Pancreatic neuroendocrine tumors (NETs) arise from cells that produce and secrete hormones. Most NETs are slow growing but malignant tumors that can metastasize. Common sites of origin include the gastrointestinal tract, lungs, and pancreas. The majority of pancreatic NETs (pNETs) are malignant, with the exception of insulinomas which are usually benign. Diagnosis of pNET requires histological or cytological confirmation, assessment of endocrine differentiation, and evaluation of prognostic markers like Ki-67.
The document discusses neuroendocrine tumors of the pancreas (PNETs). It provides information on:
1) PNETs are rare tumors that originate from neuroendocrine cells in the pancreas. They can be functional, secreting hormones like insulin, or non-functional.
2) Functional PNETs include insulinomas, gastrinomas, VIPomas, and glucagonomas. They are generally detected earlier due to hormone secretion symptoms.
3) Treatment involves surgical resection if possible. For advanced disease, options include chemotherapy, targeted drug therapy, and controlling hormone symptoms medically.
1. Neuroendocrine tumors (NETs) arise from neuroendocrine cells throughout the body and share features like secretory granules and hormone production. Pancreatic NETs (PNETs) comprise 1-2% of pancreatic tumors.
2. PNETs can be functional, producing symptoms from hormone hypersecretion, or nonfunctional. Major functional types are insulinomas, gastrinomas, VIPomas, and glucagonomas. Nonfunctional PNETs are usually larger and have worse prognosis than functional tumors.
3. Treatment involves surgical resection for localized disease. For advanced or metastatic disease, options include somatostatin analogs, hepatic artery embolization, targeted drugs, and
1. Neuroendocrine tumors (NETs) are increasing in incidence and are often metastatic at diagnosis. They originate from neuroendocrine cells and secrete hormones.
2. Somatostatin analogues are first-line treatment for symptomatic control in NETs but resistance can develop. Chemotherapy has limited efficacy except in high-grade tumors.
3. Emerging biomarkers and molecular targeted therapies such as inhibitors of angiogenesis are improving outcomes beyond traditional approaches.
A brief description of Neuroendocrine tumors of the pancreas. Includes epidemiology, different classification, syndromes produced depending of the secreted hormone, diagnostic considerations and imaging examples.
The document discusses neuroendocrine tumours (NETs), including their epidemiology, histology, classification, molecular pathogenesis, syndromes associated with NETs, and details specific neuroendocrine tumours like insulinomas, gastrinomas, their diagnosis and treatment. NETs originate from neuroendocrine cells in the gastrointestinal tract and other organs and can secrete hormones. Diagnosis and treatment of functional NETs depends on identifying the syndrome caused by hormone secretion and controlling the clinical effects.
This document provides information on pancreatic neuroendocrine tumors (NETs). It discusses that NETs arise from cells that produce and secrete hormones. The pancreas is a common site of origin for NETs. NETs are typically slow growing but can metastasize. Classification systems take into account factors like origin, characteristics, behavior, grade, and stage. The WHO classification defines NETs based on differentiation, metastases, Ki-67 index, invasion and other criteria. Pancreatic NETs (pNETs) are rare but increasing in incidence. pNETs may or may not cause symptoms through hormone secretion. Common pNET types include insulinomas, gastrinomas, and non-functional tumors. Nonspecific
This document discusses neuroendocrine tumors (NETs) which originate from diffuse endocrine system cells. NETs can occur in the pancreas (e.g. insulinomas, gastrinomas) and gastrointestinal tract (e.g. carcinoid tumors). Diagnosis involves biopsy, imaging and laboratory tests. Treatment options include surgery, somatostatin analogs, interferon alpha and chemotherapy - though surgery offers the best chance of cure if the disease is localized.
This document provides an overview of neuroendocrine tumors (NETs) that originate in the gastrointestinal tract (GIT). It discusses the classification, grading, epidemiology, pathophysiology, clinical features, and molecular biology of GIT-NETs. Some key points include:
- GIT-NETs are classified as well-differentiated or poorly-differentiated and further graded based on proliferation rate.
- The ileum is a common primary site. Symptoms vary depending on secretion of hormones.
- Carcinoid syndrome results from secretion of substances like serotonin that cause flushing, diarrhea, and heart disease.
- Molecular drivers include growth factors but causes are still not fully understood. Prognosis depends on
The document discusses neuroendocrine tumors of the pancreas (PNETs). It provides information on:
1) PNETs are rare tumors that originate from neuroendocrine cells in the pancreas. They can be functional, secreting hormones like insulin, or non-functional.
2) Functional PNETs include insulinomas, gastrinomas, VIPomas, and glucagonomas. They are generally detected earlier due to hormone secretion symptoms.
3) Treatment involves surgical resection if possible. For advanced disease, options include chemotherapy, targeted drug therapy, and controlling hormone symptoms medically.
1. Neuroendocrine tumors (NETs) arise from neuroendocrine cells throughout the body and share features like secretory granules and hormone production. Pancreatic NETs (PNETs) comprise 1-2% of pancreatic tumors.
2. PNETs can be functional, producing symptoms from hormone hypersecretion, or nonfunctional. Major functional types are insulinomas, gastrinomas, VIPomas, and glucagonomas. Nonfunctional PNETs are usually larger and have worse prognosis than functional tumors.
3. Treatment involves surgical resection for localized disease. For advanced or metastatic disease, options include somatostatin analogs, hepatic artery embolization, targeted drugs, and
1. Neuroendocrine tumors (NETs) are increasing in incidence and are often metastatic at diagnosis. They originate from neuroendocrine cells and secrete hormones.
2. Somatostatin analogues are first-line treatment for symptomatic control in NETs but resistance can develop. Chemotherapy has limited efficacy except in high-grade tumors.
3. Emerging biomarkers and molecular targeted therapies such as inhibitors of angiogenesis are improving outcomes beyond traditional approaches.
A brief description of Neuroendocrine tumors of the pancreas. Includes epidemiology, different classification, syndromes produced depending of the secreted hormone, diagnostic considerations and imaging examples.
The document discusses neuroendocrine tumours (NETs), including their epidemiology, histology, classification, molecular pathogenesis, syndromes associated with NETs, and details specific neuroendocrine tumours like insulinomas, gastrinomas, their diagnosis and treatment. NETs originate from neuroendocrine cells in the gastrointestinal tract and other organs and can secrete hormones. Diagnosis and treatment of functional NETs depends on identifying the syndrome caused by hormone secretion and controlling the clinical effects.
This document provides information on pancreatic neuroendocrine tumors (NETs). It discusses that NETs arise from cells that produce and secrete hormones. The pancreas is a common site of origin for NETs. NETs are typically slow growing but can metastasize. Classification systems take into account factors like origin, characteristics, behavior, grade, and stage. The WHO classification defines NETs based on differentiation, metastases, Ki-67 index, invasion and other criteria. Pancreatic NETs (pNETs) are rare but increasing in incidence. pNETs may or may not cause symptoms through hormone secretion. Common pNET types include insulinomas, gastrinomas, and non-functional tumors. Nonspecific
This document discusses neuroendocrine tumors (NETs) which originate from diffuse endocrine system cells. NETs can occur in the pancreas (e.g. insulinomas, gastrinomas) and gastrointestinal tract (e.g. carcinoid tumors). Diagnosis involves biopsy, imaging and laboratory tests. Treatment options include surgery, somatostatin analogs, interferon alpha and chemotherapy - though surgery offers the best chance of cure if the disease is localized.
This document provides an overview of neuroendocrine tumors (NETs) that originate in the gastrointestinal tract (GIT). It discusses the classification, grading, epidemiology, pathophysiology, clinical features, and molecular biology of GIT-NETs. Some key points include:
- GIT-NETs are classified as well-differentiated or poorly-differentiated and further graded based on proliferation rate.
- The ileum is a common primary site. Symptoms vary depending on secretion of hormones.
- Carcinoid syndrome results from secretion of substances like serotonin that cause flushing, diarrhea, and heart disease.
- Molecular drivers include growth factors but causes are still not fully understood. Prognosis depends on
1. Pancreatic neuroendocrine tumors (PNETs) are rare, slow-growing neoplasms that originate from cells that produce and secrete hormones.
2. The most common functional PNETs are insulinomas, gastrinomas, glucagonomas, and VIPomas. Non-functional PNETs make up about 75% of cases.
3. Diagnosis involves biochemical testing for hormone levels, imaging such as CT, MRI, and nuclear imaging to locate the primary tumor and metastases, and pathology to determine grade and stage. Endoscopic ultrasound can help locate small tumors.
Reporting thyroid fine needle aspiration by the bethesda systemMonika Nema
This document summarizes guidelines for thyroid fine needle aspiration (FNA) cytopathology reports. It discusses classifications including nondiagnostic/unsatisfactory, benign thyroid lesions, atypia of undetermined significance/follicular lesion of undetermined significance, and includes examples of diagnostic criteria, imaging features and recommended reporting language for each classification. Thyroid FNA is presented as an accurate and cost-effective initial test for evaluating thyroid nodules that can help determine if surgery is needed.
1. MRI is the preferred imaging modality for local staging of rectal cancer, allowing assessment of tumor stage, depth of invasion, and relationship to surrounding structures.
2. A high-quality MRI with thin slices and a small field of view is needed to accurately evaluate the tumor, lymph nodes, and circumferential resection margin.
3. Key findings on MRI include tumor distance to the mesorectal fascia, involvement of surrounding organs, and presence of extramural vascular invasion, which have prognostic significance.
This document discusses radiopharmaceutical imaging of neuroendocrine tumors. It begins by defining neuroendocrine tumors and their most common sites of origin. It then discusses the radiopharmaceuticals used in imaging NETs, including somatostatin analogues that target somatostatin receptors, catecholamine analogues that target sympathetic nervous system tumors, and FDG that targets glucose metabolism. The document provides examples of different radiopharmaceutical scans and their findings in common NETs like carcinoid tumors, pheochromocytomas, and paragangliomas. It also discusses the added value of SPECT/CT in image interpretation.
A 45-year-old female presented with recurrent vomiting, loss of appetite, abdominal pain, and significant weight loss over 6 months. Imaging revealed a 7x5cm cystic lesion in the pancreatic head and neck. The differential diagnosis for cystic pancreatic lesions includes pseudocyst, serous cystadenoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, and rarer entities. Specific imaging features, cyst fluid analysis, and clinical characteristics can help differentiate these potential diagnoses to guide management of the patient's cystic pancreatic lesion.
Soft tissue tumors are defined as mesenchymal proliferations that occur in extraskeletal, nonepithelial tissues. They are classified based on the tissue they originate from, such as muscle, fat, fibrous tissue, vessels, and nerves. The most common soft tissue tumors are lipomas, which are benign fatty tumors. Liposarcomas are malignant fatty tumors that can recur if not adequately excised. Rhabdomyosarcoma is the most common soft tissue sarcoma in children that arises in skeletal muscle tissue and is usually treated with surgery and chemotherapy.
This document discusses updates in the management of rectal cancer. It covers the anatomy, risk factors, staging, clinical features, investigations, and various treatment modalities for rectal cancer including surgery, chemotherapy, and radiotherapy. It describes in detail the different surgical procedures like local excision, anterior resection, abdominoperineal resection, and total mesorectal excision. It discusses the importance of clear circumferential resection margins and vascular ligation. Neoadjuvant chemoradiotherapy is emphasized for locally advanced tumors to downstage the cancer before surgery.
This document provides an approach for evaluating undifferentiated tumors. It begins by categorizing undifferentiated tumors into 4 groups based on morphology: small round cell tumors, epithelioid cell tumors, spindle cell tumors, and pleomorphic tumors. It then outlines the diagnostic algorithm which involves determining the main lineage (epithelial, melanocytic, hematopoietic/lymphoid, or mesenchymal), specifying a diagnosis using immunohistochemistry and clinical correlation, and considering the differential diagnoses for each category. A variety of immunohistochemical markers are also described that can help identify the cell or tumor type.
Presentation about lipoma and liposarcoma, origin, cause, description, diagnosis, treatment with pictures that help the better understanding of the topic.
The document discusses cytology of various bone lesions. It covers classification of bone tumors and describes cytological features of inflammatory conditions like osteomyelitis. It also discusses osteoid forming lesions such as fracture callus and osteoblastoma. Cartilage forming tumors described include chondroma, chondromyxoid fibroma and osteochondroma. Giant cell containing lesions and cystic bone lesions are also mentioned. The document provides cytological details of various bone tumors like osteosarcoma, chondrosarcoma and chondroblastoma through multiple case studies. It highlights differential diagnoses and ancillary techniques used in evaluation of bone lesions.
This document discusses mediastinal pathology using a compartmental approach. It describes the anatomy of the mediastinum and divides it into anterior, middle, and posterior compartments. Each compartment contains different structures and has a characteristic distribution of lesions. For example, 50% of lesions occur in the anterior compartment, which contains the thymus. The thymus is the most common site of lesions in the anterior compartment. Thymomas are the most common epithelial tumors of the thymus and mediastinum.
This document discusses the use of immunohistochemistry in breast pathology. It covers several topics:
1. Analyzing prognostic markers like hormone receptors in breast cancer and their predictive value.
2. Using myoepithelial cell markers to help solve diagnostic dilemmas and distinguish lesions.
3. Identifying tumor subtypes and assessing diagnoses using markers like luminal vs basal.
4. Evaluating cell populations in proliferative breast lesions and assessing neoplasia vs hyperplasia.
Small round cell tumors are a group of highly aggressive cancers composed of small, undifferentiated cells. The diagnostic approach involves clinical findings, imaging, pathology, and molecular genetics testing. Key small round cell tumors in pediatric patients include Ewing sarcoma, neuroblastoma, nephroblastoma, rhabdomyosarcoma, medulloblastoma, retinoblastoma, and lymphoblastic lymphoma. Immunohistochemistry and genetic testing are used to determine the specific tumor type to help guide treatment.
Pancreatic cystic neoplasm - Dr Dheeraj Yadavdheeraj_maddoc
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors. It describes the main types - serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). SCNs are usually benign and contain clear fluid, while MCNs and IPMNs have higher malignant potential and are often lined with mucin-secreting cells. Imaging plays an important role in diagnosis, with CT and MRI identifying characteristics such as central scarring in SCNs. Complete surgical resection is typically recommended for suspected malignant neoplasms.
This document provides an overview of MALToma (Mucosa Associated Lymphoid Tissue lymphoma). It discusses the lymphatic system and MALT, defining MALT and its role in the immune system. Diagnosis of MALToma involves endoscopy, biopsy of suspicious lesions, and testing for H. pylori infection. Histopathology shows neoplastic B-cell infiltration and lymphoepithelial lesions. Prognosis and treatment depend on disease stage and molecular markers; early-stage gastric MALToma often responds to H. pylori eradication alone. The document also reviews differential diagnoses and variants like IPSID (Immunoproliferative Small Intestinal Disease)
This document provides an overview of extragonadal germ cell tumors (EGGCTs), which develop outside of the ovaries or testicles. Key points include:
1) EGGCTs most commonly occur in the mediastinum, intracranial region, retroperitoneum, and sacrococcygeal area. Common histologies include seminoma, nonseminomatous tumors, teratoma, and mixed germ cell tumors.
2) Presenting symptoms vary based on location but may include chest pain, neurological deficits, or abdominal masses. Diagnosis involves tumor markers, imaging, and biopsy.
3) Treatment approaches also vary by location and histology but commonly involve
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
This document discusses germ cell tumors of the ovary. It begins by explaining that germ cell tumors originate from primordial germ cells and make up about 90-95% of ovarian malignancies in young women. It then covers the various subtypes of germ cell tumors, including their incidence rates, typical patient demographics, clinical presentations, diagnostic markers, pathological classifications, treatment approaches, and prognosis. Dysgerminoma is discussed as the most common subtype, while immature teratoma, endodermal sinus tumor, embryonal carcinoma, and choriocarcinoma are also described in terms of their defining characteristics and management. Throughout, the focus remains on applying knowledge from testicular germ cell tumor research
Cystic Neoplasms of the Pancreas
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Tumour and tumour like lesions of spleenAshwini Gowda
This document summarizes various tumors and tumor-like lesions that can occur in the spleen. It begins by covering the anatomy and histology of the spleen, then discusses classifications of splenic tumors. Several specific hematolymphoid tumors are described in detail, including lymphomas, leukemias, and myeloproliferative disorders. Other sections cover vascular tumors, other rare primary tumors, metastatic tumors to the spleen, and tumor-like conditions.
The document discusses pancreatic neuroendocrine tumors. It covers types like insulinomas, gastrinomas, vipomas, glucagonomas, and somatostatinomas. For each type it discusses incidence, location, clinical features, diagnostic tests, management options like surgery or medication, and prognosis. It also covers non-functional pancreatic neuroendocrine tumors and tumors associated with MEN1 syndrome. Surgical resection is the primary treatment when possible but some types are often metastatic at diagnosis.
This document summarizes various types of pancreatic tumours. It describes pancreatic ductal adenocarcinoma as the most common exocrine pancreatic cancer, accounting for 85% of cases. Risk factors and clinical features are provided. Other exocrine tumours discussed include acinar cell carcinoma, cystic pancreatic neoplasms such as microcystic cystadenoma and mucinous cystadenoma. Neuroendocrine tumours such as insulinomas are also summarized. Rare tumour types like anaplastic carcinoma, giant cell tumour and intraductal papillary mucinous neoplasms are described.
1. Pancreatic neuroendocrine tumors (PNETs) are rare, slow-growing neoplasms that originate from cells that produce and secrete hormones.
2. The most common functional PNETs are insulinomas, gastrinomas, glucagonomas, and VIPomas. Non-functional PNETs make up about 75% of cases.
3. Diagnosis involves biochemical testing for hormone levels, imaging such as CT, MRI, and nuclear imaging to locate the primary tumor and metastases, and pathology to determine grade and stage. Endoscopic ultrasound can help locate small tumors.
Reporting thyroid fine needle aspiration by the bethesda systemMonika Nema
This document summarizes guidelines for thyroid fine needle aspiration (FNA) cytopathology reports. It discusses classifications including nondiagnostic/unsatisfactory, benign thyroid lesions, atypia of undetermined significance/follicular lesion of undetermined significance, and includes examples of diagnostic criteria, imaging features and recommended reporting language for each classification. Thyroid FNA is presented as an accurate and cost-effective initial test for evaluating thyroid nodules that can help determine if surgery is needed.
1. MRI is the preferred imaging modality for local staging of rectal cancer, allowing assessment of tumor stage, depth of invasion, and relationship to surrounding structures.
2. A high-quality MRI with thin slices and a small field of view is needed to accurately evaluate the tumor, lymph nodes, and circumferential resection margin.
3. Key findings on MRI include tumor distance to the mesorectal fascia, involvement of surrounding organs, and presence of extramural vascular invasion, which have prognostic significance.
This document discusses radiopharmaceutical imaging of neuroendocrine tumors. It begins by defining neuroendocrine tumors and their most common sites of origin. It then discusses the radiopharmaceuticals used in imaging NETs, including somatostatin analogues that target somatostatin receptors, catecholamine analogues that target sympathetic nervous system tumors, and FDG that targets glucose metabolism. The document provides examples of different radiopharmaceutical scans and their findings in common NETs like carcinoid tumors, pheochromocytomas, and paragangliomas. It also discusses the added value of SPECT/CT in image interpretation.
A 45-year-old female presented with recurrent vomiting, loss of appetite, abdominal pain, and significant weight loss over 6 months. Imaging revealed a 7x5cm cystic lesion in the pancreatic head and neck. The differential diagnosis for cystic pancreatic lesions includes pseudocyst, serous cystadenoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, and rarer entities. Specific imaging features, cyst fluid analysis, and clinical characteristics can help differentiate these potential diagnoses to guide management of the patient's cystic pancreatic lesion.
Soft tissue tumors are defined as mesenchymal proliferations that occur in extraskeletal, nonepithelial tissues. They are classified based on the tissue they originate from, such as muscle, fat, fibrous tissue, vessels, and nerves. The most common soft tissue tumors are lipomas, which are benign fatty tumors. Liposarcomas are malignant fatty tumors that can recur if not adequately excised. Rhabdomyosarcoma is the most common soft tissue sarcoma in children that arises in skeletal muscle tissue and is usually treated with surgery and chemotherapy.
This document discusses updates in the management of rectal cancer. It covers the anatomy, risk factors, staging, clinical features, investigations, and various treatment modalities for rectal cancer including surgery, chemotherapy, and radiotherapy. It describes in detail the different surgical procedures like local excision, anterior resection, abdominoperineal resection, and total mesorectal excision. It discusses the importance of clear circumferential resection margins and vascular ligation. Neoadjuvant chemoradiotherapy is emphasized for locally advanced tumors to downstage the cancer before surgery.
This document provides an approach for evaluating undifferentiated tumors. It begins by categorizing undifferentiated tumors into 4 groups based on morphology: small round cell tumors, epithelioid cell tumors, spindle cell tumors, and pleomorphic tumors. It then outlines the diagnostic algorithm which involves determining the main lineage (epithelial, melanocytic, hematopoietic/lymphoid, or mesenchymal), specifying a diagnosis using immunohistochemistry and clinical correlation, and considering the differential diagnoses for each category. A variety of immunohistochemical markers are also described that can help identify the cell or tumor type.
Presentation about lipoma and liposarcoma, origin, cause, description, diagnosis, treatment with pictures that help the better understanding of the topic.
The document discusses cytology of various bone lesions. It covers classification of bone tumors and describes cytological features of inflammatory conditions like osteomyelitis. It also discusses osteoid forming lesions such as fracture callus and osteoblastoma. Cartilage forming tumors described include chondroma, chondromyxoid fibroma and osteochondroma. Giant cell containing lesions and cystic bone lesions are also mentioned. The document provides cytological details of various bone tumors like osteosarcoma, chondrosarcoma and chondroblastoma through multiple case studies. It highlights differential diagnoses and ancillary techniques used in evaluation of bone lesions.
This document discusses mediastinal pathology using a compartmental approach. It describes the anatomy of the mediastinum and divides it into anterior, middle, and posterior compartments. Each compartment contains different structures and has a characteristic distribution of lesions. For example, 50% of lesions occur in the anterior compartment, which contains the thymus. The thymus is the most common site of lesions in the anterior compartment. Thymomas are the most common epithelial tumors of the thymus and mediastinum.
This document discusses the use of immunohistochemistry in breast pathology. It covers several topics:
1. Analyzing prognostic markers like hormone receptors in breast cancer and their predictive value.
2. Using myoepithelial cell markers to help solve diagnostic dilemmas and distinguish lesions.
3. Identifying tumor subtypes and assessing diagnoses using markers like luminal vs basal.
4. Evaluating cell populations in proliferative breast lesions and assessing neoplasia vs hyperplasia.
Small round cell tumors are a group of highly aggressive cancers composed of small, undifferentiated cells. The diagnostic approach involves clinical findings, imaging, pathology, and molecular genetics testing. Key small round cell tumors in pediatric patients include Ewing sarcoma, neuroblastoma, nephroblastoma, rhabdomyosarcoma, medulloblastoma, retinoblastoma, and lymphoblastic lymphoma. Immunohistochemistry and genetic testing are used to determine the specific tumor type to help guide treatment.
Pancreatic cystic neoplasm - Dr Dheeraj Yadavdheeraj_maddoc
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors. It describes the main types - serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). SCNs are usually benign and contain clear fluid, while MCNs and IPMNs have higher malignant potential and are often lined with mucin-secreting cells. Imaging plays an important role in diagnosis, with CT and MRI identifying characteristics such as central scarring in SCNs. Complete surgical resection is typically recommended for suspected malignant neoplasms.
This document provides an overview of MALToma (Mucosa Associated Lymphoid Tissue lymphoma). It discusses the lymphatic system and MALT, defining MALT and its role in the immune system. Diagnosis of MALToma involves endoscopy, biopsy of suspicious lesions, and testing for H. pylori infection. Histopathology shows neoplastic B-cell infiltration and lymphoepithelial lesions. Prognosis and treatment depend on disease stage and molecular markers; early-stage gastric MALToma often responds to H. pylori eradication alone. The document also reviews differential diagnoses and variants like IPSID (Immunoproliferative Small Intestinal Disease)
This document provides an overview of extragonadal germ cell tumors (EGGCTs), which develop outside of the ovaries or testicles. Key points include:
1) EGGCTs most commonly occur in the mediastinum, intracranial region, retroperitoneum, and sacrococcygeal area. Common histologies include seminoma, nonseminomatous tumors, teratoma, and mixed germ cell tumors.
2) Presenting symptoms vary based on location but may include chest pain, neurological deficits, or abdominal masses. Diagnosis involves tumor markers, imaging, and biopsy.
3) Treatment approaches also vary by location and histology but commonly involve
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
This document discusses germ cell tumors of the ovary. It begins by explaining that germ cell tumors originate from primordial germ cells and make up about 90-95% of ovarian malignancies in young women. It then covers the various subtypes of germ cell tumors, including their incidence rates, typical patient demographics, clinical presentations, diagnostic markers, pathological classifications, treatment approaches, and prognosis. Dysgerminoma is discussed as the most common subtype, while immature teratoma, endodermal sinus tumor, embryonal carcinoma, and choriocarcinoma are also described in terms of their defining characteristics and management. Throughout, the focus remains on applying knowledge from testicular germ cell tumor research
Cystic Neoplasms of the Pancreas
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Tumour and tumour like lesions of spleenAshwini Gowda
This document summarizes various tumors and tumor-like lesions that can occur in the spleen. It begins by covering the anatomy and histology of the spleen, then discusses classifications of splenic tumors. Several specific hematolymphoid tumors are described in detail, including lymphomas, leukemias, and myeloproliferative disorders. Other sections cover vascular tumors, other rare primary tumors, metastatic tumors to the spleen, and tumor-like conditions.
The document discusses pancreatic neuroendocrine tumors. It covers types like insulinomas, gastrinomas, vipomas, glucagonomas, and somatostatinomas. For each type it discusses incidence, location, clinical features, diagnostic tests, management options like surgery or medication, and prognosis. It also covers non-functional pancreatic neuroendocrine tumors and tumors associated with MEN1 syndrome. Surgical resection is the primary treatment when possible but some types are often metastatic at diagnosis.
This document summarizes various types of pancreatic tumours. It describes pancreatic ductal adenocarcinoma as the most common exocrine pancreatic cancer, accounting for 85% of cases. Risk factors and clinical features are provided. Other exocrine tumours discussed include acinar cell carcinoma, cystic pancreatic neoplasms such as microcystic cystadenoma and mucinous cystadenoma. Neuroendocrine tumours such as insulinomas are also summarized. Rare tumour types like anaplastic carcinoma, giant cell tumour and intraductal papillary mucinous neoplasms are described.
1) The document discusses the role of targeted therapy in neuroendocrine tumors. It covers topics such as the evolution of terminology and classification of NETs, the use of biomarkers and imaging in diagnosis and monitoring, and current therapeutic approaches including somatostatin analogs.
2) Somatostatin analogs like octreotide and lanreotide are effective in controlling hormonal symptoms in NET patients by binding to somatostatin receptors that are prevalent on many NETs. They have also shown inhibitory effects on tumor proliferation.
3) A phase III study showed octreotide LAR extended time to tumor progression compared to placebo in treatment-naïve patients with well-differentiated midgut NETs
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
This document discusses multiple endocrine neoplasia (MEN) syndromes, which are rare genetic disorders where multiple endocrine tumors occur in multiple endocrine glands. It describes the six known MEN syndromes and their associated genetic mutations. Specific syndromes discussed in detail include MEN type 1 and type 2A, which are associated with tumors of the parathyroid, pancreas, and pituitary glands. Timely surgical removal of affected glands can prevent or cure malignancies associated with these syndromes.
Multiple endocrine neoplasia syndromes are inherited conditions where two or more endocrine glands develop non-cancerous or cancerous tumors due to mutations in genes regulating cell growth. There are two main types: type 1 affects the parathyroid, pituitary, pancreas and thyroid glands. Type 2 affects the parathyroid, thyroid and adrenal glands and is divided into 2A and 2B. Symptoms vary depending on affected glands but include high blood calcium and kidney problems. Diagnosis involves family history, hormone testing, imaging and genetic testing. Treatment focuses on surgically removing tumors and managing hormone levels with medication.
Presentation by Dr Lim Hwee Yong, Medical Oncologist, National Cancer Centre Singapore, at a NET cancer awareness seminar in Singapore on 20 November 2010.
This document discusses neuroendocrine tumors (NETs). It begins with disclosing the speaker's relationships with various pharmaceutical companies. It then outlines some of the challenges in diagnosing and treating NETs, which are rare tumors that can occur in many locations. The document discusses the increasing incidence of NETs and covers their pathology, classification, biomarkers, and imaging. It notes that metastatic disease is common at initial presentation for many patients. Finally, it briefly discusses the goals and options for therapy in advanced NETs, including symptom control and cytotoxic therapy.
Pancreatic neuroendocrine tumors (PNETs) are rare tumors that account for 2-3% of pancreatic tumors. They are often slow growing and have a better prognosis than pancreatic ductal adenocarcinoma. PNETs express neuroendocrine markers and do not arise from islet cells, but rather from ductal stem cells. They can be functional and secrete hormones, or non-functional. Imaging plays an important role in diagnosis, staging, and monitoring treatment response according to RECIST criteria. The 7th AJCC edition incorporates PNET staging with exocrine pancreatic tumors.
Pancreatic endocrine tumors are rare, occurring in approximately 5 per 1,000,000 people per year. The most common types are insulinomas, gastrinomas, vipomas, and glucagonomas. Insulinomas typically present with hypoglycemic symptoms and are usually benign and solitary. Gastrinomas present with peptic ulcer disease and weight loss and are often malignant. Vipomas cause severe watery diarrhea and hypokalemia. Glucagonomas result in necrolytic migratory erythema, weight loss, and diabetes. Diagnosis involves laboratory tests and imaging like CT or MRI. Treatment depends on the type but may include surgery, chemotherapy, or symptom management. Progn
Gastrointerstinal stromal tumor (GIST) recent advances and differential diagn...Indira Shastry
This document provides information on gastrointestinal stromal tumors (GISTs), including:
- GISTs arise from interstitial cells of Cajal in the gastrointestinal tract and are defined by activating mutations in KIT or PDGFRA.
- Common symptoms are nonspecific but most GISTs are found in the stomach.
- Immunohistochemistry shows positivity for CD117 in 95% of cases, as well as DOG1, CD34, and protein kinase C theta.
- Risk stratification systems exist to determine malignant potential and guide treatment, which frequently involves tyrosine kinase inhibitors.
This document discusses neuroendocrine tumors (NETs) of the gastroenteropancreatic system, focusing on gastric and duodenal NETs. It covers the molecular pathogenesis, classification, biomarkers, imaging techniques, and treatment approaches for gastroenteropancreatic NETs. Key points include that gastric NETs are classified into three types, duodenal NETs can originate from gastrinomas or somatostatinomas, and biomarkers like chromogranin A, 5-HIAA, and pancreastatin can help in diagnosis along with localization techniques like endoscopic ultrasound, CT, MRI, and somatostatin receptor imaging.
Recent advances in pancreatic pathology were presented. Key points included:
- Classification of pancreatic lesions and neoplasms has been updated.
- Precursor lesions like PanINs are important in understanding cancer development. Genetic alterations accumulate with progression.
- Endocrine neoplasms are classified based on morphology and biomarkers. Genetic syndromes confer increased risk.
- Advances in cytopathology and molecular markers aid in early cancer detection.
- Acute pancreatitis pathogenesis involves acinar cell injury, premature enzyme activation, and inflammatory cascades.
- Transplant rejection is assessed via biopsies and cytology of drained pancreatic juice.
1) Medulloblastoma is the most common malignant brain tumor in children. It arises in the cerebellum and has a tendency to metastasize through the CSF pathways.
2) It is classified into molecular subgroups - WNT, SHH, Group 3, and Group 4 - which have different characteristics and predict survival outcomes.
3) Treatment involves maximal safe surgical resection followed by craniospinal radiation and chemotherapy based on risk stratification into standard-risk and high-risk groups. Modified radiation schedules are being studied to reduce long-term side effects.
1. Carcinoma of the prostate is the second most common cancer in males. It typically occurs in men over 50 and prevalence increases with age.
2. Pathogenesis involves progression from premalignant prostatic intraepithelial neoplasia to invasive adenocarcinoma through genetic and epigenetic changes.
3. Diagnosis is made through digital rectal exam, prostate-specific antigen levels, and transrectal ultrasound-guided biopsy. Treatment involves surgery, radiation therapy, and hormone therapy such as androgen deprivation.
1. Carcinoma of the prostate is the second most common cancer in males. It typically occurs in men over 50 and prevalence increases with age.
2. Pathogenesis involves premalignant prostatic intraepithelial neoplasia progressing to adenocarcinoma through genetic and epigenetic changes.
3. Diagnosis is made through digital rectal exam, prostate-specific antigen levels, and biopsy. Treatment involves surgery, radiation therapy, and hormone deprivation therapy.
The document discusses recent advances in pancreatic pathology. It begins by classifying pancreatic lesions as endocrine or exocrine and outlines the WHO classification system for exocrine tumors. Precursor lesions like pancreatic intraepithelial neoplasia are discussed as well as genetic alterations associated with progression to cancer. Molecular markers are presented that can help diagnose early stage disease. The role of immunohistochemistry in evaluating pancreatic endocrine neoplasms is summarized. Genetic syndromes linked to familial pancreatic cancer are also mentioned.
This document summarizes neuroendocrine tumors of the gastrointestinal tract. It discusses that these tumors arise from neuroendocrine cells and can secrete markers like synaptophysin. They can be functional, secreting hormones, or non-functional. Imaging studies help in surgical planning and staging. Multiple endocrine neoplasia type 1 can cause pancreatic and gastric neuroendocrine tumors. Specific types of neuroendocrine tumors are discussed like gastrinomas, insulinomas, glucagonomas and VIPomas. Treatment involves surgery, medical management, and screening based on tumor type and location.
This document provides an overview of renal cell carcinoma (RCC), including its epidemiology, risk factors, pathology, classification, and staging. RCC accounts for 2-3% of adult cancers and its incidence is rising worldwide. The main subtypes are clear cell, papillary, and chromophobe RCC. RCC typically presents as a unilateral, solitary renal mass and can spread through direct extension or hematogenous routes. Staging involves evaluating the extent of disease to determine the appropriate treatment.
1) Papillary thyroid cancer accounts for most thyroid cancers and is usually diagnosed by FNAB. Surgery involves thyroid lobectomy but total thyroidectomy is preferred for tumors >1cm given lower recurrence rates.
2) The RET gene is often mutated in thyroid cancer and drives tumorigenesis through MAPK pathway activation. BRAF mutations also activate this pathway and indicate more aggressive disease.
3) Follicular thyroid cancer presents as a solitary thyroid nodule but cannot be diagnosed by FNAB, requiring surgery.
NEOPLASIA: Clinical Features of Tumors, Grading and Staging & Laboratory Diag...Dr. Roopam Jain
This document discusses neoplasia, including the clinical features and effects of tumors on the host. It describes local effects like compression and obstruction, as well as systemic manifestations such as cancer cachexia, fever, and paraneoplastic syndromes. Grading and staging of tumors is covered, examining differentiation and the prognostic value of staging. Methods for laboratory diagnosis of cancer are summarized, including histological analysis and the use of tumor markers.
Neuroblastoma diagnosis, treatment, complications, and further management. The main contents of this review have been accessed from MedScape. Please do not reprint or copy this material without permission from the copyright owner.
This document provides information on renal cell carcinoma (RCC), including epidemiology, risk factors, histologic subtypes, staging, clinical presentation, investigations, and management. RCC accounts for 2-3% of adult cancers. Clear cell RCC is the most common subtype. Presentation is often nonspecific, though flank pain, hematuria, and abdominal mass may occur. Imaging like CT and MRI are used to stage and characterize lesions. Treatment involves surgery (radical or partial nephrectomy) for localized disease. Up to 30% of patients experience relapse post-surgery.
This document discusses neoplasia and the clinical and laboratory diagnosis of cancer. It covers topics such as the local and hormonal effects of tumors, cancer cachexia, paraneoplastic syndromes, grading and staging of tumors, histologic and cytologic diagnostic methods, immunohistochemistry, molecular diagnostics, circulating tumor cells, tumor markers, and the potential for molecular profiling of tumors to improve cancer diagnostics.
Carcinoid tumors are slow-growing neuroendocrine tumors that commonly arise in the gastrointestinal tract and lungs. The document discusses carcinoid tumors in depth, including their definition, sites of origin, histology, staging, clinical features, diagnostic testing, and management approaches. Treatment involves surgical resection when possible, with additional therapies for advanced or metastatic disease aimed at controlling hormone secretion and tumor growth.
Renal cell carcinoma (RCC) is a type of kidney cancer that arises from renal tubular epithelial cells. It comprises approximately 3.8% of new cancers and 2-3% of adult cancers. RCC is typically diagnosed in the 6th and 7th decades of life. Risk factors include tobacco use, obesity, and occupational exposures. RCC is staged based on tumor size and spread. Treatment depends on stage but may include surgery, targeted therapy, immunotherapy, and radiation therapy. Prognosis depends on stage, grade, performance status, and biomarkers.
This document discusses neuroendocrine tumors (NETs), which arise from neuroendocrine cells derived from neural crest cells. NETs were previously called APUDomas and carcinoids but are now classified as neuroendocrine gastroenteropancreatic tumors. Specific NETs discussed include insulinomas, glucagonomas, gastrinomas, vipomas, and somatostatinomas. Diagnosis and treatment options are described for each tumor type. The document also covers carcinoid syndrome, typical and atypical carcinoid tumors, and treatment approaches for NETs such as surgery, medical therapy, peptide receptor radionuclide therapy, and hepatic artery embolization.
- Neuroblastoma is the most common abdominal cancer in children and accounts for 15% of pediatric cancer deaths. It arises from nerve tissue and occurs most often in the abdomen.
- Presentation depends on location but often includes an abdominal mass, pain, bone lesions, or organ compression. Over 40% have metastases at diagnosis.
- Staging involves imaging and biopsy to determine extent of disease. Treatment depends on risk stratification and may include surgery, chemotherapy, radiation, stem cell transplant, and targeted therapy. Surgery aims to remove the primary tumor but carries risks of injury and complications.
WHO CLASSIFICATION 2016 RENAL CELL CARCINOMA.pptxSURAJ PANCHAL
The document summarizes updates to the 2016 WHO classification of renal cell carcinoma compared to the 2004 classification. Key changes include recognizing RCC as distinct subtypes based on histology, architecture, location, associated diseases and molecular alterations. The 2016 classification adds 9 new renal tumor entities, separates some subtypes, and groups familial and sporadic forms of RCC together. It provides greater specificity in RCC diagnosis and classification based on recent advances in understanding RCC pathogenesis and genetics.
Similar to Pancreatic neuro endocrine tumours (20)
Hospice provides palliative care to patients with terminal illnesses through an interdisciplinary team approach. It focuses on comfort care and quality of life rather than cure. Dame Cicely Saunders founded the modern hospice movement in the 1960s based on her experience at St. Christopher's Hospice in London. Hospice care can be provided in the home, nursing home, hospital, or independent hospice facility. The hospice interdisciplinary team includes doctors, nurses, social workers, chaplains, home health aides, and volunteers who provide holistic physical, emotional and spiritual support to patients and their families.
This document discusses rehabilitation for patients who have undergone head and neck cancer treatment. It covers physiology of swallowing, requirements for speech production, and rehabilitation approaches after radiation therapy, surgery, and for different cancer sites. Rehabilitation may include swallowing therapy, voice therapy, exercise to prevent trismus, and prosthetics. The goal is to restore or improve swallowing, speech, and quality of life after cancer treatment.
Immunohistochemistry (IHC) combines histological and immunological techniques to identify specific tissue components using antigen-antibody reactions tagged with visible labels. IHC allows visualization of the distribution and localization of cellular components. Antibodies bind specifically to antigens, providing spatial location of particular cells and proteins. Important considerations for IHC include antibody selection, fixation, antigen retrieval, controls, and detection methods such as direct, indirect, and enzyme-linked methods. IHC is useful for tumor diagnosis, classification, predictive markers, and distinguishing between benign and malignant lesions.
The document discusses neuropathic pain management and treatment options. It defines neuropathic pain and differentiates it from acute pain. It describes the pathophysiology and possible descriptions of neuropathic pain. The goals of clinical assessment are to achieve diagnosis, identify underlying causes, evaluate comorbidities, and develop a targeted treatment plan. Treatment options discussed include nonpharmacological approaches, topical medications, systemic medications like anticonvulsants, antidepressants, and opioids. New treatments and applications of existing treatments are improving management of neuropathic pain conditions.
This document discusses various types of tobacco products and their links to cancer. It notes that chewing tobacco, loose leaf, cigars, cigarettes, bidis, and electronic cigarettes have all been shown to increase cancer risk. Epidemiological studies in the 1950s by Doll and Hill and others established smoking as a cause of lung cancer and other cancers. Continued smoking can negatively impact cancer treatment outcomes for surgeries, radiotherapy, and chemotherapy. The document also outlines various carcinogens found in tobacco and regulations on tobacco in India under the COTPA-2003 law.
The RECIST guidelines provide standardized criteria for evaluating tumor response in cancer clinical trials. They were developed in 2000 by an international working group to simplify and standardize previous WHO response criteria. Key aspects of the RECIST guidelines include defining measurable and non-measurable lesions, criteria for complete response, partial response, stable disease and progressive disease based on tumor size measurements, and recommendations for frequency of tumor re-evaluation and confirming responses. The guidelines aim to facilitate objective and reproducible assessments of tumor burden and treatment response.
- Human papillomavirus (HPV) is a non-enveloped double-stranded DNA virus that can cause various cancers and genital warts. There are over 100 HPV types, with high-risk HPV 16 and 18 causing most cervical and other cancers.
- The HPV vaccines Gardasil (HPV4) and Cervarix (HPV2) protect against HPV 16 and 18 and can prevent cancers caused by these high-risk types if administered before exposure. Vaccination is recommended for girls and boys at age 11-12.
- HPV positive oropharyngeal cancer makes up the majority of oropharyngeal cancers and is associated with improved survival compared to HPV negative orophary
1. Nuclear medicine involves using radioactive substances to diagnose and treat disease. Positron emission tomography (PET) uses radiotracers like fluorodeoxyglucose (FDG) to detect cancer cells and investigate their metabolism.
2. Cancer cells have altered metabolism and proliferation compared to normal cells. The Warburg effect shows they rely more on glycolysis than oxidative phosphorylation. This increased glycolysis can be detected on PET scans using FDG.
3. PET scans have many clinical applications, including cancer staging, detecting metastases, assessing treatment response, and distinguishing tumor recurrence from treatment effects. They provide functional information to guide diagnosis and management.
Management of prostate cancer involves assessing risk levels based on PSA, Gleason score, and percentage of positive biopsy cores. Treatment options include active surveillance for low risk prostate cancer with potential delayed treatment if cancer progresses. Radical prostatectomy is the gold standard for localized prostate cancer and provides the possibility of cure with minimal side effects when performed by an experienced surgeon. While providing excellent cancer control, radical prostatectomy carries risks of erectile dysfunction and urinary incontinence.
This document discusses testicular tumors. It notes that testicular cancer is rare but the most common solid malignancy in young men aged 15-35. The main types of testicular tumors are germ cell tumors (such as seminoma, embryonal carcinoma, teratoma, and choriocarcinoma) and non-germ cell tumors. Risk factors include cryptorchidism, family history, and testicular cancer history. Diagnostic tests include scrotal ultrasound and serum tumor markers. Radical inguinal orchiectomy is the standard treatment for removal of the testis.
Rhabdomyosarcoma is the most common soft tissue sarcoma in children. It occurs most often in children under 10 years of age and has a higher incidence in males and Caucasians. There are two main histological subtypes: embryonal rhabdomyosarcoma, which has a more favorable prognosis, and alveolar rhabdomyosarcoma, which is more aggressive and associated with metastatic disease. Treatment involves a combination of surgery, chemotherapy, and radiation therapy based on the specific site of involvement and stage of disease. Close monitoring after treatment is important to watch for potential recurrence or metastasis.
This document provides an overview of renal cell carcinoma (RCC), including:
- RCC accounts for 2-3% of adult cancers and has a rising incidence. The most common subtype is clear cell RCC.
- Risk factors include hereditary conditions like Von Hippel-Lindau disease which is linked to mutations in the VHL tumor suppressor gene.
- Presentation is often asymptomatic, but may include flank pain, hematuria, and palpable masses. Metastasis most commonly occurs in the lungs, liver, bone and brain.
- Diagnosis involves imaging like ultrasound or CT to identify masses, which are then characterized through biopsy and histopathological examination.
Renal cell carcinoma (RCC) is a common and lethal urologic cancer, accounting for 2-3% of all adult malignancies. RCC most often occurs in the sixth and seventh decades of life and is more common in males. While most RCCs are sporadic, 2-3% are familial. Historically, clear cell and papillary RCC were thought to arise from the proximal convoluted tubules, while chromophobe and collecting duct RCC arise from more distal regions. RCCs are often circumscribed by compressed parenchyma rather than a true capsule. Prognostic tools combining multiple factors have improved predictions for patient outcomes. Approximately one-third of RCC patients present with
This document summarizes the basics of penile cancer, including:
- Risk factors include lack of circumcision, HPV infection, smoking, and phimosis.
- It most commonly presents as lesions on the glans or prepuce and can spread to lymph nodes or distant organs if untreated.
- Diagnosis involves biopsy to determine depth of invasion and grade. Prognosis depends on stage, grade, growth pattern, and presence of lymphovascular invasion.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
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One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
2. – NETs arise from cells which produce and secrete hormones
– Most NETs are slow growing and malignant, with metastatic potential
– Common sites of origin are:
• GI tract
• Lungs
• Pancreas
2
Introduction to NETs
3. 3
WHO Classification for NET
Ong SL, et al. Pancreatology. 2009;9:583-600.
Neuroendocrine
Tumours
Site of Origin
• GI tract
• Pancreas
• Lungs
• Thyroid
• Pituitary
• Others
Malignant Potential
• Benign
• Benign or low
malignant potential
(uncertain)
• Low malignant
potential
• Highly malignant
Functional Activity
• Functioning
• Non-Functioning
4. The Pancreas Is the Most Common Primary Location of NET
Breakdown in Middle East & Asia Pacific Region
Stomach 6%
Liver 4%
Bile duct and gallbladder 3%
Omentum/abdominal lining 1%
Rectum 1%
Ovary 1%
Lung 1%
Hwang T, et al. Presented at: 8th Annual ENETS Conference; March 9-11, 2011; Lisbon, Portugal. Abstract C48.
5. Pancreatic neuroendocrine tumors
(pNET)
• Pancreatic endocrine tumors, islet cell carcinoma, or
pancreatic carcinoid
• Low - to intermediate-grade neoplasms and have a more
indolent course compared to pancreatic adenocarcinoma
• Functional if they are associated with a hormonal syndrome
– Disease bulk
– Stage
– Secretory status
– Whether the peptide secreted is intact and causes distinct
clinical symptoms
– Functional status of these tumors may change over time or with
treatment
6. • Majority of pNETs are malignant, with the
exception of insulinomas, which are benign in
95% of patients
7. EPIDEMIOLOGY
• Relatively rare neoplasms
• 2%-10% of all pancreatic tumors
• Incidence and prevalence are somewhat elusive
• Age-adjusted incidence of pNETs has risen significantly over
the last three decades
– Better diagnosis and
– Classification
– Environmental factors including the use of certain medications
• Incidence of pNETs in the United States was estimated to
be 5.6 per million in 2010
• Prevalen ce of small asymptomatic islet cell tumors may be
100-fold more common
8. • Slightly more common among men (53%) than women
(47%)
• Median age at diagnosis was 60 years
• At diagnosis,
– 14% had localized disease,
– 22% had regional disease, and
– 64% had distant disease.
• The survival of patients with pNETs has improved over
time
• 1988 through 2004, the 5-year survival rates among
patients with localized, regional, an distant pNETs were
79%, 62%, and 27%, respectively
9. Pathology
• Tumors arise from islets or ducts ???
– Transgenic mice expressing potent oncogenes in
endocrine cells and multiple endocrine neoplasia
(MEN)1 knockout mice point to an islet origin of
tumors
– Molecular evidence from islet microdissection in
patients with MEN1 indicate a duct cell origin
– Endocrine tumor cells largely display the same
phenotype as their normal endocrine counterpart
10. • Multiple Endocrine Neoplasia Type 1
– Tumor size may not be a completely reliable predictor
of malignant behavior, as metastatic disease may be
present in patients with MEN1 even when the primary
tumors are small
– Thompson was the first to advocate a specific surgical
procedure in patients with MEN1 with nonfunctioning
pNETs >1 cm in diameter to include distal subtotal
pancreatectomy, enucleation of any identified lesions
in the pancreatic head or uncinate process, and
regional lymphadenectomy
11. • Tuberous Sclerosis
– The genes responsible for tuberous sclerosis, TSC-1
and TSC-2, are located on chromosomes 9q34 and
16p13.3, respectively, and code for the proteins
hamartin and tuberin
– TSC1/2 complex is an inhibitor of mTOR
• Neurofibromatosis
– Von Recklinghausen disease, is an autosomal
dominant disease
– Protein neurofibromin 1 and is located on
chromosome 17
– NF1 is associated with the development of NETs in the
region of the duodenum and ampulla of Vater
– Endocrine tumors that arise from Von Recklinghausen
disease (NF1) are somatostatinomas
12. • Von Hippel-Lindau Syndrome
– Autosomal dominant
– Retinal, cerebellar, and spinal hemangioblastoma,
as well as renal cell carcinoma,
pheochromocytoma, and pNETs
– vHL gene is located on chromosome 3p26-p25
– pNETs occur in approximately 15% of patients with
VHL
13. 2010 World Health Organization (WHO) classification
• Well-differentiated tumors
– Trabecular, glandular, acinar, or mixed structures; the stroma is
generally fine and rich in welldeveloped blood vessels,
sometimes with hyalinised deposits of amyloid; tumor cells are
monomorphic with abundant, variably eosinophilic cytoplasm,
low cytological atypia and low mitotic index.
– Necrosis is usually absent or may be seen as spotty, limited
areas in histologically more aggressive neoplasms
– Neuroendocrine tumor
• Poorly differentiated neuroendocrine carcinomas
– Prevalent solid structure with abundant necrosis, often central,
round tumor cell of small to medium size with severe cellular
atypia and high mitotic index
– Neuroendocrine carcinoma
14. • Diagnosis of pNET is necessary
(1) to meet the previously defined histologic and
cytologic criteria,
(2) to assess the status of endocrine differentiation,
and
(3) to evaluate prognostic markers (proliferative
index).
15. • Fine Needle Aspiration Versus Core Needle Biopsy
– FNAC
• Simplicity, low invasiveness, and cost
• Disadvantages -operator-dependent efficacy and limited
option for further study (small sample size) to include
prognostic variables.
– Core needle biopsy (ideally 2 mm in diameter)
• Larger sized tumor sample - cyto-/histologic diagnosis
complete with all known prognostic parameters.
• Potential for further studies to include all IHC studies and
assessment of proliferative index.
• Disadvantages are the invasiveness of the procedure(s) and
the relatively higher costs
– core needle when considering biopsy of liver
metastases and FNA for biopsy of the pancreas.
16. • Immunohistochemistry Markers
– (1) positively identify the degree of endocrine
differentiation in tumor cells, and (2) determining the
proliferation activity status.
– General markers
• Neuron-specific enolase (NSE)
• Chromogranin A [CgA]
• Synaptophysin
– Hormones and/or amines are produced by specific cell
types - specific markers
– Proliferation status is achieved by Ki67 IHC using the MIB1
antibody or it can be expressed as mitoses per 10 high
power microscopic fields (or 2 mm2)
17.
18. • Low (G1) and intermediate (G2) grade neoplasms
are termed pNETs
• Aggressive high-grade (G3) neoplasm are termed
pancreatic neuroendocrine carcinoma
• Optimal Ki-67 cut-off between G1 and G2
remains debated in the literature.
• Some authors have proposed 5% (instead of 2%)
as a more discriminatory cut-point for important
outcomes including overall survival (OS)
• distinction between G1 and G2, while prognostic,
does not have major therapeutic implications
19. • Platinum-based chemotherapy is generally
recommended for G3 tumors
• Response rate to platinum-based
chemotherapy was low for the subgroup of G3
patients with Ki-67 between 20% and 55%.
• Tumors with a Ki-67 >55% appear more
responsive to platinum-based chemotherapy
20. Molecular Genetics of Pancreatic Neuroendocrine Tumors
• Exome sequencing studies identified three
main groups (pathways) of mutations in
sporadic - MEN1, DAXX or ATRX, and
mammalian target of rapamycin (mTOR)
21. • Nonfunctional Tumors
• 60%-80% of pancreatic NETs as non-functional
• Symptoms
– Usually asymptomatic
– The tumor bulk results in pain
• Invasion of the autonomic mesenteric plexus
• Liver metastases that invade the liver capsule
• Extend to the parietal peritoneum
– Jaundice due process-obstruction of the intrapancreatic
portion of the common bile ductto - right of the superior
mesenteric vessels -head or uncinate
– Gastric outlet obstruction
– Gastrointestinal hemorrhage secondary to tumor erosion
into the duodenum or secondary to splenic vein
occlusion causing gastroesophageal varices (sinistral
portal hypertension)
22. • pNETs arising to the left of the SMA and
superior mesenteric vein may cause vague,
poorly localized upper abdominal pain or
dyspepsia, but such tumors are usually
asymptomatic until they reach a considerable
size
23. • Computed tomography (CT)
– Characteristically appear hyperdense, as they are
hypervascular
– During the arterial phase is critically important to
detect these lesions and their hypervascular liver
metastases
– Occasionally appear hypodense compared with
adjacent pancreatic parenchyma, and they may
contain cystic components or microcalcifications
– Intrapancreatic accessory splenic tissue can present as
an asymptomatic, hypervascular mass involving the
distal pancreatic tail, thus mimicking a pNET
24. • Magnetic resonance imaging (MRI)
– Patients with a history of allergy to iodine contrast
material
– Renal insufficiency
– More sensitive than CT for the detection of small liver
metastases
• Endoscopic ultrasound (EUS)
– Most sensitive modality for identifying small pNETs
– Used for preoperative tumor localization in patients
with MEN1, in which multifocal disease is common
– FNA biopsy of the tumor
25. • Serum Tumor Markers
– Evaluated for the diagnosis and follow-up
management of pNETs
– General markers
– CgA - 49-kDa acidic polypeptide
• Present in the secretory granules of neuroendocrine
cells
• Elevated in the majority of patients with either
functioning or nonfunctioning pNETs
• Prognostic – decreased during therapy has increased
progress free survival
26. • NSE, is a dimmer of the glycolytic enzyme enolase
– Less specific as a diagnostic marker, it may be helpful in
the follow-up of patients with unresectable disease
• PP- at least three times the age-matched normal basal
level obtained in a fasting state
• Chromogranins such as chromogranin B and C,
pancreastatin, substance P, neurotensin, neurokinin A,
gastrin, glucagon, vasoactive intestinal peptide, insulin,
proinsulin, and cpeptide.
• In general, blood markers should be drawn in the
fasting state
27. Somatostatin receptor scinitigraphy
• Octreotide conjugated with diethylene-triamine-
pentaacetic acid (DTPA) and labeled with 111In is a
radiolabeled somatostatin analog with great
affinity for sstr2 and widely used in clinical practic
• 68Ga PET/CT is becoming the new gold standard
for somatostatin receptor imaging of PNET. The
sensitivity of this technique varies between 91
and 95% with a specificity of 82-97%
• Functional imaging with positron emission
tomography (PET) are (68)Ga-DOTATATE and
(68)Ga-DOTATOC
29. Surgical Treatment
• Goals of surgery are to maximize local disease control
and to increase the quality and length of patient
survival
• Resect localized, nonmetastatic disease confined to the
pancreas if a gross complete resection can be
performed
• If radiographically occult liver metastases are found at
the time of the operation, they are removed if possible
• If the liver metastases are of small volume but diffuse,
the primary tumor is usually removed due to the
potential for major morbidity from the primary, which
is a possibility because of the relatively long-
anticipated survival of the patient
30. • Nonfunctioning pNETs < (approximately) 2 cm in
diameter are of limited metastatic potential
• Observation may be the best approach
– Patients of advanced age
– Clinically significant comorbiditie
– Incidental finding on CT/MRI obtained for an
unrelated reason
– Repeat imaging in 6 to 12 months
– Observation is chosen - functional study such as
somatostatin receptor scintingraphy
31. • Metastatic disease or a large, borderline resectable
primary tumor, we would first initiate systemic therapy
as a bridge to eventual operation.
• Significant downstaging of the overall tumor burden
can improve the safety of surgery in some patients
• Rationale for aggressive management of the primary
tumor despite the presence of extrapancreatic disease
may become more compelling.
• However, treatment sequencing will likely emphasize a
surgery-last strategy (after induction systemic therapy)
to identify those patients most likely to benefit from
large, multiorgan resections
• Resectable primary tumor and resectable liver
metastases.
– Remove the pancreatic tumor first
– Resecting the liver under the same anesthesia induction or
two-stage procedure if all needed surgery cannot safely be
performed at one operation
32. • Because of the longer survival times of
patients with pNETs (even advanced disease),
we favor operative bypass of the bile duct and
duodenum in most cases.
33. Advanced Pancreatic Neuroendocrine Tumors
• Goals of oncologic management include palliation
or prevention of symptoms and cytoreduction of
bulky tumors in an effort to prolong survival
• Cytotoxic chemotherapy,
• Everolimus,
• Sunitinib,
• Somatostatin analogues,
• Peptide-receptor radiotherapy, as well as
• Ablative approaches such as hepatic artery
embolization and radiofrequency ablation (RFA)
34. • Somatostatin Analogues
– Octreotide and lanreotide both bind with high
affinity to SSTR 2 and with slightly lower affinity to
SSTR 5.
– Pasireotide is a novel cyclohexapeptide in
development that binds to SSRT 1, 2, 3, and 5
– Approved for the control of symptoms related to
hormonal hypersecretion in NETs
– Associated with significant benefit in PFS
35. – Somatostatin (SST)
receptors are highly
expressed on the surface
of GI NETs
• More than 80% of all
NETs express SST
receptors
– Overexpression provides
basis for regulation by
SST
– SST receptor activation
inhibits secretory and
proliferative activity
35
Pathophysiology
Significance of Somatostatin Signaling
36. Octreotide May Have a Direct
Antitumour Effect via sst2 and sst5
sst5
↑ Apoptosis ↓ Cell growth
PI3K
PDK1
Akt
GSK3β
p53
↑Zac1
mTOR
p70S6K
sst2
JNK
G protein
SHP1
NF-KB
sst2
G protein
G protein
SHP1
SHP2
Src
PTPŋ
MAPK
p27
cGMP↓
PKG↓
• sst2 and sst5 both
downregulate MAPK
• sst2 binding effects the
P13K/Akt/mTOR
pathway and SHP1
signalling
• Antiproliferative effect
also mediated via
protein tyrosine
phosphatase (PTPase)
modulation
Florio T et al. Front Biosci 2008;13:822–840
Grozinsky-Glasberg S et al. Neuroendocrinology 2008;87:168–181
Theodoropoulou M et al. Cancer Res 2006;66:1576–1582
37. • Phase III randomized, double-blind, placebo-controlled study
• Primary endpoint: Time to tumour progression (blinded central review)
• Secondary endpoints: objective response rate, survival, quality of life, safety
PROMID: Evaluation of the Antiproliferative
Effect of Octreotide LAR 30 mg
Patients with midgut NETs
• Treatment naïve
• Histologically confirmed
• Locally inoperable
or metastatic
• Well differentiated
• Measurable (CT/MRI)
• Functioning or non-
functioning
Octreotide LAR
30 mg im
every 28 days
Placebo im
every 28 days
RANDOMIZATION(1:1)
Treatment until
CT/MRI
documented
tumour
progression or
death
Month 3 6 9 12 15 18
Rinke A et al. J Clin Oncol 2009;27:4656–4663
38. Patient Demographics
Octreotide LAR
30 mg (n=42)
Placebo
(n=43)
Total
(n=85)
Median age, years (range) 63.5 (38–79) 61.0 (39–82) 62.0 (38–82)
Sex male (%)
female (%)
47.6
52.4
53.5
46.5
50.6
49.4
Time since diagnosis, months (range) 7.5 (0.8–271.2) 3.3 (0.8–109.4) 4.3 (0.8–271.2)
Karnofsky score ≤80 (%)
>80 (%)
16.7
83.3
11.6
88.4
14.1
85.9
Carcinoid syndrome* (%) 40.5 37.2 38.8
Resection of primary (%) 69.1 62.8 65.9
Hepatic tumour load
0%
0–10%
10–25%
25–50%
50%
16.7
59.5
7.1
11.9
4.8
11.6
62.8
4.7
9.3
11.6
14.1
61.2
5.9
10.6
8.2
Octreoscan positive (%) 76.2 72.1 74.1
Ki-67 up to 2% (%) 97.6 93.0 95.3
CgA elevated (%) 61.9 69.8 65.9
* not requiring octreotide for symptom control
Rinke A, Müller HH, Schade-Brittinger C, et al. J Clin Oncol. 2009;27:4656-4663.
PROMID
39. Octreotide LAR 30 mg Extends TTP in Patients with Functioning and
Non-functioning Tumours
0
0.25
0.5
0.75
1
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90
0
0.25
0.5
0.75
1
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90
Based on the per protocol analysis
P=0.0008; HR=0.25 [95% CI: 0.10–0.59]
Proportionwithoutprogression
P=0.0007; HR=0.23 [95% CI: 0.09–0.57]
Proportionwithoutprogression
Patients with non-functioning tumours Patients with functioning tumours
Time (months)Time (months)
Octreotide LAR 30 mg: 17 pts / 11 events
Median TTP 14.26 months
Placebo: 16 patients / 14 events
Median TTP 5.45 months
Octreotide LAR 30 mg: 25 pts / 9 events
Median TTP 28.8 months
Placebo: 27 patients / 24 events
Median TTP 5.91 months
Arnold R. Abst #4508 presented at ASCO 2009, Orlando FL
Rinke A et al. J Clin Oncol 2009;27:4656–4663
40. • Everolimus
– Loss of TSC2 and NF1 are both associated with
mTOR activation
– mTOR pathway mutations were also found in
sporadic pNETs
– RADIANT-1
• 160 patients were treated in two strata, with
everolimus (n = 115) or everolimus plus octreotide (n =
45) based on whether patients were on octreotide at
study entry
• Advanced pNETs with progression following
chemotherapy
• Median PFS for patients receiving everolimus or
everolimus plus octreotide were 9.7 months and 16.7
months, respectively
41. – RADIANT- 3
• 410 patients with progressive pNETs were randomly
assigned to receive everolimus or placebo
• Everolimus prolonged median PFS from 4.6 months to
11 months leading to a 65% risk reduction for
progression compared to placebo (HR = 0.35; 95% CI,
0.27 to 0.45; p <0.0001).
• Treatment also reduced the level of tumor-secreted
hormones
42. • Sunitinib
– Activity against VEGF receptors, c-Kit, and platelet-
derived growth factor receptor
– 3 study compared sunitinib to placebo in pNETs
– Results of an early unplanned analysis showed
improved PFS (5.5 months versus 11.4 months).
– Due to the small number of events and unplanned
nature of the analyses, the results failed to cross
the O’Brian Fleming efficacy threshold for
statistical significance
43.
44. Cytotoxic Chemotherapy
• Role of cytotoxic chemotherapy continues to
be debated
• Streptozocin-Based Chemotherapy
– Streptozocin was originally isolated from
streptomyces achromogenes in the 1950s
– Antitumor activity in pNETs was first reported in
1973; in a study that included 52 patients, a
response rate of 50% was reported
45. – Eastern Cooperative Oncology Group
subsequently compared this combination to
streptozocin plus doxorubicin72 and reported a
significantly higher response rate (69% versus
45%), time to progression (median, 20 months
versus 7 months), and OS (median, 2.2 years
versus 1.4 years) for streptozocin plus doxorubicin
than for streptozocin plus 5-FU.
– Based on these data, combination chemotherapy
with streptozocin-based regimens is considered
the standard treatment option by many
46. – Two small retrospective series have recently cast
doubt on the value of streptozocin-based
chemotherapy.
– Each of these studies examined only 16 patients.
– Both reported a disappointing radiologic response
rate of only 6%
47. • Dacarbazine- and Temozolomide-Based
Chemotherapy
– Dacarbazine was initially studied in a phase 2 study
that included 42 patients with pNETs. A response rate
of 33% was observed
– Temozolomide-based therapy is generally well
tolerated, absolute lymphopenia may occur and has
been associated with opportunistic infections.
– These studies suggest that temozolomide may have
activity in pNETs.
– A randomized study comparing temozolomide versus
temozolomide plus capecitabine is ongoing
48. • Peptide Receptor Radiotherapy
– 111In-, 90Y-, or 177Lu-labeled somatostatin analogues
have reported promising results in the control of
hormone-associated symptoms
– Largest reported series, a response rate of 30% was
found among a subset of 310 patients.
– However, if intent-to-treat analysis were performed,
the objective response would be approximately 18%
– Toxicities with peptide receptor radiotherapy included
nausea, vomiting, abdominal pain, cytopenia, and hair
loss.
– More serious side effects, including renal failure,
leukemia, and myelodysplastic syndrome, have also
been reported
– Large-scale random assignment trials are needed to
define its role in the management of pNETs.s
49. Liver-Directed Regional Therapy
• Liver is the most common and sometimes the
only site of metastasis
• Treatment approaches are generally palliative
• In the absence of a hormonal syndrome,
typical indications for liver-directed therapy
– Right upper quadrant pain,
– Early satiety due to gastric compression by an
enlarged left hepatic lobe, and the need to
– Control slowly progressive but bulky disease
50. • Hepatic Artery Embolization and
Chemoembolization
• Liver has dual blood supply, the normal liver
derives most of its blood supply from the portal
circulation
• pNET metastases, however, receive most of their
blood supply from the hepatic artery
• Interruption of the blood supply from the hepatic
artery preferentially causes ischemic necrosis of
the metastases while sparing most of the normal
liver
51. • The choice of embolic material varies by
center and may include lipiodol or ethiodized
oil, small plastic particles, or gelatin foam
particles
• Chemoembolization, cytotoxic agents are
administered intra-arterially before the vessels
are embolized, as this approach has the
potential to enable delivery of a higher
chemotherapy dose to liver metastases
52. • Retrospective study from MD Anderson, where the
outcome of patients with pNET were separately
examined, the objective tumor response rate was 35%
• Bland embolization group was compared with the
chemoembolization group, a trend was observed for
improved response rate with the addition of
chemotherapy (50% versus 25%; p = 0.06)
• Investigators compared doxorubicin with streptozocin
during embolization and reported a higher response
rate with streptozocin-based chemoembolization after
multivariate analyses
53. • Constellation of transient symptoms and laboratory
abnormalities, sometimes referred to as
“postembolization syndrome,” occurs in most patients
• Abdominal pain, nausea, fever, fatigue, and elevated
liver enzymes
• Crises related to massive release of hormone(s) may
occur in the presence of functional tumors;
prophylactic administration of somatostatin analogues
should always be considered
• To minimize the risk of hepatic insufficiency,
embolization should be carried out in one liver lobe at
a time
• In patients with bulky disease or poor liver function,
more limited embolization of liver segments should be
considered
54. • Radioactive microsphere embolization is
emerging as a well-tolerated outpatient
procedure providing symptom relief and
varying response rates
• Prospective studies are lacking in patients
with NETs and specifically those with pNETs
55. Hepatic Metastasectomy and
Transplantation
• Aggressive surgical resection has a role in the
management of metastatic islet cell carcinoma
• Series of 170 patients with NET at Mayo Clinic
– Total of 52 pNETs were included in this study
– OS rate for all 170 patients was reported to be
61% and 35% at 5 and 10 years, respectively
– Liver resection is not curative in most patients; the
disease recurrence rate was 85% at 5 years
56. • Patients with more extensive but still
resectable disease, we advocate resection for
those tumors with favorable biologic
characteristics
• Liver resection should be avoided in patients
with a high-grade histologic subtype
• Hepatic transplantation for the management
of pNETs should be considered investigational
57. • Radiofrequency Ablation
• RFA can be carried out during laparoscopy,
laparotomy, or via a percutaneous approach
58. • Choosing therapy at each stage should take
into account the aggressiveness of the tumor,
the burden (volume) of disease, and any
symptoms due to tumor burden or hormonal
secretion
59.
60.
61.
62.
63.
64. Functional Tumors
• Gastrinoma, or Zollinger-Ellison syndrome (ZES)
– Rare disease caused by a NET (gastrinoma) in the pancreas
or duodenum
– Hypersecretion of gastrin results in uncontrolled
stimulation of parietal cells and production of gastric acid
causing refractory peptic ulcer disease
– If the serum gastrin level is still elevated 1 week after the
patient has stopped acid-suppressive therapy, it is then
important to measure gastric pH
– Patients with ZES should have a gastric pH of <2
– Serum gastrin ≥1,000 pg/ml or 10-fold above the normal
range, and a gastric pH ≤2 secures the diagnosis of ZES
67. – Patients with gastrin levels between 100 pg/ml
and 1,000 pg/ml and a gastric pH ≤2, a secretin or
calcium stimulation test should be considered
• Positive secretin test is associated with a postinjection
serum gastrin level increase of >200 pg/ml
• Positive calcium stimulation test with a postinjection
serum gastrin level increase of >395 pg/ml
– Duodenal location being the most common
– In pancreas -pancreatic head or uncinate process
– Serum gastrin levels correlate with the extent of
disease
68. – Tumor localization studies should be performed as part of
the preoperative evaluation
– Upper endoscopy with EUS of the pancreatic head and
duodenum, multidetector CT, and somatostatin receptor
scintingraphy
– When all localization studies are negative, the gastrinoma
is most likely in the duodenum, which must be opened
surgically (duodenotomy) to successfully locate and
remove the tumor
– For pancreatic gastrinomas, the operation is based on the
anatomy of the tumor and may consist of enucleation or
pancreaticoduodenectomy
– Regional lymphadenectomy is critically important.
69. • Management of Advanced Gastrinoma
– The introduction of PPIs brought significant advances in
the management of ZES, allowing for once or twice daily
dosing
– Dose of PPIs required to manage ZES is significantly higher
than typically used in idiopathic peptic ulcer disease
– Advanced gastrinoma is the development of type II gastric
carcinoids in the setting of MEN1-associated ZES
– Gastric carcinoids are often small, multifocal, and of low
malignant potential
– When few in number, they can often be excised
endoscopically
70.
71. Insulinoma
• Most common functioning pNETs - 60% of functional
tumours
• Seldom malignant
• 10% of insulinomas are multiple, 10% malignant, and 10%
are associated with the Multiple Endocrine Neoplasm
(MEN) type 1 syndrome
• Insulinoma may occur either as a unifocal sporadic event or
as part of MEN1
• Uncontrolled secretion of insulin results in hyperglycemia,
manifested by neuroglycopenic symptoms such as blurred
vision, confusion, and abnormal behavior, which may
progress to loss of consciousness and seizure
• occur anywhere throughout the pancreas
72. • Body releases catecholamines, which elicit perspiration, anxiety,
palpitations, and hunger
• Weight gain
• Supervised fasting of the patient, including laboratory evaluation
and clinical observation
• Serum levels of plasma glucose, C-peptide, proinsulin, insulin, and
sulfonylurea are measured at intervals of 6 to 8 hours and
• When symptoms develop
– Insulin level >3 μIU/ml (usually >6 μIU/ml) when their blood glucose is
<40 to 45 mg/dL.
– The insulin-to-glucose ratio is ≥0.3 reflecting the inappropriate
secretion of insulin at the time of hypoglycemia
– Increase C peptide levels
73. • Localization studies performed as part of the
preoperative evaluation include
– Contrast-enhanced, multidetector CT
– Upper endoscopy with EUS of the pancreas
• Tumor localization is not successful
– Regionalization of an insulinoma is performed with
selective arterial calcium stimulation and hepatic vein
sampling
• Elevation of hepatic vein insulin following calcium
infusion of the gastroduodenal artery and/or SMA -
head or uncinate process
• The splenic artery - body or tail of the pancreas
74. • Standard treatment is enucleation
• Segmental resection of the pancreas, distal
pancreatectomy, or pancreatico
duodenectomy may be necessary
• Large defects in the pancreas resulting from
enucleation are usually treated with a Roux-
en-Y pancreaticojejunostomy to prevent a
pancreatic leak at the enucleation site
75. • Management of Advanced Insulinoma
– Glycemic control is a key aspect of managing malignant
insulinomas
– Mild symptoms sometimes can be controlled by diet
– Medical therapy may include diazoxide, an
antihypertensive agent known to increase blood sugar
– Glucagon may also have a role in the management of
insulinomas
– Short-acting somatostatin analogues be initiated under
direct medical supervision
– The efficacy of everolimus for the treatment of insulinoma
has been confirmed in several case series
– Streptozocin-based chemotherapy
76.
77. VIPoma
• Cause of the classic Verner-Morrison syndrome
• Vasoactive intestinal peptide, which can cause watery
diarrhea, hypokalemia, and achlorhydria
• Patients can have more than 20 bowel movements a
day, with a daily stool volume exceeding 3 L
• In adults arise from the pancreas.
• In children extrapancreatic location
• Control of diarrhea is an important part of
management
• Somatostatin analogues108; octreotide can promptly
control diarrhea in 80% to 90% of patients
• Interferon is rarely used in the frontline setting, but it
may have a role in cases refractory to somatostatin
analogues
• Cytoreduction should be initiated whenever possible.
78. • 0.05-0.2 new cases per million adults
• Third most common neuroendocrine tumor of the
pancreas
• Solitary, found in body or tail.
• 2/3 malignant
• Male-to-female ratio in children - 1:1,
in adults. - 1:3
79. • Constant features
– Watery Diarrhea
– Hypovolemia
– Hypokalemia
– Acidosis
• Variable features
– Achlorhydria or hypochlorhydria
– Hypercalcemia
– Hyperglycemia
– Flushing with rash.
80. • Diagnostic triad
– Secretory diarrhea
– High levels of circulating VIP > 150pg/ml
– A pancreatic tumor
• Localization
– SRS - 91% of primary tumors and 75% of metastases.
Nikou GC, et al. Hepatogastroenterology 2005
– Endoscopic ultrasound.
– CT
– MRI
– Arteriography
– IOUS
82. • Glucagonoma
– Diabetes and a characteristic rash known as
necrolytic migratory erythema
– Weight loss, diarrhea, glossitis, and angular
stomatitis have also been reported
– Somatostatin analogues may have a role in the
management of the hormonal syndrome in
patients with unresectable tumors
– Oral hypoglycemic agents and insulin can be used
to control the diabetes
83.
84. Somatostatinoma
• Arise from the pancreas or the duodenum
• Insidious and nonspecific nature of the symptoms
- diagnosed at an advanced stage
• Diabetes, diarrhea, and jaundice due to biliary
obstruction
• Associated with von Recklinghausen disease
(neurofibromatosis)
• Management for somatostatinomas parallel
those of nonfunctional pNETs
86. High-Grade Neuroendocrine Carcinoma
• Early systemic dissemination and rapid growth
• Clinical behavior with small-cell carcinomas of
the lung
• Induction chemotherapy even for localized
potentially resectable cases due to the
aggressive nature of this disease and the high
rate of relapse