Endoscopic treatment of sporadic small duodenal and ampullary neuroendocrine tumors

 

 Buy Article Permissions and Reprints

Background and study aim: As duodenal neuroendocrine tumors (NETs) are rare, their optimal management has not been clearly established. The aim of this study was to evaluate the feasibility and outcome of endoscopic treatment of duodenal NETs.

Patients and methods: We reviewed the files of all patients who underwent endoscopic resection of a sporadic duodenal or ampullary NET between 1996 and 2014 at two centers.

Results: A total of 29 patients with 32 uT1N0M0 NETs < 20 mm were included. Treatment consisted of endoscopic mucosal resection in 19 cases, and cap aspiration in 13 cases. Prior submucosal saline injection was used in 15 cases. Mortality was 3 % (one severe bleeding). Morbidity was 38 % (11/29). At post-resection analysis, mean tumor size was 8.9 mm (range 3 – 17 mm), 29 lesions were stage pT1, one was pT2, and 2 were pTx because of piecemeal resection. All NETs were well differentiated. A total of 27 lesions were classified as grade 1 and 5 were grade 2. The resection was R0, R1, and Rx for 16, 14, and 2 lesions, respectively. Three R1 patients underwent additional surgical treatment, with no residual tumor on the surgical specimen but with positive metastatic lymph nodes in two cases. One patient was lost to follow-up. Finally, 24 patients were included in the follow-up analysis. The median follow-up period was 56 months (range 6 – 175 months). Two patients presented a tumor recurrence during the follow-up period.

Conclusions: Endoscopic treatment of small duodenal NETs was associated with significant morbidity, a difficulty in obtaining an R0 specimen, and the risk of lymph node metastasis. Nevertheless, it represents an interesting alternative in small grade 1 duodenal lesions and in patients at high surgical risk.

• References

• 1 Hoffmann KM, Furukawa M, Jensen RT. Duodenal neuroendocrine tumors: classification, functional syndromes, diagnosis and medical treatment. Best Pract Res Clin Gastroenterol 2005; 19: 675-697
  CrossrefPubMedGoogle Scholar
• 2 Yao JC, Hassan M, Phan A et al. One hundred years after “carcinoid”: epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol 2008; 26: 3063-3072
  CrossrefPubMedGoogle Scholar
• 3 Delle Fave G, Kwekkeboom DJ, Van Cutsem E et al. ENETS Consensus Guidelines for the management of patients with gastroduodenal neoplasms. Neuroendocrinology 2012; 95: 74-87
  CrossrefPubMedGoogle Scholar
• 4 Witzigmann H, Loracher C, Geissler F et al. Neuroendocrine tumours of the duodenum. Clinical aspects, pathomorphology and therapy. Langenbecks Arch Surg 2002; 386: 525-533
  CrossrefPubMedGoogle Scholar
• 5 Hatzitheoklitos E, Buchler MW, Friess H et al. Carcinoid of the ampulla of Vater. Clinical characteristics and morphologic features. Cancer 1994; 73: 1580-1588
  CrossrefPubMedGoogle Scholar
• 6 Clements WM, Martin SP, Stemmerman G et al. Ampullary carcinoid tumors: rationale for an aggressive surgical approach. J Gastrointest Surg 2003; 7: 773-776
  CrossrefPubMedGoogle Scholar
• 7 Hartel M, Wente MN, Sido B et al. Carcinoid of the ampulla of Vater. J Gastroenterol Hepatol 2005; 20: 676-681
  CrossrefPubMedGoogle Scholar
• 8 Makhlouf HR, Burke AP, Sobin LH. Carcinoid tumors of the ampulla of Vater: a comparison with duodenal carcinoid tumors. Cancer 1999; 85: 1241-1249
  CrossrefPubMedGoogle Scholar
• 9 Pedicone R, Adham M, Hervieu V et al. Long-term survival after pancreaticoduodenectomy for endocrine tumors of the ampulla of Vater and minor papilla. Pancreas 2009; 38: 638-643
  CrossrefPubMedGoogle Scholar
• 10 Burke AP, Sobin LH, Federspiel BH et al. Carcinoid tumors of the duodenum. A clinicopathologic study of 99 cases. Arch Pathol Lab Med 1990; 114: 700-704
  PubMedGoogle Scholar
• 11 Soga J. Early-stage carcinoids of the gastrointestinal tract: an analysis of 1914 reported cases. Cancer 2005; 103: 1587-1595
  CrossrefPubMedGoogle Scholar
• 12 Scherubl H, Jensen RT, Cadiot G et al. Neuroendocrine tumors of the small bowels are on the rise: early aspects and management. World J Gastrointest Endosc 2010; 2: 325-334
  CrossrefPubMedGoogle Scholar
• 13 Sobin LH, Gospodarowicz MK, Wittekind CH. International Union Against Cancer (UICC) TNM classification of malignant tumors. 7th ed. Oxford: Wiley-Blackwell; 2009
  Google Scholar
• 14 Inoue H, Endo M, Takeshita K et al. A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Surgical endoscopy 1992; 6: 264-265
  CrossrefPubMedGoogle Scholar
• 15 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
  CrossrefPubMedGoogle Scholar
• 16 Bosman FT, Carneiro F, Hruban RH, Theise ND. WHO classification of tumours of the digestive system (4th edn). Lyon: IARC; 2010
  Google Scholar
• 17 Rindi G, Kloppel G, Alhman H et al. TNM staging of foregut (neuro)endocrine tumors: a consensus proposal including a grading system. Virchows Arch 2006; 449: 395-401
  CrossrefPubMedGoogle Scholar
• 18 Rindi G, de Herder WW, O’Toole D et al. Consensus guidelines for the management of patients with digestive neuroendocrine tumors: the second event and some final considerations. Neuroendocrinology 2008; 87: 5-7
  PubMedGoogle Scholar
• 19 Rindi G. The ENETS guidelines: the new TNM classification system. Tumori 2010; 96: 806-809
  CrossrefPubMedGoogle Scholar
• 20 Kloppel G, Perren A, Heitz PU. The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification. Ann N Y Acad Sci 2004; 1014: 13-27
  CrossrefPubMedGoogle Scholar
• 21 Yoshikane H, Tsukamoto Y, Niwa Y et al. Carcinoid tumors of the gastrointestinal tract: evaluation with endoscopic ultrasonography. Gastrointest Endosc 1993; 39: 375-383
  CrossrefPubMedGoogle Scholar
• 22 Yoshikane H, Suzuki T, Yoshioka N et al. Duodenal carcinoid tumor: endosonographic imaging and endoscopic resection. Am J Gastroenterol 1995; 90: 642-644
  PubMedGoogle Scholar
• 23 Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer 2003; 97: 934-959
  CrossrefPubMedGoogle Scholar
• 24 Zyromski NJ, Kendrick ML, Nagorney DM et al. Duodenal carcinoid tumors: how aggressive should we be?. J Gastrointest Surg 2001; 5: 588-593
  CrossrefPubMedGoogle Scholar
• 25 Yokoyama S, Takifuji K, Tani M et al. Endoscopic resection of duodenal bulb neuroendocrine tumor larger than 10 mm in diameter. BMC Gastroenterol 2011; 11: 67
  CrossrefPubMedGoogle Scholar
• 26 Kim GH, Kim JI, Jeon SW et al. Endoscopic resection for duodenal carcinoid tumors: a multicenter, retrospective study. J Gastroenterol Hepatol 2014; 29: 318-324
  CrossrefPubMedGoogle Scholar
• 27 Lee DS, Jeon SW, Park SY et al. The feasibility of endoscopic submucosal dissection for rectal carcinoid tumors: comparison with endoscopic mucosal resection. Endoscopy 2010; 42: 647-651
  Article in Thieme ConnectPubMedGoogle Scholar
• 28 Matsumoto S, Yoshida Y. Selection of appropriate endoscopic therapies for duodenal tumors: an open-label study, single-center experience. World J Gastroenterol 2014; 20: 8624-8630
  CrossrefPubMedGoogle Scholar
• 29 Kakushima N, Kanemoto H, Tanaka M et al. Treatment for superficial non-ampullary duodenal epithelial tumors. World J Gastroenterol 2014; 20: 12501-12508
  CrossrefPubMedGoogle Scholar
• 30 Nonaka S, Oda I, Tada K et al. Clinical outcome of endoscopic resection for nonampullary duodenal tumors. Endoscopy 2015; 47: 129-135
  Google Scholar
• 31 Park SM, Ham JH, Kim BW et al. Feasibility of endoscopic resection for sessile nonampullary duodenal tumors: a multicenter retrospective study. Gastroenterol Res Pract 2015; 2015: 692492
  PubMedGoogle Scholar
• 32 Li QL, Zhang YQ, Chen WF et al. Endoscopic submucosal dissection for foregut neuroendocrine tumors: an initial study. World J Gastroenterol 2012; 18: 5799-5806
  CrossrefPubMedGoogle Scholar
• 33 Park CH, Cheon JH, Kim JO et al. Criteria for decision making after endoscopic resection of well-differentiated rectal carcinoids with regard to potential lymphatic spread. Endoscopy 2011; 43: 790-795
  Article in Thieme ConnectPubMedGoogle Scholar
• 34 Kwaan MR, Goldberg JE, Bleday R. Rectal carcinoid tumors: review of results after endoscopic and surgical therapy. Arch Surg 2008; 143: 471-475
  CrossrefPubMedGoogle Scholar
• 35 Holinga J, Khalid A, Fasanella K et al. Metastatic risk of diminutive rectal carcinoid tumors: a need for surveillance rectal ultrasound?. Gastrointest Endosc 2012; 75: 913-916
  CrossrefPubMedGoogle Scholar
• 36 Yoshikane H, Goto H, Niwa Y et al. Endoscopic resection of small duodenal carcinoid tumors with strip biopsy technique. Gastrointest Endosc 1998; 47: 466-470
  CrossrefPubMedGoogle Scholar
• 37 Gervais DA, Fernandez-del Castillo C, O’Neill MJ et al. Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics 2001; 21: 673-690
  CrossrefPubMedGoogle Scholar
• 38 Cherif R, Gaujoux S, Couvelard A et al. Parenchyma-sparing resections for pancreatic neuroendocrine tumors. J Gastrointest Surg 2012; 16: 2045-2055
  CrossrefPubMedGoogle Scholar