Insulinoma classification: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
 
(18 intermediate revisions by 3 users not shown)
Line 4: Line 4:
{{CMG}}; {{AE}} {{ADS}}
{{CMG}}; {{AE}} {{ADS}}
==Overview==
==Overview==
Insulinoma may be classified according to into malignant potential into 2 sub-types: [[Benign]](90%)and [[Malignant]](10%)
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.
Insulinoma 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==
 
{|
* 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 [[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
! 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 20: Line 31:
  | pages = 711–719
  | pages = 711–719
  | year = 1991
  | year = 1991
| month = July
  | pmid = 01677058
  | pmid = 01677058
}}</ref> In one of the recent research papers, the recurrence was described as 4 times more common in individuals with 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>
}}</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>
 
|-
* Insulinoma is also classified into 2 subtypes based on the number:
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''Based on number'''
**Solitary
| style="background:#DCDCDC;" align="center" + |[[Solitary|'''Solitary''']]
**Multiple
| style="background:#F5F5F5;" + |
***90% of insulinoma are solitary while 10% can be multiple in number
*90% of insulinomas are [[solitary]].
 
|-
*It  may be classified into 2 subtypes based on the functionality(clinical manifestations):
| style="background:#DCDCDC;" align="center" + |'''Multiple'''
**Functional
| style="background:#F5F5F5;" + |
**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>
*10% of insulinomas can be multiple in number.
* According to WHO, functioning pancreatic endocrine tumors are classified as
|-
#well-differentiated endocrine tumors, with benign or uncertain behavior  
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''Based on the functionality'''
#well differentiated endocrine carcinomas with low-grade malignant behavior
'''(clinical manifestations)'''
#poorly differentiated endocrine carcinomas with high-grade malignant behavior.
| style="background:#DCDCDC;" align="center" + |'''Functional'''
#*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>
| rowspan="2" style="background:#F5F5F5;" + |
 
* According to [[WHO]], functioning [[Pancreatic endocrine tumor|pancreatic endocrine tumors]] are classified as:
* 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>:
#Well-differentiated [[endocrine tumors]], with [[benign]] or uncertain behavior.
**Group A of abundant B cells with trabecular arrangement and uniform insulin [[immunofluorescence]]
#Well-differentiated [[endocrine]] [[carcinomas]] with low-grade [[malignant]] behavior.
**Group B of scarce B cells with [[medullary]] arrangement and irregular [[immunofluorescence]]
#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>
* 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 <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:#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]].
|}


=== [[American Joint Committee on Cancer|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 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>
{| 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" + |IA
|T1
| style="background:#F5F5F5;" + |T1
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IB
| style="background:#DCDCDC;" align="center" + |IB
|T2
| style="background:#F5F5F5;" + |T2
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIA
| style="background:#DCDCDC;" align="center" + |IIA
|T3
| style="background:#F5F5F5;" + |T3
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIB
| style="background:#DCDCDC;" align="center" + |IIB
|T1-3
| style="background:#F5F5F5;" + |T1-3
|N1
| style="background:#F5F5F5;" + |N1
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|III
| 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" align="center"
|+'''AJCC 2010'''
| colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |'''AJCC 2010'''
! 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;" + |<2 cm in greatest dimension
|-
|-
|T2
| style="background:#DCDCDC;" align="center" + |T2
|>2 cm in greatest dimension
| style="background:#F5F5F5;" + |>2 cm in greatest dimension
|-
|-
|T3
| style="background:#DCDCDC;" align="center" + |T3
|Beyond the pancreas but without involvement of the superior mesenteric artery
| style="background:#F5F5F5;" + |Beyond the [[pancreas]] but without involvement of the [[superior mesenteric artery]]
|-
|-
|T4
| style="background:#DCDCDC;" align="center" + |T4
|Involvement of the celiac axis or superior mesenteric artery(unresectable tumor)
| style="background:#F5F5F5;" + |Involvement of the ''[[celiac axis]]'' or [[superior mesenteric artery]] (unresectable [[tumor]])
|-
|-
! rowspan="2" | N
! rowspan="2" style="background:#DCDCDC;" align="center" + | N
|N0
| style="background:#DCDCDC;" align="center" + |N0
|No regional lymph node metastasis
| style="background:#F5F5F5;" + |No regional [[lymph node]] [[metastasis]]
|-
|-
|N1
| style="background:#DCDCDC;" align="center" + |N1
|Regional lymph node metastasis
| style="background:#F5F5F5;" + |Regional [[lymph node]] [[metastasis]]
|-
|-
! rowspan="2" | M
! rowspan="2" style="background:#DCDCDC;" align="center" + | M
|M0
| style="background:#DCDCDC;" align="center" + |M0
|No distant metastasis
| style="background:#F5F5F5;" + |No distant [[metastasis]]
|-
|-
|M1
| style="background:#DCDCDC;" align="center" + |M1
|Distant metastasis
| style="background:#F5F5F5;" + |Distant [[metastasis]]
|-
|-
|}
|}


* 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>:
=== 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'''
|-
|-
|I
| style="background:#DCDCDC;" align="center" + |I
|T1
| style="background:#F5F5F5;" + |T1
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIA
| style="background:#DCDCDC;" align="center" + |IIA
|T2
| style="background:#F5F5F5;" + |T2
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIB
| style="background:#DCDCDC;" align="center" + |IIB
|T3
| style="background:#F5F5F5;" + |T3
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIIA
| style="background:#DCDCDC;" align="center" + |IIIA
|T4
| style="background:#F5F5F5;" + |T4
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|III B
| style="background:#DCDCDC;" align="center" + |III B
|Any T
| style="background:#F5F5F5;" + |Any T
|N1
| 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"
|+'''ENETS'''
| colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |'''ENETS'''
! 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]] 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]]
|-
|-
|}
|}
*WHO 2010 classification system combined differentiation and grading characteristics to classify the belligerence of pancraetic 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>:
 
=== [[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"
{| class="wikitable" style="text-align:center"
|'''Grade of tumor'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Grade of tumor'''
|'''Mitotic Count'''(Mitoses per 10 high powerfields)
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Mitotic Count'''(Mitoses per 10 high powerfields)
|'''Expression of Ki 67'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Expression of Ki 67'''
|-
|-
|Grade 1
| style="background:#DCDCDC;" align="center" + |Grade 1
|<2
| style="background:#F5F5F5;" + |<2
|<3 or =3%
| style="background:#F5F5F5;" + |≤3%
|-
|-
|Grade 2
| style="background:#DCDCDC;" align="center" + |Grade 2
|2-10
| style="background:#F5F5F5;" + |2-10
|3-20%
| style="background:#F5F5F5;" + |3-20%
|-
|-
|Grade 3
| style="background:#DCDCDC;" align="center" + |Grade 3
|>20
| style="background:#F5F5F5;" + |>20
|>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<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(mENETS) staging classification:
* 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>


{| 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" + |IA
|T1
| style="background:#F5F5F5;" + |T1
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IB
| style="background:#DCDCDC;" align="center" + |IB
|T2
| style="background:#F5F5F5;" + |T2
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIA
| style="background:#DCDCDC;" align="center" + |IIA
|T3
| style="background:#F5F5F5;" + |T3
|N0
| style="background:#F5F5F5;" + |N0
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|IIB
| style="background:#DCDCDC;" align="center" + |IIB
|T1-3
| style="background:#F5F5F5;" + |T1-3
|N1
| style="background:#F5F5F5;" + |N1
|M0
| style="background:#F5F5F5;" + |M0
|-
|-
|III
| 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"
|+'''mENETS'''
| 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]]
|-
|-
|}
|}
Line 271: 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"