Preoperative serum chromogranin-a is predictive of survival in locoregional jejuno-ileal small bowel neuroendocrine tumors.

BACKGROUND: Small bowel neuroendocrine tumors (SB-NET) frequently metastasize to regional lymphatic or distant sites. Although most prognostication of SB-NET focuses on lymph node involvement, findings from studies of neuroendocrine tumors from other primary sites have suggested that preoperative serum chromogranin-A (CgA) levels may provide a more accurate metric. METHODS: Using the National Cancer Database (2004-2016), we analyzed patients with locoregional SB-NET who underwent curative resection including an adequate lymphadenectomy (n = 1,274). A statistically optimized cut-point was used to dichotomize CgA cohort based on preoperative serum CgA levels. RESULTS: We determined that a CgA ≥139 ng/mL identified patients with significantly shorter estimated mean overall survival (6.6 years vs 7.6 years, log-rank P = .00001). These patients were also older (63 vs 57 years, P < .001) and had higher rates of poorly differentiated tumors (2.1% vs 0.7%, P = .04) or primary tumors >1 cm (88.2% vs 79.2%, P = .001). Clinical features associated with shorter overall survival included preoperative CgA ≥139 ng/mL (HR = 2.19, 95% CI 1.22-3.92; P = .009), age at diagnosis (HR = 1.06, 95% CI 1.03-1.09; P < .001), Charlson-Deyo score ≥2 (HR = 3.93, 95% CI 1.71-9.01; P = .001), and poorly differentiated tumors (HR = 11.22, 95% CI 4.16-30.24; P < .001). Neither lymph node metastasis nor T-stage were independently associated with shorter overall survival in patients with locoregional SB-NET. CONCLUSION: Elevated preoperative serum CgA is an adverse prognostic marker associated with shorter overall survival in patients with locoregional SB-NET.

A Plasma Protein Biomarker Strategy for Detection of Small Intestinal Neuroendocrine Tumors.

BACKGROUND: Small intestinal neuroendocrine tumors (SI-NETs) are difficult to diagnose in the early stage of disease. Current blood biomarkers such as chromogranin A (CgA) and 5-hydroxyindolacetic acid have low sensitivity (SEN) and specificity (SPE). This is a first preplanned interim analysis (Nordic non-interventional, prospective, exploratory, EXPLAIN study [NCT02630654]). Its objective is to investigate if a plasma protein multi-biomarker strategy can improve diagnostic accuracy (ACC) in SI-NETs. METHODS: At the time of diagnosis, before any disease-specific treatment was initiated, blood was collected from patients with advanced SI-NETs and 92 putative cancer-related plasma proteins from 135 patients were analyzed and compared with the results of age- and sex-matched controls (n = 143), using multiplex proximity extension assay and machine learning techniques. RESULTS: Using a random forest model including 12 top ranked plasma proteins in patients with SI-NETs, the multi-biomarker strategy showed SEN and SPE of 89 and 91%, respectively, with negative predictive value (NPV) and positive predictive value (PPV) of 90 and 91%, respectively, to identify patients with regional or metastatic disease with an area under the receiver operator characteristic curve (AUROC) of 99%. In 30 patients with normal CgA concentrations, the model provided a diagnostic SPE of 98%, SEN of 56%, and NPV 90%, PPV of 90%, and AUROC 97%, regardless of proton pump inhibitor intake. CONCLUSION: This interim analysis demonstrates that a multi-biomarker/machine learning strategy improves diagnostic ACC of patients with SI-NET at the time of diagnosis, especially in patients with normal CgA levels. The results indicate that this multi-biomarker strategy can be useful for early detection of SI-NETs at presentation and conceivably detect recurrence after radical primary resection.

Vasostatin-1: A novel circulating biomarker for ileal and pancreatic neuroendocrine neoplasms.

BACKGROUND: Chromogranin A (CgA) is a plasma biomarker widely used in the follow-up of patients with neuroendocrine neoplasms (NENs). However, its accuracy as a tumor biomarker is relatively low because plasma CgA can increase also in patients with other diseases or in subjects treated with proton-pump inhibitors (PPIs), a class of widely-used drugs. METHODS: In the attempt to identify a more reliable biomarker for NENs, we investigated, by ELISA, the circulating levels of full-length CgA (CgA1-439) and of various CgA-derived fragments in 17 patients with ileal or pancreatic NENs, 10 healthy controls, and 21 healthy volunteers before and after treatment with PPIs. RESULTS: Patients with ileal or pancreatic NENs showed increased plasma levels of total-CgA and CgA1-76 fragment (vasostatin-1, VS-1) compared to controls [median (25th-75th-percentiles); total-CgA: 1.85 nM (1.01-4.28) vs 0.75 nM (0.52-0.89), p = 0.004; VS-1: 2.76 nM (1.09-7.10) vs 0.29 nM (0.26-0.32), p<0.001, respectively], but not of CgA1-439 or CgA1-373 fragment. VS-1 positively correlated with total-CgA (r = 0.65, p<0.001). The Receiver Operating Characteristic area under the curve was 0.9935 for VS-1 and 0.8824 for total-CgA (p = 0.067). Treatment of patients with somatostatin analogues decreased both total-CgA and VS-1. In contrast, administration of PPIs increased the plasma levels of total-CgA, but not of VS-1. CONCLUSION: These findings suggest that plasma VS-1 is a novel biomarker for ileal and pancreatic NENs. Considering that VS-1 is a well-defined fragment not induced by proton-pump inhibitors, this polypeptide might represent a biomarker for NENs diagnosis and follow-up more accurate and easier to standardize than CgA.

Unusually high levels of serum p53 antibody in recurrent gastric cancer.

Serum tumor markers in patients with cancer assist with establishing diagnosis, estimating prognosis, monitoring treatment, and detecting tumor recurrence. Changes in the p53 tumor suppressor gene are the most common genetic abnormalities in many different human malignancies. Several studies have demonstrated that serum p53 antibodies (S-p53Ab) comprise an early marker of malignant disease, a marker for treatment effects and a prognostic factor for patients with several types of tumors. We recently reported that S-p53Ab is useful for patients with gastric cancer. We describe a rare situation in which unusually high serum p53 antibodies helped to detect recurrent gastric cancer in the small intestine after gastrectomy. Further studies are required to gain a more precise understanding of the clinical impact of S-p53Ab titer monitoring in gastric cancer.

Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature.

INTRODUCTION: The majority of neuroendocrine tumors (NET) are located in the gastrointestinal tract (67.5%) and in the bronchopulmonary (25.3%). CASE REPORT: CA, female, 42 years old, profuse diarrhea about two months, cramping for increased peristalsis, vomiting and weight loss. The patient, diagnosed with ileal neuroendocrine tumor, by colonoscopy with biopsy of lesion, therefore came in our unit to be subjected to surgical therapy. Plasma assay Chromogranin A was performed: 160 ng / ml (nv: 15-100 ng / ml). The patient underwent surgery of right hemicolectomy. DISCUSSION: Neuroendocrine tumors although are rare diseases, have an increasing impact, probably by virtue of improved diagnostic methods. In case of profuse diarrhea should be suspected a neuroendocrine tumor. Certainly the diagnosis of certainty is given by histological examination (biopsy or resected nodule). CONCLUSION: After surgical excision is necessary to perform the follow-up of chromogranin A, and, if not executed, perform nuclear medicine examinations such as Octreoscan and PET. KEY-WORDS: Chromogranin A, Neuroendocrine tumor, Octreoscan.

Chromogranin A is a sensitive marker of progression or regression in ileo-cecal neuroendocrine tumors.

OBJECTIVE: The correlation between plasma Chromogranin A concentrations and changes in tumor size evaluated by computed tomography (CT) - as a gold standard - was evaluated. MATERIAL AND METHODS: One hundred and sixteen patients with CgA-producing ileo-cecal neuroendocrine tumors were evaluated by events, which were recorded when a CT was followed by another CT 1 - 12 months later. Change in tumor size was defined as regression, progression, or stable disease using RECIST criteria 1.1. Of 426 events, there were 97 with progression, 279 with stable disease, and 50 with regression. Based on the ROC curves a cutoff value of 25% change was selected to discriminate between increased, decreased, or unchanged CgA concentrations in plasma, using a sensitive radioimmunoassay with well-defined epitope specificity. RESULTS: In the 97 events showing tumor progression diagnostic sensitivity and specificity of an increased CgA concentration were 86% and 86%, respectively. The positive and negative predictive values were 64% and 85%, respectively. In the 279 events with unchanged tumor size the diagnostic sensitivity and specificity of an unchanged CgA concentration were 73% and 86%, and the positive and negative predictive values were 91% and 63%, respectively. In the 50 events showing tumor regression, diagnostic sensitivity and specificity of a decrease in CgA concentration were 78% and 91%, the positive and negative predictive values being 55% and 97%. CONCLUSIONS: CgA concentrations in plasma have a high diagnostic accuracy in monitoring patients with ileo-cecal neuroendocrine tumors. In particular, an increase in plasma CgA concentration was useful to indicate tumor progression.

Circulating angiopoietin-2 is elevated in patients with neuroendocrine tumours and correlates with disease burden and prognosis.

Angiogenesis is an essential process in the development and growth of tumours. There are a large number of angiogenic mediators including the angiopoietin (Ang) family and vascular endothelial growth factor, which play an important role in both physiological and pathological angiogenesis. This study examines serum levels of Ang-1 and Ang-2 in patients with neuroendocrine tumour (NET) compared healthy controls. ELISA for Ang-1 and Ang-2 was performed in 47 patients with histologically proven NETs and 44 healthy controls. Immunohistochemical staining for Ang-2 was performed in patients to demonstrate cellular location of Ang-2. Serum Ang-2 levels were significantly elevated in patients compared controls (median 4756 vs 2495 pg/ml, P<0.001), while there was no significant difference in Ang-1 levels. The ratio of Ang-2:Ang-1 was significantly elevated in patients compared controls (0.13 vs 0.066, P<0.001). Serum Ang-2 levels were significantly elevated in patients with distant metastases compared with those without metastasis (median 5080 vs 3360 pg/ml, P=0.01). There was also a significant increase between Ang-2 levels and volume of liver metastases (P=0.014). Time to disease progression was worse in patients with serum Ang-2 levels >4756 pg/ml (P=0.04). Serum Ang-2 but not Ang-1 is elevated in NET patients. Ang-2 may be a useful serum marker for monitoring and assessment of prognosis in patients with NETs.

An increase of CA 19.9 as the first clinical sign of ileocecal valve metastasis from breast cancer.

CASE REPORT: The case of a breast cancer patient with a progressive increase of CA 19.9 that indicated gastrointestinal metastasis is reported. After the observation of an increased CA 19.9 serum value (104.00; n.v. 0.0-37.00) a colonoscopy was performed. This examination showed the presence of an erythematous and granular zone near the ileocecal valve. Histological examination of biopsies taken during the colonoscopy revealed atypical monomorphic cells between the organoid pattern of the colon-type ducts. Immunohistochemical staining was positive for cytokeratin 7 and for estrogen receptors, consistent with metastatic epithelial malignancy. After eleven months, the patient presented with signs of intestinal obstruction, requiring an ileocolic bypass. At definitive histological examination, the tumor exhibited features of mammary metastases. CONCLUSION: This is the first report in the literature of an ileocecal valve metastasis from breast cancer diagnosed by an increase of CA 19.9, which is a marker of primary colorectal carcinoma.

Malignancy in slow motion: diagnosis of biochemically apparent, but otherwise occult persistent disease 21 years after resection of a carcinoid tumour of the terminal ileum.

Carcinoid tumors may relapse after a long time span following initial diagnosis, and relapse might be clinically inapparent despite biochemical indications due to a low sensitivity of conventional methods. We present the case of a patient who had biochemical indication for hidden disease persistence for more than two decades. In 1978, a 39-year-old man underwent surgery for a carcinoid tumour of the ileum measuring 3.5 cm with multiple local lymph-node metastases. After surgery, however, serotonin- and urinary 5-hydroxy-indole-acetic-acid (5-HIAA) remained markedly elevated, and persisted over more than 20 years at levels between 600 and 950 ng/ml for serum serotonin (normal range 40-400 ng/ml) and 29-35 mg/24 h for 5-HIAA (normal range 2-9 mg/24 h). Despite this, regular radiological follow-up, including sonography and CT-scan, did not reveal the location of suspected malignancy until 1999, when the patient was re-admitted to our hospital for a hypertensive episode. CT-scanning of the abdomen showed a singular lesion within the liver, which was verified as recurrence of the carcinoid by fine needle biopsy. Somatostatin receptor scintigraphy using (111)In-DTPA-D-Phe1-Octreotide revealed a second lesion within the liver along with local recurrence at the anastomosis, which was verified by surgery. While the propensity for late relapse of ileal carcinoids has repeatedly been demonstrated, a case with biochemical signs of disease persistence over a time span of 21 years before final diagnosis is unusual. In addition, our case reflects the low sensitivity of conventional radiological evaluation for localization of carcinoid tumours as compared to somatostatin receptor scanning.

Validation of HPLC-amperometric detection to measure serotonin in plasma, platelets, whole blood, and urine.

We describe an isocratic liquid-chromatographic method with amperometric detection for determination of serotonin by rapid sample preparation. Platelet-poor plasma and platelets were injected after a single deproteinization step with perchloric acid. Addition of sodium borohydride to whole blood avoids oxidation of serotonin during the deproteinization step without any chromatographic interferences. We purified urinary serotonin by two successive cationic and anionic extraction steps. After urine dilution, urinary 5-hydroxyindoleacetic acid (5-HIAA) was measured under the same chromatographic conditions. Platelet serotonin concentrations correlated more closely with whole-blood serotonin concentrations after correction for platelet number than with concentrations expressed in nmol/L. This suggests that whole-blood serotonin measurements should be corrected for platelet count to eliminate the variability of circulating platelets. Combined determination of serotonin in whole blood and urine and of 5-HIAA in urine provides a useful tool for detecting and monitoring carcinoid tumors.

Effects of sandostatin on plasma chromogranin-A levels in neuroendocrine tumors.

We have determined the effects of Sandostatin (SMS 201-995, Sandoz) on chromogranin-A (CgA) in the blood of 14 patients with neuroendocrine tumors of the gastroenteropancreatic axis, 7 with carcinoid tumors, 5 with gastrinomas, and 1 each with a glucagonoma and tumor-secreting vasoactive intestinal peptide. Two thirds of the patients had elevated plasma CgA. Sandostatin administration suppressed CgA in 12 of the 14 patients. In 8 of 10, the clinical response to Sandostatin paralleled the reduction in CgA levels. There was a strong correlation between the change in CgA levels and the respective blood concentration of the hormone produced by the tumor. Serial measurement of CgA may provide an additional means of monitoring these tumors and their secretory activity where other measures are not available.

Histamine in carcinoid syndrome.

The exact etiology of carcinoid flushing remains unknown, but the symptoms are probably mediated through release of one or several humoral substances. Flushing seen in fore-gut carcinoids (gastric carcinoids) has been ascribed to excessive histamine release, whereas flushing seen in mid-gut carcinoids (ileal carcinoids) tentatively has been ascribed to excessive release of serotonin, bradykinin, substance P, substance K or eledoisin. In this study plasma histamine was measured in 8 patients with mid-gut carcinoids and carcinoid syndrome using an enzymatic isotopic method in order to evaluate histamine as the vasoactive agent in patients with ileal carcinoid tumours and carcinoid syndrome. All patients had raised plasma histamine values. In patients with mid-gut carcinoids histamine may be one of the substances mediating flushing.

Chemical and immunochemical characterisation of substance P-like immunoreactivity and physalaemin-like immunoreactivity in a carcinoid tumour.

Extracts of a carcinoid tumour, resected from the mid-portion of the ileum of a patient with no symptoms of endocrine disorder, were associated with a high concentration of substance P-like immunoreactivity. Using reverse-phase high performance liquid chromatography and antisera specifically directed against the C-terminal and N-terminal regions of substance P and against the N-terminal region of physalaemin, the following components were isolated and identified: substance P and its oxidised form, [pGlu5]substance P-(5-11) peptide and its oxidised form, and the oxidised form of physalaemin. The identity of tumour substance P with the undecapeptide was confirmed by amino acid analysis and high performance ion-exchange chromatography. In vitro incubation of tumour tissue from a lymph node metastasis from the same patient with [3H]leucine resulted in incorporation of radioactivity into newly synthesised substance P.

Effects of leukocyte interferon on clinical symptoms and hormone levels in patients with mid-gut carcinoid tumors and carcinoid syndrome.

We treated nine patients who had carcinoid tumors of the small intestine, six of whom had the carcinoid syndrome, with daily intramuscular doses of leukocyte interferon--3 X 10(6) U per day for one month and 6 X 10(6) U per day for another two months. Seven patients had previously been treated with streptozocin and fluorouracil, without benefit. Treatment with interferon ameliorated the manifestations of the carcinoid syndrome and led to prompt and continuing decreases in urinary levels of 5-hydroxyindoleacetic acid and serum levels of human chorionic gonadotropin subunits and pancreatic polypeptide in all six patients with liver metastases, but it had no clear effect in two of three patients with only lymph-node involvement. After the treatment period, five of the six responders had relapses in clinical manifestations and increases in hormone levels. We conclude that interferon is of benefit in treating metastatic small intestinal carcinoid tumors in patients with the carcinoid syndrome.

[High serum ferritin levels in malignant lymphoma of the ileum].

A 61-year-old woman was admitted to our hospital with lower abdominal distension, anemia and slight emaciation. Primary malignant lymphoma of the ileum was diagnosed after laparotomy and palliative surgery was performed. Pathological specimens demonstrated diffuse lymphoma, and histiocytic (Rappaport's classification) aneurysm-type macroscopic development. The preoperative serum ferritin level was high and increased postoperatively with a slight decrease during VEMP chemotherapy, suggesting it to be a marker of tumor activity. Although palliation was observed during chemotherapy, this patient died of pulmonary complications a little less than 3 months after the operation.

Localization of carcinoids and pheochromocytomas with vein catheterization and amine determination.

Selective catheterization of hepatic, intestinal and adrenal veins with blood sampling for serotonin and catecholamine determination was evaluated regarding its use in the diagnosis, location and characterization of carcinoids and pheochromocytomas. Catheterization of intestinal veins via the transhepatic route and of the adrenal veins via the femoral and caval veins was performed in 49 patients without major complications. High pressure liquid chromatography with electrochemical detection was used to quantitate norepinephrine and epinephrine in plasma and serotonin in plasma and whole blood. Serotonin in plasma was also determined by an enzymatic procedure. In 30 patients with suspected or verified carcinoid tumors concentration of serotonin in tumor-draining veins was clearly elevated in all patients but one. In this patient, who previously had been treated with temporary liver dearterialization, the serotonin concentration in the hepatic vein was within the normal range in spite of the existence of liver metastases. Hyperserotoninemia was registered in one patient without detectable carcinoid tumor cells. In three patients determination of norepinephrine and epinephrine in adrenal venous blood diagnosed a hyperplasia and tumors in the adrenal medulla. In these cases angiography and computed tomography were negative. Microscopic analyses revealed serotonin in all carcinoids and substance P-like immunoreactivity in a large percentage of these tumors. PP-like and glucagon-like immunoreactivity were observed in two endocrine pancreatic tumors. In normal adrenal medulla and in adrenal medullary tumor tissue catecholamine fluorescence and enkephalin-like immunoreactivity were demonstrated. In the two pheochromocytomas ACTH-like, somatostatin-like and calcitonin-like immunoreactivities were identified. The technique with determinations of plasma serotonin and catecholamines in combination with selective catheterization is a useful investigation for the diagnosis, location and follow-up of patients with carcinoids and pheochromocytomas.

Update on pancreatic polypeptide as a specific marker for endocrine tumours of the pancreas and gut.

Serum levels of pancreatic polypeptide (PP) were determined in 31 patients with endocrine tumours, localized in the pancreas (n = 16), small intestine (n = 13) and respiratory tract (n = 2). Two further patients with laxative abuse were investigated. Elevated serum levels in the peripheral circulation were noted in 56% of the patients with pancreatic tumours, in 60% of those with gut or bronchial tumours and in both patients with laxative abuse. Our study suggests that the elevated PP concentrations found in connection with endocrine gastrointestinal tumours originate from non-tumour pancreatic PP cells and only occasionally from the tumour. PP is a valuable tumour marker for endocrine gastrointestinal tumours, although it is not specific for pancreatic tumours. Certain inflammatory diseases, renal function and consumption of laxatives must be considered when evaluating elevated PP levels. Serum PP seems to be of limited value for evaluating the response to cytotoxic therapy.