Endoscopic treatment of sporadic small duodenal and ampullary neuroendocrine tumors

Abstract

As duodenal neuroendocrine tumors (NETs) are rare, their optimal management has not been clearly established. The aim of this study was to evaluate the feasibility and outcome of endoscopic treatment of duodenal NETs. We reviewed the files of all patients who underwent endoscopic resection of a sporadic duodenal or ampullary NET between 1996 and 2014 at two centers. A total of 29 patients with 32 uT1N0M0 NETs < 20 mm were included. Treatment consisted of endoscopic mucosal resection in 19 cases, and cap aspiration in 13 cases. Prior submucosal saline injection was used in 15 cases. Mortality was 3 % (one severe bleeding). Morbidity was 38 % (11/29). At post-resection analysis, mean tumor size was 8.9 mm (range 3 - 17 mm), 29 lesions were stage pT1, one was pT2, and 2 were pTx because of piecemeal resection. All NETs were well differentiated. A total of 27 lesions were classified as grade 1 and 5 were grade 2. The resection was R0, R1, and Rx for 16, 14, and 2 lesions, respectively. Three R1 patients underwent additional surgical treatment, with no residual tumor on the surgical specimen but with positive metastatic lymph nodes in two cases. One patient was lost to follow-up. Finally, 24 patients were included in the follow-up analysis. The median follow-up period was 56 months (range 6 - 175 months). Two patients presented a tumor recurrence during the follow-up period. Endoscopic treatment of small duodenal NETs was associated with significant morbidity, a difficulty in obtaining an R0 specimen, and the risk of lymph node metastasis. Nevertheless, it represents an interesting alternative in small grade 1 duodenal lesions and in patients at high surgical risk.

The Risk Factors for Metastasis in Non-Ampullary Duodenal Neuroendocrine Tumors Measuring 20 mm or Less in Diameter

“…Moreover, when LN dissection is not required, it is also unclear which of the following the best therapeutic approach is: local resection in surgery, EMR, or ESD. Based on the result of previous studies [22,27] and the present study, it is difficult to achieve R0 resection by EMR in all cases. Meanwhile, ESD has a higher complication risk [28], and open surgery has a potential of higher morbidity and mortality [29].…”

Short- and long-term outcomes of endoscopic submucosal dissection for non-ampullary duodenal neuroendocrine tumors

“…According to the European Neuroendocrine Tumor Society guidelines, endoscopic resection is recommended for non-ampullary duodenal neuroendocrine tumors (NAD-NET) ≤10 mm in diameter and confined to the submucosal layer, without lymph node or distant metastasis [4,5]. Various methods of endoscopic resection, including endoscopic mucosal resection (EMR), EMR with ligation device (EMR-L), EMR with circumferential precutting (EMR-P), cap-assisted EMR (EMR-C), and endoscopic submucosal dissection (ESD), have been reported in previous studies [6][7][8][9][10][11][12][13][14][15][16][17][18]. However, there is no consensus regarding the preferred method of endoscopic resection for NAD-NET.…”

Early Gastroenteropancreatic Neuroendocrine Tumors: Endoscopic Therapy and Surveillance

“…In early rectal NET/carcinoids and in particular in rectal NET G1 of 9-14 mm in size, ESD can be considered [41]. ESD of duodenal NET increases the complete resection rate to almost 100% when compared to EMR (about 50%), but at the expense of a higher perforation rate [42]. Endoscopic therapy of duodenal NET comes with some interventional morbidity and can cause mortality particularly in multimorbid elderly patients [42].…”

“…ESD of duodenal NET increases the complete resection rate to almost 100% when compared to EMR (about 50%), but at the expense of a higher perforation rate [42]. Endoscopic therapy of duodenal NET comes with some interventional morbidity and can cause mortality particularly in multimorbid elderly patients [42]. The recent German S2k guideline does not recommend ESD for early duodenal NET.…”