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Neuroendocrine tumors, Islet-cell and Carcinoid tumors

Neuroendocrine tumors of the pancreas (islet cell tumors) are much less common than tumors arising from the exocrine pancreas. Reports often indicate that there are about two to three thousand cases diagnosed in the U.S. each year – although autopsy indicates that there may be a higher incidence of these islet cell tumors than are diagnosed.

The general term used tends to be “neuroendocrine” as these tumors may arise IN or ASSOCIATED WITH the hormone producing areas of the very complicated organ which is the pancreas. This hormone producing area is termed endocrine, and the other main area which tends to produce pancreatic “juice” that makes its way to the intestine to aid in digestion is called the exocrine pancreas. These different areas of the pancreas are somewhat jumbled up together anatomically – so rather than being like neighbors, the endocrine and exocrine areas of the pancreas are more like ethnicities all living together in the city known as the pancreas. The term “islet cell tumor” is another word for neuroendocrine tumor.

About 75% of neuroendocrine tumors are “functioning.” That is they are found to be producing symptoms related to one or more of the hormone peptides that they secrete. About one quarter of islet cell tumors do not produce symptoms related to hormone secretion and thus are termed non-functioning. The predominant hormone peptide being secreted gives the functioning islet cell tumor its name. There are a surprising number of these hormonal peptides that islet cell tumors have been found to secrete; some are not even related to the pancreas. This array includes insulin, gastrin, glucagon, somatostatin, neurotensin, pancreatic polypeptide (“PP”), vasoactive intestinal peptide (“VIP”), growth hormone releasing factor (“GRF”), ACTH and others. Some of these are very rare.

Apart from producing no currently discernible hormone peptide, non-functioning tumors may include those which produce PP (“PPomas”) or neurotensin (“neurotensinomas”), as these hormones usually produce no symptoms. The most common functioning pancreatic endocrine tumors are insulinomas followed by gastrinomas, glucagonomas and VIPomas, respectively. Typically, the symptoms produced by the excess secretion of the predominant hormone in a given functioning endocrine tumor, drives the eventual diagnosis.

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With the exception of insulinomas, most of the islet cell tumors have fairly similar characteristics, belying the apparent differences caused by the large range of symptom effects related to the secretion of such different hormones. Histologically (under the microscope) they tend to be quite similar. It is not possible to ascertain malignancy from the histological appearance; malignancy is seen primarily as a function of finding additional metastatic sites. Except for insulinomas, very roughly about 60% of islet cell tumors are malignant. This rate contrasts with about 10% of insulinomas which are eventually found to be malignant. The sites of metastasis of islet cell tumors most commonly are the liver and the lymph nodes in the vicinity of the pancreas.

Insulinomas are islet cell tumors which secrete an excess of (predominantly) insulin. These tumors will typically first present symptoms between the ages of 40 and 50, are more common among women and tend to be small, solitary tumors located in the pancreas itself. The clinical features of this tumor are related to the effects of insulin-and thus primarily demonstrate symptoms related to hypoglycemia which are relieved by food intake. Other general symptoms include episodic sweating, tremor and rapid heart rate, as well as hunger, nausea, weight gain, and sometimes even central nervous system symptoms (including rarely, seizures).

Gastrinomas over-secrete the hormone gastrin. The clinical effect of this circumstance is what has come to be called the Zollinger-Ellison syndrome, a triad of signs and symptoms including atypical peptic ulcer disease, gastric hyperacidity and hyper-secretion, and an associated islet cell pancreatic tumor. About 2% of patients with non-healing peptic ulcers (after receiving an appropriate therapy regimen) are found to have Z-E syndrome with its attendant tumor. Most patients are male (~60%) and the average age at diagnosis is about 60 years.

Patients with glucagonomas tend to present with mild diabetes and a severe dermatitis. These tumors are frequently fairly large by the time of diagnosis, sometimes greater than two inches in diameter. Approximately 70% of these tumors are malignant. About 80% of VIPomas are located in the pancreas itself-the rest elsewhere. Over-secretion of this vasoactive intestinal peptide causes watery diarrhea, and low serum potassium and chloride levels. Only about 200 cases of this kind of tumor have been described in the medical literature; the majority are malignant by the time of diagnosis.

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Carcinoid cancer is the most common of the neuroendocrine tumors, with one-and-a-half diagnosed cases per 100,000 of population, although anatomy at autopsy demonstrates about 400 times those that are diagnosed clinically. They tend to be slow growing. The symptoms and signs of carcinoid tumors range widely, and depend on the location and size of the tumor, on the presence of metastases, and secretions. They can appear to the surgeon as firm nodules bulging into the intestinal lumen (can originate from pancreas, lungs, thymus, appendix, and ovaries, etc.), with possible local expansion, and possible metastases to mesenteric lymph nodes, liver, ovaries, peritoneum, testes, prostate, spleen and other anatomic locations. Carcinoid tumors can secrete any number of hormonal, growth and other factors. Symptoms related to the tumor and its factors may be intermittent and vague, but the most common presentation is periodic abdominal pain sometimes accompanied by malignant carcinoid syndrome, characterized by flushing of the face, severe diarrhea, and an asthma episode. The initial evaluation of patients often includes measurement of such factors as serotonin, 5-HT, catecholamines and histamine, and especially urinary 5-HIAA levels. In general, survival rates for patients with carcinoid cancers are related to the size of the primary tumor – and the degree of metastasis.

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The natural history of islet cell and carcinoid tumors tends to be favorable as compared with pancreatic adenocarcinoma. For example, the median survival duration from the time of diagnosis for patients with non-functioning metastatic islet cell tumors approaches five years. The diagnosis of islet cell tumors is aided by the different abnormal biochemical profiles that they may present, which often leads to radiographic means to try and locate the tumor. It would be a mistake to generalize too much about attempts to locate these tumors. But generally, dynamic CT scans with radio-contrast dye, octreotide scintigraphy, transabdominal ultrasound, and selective visceral angiography are all methods employed to elicit radiographic information about the cancer, depending on individual circumstance.

Although they arise from similar cells, these different types of neuroendocrine cancers all behave somewhat differently. The standard treatments tend to be tumor-type specific, but some general observations can be made. Immediate treatment of the symptomatic conditions created by the over-secretion of the hormone(s) may be appropriate. (For example, the use of H2-blockers, omeprazole and even octreotide in gastrinomas). The treatment of choice for localized islet cell tumors is generally curative surgery. The treatment of metastatic islet cell cancer disease, depending on the tumor type, will often include chemotherapy involving such agents as streptozocin, everolimus, sunitinib, temozolomide, capecitabine, 5-FU, doxorubicin, dacarbazine and octreotide. Recently, there have been published in the medical literature promising studies of aggressive surgery benefiting select cases of metastatic neuroendocrine tumors.

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Apparently isolated liver metastases have been treated with such creative approaches as hepatic artery embolization. This may reduce the nutrient blood supply to the metastatic liver tumor (which tend to be rather vascular), but this approach remains controversial. It is difficult per the limits of today’s radiographic methods (and even via direct inspection at surgery) to fully appreciate the presence of small tumors in the liver-thus there well may be more metastases that have been undetected. Currently, there are studies employing techniques of radioimmunotherapy to selected patients with metastatic islet cell cancer, wherein radioactive elements have been conjugated together with specific compounds (sometimes hormonal elements) which are chosen for their properties that tend to selectively target islet cell tissue. These are very interesting early studies which hold the virtue of biologic plausibility, but the final results of the efficacy of this approach is not yet fully known.

Some percentage of islet cell tumors may be a part of several well-defined hereditary syndromes in which the tendency exists for the development of tumors in various (typically multiple) endocrine glands in the body, and which are known as the multiple endocrine neoplasia (or “MEN”) syndromes.

ABSTRACTS:

The following are descriptions of titles of abstracts of medical journal articles that may be interesting or useful to those who are interested in further information about this topic.These abstracts can be searched Here.

  • November 1, 2016 – FOLFOX vs. CAPOX each plus Avastin for Metastatic NETs
  • September 23, 2016 – IV Streptozocin for hepatic NET mets
  • September 19, 2016 – Proposed new stages criteria for pancreatic NETs
  • August 18, 2016 – Dacarbazine for progressive advanced NETs
  • August 12, 2016 – Gedatolisib – dual target mTOR kinase inhibitor for NET treatment
  • August 1, 2016 – Upcoming study: EUS Ethanol ablation for small NETs
  • August 1, 2016 – O(6)-methylguanine-DNA methyltransferase – predictor of Temodal response in NETs?
  • July 1, 2016 – Radiotherapy for hepatic NET mets 
  • May 27, 2016 – Octreotide depot plus Avastin and Perjeta for metastatic NETs
  • April 1, 2016 – Pancreastatin as an outcome predictor for NETs
  • April 1, 2016 – Active surveillance vs. Surgery in Symptomless Small NETs
  • March 1, 2016 – Somatuline Depot For NETs
  • March 1, 2016 – Is 1.7 the new 2-cm prognostic inflection point in non-functioning NETS?
  • February 29, 2016 – Combination Sugical Procedures Appear Beneficial in Select NETs
  • February 9, 2016 – Xeloda Plus Temodal in Advanced NETs
  • February 1, 2016 – Ethanol Ablation of NETs
  • January 1, 2016 – PRRT for advanced NETs
  • January 1, 2016 – Induction Rx for metastatic NETs ?
  • January 1, 2016 – Hepatic Surgery vs. Medical Treatment for Advanced NETS
  • February 1, 2016 – PRRT for NETs 
  • January 1, 2015 – Postive Case Study of 70 year old with insulinoma treated with PRRT
  • January 1, 2016 – Surgery Improves Results Even in Metastatic Pancreatic NETs
  • December 29, 2015 – Efficacy of Ki-67 Differental Capability Between Higher and Low-grade Aggressiveness of Pancreatic Neuroendocrine Tumors
  • December 21, 2015 – Nonfunctioning Pancreatic NETS: to Operate or Not
  • December 17, 2015 – Meta Analysis of the Ki-67 marker for Prognosis in NETs
  • December 17, 2015 – Everything Old Becomes new Again: CRP for Prognosis in Pancreatic Neuroendocrine Tumors
  • December 5, 2015 – Etoposide plus Carboplatin and Etoposide in NETs
  • December 3, 2015 – Platinum-based Combination Chemo for 1st Line in Pancreatica Neuroendocrine Tumors?
  • December 3, 2015 – Radio-therapy for Liver Mets in Neuroendocrine Tumors
  • December 2, 2015 – Streptozocin in Combination Chemo Regimens for Metastatic Neuroendocrine Tumors
  • December 1, 2015 – Afinitor for regulation of Symptoms in NETs
  • December 1, 2015 – Early I-131-MIBG Result is a Predictor of Future Response for Advanced pancreatic NETs
  • November 1, 2015 – Portal Vein Surgery in Pancreatic NETs
  • November 1, 2015 – Induction Therapy with (177)Lu-octreotate for Non-functioning NETs Can Provide Some Patients a Surgical Option
  • October 28, 2015 – The Curious Encouraging Pre-clinical Results of Valproate on NET Cells
  • August 25, 2015 – Can the Grade of a Metastasis Vary From That of the Primary in Pancreatic NETs?
  • August 7, 2015 – Fluorouracil Plus Streptozocin Combination Chemotherapy for Pancreatic NETs
  • August 1, 2015 – A Clinical Trial of the PRRT (177)Lu-octreotate Plus Afinitor for Advanced NETs
  • August 1, 2015 – Hepatic Transplant for Advanced NETs
  • July 4, 2015 – Somatostatin Analogues Plus mTOR Inhibitors (Afinitor and Sutent) for NETs
  • July 1, 2015- Successful Microwave Surgical Ablation via Percutaneous Route for a Patient with Conditions Prohibiting Full Surgery
  • June 1, 2015 – Clinical Trial of a VEGF Inhibitor Plus Octreotide in Metastatic and Locally-advanced NETs
  • June 1, 2015 – Combination of a Recombinant Human Monoclonal Immunoglobulin G1 Antibody Plus Afinitor and Octreotide LAR for Metastatic NETs
  • June 1, 2015 – Could the FOLFOX Combination Chemotherapy Regimen be Considered as 2nd Line for Progressing Neuroendocrine Tumors ?
  • May 10, 2015 – Combination Therapy with Torisel Plus Avastin for Pancreatic NETs
  • March 31, 2016 – Markers of Sutent Efficacy in Metastatic NETs
  • March 7, 2015 – Extended Afinitor Therapy in Pancreatic NETs
  • March 3, 2015 – Clinical Trial Implications: Effect of Earlier Somatostatin Analogue Usage on Afinitor in Metastatic NETs
  • March 1, 2015 – Considerations of a Clinical Trial: Results of Earlier Chemotherapy on the effect of Afinitor in Metastatic NETs
  • January 1, 2015 – Sutent Regulation of Untoward Effects of a VIPoma-related Verner-Morrison syndrome: a two-patient case study
  • December 14, 2014 – Addition of I-131-MIBG to (90)Y DOTA Phe1-Tyr3-octreotide as PRRT Therapy for Metastatic NETs
  • December 1, 2014 – Xeloda and Avastin for Metastatic NETs: a Clinical Trial
  • December 1, 2014 – Clinical Trial: Avastin Plus Fluorouracil and Streptozocin for Advanced Pancreatic NETs
  • November 1, 2014 – Is there a Careful Place for the Use of Alpha Interferon in NETs ?
  • November 1, 2014 – Temodar Plus Xeloda for Advanced NETs
  • October 1, 2014 – Metronomic Xeloda for Pancreatic NETs
  • July 28, 2014 – A Review of the 2014 Annual ASCO Convention: Metformin and Other Chemotherapy for Pancreatic Cancer and NETs
  • June 1, 2014 – Gleevec as Successful in Treating a Patient with a Neuroendocrine Tumor Containing the Kit Mutation
  • June 1, 2014 – Ki-67 as an Aid in the Staging of NETs
  • May 1, 2014 – Clinical Trial: PRRT Via 177Lu-DOTATATE for NETs
  • March 1, 2014 – The Combination Therapy of Streptozocin Plus Xeloda With and Without Cisplatin for Metastatic Pancreatic NETs
  • January 10, 2014 – Gemzar as Salvage in NETs?
  • December 1, 2013 – Natural History of Small Nonfunctional NETs
  • November 18, 2013 – Lymphadenectomy in NETs?
  • November 1, 2013 – Improving the Grading of NETs
  • October 1, 2013 – Virulence in Non-functioning NETs
  • September 19, 2013 – Cell Proliferation Marker Versus Staging as an Outcome Predictor in NETs
  • September 17, 2013 – Phase 2 Clinical Trial of Votrient for NETs
  • September 1, 2013 – Whither Small NETs?
  • September 1, 2013 – Platinum Combination Drug Regimen for NETs
  • June 22, 2013 – Somatostatin Analogues as Initial Treatment for NETs
  • June 21, 2013 – EUS for NET Diagnosis
  • June 3, 2013 – Temodar plus Afinitor for Metastatic NETs
  • June 1, 2013 – FDG PET for Predicting Response to Peptide Receptor Radionuclide Therapy in NETs
  • January 1, 2013 – Peptide Receptor Radionuclide Therapy as Neoadjuvant Treatment for Neuroendocrine Tumors.
  • December 1, 2012 – Observation as a Strategy for Incidentally-discovered, Small Neuroendocrine Tumors of the Pancreas?
  • November 15, 2012 – A Single blood 5-Hydroxyindoleacetic-Acid Level Compares Well with 24-Hour Urine Testing for Neuroendocrine Tumors.
  • November 6, 2012 – A 4-Drug Fluorouracil Regimen for 2nd Line Chemo in Neuroendocrine Tumors.
  • September 1, 2012 – Advanced NET Treated with Xeloda and Temodar.
  • August 1, 2012 – The Doublet Cisplatin plus Irinotecan as Treatment for NETs.
  • August 20, 2012 – Avastin and Temodar Combination for Neuroendocrine Tumors.
  • August 22, 2012 – Temodar in the Therapy of NETs.
  • December 1, 2011 – Phase II Study of Afinitor and Octreotide for Neuroendocrine Tumors.
  • November 3, 2011 – Streptozocin Plus 5-FU in NETs.
  • May 27, 2011 – Somatostatin Analogues Coupled with Liver Embolization for Insulinoma.
  • May 26, 2011 – The Vincristine, Etoposide and Carboplatin Regimen for Neuroendocrine Tumors.
  • March 15, 2011 – Hepatic Neuroendocrine Metastases: When is a Transplant Indicated?
  • February 10, 2011 – Afinitor Treatment for NETs?
  • February 10, 2011 – Sutent Therapy for Advanced NETs.
  • February 1, 2011 – Xeloda Plus Radiopeptide 177Lu-octreotate for NETs.
  • December 1, 2010 – Radio-Ablation of Liver Mets.
  • November 24, 2010 – Embolization in the Treatment of Hepatic Mets from NETs.
  • October 1, 2010 – Evaluation of Epirubicin, Fluorouracil and Dacarbazine Chemo Regimen in NETs.
  • August 14, 2010 – Gemcitabine for a Neuroendocrine Tumor.
  • March 1, 2010 – An Advanced Carcinoid Tumor Treated with 90Y-edotreotide.
  • February 1, 2010 – Coupled (90)Y- DOTA-TATE and (177)Lu- DOTA-TATE for Advanced NETs.
  • November 1, 2009 – Xeloda plus Caelyx for a NET.
  • October 1, 2009 – Radiofrequency Ablation Plus Surgery for Hepatic Neuroendocrine Metastases.
  • October 1, 2009 – Fluorouracil plus 111 Octreotide for NETs.
  • June 30, 2009 – Rapamycin for Glucose Regulation in an Insulinoma with Mets.
  • June 9, 2009 – Neoadjuvant (90)Y-DOTATOC for Liver Mets in an NET.
  • May 19, 2008 – NET Risk Factors.
  • March 10, 2008 – Avastin, Octreotide and PEG-Interferon for Neuroendocrine Tumors.
  • February 18, 2008 – Liposomal Doxorubicin and Streptozotocin Doublet for Advanced NETs.
  • January 1, 2008 – A Quarter of a Century of Experience at Mass General in Treating Insulin Secreting Neuroendocrine Tumors.
  • May 15, 2007 – Temodar for NETs.
  • February 1, 2007 – Surgical Intervention for NETs.
  • August 26, 2006 – An Evaluation of the Xeloda and Oxaliplatin Combination for NETs.
  • January 1, 2006 – PEG-Interferon-alpha for Patients with NETs.
  • January 20, 2006 – Temodar plus Thalidomide for NETs.
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