Imaging and Management of Pancreatic Endocrine Tumors in MEN 1

Transcription

1 October 20, 2008 Imaging and Management of Pancreatic Endocrine Tumors in MEN 1 Marie Elaine Stevens Georgetown University School of Medicine, Year IV Dr.

2 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 2

3 Our Patient: History Mr. T is a 32 yo male with a strong family history of MEN 1 presenting with severe abdominal pain He has a known history of Zollinger-Ellison syndrome from presumed gastrinoma (although prior imaging studies were negative) His disease is currently fairly well controlled with Omeprazole 40mg BID 3

4 Our Patient: Laboratory Findings In addition to elevated serum gastrin, laboratory work-up revealed hyperprolactinemia and hypercalcemia These findings are suggestive of a prolactinoma and parathyroid adenoma, compatible with Mr. T s presumed diagnosis of MEN 1 At this time, Mr. T elected to undergo a full imaging work-up 4

5 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 5

6 Multiple Endocrine Neoplasia: Epidemiology MEN syndromes are part of a group of autosomal dominant endocrine disorders first recognized in the early part of the 20th century The population prevalence of MEN 1 is about 1 in 30,000 M EN 2 affects about 1 in 40,000 individuals MEN 2-A accounts for most cases of MEN 2 MEN 2-B represents about 5% of all cases of MEN 2 6

7 Spectrum of Disease: MEN 1 (Wermer Syndrome) Parathyroid Adenoma - 95% Pituitary Adenoma - 50% Prolactinoma 25% Nonfunctioning 10% Growth Hormone 5%, ACTH 2%, Thyrotropin 5% Pancreatic Endocrine Tumors - 80% Gastrinoma 40% Insulinoma 10% Nonfunctioning 20% Glucagonoma 2%, VIPoma 2%, Somatostatinoma 2% Other Features Forgut Carcinoid 15%, Adrenal Neoplasms 30% Facial Angiofibroma 85%, Collagenoma 70%, Lipoma 30%, Leiomyoma 5%, Meningioma 5% 7

8 Spectrum of Disease: MEN 2 MEN 2-A (Sipple Syndrome) Medullary Thyroid Carcinoma - 100% Pheochromocytoma - 50% Parathyroid Adenoma % MEN 2-B Medullary Thyroid Carcinoma - 100% Pheochromocytoma - 50% Marfanoid Habitus - >95% Intestinal Ganglioneuromatosis and Mucosal Neuromas - >98% 8

9 Multiple Endocrine Neoplasia: Pathophysiology Patients with MEN 1 possess a germline mutation in the MENIN gene The MENIN gene is located on chromosome 11 and produces a tumor suppressor protein called menin The gene responsible for MEN 2 is protooncogene RET RET is expressed in neural crest-derived cells and encodes for RET protein (the tyrosine kinase subunit of a cell surface receptor) Activation of RET leads to hyperplasia of target cells in vivo 9

10 MEN Syndromes: Comparison MEN 1 MEN 2-A MEN 2-B Pituitary Adenoma >50% Pancreatic Endocrine >80% Tumor Parathyroid Adenoma 95% 10-35% Pheochromocytoma 50% 50% Medullary Thyroid 100% 100% Carcinoma Intestinal Neuromas >98% Marfanoid Habitus >95% 10

11 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 11

12 Our Patient: Imaging Work- Up for Hyperprolactinemia 12

13 MRI of the Brain Axial post-gadolinium T1WI Sagittal post-gadolinium T1WI * * PACS, BIDMC PACS, BIDMC Findings: a 1.4 x 1.4 x 1.5 cm enhancing lesion likely representing a macroadenoma invading the left sphenoid sinus 13

14 CT of the Sella and Sinuses Axial C- CT PACS, BIDMC Findings: expansion, scalloping and erosion of the floor of the sella, with scalloping of the anterior and posterior aspects of the sella 14

15 Mr. T: Follow-up of Hyperprolactinemia Our Patient Underwent Transsphenoidal Resection of the Prolactinoma 15

16 Our Patient: Imaging Work-Up for Hypercalcemia 16

17 Nuclear Medicine Scan Technetium-99m Sestamibi Scan * * * * Parotid Glands Technetium-99m Sestamibi Scan * * Submandibular Glands Thyroid PACS, BIDMC PACS, BIDMC Findings: no focal tracer uptake to indicate a parathyroid adenoma 17

18 Thyroid Ultrasound Thyroid Ultrasound Technetium-99m Sestamibi Scan Submandibular Glands * * * Thyroid Probable Parathyroid Adenoma PACS, BIDMC PACS, BIDMC Findings: a probable enlarged left parathyroid gland, which could represent adenoma Can this be visualized retrospectively seen on the patient s Sestamibi scan? 18

19 Mr. T: Follow-up of Hypercalcemia Our Patient Underwent Resection of a Left Inferior Parathyroid Adenoma 19

20 Our Patient: Follow-Up Imaging for Known History of Zollinger-Ellison Syndrome 20

21 CT of the Abdomen Axial C+ CT Axial C+ CT PACS, BIDMC PACS, BIDMC Findings: new nodular hyperenhancing area within the pancreatic head, relative to the remainder of the pancreas and several smaller foci of relative hyperattenuation seen within the pancreatic tail, suggestive of multiple gastrinomas 21

22 Follow-Up of Zollinger-Ellison Syndrome: Newly Discovered Multiple Pancreatic Gastrinomas Mr. T Elected to Undergo Further Imaging Work-Up for Staging and Surgical Planning to Resect the Gastrinomas 22

23 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 23

24 Pancreatic Endocrine Tumors: Pathophysiology Pancreatic endocrine tumors occur in 80% of patients with MEN 1 Tumors are often multicentric and may undergo malignant transformation Patients with MEN 1 have a decreased life expectancy, with a 50% probability of death by age 50 years Half of the deaths result from a malignant process or a sequela of the endocrine disease ZES is the major cause of morbidity and mortality in patients with MEN 1 24

25 Types of Pancreatic Endocrine Tumors: Nonfunctioning Tumors Nonfunctioning pancreatic endocrine tumors are the most common pancreatic tumors, occurring in % of cases The name is a misnomer because most of them produce pancreatic polypeptide 25

26 Types of Pancreatic Endocrine Tumors: Gastrinomas Gastrinomas are the most common cause of symptomatic disease and are found in approximately 60% of patients with MEN 1 Compared to the sporadic form in Zollinger-Ellison syndrome, gastrinomas in MEN 1 are more often duodenal, small, and multicentric 26

27 Types of Pancreatic Endocrine Tumors: Insulinomas and Glucagonomas Insulinomas account for approximately 20-35% of pancreatic endocrine tumors Similar to gastrinomas, they can be multicentric (10-20%), where 25% metastasize either to regional lymph nodes or to the liver Glucagonomas occur in 3% of patients with MEN 1 and are silent or present with hyperglycemia Typical skin lesions (necrolytic migratory erythema) are rare in patients with MEN 1 27

28 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 28

29 Pancreatic Endocrine Tumors: Imaging Modalities Contrast- Enhanced CT MRI Somatostatin Receptor Scintigraphy Endoscopic Ultrasound Intraoperative Ultrasound 29

30 Our Patient: CT of the Pancreas Axial C+ CT of the Abdomen High-resolution contrastenhanced CT is the initial imaging technique used to localize and stage most pancreatic endocrine tumors However, it fails to help identify as many as 70% of lesions PACS, BIDMC Axial C+ CT of the Abdomen Nodular hyperenhancing lesion in the pancreatic head Several smaller hyperattenuating lesions in the pancreatic tail PACS, BIDMC 30

31 Our Patient: Reconstructed Images C+ CTA Reconstruction of the Abdominal Aorta C+ CTA Reconstruction of the Portal Vein Celiac Trunk * * SMA Portosplenic Confluence * PACS, BIDMC PACS, BIDMC High-resolution contrast-enhanced CT can also be used to generate reconstructed images used in operative planning 31

32 Pancreatic Endocrine Tumors: Imaging Modalities Contrast- Enhanced CT MRI Somatostatin Receptor Scintigraphy Endoscopic Ultrasound Intraoperative Ultrasound 32

33 Companion Patient #1: MRI of the Pancreas Axial Fat-Saturated T1WI Axial Fat-Saturated T2WI Owen NJ. British J Rad 2001; 74: Owen NJ. British J Rad 2001; 74: Pancreatic endocrine tumors have high relaxation times result in greater enhancement on T1- and T2-weighted images of pancreatic endocrine tumors, compared to adenocarcinomas The images above show lesions of the pancreas with solid and cystic components 33

34 Pancreatic Endocrine Tumors: Imaging Modalities Contrast- Enhanced CT MRI Somatostatin Receptor Scintigraphy Endoscopic Ultrasound Intraoperative Ultrasound 34

35 Companion Patient #2: Somatostatin Receptor Scintigraphy (SRS) Pancreatic endocrine tumors express large numbers of SST receptors on their cell surfaces (except SSTomas) Radiolabeled octreotide used in SRS preferentially binds to SST receptors SRS is helpful in diagnosing small extrapancreatic metastases The octreotide scan to the right shows a large pancreatic-tail neoplasm, several tracerenhancing hepatic metastases, and excretion of tracer in the bladder Octreotide Scan * 35

36 Companion Patient #3: Somatostatin Receptor Scintigraphy Octreotide Scan Endoscopic Ultrasound * * Norton JA. Annals of Surgery 2004; 240: Norton JA. Annals of Surgery 2004; 240: Another example of SRS localization of a gastrinoma in the area of the duodenum/pancreatic head The same patient undersent endoscopic ultrasound (EUS), which revealed a lesion situated between the pancreatic duct and CBD 36

37 Pancreatic Endocrine Tumors: Imaging Modalities Contrast- Enhanced CT MRI Somatostatin Receptor Scintigraphy Endoscopic Ultrasound Intraoperative Ultrasound 37

38 Companion Patient #4: Endoscopic Ultrasound Endoscopic Ultrasound Endoscopic Ultrasound * * Gauger PG. British Journal of Surgery 2003; 90: Gauger PG. British Journal of Surgery 2003; 90: EUS can help localize pancreatic endocrine tumors assess lymph node metastases It cannot, however, be used to evaluate hepatic and distant spread The images above show of pancreatic endocrine tumors in the pancreatic tail and uncinate process 38

39 Distribution of Tumors by Endoscopic Ultrasound In this study, 43 pancreatic endocrine tumors were demonstrated on initial EUS in 15 asymptomatic patients with MEN 1 60% of tumors were found in tail of pancreas 16% body 24% head/uncinate process Distribution of Pancreatic Endocrine Tumors by EUS Gauger PG. British Journal of Surgery 2003; 90:

40 Pancreatic Endocrine Tumors: Imaging Modalities Contrast- Enhanced CT MRI Somatostatin Receptor Scintigraphy Endoscopic Ultrasound Intraoperative Ultrasound 40

41 Our Patient: Intraoperative Ultrasound Intraoperative Ultrasound Intraoperative Ultrasound * * PACS, BIDMC PACS, BIDMC The advantage of intraoperative ultrasound is that it provides realtime images and information about the location and number of pancreatic endocrine tumors (sensitivity 90%) The images above show multiple solid hypoechoic nodules in the tail of our patient s pancreas 41

42 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 42

43 Pancreatic Endocrine Tumors: Surgical Treatment Options Role of surgery in MEN 1 is controversial Most tumors are multicentric and cure is achieved only occasionally Surgery may be indicated in patients with no distant metastases Removal of tumors > 2 cm in reduces the frequency of liver metastasis Local tumor excision is preferred, with larger tumors of the pancreatic body or tail removed by distal pancreatectomy 43

44 Goals of Surgical Therapy The goals of surgical therapy for pancreatic endocrine neoplasms include: Controlling the symptoms of hormone excess Safely resecting the maximal amount of tumor mass possible Preserving the maximal amount of pancreatic parenchyma possible 44

45 Surgical Treatment Options: Total Pancreatectomy Total Pancreatectomy Long-term benefit of total pancreatectomy is unproven in pancreatic endocrine tumors and the associated surgical morbidity seems unacceptable 45

46 Surgical Treatment Options: Classic Whipple Procedure Classic Whipple Procedure Axial C+ CT In our patient, the lesion in the head of the pancreas was excised with a classic Whipple Procedure Unfortunately, multiple lesions in the pancreatic tail were left behind PACS, BIDMC Intraoperative Ultrasound Axial C+ CT * PACS, BIDMC PACS, BIDMC Lesions in the head or uncinate process of the pancreas can be resected with pancreaticoduodenectomy (Whipple Procedure) 46

47 Surgical Treatment Options: Distal Pancreatectomy Endoscopic Ultrasound Distal Pancreatectomy * Gauger PG. British Journal of Surgery 2003; 90: Gauger PG. British Journal of Surgery 2003; 90: The EUS above of companion patient #4 shows a tumor in the tail of the pancreas This patient underwent distal pancreatectomy and splenectomy, enucleation of a pancreatic head endocrine tumor, and duodenotomy with excision of duodenal gastrinoma 47

48 Agenda Discuss Our Patient s Presentation Review MEN Syndromes Present Our Patient s Imaging Studies Discuss Pancreatic Endocrine Tumors Pathophysiology Imaging Treatment Present Conclusions 48

49 Pancreatic Endocrine Tumors: Conclusions The major cause of morbidity and mortality in patients with MEN 1 is the sequela of endocrine disease (eg Zollinger-Ellison Syndrome) Contrast-enhanced CT, MRI, somatostatin receptor scintigraphy, EUS and intraoperative ultrasound all have important, complimentary roles in the diagnosis and treatment of pancreatic endocrine tumors The role of surgery in MEN 1 is controversial and efforts should be made to preserve the maximal amount of pancreatic parenchyma possible while resecting the tumor mass 49

50 References Kroneberg: Williams Textbook of Endocrinology, 11th Edition. Chapter 40 - Multiple Endocrine Neoplasia. Robert F. Gagel, Stephen J. Marx. Saunders, Squire s Fundamentals of Radiology: 6th Edition. Robert A. Novelline, MD. Harvard University Press, emedicine: Multiple Endocrine Neoplasia. Robert J Ferry Jr, MD. Article Last Updated: Jun 12, 2008 emedicine: Wermer Syndrome (MEN Type 1). Irina Lendel, MD. Article Last Updated: Jan 8, 2007 emedicine: Neoplasms of the Endocrine Pancreas. Eric J Hanly, MD. Article Last Updated: Jun 29, Hellman P, Hennings J, Akerstrom G, Skogseid B. Endoscopic ultrasonography for evaluation of pancreatic tumours in multiple endocrine neoplasia type 1. British Journal of Surgery 2005; 92: Owen NJ, Sohaib SAA, Peppercorn PD, Monson JP, Grossman AB, Besser GM, Reznek RH. MRI of pancreatic neuroendocrine tumours: Pictoral Review. The British Journal of Radiology 2001; 74: Doherty GM. Multiple Endocrine Neoplasia Type 1. Journal of Surgical Oncology 2005; 89: Norton JA, Jensen RT. Resolved and Unresolved Controversies in the Surgical Management of Patients With Zollinger-Ellison Syndrome. Annals of Surgery 2004; 240: Gauger PG, Scheiman JM, Wamsteker EG, Richards MI, Doherty GM, Thompson NW. Role of endoscopic ultrasonography in screening and treatment of pancreatic endocrine tumours in asymptomatic patients with multiple endocrine neoplasia type 1. British Journal of Surgery 2003; 90:

51 Acknowledgements Dr. Robert Kane Dr. Katie Krajewski Dr. Andrew Hines-Peralta Dr. Gillian Lieberman Maria Levantakis Larry Barbaras 51