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Yu T, Hou S, He H, Li Y, Zhang L, Tian J, Hou S. Combined endoscopic drainage for afferent loop obstruction and bilioenteric anastomosis stricture in a patient after pancreatoduodenectomy. Endoscopy 2024; 56:E701-E702. [PMID: 39111762 PMCID: PMC11305892 DOI: 10.1055/a-2346-4685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Affiliation(s)
- Tingting Yu
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Suning Hou
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongfei He
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yaoting Li
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lichao Zhang
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jiao Tian
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Senlin Hou
- Biliopancreatic Endoscopic Surgery Department, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Takeshita K, Hijioka S, Nagashio Y, Maruki Y, Ohba A, Kawasaki Y, Takasaki T, Yagi S, Agarie D, Hara H, Hagiwara Y, Yamashige D, Okamoto K, Fukuda S, Kuwada M, Chatto M, Kondo S, Morizane C, Ueno H, Saito Y, Okusaka T. Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction. Endosc Int Open 2024; 12:E875-E886. [PMID: 38989254 PMCID: PMC11236478 DOI: 10.1055/a-2333-7898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/12/2024] [Indexed: 07/12/2024] Open
Abstract
Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy with bridging between the left and right bile ducts is an alternative to endoscopic transpapillary drainage for malignant hilar biliary obstruction. We aimed to analyze the long-term stent patency of endoscopic ultrasound-guided hepaticogastrostomy with bridging. Patients and methods Patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with bridging between April 2018 and July 2023 were retrospectively analyzed. We retrospectively compared the stent patency of these patients with that of the individuals who underwent endoscopic transpapillary drainage-multi-stenting using unmatched (entire) and propensity score-matched cohorts. Results Endoscopic ultrasound-guided hepaticogastrostomy with bridging had a technical success rate of 90% (18/20). Adverse events were minimal. The number of clinical success cases was 17 and 82 for endoscopic ultrasound-guided hepaticogastrostomy with bridging using metallic stent and endoscopic transpapillary drainage-multi-stenting, respectively. The recurrent biliary obstruction rate was 17.6% and 58.5% for endoscopic ultrasound-guided hepaticogastrostomy with bridging and endoscopic transpapillary drainage-multi-stenting, respectively; the median time to recurrent biliary obstruction (days) was significantly longer for endoscopic ultrasound-guided hepaticogastrostomy with bridging in the entire (not reached vs. 104, P =0.03) and propensity score-matched (183 vs. 79, P =0.05) cohorts. The non-recurrent biliary obstruction rate for endoscopic ultrasound-guided hepaticogastrostomy with bridging was 91.6% at 3 and 6 months and 57% at 12 months. Multivariate analyses revealed that endoscopic ultrasound-guided hepaticogastrostomy with bridging contributed to a lower recurrent biliary obstruction incidence (hazard ratio, 0.31, P =0.05) without significant difference. Conclusions Stent patency was significantly better for endoscopic ultrasound-guided hepaticogastrostomy with bridging. However, future prospective studies are needed.
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Affiliation(s)
- Kotaro Takeshita
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshikuni Nagashio
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Akihiro Ohba
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuki Kawasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tetsuro Takasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shin Yagi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Daiki Agarie
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hidenobu Hara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuya Hagiwara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Daiki Yamashige
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kohei Okamoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Soma Fukuda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Masaru Kuwada
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Mark Chatto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hideki Ueno
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
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Ye JY, Fang P, Peng ZP, Huang XT, Xie JZ, Yin XY. A radiomics-based interpretable model to predict the pathological grade of pancreatic neuroendocrine tumors. Eur Radiol 2024; 34:1994-2005. [PMID: 37658884 PMCID: PMC10873440 DOI: 10.1007/s00330-023-10186-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/22/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVES To develop a computed tomography (CT) radiomics-based interpretable machine learning (ML) model to predict the pathological grade of pancreatic neuroendocrine tumors (pNETs) in a non-invasive manner. METHODS Patients with pNETs who underwent contrast-enhanced abdominal CT between 2010 and 2022 were included in this retrospective study. Radiomics features were extracted, and five radiomics-based ML models, namely logistic regression (LR), random forest (RF), support vector machine (SVM), XGBoost, and GaussianNB, were developed. The performance of these models was evaluated using a time-independent testing set, and metrics such as sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve (AUC) were calculated. The accuracy of the radiomics model was compared to that of needle biopsy. The Shapley Additive Explanation (SHAP) tool and the correlation between radiomics and biological features were employed to explore the interpretability of the model. RESULTS A total of 122 patients (mean age: 50 ± 14 years; 53 male) were included in the training set, whereas 100 patients (mean age: 48 ± 13 years; 50 male) were included in the testing set. The AUCs for LR, SVM, RF, XGBoost, and GaussianNB were 0.758, 0.742, 0.779, 0.744, and 0.745, respectively, with corresponding accuracies of 73.0%, 70.0%, 77.0%, 71.9%, and 72.9%. The SHAP tool identified two features of the venous phase as the most significant, which showed significant differences among the Ki-67 index or mitotic count subgroups (p < 0.001). CONCLUSIONS An interpretable radiomics-based RF model can effectively differentiate between G1 and G2/3 of pNETs, demonstrating favorable interpretability. CLINICAL RELEVANCE STATEMENT The radiomics-based interpretable model developed in this study has significant clinical relevance as it offers a non-invasive method for assessing the pathological grade of pancreatic neuroendocrine tumors and holds promise as an important complementary tool to traditional tissue biopsy. KEY POINTS • A radiomics-based interpretable model was developed to predict the pathological grade of pNETs and compared with preoperative needle biopsy in terms of accuracy. • The model, based on CT radiomics, demonstrated favorable interpretability. • The radiomics model holds potential as a valuable complementary technique to preoperative needle biopsy; however, it should not be considered a replacement for biopsy.
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Affiliation(s)
- Jing-Yuan Ye
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Peng Fang
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zhen-Peng Peng
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, Guangdong, People's Republic of China
| | - Xi-Tai Huang
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jin-Zhao Xie
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xiao-Yu Yin
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Er Road, Guangzhou, 510080, Guangdong, People's Republic of China.
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Bourdeleau P, Couvelard A, Ronot M, Lebtahi R, Hentic O, Ruszniewski P, Cros J, de Mestier L. Spatial and temporal heterogeneity of digestive neuroendocrine neoplasms. Ther Adv Med Oncol 2023; 15:17588359231179310. [PMID: 37323185 PMCID: PMC10262621 DOI: 10.1177/17588359231179310] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) are initially monoclonal neoplasms that progressively become polyclonal, with very different genotypic and phenotypic characteristics leading to biological differences, including the Ki-67 proliferation index, morphology, or sensitivity to treatments. Whereas inter-patient heterogeneity has been well described, intra-tumor heterogeneity has been little studied. However, NENs present a high degree of heterogeneity, both spatially within the same location or between different lesions, and through time. This can be explained by the emergence of tumor subclones with different behaviors. These subpopulations can be distinguished by the Ki-67 index, but also by the expression of hormonal markers or by differences in the intensity of uptake on metabolic imaging, such as 68Ga-somatostatin receptor and Fluorine-18 fluorodeoxyglucose positron emission tomography. As these features are directly related to prognosis, it seems mandatory to move toward a standardized, improved selection of the tumor areas to be studied to be as predictive as possible. The temporal evolution of NENs frequently leads to changes in tumor grade over time, with impact on prognosis and therapeutic decision-making. However, there is no recommendation regarding systematic biopsy of NEN recurrence or progression, and which lesion to sample. This review aims to summarize the current state of knowledge, the main hypotheses, and the main implications regarding intra-tumor spatial and temporal heterogeneity in digestive NENs.
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Affiliation(s)
- Pauline Bourdeleau
- Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP.Nord), Université Paris-Cité, Clichy, France
| | - Anne Couvelard
- Department of Pathology, Beaujon/Bichat Hospitals (APHP.Nord), Université Paris-Cité, Clichy/Paris, France
- Centre de Recherche sur l’Inflammation, INSERM UMR1149, FHU MOSAIC, Paris, France
| | - Maxime Ronot
- Department of Radiology, Beaujon Hospital (APHP.Nord), Université Paris-Cité, Clichy, France, and Centre de Recherche sur l’Inflammation, INSERM UMR1149, FHU MOSAIC, Paris, France
| | - Rachida Lebtahi
- Department of Nuclear Medicine, Beaujon Hospital (APHP.Nord), Université Paris-Cité, Clichy, France Centre de Recherche sur l’Inflammation, INSERM UMR1149, FHU MOSAIC, Paris, France
| | - Olivia Hentic
- Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP.Nord), Université Paris-Cité, Clichy, France
| | - Philippe Ruszniewski
- Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP.Nord), Université Paris-Cité, Clichy, France
- Centre de Recherche sur l’Inflammation, INSERM UMR1149, FHU MOSAIC, Paris, France
| | - Jérôme Cros
- Department of Pathology, Beaujon/Bichat Hospitals (APHP.Nord), Université Paris-Cité, Clichy/Paris, France
- Centre de Recherche sur l’Inflammation, INSERM UMR1149, FHU MOSAIC, Paris, France
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Comparison between three types of needles for endoscopic ultrasound-guided tissue acquisition of pancreatic solid masses: a multicenter observational study. Sci Rep 2023; 13:3677. [PMID: 36871105 PMCID: PMC9985625 DOI: 10.1038/s41598-023-30920-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
It is debatable which needle has clear superiority of diagnostic performance in endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of solid pancreatic masses. This study aimed to compare the performance of three needles and determine the variables that affect diagnostic accuracy. From March 2014 to May 2020, 746 patients with solid pancreatic masses who underwent EUS-FNB using three types of needles (Franseen needle, Menghini-tip needle, and Reverse-bevel needle) were retrospectively reviewed. Multivariate analysis using a logistic regression model was used to identify factors related to diagnostic accuracy. There were significant differences between the groups regarding the procurement rate of the histologic and optimal quality cores (Franseen vs. Menghini-tip vs. Reverse-bevel: 98.0% [192/196] vs. 85.8% [97/113] vs. 91.9% [331/360], P < 0.001 and 95.4% [187/196] vs. 65.5% [74/113] vs. 88.3% [318/360], P < 0.001, respectively). The sensitivity and accuracy using histologic samples were 95.03% and 95.92% for Franseen, 82.67% and 88.50% for Menghini-tip, and 82.61% and 85.56% for Reverse-bevel needles, respectively. In direct comparison between the needles using histologic samples, the Franseen needle showed significantly superior accuracy than the Menghini-tip (P = 0.018) and Reverse-bevel needles (P < 0.001). Multivariate analysis indicated that tumor size ≥ 2 cm (odds ratio [OR] 5.36, 95% confidence interval [CI] 3.40-8.47, P < 0.001) and fanning technique (OR 1.70, 95% CI 1.00-2.86, P = 0.047) were significantly associated with an accurate diagnosis. EUS-FNB using the Franseen needle enables the acquisition of a larger and more adequate histologic core tissue and achieves an accurate histological diagnosis when using the fanning technique.
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Kato H, Matsumoto K, Okada H. Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction. DEN OPEN 2022; 2:e33. [PMID: 35310763 PMCID: PMC8828235 DOI: 10.1002/deo2.33] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent-in-stent (SIS) method and side-by-side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)-guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS-guided hepaticogastrostomy (EUS-HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS-HGS route or EUS-guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6-mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
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Pawa R, Pleasant T, Tom C, Pawa S. Endoscopic ultrasound-guided biliary drainage: Are we there yet? World J Gastrointest Endosc 2021; 13:302-318. [PMID: 34512878 PMCID: PMC8394188 DOI: 10.4253/wjge.v13.i8.302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/14/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.
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Affiliation(s)
- Rishi Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Troy Pleasant
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Chloe Tom
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, United States
| | - Swati Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
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Winkler J, Caillol F, Ratone JP, Bories E, Pesenti C, Giovannini M. Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures. Endosc Ultrasound 2021; 10:51-56. [PMID: 33402550 PMCID: PMC7980690 DOI: 10.4103/eus.eus_68_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and Objectives EUS-guided biliary drainage (EUS-BD) has emerged as a complementary technique for primary drainage or as a rescue technique after failed endoscopic retrograde cholangiography. The objective of this study was to demonstrate the feasibility of EUS-BD for malignant hilar stenosis (MHS), both as an initial and rescue procedure. Patients and Methods This study was a retrospective work based on a prospective registry of patients with malignant drainage stenosis of the hilum. For this analysis, only patients who underwent EUS-BD drainage were included. The drainage procedure could be performed by EUS-BD alone or in combination with another technique, for initial drainage or reintervention. Results Between January 2015 and September 2018, 20 patients were included. The mean patient age was 68 years. Seven patients had primary liver tumors and 13 had obstructions caused by metastasis. Four patients had Type II stenosis, 7 had Type IIIA, 2 had Type IIIb, and 7 had Type IV stenosis. Sixteen patients underwent EUS-guided hepaticogastrostomy (EUS-HGS) for initial drainage and four as reintervention. For initial drainage, 2 patients underwent EUS-HGS alone and 14 underwent EUS-HGS in combination with another technique: 11 combined with endoscopic retrograde cholangiopancreatography (ERCP), 2 with percutaneous transhepatic drainage, and 1 with ERCP and percutaneous transhepatic drainage. The technical success rate for EUS-HGS in the drainage of MHS was 100%, and the clinical success rate was 95%. The mean percentage of liver drained was 84%, with an average 1.7 endoscopic sessions and an average 2.7 protheses. The early complication rate was 35% and the mortality rate was 5%. Five EUS-HGS/ERCP combination drainage procedures were performed in one session and six were performed in two sessions with similar complication rates and percentages of liver segments drained. Conclusion EUS-BD is a feasible and safe technique for initial drainage and for reintervention procedures. The EUS-HGS/ERCP combination seemed to be useful in cases of complex stenosis and could be performed during the same session or in two sessions.
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Affiliation(s)
- Jérôme Winkler
- Department of Endoscopy, Institut Paoli-Calmette, Marseille, France
| | - Fabrice Caillol
- Department of Endoscopy, Institut Paoli-Calmette, Marseille, France
| | | | - Erwan Bories
- Department of Endoscopy, Institut Paoli-Calmette, Marseille, France
| | | | - Marc Giovannini
- Department of Endoscopy, Institut Paoli-Calmette, Marseille, France
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Barenboim A, Lahat G, Nachmany I, Nakache R, Goykhman Y, Geva R, Osher E, Scapa E, Wolf I, Orbach L, Brazowski E, Isakov O, Klausner JM, Lubezky N. Resection Versus Observation of Small Asymptomatic Nonfunctioning Pancreatic Neuroendocrine Tumors. J Gastrointest Surg 2020; 24:1366-1374. [PMID: 31197692 DOI: 10.1007/s11605-019-04285-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Management of asymptomatic, nonfunctioning small pancreatic neuroendocrine tumors (PNETs) is controversial because of their overall good prognosis, and the morbidity and mortality associated with pancreatic surgery. Our aim was to compare the outcomes of resection with expectant management of patients with small asymptomatic PNETs. METHODS Retrospective review of patients with nonfunctioning asymptomatic PNETs < 2 cm that underwent resection or expectant management at the Tel-Aviv Medical Center between 2001 and 2018. RESULTS Forty-four patients with small asymptomatic, biopsy-proven low-grade PNETs with a KI67 proliferative index < 3% were observed for a mean of 52.48 months. Gallium67DOTATOC-PET scan was completed in 32 patients and demonstrated uptake in the pancreatic tumor in 25 (78%). No patient developed systemic metastases. Two patients underwent resection due to tumor growth, and true tumor enlargement was evidenced in final pathology in one of them. Fifty-five patients underwent immediate resection. Significant complications (Clavien-Dindo grade ≥ 3) developed in 10 patients (18%), mostly due to pancreatic leak, and led to one mortality (1.8%). Pathological evaluation revealed lymphovascular invasion in 1 patient, lymph node metastases in none, and a Ki67 index ≥ 3% in 5. No case of tumor recurrence was diagnosed after mean follow-up of 52.8 months. CONCLUSIONS No patients with asymptomatic low-grade small PNETs treated by expectant management were diagnosed with regional or systemic metastases after a 52.8-month follow-up. Local tumor progression rate was 2.1%. Surgery has excellent long-term outcomes, but it harbors significant morbidity and mortality. Observation can be considered for selected patients with asymptomatic, small, low grade PNETs.
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Affiliation(s)
- Alex Barenboim
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Guy Lahat
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ido Nachmany
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Richard Nakache
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Yaakov Goykhman
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ravit Geva
- Institute of Oncology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ester Osher
- Department of Endocrinology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Erez Scapa
- Institute of Gastroenterology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ido Wolf
- Institute of Oncology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Lior Orbach
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Eli Brazowski
- Institute of Pathology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ofer Isakov
- Department of Internal Medicine "T", Tel-Aviv Medical Center, (affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.), Tel Aviv, Israel
| | - Joseph M Klausner
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Nir Lubezky
- Unit of Liver Surgery Department of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel.
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Kurita Y, Hara K, Kuwahara T, Mizuno N, Okuno N, Haba S, Okuno M, Natsume S, Senda Y, Kubota K, Nakajima A, Niwa Y, Shimizu Y. Comparison of prognosis between observation and surgical resection groups with small sporadic non-functional pancreatic neuroendocrine neoplasms without distant metastasis. J Gastroenterol 2020; 55:543-552. [PMID: 31858231 DOI: 10.1007/s00535-019-01655-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/30/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of small (≤ 2 cm), sporadic localized non-functional pancreatic neuroendocrine neoplasms (PNENs) is often controversial. This study aimed to investigate the clinical outcomes with observation and surgical resection in small PNENs. METHODS Seventy-five patients with small localized sporadic non-functional PNENs ≤ 2 cm, who underwent observation or surgical resection, were retrospectively reviewed. Changes in tumor size during follow-up in the observation group were also investigated. RESULTS The median age of the cohort was 61 (range 35-81) years. The tumor grades were G1, G2, and unknown, in 61 (81.3%), 8 (10.7%), and 6 (8.0%) patients, respectively. The mean follow-up periods in the observation (n = 23) and surgical resection groups (n = 52) were 52.3 (range 6.8-133.3) months and 73.0 (range 9.1-179.9) months, respectively. The median overall survival was not reached. During follow-up, no patient died of PNENs, two died of other diseases, three had lymph node metastases, and one experienced recurrence after surgical resection. There was no significant difference in overall survival between the observation and surgical resection groups (hazard ratio: 0.031, P = 0.417). The mean change in tumor size in the observation group was + 0.30 mm (range - 1.6 to + 3.0 mm). No deaths, tumor progression, lymph node metastases, distant metastases, or recurrence were noted in patients with PNENs ≤ 1 cm (n = 36). CONCLUSIONS The prognosis of small localized PNENs is good. Observation may be an alternative to surgery in high-risk patients and those with small G1 tumors, particularly those measuring ≤ 1 cm.
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Affiliation(s)
- Yusuke Kurita
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Shin Haba
- Department of Gastroenterology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Masataka Okuno
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Yoshiki Senda
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Kensuke Kubota
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
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11
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Caillol F, Rouy M, Pesenti C, Ratone JP, Giovannini M. Drainage of the right liver using EUS guidance. Endosc Ultrasound 2019; 8:S50-S56. [PMID: 31897380 PMCID: PMC6896427 DOI: 10.4103/eus.eus_52_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Hepaticogastrostomy (HGS) has been reported for the management of palliative malignant hilar stricture and involves draining the left liver as rescue therapy. For the management of this complex stenosis, another new option for draining the right liver under EUS guidance was introduced. Ten publications involving 38 patients have been reported in the literature, in which the following two main techniques have been described: direct puncture of the right liver from the bulbus and the bridge technique allowing the drainage of the right liver across the left liver through HGS. In this review, we describe the techniques used and the potential advantages and complications of these procedures. Although this kind of drainage is demanding and probably limited to specific patients, EUS-biliary drainage of the right liver seems feasible with acceptable complications.
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Affiliation(s)
- Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Mathieu Rouy
- Surgery Unit, Paoli Calmettes Institute, Marseille, France
| | | | | | - Marc Giovannini
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
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12
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Sun H, Zhang S, Liu K, Zhou J, Wang X, Shen T, Wang X. Predictive value of preoperative MRI features for the Ki-67 index in well-differentiated G1/G2 pancreatic neuroendocrine tumors. Acta Radiol 2019; 60:1394-1404. [PMID: 30913907 DOI: 10.1177/0284185119840212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Haitao Sun
- Shanghai Institute of Medical Imaging, Shanghai, PR China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Shilong Zhang
- Institute of Fudan-Minhang Academic Health System, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Kai Liu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Jianjun Zhou
- Shanghai Institute of Medical Imaging, Shanghai, PR China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Xingxing Wang
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Tingting Shen
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Xiaolin Wang
- Shanghai Institute of Medical Imaging, Shanghai, PR China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, PR China
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13
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Takada S, Kato H, Saragai Y, Muro S, Uchida D, Tomoda T, Matsumoto K, Horiguchi S, Tanaka N, Okada H. Contrast-enhanced harmonic endoscopic ultrasound using time-intensity curve analysis predicts pathological grade of pancreatic neuroendocrine neoplasm. J Med Ultrason (2001) 2019; 46:449-458. [PMID: 31377939 DOI: 10.1007/s10396-019-00967-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/15/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Histological grading is important for the treatment algorithm in pancreatic neuroendocrine neoplasms (PNEN). The present study examined the efficacy of contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) and time-intensity curve (TIC) analysis of PNEN diagnosis and grading. METHODS TIC analysis was performed in 30 patients using data obtained from CH-EUS, and a histopathological diagnosis was made via EUS-guided fine-needle aspiration or surgical resection. The TIC parameters were analyzed by dividing them into G1/G2 and G3/NEC groups. Then, patients were classified into non-aggressive and aggressive groups and evaluated. RESULTS Twenty-six patients were classified as G1/G2, and four as G3/NEC. From the TIC analysis, five parameters were obtained (I: echo intensity change, II: time for peak enhancement, III: speed of contrast, IV: decrease rate for enhancement, and V: enhancement ratio for node/pancreatic parenchyma). Three of these parameters (I, IV, and V) showed high diagnostic performance. Using the cutoff value obtained from the receiver-operating characteristic (ROC) analysis, the correct diagnostic rates of parameters I, IV, and V were 96.7%, 100%, and 100%, respectively, between G1/G2 and G3/NEC. A total of 21 patients were classified into the non-aggressive group, and nine into the aggressive group. Using the cutoff value obtained from the ROC analysis, the accurate diagnostic rates of I, IV, and V were 86.7%, 86.7%, and 88.5%, respectively, between the non-aggressive and aggressive groups. CONCLUSION CH-EUS and TIC analysis showed high diagnostic accuracy for grade diagnosis of PNEN. Quantitative perfusion analysis is useful to predict PNEN grade diagnosis preoperatively.
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Affiliation(s)
- Saimon Takada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Yosuke Saragai
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichiro Muro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Uchida
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Noriyuki Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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14
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Caillol F, Bosshardt C, Reimao S, Francioni E, Pesenti C, Bories E, Ratone JP, Giovannini M. Drainage of the right liver under EUS guidance: A bridge technique allowing drainage of the right liver through the left liver into the stomach or jejunum. Endosc Ultrasound 2019; 8:199-203. [PMID: 30880722 PMCID: PMC6590001 DOI: 10.4103/eus.eus_64_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background and Objective: EUS-guided biliary drainage is now comparable to percutaneous drainage. This technique can be used in cases of complex drainage of the hilum, mainly for salvage therapy to drain the left liver. In cases of inaccessible papilla or altered anatomy, EUS-guided biliary drainage for hilar stenosis of the liver could be used as the first approach. However, this technique has limited applicability for the right liver. In this feasibility study, we reported drainage of the right liver using the bridge technique and hepaticogastrostomy. Patients and Methods: This retrospective study was based on a prospective registry from January 2013 to February 2017. Patients with inaccessible papilla due to altered anatomy or duodenal invasion and drainage under EUS guidance and bridge technique without previous biliary drainage were included in the study. The bridge technique was used to place an uncovered biliary stent between the right and left liver. The left liver was drained with a hepaticogastrostomy. Results: Twelve patients were included in the study. Stenosis was Type II for nine, IIIA for two, and Type IV for one patient. Technical and clinical success was 100% and 83%, respectively. Morbidity was 33% (four patients), including three with abdominal pain managed conservatively and one with a percutaneous salvage drainage. Postoperative mortality was 8% (uncontrolled sepsis). The mean survival was 6 months. Chemotherapy could be administered in 70% (seven) patients in cases of clinical success. Conclusion: The bridge technique under EUS guidance could be a first alternative for draining malignant hilar stenosis in cases of the inaccessible papilla.
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Affiliation(s)
- Fabrice Caillol
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Coline Bosshardt
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Sylvia Reimao
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Ellen Francioni
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Christian Pesenti
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Erwan Bories
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Jean Philippe Ratone
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Marc Giovannini
- Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
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15
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Nakai Y, Kogure H, Isayama H, Koike K. Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction. Clin Endosc 2018; 52:220-225. [PMID: 30472818 PMCID: PMC6547346 DOI: 10.5946/ce.2018.094] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/27/2018] [Indexed: 12/11/2022] Open
Abstract
Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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16
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Lee L, Ito T, Jensen RT. Imaging of pancreatic neuroendocrine tumors: recent advances, current status, and controversies. Expert Rev Anticancer Ther 2018; 18:837-860. [PMID: 29973077 PMCID: PMC6283410 DOI: 10.1080/14737140.2018.1496822] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recently, there have been a number of advances in imaging pancreatic neuroendocrine tumors (panNETs), as well as other neuroendocrine tumors (NETs), which have had a profound effect on the management and treatment of these patients, but in some cases are also associated with controversies. Areas covered: These advances are the result of numerous studies attempting to better define the roles of both cross-sectional imaging, endoscopic ultrasound, with or without fine-needle aspiration, and molecular imaging in both sporadic and inherited panNET syndromes; the increased attempt to develop imaging parameters that correlate with tumor classification or have prognostic value; the rapidly increasing use of molecular imaging in these tumors and the attempt to develop imaging parameters that correlate with treatment/outcome results. Each of these areas and the associated controversies are reviewed. Expert commentary: There have been numerous advances in all aspects of the imaging of panNETs, as well as other NETs, in the last few years. The advances are leading to expanded roles of imaging in the management of these patients and the results being seen in panNETs/GI-NETs with these newer techniques are already being used in more common tumors.
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Affiliation(s)
- Lingaku Lee
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
| | - Tetsuhide Ito
- c Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital International University of Health and Welfare 3-6-45 Momochihama , Sawara-Ku, Fukuoka , Japan
| | - Robert T Jensen
- b Digestive Diseases Branch , NIDDK, NIH , Bethesda , MD , USA
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17
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De Robertis R, Maris B, Cardobi N, Tinazzi Martini P, Gobbo S, Capelli P, Ortolani S, Cingarlini S, Paiella S, Landoni L, Butturini G, Regi P, Scarpa A, Tortora G, D'Onofrio M. Can histogram analysis of MR images predict aggressiveness in pancreatic neuroendocrine tumors? Eur Radiol 2018; 28:2582-2591. [PMID: 29352378 DOI: 10.1007/s00330-017-5236-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/28/2017] [Accepted: 12/01/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate MRI derived whole-tumour histogram analysis parameters in predicting pancreatic neuroendocrine neoplasm (panNEN) grade and aggressiveness. METHODS Pre-operative MR of 42 consecutive patients with panNEN >1 cm were retrospectively analysed. T1-/T2-weighted images and ADC maps were analysed. Histogram-derived parameters were compared to histopathological features using the Mann-Whitney U test. Diagnostic accuracy was assessed by ROC-AUC analysis; sensitivity and specificity were assessed for each histogram parameter. RESULTS ADCentropy was significantly higher in G2-3 tumours with ROC-AUC 0.757; sensitivity and specificity were 83.3 % (95 % CI: 61.2-94.5) and 61.1 % (95 % CI: 36.1-81.7). ADCkurtosis was higher in panNENs with vascular involvement, nodal and hepatic metastases (p= .008, .021 and .008; ROC-AUC= 0.820, 0.709 and 0.820); sensitivity and specificity were: 85.7/74.3 % (95 % CI: 42-99.2 /56.4-86.9), 36.8/96.5 % (95 % CI: 17.2-61.4 /76-99.8) and 100/62.8 % (95 % CI: 56.1-100/44.9-78.1). No significant differences between groups were found for other histogram-derived parameters (p >.05). CONCLUSIONS Whole-tumour histogram analysis of ADC maps may be helpful in predicting tumour grade, vascular involvement, nodal and liver metastases in panNENs. ADCentropy and ADCkurtosis are the most accurate parameters for identification of panNENs with malignant behaviour. KEY POINTS • Whole-tumour ADC histogram analysis can predict aggressiveness in pancreatic neuroendocrine neoplasms. • ADC entropy and kurtosis are higher in aggressive tumours. • ADC histogram analysis can quantify tumour diffusion heterogeneity. • Non-invasive quantification of tumour heterogeneity can provide adjunctive information for prognostication.
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Affiliation(s)
- Riccardo De Robertis
- Department of Radiology, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy.
| | - Bogdan Maris
- Department of Computer Science, University of Verona, Strada le Grazie 15, 37134, Verona, Italy
| | - Nicolò Cardobi
- Department of Radiology, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Paolo Tinazzi Martini
- Department of Radiology, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Stefano Gobbo
- Department of Pathology, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Paola Capelli
- Department of Pathology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Silvia Ortolani
- Department of Oncology, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Sara Cingarlini
- Department of Oncology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Department of Pancreatic Surgery, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Luca Landoni
- Department of Pancreatic Surgery, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Giovanni Butturini
- Department of Pancreatic Surgery, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Paolo Regi
- Department of Pancreatic Surgery, P. Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Italy
| | - Aldo Scarpa
- Department of Pathology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Giampaolo Tortora
- Department of Oncology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
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18
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Grillo F, Valle L, Ferone D, Albertelli M, Brisigotti MP, Cittadini G, Vanoli A, Fiocca R, Mastracci L. KI-67 heterogeneity in well differentiated gastro-entero-pancreatic neuroendocrine tumors: when is biopsy reliable for grade assessment? Endocrine 2017; 57:494-502. [PMID: 28726181 DOI: 10.1007/s12020-017-1364-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Ki-67 heterogeneity can impact on gastroenteropancreatic neuroendocrine tumor grade assignment, especially when tissue is scarce. This work is aimed at devising adequacy criteria for grade assessment in biopsy specimens. METHOD To analyze the impact of biopsy size on reliability, 360 virtual biopsies of different thickness and lengths were constructed. Furthermore, to estimate the mean amount of non-neoplastic tissue component present in biopsies, 28 real biopsies were collected, the non-neoplastic components (fibrosis and inflammation) quantified and the effective area of neoplastic tissue calculated for each biopsy. RESULTS Heterogeneity of Ki-67 distribution, G2 tumors and biopsy size all play an important role in reducing the reliability of biopsy samples in Ki-67-based grade assignment. In particular in G2 cases, 59.9% of virtual biopsies downgraded the tumor and the smaller the biopsy, the more frequent downgrading occurs. In real biopsies the presence of non-neoplastic tissue reduced the available total area by a mean of 20%. CONCLUSIONS By coupling the results from these two different approaches we show that both biopsy size and non-neoplastic component must be taken into account for biopsy adequacy. In particular, we can speculate that if the minimum biopsy area, necessary to confidently (80% concordance) grade gastro-entero-pancreatic neuroendocrine tumors on virtual biopsies ranges between 15 and 30 mm2, and if real biopsies are on average composed of only 80% of neoplastic tissue, then biopsies with a surface area not <12 mm2 should be performed; using 18G needles, this corresponds to a minimum total length of 15 mm.
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Affiliation(s)
- Federica Grillo
- Pathology Unit, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy.
- Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy.
| | - Luca Valle
- Pathology Unit, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Diego Ferone
- Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
- Endocrinology, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Manuela Albertelli
- Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
- Endocrinology, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Maria Pia Brisigotti
- Pathology Unit, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Giuseppe Cittadini
- Department of Radiology, Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Alessandro Vanoli
- Unit of Pathology, Department of Molecular Medicine, University of Pavia, Via Forlanini 14, Pavia, 27100, Italy
| | - Roberto Fiocca
- Pathology Unit, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
- Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
| | - Luca Mastracci
- Pathology Unit, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
- Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy
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19
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Minaga K, Takenaka M, Kitano M, Chiba Y, Imai H, Yamao K, Kamata K, Miyata T, Omoto S, Sakurai T, Watanabe T, Nishida N, Kudo M. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017; 31:4764-4772. [PMID: 28424912 DOI: 10.1007/s00464-017-5553-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/28/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of unresectable malignant hilar biliary stricture (UMHBS) is challenging, especially after failure of repeated transpapillary endoscopic stenting. Endoscopic ultrasonography-guided intrahepatic biliary drainage (EUS-IBD) is a recent technique for intrahepatic biliary decompression, but indications for its use for complex hilar strictures have not been well studied. The aim of this study was to assess the feasibility and safety of EUS-IBD for UMHBS after failed transpapillary re-intervention. METHODS Retrospective analysis of all consecutive patients with UMHBS of Bismuth II grade or higher who, between December 2008 and May 2016, underwent EUS-IBD after failed repeated transpapillary interventions. The technical success, clinical success, and complication rates were evaluated. Factors associated with clinical ineffectiveness of EUS-IBD were explored. RESULTS A total of 30 patients (19 women, median age 66 years [range 52-87]) underwent EUS-IBD for UMHBS during the study period. Hilar biliary stricture morphology was classified as Bismuth II, III, or IV in 5, 13, and 12 patients, respectively. The median number of preceding endoscopic interventions was 4 (range 2-14). EUS-IBD was required because the following procedures failed: duodenal scope insertion (n = 4), accessing the papilla after duodenal stent insertion (n = 5), or achieving desired intrahepatic biliary drainage (n = 21). Technical success with EUS-IBD was achieved in 29 of 30 patients (96.7%) and clinical success was attained in 22 of these 29 (75.9%). Mild peritonitis occurred in three of 30 (10%) and was managed conservatively. Stent dysfunction occurred in 23.3% (7/30). There was no procedure-related mortality. On multivariable analysis, Bismuth IV stricture predicted clinical ineffectiveness (odds ratio = 12.7, 95% CI 1.18-135.4, P = 0.035). CONCLUSIONS EUS-IBD may be a feasible and effective rescue alternative with few major complications after failed transpapillary endoscopic re-intervention in patients with UMHBS, particularly for Bismuth II or III strictures.
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Affiliation(s)
- Kosuke Minaga
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan.
| | - Masayuki Kitano
- Second Department of Internal Medicine, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, Osaka-Sayama, Japan
| | - Hajime Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Takeshi Miyata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
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Ito T, Hijioka S, Masui T, Kasajima A, Nakamoto Y, Kobayashi N, Komoto I, Hijioka M, Lee L, Igarashi H, Jensen RT, Imamura M. Advances in the diagnosis and treatment of pancreatic neuroendocrine neoplasms in Japan. J Gastroenterol 2017; 52:9-18. [PMID: 27539256 DOI: 10.1007/s00535-016-1250-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Several new developments have occurred in the field of pancreatic neuroendocrine neoplasm (PNEN) recently in Japan. First, the utility of chromogranin A (CgA), useful for the diagnosis and monitoring of the treatment response of neuroendocrine neoplasm (NEN), has been demonstrated in Japan. For PNEN diagnosis and treatment, grading and correct histological diagnosis according to the WHO 2010 classification is important. Regarding the histological diagnosis, the advent of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has enabled correct pathological diagnosis and suitable treatment for the affected tissue. Furthermore, EUS-FNA has also facilitates the assessment of the presence or absence of gene mutations. In addition, patients who have a well-differentiated neuroendocrine tumor (NET) showing a Ki-67 index of higher than 20 % according to the WHO 2010 classification, have also been identified, and their responses to treatment were found to be different from those of patients with poorly differentiated neuroendocrine carcinoma (NEC). Therefore, the concept of NET G3 was proposed. Additionally, somatostatin receptor type 2 is expressed in several cases of NET, and somatostatin receptor scintigraphy (111In-octreoscan) has also been approved in Japan. This advancement will undoubtedly contribute to the localization diagnosis, the identification of remote metastasis, and assessments of the treatment responses of PNEN. Finally, regarding the treatment strategy for PNEN, the management of liver metastasis is important. The advent of novel molecular-targeted agents has dramatically improved the prognosis of advanced PNEN. Multimodality therapy that accounts for the tumor stage, degree of tumor differentiation, tumor volume, and speed of tumor growth is required.
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Affiliation(s)
- Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Toshihiko Masui
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsuko Kasajima
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Noritoshi Kobayashi
- Department of Oncology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Izumi Komoto
- Department of Surgery, Kansai Electric Power Hospital, Osaka, Japan
| | - Masayuki Hijioka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Lingaku Lee
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hisato Igarashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Robert Thomas Jensen
- Digestive Diseases Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Masayuki Imamura
- Neuroendocrine Tumor Center, Kansai Electric Power Hospital, Osaka, Japan
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21
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Fujimori N, Osoegawa T, Lee L, Tachibana Y, Aso A, Kubo H, Kawabe K, Igarashi H, Nakamura K, Oda Y, Ito T. Efficacy of endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration for the diagnosis and grading of pancreatic neuroendocrine tumors. Scand J Gastroenterol 2016; 51:245-52. [PMID: 26513346 DOI: 10.3109/00365521.2015.1083050] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Pancreatic neuroendocrine tumors (pNETs) are histologically categorized according to the WHO 2010 classification by their mitotic index or Ki-67 index as G1, G2, or G3. The present study examined the efficacy of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis and grading of pNET. METHODS We retrospectively reviewed 61 pNETs in 51 patients who underwent EUS between January 2007 and June 2014. All lesions were pathologically diagnosed by surgical resection or EUS-FNA. We evaluated the detection rates of EUS for pNET and sensitivity of EUS-FNA, and compared the Ki-67 index between EUS-FNA samples and surgical specimens. EUS findings were compared between G1 and G2/G3 tumors. RESULTS EUS showed significantly higher sensitivity (96.7%) for identifying pNET than CT (85.2%), MRI (70.2%), and ultrasonography (75.5%). The sensitivity of EUS-FNA for the diagnosis of pNET was 89.2%. The concordance rate of WHO classification between EUS-FNA and surgical specimens was 69.2% (9/13). The concordance rate was relatively high (87.5%, 5/6) in tumors <20 mm but lower (57.1%; 4/7) in tumors ≥20 mm. Regarding EUS findings, G2/G3 tumors were more likely to be large (>20 mm), heterogeneous, and have main pancreatic duct (MPD) obstruction than G1 tumors. Multivariate analysis showed large diameter and MPD obstruction were significantly associated with G2/G3 tumors. CONCLUSIONS EUS and EUS-FNA are highly sensitive and accurate diagnostic methods for pNET. Characteristic EUS findings such as large tumor size and MPD obstruction are suggestive of G2/G3 tumors and would be helpful for grading pNETs.
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Affiliation(s)
- Nao Fujimori
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan .,b Department of Gastroenterology , Clinical Research Institute, National Hospital Organization Kyushu Medical Center , Fukuoka , Japan , and
| | - Takashi Osoegawa
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Lingaku Lee
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Yuichi Tachibana
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Akira Aso
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Hiroaki Kubo
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Ken Kawabe
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan .,b Department of Gastroenterology , Clinical Research Institute, National Hospital Organization Kyushu Medical Center , Fukuoka , Japan , and
| | - Hisato Igarashi
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Kazuhiko Nakamura
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Yoshinao Oda
- c Department of Anatomic Pathology , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Tetsuhide Ito
- a Department of Medicine and Bioregulatory Science , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
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22
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Prediction of pancreatic neuroendocrine tumour grade with MR imaging features: added value of diffusion-weighted imaging. Eur Radiol 2016; 27:1748-1759. [PMID: 27543074 DOI: 10.1007/s00330-016-4539-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/21/2016] [Accepted: 08/01/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the value of MR imaging including diffusion-weighted imaging (DWI) for the grading of pancreatic neuroendocrine tumours (pNET). MATERIAL AND METHODS Between 2006 and 2014, all resected pNETs with preoperative MR imaging including DWI were included. Tumour grading was based on the 2010 WHO classification. MR imaging features included size, T1-w, and T2-w signal intensity, enhancement pattern, apparent (ADC) and true diffusion (D) coefficients. RESULTS One hundred and eight pNETs (mean 40 ± 33 mm) were evaluated in 94 patients (48 women, 51 %, mean age 52 ± 12). Fifty-five (51 %), 42 (39 %), and 11 (10 %) tumours were given the following grades (G): G1, G2, and G3. Mean ADC and D values were significantly lower as grade increased (ADC: 2.13 ± 0.70, 1.78 ± 0.72, and 0.86 ± 0.22 10-3 mm2/s, and D: 1.92 ± 0.70, 1.75 ± 0.74, and 0.82 ± 0.19 10-3 mm2/s G1, G2, and G3, all p < 0.001). A higher grade was associated with larger sized tumours (p < 0.001). The AUROC of ADC and D to differentiate G3 and G1-2 were 0.96 ± 0.02 and 0.95 ± 0.02. Optimal cut-off values for the identification of G3 were 1.19 10-3 mm2/s for ADC (sensitivity 100 %, specificity 92 %) and 1.04 10-3 mm2/s for D (sensitivity 82 %, specificity 92 %). CONCLUSION Morphological/functional MRI features of pNETS depend on tumour grade. DWI is useful for the identification of high-grade tumours. KEY POINTS • Morphological and functional MRI features of pNETs depend on tumour grade. • Their combination has a high predictive value for grade. • All pNETs should be explored by MR imaging including DWI. • DWI is helpful for identification of high-grade and poorly-differentiated tumours.
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23
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Yang Y, Li L, Qu C, Liang S, Zeng B, Luo Z. Endoscopic ultrasound-guided fine needle core biopsy for the diagnosis of pancreatic malignant lesions: a systematic review and Meta-Analysis. Sci Rep 2016; 6:22978. [PMID: 26960914 PMCID: PMC4785370 DOI: 10.1038/srep22978] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 02/24/2016] [Indexed: 12/14/2022] Open
Abstract
Endoscopic ultrasound-guided fine needle core biopsy (EUS-FNB) has been used as an effective method of diagnosing pancreatic malignant lesions. It has the advantage of providing well preserved tissue for histologic grading and subsequent molecular biological analysis. In order to estimate the diagnostic accuracy of EUS-FNB for pancreatic malignant lesions, studies assessing EUS-FNB to diagnose solid pancreatic masses were selected via Medline. Sixteen articles published between 2005 and 2015, covering 828 patients, met the inclusion criteria. The summary estimates for EUS-FNB differentiating malignant from benign solid pancreatic masses were: sensitivity 0.84 (95% confidence interval (CI), 0.82–0.87); specificity 0.98 (95% CI, 0.93–1.00); positive likelihood ratio 8.0 (95% CI 4.5–14.4); negative likelihood ratio 0.17 (95% CI 0.10–0.26); and DOR 64 (95% CI 30.4–134.8). The area under the sROC curve was 0.96. Subgroup analysis did not identify other factors that could substantially affect the diagnostic accuracy, such as the study design, location of study, number of centers, location of lesion, whether or not a cytopathologist was present, and so on. EUS-FNB is a reliable diagnostic tool for solid pancreatic masses and should be especially considered for pathology where histologic morphology is preferred for diagnosis.
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Affiliation(s)
- Yongtao Yang
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
| | - Lianyong Li
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
| | - Changmin Qu
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
| | - Shuwen Liang
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
| | - Bolun Zeng
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
| | - Zhiwen Luo
- Department of Gastroenterology, The 306th Hospital of PLA, Chaoyang District, Beijing 100101, China
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24
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Hijioka S, Hara K, Mizuno N, Imaoka H, Bhatia V, Mekky MA, Yoshimura K, Yoshida T, Okuno N, Hieda N, Tajika M, Tanaka T, Ishihara M, Yatabe Y, Shimizu Y, Niwa Y, Yamao K. Diagnostic performance and factors influencing the accuracy of EUS-FNA of pancreatic neuroendocrine neoplasms. J Gastroenterol 2016; 51:923-30. [PMID: 26768605 PMCID: PMC4990623 DOI: 10.1007/s00535-016-1164-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/24/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Multiple studies have investigated sampling adequacy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic neuroendocrine neoplasms (pNENs). However, none have described the diagnostic performance of EUS-FNA for pNENs, or the influencing factors. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA, with post-operative pathological diagnosis as the gold standard, and factors predictive of inadequate EUS sampling. METHODS From 1998 to 2014, a total of 698 patients underwent pancreatic resection and 1455 patients underwent EUS-FNA sampling for pancreatic lesions. A total of 410 cases underwent both surgical resection and preceding EUS-FNA. Of these, 60 cases (49 true pNEN, nine non-diagnostic, two misdiagnoses) were included. We studied diagnostic performance of EUS-FNA and factors that were associated with failed diagnosis. RESULTS Of the 60 cases, EUS-FNA yield was 49 true-positive cases, two misdiagnoses, and nine non-diagnostic cases (including six suggestive cases). Sensitivity, specificity, and accuracy were 84.5, 99.4, and 97.3 %, respectively; including the six suggestive cases, diagnostic values were 94.8 % sensitivity (55/58), 99.4 % specificity (350/352), and 98.7 % accuracy (405/410). In multivariate analysis, sampling adequacy rates were significantly lower when lesions were located in the pancreatic head [odds ratio (OR) = 10.0] and in tumor-rich stromal fibrosis (OR = 10.45). Tumor size, needle type, tumor grading, presence of cystic component, and time period were not significant factors. CONCLUSIONS EUS-FNA offers high accuracy for pNEN. However, location of the tumor in the pancreatic head and presence of rich stromal fibrosis negatively impacts sampling adequacy.
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Affiliation(s)
- Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Vikram Bhatia
- Department of Gastroenterology, Fortis Escorts Liver and Digestive Institute, New Delhi, India
| | - Mohamed A Mekky
- Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, Egypt
| | - Kenichi Yoshimura
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Tsukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nobuhiro Hieda
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
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Lee L, Igarashi H, Fujimori N, Hijioka M, Kawabe K, Oda Y, Jensen RT, Ito T. Long-term outcomes and prognostic factors in 78 Japanese patients with advanced pancreatic neuroendocrine neoplasms: a single-center retrospective study. Jpn J Clin Oncol 2015; 45:1131-1138. [PMID: 26378090 PMCID: PMC4668751 DOI: 10.1093/jjco/hyv143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/25/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Despite an increase in the number of Japanese patients with pancreatic neuroendocrine neoplasms, long-term outcomes and prognostic factors, especially for those with advanced disease, remain unclear. METHODS We retrospectively reviewed the medical records of 78 patients with unresectable pancreatic neuroendocrine neoplasms treated at our hospital from January 1987 to March 2015. Survival analyses were performed using Kaplan-Meier methods. Prognostic significance of several clinicopathological factors were analyzed by univariate and multivariate analyses using a Cox regression model. RESULTS Median overall survivals of pancreatic neuroendocrine tumor (n = 64) and pancreatic neuroendocrine carcinoma (n = 14) were 83.7 and 9.1 months, respectively (hazard ratio: 0.02, 95% confidence interval: 0.01-0.08, P < 0.001). Although no significant differences were observed using a Ki-67 cut-off value of 2% (hazard ratio: 0.46, 95% confidence interval: 0.16-1.13, P = 0.0989), a Ki-67 cut-off of 10% was a significant predictor in patients with pancreatic neuroendocrine tumor (hazard ratio: 9.95, 95% confidence interval, 3.01-32.97, P < 0.001). Treatment after the advent of targeted therapy (hazard ratio: 0.07, 95% confidence interval: 0.03-0.19, P < 0.001) and the presence of bone metastases (hazard ratio: 4.38, 95% confidence interval: 1.42-11.29, P = 0.013) were significant prognostic factors in patients with pancreatic neuroendocrine tumor evaluated by univariate analysis. Multivariate analysis also revealed that a Ki-67 index ≥10% (hazard ratio: 38.8, 95% confidence interval: 8.42-226.62, P < 0.001), approval of targeted therapy (hazard ratio: 0.02, 95% confidence interval: 0.00-0.11, P < 0.001) and bone metastases (hazard ratio: 5.56, 95% confidence interval: 1.10-24.00, P = 0.039) were independent prognostic factors. CONCLUSIONS We elucidated the long-term outcomes and prognostic factors in Japanese patients with advanced pancreatic neuroendocrine neoplasms.
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Affiliation(s)
- Lingaku Lee
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Hisato Igarashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Masayuki Hijioka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Ken Kawabe
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
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Srinivasan I, Tang SJ, Vilmann AS, Menachery J, Vilmann P. Hepatic applications of endoscopic ultrasound: Current status and future directions. World J Gastroenterol 2015; 21:12544-12557. [PMID: 26640331 PMCID: PMC4658609 DOI: 10.3748/wjg.v21.i44.12544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/28/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and staging of various gastrointestinal malignancies have been made possible with the use of endoscopic ultrasound, which is a relatively safe procedure. The field of endoscopic ultrasound is fast expanding due to advancements in therapeutic endoscopic ultrasound. Though various studies have established its role in gastrointestinal malignancies and pancreatic conditions, its potential in the field of hepatic lesions still remains vastly untapped. In this paper the authors attempt to review important and landmark trials, case series and case studies involving hepatic applications of endoscopic ultrasound, thus not only providing an overview of utilization of endoscopic ultrasound in various liver conditions but also speculating its future role.
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27
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Tanaka H, Matsusaki S, Baba Y, Isono Y, Kumazawa H, Sase T, Okano H, Saito T, Mukai K, Kaneko H. Neuroendocrine tumor G3: a pancreatic well-differentiated neuroendocrine tumor with a high proliferative rate. Clin J Gastroenterol 2015; 8:414-20. [PMID: 26439620 DOI: 10.1007/s12328-015-0609-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/20/2015] [Indexed: 01/03/2023]
Abstract
A 68-year-old man was referred to our hospital because of left upper quadrant pain. Contrast enhanced computed tomography showed a low density mass with delayed contrast effects as well as para-aortic node swelling with homogenous contrast effects. Histological examination of specimens obtained by endoscopic ultrasound fine needle aspiration revealed a pancreatic neuroendocrine tumor (NET) G2, according to the World Health Organization 2010 classification, and lymph node metastasis. Distal pancreatectomy and lymph node dissection were performed. On histological examination, the tumor showed well-differentiated morphology with an organoid pattern. The Ki67 labeling index was 21.6 %, and the mitotic count was 25/10 high power fields. As mentioned above, we made a final diagnosis of the lesion as "NET G3," because the tumor presented with well-differentiated morphology. Chemotherapy with Everolimus was administered. Liver metastasis occurred 11 months after the first operation, and a partial hepatectomy was performed. Histological findings were similar to those of the first operation. Herein we present a case of pancreatic well-differentiated neuroendocrine tumor with a high proliferative rate referred to as "NET G3," and review the relevant literature.
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Affiliation(s)
- Hiroki Tanaka
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan.
| | | | - Youichirou Baba
- Department of Pathology, Suzuka General Hospital, Mie, Japan
| | - Yoshiaki Isono
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Hiroaki Kumazawa
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Tomohiro Sase
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Hiroshi Okano
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Tomonori Saito
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Katsumi Mukai
- Department of Gastroenterology, Suzuka General Hospital, Mie, Japan
| | - Hiroshi Kaneko
- Department of Surgery, Suzuka General Hospital, 1275-53, Yamanohana, Yasuzuka, Suzuka-shi, Mie, Japan
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Hijioka S, Hosoda W, Mizuno N, Hara K, Imaoka H, Bhatia V, Mekky MA, Tajika M, Tanaka T, Ishihara M, Yogi T, Tsutumi H, Fujiyoshi T, Sato T, Hieda N, Yoshida T, Okuno N, Shimizu Y, Yatabe Y, Niwa Y, Yamao K. Does the WHO 2010 classification of pancreatic neuroendocrine neoplasms accurately characterize pancreatic neuroendocrine carcinomas? J Gastroenterol 2015; 50:564-72. [PMID: 25142799 PMCID: PMC4653242 DOI: 10.1007/s00535-014-0987-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/31/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND The WHO classified pancreatic neuroendocrine neoplasms in 2010 as G1, G2, and neuroendocrine carcinoma (NEC), according to the Ki67 labeling index (LI). However, the clinical behavior of NEC is still not fully studied. We aimed to clarify the clinicopathological and molecular characteristics of NECs. METHODS We retrospectively evaluated the clinicopathological characteristics, KRAS mutation status, treatment response, and the overall survival of eleven pNEC patients diagnosed between 2001 and 2014 according to the WHO 2010. We subclassified WHO-NECs into well-differentiated NEC (WDNEC) and poorly differentiated NEC (PDNEC). The latter was further subdivided into large-cell and small-cell subtypes. RESULTS The median Ki67 LI was 69.1% (range 40-95%). Eleven WHO-NECs were subclassified into 4 WDNECs and 7 PDNECs. The latter was further separated into 3 large-cell and 4 small-cell subtypes. Comparisons of WDNEC vs. PDNEC revealed the following traits: hypervascularity on CT, 50% (2/4) vs. 0% (0/7) (P = 0.109); median Ki67 LI, 46.3% (40-53%) vs. 85% (54-95%) (P = 0.001); Rb immunopositivity, 100% (4/4) vs. 14% (1/7) (P = 0.015); KRAS mutations, 0% (0/4) vs. 86% (6/7) (P = 0.015); response rates to platinum-based chemotherapy, 0% (0/2) vs. 100% (4/4) (P = 0.067), and median survival, 227 vs. 186 days (P = 0.227). CONCLUSIONS The WHO-NEC category may be composed of heterogeneous disease entities, namely WDNEC and PDNEC. These subgroups tended to exhibit differing profiles of Ki67 LI, Rb immunopositivity and KRAS mutation, and distinct response to chemotherapy. Further studies for the reevaluation of the current WHO 2010 classification are warranted.
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Affiliation(s)
- Susumu Hijioka
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Waki Hosoda
- />Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Kazuo Hara
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Hiroshi Imaoka
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Vikram Bhatia
- />Department of Medical Hepatology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Mohamed A. Mekky
- />Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, Egypt
| | - Masahiro Tajika
- />Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- />Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- />Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tatsuji Yogi
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Hideharu Tsutumi
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Toshihisa Fujiyoshi
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Takamitsu Sato
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Nobuhiro Hieda
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Tsukasa Yoshida
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Nozomi Okuno
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
| | - Yasuhiro Shimizu
- />Department of Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasushi Yatabe
- />Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- />Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- />Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681 Japan
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29
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Unno J, Kanno A, Masamune A, Kasajima A, Fujishima F, Ishida K, Hamada S, Kume K, Kikuta K, Hirota M, Motoi F, Unno M, Shimosegawa T. The usefulness of endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic neuroendocrine tumors based on the World Health Organization classification. Scand J Gastroenterol 2014; 49:1367-74. [PMID: 25180490 DOI: 10.3109/00365521.2014.934909] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND We assessed the controversial topic of using 22-gauge needles in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis and evaluation of Ki67 labeling indices (Ki67LI) of pancreatic neuroendocrine tumors (pNET). METHODS Thirty-eight patients with pNET who underwent EUS-FNA between January 1, 2008 and December 31, 2012 were enrolled in this study. When available, the Ki67LI and WHO classifications obtained by EUS-FNA and surgical resection were compared. RESULTS EUS-FNA with a 22-gauge needle acquired sufficient histological sample to correctly diagnose pNET in 35 cases (92.1%). Both EUS-FNA and surgical histological specimens were available for 19 cases, and grading classes of the 2 procedures were consistent in 17 cases (89.5%) according to the WHO classification based on the Ki67LI. Tumor size was associated with a difference in the Ki67LI between the 2 procedures, although the Ki67LI was almost completely consistent for tumors less than 18 mm in size. CONCLUSIONS EUS-FNA with a 22-gauge needle is a safe and highly accurate technique for the diagnosis of pNET. There was a clear correlation between the Ki67LI of histological specimens acquired by EUS-FNA and surgery. EUS-FNA with a 22-gauge needle is useful to predict the WHO classification of pNET.
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Affiliation(s)
- Jun Unno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine , Sendai , Japan
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