Causes of death and prognostic factors in multiple endocrine neoplasia type 1: a prospective study: comparison of 106 MEN1/Zollinger-Ellison syndrome patients with 1613 literature MEN1 patients with or without pancreatic endocrine tumors

Tetsuhide Ito, Hisato Igarashi, Hirotsugu Uehara, Marc J Berna, Robert T Jensen, Tetsuhide Ito, Hisato Igarashi, Hirotsugu Uehara, Marc J Berna, Robert T Jensen

Abstract

Multiple endocrine neoplasia type 1 (MEN1) is classically characterized by the development of functional or nonfunctional hyperplasia or tumors in endocrine tissues (parathyroid, pancreas, pituitary, adrenal). Because effective treatments have been developed for the hormone excess state, which was a major cause of death in these patients in the past, coupled with the recognition that nonendocrine tumors increasingly develop late in the disease course, the natural history of the disease has changed. An understanding of the current causes of death is important to tailor treatment for these patients and to help identify prognostic factors; however, it is generally lacking.To add to our understanding, we conducted a detailed analysis of the causes of death and prognostic factors from a prospective long-term National Institutes of Health (NIH) study of 106 MEN1 patients with pancreatic endocrine tumors with Zollinger-Ellison syndrome (MEN1/ZES patients) and compared our results to those from the pooled literature data of 227 patients with MEN1 with pancreatic endocrine tumors (MEN1/PET patients) reported in case reports or small series, and to 1386 patients reported in large MEN1 literature series. In the NIH series over a mean follow-up of 24.5 years, 24 (23%) patients died (14 MEN1-related and 10 non-MEN1-related deaths). Comparing the causes of death with the results from the 227 patients in the pooled literature series, we found that no patients died of acute complications due to acid hypersecretion, and 8%-14% died of other hormone excess causes, which is similar to the results in 10 large MEN1 literature series published since 1995. In the 2 series (the NIH and pooled literature series), two-thirds of patients died from an MEN1-related cause and one-third from a non-MEN1-related cause, which agrees with the mean values reported in 10 large MEN1 series in the literature, although in the literature the causes of death varied widely. In the NIH and pooled literature series, the main causes of MEN1-related deaths were due to the malignant nature of the PETs, followed by the malignant nature of thymic carcinoid tumors. These results differ from the results of a number of the literature series, especially those reported before the 1990s. The causes of non-MEN1-related death for the 2 series, in decreasing frequency, were cardiovascular disease, other nonendocrine tumors > lung diseases, cerebrovascular diseases. The most frequent non-MEN1-related tumor deaths were colorectal, renal > lung > breast, oropharyngeal. Although both overall and disease-related survival are better than in the past (30-yr survival of NIH series: 82% overall, 88% disease-related), the mean age at death was 55 years, which is younger than expected for the general population.Detailed analysis of causes of death correlated with clinical, laboratory, and tumor characteristics of patients in the 2 series allowed identification of a number of prognostic factors. Poor prognostic factors included higher fasting gastrin levels, presence of other functional hormonal syndromes, need for >3 parathyroidectomies, presence of liver metastases or distant metastases, aggressive PET growth, large PETs, or the development of new lesions.The results of this study have helped define the causes of death of MEN1 patients at present, and have enabled us to identify a number of prognostic factors that should be helpful in tailoring treatment for these patients for both short- and long-term management, as well as in directing research efforts to better define the natural history of the disease and the most important factors determining long-term survival at present.

Figures

FIGURE 1
FIGURE 1
Schematic diagram of causes of death in the 2 study groups. The top panel shows the results of the 106 prospectively studied NIH MEN1/ZES patients followed for a mean of 15.5 years from the time of diagnosis of MEN1. During this time 24 patients died; 14 deaths were due to MEN1-related causes and 10 patients died of non-MEN1-related causes. The deaths were stratified as to whether they were (n = 9) or were not (n = 15) directly due to a PET causing the death. In the bottom panel a similar diagram is shown for the 227 MEN1/PET patients from the pooled literature from case reports and small series (

FIGURE 2

Total and disease-related survival for…

FIGURE 2

Total and disease-related survival for the 2 groups of MEN1/PET patients studied. In…

FIGURE 2
Total and disease-related survival for the 2 groups of MEN1/PET patients studied. In the top 2 panels survival data for the 106 NIH MEN1/ZES patients are shown in Kaplan and Meier plots. The top panel shows disease-related and total survival from the time of MEN1 onset and the middle panel from the time of MEN1 diagnosis. The bottom panel shows total survival and disease-related survival from the time of MEN1 diagnosis for the 227 MEN1/PET patients from the pooled literature review of case reports and small series.
FIGURE 2
FIGURE 2
Total and disease-related survival for the 2 groups of MEN1/PET patients studied. In the top 2 panels survival data for the 106 NIH MEN1/ZES patients are shown in Kaplan and Meier plots. The top panel shows disease-related and total survival from the time of MEN1 onset and the middle panel from the time of MEN1 diagnosis. The bottom panel shows total survival and disease-related survival from the time of MEN1 diagnosis for the 227 MEN1/PET patients from the pooled literature review of case reports and small series.

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