VIPoma overview

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Overview

Historical Perspective

Pathophysiology

Causes

Differentiating VIPoma from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Madhu Sigdel M.B.B.S.[2]Parminder Dhingra, M.D. [3] Homa Najafi, M.D.[4]

Overview

VIPoma was first described in 1958 by Verner and Morrison. A VIPoma is a rare tumor of the non-beta cells of the pancreas that results in the overproduction of the hormone vasoactive intestinal peptide (VIP). On microscopic histopathological analysis, findings of VIPoma are composition of uniform, small to intermediate-sized cells in clusters, nests, and trabecular growth patterns with hyperchromatic nuclei and scant cytoplasm. There are no established causes for VIPoma. VIPoma must be differentiated from ganglioneuroblastoma, ganglioneuroma, factitious diarrhea, bile salt enteropathy, rectal vilous adenomas, and laxative abuse. The incidence VIPoma is approximately 0.01 per 100,000 individuals worldwide. Females are more commonly affected with VIPoma than male. The incidence of VIPoma increases with age, the median age at diagnosis is 50 years. The most common risk factor in the development of VIPoma is positive family history of multiple endocrine neoplasia type 1. If left untreated, patients with VIPoma may progress to develop watery diarrhea, abdominal pain, bloating, nausea, vomiting, skin rash, backache, flushing, and lethargy. Common complications of VIPoma include metastasis, cardiac arrest from low blood potassium level, and dehydration. The presence of metastasis is associated with a particularly poor prognosis among patients with VIPoma, with a 5 year survival rate of 20% and 3 year survival rate of 40%. The hallmark of VIPoma is watery diarrhea. A positive history of abdominal pain, weight loss, numbness, and weakness is suggestive of VIPoma. Common physical examination findings of VIPoma include tachycardia, rash, facial flushing, abdominal tenderness, and abdominal distention. Laboratory tests used in the diagnosis of VIPoma include serum vasoactive intestinal polypeptide (VIP) levels, basal gastric acid output, and basic metabolic pannel for potassium, bicarbonate, magnesium, and calcium levels. On CT scan VIPoma is characterized by hypervascularity with diffuse multiple metastatic nodulation. Abdominal MRI is helpful in the diagnosis of VIPoma. On abdominal MRI, VIPoma is characterized by a mass which is hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI. Abdominal ultrasound scan may be helpful in the diagnosis of VIPoma. Finding on ultrasound scan suggestive of VIPoma is hypoechoic tumor in the distal pancreas. Other imaging studies for VIPoma include somatostatin receptor scintigraphy and PET scan. Initial treatment in patient with VIPoma is prompt replacement of fluid and electrolyte losses. Steroids may be used to provide symptomatic relief. Surgery is the mainstay of treatment for VIPoma. Secondary prevention measures of VIPoma include a detailed history, physical examination, and imaging every 3 to 12 months up to one year post resection and every 6 to 12 months thereafter.

Historical Perspective

VIPoma which is also known as Verner-Morrison syndrome was first described in 1958 by Verner and Morrison.

Pathophysiology

A VIPoma is a rare tumor of the non-beta cells of the pancreas that results in the overproduction of the hormone vasoactive intestinal peptide (VIP). On microscopichistopathological analysis, findings of VIPoma are composition of uniform, small to intermediate-sized cells in clusters, nests, and trabecular growth patterns with hyperchromatic nuclei and scant cytoplasm.

Causes

The cause of VIPoma has not been identified.

Differentiating VIPoma From Other Diseases

VIPoma must be differentiated from ganglioneuroblastoma, ganglioneuroma, factitious diarrhea, bile salt enteropathy, rectal vilous adenomas, and laxative abuse.

Epidemiology and Demographics

The annual incidence of VIPoma is approximately 0.01 per 100,000 (approx. 1 in 10 million) individuals worldwide. Female are more commonly affected by VIPoma than male. The incidence of VIPoma increases with age, the median age at diagnosis in adults is 50 years. VIPoma in children is usually diagnosed between age 2 to 4.

Risk Factors

The most common risk factor in the development of VIPoma is positive family history of multiple endocrine neoplasia type 1.

Screening

According to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for VIPoma.

Natural History, Complications and Prognosis

If left untreated, patients with VIPoma may progress to develop watery diarrhea, abdominal pain, bloating, nausea, vomiting, skin rash, backache, flushing, and lethargy. Common complications of VIPoma include metastasis, cardiac arrest from low blood potassium level, and dehydration. The presence of metastasis is associated with a particularly poor prognosis among patients with VIPoma, with a 5 year survival rate of 20% and 3 year survival rate of 40%.

Diagnosis

Diagnostic Study of Choice

History and Symptoms

The hallmark of VIPoma is watery diarrhea. A positive history of abdominal pain, weight loss, numbness, and weakness is suggestive of VIPoma.

Physical Examination

Common physical examination findings of VIPoma include tachycardia, rash, facial flushing, abdominal tenderness, and abdominal distention.

Laboratory Findings

Laboratory tests used in the diagnosis of VIPoma include serum vasoactive intestinal polypeptide (VIP) levels, basal gastric acid output, potassium, bicarbonate, magnesium, and calcium levels.

Electrocardiogram

X-ray

There are no x-ray findings associated with VIPoma.

CT

On CT scan VIPoma is characterized by hypervascularity with diffuse multiple metastatic nodulation. CT scan are highly accurate for tumor localization of primary neuroendocrine pancreatic tumor. Since most of them are more than 3cm in size at the time of presentation. Sensitivity of contrast enhanced CT for VIPoma approaches 100%.

MRI

Abdominal MRI is helpful in the diagnosis of VIPoma. On abdominal MRI, VIPoma is characterized by a mass which is hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI.

Echocardiography or Ultrasound

Endoscopic ultrasound may be helpful in the diagnosis of VIPoma. Finding on ultrasound suggestive of VIPoma is hypoechoic tumor in the distal part of pancreas.

Other Imaging Findings

Other imaging studies for VIPoma include somatostatin receptor scintigraphy and PET scan using radiolabeled somatostatin analogs.

Other Diagnostic Studies

Other diagnostic studies for VIPoma include immunohistochemical staining test, which demonstrates staining for markers such as chromogranin A, cytokeratin 19, synaptophysin, Ki-67, neuron specific enolase, PGP 9.5.

Treatment

Medical Therapy

Initial treatment in patient with VIPoma is prompt replacement of fluid and correction of electrolyte imbalance and acid-base disturbance. Somatostatin analogues like short acting octreotide is useful for controlling diarrhea by blocking the release of VIP. Octreotide is later replaced by longer acting depot preparation of somatostatin analogues like sandostatin or lanreotide.

Interventions

Surgery

Surgery is the mainstay of treatment for VIPoma. Surgery should be considered after initial symptomatic management of VIPoma inoperable cases. Complete surgical resection of the tumor is the only curative treatment for VIPoma. If the tumor cannot be removed completely, surgical debulking may have palliative effect for control of hormonal symptoms.

Primary Prevention

There are no established measures for the primary prevention of VIPoma.

Secondary Prevention

Effective measures for the secondary prevention of VIPoma include history and physical examination, serum VIP levels and indicated markers, and multi-phasic CT scan or MRI.

References


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