Introduction
Location |
All gastrinomas arise in the duodenum and about 60% are multiple |
Currently, the selective arterial secretagogue injection (SASI) test is the only useful technique to locate gastrinomas in MEN 1 patients. While 68Ga-DOTATOC (or DOTATATE)-PET/CT (SRI) can localize small neuroendocrine tumors (NETs), it cannot differentiate gastrinomas among multiple duodenopancreatic NETs in MEN1 patients [1, 4]. |
Malignant potential |
The rate of nodal metastases of the duodenal gastrinomas is about 60%, even for gastrinomas less than 5 mm in diameter. It was reported that the rate of hepatic metastases reached 23–29% when the primary duodenal gastrinomas had not been resected, although it remained in the range of 3–5% when they had been resected [14‐16]. |
Surgery aided by the results of the SASI test |
1. When the gastroduodenal artery is identified as a feeder of gastrinomas and the splenic artery is not, we perform pancreas-preserving total duodenectomy (PPTD) |
2. When the splenic artery is also identified as a feeder of gastrinomas by the stimulation via a small catheter placed at different points in the splenic artery, we perform local resection of the body or the tail of the pancreas to preserve the pancreatic endocrine function as much as possible |
To treat coexisting nonfunctioning pancreatic NETs, pancreatic NETs more than 2 cm in diameter are indication for resection. A different kind of method of resection is performed according to the situation (enucleation, central resection of the pancreas, distal pancreatectomy or PD) [6]. |
Chronology of the treatment of gastrinomas in MEN1 patients
History
Now
Pancreas |
Multiple nonfunctioning micro- or macro-NETs exist diffusely throughout the whole pancreas. The malignant potential of these NETs increases with their size |
Indications for resection of these NETs are a size of 2 cm or more in diameter and rapid growth. The JNETS guidelines recommend avoiding total pancreatectomy when possible, to preserve the pancreatic endocrine function |
Thymus |
NETs and neuroendocrine carcinoma (NECs) of the thymus are highly malignant |
Curative resection with dissection of the regional lymph nodes of any size is recommended |
Parathyroid |
Hyperparathyroidism (HPT) caused by hyperplasia of the parathyroid glands occurs in more than 90% of MEN1 patients and results in hypercalcemia |
Total parathyroidectomy with transplantation or subtotal parathyroidectomy is recommended. For patients with ZES, surgery for HPT is usually performed prior to surgery for gastrinomas |
Pituitary |
Most tumors are benign and slow growing |
Observation or medical treatment is usually recommended, with resection generally only recommended for occasional symptomatic tumors |
Characteristics of gastrinomas in patients with MEN1 (Table 1)
What kind of surgery has been performed for gastrinomas in patients with MEN1?
Side effects of the long-term use of PPIs
Anti-acid medicines cannot prevent the progression of gastrinomas, and the hypergastrinemia caused by both use of PPI and the gastrinomas may be tumorigenic
Imaging techniques have not advanced to the level that can differentiate gastrinomas among multiple duodenopancreatic NETs (Fig. 1)
Results of our surgery for patients with MEN1 and gastrinomas
# | Age y.o sex | Operation for gastrinoma | Location of gastrinoma (size: mm) | Mets. of gastrinoma | Nonfunctioning panc- NET size | HPT age at surg: y.o | Pit- NET age at surg: y.o | Prognosis, recurrence of gastrinoma | ||
---|---|---|---|---|---|---|---|---|---|---|
D | P | N | L | |||||||
1 | 44 M | PD | 1 (5) | 0 | 1 | 0 | 5 1-2 mm | – | + 41,42 | No recurrence 18 years post-op, alive and well, then lost to follow-up |
2 | 39 F | PD | 7 (2–7) | 0 | 1 | 0 | 6 1-2 mm | + 39 | – | No recurrence 4 years post-op, died of other disease |
3 | 21 M | PD | 1 (10) | 0 | 0 | 0 | 0 | – | + 21 | No recurrence 25 years post-op, alive and well |
4 | 49 M | DX, DP | 9 (1–7) | 0 | 0 | 0 | 1 15 mm (gluc) | + 47 | + 59 | No recurrence 25 years post-op, alive and well |
5 | 61 F | DX (twice), P-Enucl | 4 (1–4) | 2 | 1 | 0 | 2 3 mm, 5 mm | + 55 | – | No recurrence 14 years post-op, alive and well, then lost to follow-up |
6 | 56 F | DX(twice) P-Enucl | 2 (1–3) | 0 | 0 | 0 | 3 3-10 mm | + 55 | – | No recurrence 21 years post-op, alive and well |
7 | 44 F | DX | 1 (9) | 0 | 0 | 0 | 1 (PD 36 yo) 8 cm | + 44 | – | No recurrence 21 years post-op, alive and well |
8 | 33 M | DX, DP | 1 (10) | 0 | 1 | 0 | Multiple gluc | + 23, 33 | + 50 | No recurrence 19 years post-op, alive with post-craniotomy complications |
9 | 54 F | DX, | 2 (6, 12) | 1 15 mm | 3 | 0 | Multiple insulinomas (DP:23 y) | + 34 | + Γknife 23, 40 | No recurrence 12 years post-op, alive and well |
10 | 59 F | DX | 1 (7) | 0 | 1 | 0 | 0 | + 59 | + | No recurrence 12 years post-op, alive and well |
11 | 51 F | PPTD | Multi (1–4) | 0 | 2 | + – | 9 | + 51 | – | Died of liver mets. 6 years post-op, probably as a result of non-curative surgery due to liver metastases |
12 | 30 M | PPTD, DP | 1 (5) | 0 | 0 | 0 | 2 | + 30 | + | 18 years post-op, alive with liver mets |
13 | 32 M | PPTD | 2 (5, 7) | 0 | 1 | 0 | Multi 1-5 mm | + 31 | + | No recurrence 18 years post-op, alive and well |
14 | 48 F | PPTD | Multi (1–5) | 0 | 1 | 0 | Multi 2-9 mm | + 48 | – | 15 years post-op, alive with liver mets controlled by somatostatin analog |
15 | 33 M | PPTD | 1 (8) | 0 | 2 | 0 | Multi 1-5 mm | + 26 | – | 14 years post-op, alive with liver mets. after resection of NETG2 of thymus (49 yo) |
16 | 57 F | PPTD | 7 (< 2) | 0 | 1 | 0 | 0 | + 56 | – | No recurrence 5 years post-op, died of other disease |
17 | 32 M | PPTD Enucl, DP | 12 (2–4) | 2 | 3 | 0 | Multi < 5 mm | + 32 | – | 12 years post-op, alive and well but with #16 LN met |
18 | 68 M | PPTD | 8 (2–13) | 0 | 3 | 0 | 3 (gluc) | + 68 | + | No recurrence 10 years post-op, alive and well |
19 | 62 M | PPTD | 2 (3–5) | 0 | 0 | 0 | Multi < 10 mm | + 42 | + | No recurrence 8 years post-op, alive and well |
20 | 47 M | PPTD | 1 (7) | 0 | 0 | 0 | Multi < 13 mm | + 47 | – | No recurrence, 4 years post-op, alive and well |