Evolving patterns in the detection and outcomes of pancreatic neuroendocrine neoplasms: the Massachusetts General Hospital experience from 1977 to 2005

Parsia A Vagefi, Oswaldo Razo, Vikram Deshpande, Deborah J McGrath, Gregory Y Lauwers, Sarah P Thayer, Andrew L Warshaw, Carlos Fernández-Del Castillo, Parsia A Vagefi, Oswaldo Razo, Vikram Deshpande, Deborah J McGrath, Gregory Y Lauwers, Sarah P Thayer, Andrew L Warshaw, Carlos Fernández-Del Castillo

Abstract

Objective: To assess changing patterns in the detection and outcomes of pancreatic neuroendocrine neoplasms (PNENs).

Design: Retrospective review from May 21, 1977, through September 16, 2005.

Setting: Massachusetts General Hospital, a tertiary care center.

Patients: We evaluated 168 patients (51% male; mean age, 56 years) who underwent surgery for histologically confirmed PNENs.

Main outcome measures: Surgical outcomes, survival, and changes in presentation of PNENs in 2 time groups: 1977-1999 (77 patients) and 2000-2005 (91 patients).

Results: Ninety-eight patients (58.3%) had nonfunctioning PNENs, 86 of which were incidental. Insulinomas were the most common type of functional neoplasm (33.3%), followed by gastrinomas and glucagonomas; 12 patients (7.1%) had multiple endocrine neoplasia type 1. Of the neoplasms, 107 (63.7%) were located in the pancreatic body or tail. A pancreaticoduodenectomy was performed in 37 patients (22.0%), distal pancreatectomy was done in 88 (52.4%), and the rest had either middle segment pancreatectomy or enucleation. There were no operative deaths. We classified 76.8% of neoplasms as benign; of those classified as malignant, 25.6% had liver metastases. Of the patients, 10.1% received adjuvant therapy. Complete follow up was available in 90.5% of patients (mean, 63.3 months). Five- and 10-year actuarial survival rates were 77% and 62%, respectively. Incidentally discovered nonfunctioning neoplasms were significantly more frequent in the last 5 years (60.4% vs 40.3%; P = .007), with a trend toward smaller neoplasms (mean, 4.2 cm vs 5.6 cm; P = .19) and lesser likelihood of malignancy (21.8% vs 40.0%; P = .08).

Conclusions: We report a large single-center experience with PNENs. Increasing numbers of PNENs are being resected, largely owing to the incidental detection of nonfunctioning neoplasms. This may lead to the treatment of smaller and less malignant neoplasms.

Figures

Figure 1
Figure 1
Resection of pancreatic neuroendocrine neoplasms by year for the period from 1977 to 2005 at Massachusetts General Hospital. Nonfunctional and functional neoplasms are indicated separately per year.
Figure 2
Figure 2
Classification of 168 resected pancreatic neuroendocrine neoplasms. Of the nonfunctional neoplasms, 87.8% were discovered incidentally. ACTH indicates adrenocorticotropic hormone; VIP, vasoactive intestinal polypeptide.
Figure 3
Figure 3
Location of 168 pancreatic neuroendocrine neoplasms.
Figure 4
Figure 4
Long-term follow-up of 168 patients who underwent pancreatic neuroendocrine neoplasm (PNEN) resection.
Figure 5
Figure 5
Survival rates for the entire study cohort of 168 patients with pancreatic neuroendocrine neoplasms.
Figure 6
Figure 6
Comparison of survival rates among patients with pancreatic neuroendocrine neoplasms for benign and malignant neoplasms (A) as well as functional and nonfunctional neoplasms (B).

References

    1. Jensen RT. Pancreatic neuroendocrine neoplasms: overview of recent advances and diagnosis. J Gastrointest Surg. 2006;10:324–326.
    1. Phan GQ, Yeo CJ, Hruban RH, Lillemoe KD, Pitt HA, Cameron JL. Surgical experience with pancreatic and peripancreatic neuroendocrine neoplasms: review of 125 patients. J Gastrointest Surg. 1998;2:472–482.
    1. Mansour JC, Chen H. Pancreatic endocrine neoplasms. J Surg Res. 2004;120:139–161.
    1. Cleary SP, Gryfe R, Guindi M, et al. Prognostic factors in resected pancreatic adenocarcinoma: analysis of actual 5-year survivors. J Am Coll Surg. 2004;198:722–731.
    1. Alexander RA, Jensen RT. Pancreatic endocrine neoplasms. In: DeVita VT, Hell-man S, Rosenberg SA, editors. Cancer Principles and Practice of Oncology. Philadelphia: Lippincott Williams & Wilkins; 2001. pp. 1788–1813.
    1. Balcom JH, Rattner DW, Warshaw AL, et al. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001;136:391–398.
    1. Wilder RM, Allan FN, Power MH, Robertson HE. Carcinoma of the islets of the pancreas: hyperinsulinism and hypoglycemia. JAMA. 1927;89:348–355.
    1. van Heerden JA, Churchward MM. Dr Dickinson Ober Wheelock-a case of sporadic insulinoma or multiple endocrine neoplasia type 1? Mayo Clin Proc. 1999;74:735–738.
    1. Howland ZG, Campbell WR, Maltby EJ, et al. Dysinsulinism, convulsions, and coma due to islet cell neoplasm of the pancreas, with operation and cure. JAMA. 1929;93:674–679.
    1. Snow ND, Liddle RA. Neuroendocrine neoplasms. In: Rustigi AK, editor. Gastrointestinal Cancers: Biology, Diagnosis and Therapy. Philadelphia, Pa: Lippincott-Raven; 1995. p. 585.
    1. Broder LE, Carter SK. Pancreatic islet cell carcinoma, I: clinical features of 52 patients. Ann Intern Med. 1973;79:101–107.
    1. Kent RB, III, van Heerden JA, Weiland LH. Nonfunctioning islet cell neoplasms. Ann Surg. 1981;193:185–190.
    1. Kazartjian KK, Reber HA, Hines OJ. Resection of pancreatic neuroendocrine tumors: results of 70 cases. Arch Surg. 2006;141:765–769.
    1. Fitzgerald TL, Smith AJ, Ryan M, et al. Surgical treatment of incidentally identified pancreatic masses. Can J Surg. 2003;46:413–418.
    1. Fernandez-del Castillo C, Targarona J, Thayer SP, Rattner DW, Brugge WR, Warshaw AL. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg. 2003;138:427–434.
    1. Gullo L, Migliori M, Falconi M, et al. Nonfunctioning pancreatic endocrine neoplasms: a multicenter clinical study. Am J Gastroenterol. 2003;98:2435–2439.
    1. Weber HC, Venzon DJ, Lin JT, et al. Determinants of metastatic rate and survival in patients with Zollinger-Ellison syndrome: a prospective long-term study. Gastroenterology. 1995;108:1637–1649.
    1. Solorzano CC, Lee JE, Pisters PW, et al. Nonfunctioning islet cell carcinoma of the pancreas: survival results in a contemporary series of 163 patients. Surgery. 2001;130:1078–1085.
    1. Rubbia-Brandt L, Terris B, Giostra E, Dousset B, Morel P, Pepper MS. Lymphatic vessel density and vascular endothelial growth factor-C expression correlate with malignant behavior in human pancreatic endocrine neoplasms. Clin Cancer Res. 2004;10:6919–6928.
    1. Deshpande V, Fernandez-del Castillo C, Muzikansky A, et al. Cytokeratin 19 is a powerful predictor of survival in pancreatic endocrine neoplasms. Am J Surg Pathol. 2004;28:1145–1153.
    1. Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228:429–438.
    1. van Heek NT, Kuhlmann KF, Scholten RJ, et al. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg. 2005;242:781–788.
    1. Warshaw AL, Rattner DW, Fernandez-del Castillo C, Z'graggen K. Middle segment pancreatectomy: a novel technique for conserving pancreatic tissue. Arch Surg. 1998;133:327–331.
    1. Mabrut JY, Fernandez-Cruz L, Azagra JS, et al. Laparoscopic pancreatic resection: results of a multicenter European study of 127 patients. Surgery. 2005;137:597–605.
    1. Singh N, Lo CY, Chan WF. Laparoscopic enucleation of a nonfunctioning neuroendocrine neoplasm at the head of the pancreas. JSLS. 2006;10:259–262.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться