Endoscopic and surgical management of gastric and duodenal NETS - - PowerPoint PPT Presentation

U N I V E R S I T Ä T S M E D I Z I N B E R L I N

The 2018 Gastrointestinal Oncology Conference 2nd November 2018, Arlington WA

Endoscopic and surgical management of gastric and duodenal NETS

Sebastian Maasberg

• Med. Dep. Of Gastroenterology and Hepatology

University Medicine Charité Berlin

Epidemiology of neuroendocrine neoplasia

Yao J et al,., JCO 2008 Dasari A et al, JAMA Oncol 2017

1.09 5.25 1.09 6.98 Lung Rektum Small Intestine Stomach

Primary tumor localization in population-based studies

Niederle et al, Endocr Rel Cancer 2010

Austria

11.6% 22.8% 5.6% 15.4% 20.7% 7.0% 15.4% 1.7% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% P a n c r e a s S t

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l e u m A p p e n d i x C

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Phenotyp of gastric NET

Small & solitary Mucosa: atrophic Small & multiple Mucosa: atrophic Large & solitary Mucosa: normal Small & multiple Mucosa: hypertrophic

T ype 1 T ype 2 T ype 3 T ype 4 Proportion of Gastric-NEN [%] 70 - 80 5–6 10-20 <5 Characteristic Mostly small (< 1-2 cm), in 65% multipel, in 78% polypoid Mostly small (<1–2 cm) and multipel, polypoid solitary, frequently large (>2cm), polypoid & sometimes ulcerated solitary, mostly large (>2cm), polypoid & mostly ulcerated Association chronic atrophic gastritis (CAG) Gastrinoma & ZES in MEN1 none none Pathology G1/2-NET G1/2-NET mostly G2-NET G3-NEC Serum-Gastrin ↑ ↑↑ normal normal Stomach-pH ↑↑ ↓↓ normal normal Metastasis [%] 2-5 5-15 30-80 50-100 Tumor-associated deaths [%] <10 25-30 60-95

ZES = Zollinger-Ellison-Syndrom Klöppel et al Yale J Biol Med 1996

Phenotyp of gastric NET

G3 G2 G1 Stage I

• St. II
• St. III
• St. IV

La Rosa et al Hum Pathol 2011

Prognosis depends on: Ø Type of gastric-NEN Ø TNM-Staging Ø Ki67-Grading

Prognostic factors in gastric NEN

Type 1/2 Type 3 Type 4 & MANEC

Staging in gastroduodenal NEN

• Endoscopy including biopsy or polypectomy of the largest polyp

and mucosal biopsies of antrum (2x) and corpus & fundus (min. 4x each) ØEUS in gastric polyps > 1-2cm and in duodenal NEN

• Laboratory: Chromogranin A, Gastrin (Type 1/2 gNET, dNET),

Vitamin B12 and anti-parietal cell Ab (type 1), H. pylori (type I)

• MEN-1 diagnostic in type II gastric NET and gastrinoma dNEN
• CT/MRI in type 2-4 gastric NEN and duodenal NEN
• Somatostatin-receptor imaging in metastatic g/d NEN

Therapeutic Management of gastric NETs

Type 1 or 2 Gastric NET

<1cm T1 1- 2 cm T1 >2 cm Endoscopic Therapy (PE by Forceps, EMR) Endoscopic Therapy (EMR, ESD) Surgery (partial or total gastrectomy) Endoscopic Follow up: Type 1 every 1-2 Year Type 2 every Year Regular Follow: CT/MRI/Sonography + Endoscopy + possibly SRS/Ga68 oder FDG- PET/CT

Type 1/2

(>T2 or incomplete resection)

and Type 3 or 4

Adapted from Delle Favre et al, Neuroendocrinology 2012 & 2016

NANETS Guidelines on Gastric NEN

Indvidualized therapeutic approach: endoscopic-assisted laparoscopic resection in gastric NET

Kunz P et al, Pancreas 2013 Maasberg et al, Der Chirurg 2016

recurrence rate and risk factors for metastases in type I gastric NET

Merola E et al, Neuroendocrinology 2012 Grozinsky-Glasberg et al, WCG 2013

median recurrence free survival 8 months

Classification of duodenal NET

Typ 1 Typ 2 Typ 3 Typ 4 Typ 5 Characteristic Gastrin Secretion Somatostatin Secretion Gangliocytic Paraganglioma Gastrin- /Serotoin- /Calcitonin Expression w/out Symptoms Poorly differentiated Associated Disease ZES/MEN-1 NF-1 None None None Localization Proximal Duodenum Periampullary /ampullary Periampullary/ ampullary Proximal Duodenum Periampullary /ampullary Size 77% <1cm, Mean 9,3mm 15-23mm 10-25mm 10-15mm Mean 25mm (8-40mm) Histology NET

• G1

NET

• G1/G2

NET

• G1/G2

NET

• G1/G2

NEC-G3

Adapted from Maasberg et al., Der Chirurg 2016

Disease specific survival of duodenal NET

Vanoli et al, Neuroendocrinology 2017

ENETS Guidelines – Therapy of Duodenal NET

Delle Favre et al, Neuroendocrinology 2016

Outcome of endoscopic treatment in dNET

Outcome of EMR vs ESD

Endoscopic mucosal resection (EMR) Endoscopic submucosal dissection (ESD)

Masumoto S. et al, WJG 2014 Kim GH et al, J Gastroenterol Hepatol 2014

To conclude:

• Management of localized gastric NEN comprises:

– Endoscopic therapy in type I/II NET with polyps <2cm and absence of submucosal invasion – Type III/IV and TNM-Stage >T2 need surgical resections

• In localized duodenal NEN management consists of:

– Endoscopic treatment in non-periampullar polyps <1cm – Polyps between 1-2cm can be treated by endoscopy or surgery – Larger polyps (>2cm) and polyps located periampullary need a surgical treatment approach

Thank you for your attention

Interactive Question No 1:

What treatment strategy would you recommend in type I gastric NET with >10 polyps of differented sizes (<2cm) and without submucosal infiltration or locoregional/distant metastasis ? 1.) endoscopic resection of all polyps 2.) endoscopic resection of every polyp >1cm 3.) surgery 4.) treatment with somatostatin analogue 5.) antrectomy to suppress hypergastrinemia

Interactive Question No 2:

What treatment strategy would you recommend in a non ampullary NET of the duodenum 1.1cm in size but and without submucosal infiltration or locoregional/distant metastasis ? 1.) endoscopic resection with EMR 2.) endoscopic resection with ESD 3.) local resection 4.) pancreaticduodenectomy