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Van Den Heede K, van Beek DJ, Van Slycke S, Borel Rinkes I, Norlén O, Stålberg P, Nordenström E. Surgery for advanced neuroendocrine tumours of the small bowel: recommendations based on a consensus meeting of the European Society of Endocrine Surgeons (ESES). Br J Surg 2024; 111:znae082. [PMID: 38626261 DOI: 10.1093/bjs/znae082] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Small bowel neuroendocrine tumours often present with locally advanced or metastatic disease. The aim of this paper is to provide evidence-based recommendations regarding (controversial) topics in the surgical management of advanced small bowel neuroendocrine tumours. METHODS A working group of experts was formed by the European Society of Endocrine Surgeons. The group addressed 11 clinically relevant questions regarding surgery for advanced disease, including the benefit of primary tumour resection, the role of cytoreduction, the extent of lymph node clearance, and the management of an unknown primary tumour. A systematic literature search was performed in MEDLINE to identify papers addressing the research questions. Final recommendations were presented and voted upon by European Society of Endocrine Surgeons members at the European Society of Endocrine Surgeons Conference in Mainz in 2023. RESULTS The literature review yielded 1223 papers, of which 84 were included. There were no randomized controlled trials to address any of the research questions and therefore conclusions were based on the available case series, cohort studies, and systematic reviews/meta-analyses of the available non-randomized studies. The proposed recommendations were scored by 38-51 members and rated 'strongly agree' or 'agree' by 64-96% of participants. CONCLUSION This paper provides recommendations based on the best available evidence and expert opinion on the surgical management of locally advanced and metastatic small bowel neuroendocrine tumours.
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Affiliation(s)
- Klaas Van Den Heede
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
| | - Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
- Department of General Surgery, AZ Damiaan, Ostend, Belgium
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
| | - Inne Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Erik Nordenström
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Van Beek DJ, Van Den Heede K, Borel Rinkes I, Norlén O, Van Slycke S, Stålberg P, Nordenström E. Surgery for advanced pancreatic neuroendocrine neoplasms: recommendations based on a consensus meeting of the European Society of Endocrine Surgeons (ESES). Br J Surg 2024; 111:znae017. [PMID: 38364061 DOI: 10.1093/bjs/znae017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/16/2023] [Accepted: 01/06/2024] [Indexed: 02/18/2024]
Abstract
This European Society of Endocrine Surgeons (ESES) guideline provides evidence-based recommendations based on the surgical management for locally advanced pancreatic neuroendocrine neoplasms, indications for neoadjuvant therapy, primary tumor resections in the setting of metastatic disease and surgical indications for Grade 3 pancreatic neuroendocrine tumours and pancreatic neuroendocrine carcinoma.
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Affiliation(s)
- Dirk-Jan Van Beek
- Department of Endocrine Surgical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Klaas Van Den Heede
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
| | - Inne Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of General Surgery, AZ Damiaan, Ostend, Belgium
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Erik Nordenström
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Annebäck M, Osterman C, Arlebrink J, Mellerstedt S, Papathanasakis N, Wallin G, Hessman O, Annerbo M, Norlén O. Validating the risk of hypoparathyroidism after total thyroidectomy in a population-based cohort: plea for improved follow-up. Br J Surg 2024; 111:znad366. [PMID: 37995259 PMCID: PMC10776524 DOI: 10.1093/bjs/znad366] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/28/2023] [Accepted: 09/27/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND A previous nationwide study from Sweden showed that the rate of permanent hypoparathyroidism is high and under-rated in the Swedish Quality Register. This retrospective population-based study aimed to validate the rate and diagnosis of permanent hypoparathyroidism found in the previous study. A secondary aim was to assess the relationship between the rate of low parathyroid hormone (PTH) levels within 24 h after surgery and the rate of permanent hypoparathyroidism. METHODS All patients who underwent total thyroidectomy from 2005 to 2015 in a region of Sweden were included. Data were retrieved from local health records, the National Patient Registry, the Swedish Prescribed Drug Registry, and the Swedish Quality Register. A strict definition of permanent hypoparathyroidism was used, including biochemical data and attempts to stop the treatment. RESULTS A total of 1636 patients were included. Altogether, 143 patients (8.7 per cent) developed permanent hypoparathyroidism. Of these, 102 (6.2 per cent) had definitive permanent hypoparathyroidism, whereas 41 (2.5 per cent) had possible permanent hypoparathyroidism, because attempts to stop the treatment were lacking (28) or patients were lost to follow-up (13). The agreement between the Swedish Quality Register and the chart review was 29.3 per cent. A proportion of 23.2 per cent with a PTH level below the reference value corresponded to a 6.7 per cent rate of permanent hypoparathyroidism. CONCLUSION The risk of permanent hypoparathyroidism after total thyroidectomy is high. Some patients are overtreated because attempts to stop the treatment are lacking. Quality registers might underestimate the risk of permanent hypoparathyroidism. Approximately one-quarter of all patients with low PTH levels immediately after surgery developed permanent hypoparathyroidism.
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Affiliation(s)
- Matilda Annebäck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Jesper Arlebrink
- Department of Surgery, Karlstad Central Hospital, Karlstad, Sweden
| | | | | | - Göran Wallin
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Ola Hessman
- Department of Surgery, Västerås Central Hospital, Västerås, Sweden
| | - Maria Annerbo
- Department of Surgery, Falu Hospital, Karlstad, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Kjaer J, Norlén O, Hellman P, Stalberg P. Author´s Reply: Overall Survival in Patients with Stage IV Pan-NET Eligible for Liver Transplantation. World J Surg 2023; 47:1084-1085. [PMID: 36705741 DOI: 10.1007/s00268-023-06916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Josefine Kjaer
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden.
- Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden.
| | - Olov Norlén
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden
- Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden
- Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
| | - Peter Stalberg
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden
- Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
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Kjaer J, Norlén O, Hellman P, Stalberg P. Correction: Author´s Reply: Overall Survival in Patients with Stage IV Pan-NET Eligible for Liver Transplantation. World J Surg 2023; 47:1086. [PMID: 36757425 DOI: 10.1007/s00268-023-06938-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Josefine Kjaer
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden. .,Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden.
| | - Olov Norlén
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden.,Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden.,Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
| | - Peter Stalberg
- Department of Surgical Sciences, Surgical Sciences, Uppsala University, Uppsala, Sweden.,Endocrine Surgical Unit, Surgery, Uppsala University, Uppsala, Sweden
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Kjaer J, Smith S, Hellman P, Stålberg P, Crona J, Welin S, Norlén O. Overall Survival in Patients with Stage IV Pan-NET Eligible for Liver Transplantation. World J Surg 2023; 47:340-347. [PMID: 36175647 PMCID: PMC9803729 DOI: 10.1007/s00268-022-06736-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND The use of liver transplantation (LT) in patients with stage IV neuroendocrine pancreatic tumors (pan-NET) is under debate. Previous studies report a 5-year survival of 27-53% after LT in pan-NET and up to 92.7% in patients with mixed NETs. This study aimed to determine survival rates of patients with stage IV pan-NET meeting criteria for LT while only subjected to multimodal treatment. METHODS Medical records of patients with pan-NET diagnosed from 2000 to 2021 at a tertiary referral center were evaluated for eligibility. Patients without liver metastases, who did not undergo primary tumor surgery, age > 75 years and with grade 3 tumors were excluded. The patients were divided into groups; all included patients, patients meeting the Milan, the United Network for Organ Sharing (UNOS) or the European Neuroendocrine Tumor Society (ENETS) criteria for LT. Kaplan-Meier survival analysis was used to calculate overall survival. RESULTS Out of 519 patients with pan-NET, 41 patients were included. Mean follow-up time was 5.4 years. Overall survival was 9.3 years (95% Cl 6.8-11.7), and 5-year survival was 64.7% (95% CI 48.2-81.2). Patients meeting the Milan, ENETS and UNOS criteria for LT had a 5-year survival of 64.9% (95% CI 32.2-97.6), 85.7% (95% CI 59.8-100.0) and 55.4% (95% CI 26.0-84.8), respectively. CONCLUSIONS In patients with stage IV pan-NET, grade 1 and 2, with no extra abdominal disease, 5-year survival was 64.7% (95% CI 48.2-81.2). As these survival rates exceed previously published series of LT for pan-NET, the evidence base for this treatment is very weak.
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Affiliation(s)
- Josefine Kjaer
- Department of Surgical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Sara Smith
- Department of Surgical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, 751 85 Uppsala, Sweden
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Annebäck M, McHale Sjödin E, Hellman P, Stålberg P, Norlén O. Preoperative prophylactic active vitamin D to streamline total thyroidectomy. BJS Open 2022; 6:6594928. [PMID: 35640612 PMCID: PMC9155618 DOI: 10.1093/bjsopen/zrac060] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hypocalcaemia is a common complication after total thyroidectomy (TT). Treatment consists of calcium and active vitamin D supplementation. Low levels of vitamin D before surgery have been shown to be a risk factor for postoperative hypocalcaemia, yet studies examining routine preoperative vitamin D supplementation have shown conflicting results. This retrospective cohort study aims to investigate the potential benefit of preoperative active vitamin D supplementation on hypocalcaemia and its symptoms after TT. Methods This study included patients undergoing TT at Uppsala University Hospital from January 2013 to December 2020, resulting in a total of 401 patients after exclusion. Routine preoperative alfacalcidol treatment was initiated for all TT patients in January 2017 resulting in two groups for comparison: one group (pre-January 2017) that was prescribed preoperative alfacalcidol and one that was not. Propensity score matching was used to reduce bias. The primary outcome was early postoperative hypocalcaemia (serum calcium, S-Ca less than 2.10 mmol/l); secondary outcomes were symptoms of hypocalcaemia and length of stay. Results After propensity score matching, there were 108 patients in each group. There were 2 cases with postoperative day one S-Ca less than 2.10 in the treated group and 10 cases in the non-treated group (P < 0.001). No patients in the treated group had a S-Ca below 2.00 mmol/l. Preoperative alfacalcidol was associated with higher mean serum calcium level day one (2.33 versus 2.27, P = 0.022), and reduced duration of hospital stay (P < 0.001). There was also a trend toward fewer symptoms of hypocalcaemia (18.9 per cent versus 30.5 per cent, P = 0.099). Conclusions Prophylactic preoperative alfacalcidol was associated with reduced biochemical hypocalcaemia and duration of hospital stay following TT. Also, with this protocol, it is suggested that routine day 1 postoperative S-Ca measurement is not required.
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Affiliation(s)
- Matilda Annebäck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Kjaer J, Clancy TE, Thornell A, Andersson N, Hellman P, Crona J, Welin S, Sulciner M, Powell B, Brais L, Astone K, Baddoo W, Doherty G, Chan JA, Norlén O, Stålberg P. Benefit of Primary Tumor Resection in Stage IV, Grade 1 and 2, Pancreatic Neuroendocrine Tumors: A Propensity-Score Matched Cohort Study. Ann Surg Open 2022; 3:e151. [PMID: 37600107 PMCID: PMC10431300 DOI: 10.1097/as9.0000000000000151] [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] [Received: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To determine the association of primary tumor resection in stage IV pancreatic neuroendocrine tumors (Pan-NET) and survival in a propensity-score matched study. Background Pan-NET are often diagnosed with stage IV disease. The oncologic benefit from primary tumor resection in this scenario is debated and previous studies show contradictory results. Methods Patients from 3 tertiary referral centers from January 1, 1985, through December 31, 2019: Uppsala University Hospital (Uppsala, Sweden), Sahlgrenska University Hospital (Gothenburg, Sweden), and Brigham and Women's Hospital/Dana-Farber Cancer Institute (Boston, USA) were assessed for eligibility. Patients with sporadic, grade 1 and 2, stage IV pan-NET, with baseline 2000-2019 were divided between those undergoing primary tumor resection combined with oncologic treatment (surgery group [SG]), and those who received oncologic treatment without primary tumor resection (non-SG). A propensity-score matching was performed to account for the variability in the extent of metastatic disease and comorbidity. Primary outcome was overall survival. Results Patients with stage IV Pan-NET (n = 733) were assessed for eligibility, 194 were included. Patients were divided into a SG (n = 65) and a non-SG (n = 129). Two isonumerical groups with 50 patients in each group remained after propensity-score matching. The 5-year survival was 65.4% (95% CI, 51.5-79.3) in the matched SG and 47.8% (95% CI, 30.6-65.0) in the matched non-SG (log-rank, P = 0.043). Conclusions Resection of the primary tumor in patients with stage IV Pan-NET and G1/G2 grade was associated with prolonged overall survival compared to nonoperative management. A surgically aggressive regime should be considered where resection is not contraindicated.
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Affiliation(s)
- Josefine Kjaer
- From the Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Anders Thornell
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niklas Andersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hellman
- From the Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Joakim Crona
- Department of Medical sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical sciences, Uppsala University, Uppsala, Sweden
| | - Megan Sulciner
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Brittany Powell
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Lauren Brais
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kristina Astone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - William Baddoo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Gerhard Doherty
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Olov Norlén
- From the Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- From the Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Lase I, Grönberg M, Norlén O, Stålberg P, Welin S, Janson ET. Adrenalectomy in ectopic Cushing's syndrome: A retrospective cohort study from a tertiary care centre. J Neuroendocrinol 2021; 33:e13030. [PMID: 34448524 DOI: 10.1111/jne.13030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
Neuroendocrine neoplasms (NENs) causing ectopic Cushing's syndrome (ECS) are rare and challenging to treat. In this retrospective cohort study, we aimed to evaluate different approaches for bilateral adrenalectomy (BA) as a treatment option in ECS. Fifty-three patients with ECS caused by a NEN (35 females/18 men; mean ± SD age: 53 ± 15 years) were identified from medical records. Epidemiological and clinical parameters, survival, indications for surgery and timing, as well as duration of surgery, complications and surgical techniques, were collected and further analysed. The primary tumour location was thorax (n = 30), pancreas (n = 14) or unknown (n = 9). BA was performed in 37 patients. Median time from diagnosis of ECS to BA was 2 months (range 1-10 months). Thirty-two patients received different steroidogenesis inhibitors before BA to control hypercortisolaemia. ECS resolved completely after surgery in 33 patients and severe peri- or postoperative complications were detected in 12 patients. There were fewer severe complications in the endoscopic group compared to open surgery (p = .030). Posterior retroperitoneoscopic BA performed simultaneously by a two surgeon approach had the shortest operating time (p = .001). Despite the frequent use of adrenolytic treatment, BA was necessary in a majority of patients to gain control over ECS. Complication rate was high, probably as a result of the combination of metastatic disease and metabolic disorders caused by high cortisol levels. The two surgeon approach BA may be considered as the method of choice in ECS compared to other BA approaches as a result of fewer complications and a shorter operating time.
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Affiliation(s)
- Ieva Lase
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Malin Grönberg
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Eva Tiensuu Janson
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
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Adwall L, Pantiora E, Hultin H, Norlén O. Association of postoperative infection and oncological outcome after breast cancer surgery. BJS Open 2021; 5:6317571. [PMID: 34240113 PMCID: PMC8266532 DOI: 10.1093/bjsopen/zrab052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
Background Surgical-site infection (SSI) is a well known complication after breast cancer surgery and has been reported to be associated with cancer recurrence. The aim of this study was to investigate the association between SSI and breast cancer recurrence, adjusting for several known confounders. The secondary aim was to assess a possible association between any postoperative infection and breast cancer recurrence. Method This retrospective cohort study included all patients who underwent breast cancer surgery from January 2009 to December 2010 in the Uppsala region of Sweden. Data collected included patient, treatment and tumour characteristics, infection rates and outcome. Association between postoperative infection and oncological outcome was examined using Kaplan–Meier curves and Cox regression analysis. Results Some 492 patients (439 with invasive breast cancer) with a median follow-up of 8.4 years were included. Mean(s.d.) age was 62(13) years. Sixty-two (14.1 per cent) of those with invasive breast cancer had an SSI and 43 (9.8 per cent) had another postoperative infection. Some 26 patients had local recurrence; 55 had systemic recurrence. Systemic recurrence was significantly increased after SSI with simple analysis (log rank test, P = 0.035) but this was not observed on adjusted analysis. However, tumour size and lymph node status remained significant predictors for breast cancer recurrence on multiple regression. Other postoperative infections were not associated with recurrence. Conclusion Neither SSI nor other postoperative infections were associated with worse oncological outcome in this study. Rather, other factors that relate to both SSI and recurrence may be responsible for the association seen in previous studies.
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Affiliation(s)
- L Adwall
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - E Pantiora
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - H Hultin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - O Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Botling J, Lamarca A, Bajic D, Norlén O, Lönngren V, Kjaer J, Eriksson B, Welin S, Hellman P, Rindi G, Skogseid B, Crona J. High-Grade Progression Confers Poor Survival in Pancreatic Neuroendocrine Tumors. Neuroendocrinology 2020; 110:891-898. [PMID: 31658459 DOI: 10.1159/000504392] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/26/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Little is known about how pancreatic neuroendocrine tumors (PanNETs) evolve over time and if changes toward a more aggressive biology correlate with prognosis. The purpose of this study was to characterize changes in PanNET differentiation and proliferation over time and to correlate findings to overall survival (OS). PATIENTS AND METHODS In this retrospective cohort study, we screened 475 PanNET patients treated at Uppsala University Hospital, Sweden. Sporadic patients with baseline and follow-up tumor samples were included. Pathology reports and available tissue sections were reevaluated with regard to tumor histopathology and Ki-67 index. RESULTS Forty-six patients with 106 tumor samples (56 available for pathology reevaluation) were included. Median Ki-67 index at diagnosis was 7% (range 1-38%), grade 1 n = 8, grade 2 n = 36, and grade 3 n = 2. The median change in Ki-67 index (absolute value; follow-up - baseline) was +14% (range -11 to +80%). Increase in tumor grade occurred in 28 patients (63.6%), the majority from grade 1/2 to grade 3 (n = 24, 54.5%). The patients with a high-grade progression had a median OS of 50.2 months compared to 115.1 months in patients without such progression (hazard ratio 3.89, 95% CI 1.91-7.94, p < 0.001). CONCLUSIONS A longitudinal increase in Ki-67 index and increase in tumor grade were observed in a majority of PanNETs included in this study. We propose that increase in Ki-67 index and high-grade progression should be investigated further as important biomarkers in PanNET.
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Affiliation(s)
- Johan Botling
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Duska Bajic
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Vincent Lönngren
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Josefine Kjaer
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Barbro Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Guido Rindi
- Anatomia Patologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Anatomia Patologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Britt Skogseid
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden,
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Eriksson J, Norlén O, Ögren M, Garmo H, Ihre-Lundgren C, Hellman P. Primary small intestinal neuroendocrine tumors are highly prevalent and often multiple before metastatic disease develops. Scand J Surg 2019; 110:44-50. [PMID: 31587594 DOI: 10.1177/1457496919874484] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 02/05/2023]
Abstract
BACKGROUND Small intestinal neuroendocrine tumors are the most common of small bowel malignancies with a clinical incidence of about 1 per 100,000 persons per year. There has been a threefold increase in the incidence of small intestinal neuroendocrine tumor during later decades, but there are no studies that clarify whether this is due to a true higher incidence or if the rise is a mere product of, for instance, improved diagnostic modalities. The aim of this study was to investigate the incidence of clinical as well as subclinical small intestinal neuroendocrine tumors found at autopsy as well as describing the frequency of concomitant malignancies in patients with small intestinal neuroendocrine tumor. MATERIALS AND METHODS An autopsy registry from the Malmö county population from 1970 to 1982 with an 87% autopsy rate was used. The clinical autopsy reports for patients coded for the existence of "carcinoid tumor" were scrutinized for the presence of small intestinal neuroendocrine tumor, metastatic disease, and concomitant malignancies. Details of patients with clinically diagnosed small intestinal neuroendocrine tumor during this time period were gathered from the Swedish Cancer Registry. RESULTS The mean annual incidence of small intestinal neuroendocrine tumor during this period was 5.33 per 100,000 individuals, and the mean annual prevalence was 581 per 100,000. The cause of death in the majority of cases was not due to small intestinal neuroendocrine tumor. In total, 48% of the people with small intestinal neuroendocrine tumor had at least one other malignancy, most commonly colorectal cancer. CONCLUSION Most small intestinal neuroendocrine tumors are subclinical, and persons living with them will often die due to other causes. There was a high rate of multiple primary tumors (40%), suggesting that multiple tumors seem to arise before the advent of metastatic disease. Moreover, a comparably high rate of associated colorectal carcinoma was found.
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Affiliation(s)
- J Eriksson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - O Norlén
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - M Ögren
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - H Garmo
- Division of Cancer Studies, Cancer Epidemiology Group, Research Oncology, King's College London, London, UK.,Regional Oncologic Centre, Uppsala University, Uppsala, Sweden
| | - C Ihre-Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P Hellman
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Daskalakis K, Karakatsanis A, Hessman O, Stuart HC, Welin S, Tiensuu Janson E, Öberg K, Hellman P, Norlén O, Stålberg P. Association of a Prophylactic Surgical Approach to Stage IV Small Intestinal Neuroendocrine Tumors With Survival. JAMA Oncol 2019; 4:183-189. [PMID: 29049611 DOI: 10.1001/jamaoncol.2017.3326] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Primary tumor resection and mesenteric lymph node dissection in asymptomatic patients with stage IV small intestinal neuroendocrine tumors (SI-NETs) are controversial. Objective To determine the association of locoregional surgery (LRS) performed at diagnosis with outcomes in patients with asymptomatic SI-NETs and distant metastases. Design, Setting, and Participants This cohort study included asymptomatic patients with stage IV SI-NETs diagnosed from January 1, 1985, through December 31, 2015, and identified using the prospective database of SI-NETs from Uppsala University Hospital, Uppsala, Sweden. Patients included were treated at a tertiary referral center and followed up until May 31, 2016, with data from the Swedish National Patient Register. The 363 patients with stage IV SI-NETs without abdominal symptoms were divided between those who underwent prophylactic up-front surgery within 6 months from diagnosis combined with oncologic treatment (hereafter referred to as LRS group [n = 161]) and those who underwent nonsurgical treatment or delayed surgery as needed combined with oncologic treatment (hereafer referred to as delayed LRS group [n = 202]). Exposures Prophylactic up-front surgery within 6 months from diagnosis combined with oncologic treatment vs nonsurgical treatment or delayed surgery as needed combined with oncologic treatment. Main Outcomes and Measures Overall survival (OS), length of hospital stay (LOS), postoperative morbidity and mortality, and reoperation rates measured from baseline. Propensity score matching was performed between the 2 groups. Results The 363 patients included 173 women (47.7%) and 190 men (52.3%), with a mean (SD) age at diagnosis of 62.4 (11.1) years. Two isonumerical groups with 91 patients in each resulted after propensity score matching. The LRS and delayed LRS groups were comparable in median OS (7.9 years [range, 5.1-10.7 years] vs 7.6 years [range, 5.8-9.5 years]; hazard ratio [HR], 0.98; 95% CI, 0.70-1.37; log-rank P = .93) and cancer-specific survival (7.7 years [range, 4.5-10.8 years] vs 7.6 years [range, 5.6-9.7 years]; HR, 0.99; 95% CI, 0.71-1.40; log-rank P = .99). No difference was found in 30-day mortality (0 patients in both matched groups) or postoperative morbidity (2 [2.2%] vs 1 [1.1%]; P > .99), median LOS (73 days [range, 2-270 days] vs 76 days [range, 0-339 days]; P = .64) or LOS due to local tumor-related symptoms (7.0 days [range, 0-90 days] vs 11.5 days [range, 0-69 days]; P = .81), or incisional hernia repairs (4 patients [4.4%] in both groups; P > .99). Patients in the LRS group underwent more reoperative procedures (13 [14.3%]) compared with those in the delayed LRS group (3 [3.3%]) owing to intestinal obstruction (P < .001). Conclusions and Relevance Prophylactic up-front LRS conferred no survival advantage in asymptomatic patients with stage IV SI-NETs. Delayed surgery as needed was comparable in all examined outcomes and was associated with fewer reoperations for intestinal obstruction. The value of a priori LRS in the presence of distant metastases is challenged and needs to be elucidated in a randomized clinical study.
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Affiliation(s)
- Kosmas Daskalakis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Ola Hessman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Heather C Stuart
- Division of Surgical Oncology, University of Miami, Miami, Florida
| | - Staffan Welin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Kjell Öberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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14
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Vyakaranam AR, Crona J, Norlén O, Granberg D, Garske-Román U, Sandström M, Fröss-Baron K, Thiis-Evensen E, Hellman P, Sundin A. Favorable Outcome in Patients with Pheochromocytoma and Paraganglioma Treated with 177Lu-DOTATATE. Cancers (Basel) 2019; 11:cancers11070909. [PMID: 31261748 PMCID: PMC6678507 DOI: 10.3390/cancers11070909] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 12/23/2022] Open
Abstract
Peptide receptor radiotherapy (PRRT) with 177Lu-DOTATATE has emerged as a promising therapy for neuroendocrine tumors (NETs). This retrospective cohort study aimed to assess the outcome of PRRT for 22 patients with histopathologically confirmed pheochromocytoma (PCC) and paraganglioma (PGL), of which two were localized and 20 metastatic. Radiological response utilized response evaluation criteria in solid tumors 1.1 and toxicity was graded according to common terminology criteria for adverse events version 4. Median 4 (range 3–11) 7.4 GBq cycles of 177Lu-DOTATATE were administered as first-line therapy (n = 13) or because of progressive disease (n = 9). Partial response (PR) was achieved in two and stable disease (SD) in 20 patients. The median overall survival (OS) was 49.6 (range 8.2–139) months and median progression-free survival (PFS) was 21.6 (range 6.7–138) months. Scintigraphic response >50% was achieved in 9/19 (47%) patients. Biochemical response (>50% decrease) of chromogranin A was found in 6/15 (40%) patients and of catecholamines in 3/12 (25%) patients. Subgroup analysis showed Ki-67 <15% associated with longer OS (p = 0.013) and PFS (p = 0.005). PRRT as first-line therapy was associated with increased OS (p = 0.041). No hematological or kidney toxicity grade 3–4 was registered. 177Lu-DOTATATE therapy was associated with favorable outcome and low toxicity. High Ki-67 (≥15%) and PRRT received because of progression on previous therapy could constitute negative predictive factors for OS.
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Affiliation(s)
- Achyut Ram Vyakaranam
- Section of Radiology, Molecular Imaging, Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | - Olov Norlén
- Section of Endocrine Surgery, Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | - Dan Granberg
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | - Ulrike Garske-Román
- Section of Radiology, Molecular Imaging, Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
- Department of Nuclear Medicine, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Mattias Sandström
- Section of Radiology, Molecular Imaging, Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
| | - Katarzyna Fröss-Baron
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | - Espen Thiis-Evensen
- Department of Gastroenterology, Oslo University Hospital, Rikshospitalet, 0372 Oslo, Norway
| | - Per Hellman
- Section of Endocrine Surgery, Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | - Anders Sundin
- Section of Radiology, Molecular Imaging, Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
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Daskalakis K, Norlén O, Hellman P, Stålberg P. Applying the use of novel biomarkers for neuroendocrine tumors in the clinic: where are we now? International Journal of Endocrine Oncology 2019. [DOI: 10.2217/ije-2017-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kosmas Daskalakis
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Endocrine Surgical Unit, Uppsala University Hospital, 751 85 Uppsala, Sweden
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16
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Norlén O, Montan H, Hellman P, Stålberg P, Sundin A. Preoperative 68Ga-DOTA-Somatostatin Analog-PET/CT Hybrid Imaging Increases Detection Rate of Intra-abdominal Small Intestinal Neuroendocrine Tumor Lesions. World J Surg 2018; 42:498-505. [PMID: 29159606 PMCID: PMC5762814 DOI: 10.1007/s00268-017-4364-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Small intestinal neuroendocrine tumors (SI-NETs) are the most common form of neoplasm in the small bowel. Radiological identification of primary tumors (PT), which may be multiple, is difficult, and therefore palpation of the entire small bowel is routinely performed during laparotomy. The aim was to determine detection rates of PT and peritoneal carcinomatosis (PC) with 68Ga-DOTATOC/TATE-PET/CT in comparison with i.v. contrast-enhanced computed tomography (CE-CT) and thus to clarify whether modern functional imaging can mitigate the need for palpation of bowel during surgery enabling oncologically adequate laparoscopic resection. Methods A total of 28 patients with SI-NET who preoperatively underwent both 68Ga-DOTATOC/TATE-PET/CT and CE-CT were included. The detection rates of PT and PC for PET/CT and CE-CT were compared to the findings in the surgical and histopathological reports. Appropriate statistical tests were used, and significance was set to p < 0.05. Results Out of 82 PT, 43 PT were not detected by any imaging modality. More PT lesions were detected with PET/CT (n = 39 [47.5%]) than with CE-CT (n = 10 [12.2%], p < 0.001). Also, PET/CT identified significantly more PC lesions than CE-CT (78 and 38%, p = 0.004, respectively). Conclusion PET/CT detected more PT and PC lesions than CE-CT. Some PTs and PC lesions were only detected by one of the modalities, and CT performed in conjunction with PET/CT should therefore be performed as a fully diagnostic CE-CT for optimal results. Palpation of the small bowel remains crucial during surgery in these patients because several PTs escaped detection by both PET/CT and CE-CT.
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Affiliation(s)
- Olov Norlén
- Department of Surgery, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Harald Montan
- Department of Radiology and Molecular Imaging, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Hellman
- Department of Surgery, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgery, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Anders Sundin
- Department of Radiology and Molecular Imaging, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden.
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Barazeghi E, Prabhawa S, Norlén O, Hellman P, Stålberg P, Westin G. Decrease of 5-hydroxymethylcytosine and TET1 with nuclear exclusion of TET2 in small intestinal neuroendocrine tumors. BMC Cancer 2018; 18:764. [PMID: 30045709 PMCID: PMC6060499 DOI: 10.1186/s12885-018-4579-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 06/07/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Small intestinal neuroendocrine tumors (SI-NETs) originate from enterochromaffin cells scattered in the intestinal mucosa of the ileum and jejunum. Loss of one copy of chromosome 18 is the most frequent observed aberration in primary tumors and metastases. The aim of this study was to investigate possible involvement of 5-hydroxymethylcytosine (5hmC), TET1 and TET2 in SI-NETs. METHODS The analysis was conducted using 40 primary tumors and corresponding 47 metastases. The level of 5hmC, TET1 and TET2 was analyzed by DNA immune-dot blot assay and immunohistochemistry. Other methods included a colony forming assay, western blotting analysis, and quantitative bisulfite pyrosequencing analysis. The effect of the exportin-1 nuclear transport machinery inhibitors on cell proliferation and apoptosis was also explored using two SI-NET cell lines. RESULTS Variable levels of 5hmC and a mosaic staining appearance with a mixture of positive and negative cell nuclei, regardless of cell number and staining strength, was observed overall both in primary tumors and metastases. Similarly aberrant staining pattern was observed for TET1 and TET2. In a number of tumors (15/32) mosaic pattern together with areas of negative staining was also observed for TET1. Abolished expression of TET1 in the tumors did not seem to involve hypermethylation of the TET1 promoter region. Overexpression of TET1 in a colony forming assay supported a function as cell growth regulator. In contrast to 5hmC and TET1, TET2 was also observed in the cytoplasm of all the analyzed SI-NETs regardless of nuclear localization. Treatment of CNDT2.5 and KRJ-I cells with the exportin-1 (XPO1/CRM1) inhibitor, leptomycin B, induced reduction in the cytoplasm and nuclear retention of TET2. Aberrant partitioning of TET2 from the nucleus to the cytoplasm seemed therefore to involve the exportin-1 nuclear transport machinery. Reduced cell proliferation and induction of apoptosis were observed after treatment of CNDT2.5 and KRJ-I cells with leptomycin B or KPT-330 (selinexor). CONCLUSIONS SI-NETs are epigenetically dysregulated at the level of 5-hydroxymethylcytosine/ TET1/TET2. We suggest that KPT-330/selinexor or future developments should be considered and evaluated for single treatment of patients with SI-NET disease and also in combinations with somatostatin analogues, peptide receptor radiotherapy, or everolimus.
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Affiliation(s)
- Elham Barazeghi
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden
| | - Surendra Prabhawa
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden.
| | - Gunnar Westin
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Rudbeck Laboratory, SE-751 85, Uppsala, Sweden.
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18
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Daskalakis K, Norlén O, Karakatsanis A, Hellman P, Larsson R, Nygren P, Stålberg P. Ex vivo activity of cytotoxic drugs and targeted agents in small intestinal neuroendocrine tumors. Endocr Relat Cancer 2018; 25:471-480. [PMID: 29440231 DOI: 10.1530/erc-17-0404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/12/2018] [Indexed: 12/16/2022]
Abstract
Small intestinal neuroendocrine tumors (SI-NETs) are generally considered resistant to systemic treatment. To date, predictive markers for drug activity are lacking. Tumor samples from 27 patients with SI-NETs were analyzed ex vivo for sensitivity to a panel of cytotoxic drugs and targeted agents using a short-term total cell kill assay. Samples of renal cancer, colorectal cancer (CRC), ovarian cancer and chronic lymphocytic leukemia (CLL) were included for comparison. For the SI-NET subset, drug sensitivity was analyzed in relation to clinicopathological variables and pre-treatment biomarkers. For cytotoxic drugs, SI-NETs demonstrated similar or higher sensitivity to 5-FU, platinum, gemcitabine and doxorubicin compared with CRC. For several of the targeted kinase inhibitors, SI-NET was among the most sensitive solid tumor types. CLL and ovarian cancer were generally the most sensitive tumor types to both cytotoxic drugs and protein kinase inhibitors. SI-NET was more sensitive to the mTOR inhibitor sirolimus than the other solid tumor types tested. Individual SI-NET samples demonstrated great variability in ex vivo sensitivity for most drugs. Cross-resistance between different drugs also varied considerably, being higher among protein kinase inhibitors. Age, stage, grade, peritoneal carcinomatosis and extra-abdominal metastases as well as serum chromogranin A and urine 5-HIAA concentrations at diagnosis did not correlate to drug sensitivity ex vivo SI-NETs exhibit intermediate sensitivity ex vivo to cytotoxic and targeted drugs. Clinicopathological factors and currently used biomarkers are not clearly associated to ex vivo sensitivity, challenging these criteria for treatment decisions in SI-NET. The great variability in drug sensitivity calls for individualized selection of therapy.
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Affiliation(s)
- Kosmas Daskalakis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Rolf Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Nygren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Fraser S, Norlén O, Bender K, Davidson J, Bajenov S, Fahey D, Li S, Sidhu S, Sywak M. Randomized trial of low versus high carbon dioxide insufflation pressures in posterior retroperitoneoscopic adrenalectomy. Surgery 2018; 163:1128-1133. [PMID: 29395236 DOI: 10.1016/j.surg.2017.10.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/10/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy has gained widespread acceptance for the removal of benign adrenal tumors. Higher insufflation pressures using carbon dioxide (CO2) are required, although the ideal starting pressure is unclear. This prospective, randomized, single-blinded, study aims to compare physiologic differences with 2 different CO2 insufflation pressures during posterior retroperitoneoscopic adrenalectomy. METHODS Participants were randomly assigned to a starting insufflation pressure of 20 mm Hg (low pressure) or 25 mm Hg (high pressure). The primary outcome measure was partial pressure of arterial CO2 at 60 minutes. Secondary outcomes included end-tidal CO2, arterial pH, blood pressure, and peak airway pressure. Breaches of protocol to change insufflation pressure were permitted if required and were recorded. RESULTS A prospective randomized trial including 31 patients (low pressure: n = 16; high pressure: n = 15) was undertaken. At 60 minutes, the high pressure group had greater mean partial pressure of arterial CO2 (64 vs 50 mm Hg, P = .003) and end-tidal CO2 (54 vs 45 mm Hg, P = .008) and a lesser pH (7.21 vs 7.29, P = .0005). There were no significant differences in base excess, peak airway pressure, operative time, or duration of hospital stay. Clinically indicated protocol breaches were more common in the low pressure than the high pressure group (8 vs 3, P = .03). CONCLUSION In posterior retroperitoneoscopic adrenalectomy, greater insufflation pressures are associated with greater partial pressure of arterial CO2 and end-tidal CO2 and lesser pH at 60 minutes, be significant. Commencing with lesser CO2 insufflation pressures decreases intraoperative acidosis.
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Affiliation(s)
- Sheila Fraser
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Olov Norlén
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kyle Bender
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Joanne Davidson
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Sonya Bajenov
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - David Fahey
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Shawn Li
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Stan Sidhu
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Mark Sywak
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia.
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20
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Abstract
Primary hyperparathyroidism (pHPT) is rarely caused by parathyroid carcinoma (PC, <1-5% of pHPT cases). The TET proteins oxidize the epigenetic mark 5-methylcytosine to 5-hydroxymethylcytosine (5hmC) and inactivation by mutation or epigenetic deregulation of TET1 and TET2 play important roles in various cancers. Recently, we found that 5hmC was severely reduced in all of the analyzed PCs and with deranged expression of TET1 for the majority of PCs. Here, we have examined the expression of the TET2 protein in 15 5hmC-negative PCs from patients who had local invasion or metastases. Cell growth and cell migratory roles for TET2 as well as epigenetic deregulated expression were addressed. Immunohistochemistry revealed very low/undetectable expression of TET2 in all PCs and verified for two PCs that were available for western blotting analysis. Knockdown of TET2 in the parathyroid cell line sHPT-1 resulted in increased cell growth and increased cell migration. DNA sequencing of TET2 in PCs revealed two common variants and no obvious inactivating mutations. Quantitative bisulfite pyrosequencing analysis of the TET2 promoter CpG island revealed higher CpG methylation level in the PCs compared to that in normal tissues and treatment of a PC primary cell culture with the DNA methylation inhibitor 5-aza-2'-deoxycytidine caused increased expression of the methylated TET2 gene. Hence, the data suggest that deregulated expression of TET2 by DNA hypermethylation may contribute to the aberrantly low level of 5hmC in PCs and further that TET2 plays a cell growth and cell migratory regulatory role and may constitute a parathyroid tumor suppressor gene.
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Affiliation(s)
- Elham Barazeghi
- Department of Surgical SciencesEndocrine Unit, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Research GroupKolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Stan Sidhu
- Department of SurgeryRoyal North Shore Hospital, St Leonards, New South Wales, Australia
- University of SydneySydney, New South Wales, Australia
| | - Olov Norlén
- Department of Surgical SciencesEndocrine Unit, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
- Department of SurgeryRoyal North Shore Hospital, St Leonards, New South Wales, Australia
- University of SydneySydney, New South Wales, Australia
| | - Roberto Dina
- Department of HistopathologyHammersmith Hospital, Imperial College, London, UK
| | - F Fausto Palazzo
- Department of Endocrine SurgeryHammersmith Hospital, Imperial College, London, UK
| | - Per Hellman
- Department of Surgical SciencesEndocrine Unit, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical SciencesEndocrine Unit, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Gunnar Westin
- Department of Surgical SciencesEndocrine Unit, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
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21
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Backman S, Norlén O, Eriksson B, Skogseid B, Stålberg P, Crona J. Detection of Somatic Mutations in Gastroenteropancreatic Neuroendocrine Tumors Using Targeted Deep Sequencing. Anticancer Res 2017; 37:705-712. [PMID: 28179320 DOI: 10.21873/anticanres.11367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 11/10/2022]
Abstract
Mutations affecting the mechanistic target of rapamycin (MTOR) signalling pathway are frequent in human cancer and have been identified in up to 15% of pancreatic neuroendocrine tumours (NETs). Grade A evidence supports the efficacy of MTOR inhibition with everolimus in pancreatic NETs. Although a significant proportion of patients experience disease stabilization, only a minority will show objective tumour responses. It has been proposed that genomic mutations resulting in activation of MTOR signalling could be used to predict sensitivity to everolimus. PATIENTS AND METHODS Patients with NETs that underwent treatment with everolimus at our Institution were identified and those with available tumour tissue were selected for further analysis. Targeted next-generation sequencing (NGS) was used to re-sequence 22 genes that were selected on the basis of documented involvement in the MTOR signalling pathway or in the tumourigenesis of gastroenterpancreatic NETs. Radiological responses were documented using Response Evaluation Criteria in Solid Tumours. RESULTS Six patients were identified, one had a partial response and four had stable disease. Sequencing of tumour tissue resulted in a median sequence depth of 667.1 (range=404-1301) with 1-fold coverage of 95.9-96.5% and 10-fold coverage of 87.6-92.2%. A total of 494 genetic variants were discovered, four of which were identified as pathogenic. All pathogenic variants were validated using Sanger sequencing and were found exclusively in menin 1 (MEN1) and death domain associated protein (DAXX) genes. No mutations in the MTOR pathway-related genes were observed. CONCLUSION Targeted NGS is a feasible method with high diagnostic yield for genetic characterization of pancreatic NETs. A potential association between mutations in NETs and response to everolimus should be investigated by future studies.
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Affiliation(s)
- Samuel Backman
- Department of Surgical, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical, Uppsala University, Uppsala, Sweden
| | - Barbro Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Britt Skogseid
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical, Uppsala University, Uppsala, Sweden
| | - Joakim Crona
- Department of Surgical, Uppsala University, Uppsala, Sweden
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22
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Edfeldt K, Daskalakis K, Bäcklin C, Norlén O, Tiensuu Janson E, Westin G, Hellman P, Stålberg P. DcR3, TFF3, and Midkine Are Novel Serum Biomarkers in Small Intestinal Neuroendocrine Tumors. Neuroendocrinology 2017; 105:170-181. [PMID: 27829249 DOI: 10.1159/000452891] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/27/2016] [Indexed: 11/19/2022]
Abstract
Small intestinal neuroendocrine tumors (SI-NETs) are amine- and peptide-producing neoplasms. Most patients display metastases at the time of diagnosis; they have an unpredictable individual disease course and the tumors are often therapy resistant. Chromogranin A and 5-hydroxyindoleacetic acid are the biomarkers clinically used most often today, but there is a great need for novel diagnostic and prognostic biomarkers and new therapeutic targets. Sixty-nine biomarkers were screened in serum from 23 SI-NET patients and 23 healthy controls using the multiplex proximity ligation assay (PLA). A refined method, the proximity extension assay (PEA), was used to analyze 76 additional biomarkers. Statistical testing and multivariate classification were performed. Immunohistochemistry and ELISA were performed in an extended cohort. Using PLA, 19 biomarkers showed a significant difference in serum concentrations between patients and controls, and PEA revealed a difference in the concentrations of 17 proteins. Multivariate classification analysis revealed decoy receptor 3 (DcR3), trefoil factor 3 (TFF3), and midkine to be good biomarkers for the disease, which was confirmed by ELISA analysis. All 3 biomarkers were expressed in tumor tissue. DcR3 concentrations were elevated in patients with stage IV disease. High concentrations of DcR3 and TFF3 were correlated to poor survival. DcR3, TFF3, and midkine exhibited elevated serum concentrations in SI-NET patients compared to healthy controls, and DcR3 and TFF3 were associated with poor survival. DcR3 seems to be a marker for liver metastases, while TFF3 and midkine may be new diagnostic biomarkers for SI-NETs.
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Affiliation(s)
- Katarina Edfeldt
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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23
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Daskalakis K, Karakatsanis A, Stålberg P, Norlén O, Hellman P. Clinical signs of fibrosis in small intestinal neuroendocrine tumours. Br J Surg 2016; 104:69-75. [PMID: 27861745 DOI: 10.1002/bjs.10333] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/09/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with small intestinal neuroendocrine tumours (SI-NETs), serotonin and other cytokines released from tumour cells may induce fibrosis, leading to carcinoid heart disease and abdominal fibrotic reactions. The aim of this study was to assess the prevalence, clinical complications and management of this reaction in the abdomen. METHODS This was a retrospective cohort study of patients with SI-NETs diagnosed between 1985 and 2015. Clinical data, outcomes, radiological findings, and surgical and radiological interventions were reviewed. RESULTS A total of 824 patients were diagnosed with SI-NETs in the study interval. Clinically significant abdominal signs and symptoms of fibrosis occurred in 36 patients. Of these, 20 had critically symptomatic central mesenteric fibrosis causing obstruction of mesenteric vessels, and 16 had retroperitoneal fibrosis causing obstructive uropathy with hydronephrosis. Extensive fibrosis causing mesenteric vessel obstruction and/or obstructive uropathy was more often associated with symptomatic and advanced disease encompassing lymph node metastases in the mesenteric root, para-aortic lymph node metastases, as well as liver metastases and peritoneal carcinomatosis. Palliative intervention in terms of superior mesenteric vein stenting or resection of central mesenteric metastases and/or percutaneous nephrostomy and J stent treatment was beneficial in the majority of the patients. CONCLUSION Extensive abdominal fibrosis associated with clinically significant symptoms of intestinal ischaemia and/or obstructive uropathy was linked to advanced disease in patients with SI-NETs. Prompt recognition and minimally invasive intervention was effective in disease palliation.
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Affiliation(s)
- K Daskalakis
- Department of Surgical Sciences, Uppsala University Hospital, SE75185, Uppsala, Sweden
| | - A Karakatsanis
- Department of Surgical Sciences, Uppsala University Hospital, SE75185, Uppsala, Sweden
| | - P Stålberg
- Department of Surgical Sciences, Uppsala University Hospital, SE75185, Uppsala, Sweden
| | - O Norlén
- Department of Surgical Sciences, Uppsala University Hospital, SE75185, Uppsala, Sweden
| | - P Hellman
- Department of Surgical Sciences, Uppsala University Hospital, SE75185, Uppsala, Sweden
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Fraser S, Zaidi N, Norlén O, Glover A, Kruijff S, Sywak M, Delbridge L, Sidhu SB. Incidence and Risk Factors for Occult Level 3 Lymph Node Metastases in Papillary Thyroid Cancer. Ann Surg Oncol 2016; 23:3587-3592. [PMID: 27188295 DOI: 10.1245/s10434-016-5254-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Papillary thyroid cancer (PTC) frequently disseminates into cervical lymph nodes. Lateral node involvement is described in up to 50 % patients undergoing prophylactic lateral neck dissection. This study aimed to assess this finding and identify which factors predict for occult lateral node disease. METHODS Patients with fine needle aspiration-confirmed PTC (Bethesda V or VI), without evidence of cervical lymph node metastases, underwent a total thyroidectomy with prophylactic ipsilateral central and level 3 dissection. Level 3 nodes were removed by compartmental dissection or by sampling the sentinel nodes overlying the jugular vein, according to surgeon preference. Data were collected prospectively from January 2011 to August 2014. Statistical analysis was performed by SPSS software. RESULTS A total of 137 patients underwent total thyroidectomy with prophylactic ipsilateral central and level 3 dissection for PTC. The incidence of occult level 3 disease was 30 % (41/137 patients). A total of 48 % of patients (66/137) harbored occult central neck disease. A total of 80.5 % of patients with pN1b disease had macrometastases (≥2 mm), and 15 % exhibited skip metastases with central compartment sparing. In patients with pN1b disease, a median of 6 level 3 nodes were retrieved, with an average involved nodal ratio of 0.29. Multivariate regression demonstrated risk factors for occult lateral neck metastasis include tumor size (odds ratio 1.1), upper pole tumors (odds ratio 6.6), and vascular invasion (odds ratio 3.2) (p < 0.05). CONCLUSIONS PTC is associated with a significant incidence of occult central and lateral nodal metastases. In patients undergoing prophylactic central neck dissection, inclusion of level 3 dissection should be considered in patients with large upper lobe cancers.
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Affiliation(s)
- Sheila Fraser
- Endocrine Surgery Unit, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia.
| | - Nisar Zaidi
- Endocrine Surgery Unit, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anthony Glover
- Kolling Institute of Medical Research, University of Sydney, St. Leonards, Australia
| | - Schelto Kruijff
- Department of Surgical Oncology, University Medical Centre Groningen, Groningen, Netherlands
| | - Mark Sywak
- Endocrine Surgery Unit, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia
| | - Leigh Delbridge
- Endocrine Surgery Unit, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia
| | - Stan B Sidhu
- Endocrine Surgery Unit, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia.,Kolling Institute of Medical Research, University of Sydney, St. Leonards, Australia
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Barazeghi E, Gill AJ, Sidhu S, Norlén O, Dina R, Palazzo FF, Hellman P, Stålberg P, Westin G. 5-Hydroxymethylcytosine discriminates between parathyroid adenoma and carcinoma. Clin Epigenetics 2016; 8:31. [PMID: 26973719 PMCID: PMC4789293 DOI: 10.1186/s13148-016-0197-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/02/2016] [Indexed: 12/14/2022] Open
Abstract
Background Primary hyperparathyroidism is characterized by enlarged parathyroid glands due to an adenoma (80–85 %) or multiglandular disease (~15 %) causing hypersecretion of parathyroid hormone (PTH) and generally hypercalcemia. Parathyroid cancer is rare (<1–5 %). The epigenetic mark 5-hydroxymethylcytosine (5hmC) is reduced in various cancers, and this may involve reduced expression of the ten-eleven translocation 1 (TET1) enzyme. Here, we have performed novel experiments to determine the 5hmC level and TET1 protein expression in 43 parathyroid adenomas (PAs) and 17 parathyroid carcinomas (PCs) from patients who had local invasion or metastases and to address a potential growth regulatory role of TET1. Results The global 5hmC level was determined by a semi-quantitative DNA immune-dot blot assay in a smaller number of tumors. The global 5hmC level was reduced in nine PCs and 15 PAs compared to four normal tissue samples (p < 0.05), and it was most severely reduced in the PCs. By immunohistochemistry, all 17 PCs stained negatively for 5hmC and TET1 showed negative or variably heterogeneous staining for the majority. All 43 PAs displayed positive 5hmC staining, and a similar aberrant staining pattern of 5hmC and TET1 was seen in about half of the PAs. Western blotting analysis of two PCs and nine PAs showed variable TET1 protein expression levels. A significantly higher tumor weight was associated to PAs displaying a more severe aberrant staining pattern of 5hmC and TET1. Overexpression of TET1 in a colony forming assay inhibited parathyroid tumor cell growth. Conclusions 5hmC can discriminate between PAs and PCs. Whether 5hmC represents a novel marker for malignancy warrants further analysis in additional parathyroid tumor cohorts. The results support a growth regulatory role of TET1 in parathyroid tissue. Electronic supplementary material The online version of this article (doi:10.1186/s13148-016-0197-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elham Barazeghi
- Department of Surgical Sciences, Endocrine Unit, Uppsala University, Uppsala, SE-751 85 Sweden
| | - Anthony J Gill
- Department of Anatomical Pathology, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065 Australia ; University of Sydney, Sydney, NSW 2006 Australia
| | - Stan Sidhu
- University of Sydney, Sydney, NSW 2006 Australia ; Department of Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065 Australia
| | - Olov Norlén
- Department of Surgical Sciences, Endocrine Unit, Uppsala University, Uppsala, SE-751 85 Sweden ; University of Sydney, Sydney, NSW 2006 Australia ; Department of Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065 Australia
| | - Roberto Dina
- Department of Histopathology, Hammersmith Hospital, Imperial College, London, UK
| | - F Fausto Palazzo
- Endocrine Surgery, Hammersmith Hospital, Imperial College, London, UK
| | - Per Hellman
- Department of Surgical Sciences, Endocrine Unit, Uppsala University, Uppsala, SE-751 85 Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Endocrine Unit, Uppsala University, Uppsala, SE-751 85 Sweden
| | - Gunnar Westin
- Department of Surgical Sciences, Endocrine Unit, Uppsala University, Uppsala, SE-751 85 Sweden
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Crona J, Norlén O, Antonodimitrakis P, Welin S, Stålberg P, Eriksson B. Multiple and Secondary Hormone Secretion in Patients With Metastatic Pancreatic Neuroendocrine Tumours. J Clin Endocrinol Metab 2016; 101:445-52. [PMID: 26672633 DOI: 10.1210/jc.2015-2436] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CONTEXT As a group, neuroendocrine tumors (NETs) secrete many different peptide hormones, yet heretofore each NET patient is typically thought to produce at most one hormone that causes a distinct hormonal syndrome. A minority of patients have multiple hormones at diagnosis and may also develop secondary hormone secretion at a later stage. OBJECTIVES The objectives of the study were to determine the frequency and to describe the impact of multiple and secondary hormone secretion in sporadic gasteroenteropancreatic NET patients. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis of patients (n = 972) with gasteroenteropancreatic NET treated at Uppsala University Hospital, Uppsala, Sweden. Patients with the secretion of multiple hormones at diagnosis and/or those developing secondary hormone secretion during the disease course were identified and studied in further detail. RESULTS In pancreatic NETs (PNETs), a total of 19 of 323 patients (6%) had secretion of multiple hormones at diagnosis, and 14 of 323 (4%) had secondary changes during the disease course. These phenomena occurred exclusively in patients with an advanced disease stage, and secondary hormones were detected in a close time span with progressive disease. Patients with secondary insulin hypersecretion had increased morbidity as well as reduced survival (P < .002). In contrast, multiple and secondary hormone secretion was rarely seen in NETs of the small intestine with 0 and 1 of 603 cases, respectively. CONCLUSION Diversity of PNET hormone secretion either at diagnosis or during the disease course occurred in a minority of patients (9.3%). These phenomena had a major impact on patient outcome both through increased morbidity and mortality. Our results support that patients with metastatic PNETs should be monitored for clinical symptoms of secondary hormone secretion during the disease course.
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Affiliation(s)
- Joakim Crona
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
| | - Olov Norlén
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
| | - Pantelis Antonodimitrakis
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
| | - Staffan Welin
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
| | - Peter Stålberg
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
| | - Barbro Eriksson
- Departments of Medical Sciences (J.C., P.A., S.W., B.E.) and Surgical Sciences (O.N., P.S.), Uppsala University, 75185 Uppsala, Sweden
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Norlén O, Charlton A, Sarkis LM, Henwood T, Shun A, Gill AJ, Delbridge L. Risk of malignancy for each Bethesda class in pediatric thyroid nodules. J Pediatr Surg 2015; 50:1147-9. [PMID: 25783310 DOI: 10.1016/j.jpedsurg.2014.10.046] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 10/01/2014] [Accepted: 10/14/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE The Bethesda classification for cytology is used to classify thyroid nodules into one of six categories, and for each category there is an implied cancer risk and also recommendation for management. Despite lack of data in children, the American thyroid association promotes the use of the same management guidelines as in adults. Our aim was to study the risk of malignancy for each Bethesda class in children with thyroid nodules. METHODOLOGY We included all patients ≤18years of age that had underwent a thyroid fine needle aspiration (FNA) at one of two centers between January 1998 and July 2013. FNA results were reclassified according to the Bethesda criteria. Histological, repeat cytological, radiological and clinical follow-up were recorded. RESULTS Fifty-six patients (66 nodules) underwent FNB. Mean age was 13.6 years. Numbers of nodules reported as BI-BVI were 7, 38, 11, 4, 3 and 3, respectively. Follow-up was achieved for 55 (83%) nodules. Twelve (18%) nodules were malignant by histology and revealed papillary (n=7), follicular (n=3) or insular thyroid cancer (n=2), The proportion of nodules with malignancy for BI-BVI was: 0%, 0%, 18%, 100%, 100% and 100%. CONCLUSION The rate of malignancy in thyroid nodules in children seems to be higher than reported in adults. The Bethesda criteria seem to accurately identify benign nodules, but other categories have a very high rate of malignancy and BIII nodules pose a particular challenge.
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Affiliation(s)
- Olov Norlén
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Australia; Department of Surgical Sciences, Uppsala University, Sweden
| | - Amanda Charlton
- Department of Histopathology, Children's Westmead Hospital, Australia
| | - Leba M Sarkis
- Department of Anatomical Pathology, Royal North Shore Hospital and University of Sydney, Australia
| | - Tony Henwood
- Department of Histopathology, Children's Westmead Hospital, Australia
| | - Albert Shun
- Department of Surgery, Children's Westmead Hospital, Australia
| | - Anthony J Gill
- Department of Anatomical Pathology, Royal North Shore Hospital and University of Sydney, Australia
| | - Leigh Delbridge
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Australia
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Åkerström G, Norlén O, Edfeldt K, Crona J, Björklund P, Westin G, Hellman P, Stålberg P. A review on management discussions of small intestinal neuroendocrine tumors ‘midgut carcinoids’. International Journal of Endocrine Oncology 2015. [DOI: 10.2217/ije.15.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
European Neuroendocrine Tumor Society staging, together with the Ki67 grading system, has appeared as superior for classification of neuroendocrine tumors (NET). The management of small intestinal NET (SI-NET) has been overall controversial. Mesenteric metastases occur also with the smallest SI-NET, and the majority of patients risk to ultimately progress with liver metastases. 68Gallium (somatostatin receptor)/PET/CT has appeared as most sensitive for imaging, and fluorodeoxyglucose-PET is recommended to identify lesions with high proliferation. Our treatment policy for SI-NET is to initiate somatostatin analog treatment, and in order to prevent abdominal complications we recommend early intestinal resection for removal of primary tumors and clearance of lymph node metastases. Liver metastases are liberally treated by resection (or ablation), as this can efficiently palliate carcinoid syndrome-associated symptoms.
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Affiliation(s)
- Göran Åkerström
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Katarina Edfeldt
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Joakim Crona
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Peyman Björklund
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Gunnar Westin
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
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Norlén O, Glover A, Zaidi N, Aniss A, Sywak M, Sidhu S, Delbridge L. The Weight of the Resected Gland Predicts Rate of Success After Image-Guided Focused Parathyroidectomy. World J Surg 2015; 39:1922-7. [DOI: 10.1007/s00268-015-3017-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sarkis LM, Zaidi N, Norlén O, Delbridge LW, Sywak MS, Sidhu SB. Bilateral recurrent laryngeal nerve injury in a specialized thyroid surgery unit: would routine intraoperative neuromonitoring alter outcomes? ANZ J Surg 2015; 87:364-367. [DOI: 10.1111/ans.12980] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Leba M. Sarkis
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Nisar Zaidi
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Olov Norlén
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Stan B. Sidhu
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
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Crona J, Gustavsson T, Norlén O, Edfeldt K, Åkerström T, Westin G, Hellman P, Björklund P, Stålberg P. Somatic Mutations and Genetic Heterogeneity at the CDKN1B Locus in Small Intestinal Neuroendocrine Tumors. Ann Surg Oncol 2015; 22 Suppl 3:S1428-35. [PMID: 25586243 DOI: 10.1245/s10434-014-4351-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Until recently, the genetic landscape of small intestinal neuroendocrine tumors (SI-NETs) was limited to recurrent copy number alterations, most commonly a loss on chromosome 18. Intertumor heterogeneity with nonconcordant genotype in paired primary and metastatic lesions also is described, further contributing to the difficulty of unraveling the genetic enigma of SI-NETs. A recent study analyzing 55 SI-NET exomes nominated CDKN1B (p27) as a haploinsufficient tumor suppressor gene. METHODS This study aimed to determine the frequency of CDKN1B inactivation and to investigate genotype-phenotype correlations. It investigated 362 tumors from 200 patients. All samples were resequenced for mutations in CDKN1B using automated Sanger sequencing. The expression of p27 was investigated in 12 CDKN1B mutant and nine wild type tumors. RESULTS Some 8.5 % (17/200) of patients had tumors with pathogenic mutations in CDKN1B including 13 insertion deletions, four nonsense variants, and one stop-loss variant. All variants with available nontumoral DNA were classified as somatic. Inter- and intratumor heterogeneity at the CDKN1B locus was detected respectively in six of ten and two of ten patients. Patients with CDKN1B mutated tumors had both heterogeneous disease presentation and diverse prognosis. Expression of the p27 protein did not correlate with CDKN1B mutation status, and no differences in the clinical characteristics between CDKN1B mutated and CDKN1B wild type tumor carriers were found. CONCLUSION This study corroborates the finding of CDKN1B as a potential haplo-insufficient tumor suppressor gene characterized by inter- and intratumor heterogeneity in SI-NETs.
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Affiliation(s)
- Joakim Crona
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Tobias Gustavsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Katarina Edfeldt
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tobias Åkerström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnar Westin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peyman Björklund
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Norlén O, Edfeldt K, Akerstrom G, Westin G, Hellman P, Bjorklund P, Stalberg P. Peritoneal carcinomatosis from small intestinal neuroendocrine tumors: Clinical course and genetic profiling. Surgery 2014; 156:1512-21; discussion 1521-2. [PMID: 25456945 DOI: 10.1016/j.surg.2014.08.090] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 08/26/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND One-fifth of all patients with small-intestinal neuroendocrine tumors (SI-NETs) present with or develop peritoneal carcinomatosis (PC). Our aim was to determine the prognosis and genetic profiles of tumors in patients with PC compared with tumors in patients without PC. METHODS We included SI-NET patients (cases with PC, n = 73, and controls without PC, n = 468) who underwent operation between 1985 and 2012. The Lyon prognostic index was used to correlate the amount of PC to survival. DNA samples from patients with (n = 8) and without (n = 7) PC were analyzed with a single-nucleotide polymorphism array (HumanOmni2.5 BeadChip, Illumina) to investigate genetic disparities between groups. RESULTS Patients with PC had poorer survival (median 5.1 years) than controls (11.1 years). An advanced postoperative Lyon prognostic index was a negative prognostic marker for survival by multivariable analysis (P = .042). Patients with and without PC clustered differently based on loss of heterozygosity and copy number variation data from single-nucleotide polymorphism array of the primary tumors (P = .042). CONCLUSION SI-NET patients with PC have poor survival, which diminishes with increasing PC load after surgery. Clustering based on copy number variation and loss of heterozygosity data suggests different genotypes in primary tumors comparing patients with and without PC.
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Affiliation(s)
- Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Katarina Edfeldt
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Goran Akerstrom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnar Westin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peyman Bjorklund
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stalberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Norlén O, Daskalakis K, Öberg K, Åkerström G, Stålberg P, Hellman P. Indication for liver transplantation in young patients with small intestinal NETs is rare? World J Surg 2014; 38:742-7. [PMID: 24233660 DOI: 10.1007/s00268-013-2331-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A majority of patients with small intestinal neuroendocrine tumors (SI-NETs) present with or develop liver metastases (LM). A number of treatments for LM are used clinically, including liver transplantation (LTx). Indications for LTx are under debate; young age(<65 years), absence of extrahepatic disease, resected primary tumor and limited extent of LM have been suggested as inclusion criteria for LTx with the aim to optimize outcome. MATERIALS AND METHODS From our series of 672 patients with SI-NET treated at the University Hospital in Uppsala between 1985 and 2012, we identified 78 patients according to the following criteria: <65 years of age, locoregional surgery (LRS) of the primary tumor and mesenteric metastases successfully performed, LM present but no extrahepatic disease. Baseline was chosen as the first date the following points were met: First visit to our center,LRS performed, LM present. The patients underwent treatment according to the standard clinical protocols at our center, and during this time period we did not perform or refer any SI-NET patients for LTx. Kaplan-Meier survival analyses were performed in three different groups based on hypothetical criteria for LTx. RESULTS Five-year overall survival rates for patients <65 years (n = 78) and <55 years (n = 36) of age were 84 ± 8 and 92 ± 9 %, respectively. For patients fulfilling the Milan criteria (n = 33) the 5-year survival was 97 ± 6 %. CONCLUSIONS Most young patients (<65 years) with SINET and LM have a favorable survival with standardized multimodality treatment. Indeed, most survival figures reported after LTx of NET do not surpass these figures.
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Glover AR, Norlén O, Gundara JS, Morris M, Sidhu SB. Use of the Nerve Integrity Monitor during Thyroid Surgery Aids Identification of the External Branch of the Superior Laryngeal Nerve. Ann Surg Oncol 2014; 22:1768-73. [PMID: 25319580 DOI: 10.1245/s10434-014-4142-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The external branch of the superior laryngeal nerve (EBSLN) is at risk during thyroid surgery. Despite meticulous dissection and visualization, the EBSLN can be mistaken for other structures. The nerve integrity monitor (NIM) allows EBSLN confirmation with cricothyroid twitch on stimulation. AIMS The aim of this study was to assess any difference in identification of EBSLN and its anatomical sub-types by dissection alone compared to NIM-aided dissection. METHODS Routine intra-operative nerve monitoring (IONM) was used, when available, for 228 consecutive thyroid operations (129 total thyroidectomies, 99 hemi-thyroidectomies) over a 10-month period. EBSLN identification by dissection alone (with NIM confirmation of cricothyroid twitch) and by NIM-assisted dissection was recorded prospectively. Anatomical sub-types were defined by the Cernea classification. RESULTS Of 357 nerves at risk, 97.2 % EBSLNs (95 % confidence interval [CI], 95.5-98.9) were identified by visualization and NIM-aided dissection compared to 85.7 % (95 % CI, 82.1-89.3) identified by dissection alone (<0.001). EBSLN frequency was 34 % for type 1, 55 % for type 2a, and 11 % for type 2b. All identified EBSLNs were stimulated to confirm a cricothyroid twitch after superior thyroid vessel ligation. CONCLUSION Using the NIM and meticulous dissection of the upper thyroid pole improves EBSLN identification. As the EBSLN is at risk during thyroidectomy and can lead to voice morbidity, the NIM can aid identification of the EBSLN and provide a functional assessment of the EBSLN after thyroid resection.
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Affiliation(s)
- Anthony R Glover
- Kolling Institute of Medical Research, Royal North Shore Hospital and University of Sydney, St. Leonards, NSW, Australia,
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Glover AR, Gundara JS, Norlén O, Lee JC, Sidhu SB. The pros and cons of prophylactic central neck dissection in papillary thyroid carcinoma. Gland Surg 2014; 2:196-205. [PMID: 25083483 DOI: 10.3978/j.issn.2227-684x.2013.10.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/17/2013] [Indexed: 01/26/2023]
Abstract
Prophylactic central neck dissection (pCND) for management of papillary thyroid carcinoma (PTC) is controversial. Compared to many malignancies, PTC has a high overall survival but local recurrence due to lymph node metastases continue to present management challenges. Unlike lateral cervical nodal metastasis metastasis, central neck nodal metastasis are unable to be reliably detected clinically or radiologically at pre-operative assessment. Residual disease (recurrent or persistent) typically requires re-operative surgery in the central compartment, which carries a heightened risk of significant morbidity. These nodal groups can be accessed during the index thyroidectomy for PTC. Thus, pCND offers potential to reduce the rates of recurrence and the need for re-operative surgery in the central neck. This benefit needs to be balanced with the potential morbidity risk from pCND itself at the index resection. This review will discuss the advantages and disadvantages of pCND with regard to long-term outcomes and potential morbidity. The rationale of pCND will be discussed, along with the indications for ipsilateral and contralateral pCND, the role of re-operative surgery for recurrence and the use of selective versus routine pCND. Strategies to select higher risk patients for pCND with the use of molecular markers will be addressed, along with a discussion of quality of life (QoL) research in PTC.
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Affiliation(s)
- Anthony R Glover
- Kolling Institute of Medical Research, Cancer Genetics Laboratory, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia
| | - Justin S Gundara
- Kolling Institute of Medical Research, Cancer Genetics Laboratory, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia
| | - Olov Norlén
- University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - James C Lee
- Kolling Institute of Medical Research, Cancer Genetics Laboratory, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia
| | - Stan B Sidhu
- Kolling Institute of Medical Research, Cancer Genetics Laboratory, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia ; ; University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
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Norlén O, Sidhu S, Sywak M, Delbridge L. Long-term outcome after parathyroidectomy for lithium-induced hyperparathyroidism. Br J Surg 2014; 101:1252-6. [PMID: 25043401 DOI: 10.1002/bjs.9589] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 03/27/2014] [Accepted: 05/09/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND The accepted management of lithium-associated hyperparathyroidism (LiHPT) is open four-gland parathyroid exploration (OPTX). This approach has recently been the subject of controversy. A recent study has shown very high long-term recurrence rates after OPTX, whereas some have promoted unilateral focused parathyroidectomy as appropriate management. The aim was to evaluate long-term outcomes after surgery for LiHPT and to assess the accuracy of preoperative imaging. METHODS This was a retrospective cohort study that comprised all patients undergoing initial surgery for LiHPT between 1990 and 2013. The cumulative recurrence rate was calculated by the Kaplan-Meier method. The sensitivity and specificity of sestamibi scintigraphy and ultrasound imaging for identification of single-gland versus multigland disease was investigated using intraoperative assessment as reference. RESULTS Of 48 patients, 45 had OPTX and three underwent focused parathyroidectomy. Multiglandular disease was documented in 27 patients and 21 had a single adenoma. The median follow-up was 5·9 (range 0·3-22) years and 16 patients died during follow-up. The 10-year cumulative recurrence rate was 16 (95 per cent confidence interval 2 to 29) per cent. No permanent complications occurred after primary surgery for LiHPT. Twenty-four patients had at least one preoperative ultrasound or sestamibi scan. For concordant sestamibi scintigraphy and ultrasound imaging, the sensitivity and specificity for identifying single-gland versus multigland disease was five of nine and five of eight respectively. CONCLUSION Surgery provided a safe and effective management option for patients with LiHPT in this series, with a long-term cure rate of well over 80 per cent.
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Affiliation(s)
- O Norlén
- University of Sydney Endocrine Surgery Unit, Sydney, New South Wales, Australia; Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
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Norlén O, Popadich A, Kruijff S, Gill AJ, Sarkis LM, Delbridge L, Sywak M, Sidhu S. Bethesda III thyroid nodules: the role of ultrasound in clinical decision making. Ann Surg Oncol 2014; 21:3528-33. [PMID: 24806117 DOI: 10.1245/s10434-014-3749-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Assessment for thyroid nodules includes ultrasound (US) and cytology according to the Bethesda classification. There is no firm consensus regarding clinical management for nodules classified as Bethesda III. Our aim was investigate the value of US to predict malignancy in these nodules. METHODS Patients with Bethesda III nodules who underwent thyroid surgery from July 2011 to July 2013 were included. Inclusion criteria mandated that US were available for review by two observers blinded to each other's results and histological outcome. The nodules were scrutinized with six US criteria: hypoechoic attenuation (HA), irregular margins (IM), taller than wide, microcalcifications (MC), loss of halo, and increased central vascularity. Disagreements between observers were solved by consensus. RESULTS There were 141 patients (121 women) with a mean age of 55 years. Mean nodule size was 25 mm. The malignancy rate was 13 %. Interobserver ratios were moderate to very strong for all six predictors (kappa = 0.60-0.94). However, only HA, IM, and MC were predictors of malignancy by univariate analysis (all p < 0.002). Logistic regression revealed an odds ratio of malignancy versus no malignancy for HA 4.8, IM 3.3, and MC 4.0 (all p < 0.05). The positive and negative predictive value for malignancy when having one or more of these three criteria was 22 % and 98 %, respectively. CONCLUSION HA, IM, and MC were predictors of malignancy in Bethesda III nodules. In addition, the negative predictive value for any of these three criteria was high; a nodule that lacks all of these three criteria is thus unlikely to be malignant.
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Affiliation(s)
- Olov Norlén
- University of Sydney Endocrine Surgery Unit, Sydney, NSW, Australia,
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Norlén O, Stålberg P, Zedenius J, Hellman P. Outcome after resection and radiofrequency ablation of liver metastases from small intestinal neuroendocrine tumours. Br J Surg 2013; 100:1505-14. [PMID: 24037573 DOI: 10.1002/bjs.9262] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with small intestinal neuroendocrine tumour (SI-NET), liver resection or radiofrequency ablation (RFA) of liver metastases is performed for palliation of carcinoid syndrome, and in an effort to improve survival. Data are generally reported from case series, and no randomized trials have studied these treatments. The aim was to compare outcome after liver resection and/or RFA with that of non-surgical treatment in patients with liver metastases from SI-NET. METHODS The study included patients with liver metastases from SI-NET who underwent liver RFA/resection or were treated non-surgically. A propensity score match was performed to reduce bias between groups, using baseline variables such as the Charlson co-morbidity index, age, symptoms, carcinoid heart disease, extent of metastases and proliferation index. RESULTS Some 103 patients who had RFA and/or liver resection were compared with 273 controls. Propensity score matching resulted in two matched groups, each of 72 patients, with no significant differences in baseline variables. The matched resection/RFA and control groups showed no difference in overall survival (both 74 per cent at 5 years; P = 0·869) or disease-specific survival (74 versus 78 per cent respectively at 5 years; P = 1·000). However, urinary 5-hydroxyindoleacetic acid levels were lower (median 77 versus 120 µmol per 24 h; P = 0·005) and the proportion of patients with progressive disease within the liver was smaller (2 of 18 versus 8 of 18; P < 0·001) in the resection/RFA group after 5 years. CONCLUSION These data do not support the use of liver resection and/or RFA in an effort to prolong survival in patients with liver metastases from SI-NET.
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Affiliation(s)
- O Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Norlén O, Nilsson A, Krause J, Stålberg P, Hellman P, Sundin A. 11C-5-hydroxytryptophan positron emission tomography after radiofrequency ablation of neuroendocrine tumor liver metastases. Nucl Med Biol 2012; 39:883-90. [PMID: 22381780 DOI: 10.1016/j.nucmedbio.2011.12.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 10/08/2011] [Accepted: 12/18/2011] [Indexed: 01/05/2023]
Abstract
AIM The aim was to assess the feasibility of (11)C-5-hydroxy-tryptophan positron emission tomography ((11)C-5-HTP-PET) in the follow-up after radiofrequency ablation (RFA) of liver metastases from neuroendocrine tumors (NETs). BACKGROUND Contrast-enhanced computed tomography (CECT) and contrast-enhanced ultrasound (CEUS) are commonly used to evaluate the liver after RFA of NETs. In general, (11)C-5-HTP-PET is more sensitive in the visualization of NETs, but no studies have investigated its role after RFA. METHODS Six consecutive patients with liver metastases from NETs were subjected to RFA treatment. All patients underwent baseline imaging before RFA and on two occasions (1-2 and 6-11 months) after RFA. The imaging consisted of (11)C-5-HTP-PET, CEUS and CECT on all three occasions. RESULTS Thirty RFA areas were evaluated, and residual tumors (RTs) were depicted in eight areas (22%). (11)C-5-HTP-PET depicted RTs after RFA with maximum sensitivity (100%) and specificity (100%), using radiological follow-up as the gold standard. (11)C-5-HTP-PET detected five out of eight RTs earlier than CECT or CEUS. In general, the sensitivity of (11)C-5-HTP-PET exceeded that of CECT and CEUS for early visualization of NET liver metastases. CONCLUSION (11)C-5-HTP-PET can be used in the follow-up after RFA for the purpose of detecting RT, and it provides additional information to CEUS and CECT by detecting new lesions.
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Affiliation(s)
- Olov Norlén
- Department of Surgery, Uppsala University, Uppsala, Sweden.
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Abstract
N. meningitidis is the only Neisseria species known to express two outer membrane porins, PorA and PorB. However, a porA pseudogene has been identified in N. gonorrhoeae. The present study investigated the prevalence and genetic polymorphism of this porA pseudogene in 87 different N. gonorrhoeae strains. The porA pseudogene was identified in all isolates. The pseudogene comprised 12 (5.5%), of which 10 were located in the promoter spacer, and 11 (1.0%) polymorphic nucleotide sites in the upstream segment containing the promoter region, i.e. the putative -10 and -35 sequences and the promoter spacer in-between, and the hypothetical PorA coding sequence, respectively. A phylogenetic analysis of the upstream segment and the hypothetical coding sequence identified 36 sequence variants, of which 30 were not previously described. All strains comprised at least two identical confirmed inactivating deletions, of which one was located in the promoter region and one in the hypothetical PorA coding sequence. In conclusion, the porA pseudogene and its few inactivating mutations are widespread in the N. gonorrhoeae population and the homology with the N. meningitidis porA gene reflects their common evolutionary origin. The highly conserved N. gonorrhoeae porA pseudogene may reflect an evolutionary neutral molecular clock and may be a suitable genetic target for diagnosis of N. gonorrhoeae.
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Affiliation(s)
- Magnus Unemo
- National Reference Laboratory for Pathogenic Neisseria, Orebro University Hospital, Orebro, Sweden.
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