A multigenomic liquid biopsy biomarker for neuroendocrine tumor disease outperforms CgA and has surgical and clinical utility.

BACKGROUND: Biomarkers are key tools in cancer management. In neuroendocrine tumors (NETs), Chromogranin A (CgA) was considered acceptable as a biomarker. We compared the clinical efficacy of a multigenomic blood biomarker (NETest) to CgA over a 5-year period. PATIENTS AND METHODS: An observational, prospective, cross-sectional, multicenter, multinational, comparative cohort assessment. Cohort 1: NETest evaluation in NETs (n = 1684) and cancers, benign diseases, controls (n = 731). Cohort 2: (n = 1270): matched analysis of NETest/CgA in a sub-cohort of NETs (n = 922) versus other diseases and controls (n = 348). Disease status was assessed by response evaluation criteria in solid tumors (RECIST). NETest measurement: qPCR [upper limit of normal (ULN: 20)], CgA (EuroDiagnostica, ULN: 108 ng/ml). STATISTICS: Mann-Whitney U-test, AUROC, chi-square and McNemar' test. RESULTS: Cohort 1: NETest diagnostic accuracy was 91% (P < 0.0001) and identified pheochromocytomas (98%), small intestine (94%), pancreas (91%), lung (88%), gastric (80%) and appendix (79%). NETest reflected grading: G1: 40 ± 1, G2 (50 ± 1) and G3 (52 ± 1). Locoregional disease levels were lower (38 ± 1) than metastatic (52 ± 1, P < 0.0001). NETest accurately stratified RECIST-assessed disease extent: no disease (21 ± 1), stable (43 ± 2), progressive (62 ± 2) (P < 0.0001). NETest concordance with imaging (CT/MRI/68Ga-SSA-PET) 91%. Presurgery, all NETs (n = 153) were positive (100%). After palliative R1/R2 surgery (n = 51) all (100%) remained elevated. After curative R0-surgery (n = 102), NETest levels were normal in 81 (70%) with no recurrence at 2 years. In the 31 (30%) with elevated levels, 25 (81%) recurred within 2 years. Cohort #2: NETest diagnostic accuracy was 87% and CgA 54% (P < 0.0001). NETest was more accurate than CgA for grading (chi-square = 7.7, OR = 18.5) and metastatic identification (chi-square = 180, OR = 8.4). NETest identified progressive disease (95%) versus CgA (57%, P < 0.0001). Imaging concordance for NETest was 91% versus CgA (46%) (P < 0.0001). Recurrence prediction after surgery was NETest-positive in >94% versus CgA 11%. CONCLUSION: NETest accurately diagnoses NETs and is an effective surrogate marker for imaging, grade, metastases and disease status compared to CgA. A multigenomic liquid biopsy is an accurate biomarker of NET disease.

A meta-analysis of the accuracy of a neuroendocrine tumor mRNA genomic biomarker (NETest) in blood.

BACKGROUND: The lack of an accurate blood biomarker in neuroendocrine tumor (NET) disease has hindered management. The advance of genomic medicine and the development of molecular biomarkers has provided a strategy-liquid biopsy-to facilitate real-time management. We reviewed the role of a blood mRNA-based NET biomarker, the NETest, as an in vitro diagnostic (IVD). PATIENTS AND METHODS: A systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was undertaken. The methodological quality was evaluated using the QUADAS-2 tool. We identified ten original scientific papers that met the inclusion criteria. These were assessed by qualitative analysis and thereafter meta-analysis. Data were pooled and a median [95% confidence interval (CI)] diagnostic odds ratio (DOR), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated. For the meta-analysis, a generic inverse variance method was undertaken using the accuracy and area under the curve (AUC) data. RESULTS: The ten studies exhibited moderate to high methodological quality. They evaluated NETest usage both as a diagnostic and as a monitoring tool. The meta-analysis identified the diagnostic accuracy of the NETest to be 95%-96% with a mean DOR of 5 853, +LR of 195, and -LR of 0.06. The NETest was 84.5%-85.5% accurate in differentiating stable disease from progressive disease. As a marker of natural history, the accuracy was 91.5%-97.8%. As an interventional/response biomarker, the accuracy was 93.7%-97.4%. The pooled AUC for the NETest was 0.954 ± 0.005, with a z-statistic of 175.06 (P < 0.001). CONCLUSIONS: The NETest is an accurate biomarker suitable for clinical use in NET disease management. The meta-analysis supports the utility of the NETest as an IVD to establish a diagnosis and monitor therapeutic efficacy. The use of this as a biomarker provides information relevant to NET management consistent with observations regarding utility of liquid biopsies in other oncological disciplines.

Role of Ki-67 proliferation index in the assessment of patients with neuroendocrine neoplasias regarding the stage of disease.

BACKGROUND: Neuroendocrine neoplasias (NEN) of the gastroenteropancreatic (GEP) system frequently present with metastatic deposits. The proliferation marker Ki-67 is used for diagnosis and to assess the prognosis of disease. The aim of our study was to evaluate the usefulness of Ki-67 % in the assessment of NEN patients with regard to their disease stage in clinical practice. Additionally, a comparative analysis of Ki-67 levels among different sites of disease was performed. METHODS: This retrospective study included patients with GEP NEN referred to our center from 2010 to 2012. The NEN diagnosis was confirmed by standard histopathology. Ki-67 immunohistochemistry was done on paraffin-embedded sections using an automated Leica immunohistochemistry machine. NEN grading was carried out according to European Neuroendocrine Tumor Society recommendations (low grade [G1] to intermediate grade [G2], well to moderately differentiated neuroendocrine neoplasms; high-grade [G3], moderately to poorly differentiated neuroendocrine neoplasms). Results of tumor staging and grading were correlated. In a subgroup of cases, comparative analysis of Ki-67 levels in different sites of disease was carried out. RESULTS: One hundred sixty-one GEP NEN patients were included in the study. Metastatic disease was seen in 46.1 % (53/115) of G1 tumors, 77.8 % (28/36) of G2 tumors, and 100 % of (10/10) G3 tumors (p = 0.0002). When stratified according to primary tumor site, metastatic disease was documented in 42.9 % (36/84) of patients with pancreatic NEN and in 91.9 % (34/37) of those with small intestinal primary. Stage IV metastatic disease was present in 27.8 % (32/115) and 72.2 % (26/36) of the G1 and G2 tumors, respectively, and in 90 % (9/10) of the G3 tumors. Assessment of the Ki-67 index for a subset of cases at metastatic sites as well as the primary tumor site showed discrepancies in 35.3 % cases. In 7/9 (77.8 %) patients with liver metastases, Ki-67 % was higher in the liver lesions than in the primary tumor. CONCLUSIONS: Patients with GEP NEN exhibiting a high Ki-67 proliferation index present with metastatic disease in the vast majority of cases. Depending upon the primary tumor site, metastases are to be expected also in tumors with low Ki-67 %, although they are considered less aggressive. Different disease sites may express heterogeneous Ki-67 levels.

Specific mutations of the RET proto-oncogene are related to disease phenotype in MEN 2A and FMTC.

We have analysed 118 families with inherited medullary thyroid carcinoma (MTC) for mutations of the RET proto-oncogene. These included cases of multiple endocrine neoplasia types 2A (MEN 2A) and 2B (MEN 2B) and familial MTC (FMTC). Mutations at one of 5 cysteines in the extracellular domain were found in 97% of patients with MEN 2A and 86% with FMTC but not in MEN 2B patients or normal controls. 84% of the MEN2A mutations affected codon 634. MEN 2A patients with a Cys634 to Arg substitution had a greater risk of developing parathyroid disease than those with other codon 634 mutations. Our data show a strong correlation between disease phenotype and the nature and position of the RET mutation, suggesting that a simple, constitutive activation of the RET tyrosine kinase is unlikely to explain the events leading to MEN 2A and FMTC.

Liver resection of colorectal metastases in elderly patients.

BACKGROUND: This study evaluated the outcome of liver surgery for colorectal metastases (CLM) in patients over 70 years old in a large international multicentre cohort. METHODS: Among 7764 patients who had resection of CLM, 999 (12.9 per cent) were aged 70-75 years, 468 (6.0 per cent) were aged 75-80 years and 157 (2.0 per cent) were at least 80 years old. Elderly patients were compared with the younger population. RESULTS: Multinodular and bilateral metastases were less common in elderly than in younger patients (P < 0.001). Preoperative chemotherapy was used less frequently and more limited surgery was performed (P < 0.001). Sixty-day postoperative mortality and morbidity rates were 3.8 and 32.3 per cent respectively, compared with 1.6 and 28.7 per cent in younger patients (both P < 0.001). Three-year overall survival was 57.1 per cent in elderly and 60.2 per cent in younger patients (P < 0.001), and was similar among patients aged 70-75, 75-80 or at least 80 years (57.8, 55.3 and 54.1 per cent respectively; P = 0.160). Independent predictors of survival were more than three metastases, bilateral metastases, concomitant extrahepatic disease and no postoperative chemotherapy. CONCLUSION: Liver resection for CLM in elderly patients can achieve a reasonable 3-year survival rate, with an acceptable morbidity rate. There should be no upper age limit but risk factors may help predict potential benefit.

Radioembolization with 90Y Resin Microspheres of Neuroendocrine Liver Metastases After Initial Peptide Receptor Radionuclide Therapy.

PURPOSE: Peptide receptor radionuclide therapy (PRRT) and radioembolization are increasingly used in neuroendocrine neoplasms patients. However, concerns have been raised on cumulative hepatotoxicity. The aim of this sub-analysis was to investigate hepatotoxicity of yttrium-90 resin microspheres radioembolization in patients who were previously treated with PRRT. METHODS: Patients treated with radioembolization after systemic radionuclide treatment were retrospectively analysed. Imaging response according to response evaluation criteria in solid tumours (RECIST) v1.1 and clinical response after 3 months were collected. Clinical, biochemical and haematological toxicities according to common terminology criteria for adverse events (CTCAE) v4.03 were also collected. Specifics on prior PRRT, subsequent radioembolization treatments, treatments after radioembolization and overall survival (OS) were collected. RESULTS: Forty-four patients were included, who underwent a total of 58 radioembolization procedures, of which 55% whole liver treatments, at a median of 353 days after prior PRRT. According to RECIST 1.1, an objective response rate of 16% and disease control rate of 91% were found after 3 months. Clinical response was seen in 65% (15/23) of symptomatic patients after 3 months. Within 3 months, clinical toxicities occurred in 26%. Biochemical and haematological toxicities CTCAE grade 3-4 occurred in ≤ 10%, apart from lymphocytopenia (42%). Radioembolization-related complications occurred in 5% and fatal radioembolization-induced liver disease in 2% (one patient). A median OS of 3.5 years [95% confidence interval 1.8-5.1 years] after radioembolization for the entire study population was found. CONCLUSION: Radioembolization after systemic radionuclide treatments is safe, and the occurrence of radioembolization-induced liver disease is rare. LEVEL OF EVIDENCE: 4, case series.

Treatment of liver metastases from neuroendocrine tumours in relation to the extent of hepatic disease.

BACKGROUND: Hepatic surgery is presumed to improve survival of patients with liver metastases (LM) from neuroendocrine tumours (NET). This study identified LM-specific variables that could be used as additional selection criteria for aggressive treatment. METHODS: A novel classification of LM from NET was established based on their localization and presentation. RESULTS: From 1992 to 2006, 119 patients underwent staging and treatment of LM. Three growth types of LM were identified radiologically: single metastasis (type I), isolated metastatic bulk accompanied by smaller deposits (type II) and disseminated metastatic spread (type III). The three groups differed significantly in terms of chronological presentation of LM, hormonal symptoms, Ki-67 index, 5-hydroxyindoleacetic acid and chromogranin A levels, lymph node involvement, presence of bone metastases and treatment options. The 3-, 5- and 10-year disease-specific survival rates for the entire cohort were 76.4, 63.9 and 46.5 per cent respectively. There were significant differences in survival between the three groups: 5- and 10-year rates were both 100 per cent for type I, 84 and 75 per cent respectively for type II, and 51 and 29 per cent for type III. CONCLUSION: The localization and biological features of LM from NET defines therapeutic management and is predictive of outcome.

Radioembolization with 90Y Resin Microspheres of Neuroendocrine Liver Metastases: International Multicenter Study on Efficacy and Toxicity.

PURPOSE: Radioembolization of liver metastases of neuroendocrine neoplasms (NEN) has shown promising results; however, the current literature is of limited quality. A large international, multicentre retrospective study was designed to address several shortcomings of the current literature. MATERIALS: 244 NEN patients with different NEN grades were included. METHODS: Primary outcome parameters were radiologic response 3 and 6 months after treatment according to RECIST 1.1 and mRECIST. Secondary outcome parameters included clinical response, clinical and biochemical toxicities. RESULTS: Radioembolization resulted in CR in 2%, PR in 14%, SD in 75% and PD 9% according to RECIST 1.1 and in CR in 8%, PR in 35%, SD in 48% and PD in 9% according to mRECIST. Objective response rates improved over time in 20% and 26% according to RECIST 1.1. and mRECIST, respectively. Most common new grade 3-4 biochemical toxicity was lymphocytopenia (6.7%). No unexpected clinical toxicities occurred. Radioembolization-specific complications occurred in < 4%. In symptomatic patients, improvement and resolution of symptoms occurred in 44% and 34%, respectively. Median overall survival from first radioembolization was 3.7, 2.7 and 0.7 years for G1, G2 and G3, respectively. Objective response is independent of NEN grade or primary tumour origin. Significant prognostic factors for survival were NEN grade/Ki67 index, ≥ 75% intrahepatic tumour load, the presence of extrahepatic disease and disease control rate according to RECIST 1.1. CONCLUSION: Safety and efficacy of radioembolization in NEN patients was confirmed with a high disease control rate of 91% in progressive patients and alleviation of NEN-related symptoms in 79% of symptomatic patients. LEVEL OF EVIDENCE: 4.

Management of concomitant hepatic artery injury in patients with iatrogenic major bile duct injury after laparoscopic cholecystectomy.

BACKGROUND: Concomitant hepatic artery injury is a rare but severe complication associated with bile duct injury during laparoscopic cholecystectomy (LC). METHODS: Sixty patients referred with biliary injury after LC between April 1998 and December 2005 were divided into two groups according to the time elapsed between injury and definitive surgical revision; patients in group 1 were referred early (within 4 days) after operation and those in group 2 were referred later. Hepatic rearterialization was performed in addition to biliary reconstruction when technically possible. RESULTS: Damage to the hepatic artery was detected in ten patients. Hepatic rearterialization was carried out in five patients by end-to-end anastomosis (one), or by using an autologous graft (three) or allogeneic vascular graft (one). Three patients in group 2 underwent right hemihepatectomy without arterial reconstruction owing to liver necrosis or lobar atrophy. Three of ten patients died from postoperative complications. CONCLUSION: Combined bile duct and hepatic artery injury during LC led to a complicated clinical course, with a high mortality rate. Reconstruction of the right hepatic artery might be helpful in reducing hepatic ischaemia, but is usually feasible only if the injury is identified early.

Cancer of unknown primary.

FDG-PET has been proven to be very sensitive in detecting a large variety of carcinomas. The FDG accumulation in malignant tumors is quite stereotyped and often reflects the aggressiveness of the tumor. Therefore, FDG appears to be suitable to detect unknown primaries independent of the type of disease. Being unaware of the site of the primary and also being unaware of the intensity of glucose metabolism, the interpretation of FDG-PET images needs rules accepting a reduced specificity for the definition of malignancy. However, due to physiological FDG-uptake in the head and neck area, especially in lymphatic tissue and vocal cords, one has to accept a high rate of equivocal findings interpreting FDG-PET alone. In this situation, the use of dual-modality PET/CT is of particular value. It allows for correlating the suspicious or unclear PET finding directly with morphology and by that the rate of false-equivocal or false-positive findings is reduced. In addition, PET/CT can precisely define the site of the PET finding in terms of anatomy, helping to direct the surgeon. This characteristic is of different value depending on the location of the primary and tends to be of utmost importance in the head and neck area. Finally, CT by itself may contribute with the detection of PET-negative findings. Thus in conclusion, PET and PET/CT can help localize the primary in CUP in approximately 40% of all cases, even after a thorough work-up with a variety of other investigations.

Single-center experience on liver transplantation for hepatocellular carcinoma arising in alcoholic cirrhosis: results and ethical issues.

BACKGROUND: Liver transplantation is currently recognized as the optimal treatment for both early hepatocellular carcinoma in the setting of cirrhosis (HCC) as well as for alcoholic liver disease (ALD). The purpose of this study was to evaluate the outcome of patients with HCC and ALD in the absence of viral hepatitic infections. METHODS: Twelve recipients were transplanted with a diagnosis of HCC and ALD in the absence of viral hepatitis during a 6-year period. Nine received deceased donor livers, and 3 live donor grafts. Our results were compared to those obtained by a search of the world literature. RESULTS: The postoperative course was uneventful in all but one patient. All recipients experienced a good quality of life postoperatively. Three-year overall and recurrence-free survival rates were 82 and 73%, respectively. Nine patients are currently alive, after a median follow-up of 29 months. CONCLUSION: This is the first study to evaluate liver transplantation for HCC in ALD. Although outcomes are excellent, the evaluation of patients with ALD and HCC constitutes a challenging topic in transplantation surgery, especially when live liver donation is considered. An interdisciplinary structured approach is recommended, with special emphasis on ethical considerations.

[Living donor liver transplantation]. / Leberlebendspende.

Sixteen years after its first successful application, living donor liver transplantation now has a small but well-established role in treatment for liver failure in Germany. It remains problematic in both child and adult patients concerning effort, expected results, and assessment of risks to the donor. Therefore the method shall remain limited to more research-oriented institutions for the time being before it can be established more broadly as an alternative to postmortal donation. In Germany it presents generally the same limitations as living donor kidney transplantation.

Clinical trial: switch to combined mycophenolate mofetil and minimal dose calcineurin inhibitor in stable liver transplant patients--assessment of renal and allograft function, cardiovascular risk factors and immune monitoring.

BACKGROUND: Calcineurin inhibitor (CNI)-related nephrotoxicity significantly contributes to chronic renal failure after liver transplantation. METHODS: In this prospective study, liver transplantation patients with renal dysfunction were randomized either to receive mycophenolate mofetil (MMF) followed by stepwise reduction of CNI with defined minimal CNI-trough levels (MMF group), or to continue their maintenance CNI dose (control group). Immune monitoring was performed in a subgroup of the patients. RESULTS: In the MMF group (n = 50), renal function assessed by serum creatinine improved >10% in 62% of patients, was stable in 36% and deteriorated >10% in 2% after 12 months compared with baseline values. Mean serum creatinine levels (+/- s.d.) significantly decreased from 1.90 +/- 0.44 mg/dL to 1.61 +/- 0.39 mg/dL and the corresponding calculated glomerular filtration rate significantly increased from 38.8 +/- 9.6 mL/min/1.73 m(2) to 47.0 +/- 11.8 mL/min/1.73 m(2) over a 12-month follow-up period. Blood pressure and levels of liver enzymes significantly decreased. In the control group (n = 25), there were no significant changes with respect to the investigated parameters. The MMF group had significantly lower numbers of circulating cytotoxic T cells compared with the controls; whereas regulatory T cells significantly increased. CONCLUSION: Combined MMF and minimal dose CNI therapy after liver transplantation is nephroprotective and may promote allograft tolerance.

Gallbladder endometriosis as a cause of occult bleeding.

A 17-year-old girl with colicky abdominal pain and chronic anemia presented to the gastrointestinal service of the University Hospital of Essen. In the routine workup, there were no pathological findings despite the anemia. Because of the fluctuation of symptoms with a climax at the time of menstruation, consecutive ultrasound studies were performed revealing a visible mass inside the gallbladder. This finding was confirmed by a magnetic resonance imaging (MRI) study performed at the same time. Because of the severe anemia by that time, a cholecystectomy was performed, and histology reconfirmed the diagnosis of isolated gallbladder endometriosis. The patient recovered well and has had no recurrence of the disease to date.

[Radiofrequency ablation of malignant liver tumors: use of a volumetric necrosis-tumor ratio for local control]. / Radiofrequenzablation von malignen Lebertumoren: Erlaubt ein volumetrischer Nekrose-/Tumor-Quotient eine Vorhersage zur lokalen Tumorkontrolle?

PURPOSE: Sufficient safety margins are essential for preventing local tumor recurrence after radiofrequency ablation RFA of malignant liver tumors. The aim was to determine the initial tumor volume, ablation necrosis volume, and the necrosis-tumor quotient in order to compare these parameters with the rate of local control during follow-up. MATERIALS AND METHODS: 35 patients with 53 tumor nodules (29 colorectal metastases and 24 HCC nodules) were enrolled. RFA procedures were performed under CT guidance with intravenous conscious sedation. Tumor volumes were measured based on CT data sets and the necrosis volume was assessed using the sum-of-area method. A volumetric necrosis/tumor quotient (NTQ) was calculated for all lesions. Follow-up examinations were performed after 3, 6, and 12 months and then on a yearly basis to identify local recurrent tumors. RESULTS: The CRC metastases and HCC nodules had a median tumor volume of 8.3 ml and 7.4 ml, respectively. The mean ablation volumes were 37.6 ml and 29.5 ml, respectively. This resulted in a median NTQ of 3.9 for metastases and 3.4 for HCC. The follow-up (mean time 18 months) revealed local tumor recurrence in 16 of 29 (55 %) metastases and 10 of 24 (42 %) HCC nodules. In lesions with local recurrence, the initial tumor volume was significantly greater and the NTQ was significantly smaller. A threshold value of 3.4 for NTQ has the highest predictive value for local tumor recurrence. CONCLUSION: The volumetric necrosis/tumor quotient NTQ makes it possible to predict the local outcome and can be used for the planning of additional therapy.

Target range maximum of cyclosporine blood concentration two hours post dose in stable liver transplant patients.

Recently, single blood level measurement 2 hours after cyclosporine administration (C2) is taken as a more sensitive indicator of drug exposure in de novo transplant recipients than trough levels (C0). However, few studies focused on the determination of the C2 target range maximum and its associated adverse events in stable liver recipients. This prospective study was designed to assess the relative risk of developing CsA related side effects in patients with high C2-levels. Adverse effects were determined clinically, and by using a specially designed questionnaire. Eventual adverse events as well as C2 levels were determined repeatedly up to 4 times in 3-months intervals (observation period 9 +/- 3 months) in 36 long-term liver recipients (1-13.5 years post-transplant), in addition to conventional C0 levels. Cyclosporine dose was adjusted according to a predefined C0 target level range and clinical status. Totally 103 questionnaires and the corresponding paired CsA blood level records were obtained. C0 levels and C2 levels ranged from 90 to 287 (143 +/- 31) ng/ml and from 212 to 1358 (672 +/- 203) ng/ml respectively. No patient experienced a rejection episode during the observation period, demonstrating the efficiency of the immunosuppressive therapy. However, 33/36 patients (91%) showed symptoms attributable to CsA therapy. C2 levels above 750 ng/ml, determined at least twice in an interval of 3 months, were identified as a relevant risk factor for the presence of multiple adverse effects, which were defined as the combination of hypertension, renal insufficiency and more than two neurological complaints (RR = 3.11, p<0.01). This risk population was not completely identified by determination of C0 level.

Liver transplantation for hepatocellular carcinoma in patients beyond the Milan but within the UCSF criteria.

AIM: Liver transplantation (LT) is the best therapy for early hepatocellular carcinoma (HCC) in cirrhosis. Whereas the Milan criteria are routinely applied, the University of California San Francisco (UCSF) criteria are occasionally considered in large-volume transplant centers. Poor information is available about the real "gain" in patients' outcome when extending the listing criteria from Milan to UCSF. PATIENTS AND METHODS: Out of 100 patients transplanted for HCC at our center, 4 patients exceeding the Milan but meeting the UCSF criteria were identified. Data of these patients were analysed for the purposes of this study. RESULTS: Three of them are currently alive after a median follow up of 57 months. One patient died 20 months post-transplant as a result of complications from hepatitis. Of the three who are alive, one underwent surgery for HCC recurrence 81 months post transplant. The remaining two have no evidence of tumor 56 and 57 months post transplant, respectively. CONCLUSION: Our results, as well as the reviewed literature, showed that only a small percentage of transplanted HCC patients can be classified as "beyond Milan-within UCSF". These patients seem to have acceptable overall, as well as recurrence free survivals. Large-volume patients' series, intention- to-treat analysis based on the radiological findings and multi-center prospective studies are required, in order to further explore the outcome of patients "beyond Milan-within UCSF" criteria and in order to better define the risk/benefit ratio of a potential expansion of the current listing criteria.