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Transarterial chemoembolization (TACE) with doxorubicin and lipiodol for liver metastasis due to ileal NEN in a 50-year-old male. a Diagnostic digital subtraction angiography (DSA) image of right hepatic artery shows multiple hypervascular lesions in the liver. b DSA image post TACE shows lipiodol deposition in the lesions (black asterisk)
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Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine system (DES). The gastrointestinal tract (GIT) is the most common site of NEN. The WHO classification divides NEN into three broad categories viz. well-differentiated NENs, poorly differentiated NENs, and mixed neuroendocrine-non-neuroendocrine neoplasms. Al...
Citations
... For enhanced visualization of SB-NENs, employing a CT enterography protocol that includes low-density neutral oral contrast and spasmolytic agents is recommended. Notably, CT enterography has demonstrated a high detection accuracy, with a specificity of 85% and a sensitivity of 97% in identifying primary SB-NENs ( Figure 3) [28,29]. In the realm of SB-NENs, the distal ileum is the most common site, often arising within the last 100 cm of the ileum [30]. ...
Neuroendocrine neoplasms (NENs) are a diverse group of tumors with varying clinical behaviors. Their incidence has risen due to increased awareness, improved diagnostics, and aging populations. The 2019 World Health Organization classification emphasizes integrating radiology and histopathology to characterize NENs and create personalized treatment plans. Imaging methods like CT, MRI, and PET/CT are crucial for detection, staging, treatment planning, and monitoring, but each of them poses different interpretative challenges and none are immune to pitfalls. Treatment options include surgery, targeted therapies, and chemotherapy, based on the tumor type, stage, and patient-specific factors. This review aims to provide insights into the latest developments and challenges in NEN imaging, diagnosis, and management.
... The distal ileum is the most common site of SB-NENs, which tend to occur in the distal 100 cm of the ileum. 56 Generally, jejunoileal NENs are thought to have more malignant potential, with regional or distant metastases often observed even with small lesions. 57 Primary tumors in the small bowel can lead to complications such as bowel obstruction or fibrosis. ...
... NENs of the rectum are typically small and localized at the time of diagnosis; on the other hand, colonic NENs are aggressive, poorly differentiated, large, and typically metastatic at initial presentation. 56 CT can be of limited value for assessing rNENs given their small size, but EUS can accurately detect and delineate the tumor from the surrounding tissues and assess the depth of invasion. 63 The reported sensitivity of EUS for evaluation of tumor depth ranges from 76% to 93%. ...
... 64 As a result, EUS has become a crucial examination for precise localization and delineation of rNENs, tissue sampling, and local staging. 56 MRI of rNENs is useful for assessing local spread and determining surgical resectability. 65 MRI acquisition protocols for rNENs are analogous to high-resolution rectal cancer MRI acquisition protocols. ...
Neuroendocrine neoplasms are a heterogeneous group of gastrointestinal and lung tumors. Their diverse clinical manifestations, variable locations, and heterogeneity present notable diagnostic challenges. This article delves into the imaging modalities vital for their detection and characterization. Computed tomography is essential for initial assessment and staging. At the same time, magnetic resonance imaging (MRI) is particularly adept for liver, pancreatic, osseous, and rectal imaging, offering superior soft tissue contrast. The article also highlights the limitations of these imaging techniques, such as MRI's inability to effectively evaluate the cortical bone and the questioned cost-effectiveness of computed tomography and MRI for detecting specific gastric lesions. By emphasizing the strengths and weaknesses of these imaging techniques, the review offers insights into optimizing their utilization for improved diagnosis, staging, and therapeutic management of neuroendocrine neoplasms.
... 47 The restricted diffusion on MRI aids in distinguishing liver metastases from hepatic hemangioma, which are usually hyperintense on T2W-MRI. 1,3 Studies reported that the apparent diffusion coefficient (ADC) values are inversely correlated with the tumor grade. An ADC value less than 0.95 to 1.19 Â 10 −3 mm 2 /s is more indicative of grade III NEN. ...
Neuroendocrine neoplasms (NENs) are rapidly evolving small bowel tumors, and the patients are asymptomatic at the initial stages. Metastases are commonly observed at the time of presentation and diagnosis. This review addresses the small bowel NEN (SB-NEN) and its molecular, histological, and imaging features, which aid diagnosis and therapy guidance. Somatic cell number alterations and epigenetic mutations are studied to be responsible for sporadic and familial SB-NEN. The review also describes the grading of SB-NEN in addition to rare histological findings such as mixed neuroendocrine-non-NENs. Anatomic and nuclear imaging with conventional computed tomography, magnetic resonance imaging, computed tomographic enterography, and positron emission tomography are adopted in clinical practice for diagnosing, staging, and follow-up of NEN. Along with the characteristic imaging features of SB-NEN, the therapeutic aspects of imaging, such as peptide receptor radionuclide therapy, are discussed in this review.
... 34 As such, functional imaging may include somatostatin receptor scintigraphy (now largely replaced by more specific PET tracers), 68 Gallium-PET and 18 FDG-PET, with more novel tracers in use per institutional availability (Fig. 2). 35,38,39 For high-grade NET (e.g., Ki-67 proliferation index > 15%) and NEC, 40 the sensitivity is considered better for FDG-PET, and hence FDG-PET is preferred due to a higher glucose uptake for these often overt malignant tumors. [41][42][43] Of note, G3 NETs and NEC are rather unusual for SB-NETs (< 1%). ...
Small bowel neuroendocrine tumors (SB-NETs) are increasingly identified and have become the most frequent entity among small bowel tumors. An increasing incidence, a high prevalence, and a prolonged survival with optimal modern multidisciplinary management makes SB-NETs a unique set of tumors to consider for surgical oncologists. The major goals of surgical treatment in the setting of SB-NET include control of tumor volume, control of endocrine secretion, and prevention of locoregional complications. Key considerations include assessment of multifocality and resection of mesenteric nodal masses with the use of mesenteric-sparing approaches and acceptance of R1 margins if necessary to clear disease while avoiding short bowel syndrome. A description through eight steps for consideration is presented to allow for systematic surgical planning and execution of resection. Moreover, some controversies and evolving considerations to the surgical principles and technical procedures remain. The role of primary tumor resection in the presence of (unresectable) liver metastasis is still unclear. Reports of feasibility of minimally invasive surgery are emerging, with undetermined selection criteria for appropriateness or long-term outcomes. Resection of SB-NETs should be considered in all patients fit for surgery and should follow principles to achieve surgical oncological control that is appropriate for the stage and tumor burden, considering the age and comorbidity of the individual patient.
... Imaging patients with NETs can be extremely complex because of high tumour heterogeneity. Table 3 summarises our recommendations for using CT, MRI and ultrasound in the follow-up of patients with GEP-NETs, based on current recommendations and evidence [37][38][39][40]. PET plays only a marginal role during prolonged follow-up because of the cost. ...
... Mandatory for diagnosis [39], including recurrences, so use if recurrence suspected During diagnosis, use DWI and liverspecific contrast media for better study of the liver [37,38] Can be used at any stage. The use of US contrast medium does not carry any risks, so can be used repeatedly during long-term follow-up [40] Dynamic CT scanning should be used after contrast medium injection; quadriphasic acquisition should be used for imaging the liver During prolonged follow-up, MRI may be used in order to reduce the use of CT and risks associated with ionising radiation and the use of contrast agents ...
Radioligand therapy (RLT) with lutetium (177Lu) oxodotreotide is an approved therapy in combination with somatostatin analogues (SSAs) for patients with advanced, well-differentiated G1–G2, gastro-entero-pancreatic neuroendocrine tumours (GEP-NETs) that progress on SSAs. We conducted a series of round table meetings throughout Italy to identify issues related to RLT delivery to patients with GEP-NETs. Four key issues were identified: (1) the proper definition of tumour progression prior to RLT initiation; (2) the impact of RLT in patients with bone metastases and/or high hepatic tumour burden; (3) the optimal follow-up protocol after RLT; and (4) organisational issues related to RLT use and managerial implications. This article reviews the literature relating to the aforementioned issues and makes recommendations based on available evidence and Italian NET experts’ opinions. In particular, the group recommends the development of a diagnostic–therapeutic care pathway (DTCP) for patients undergoing RLT which provides systematic guidance but can still be individualised for each patient’s clinical and psychosocial needs. A DTCP may clarify the diagnostic, therapeutic and post-treatment monitoring process, and improve communication and the coordination of care between hub and spoke centres. The DTCP may also contribute to changes in the care process related to the 2013/59/EURATOM Directive and to the definition of costs when planning for future or updated reimbursement of RLT in Italy.
... Duodenoscopy showed no recurrence (▶ Fig. 4) and repeat ampullary biopsies showed no residual tumor. Duodenal ESD is deemed risky for lesions larger than 2 cm [1,2]; however, it is safe and effective in experienced hands. Here, we describe a novel hybrid ESD-EMR technique for a large vascular ampullary lesion. ...
... In suspected small bowel NETs, CT enteroclysis is an excellent imaging modality with sensitivity up to 100%. MRI is less frequently utilized due to long scan times and susceptibility to motion artifacts [5]. However, MRI is a radiation-free alternative and probably superior to CT scan for detecting liver metastases. ...
The incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has increased over the last several decades. In general, NETs are slow-growing neoplasms and the data on the natural history is still evolving. The availability and improved utilization of advanced imaging modalities have allowed the selection of cases suitable for endotherapy. In this regard, endoscopic ultrasound (EUS) has emerged as a central imaging modality to assess the depth of infiltration in gastroduodenal as well as rectal NETs. Enhanced EUS modalities, including contrast-enhanced EUS and EUS elastography, reliably differentiate pancreatic neuroendocrine tumors (PNETs) from adenocarcinomas and may enable prediction of aggressive PNETs. With recent developments in therapeutic endoscopy, a large proportion of GEP-NETs can be safely managed endoscopically. Endoscopic resection techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), allow the safe removal of gastroduodenal and rectal NETs. Recent data indicate that modified EMR techniques may be superior to conventional EMR with regard to histologically complete resection. Device-assisted endoscopic full thickness resection is emerging as a safe and effective technique for upper gastrointestinal as well as rectal NETs. In selected cases with PNETs, who are otherwise unfit for surgery, EUS-guided ablation is increasingly being recognized as a safe treatment option. This review focusses on evidence-based approaches to endoscopic evaluation and the management of GEP-NETs with special emphasis on recent advancements.
... Although this classification is not yet part of the grading system of lung NETs, it is currently used in gastrointestinal neuroendocrine tumours (GEP-NENs) according to the 2019 WHO classification. Well-differentiated NENs are further divided into grades based solely on Ki-67 proliferation index and mitotic index: into grade 1 (G1, mitotic rate < 2, Ki-67 index < 3), grade 2 (G2, mitotic rate 2-20, Ki-67 index between 3 and 20) and grade 3 (G3, mitotic rate > 20, Ki-67 index > 20) [12,13]. It has been studied how these grading values can play a fundamental role in prognostic evaluation and differentiation between various tumour histotypes and in particular in discriminating between TCs and ACs tumours or high-grade SCLS and LCNEC from carcinoid tumours [12,13]. ...
... Well-differentiated NENs are further divided into grades based solely on Ki-67 proliferation index and mitotic index: into grade 1 (G1, mitotic rate < 2, Ki-67 index < 3), grade 2 (G2, mitotic rate 2-20, Ki-67 index between 3 and 20) and grade 3 (G3, mitotic rate > 20, Ki-67 index > 20) [12,13]. It has been studied how these grading values can play a fundamental role in prognostic evaluation and differentiation between various tumour histotypes and in particular in discriminating between TCs and ACs tumours or high-grade SCLS and LCNEC from carcinoid tumours [12,13]. ...
Background
The aim is to find a correlation between texture features extracted from neuroendocrine (NET) lung cancer subtypes, both Ki-67 index and the presence of lymph-nodal mediastinal metastases detected while using different computer tomography (CT) scanners.
Methods
Sixty patients with a confirmed pulmonary NET histological diagnosis, a known Ki-67 status and metastases, were included. After subdivision of primary lesions in baseline acquisition and venous phase, 107 radiomic features of first and higher orders were extracted. Spearman’s correlation matrix with Ward’s hierarchical clustering was applied to confirm the absence of bias due to the database heterogeneity. Nonparametric tests were conducted to identify statistically significant features in the distinction between patient groups (Ki-67 < 3—Group 1; 3 ≤ Ki-67 ≤ 20—Group 2; and Ki-67 > 20—Group 3, and presence of metastases).
Results
No bias arising from sample heterogeneity was found. Regarding Ki-67 groups statistical tests, seven statistically significant features ( p value < 0.05) were found in post-contrast enhanced CT; three in baseline acquisitions. In metastasis classes distinction, three features (first-order class) were statistically significant in post-contrast acquisitions and 15 features (second-order class) in baseline acquisitions, including the three features distinguishing between Ki-67 groups in baseline images (MCC, ClusterProminence and Strength).
Conclusions
Some radiomic features can be used as a valid and reproducible tool for predicting Ki-67 class and hence the subtype of lung NET in baseline and post-contrast enhanced CT images. In particular, in baseline examination three features can establish both tumour class and aggressiveness.
... Pedrosa et al. [207] suggested reserving the standard contrast-enhanced MRI protocol with MRCP for the first diagnosis of PCN, while for the follow-up, suggested a 10-min protocol consisting of axial and coronal SSFSE T2-weighted, 2D and 3D single-shot MRCP, and 3D T1weighted spoiled-gradient echo. With regard to the utility of DWI in the surveillance of pancreatic cystic lesions, there is a debate in the literature [208][209][210][211][212][213]. DWI should be included to avoid the risk of missing a concomitant pancreatic cancer. ...
... Several abbreviated protocols (AP) for PC have been proposed [198][199][200][201][202][203][204][205][206][207][208]. For PCN surveillance, AP-MRI could be a good alternative. ...
... Pedrosa et al. [207] suggested reserving the standard contrast-enhanced MRI protocol with MRCP for the first diagnosis of PCN, while for the follow-up, suggested a 10-min protocol consisting of axial and coronal SSFSE T2-weighted, 2D and 3D single-shot MRCP, and 3D T1-weighted spoiled-gradient echo. With regard to the utility of DWI in the surveillance of pancreatic cystic lesions, there is a debate in the literature [208][209][210][211][212][213]. DWI should be included to avoid the risk of missing a concomitant pancreatic cancer. ...
Simple Summary
Pancreatic cancer (PC) is one of the deadliest cancers. Its high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate.
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.
... As the clinical manifestations are nonspecific, imaging examinations are crucial for the diagnosis. Endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) can be used for the diagnosis, localization, and staging of R-NEN [16]. EUS has high spatial resolution and can accurately identify the depth of invasion for R-NEN restricted to the mucosa and submucosa. ...
PurposeTo investigate the four-phase computed tomography (CT) features of rectal neuroendocrine neoplasms (R-NENs) as they relate to different World Health Organization pathological grades.MethodsA total of 42 patients who underwent pre-operative four-phase CT for evaluation of neoplasms confirmed as different pathological grades of R‐NENs by surgery were included. The CT features were retrospectively analyzed by two radiologists in consensus including the tumor location, shape, long diameter, necrosis, boundary, transmural invasion, CT attenuation values of noncontrast and different enhancement phases, intra mesenteric metastasis, lateral lymph node metastasis, and distant metastasis. The differences among R-NENs of different pathological grades were analyzed using T-test, analysis of variance, and non-parametric rank sum test.ResultsAmong 42 cases (23 males, 19 females, aged 57 ± 10.48 years) of R-NENs, neuroendocrine tumors G1, G2, and G3 (NET G1, NET G2, NET G3) and neuroendocrine carcinoma (NEC) were 13, 13, 3 and 13 cases, respectively. There were statistically significant differences in tumor long diameter, shape, necrosis, boundary, transmural invasion, CT values in delayed phase, intra mesenteric metastasis, lateral lymph node metastasis, and liver metastasis of different pathological grades (P < 0.001, P = 0.014, P = 0.004, P < 0.001, P < 0.001, P = 0.038, P = 0.006, P = 0.022, and P = 0.020, respectively).Conclusion
Features on four-phase CT can correlate with WHO pathological grades of R-NENs; this may be helpful for preoperative diagnosis and prognosis evaluation.Graphical abstract
