Francesca Lugli

Ki-67 grading of nonfunctioning pancreatic neuroendocrine tumors on histologic samples obtained by EUS-guided fine-needle tissue acquisition: a prospective study

BACKGROUND Preoperative determination of Ki-67 expression, an important prognostic factor for grading nonfunctioning pancreatic endocrine tumors (NF-PETs), remains an important clinical challenge. OBJECTIVE To prospectively evaluate the feasibility, yield, and clinical impact of EUS-guided fine-needle tissue acquisition (EUS-FNTA) with a large-gauge needle to obtain tissue samples for histologic diagnosis and Ki-67 analysis in patients with suspected NF-PETs. DESIGN Prospective cohort study. SETTING Tertiary-care academic medical center. PATIENTS Consecutive patients with a single pancreatic lesion suspicious for NF-PET on imaging. INTERVENTION EUS-FNTA with a 19-gauge needle. MAIN OUTCOME MEASUREMENTS Feasibility and yield of EUS-FNTA for diagnosis and Ki-67 expression determination. RESULTS Thirty patients (mean [± SD] age 55.7 ± 14.9 years), with a mean (± SD) lesion size of 16.9 ± 6.1 mm were enrolled. EUS-FNTA was successfully performed without complications in all patients, with a mean (± SD) of 2.7 ± 0.5 passes per patient. Adequate samples for histologic examination were obtained in 28 of the 30 patients (93.3%). Ki-67 determination could be performed in 26 of these 28 patients (92.9%, 86.6% overall), 12 of whom underwent surgical resection. Preoperative and postoperative Ki-67 proliferation indexes were concordant in 10 patients (83.3%), whereas 2 patients were upstaged from G1 to G2 or downstaged from G2 to G1, respectively. LIMITATIONS Single center study with a single operator. CONCLUSION In patients with suspected nonfunctioning low-grade to intermediate-grade pancreatic neuroendocrine tumors (p-NETs), retrieval of tissue specimens with EUS-FNTA by using a 19-gauge needle is safe, feasible, and highly accurate for both diagnosis and Ki-67 determination. A Ki-67 proliferative index acquired through this technique might be of great help for further therapeutic decisions.

Factors predicting pasireotide responsiveness in somatotroph pituitary adenomas resistant to first generation somatostatin analogues: an immunohistochemical study

AIM To gather data regarding factors predicting responsiveness to pasireotide in acromegaly. PATIENTS AND METHODS SSTR2a, SSTR3, SSTR5, AIP, Ki-67 and the adenoma subtype were evaluated in somatotroph adenomas from 39 patients treated post-operatively with somatostatin analogues (SSAs). A standardized SSTR scoring system was applied (scores 0-3). All patients received first-generation SSAs, and 11 resistant patients were subsequently treated with pasireotide LAR. RESULTS None of the patients with negative or cytoplasmic-only SSTR2a expression (scores 0-1) were responsive to first-generation SSAs, as opposed to 20% (score 2) and 50% of patients with a score of 3 (P=0.04). None of the patients with an SSTR5 score of 0-1 were responsive to pasireotide, as opposed to 5/7 cases with a score of 2 or 3 (P=0.02). SSTR3 expression did not influence first-generation SSAs or pasireotide responsiveness. Tumours with low AIP were resistant to first-generation SSAs (100 vs 60%; P=0.02), while they had similar responsiveness to pasireotide compared to tumours with conserved AIP expression (50 vs 40%; P=0.74). Tumours with low AIP displayed reduced SSTR2 (SSTR2a scores 0-1 44.4 vs 6.7%; P=0.006) while no difference was seen in SSTR5 (SSTR5 scores 0-1 33.3 vs 23.3%; P=0.55). Sparsely granulated adenomas responded better to pasireotide compared to densely granulated ones (80 vs 16.7%; P=0.04). CONCLUSION The expression of SSTR5 might predict responsiveness to pasireotide in acromegaly. AIP deficient and sparsely granulated adenomas may benefit from pasireotide treatment. These results need to be confirmed in larger series of pasireotide-treated patients.

The treatment of neuroendocrine tumors with long-acting somatostatin analogs: A single center experience with lanreotide autogel

The aim of this retrospective study was to evaluate the efficacy, safety, and tolerability of lanreotide autogel given to metastatic well-differentiated (WD) neuroendocrine tumors (NET) patients observed in our Institute between 2005 and 2008. Patients with metastatic NET referred to our tertiary referral center were given lanreotide autogel 120 mg/month by deep sc injection for a period of at least 24 months. The efficacy was evaluated by the relief of disease symptoms, behavior of tumor markers and response rate in terms of time to tumor progression. Safety and tolerability were evaluated by assessing the onset of adverse events and treatment feasibility. Twenty-three patients (13 males), median age 62 yr (range 32–87) were considered for the study. All patients were affected by WD metastatic NET and had tumor progression in the last 6 months before the enrolment in the study. Median duration of response was 28 months (range 6–50 months). Fourteen patients (60.9%) showed flushing and diarrhea which improved by 85.7% and 55.6%, respectively, bronchoconstrinction and abdominal pain also ameliorated. A complete, partial or no-changed response in the tumor markers behavior was observed, respectively, in 42.9%, 22.9%, and 17.1% of cases. According to RECIST (Response Evaluation Criteria In Solid Tumors) criteria (version 1.1), there were 2 partial regression (8.7%) and 15 stable disease (65.3%); 6 patients (26.0%) progressed. No patient complained from any severe adverse reaction. The results of our study suggest that lanreotide autogel is effective in the symptoms, biochemical markers, and tumor progression control of WD metastatic NET and confirm that the treatment is well tolerated.

Ectopic posterior pituitary causing hyperprolactinemia

Hyperprolactinemia may recognize different causes. Many physiological conditions (pregnancy, breast-feeding, stress, exercise, sleep) can cause hyperprolactinemia as medications that interfere with the hypothalamic-pituitary dopaminergic pathways (e.g., antipsychotics or prokinetics). A number of pathological conditions (e.g., hypothyroidism or renal failure) can also raise prolactin levels. Increased autonomous prolactin secretion occurs from lactotroph adenomas, which account for *40 % of all pituitary tumors. Because prolactin secretion is tonically inhibited by hypothalamic dopamine, disruption or compression of the pituitary stalk by a pituitary tumor, or other parasellar mass will lead to hyperprolactinemia [1–3]. Monomeric prolactin is the most common and biologically active form of circulating prolactin in healthy individuals and most patients with true hyperprolactinemia, but forms with higher molecular mass are also present, such as big prolactin and big–big prolactin or macroprolactin. Molecular aggregates as macroprolactin are regarded to have low biologic activity, so that macroprolactinemia should be suspected when typical symptoms of hyperprolactinemia are absent. We report the case of a 43-year-old woman with history of oligomenorrhea and mild hyperprolactinemia since her puberty. In 2000, a pituitary MRI showed a 3 mm T1hyperintense lesion adherent to the pituitary stalk. PRL was raised at 48 ng/ml (n.v. 5–25). Treatment with cabergoline was started (0.5 mg weekly) with normalization of prolactin levels and oligomenorrhea resolution. Periodic MRI evaluations documented the stability of the lesion. In February 2011, cabergoline was discontinued on the advice of another endocrinologist. In February 2012, she came to our attention due to relapse of her symptoms. Blood tests, performed in our lab, showed hyperprolactinemia (56.3 ng/ml, n.v. 3.5–26.5) in the absence of biochemical and clinical signs of anterior hypopituitarism. A new MRI documented a normal anterior pituitary gland with normal enhancement and confirmed the presence of a 3-mm nodular lesion hyperintense in T1 and hypointense in T2 localized at the medium portion of the pituitary stalk (Fig. 1a, b), compatible with ectopic posterior pituitary (EPP). The hypothesis of an ectopic pituitary adenoma was ruled out because of the absence of the typical radiological findings of microadenomas and considering the stability of the lesion during a 12-yearfollow-up despite the previous medical treatment. EPP was considered as the origin of hyperprolactinemia as other causes were excluded, including the presence of macroprolactin and hypothyroidism. Treatment with cabergoline was reintroduced with regularization of menses. EPP is a rare morphological alteration of the hypothalamic-pituitary region that can be associated with isolated growth hormone deficiency or combined pituitary hormone deficiency. EPP may be associated with an abnormal pituitary stalk and a small anterior pituitary gland and is seen in septo-optic dysplasia [4]. Some mutations in genes (e.g., HESX1, LHX4, SOX3) involved in the development of the pituitary region have been described [5]. We can suppose that, in our case, hyperprolactinemia was due to the presence of EPP adherent to the pituitary stalk, probably because of alterations in the dopaminergic action. D. Iacovazzo (&) F. Lugli A. Giampietro Division of Endocrinology, Catholic University, Policlinico ‘‘A. Gemelli’’, Largo A. Gemelli, 8, 00168 Rome, Italy e-mail: donatoiacovazzo@gmail.com

Systemic mastocytosis mimicking carcinoid syndrome

We report the case of a 70-year-old woman who came to our attention in January 2013 complaining of recurrent episodes of severe flushing, diarrhea, dyspnea, and hypotension, that had started in 2011 and were considerably worsening over time, and were partially responsive to steroid and antihistamine drugs. In 2012, suspecting carcinoid syndrome, the patient underwent dosing of chromogranin A (56 ng/ml, n.v.\90), urinary 5-HIAA (6 mg/24 h, n.v. 2–6), and urinary serotonin ? 5-OH tryptophan, which came mildly elevated (11 mg/24 h, n.v. 0–5). A CT scan did not show any liver lesions or other malignancies, and an Octreoscan scintigraphy was negative as well. Nonetheless, the patient was put on octreotide LAR treatment and, in the following weeks, she presented a slight symptomatic improvement. In January 2013, however, the frequency of these crises increased, and the patient was hospitalized at our Institution. Considering the recurring crises and suspecting carcinoid syndrome, short-acting octreotide treatment was started with some improvement. Chromogranin A came normal (33.5 ng/ml, n.v. 19.4–98.1) and urinary 5-HIAA was mildly elevated (19.2 mg/24 h, n.v. 1–10). A new CT scan did not show focal lesions, and a Ga-DOTANOC PET-CT did not reveal any pathologic hyperuptake of the tracer. Suspecting systemic mastocytosis, we measured serum tryptase, a serine proteinase contained in mast cells: the levels were markedly elevated (200 mcg/l, n.v. \9.4). Her blood count was unremarkable, and no skin involvement was seen. Bone marrow biopsy was done, and it confirmed the diagnosis of systemic mastocytosis (Fig. 1). Moreover, the KIT D816V mutation was revealed in the bone marrow aspirate. Somatostatin analogue treatment was withdrawn and treatment with dasatinib, a second generation tyrosine kinase inhibitor, was started at the dosage of 100 mg/day. After more than 12 months of treatment, the patient is doing well, without any crises relapse. According to the WHO 2008 classification, major criterion for the diagnosis of systemic mastocytosis is the presence of multifocal dense mast cell (MC) infiltrates in the bone marrow or in another extracutaneous organ; minor criteria are (1) [25 % spindle-shaped cells in MC-infiltrates or [25 % of all MC being atypical MC in bone marrow smears, (2) expression of CD2 and/or CD25 in bone marrow MC, (3) serum tryptase level[20 ng/ml, and (4) KIT point mutation at codon 816 (mostly D816V) in bone marrow or in another extracutaneous organ. The diagnosis can be established if at least 1 major and 1 minor or 3 minor criteria are fulfilled. Indeed our patient presented 1 major and 2 minor criteria for the diagnosis of systemic mastocytosis. We report a case of systemic mastocytosis mimicking carcinoid syndrome. The clinical and biochemical features of these conditions can be highly overlapping [1] and D. Iacovazzo (&) F. Lugli S. Piacentini A. Bianchi L. De Marinis Endocrinology, Catholic University, Policlinico ‘‘A. Gemelli’’, Largo A. Gemelli, 8, 00168 Rome, Italy e-mail: donatoiacovazzo@gmail.com