Insulinoma classification: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
 
(45 intermediate revisions by 3 users not shown)
Line 2: Line 2:
{{Insulinoma}}
{{Insulinoma}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{ADS}}
==Overview==
==Overview==
*There is no established system for the classification of [disease name].
Insulinoma may be classified according to their [[malignant]] potential into 2 sub-types: [[Benign]] (90%) and [[malignant]] (10%). It is also classified into 2 subtypes based on the number: solitary (90%) and multiple (10%). Previously insulinoma was classified into 2 subtypes based on [[hormonal]] level as determined by [[radioimmunoassay]] into group A and group B. The staging of [[malignant]] insulinoma is based on the [[AJCC|AJCC 2010]], ENETS and modified ENETS staging classification.
OR
*[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
OR
*[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
*[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
OR
*Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
OR
*If the staging system involves specific and characteristic findings and features:
*According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
OR
*The staging of [malignancy name] is based on the [staging system].
OR
*There is no established system for the staging of [malignancy name].


==Classification==
==Classification==
 
{|
* Insulinoma may be classified according to malignant potential into 2 sub-types:  
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" + |Classification of insulinoma
**Benign
|-
**Malignant
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Criteria
***90% of insulinoma are benign in nature while 10% has a malignant potential to invade adjacent soft tissues or structures. The malignant type is mostly associated with MEN 1 syndrome.They also have a recurrence rate which is higher in those with MEN1 (21% at 10 and 20 years) than without it(5% at 10 and 7% at 20 years)<ref>{{Cite journal
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Classification
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Features
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''[[Malignant|Malignancy]] potential'''
| style="background:#DCDCDC;" align="center" + |[[Benign|'''Benign''']]
| style="background:#F5F5F5;" + |
*90% of insulinomas are benign in nature.
|-
| style="background:#DCDCDC;" align="center" + |[[Malignant|'''Malignant''']]
| style="background:#F5F5F5;" + |
* 10% of Insulinomas have a [[malignant]] potential to invade adjacent [[Soft tissue|soft tissues]] or structures.
*The [[malignant]] type is mostly associated with [[Multiple endocrine neoplasia type 1|MEN 1 syndrome]].
*They also have a recurrence rate which is higher in those with [[MEN1]] (21% at 10 and 20 years) than without it (5% at 10 and 7% at 20 years).<ref>{{Cite journal
  | author = [[F. J. Service]], [[M. M. McMahon]], [[P. C. O'Brien]] & [[D. J. Ballard]]
  | author = [[F. J. Service]], [[M. M. McMahon]], [[P. C. O'Brien]] & [[D. J. Ballard]]
  | title = Functioning insulinoma--incidence, recurrence, and long-term survival of patients: a 60-year study
  | title = Functioning insulinoma--incidence, recurrence, and long-term survival of patients: a 60-year study
Line 33: Line 31:
  | pages = 711–719
  | pages = 711–719
  | year = 1991
  | year = 1991
| month = July
  | pmid = 01677058
  | pmid = 01677058
}}</ref>
}}</ref> In one of the recent research papers, the recurrence was described as 4 times more common in individuals with [[MEN 1 syndrome|MEN 1]].<ref name="pmid28567298">{{cite journal| author=Ahmad N, Almutawa AM, Abubacker MZ, Elzeftawy HA, Bawazir OA| title=Recurrent insulinoma in a 10-year-old boy with Down's syndrome. | journal=Endocrinol Diabetes Metab Case Rep | year= 2017 | volume= 2017 | issue=  | pages=  | pmid=28567298 | doi=10.1530/EDM-16-0155 | pmc=5445445 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28567298  }} </ref>
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''Based on number'''
| style="background:#DCDCDC;" align="center" + |[[Solitary|'''Solitary''']]
| style="background:#F5F5F5;" + |
*90% of insulinomas are [[solitary]].
|-
| style="background:#DCDCDC;" align="center" + |'''Multiple'''
| style="background:#F5F5F5;" + |
*10% of insulinomas can be multiple in number.
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''Based on the functionality'''
'''(clinical manifestations)'''
| style="background:#DCDCDC;" align="center" + |'''Functional'''
| rowspan="2" style="background:#F5F5F5;" + |
* According to [[WHO]], functioning [[Pancreatic endocrine tumor|pancreatic endocrine tumors]] are classified as:
#Well-differentiated [[endocrine tumors]], with [[benign]] or uncertain behavior.
#Well-differentiated [[endocrine]] [[carcinomas]] with low-grade [[malignant]] behavior.
#Poorly differentiated [[endocrine]] [[Carcinoma|carcinomas]] with high-grade [[malignant]] behavior.
:'''Note:''' Most insulinomas are classified as well-differentiated [[endocrine tumors]] ([[WHO]] 1) but occasionally they belong to [[WHO]] 2 or 3. <ref name="de HerderNiederle2007">{{cite journal|last1=de Herder|first1=Wouter W.|last2=Niederle|first2=Bruno|last3=Scoazec|first3=Jean-Yves|last4=Pauwels|first4=Stanislas|last5=Klöppel|first5=Günter|last6=Falconi|first6=Massimo|last7=Kwekkeboom|first7=Dik J.|last8=Öberg|first8=Kjel|last9=Eriksson|first9=Barbro|last10=Wiedenmann|first10=Bertram|last11=Rindi|first11=Guido|last12=O’Toole|first12=Dermot|last13=Ferone|first13=Diego|title=Well-Differentiated Pancreatic Tumor/Carcinoma: Insulinoma|journal=Neuroendocrinology|volume=84|issue=3|year=2007|pages=183–188|issn=0028-3835|doi=10.1159/000098010}}</ref><ref name="pmid21629514">{{cite journal |vauthors=Schott M, Klöppel G, Raffel A, Saleh A, Knoefel WT, Scherbaum WA |title=Neuroendocrine neoplasms of the gastrointestinal tract |journal=Dtsch Arztebl Int |volume=108 |issue=18 |pages=305–12 |year=2011 |pmid=21629514 |pmc=3103981 |doi=10.3238/arztebl.2011.0305 |url=}}</ref><ref>{{cite book | last = Bosman | first = F. T. | title = WHO classification of tumours of the digestive system | publisher = International Agency for Research on Cancer | location = Lyon | year = 2010 | isbn = 978-9283224327 }}</ref><ref name="pmid28357177">{{cite journal |vauthors=Sun J |title=Pancreatic neuroendocrine tumors |journal=Intractable Rare Dis Res |volume=6 |issue=1 |pages=21–28 |year=2017 |pmid=28357177 |pmc=5359348 |doi=10.5582/irdr.2017.01007 |url=}}</ref>
|-
| style="background:#DCDCDC;" align="center" + |'''Non-functional<ref name="pmid15522939">{{cite journal| author=Mittendorf EA, Liu YC, McHenry CR| title=Giant insulinoma: case report and review of the literature. | journal=J Clin Endocrinol Metab | year= 2005 | volume= 90 | issue= 1 | pages= 575-80 | pmid=15522939 | doi=10.1210/jc.2004-0825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15522939  }} </ref>'''
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''Based on [[hormonal]] level determined by [[radioimmunoassay]]<ref name="pmid6311653">{{cite journal| author=Berger M, Bordi C, Cüppers HJ, Berchtold P, Gries FA, Münterfering H et al.| title=Functional and morphologic characterization of human insulinomas. | journal=Diabetes | year= 1983 | volume= 32 | issue= 10 | pages= 921-31 | pmid=6311653 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6311653  }} </ref>'''
'''(previously used)'''
| style="background:#DCDCDC;" align="center" + |'''Group A'''
| style="background:#F5F5F5;" + |
*Abundant [[B cells]] with a [[Trabecula|trabecular]] arrangement and uniform [[insulin]] [[immunofluorescence]].
|-
| style="background:#DCDCDC;" align="center" + |'''Group B'''
| style="background:#F5F5F5;" + |
*Scarce [[B cells]] with a [[medullary]] arrangement and irregular [[immunofluorescence]].
|}


* Previously insulinoma was classified into 2 subtypes based on hormonal level as determined by radioimmunoassay<ref name="pmid6311653">{{cite journal| author=Berger M, Bordi C, Cüppers HJ, Berchtold P, Gries FA, Münterfering H et al.| title=Functional and morphologic characterization of human insulinomas. | journal=Diabetes | year= 1983 | volume= 32 | issue= 10 | pages= 921-31 | pmid=6311653 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6311653  }} </ref>:
=== [[American Joint Committee on Cancer|American Joint Cancer Committee]] ([[AJCC]]) 7th edition 2010 calssification ===
**Group A of abundant B cells with trabecular arrangement and uniform insulin immunofluorescence
The staging of [[malignant]] insulinoma being a [[pancreatic neuroendocrine tumor]] may be classified into several subtypes based on [[American Joint Committee on Cancer|American Joint Cancer Committee]] ([[AJCC]]) 7th edition 2010: <ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref><ref name="pmid25816036">{{cite journal| author=Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW et al.| title=TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution. | journal=Medicine (Baltimore) | year= 2015 | volume= 94 | issue= 12 | pages= e660 | pmid=25816036 | doi=10.1097/MD.0000000000000660 | pmc=4554009 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25816036  }} </ref>  
**Group B of scarce B cells with medullary arrangement and irregular immunofluorescence
{| class="wikitable" align="right"
* Insulinoma being a pancreatic neuroendocrine tumor may be classified/staged into several subtypes based on American Joint Cancer Committee(AJCC) 7th edition 2010 <ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref><ref name="pmid25816036">{{cite journal| author=Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW et al.| title=TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution. | journal=Medicine (Baltimore) | year= 2015 | volume= 94 | issue= 12 | pages= e660 | pmid=25816036 | doi=10.1097/MD.0000000000000660 | pmc=4554009 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25816036  }} </ref> :
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Stage'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''T'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''N'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''M'''
|-
| style="background:#DCDCDC;" align="center" + |IA
| style="background:#F5F5F5;" + |T1
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
| style="background:#DCDCDC;" align="center" + |IB
| style="background:#F5F5F5;" + |T2
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
| style="background:#DCDCDC;" align="center" + |IIA
| style="background:#F5F5F5;" + |T3
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
| style="background:#DCDCDC;" align="center" + |IIB
| style="background:#F5F5F5;" + |T1-3
| style="background:#F5F5F5;" + |N1
| style="background:#F5F5F5;" + |M0
|-
| style="background:#DCDCDC;" align="center" + |III
| style="background:#F5F5F5;" + |T4
| style="background:#F5F5F5;" + |Any N
| style="background:#F5F5F5;" + |M0
|-
| style="background:#DCDCDC;" align="center" + |IV
| style="background:#F5F5F5;" + |Any T
| style="background:#F5F5F5;" + |Any N
| style="background:#F5F5F5;" + |M1
|}
{| class="wikitable" align="center"
| colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |'''AJCC 2010'''
|-
! rowspan="4" style="background:#DCDCDC;" align="center" + | T
| style="background:#DCDCDC;" align="center" + | T1
| style="background:#F5F5F5;" + |<2 cm in greatest dimension
|-
| style="background:#DCDCDC;" align="center" + |T2
| style="background:#F5F5F5;" + |>2 cm in greatest dimension
|-
| style="background:#DCDCDC;" align="center" + |T3
| style="background:#F5F5F5;" + |Beyond the [[pancreas]] but without involvement of the [[superior mesenteric artery]]
|-
| style="background:#DCDCDC;" align="center" + |T4
| style="background:#F5F5F5;" + |Involvement of the ''[[celiac axis]]'' or [[superior mesenteric artery]] (unresectable [[tumor]])
|-
! rowspan="2" style="background:#DCDCDC;" align="center" + | N
| style="background:#DCDCDC;" align="center" + |N0
| style="background:#F5F5F5;" + |No regional [[lymph node]] [[metastasis]]
|-
| style="background:#DCDCDC;" align="center" + |N1
| style="background:#F5F5F5;" + |Regional [[lymph node]] [[metastasis]]
|-
! rowspan="2" style="background:#DCDCDC;" align="center" + | M
| style="background:#DCDCDC;" align="center" + |M0
| style="background:#F5F5F5;" + |No distant [[metastasis]]
|-
| style="background:#DCDCDC;" align="center" + |M1
| style="background:#F5F5F5;" + |Distant [[metastasis]]
|-
|}


=== European Neuroendocrine Tumor Society (ENETS) classification: ===
Being a [[pancreatic neuroendocrine tumor]], it is also staged by European Neuroendocrine Tumor Society (ENETS) as: <ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref><ref name="pmid25816036">{{cite journal| author=Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW et al.| title=TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution. | journal=Medicine (Baltimore) | year= 2015 | volume= 94 | issue= 12 | pages= e660 | pmid=25816036 | doi=10.1097/MD.0000000000000660 | pmc=4554009 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25816036  }} </ref>
{| class="wikitable" align="right"
{| class="wikitable" align="right"
| '''Stage'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Stage'''
|'''T'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''T'''
|'''N'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''N'''
|'''M'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''M'''
|-
|-
|IA
| style="background:#DCDCDC;" align="center" + |I
|T1
| style="background:#F5F5F5;" + |T1
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IB
| style="background:#DCDCDC;" align="center" + |IIA
|T2
| style="background:#F5F5F5;" + |T2
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIA
| style="background:#DCDCDC;" align="center" + |IIB
|T3
| style="background:#F5F5F5;" + |T3
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIB
| style="background:#DCDCDC;" align="center" + |IIIA
|T1-3
| style="background:#F5F5F5;" + |T4
|N1
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|III
| style="background:#DCDCDC;" align="center" + |III B
|T4
| style="background:#F5F5F5;" + |Any T
|Any N
| style="background:#F5F5F5;" + |N1
| M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IV
| style="background:#DCDCDC;" align="center" + |IV
|Any T
| style="background:#F5F5F5;" + |Any T
|Any N
| style="background:#F5F5F5;" + |Any N
|M1
| style="background:#F5F5F5;" + |M1
|}
|}
{| class="wikitable" style="text-align:center"
{| class="wikitable" style="text-align:center"
|+'''AJCC 2010'''
| colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |'''ENETS'''
! rowspan="4"| T
|-
| T1
! rowspan="4" style="background:#DCDCDC;" align="center" + | T
|<2 cm in greatest dimension
| style="background:#DCDCDC;" align="center" + |T1
| style="background:#F5F5F5;" + |[[Tumor]] limited to [[pancreas]], <2 cm
|-
| style="background:#DCDCDC;" align="center" + |T2
| style="background:#F5F5F5;" + |[[Tumor]] limited to [[pancreas]], 2-4 cm
|-
|-
|T2
| style="background:#DCDCDC;" align="center" + |T3
|>2 cm in greatest dimension
| style="background:#F5F5F5;" + |>4cm, or invading the [[duodenum]] or [[common bile duct]]
|-
|-
|T3
| style="background:#DCDCDC;" align="center" + |T4
|Beyond the pancreas but without involvement of the superior mesentric artery
| style="background:#F5F5F5;" + |[[Tumor]] invades adjacent structures
|-
|-
|T4
! rowspan="2" style="background:#DCDCDC;" align="center" + | N
|Involvement of the celiac axis or superior mesenteric artery(unresectable tumor)
| style="background:#DCDCDC;" align="center" + |N0
| style="background:#F5F5F5;" + |No regional [[lymph node]] [[metastasis]]
|-
|-
! rowspan="2"| N
| style="background:#DCDCDC;" align="center" + | N1
|N0
| style="background:#F5F5F5;" + |Regional [[lymph node]] [[metastasis]]
|No regional lymph node metastasis
|-
! rowspan="2" style="background:#DCDCDC;" align="center" + | M
| style="background:#DCDCDC;" align="center" + |M0
| style="background:#F5F5F5;" + |No distant [[metastasis]]
|-
| style="background:#DCDCDC;" align="center" + |M1
| style="background:#F5F5F5;" + |Distant [[metastasis]]
|-
|}
 
=== [[WHO]] 2010 classification system ===
*WHO classification system combined differentiation and grading characteristics to classify the belligerence of a [[pancreatic neuroendocrine tumor]].
*The aggressiveness of tumor was expressed in form of [[mitotic]] count and staining of a nuclear antigen called [[Ki-67]]: <ref>{{cite book | last = Bosman | first = F. T. | title = WHO classification of tumours of the digestive system | publisher = International Agency for Research on Cancer | location = Lyon | year = 2010 | isbn = 978-9283224327 }}</ref><ref name="pmid28357177">{{cite journal |vauthors=Sun J |title=Pancreatic neuroendocrine tumors |journal=Intractable Rare Dis Res |volume=6 |issue=1 |pages=21–28 |year=2017 |pmid=28357177 |pmc=5359348 |doi=10.5582/irdr.2017.01007 |url=}}</ref>
{| class="wikitable" style="text-align:center"
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Grade of tumor'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Mitotic Count'''(Mitoses per 10 high powerfields)
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Expression of Ki 67'''
|-
|-
|N1
| style="background:#DCDCDC;" align="center" + |Grade 1
|Regional lymph node metastasis
| style="background:#F5F5F5;" + |<2
| style="background:#F5F5F5;" + |≤3%
|-
|-
! rowspan="2"| M
| style="background:#DCDCDC;" align="center" + |Grade 2
|M0
| style="background:#F5F5F5;" + |2-10
|No distant metastasis
| style="background:#F5F5F5;" + |3-20%
|-
|-
|M1
| style="background:#DCDCDC;" align="center" + |Grade 3
|Distant metastasis
| style="background:#F5F5F5;" + |>20
| style="background:#F5F5F5;" + |>20%
|-
|-
|}
|}
*Grade 1 and 2 tumors were classified as [[Neuroendocrine|neuroendocrine neoplasm]] (NET) and grade 3 were classified as neuroendocrine carcinoma (NEC).


* In its new 8th edition of [[AJCC]] which is planned to be published on January 1, 2018; [[AJCC]] had developed a modified ENETS (mENETS) staging classification:<ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref>


* Being a pancreatic neuroendocrine tumor, it is also staged by European Neuroendocrine Tumor Society (ENETS)as <ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref><ref name="pmid25816036">{{cite journal| author=Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW et al.| title=TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution. | journal=Medicine (Baltimore) | year= 2015 | volume= 94 | issue= 12 | pages= e660 | pmid=25816036 | doi=10.1097/MD.0000000000000660 | pmc=4554009 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25816036  }} </ref>:
{| class="wikitable" align="right"
{| class="wikitable" align="right"
| '''Stage'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Stage'''
|'''T'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''T'''
|'''N'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''N'''
|'''M'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''M'''
|-
|-
|I
| style="background:#DCDCDC;" align="center" + |IA
|T1
| style="background:#F5F5F5;" + |T1
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIA
| style="background:#DCDCDC;" align="center" + |IB
|T2
| style="background:#F5F5F5;" + |T2
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIB
| style="background:#DCDCDC;" align="center" + |IIA
|T3
| style="background:#F5F5F5;" + |T3
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIIA
| style="background:#DCDCDC;" align="center" + |IIB
|T4
| style="background:#F5F5F5;" + |T1-3
|N1
| style="background:#F5F5F5;" + |N1
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|III B
| style="background:#DCDCDC;" align="center" + |III
|T4
| style="background:#F5F5F5;" + |T4
|Any N
| style="background:#F5F5F5;" + |Any N
| M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IV
| style="background:#DCDCDC;" align="center" + |IV
|Any T
| style="background:#F5F5F5;" + |Any T
|Any N
| style="background:#F5F5F5;" + |Any N
|M1
| style="background:#F5F5F5;" + |M1
|}
|}
{| class="wikitable" style="text-align:center"
{| class="wikitable" style="text-align:center"
|+'''ENETS'''
| colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" coolspan="4" + |'''mENETS'''
! rowspan="4"| T
| T1
|Tumor limited to pancreas,<2 cm
|-
|-
|T2
! rowspan="4" style="background:#DCDCDC;" align="center" + |T
|Tumor limited to pancreas,2-4 cm  
| style="background:#DCDCDC;" align="center" + |T1
| style="background:#F5F5F5;" + |[[Tumor-associated calcium signal transducer 1|Tumor]] limited to [[pancreas]], <2 cm
|-
|-
|T3
| style="background:#DCDCDC;" align="center" + |T2
|>4cm, or invading the duodenum or common bile duct
| style="background:#F5F5F5;" + |[[Tumor]] limited to [[pancreas]], 2-4 cm
|-
|-
|T4
| style="background:#DCDCDC;" align="center" + |T3
|Tumor invades adjacent structures
| style="background:#F5F5F5;" + |>4cm, or invading the [[duodenum]] or [[common bile duct]]
|-
|-
! rowspan="2"| N
| style="background:#DCDCDC;" align="center" + |T4
|N0
| style="background:#F5F5F5;" + |[[Tumor]] invades adjacent structures
|No regional lymph node metastasis
|-
|-
|N1
! rowspan="2" style="background:#DCDCDC;" align="center" + | N
|Regional lymph node metastasis
| style="background:#DCDCDC;" align="center" + |N0
| style="background:#F5F5F5;" + |No regional [[lymph node]] metastasis
|-
|-
! rowspan="2"| M
| style="background:#DCDCDC;" align="center" + |N1
|M0
| style="background:#F5F5F5;" + |Regional [[lymph node]] metastasis
|No distant metastasis
|-
|-
|M1
! rowspan="2" style="background:#DCDCDC;" align="center" + | M
|Distant metastasis
| style="background:#DCDCDC;" align="center" + |M0
| style="background:#F5F5F5;" + |No distant [[metastasis]]
|-
| style="background:#DCDCDC;" align="center" + |M1
| style="background:#F5F5F5;" + |Distant [[metastasis]]
|-
|-
|}
|}
* In its new 8th edition of AJCC which is planned to be published on January 1, 2018; recent research<ref name="pmid27646952">{{cite journal| author=Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C et al.| title=Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems. | journal=J Clin Oncol | year= 2017 | volume= 35 | issue= 3 | pages= 274-280 | pmid=27646952 | doi=10.1200/JCO.2016.67.8193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27646952  }} </ref> had developed a modified ENETS staging classification:


==References==
==References==
Line 184: Line 303:
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
​

Latest revision as of 14:39, 5 December 2017

Insulinoma Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Insulinoma from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Staging

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

X-ray

Ultrasound

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Insulinoma classification On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Insulinoma classification

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Insulinoma classification

CDC on Insulinoma classification

Insulinoma classification in the news

Blogs on Insulinoma classification

Directions to Hospitals Treating Insulinoma

Risk calculators and risk factors for Insulinoma classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

Insulinoma may be classified according to their malignant potential into 2 sub-types: Benign (90%) and malignant (10%). It is also classified into 2 subtypes based on the number: solitary (90%) and multiple (10%). Previously insulinoma was classified into 2 subtypes based on hormonal level as determined by radioimmunoassay into group A and group B. The staging of malignant insulinoma is based on the AJCC 2010, ENETS and modified ENETS staging classification.

Classification

Classification of insulinoma
Criteria Classification Features
Malignancy potential Benign
  • 90% of insulinomas are benign in nature.
Malignant
  • 10% of Insulinomas have a malignant potential to invade adjacent soft tissues or structures.
  • The malignant type is mostly associated with MEN 1 syndrome.
  • They also have a recurrence rate which is higher in those with MEN1 (21% at 10 and 20 years) than without it (5% at 10 and 7% at 20 years).[1] In one of the recent research papers, the recurrence was described as 4 times more common in individuals with MEN 1.[2]
Based on number Solitary
Multiple
  • 10% of insulinomas can be multiple in number.
Based on the functionality

(clinical manifestations)

Functional
  1. Well-differentiated endocrine tumors, with benign or uncertain behavior.
  2. Well-differentiated endocrine carcinomas with low-grade malignant behavior.
  3. Poorly differentiated endocrine carcinomas with high-grade malignant behavior.
Note: Most insulinomas are classified as well-differentiated endocrine tumors (WHO 1) but occasionally they belong to WHO 2 or 3. [3][4][5][6]
Non-functional[7]
Based on hormonal level determined by radioimmunoassay[8]

(previously used)

Group A
Group B

American Joint Cancer Committee (AJCC) 7th edition 2010 calssification

The staging of malignant insulinoma being a pancreatic neuroendocrine tumor may be classified into several subtypes based on American Joint Cancer Committee (AJCC) 7th edition 2010: [9][10]

Stage T N M
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1-3 N1 M0
III T4 Any N M0
IV Any T Any N M1
AJCC 2010
T T1 <2 cm in greatest dimension
T2 >2 cm in greatest dimension
T3 Beyond the pancreas but without involvement of the superior mesenteric artery
T4 Involvement of the celiac axis or superior mesenteric artery (unresectable tumor)
N N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
M M0 No distant metastasis
M1 Distant metastasis

European Neuroendocrine Tumor Society (ENETS) classification:

Being a pancreatic neuroendocrine tumor, it is also staged by European Neuroendocrine Tumor Society (ENETS) as: [9][10]

Stage T N M
I T1 N0 M0
IIA T2 N0 M0
IIB T3 N0 M0
IIIA T4 N0 M0
III B Any T N1 M0
IV Any T Any N M1
ENETS
T T1 Tumor limited to pancreas, <2 cm
T2 Tumor limited to pancreas, 2-4 cm
T3 >4cm, or invading the duodenum or common bile duct
T4 Tumor invades adjacent structures
N N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
M M0 No distant metastasis
M1 Distant metastasis

WHO 2010 classification system

  • WHO classification system combined differentiation and grading characteristics to classify the belligerence of a pancreatic neuroendocrine tumor.
  • The aggressiveness of tumor was expressed in form of mitotic count and staining of a nuclear antigen called Ki-67: [11][6]
Grade of tumor Mitotic Count(Mitoses per 10 high powerfields) Expression of Ki 67
Grade 1 <2 ≤3%
Grade 2 2-10 3-20%
Grade 3 >20 >20%
  • Grade 1 and 2 tumors were classified as neuroendocrine neoplasm (NET) and grade 3 were classified as neuroendocrine carcinoma (NEC).
  • In its new 8th edition of AJCC which is planned to be published on January 1, 2018; AJCC had developed a modified ENETS (mENETS) staging classification:[9]
Stage T N M
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1-3 N1 M0
III T4 Any N M0
IV Any T Any N M1
mENETS
T T1 Tumor limited to pancreas, <2 cm
T2 Tumor limited to pancreas, 2-4 cm
T3 >4cm, or invading the duodenum or common bile duct
T4 Tumor invades adjacent structures
N N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
M M0 No distant metastasis
M1 Distant metastasis

References

  1. ↑ F. J. Service, M. M. McMahon, P. C. O'Brien & D. J. Ballard (1991). "Functioning insulinoma--incidence, recurrence, and long-term survival of patients: a 60-year study". Mayo Clinic proceedings. 66 (7): 711–719. PMID 01677058.
  2. ↑ Ahmad N, Almutawa AM, Abubacker MZ, Elzeftawy HA, Bawazir OA (2017). "Recurrent insulinoma in a 10-year-old boy with Down's syndrome". Endocrinol Diabetes Metab Case Rep. 2017. doi:10.1530/EDM-16-0155. PMC 5445445. PMID 28567298.
  3. ↑ de Herder, Wouter W.; Niederle, Bruno; Scoazec, Jean-Yves; Pauwels, Stanislas; Klöppel, Günter; Falconi, Massimo; Kwekkeboom, Dik J.; Öberg, Kjel; Eriksson, Barbro; Wiedenmann, Bertram; Rindi, Guido; O’Toole, Dermot; Ferone, Diego (2007). "Well-Differentiated Pancreatic Tumor/Carcinoma: Insulinoma". Neuroendocrinology. 84 (3): 183–188. doi:10.1159/000098010. ISSN 0028-3835.
  4. ↑ Schott M, Klöppel G, Raffel A, Saleh A, Knoefel WT, Scherbaum WA (2011). "Neuroendocrine neoplasms of the gastrointestinal tract". Dtsch Arztebl Int. 108 (18): 305–12. doi:10.3238/arztebl.2011.0305. PMC 3103981. PMID 21629514.
  5. ↑ Bosman, F. T. (2010). WHO classification of tumours of the digestive system. Lyon: International Agency for Research on Cancer. ISBN 978-9283224327.
  6. ↑ 6.0 6.1 Sun J (2017). "Pancreatic neuroendocrine tumors". Intractable Rare Dis Res. 6 (1): 21–28. doi:10.5582/irdr.2017.01007. PMC 5359348. PMID 28357177.
  7. ↑ Mittendorf EA, Liu YC, McHenry CR (2005). "Giant insulinoma: case report and review of the literature". J Clin Endocrinol Metab. 90 (1): 575–80. doi:10.1210/jc.2004-0825. PMID 15522939.
  8. ↑ Berger M, Bordi C, Cüppers HJ, Berchtold P, Gries FA, Münterfering H; et al. (1983). "Functional and morphologic characterization of human insulinomas". Diabetes. 32 (10): 921–31. PMID 6311653.
  9. ↑ 9.0 9.1 9.2 Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C; et al. (2017). "Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems". J Clin Oncol. 35 (3): 274–280. doi:10.1200/JCO.2016.67.8193. PMID 27646952.
  10. ↑ 10.0 10.1 Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW; et al. (2015). "TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution". Medicine (Baltimore). 94 (12): e660. doi:10.1097/MD.0000000000000660. PMC 4554009. PMID 25816036.
  11. ↑ Bosman, F. T. (2010). WHO classification of tumours of the digestive system. Lyon: International Agency for Research on Cancer. ISBN 978-9283224327.

Template:WH Template:WS ​

Retrieved from "https://www.wikidoc.org/index.php?title=Insulinoma_classification&oldid=1401338"