, Smart HL, Stephens N, Grocock C, Kaul A, Gunasekera RT, Hartley MN, Howes NR. Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy. Ann R Coll Surg Engl 2020; 102:693-696. [PMID: 32538118 DOI: 10.1308/rcsann.2020.0136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment. METHODS All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP. RESULTS Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications. CONCLUSIONS This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.
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Affiliation(s)
- E J Nevins
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R Rao
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - J Nicholson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - K D Murphy
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Moore
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - H L Smart
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N Stephens
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - C Grocock
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Kaul
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R T Gunasekera
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - M N Hartley
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N R Howes
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
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Nicholson JA, Greenhalf W, Jackson R, Cox TF, Butler JV, Hanna T, Harrison S, Grocock CJ, Halloran CM, Howes NR, Raraty MG, Ghaneh P, Johnstone M, Sarkar S, Smart HL, Evans JC, Aithal GP, Sutton R, Neoptolemos JP, Lombard MG. Incidence of post-ERCP pancreatitis from direct pancreatic juice collection in hereditary pancreatitis and familial pancreatic cancer before and after the introduction of prophylactic pancreatic stents and rectal diclofenac. Pancreas 2015; 44:260-5. [PMID: 25438071 DOI: 10.1097/mpa.0000000000000246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP). METHODS A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008. RESULTS There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035). CONCLUSIONS Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.
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Affiliation(s)
- James A Nicholson
- From the *National Institute for Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital; †Liverpool Clinical Trials Unit; Departments of ‡Gastroenterology, and §Radiology, Royal Liverpool University Hospital, Liverpool; and ║Digestive Diseases Biomedical Research Unit, National Institute for Health Research Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
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Abstract
There are multiple PRSS1 mutations described in hereditary pancreatitis but only a minority of these are clinically relevant. The two most frequent point mutations are in exon 2 (N29I) and exon3 (R122H), found in diverse racial populations. Both mutations result in early onset pancreatitis but the mechanism underlying this phenotype is unclear. The frequency of these mutations in such diverse populations suggests they have spontaneously occurred many times. The origin of the major mutations may be explained by gene conversions, accounting for multiple founders. The implications are discussed in terms of mechanism of action of the mutations and clinical presentation.
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Affiliation(s)
- Louis J Vitone
- Division of Surgery and Oncology, The University of Liverpool, 5th Floor UCD Building, Daulby Street, Liverpool, L69 3GA, United Kingdom
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Vitone LJ, Greenhalf W, Howes NR, Neoptolemos JP. Hereditary pancreatitis and secondary screening for early pancreatic cancer. Rocz Akad Med Bialymst 2005; 50:73-84. [PMID: 16358943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Hereditary pancreatitis is an autosomal dominant disease with incomplete penetrance (80%), accounting for approximately 1% of all cases of pancreatitis. It is characterized by the onset of recurrent attacks of acute pancreatitis in childhood and frequent progression to chronic pancreatitis. Whitcomb et al. identified the cationic trypsinogen gene (PRSS1) on chromosome 7q35 as the site of the mutation that causes hereditary pancreatitis. The European registry of hereditary pancreatitis and familial pancreatic cancer (EUROPAC) aims to identify and make provisions for those affected by hereditary pancreatitis and familial pancreatic cancer. The most common mutations in hereditary pancreatitis are R122H, N29I and A16V but many families have been described with clinically defined hereditary pancreatitis where there is no PRSS1 mutation. It is known that the cumulative lifetime risk (to age 70 years) of pancreatic cancer is 40% in individuals with hereditary pancreatitis. This subset of individuals form an ideal group for the development of a screening programme aimed at detecting pancreatic cancer at an early stage in an attempt to improve the presently poor long-term survival. Current screening strategies involve multimodality imaging (computed tomography, endoluminal ultrasound) and endoscopic retrograde cholangiopancreatography for pancreatic juice collection followed by molecular analysis of the DNA extracted from the juice. The potential benefit of screening (curative resection) must be balanced against the associated morbidity and mortality of surgery. Philosophically, the individual's best interest must be sought in light of the latest advances in medicine and science following discussions with a multidisciplinary team in specialist pancreatic centres.
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Affiliation(s)
- L J Vitone
- Division of Surgery & Oncology, The University of Liverpool, United Kingdom
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