Marco Manzoni

Natural history of gastro-entero-pancreatic and thoracic neuroendocrine tumors. Data from a large prospective and retrospective Italian Epidemiological study: THE NET MANAGEMENT STUDY

Background: The few epidemiological data available in literature on neuroendocrine tumors (NET) are mainly based on Registry databases, missing therefore details on their clinical and natural history. Aim: To investigate epidemiology, clinical presentation, and natural history of NET. Design and setting: A large national retrospective survey was conducted in 13 Italian referral centers. Among 1203 NET, 820 originating in the thorax (T-NET), in the gastro-entero-pancreatic tract (GEP-NET) or metastatic NET of unknown primary origin (U-NET) were enrolled in the study. Results: 93% had a sporadic and 7% a multiple endocrine neoplasia type 1 (MEN1)-associated tumor; 63% were GEP-NET, 33% T-NET, 4% U-NET. Pancreas and lung were the commonest primary sites. Poorly differentiated carcinomas were <10%, all sporadic. The incidence of NET had a linear increase from 1990 to 2007 in all the centers. The mean age at diagnosis was 60.0±16.4 yr, significantly anticipated in MEN1 patients (47.7±16.5 yr). Association with cigarette smoking and other non-NET cancer were more prevalent than in the general Italian population. The first symptoms of the disease were related to tumor burden in 46%, endocrine syndrome in 23%, while the diagnosis was fortuity in 29%. Insulin (37%) and serotonin (35%) were the most common hormonal hyper-secretions. An advanced tumor stage was found in 42%, more frequently in the gut and thymus. No differences in the overall survival was observed between T-NET and GEP-NET and between sporadic and MEN1 -associated tumors at 10 yr from diagnosis, while survival probability was dramatically reduced in U-NET. Conclusions: The data obtained from this study furnish relevant information on epidemiology, natural history, and clinico-pathological features of NET, not available from the few published Register studies.

Cytological Ki-67 in pancreatic endocrine tumours: An opportunity for pre-operative grading

The cytological Ki-67 expression measured on cytological samples collected by endoscopic ultrasonography-guided fine needle aspiration cytology (EUS-FNAC) may provide pre-operative indications for pancreatic endocrine tumours (PETs) management. The aim of our study was to assess reliability of Ki-67 expression measured on cytological samples obtained by EUS-FNAC in patients with PETs. Eighteen patients with PETs underwent EUS-FNAC before surgery. Ki-67 expression was measured on FNACs and on histological sections. Using a cut-off of 2%, percent agreement of Ki-67 expression on cytological and histological samples was 89% (k-statistic: 0.78, 95% confidence intervals (95% CI): 0.5, 1.0). Using cut-off values of 2 and 10%, percent agreement was 78% (k-statistic: 0.65, 95% CI: 0.3, 0.9). Ki-67 expression measured on cytological samples obtained by EUS-FNAC before surgery showed good agreement with that measured on histological samples.

Laparoscopic bilateral adrenalectomy for persistent Cushing's disease after transsphenoidal surgery ☆

BACKGROUND We performed bilateral laparoscopic adrenalectomies on four patients (three women and one man) with Cushings disease (pituitary-dependent Cushings syndrome) showing persistent hypercortisolism after transsphenoidal surgery. METHODS The technique for bilateral transperitoneal laparoscopic adrenalectomy was derived from the one previously adopted by our group for unilateral adrenalectomy and previously described. Eight trocars were used, of which two were used for both left and right adrenalectomy. RESULTS Bilateral laparoscopic adrenalectomy was performed in a one-stage procedure in the three women and, because of the abundant abdominal fat of the patient, in a two-stage procedure (after a 1-week interval) in the man. Operating times for the three women were 255 minutes, 230 minutes, and 220 minutes, and for the man 170 minutes for right adrenalectomy and 140 minutes for left adrenalectomy. No surgical or anesthesiologic complications were encountered. All patients were discharged from the hospital within 5 days after operation. At present, after follow-up periods of 23, 8, 6, and 18 months, all patients show remission of Cushings disease and undetectable cortisol levels. CONCLUSIONS Our experience suggests that bilateral laparoscopic adrenalectomy is a safe and effective procedure and a valid therapeutic option in patients with Cushings disease showing persistent hypercortisolism after transsphenoidal surgery. However, the decision to remove both adrenal glands in such patients needs to be weighed against the risk of their having Nelsons syndrome or other long-term complications.

A patient with maternal chromosome 14 UPD presenting with a mild phenotype and MODY

To the Editor: Maternal uniparental disomy for chromosome 14 (upd(14)mat) is associated with a distinct clinical picture, including intrauterine growth retardation (IUGR), motor developmental delay, premature puberty, hypotonia, joint laxity, macrocephaly, short stature, and small hands [for review see (1)]. This phenotype suggests the existence of one or more maternally imprinted genes lying on chromosome 14. More recently, upd(14)mat has been found in patients with neonatal poor sucking, very skilled with jigsaw puzzles, skin picking, and obesity, who disclose a Prader–Willi-like phenotype (2, 3). We here report on a 19-year-old caucasian boy with i(14)(q10) and upd(14)mat presenting with a clinical picture of diabetes mellitus consistent with maturity onset diabetes of the young (MODY). The propositus was the only child of a non-consanguineous couple. The family history was unremarkable. He was born via Cesarean section due to placenta detachment to his then 18-year-old G1P1 mother. Birth weight was 2 kg, length was 45 cm, and head circumference was 31 cm. The Apgar scores were 3 at 1% and 9 at 5%. His psychomotor developmental milestones were achieved at a normal age. He showed pubic and axillary hair beginning at the age of 9 years. At the age of 19, the propositus showed polyuria, polydypsia, and weight loss. At that time, his weight was 85 kg (75–90th percentile), his height was 166 cm (5th percentile), and his head circumference was 54.5 cm (50th percentile). On physical examination, he showed mild dysmorphic features consisting of dolicocephaly, high arched palate, hypoplasia of the scapha helix, synophris, prominent nasal bridge, brachydactyly, with his hands showing a proximal placement of the 5th fingers, and 5th finger clinodactyly bilaterally (Fig. 1A). Hormone and metabolic investigation showed: a marked elevation of fasting plasma glucose (425 mg/dl) and glycated haemoglobin (HbA1c, 15.7%) associated with elevated levels of serum C-peptide concentrations, both basal (3.1 ng/ml) and glucagon-stimulated (5.06 mg/dl) conditions; a mild increment of thyroid-stimulating hormone (TSH) concentrations (5.47 mU/l) with low free-T3 (2.5 ng/l) and normal free-T4 (1.1 ng/dl); and a marked elevation of serum cholesterol (282 mg/dl) and triglyceride (884 mg/dl). An ophthalmologic evaluation was normal. The head magnetic resonance imaging (MRI) scan and the spine X-ray were normal. A formal evaluation of his IQ (Wechsler Adult Intelligence Scale) showed a mean score of 75, with a score of 91 for the verbal items and a score of 61 for the non-verbal items. A chromosome analysis showed a 45,XY,der(14;14)(q10;q10) karyotype. The chromosome analysis performed on the mother was normal. The father was unavailable for clinical and genetic studies. The genotyping of the propositus and his mother, performed with nine microsatellite markers scattered throughout the entire chromosome 14, showed heterozygosity for seven markers in the mother, for which the propositus was homozygous

Animal models of medullary thyroid cancer: state of the art and view to the future

Medullary thyroid carcinoma is a neuroendocrine tumour originating from parafollicular C cells accounting for 5-10% of thyroid cancers. Increased understanding of disease-specific molecular targets of therapy has led to the regulatory approval of two drugs (vandetanib and cabozantinib) for the treatment of medullary thyroid carcinoma. These drugs increase progression-free survival; however, they are often poorly tolerated and most treatment responses are transient. Animal models are indispensable tools for investigating the pathogenesis, mechanisms for tumour invasion and metastasis and new therapeutic approaches for cancer. Unfortunately, only few models are available for medullary thyroid carcinoma. This review provides an overview of the state of the art of animal models in medullary thyroid carcinoma and highlights future developments in this field, with the aim of addressing salient features and clinical relevance.

Ileal “carcinoid” tumors—small size belies deadly intent: high rate of nodal metastasis in tumors ≤1 cm in size

Neuroendocrine tumors (NETs) account for 2% of tumors of the gastrointestinal tract, most occurring in the small intestine. A size of 2 cm is generally regarded as a cut-off point for risk of lymph node metastasis in intestinal neuroendocrine tumors in the absence of other high-risk features; however, metastatic disease has been reported in 12% of tumors of the jejunum and ileum measuring 1 cm or less. Archives from 2 institutions were searched for ileal NETs measuring 1 cm or less, and selected data were recorded. Twenty-one ileal NETs were identified measuring ≤1 cm. Six (29%) were multifocal and 7 (33%) had distant metastasis at diagnosis. Regional lymph nodes were examined in 14 cases (67%), and 10 of these cases (71%) showed lymph node metastasis. Mean primary tumor size in cases with nodal metastasis was 7.3 mm. In this series of ileal NETs ≤1 cm in size, the rate of lymph node metastasis was 48% overall and 71% for cases with regional lymph node resections. In addition, 33% showed distant metastasis at the time of diagnosis. Tumors as small as 3 mm and those confined to the submucosa can give rise to nodal metastasis, emphasizing the need for consideration of local resection with regional lymphadenectomy, even for subcentimeter ileal NETs.

EUS-guided FNA for proliferative rate in pancreatic neuroendocrine tumors: a single center experience over a 11-year period.

Context Pancreatic neuroendocrine tumors (PNTs) are rare, representing 1% to 2% of all pancreatic neoplasms. Endoscopic ultrasonography in combination with fine needle aspiration (EUS-FNA) has been shown to be an highly accurate method for the preoperative localization and diagnosis of PNTs and several studies have shown that proliferative activity index (Ki-67) represents one of the most important criteria of malignancy. Objective The aim of this study was to evaluate the role of EUS-FNA in the assessment of the proliferation index (Ki-67) expression on cytological material in a consecutive cohort with histologically confirmed PNT. Methods Data of all consecutive patients undergone EUS-FNA of pancreatic mass over a 11-year period, were prospectively stored in a data base. All cases with both cytological and histological diagnosis of PNT were evaluated for the present study. Pre-surgical FNAs’ immunocytochemical results (Ki-67) were compared to the corresponding findings obtained from surgical specimens. We categorized Ki-67 expression using a cut-off of 2% (Ki-67≤2% and Ki-67>2%). Results About 2,000 pancreatic mass FNAs were performed over a 11-year period. Eighty-two patients (mean age 55.6±14.3 years) had cytological diagnosis of PNT, of whom 78 had confirmed histopathology. Sensitivity of EUS-FNA for the diagnosis of a PNT was 87.5%. The mean number of needle passes to obtain adequate sample was 2.6±0.98. Proliferative index was evaluable in 35 FNAs (44.8%); in the remaining patients we could not measure Ki-67 because not enough material was left after performing routine staining. When using a cut-off of 2%, Ki-67 expression measured was concordant in 17 out of 22 and the remaining 5 cases were discordant. When using a cut-off >2%, Ki-67 expression was concordant in 11 out of 13. Overall concordance between cytological and histological samples for Ki-67 was 80% (28/35). Kappa statistics was 0.64 (95% CI: 0.25-0.83). Sensitivity and specificity of FNAs for Ki-67 were 0.79 (95% CI: 0.61-0.91) and 0.69 (95% CI: 0.48-0.83), respectively (P value=0.007). Conclusion It is possible to determine proliferative index in PNTs on cytological material obtained by EUS-FNAs with an overall good agreement in the expression of Ki-67 measured either on cellular material and on histological tissue. The cytological Ki-67 may effectively improve the preoperative assessment of PNTs. A careful quantitative analysis of specimens at the time of FNA should be done in order to ensure sufficient material for Ki-67 assessment.

Severe Hypothyroidism Causing Pre-Eclampsia-Like Syndrome

Objective. Analyzing and managing pre-eclampsia-like syndrome due to severe hypothyroidism. Methods. Presentation of a case of severe hypothyroidism due to Hashimotos syndrome, associated with a severe early-onset preeclampsia-like syndrome, managed in our Gynecology Department. Results. Severe pre-eclampsia led to miscarriage at 24 weeks of gestational age in a 42-year-old woman, although we attempted to correct hypothyroidism with increasing doses of levothyroxine and liothyronine sodium. Conclusion. Recognizing pre-eclampsia-like syndrome caused by overt hypothyroidism from other forms of pregnancy-induced hypertension is essential for choosing the correct treatment.

A new mutation in the MEN1 gene

The multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominantly inherited syndrome with an estimated prevalence of 1 to 10 per 100,000 in the general population. Patients with MEN1 develop various combinations of different endocrine tumors that mainly involve the parathyroid glands (90e97%), the pancreatic islet cells and duodenum (30e80%), and the anterior pituitary gland (15e50%). The prognosis of MEN1 is mainly related to the development of entero-pancreatic tumors. They are usually benign, small and multiple, nonfunctional, and with the tendency to recur after surgical removal [1]. MEN 1 is caused by germline mutations in the MEN1 gene, mapped to chromosome 11q13. This gene encodes for a 610eamino acid protein known as menin, which behaves as a tumor-suppressor gene [2]. Mutations most often lead to a truncated protein [3], resulting in major changes of the menin structure or in its absence, with loss of tumor-suppressing function and deregulation of cell growth and cell cycle. This results in an increased risk of developing multiple endocrine tumors [4,5]. MEN1 gene mutations have been reported in MEN1 syndrome [6] and in sporadic endocrine tumors [7]. The phenotypic expression of MEN1 may vary extensively between families and even among affected members within the same family [8]. In addition to variable penetrance of the MEN1 gene, it has been suggested that disease expression may be influenced by geneeenvironment and geneegene interactions [9]. We report on a new splice variant 4676-2A / G of MEN1, which causes the production of a truncated protein, observed in a woman with pancreatic endocrine tumors. In April 2008, a 28-year-old woman presented with a 1-year history of recurrent abdominal pain, vomiting, and weight loss. She reported a vague family history positive for unspecified tumors. According to her medical history, she had undergone a pancreaticoduodenectomy with an uncertain diagnosis of a low-grade endocrine tumor back in December 2003. Since November 2007, the patient complained of many episodes of abdominal pain and vomiting, as well as a rapid weight loss (8 kilograms in few weeks). She was then hospitalized in Naples, where she underwent positron emission tomography, which showed a nonhomogeneous accumulation of the tracer at the posterior stomach wall and in the subcutaneous adipose tissue in the right anterior abdominal wall. Scintigraphy with 111In-pentetreotide (Octreoscan, Mallinckrodt Medical, Petten, NL) and abdominal magnetic resonance imaging (MRI) were negative for a relapse of the pancreatic tumor. During

Impact of Ki67 re-assessment at time of disease progression in patients with pancreatic neuroendocrine neoplasms

Background Although re-assessment of proliferative activity by K67 evaluation during the course of neuroendocrine neoplasms (NENs) is recommended in selected patients, its impact on patients’ management is not clear due to the lack of data supporting this practice. Aim To investigate Ki67 change at time of progressive disease (PD) in entero-pancreatic NENs (EP-NENs). Patients and methods Retrospective analysis of sporadic EP-NENs which received histological re-assessment after PD once radiologically documented. Results Forty-three patients were evaluated, including 24 pancreatic NENs (PNENs), and 19 small intestine NENs (SI-NENs). At time of initial histological evaluation, 19 patients had grade 1 (G1) NETs (44.2%), and 24 grade 2 (G2) NETs (55.8%), overall median Ki67 being 3% (range 1%-20%). At time of PD, 13 patients had G1 NETs (30.2%), 26 G2 NETs (60.5%), and 4 had grade 3 (G3) NECs (9.3%), thus resulting in a significant median Ki67 increase (8%, range 1%-70%; p = 0.0006), and a G upgrading in 12 patients (27.9%). A statistically significant Ki67 increase and G grading change at time of PD was observed in PNENs (p = 0.0005 and p = 0.028, respectively). Conversely, no statistically significant change occurred in non-PNENs. Conclusions In PNENs with documented PD, Ki67 increase occurs in a significant proportion of patients, providing useful information necessary to choose appropriate therapeutic options.