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The aim of the study is to evaluate the most appropriate management of sporadic asymptomatic non-functioning pancreatic neuroendocrine neoplasms (NF-PNEN) ≤ 2 cm. P NF-PNEN management will be decided at the hospital and all therapeutics decision will be decided/coordinated by the treating physician.
Patients will be either submitted to surgical resection or to active surveillance.
In the last decade a dramatic increase in diagnosis of small, incidentally discovered, NF-PNEN was observed. Various study indicates the safety of a conservative management for this lesion and the The European Neuroendocrine Tumor Society (ENETS) proposed a "wait and see" approach for small NF-PNEN.
Indications for surgery include the presence of a localized NF-PNEN in the absence of distant metastases as curative resection of these tumors is associated with favourable prognosis especially for low grade.
In the last decade a dramatic increase in diagnosis of small, incidentally discovered, NF-PNEN was observed.Moreover, other investigators observed a clear relationship between the tumor diameter and low risk of malignancy and systemic progression.
In particular, a tumor size ≤ 2 cm seems to be associated with a negligible risk of disease recurrence and with a very low incidence of aggressive features such as lymph node involvement.On this basis, the European Neuroendocrine Tumor Society (ENETS) proposed a "wait and see" approach for small NF-PNEN when incidentally discovered. Since then, various series evaluated the safety of a conservative management for small, sporadic, incidentally diagnosed, NF-PNEN.
After a median follow-up of 28-45 months, all the studies confirmed that an intensive surveillance for incidental and small NF-PNEN is safe in selected cases.
Nevertheless, available data are based only on retrospective series with a significant heterogeneity of inclusion criteria and different tumor diameter cut-off and the appropriate management of this entities (surveillance versus surgery) is still a matter of debate.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Active surveillance group | Advised surveillance strategy consists of imaging studies (MR or EUS or US), every 6 months for the first two years and yearly thereafter for five years in the absence of significant changes on imaging or symptoms appearance. During surveillance, a high-quality imaging technique (MRI or CT) is mandatory at least every 12 months. Determination of CgA during follow-up is at physician's discretion. During follow-up, the treating physician is responsible for patient management and decision-making. |
| |
| Surgical resection group | Timing and type of resection will be established by the treating physician. Follow up strategy after surgery consists of imaging studies (MR or CT), every 6 months for the first two years and yearly thereafter for five years. An high-quality imaging technique (MRI or CT) is mandatory at least every 12 months. Determination of CgA during follow-up is at physician's discretion. During follow-up, the treating physician is responsible for patient management and decision-making. Date of surgery does not change the timing of follow up which starts from the date of enrolment. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Radiological imaging studies | Diagnostic Test | Patients will be submitted to radiological imaging studies (CT scan and/or MRI and/ or 68Gallium PET/CT and/or Octreoscan and/or EUS+FNAand/or Octreoscan and/or EUS+FNA) at diagnosis, and then every 6 months for the first two years and yearly thereafter for five years in the absence of significant changes on imaging or symptoms appearance. Every 12 months (or 6 months for patients with Ki67> 2%) a high quality imaging (CT scan or MRI) is required. |
| Measure | Description | Time Frame |
|---|---|---|
| Disease/progression-free survival of NF-PNEN ≤ 2 cm | The primary endpoint is disease/progression-free survival, defined as the time from study enrolment to the first evidence of progression (active surveillance group) or recurrence of disease (surgical resection group) or death from disease. | From date of enrolment until the date of first documented progression or first evidence of recurrence, from 6 months up to 6 years. |
| Measure | Description | Time Frame |
|---|---|---|
| Frequency of NF-PNEN ≤ 2 cm | The secondary end point is to evaluate the frequency of asymptomatic sporadic NF-PNEN ≤ 2 cm among overall sporadic NF-PNEN. Participating centers are required to give yearly the number of patients with NF-PNEN referred to their institution. | 6 years |
| Outcome of surgical intervention of NF-PNEN ≤ 2 cm |
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Inclusion Criteria:
Exclusion Criteria:
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Patients with a newly diagnosis (less thn 12 months) of non- functioning pancreatic endocrine neoplasia (NF-PNEN) ≤ 2 cm of diameter. Either patients submitted to surgery or in active surveillance can be enrolled. Patients with sindrome or genetics disorders are excluded from the study.
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Massimo Falconi, Professor | Contact | 0039 022643 6046 | falconi.massimo@hsr.it | |
| Stefano Partelli, MD PhD | Contact | 0039 022643 7697 | partelli.stefano@hsr.it |
| Name | Affiliation | Role |
|---|---|---|
| Massimo Falconi, Professor | IRCCS San Raffaele | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| IRCCS San Raffaele Hospital | Recruiting | Milan | 20132 | Italy |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 26742109 | Background | Falconi M, Eriksson B, Kaltsas G, Bartsch DK, Capdevila J, Caplin M, Kos-Kudla B, Kwekkeboom D, Rindi G, Kloppel G, Reed N, Kianmanesh R, Jensen RT; Vienna Consensus Conference participants. ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors. Neuroendocrinology. 2016;103(2):153-71. doi: 10.1159/000443171. Epub 2016 Jan 5. No abstract available. | |
| 26608956 |
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| ID | Term |
|---|---|
| C536126 | Non functioning pancreatic endocrine tumor |
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| Quality of Life Assessment | Other | quality of life and the perceived burden of surveillance or follow-up after surgery for participants, will be investigated by administrating HADS questionnaire and EORTC QLQ-C30 (version 3) and EORTC QLQ-GI.NET21 Module. |
|
Morbidity and mortality of patients submitted to surgical resection |
| from the date of surgery to 1 months later the surgery |
| Epidemiology of patients submitted to surgical intervention for NF-PNEN ≤ 2 cm | Number of patients submitted to surgery andh type of surgical procedures. | from the date of surgery, up to 6 years |
| Evolution of NF-PNEN ≤ 2 cm | NF-PNEN evolution, in terms of development of symptoms, tumour growth, development of distant metastases and secondary pancreatic duct dilatation. | From date of enrolment until the date of first documented radiological evolution, from 6 months up to 6 years. |
| Quality of Life of NF-PNEN ≤ 2 cm | The perceived burden of surveillance or follow-up after surgery for participants, as assessed by questionnaires regarding attitude towards surveillance and general anxiety and depression (Hospital Anxiety and Depression scale, HADS). Quality of Life will be investigated, by filling in EORTC QLQ-C30 (version 3) and EORTC QLQ-GI.NET21 Module. | from 6 months up to 6 years. |
| Background |
| Jilesen AP, van Eijck CH, Busch OR, van Gulik TM, Gouma DJ, van Dijkum EJ. Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor. World J Surg. 2016 Mar;40(3):715-28. doi: 10.1007/s00268-015-3341-9. |
| 24253141 | Background | Hashim YM, Trinkaus KM, Linehan DC, Strasberg SS, Fields RC, Cao D, Hawkins WG. Regional lymphadenectomy is indicated in the surgical treatment of pancreatic neuroendocrine tumors (PNETs). Ann Surg. 2014 Feb;259(2):197-203. doi: 10.1097/SLA.0000000000000348. |
| 23771245 | Background | Kuo EJ, Salem RR. Population-level analysis of pancreatic neuroendocrine tumors 2 cm or less in size. Ann Surg Oncol. 2013 Sep;20(9):2815-21. doi: 10.1245/s10434-013-3005-7. Epub 2013 Jun 15. |
| 17438169 | Background | Vagefi PA, Razo O, Deshpande V, McGrath DJ, Lauwers GY, Thayer SP, Warshaw AL, Fernandez-Del Castillo C. Evolving patterns in the detection and outcomes of pancreatic neuroendocrine neoplasms: the Massachusetts General Hospital experience from 1977 to 2005. Arch Surg. 2007 Apr;142(4):347-54. doi: 10.1001/archsurg.142.4.347. |
| 24646958 | Background | Crippa S, Partelli S, Zamboni G, Scarpa A, Tamburrino D, Bassi C, Pederzoli P, Falconi M. Incidental diagnosis as prognostic factor in different tumor stages of nonfunctioning pancreatic endocrine tumors. Surgery. 2014 Jan;155(1):145-53. doi: 10.1016/j.surg.2013.08.002. |
| 24238123 | Background | Birnbaum DJ, Gaujoux S, Cherif R, Dokmak S, Fuks D, Couvelard A, Vullierme MP, Ronot M, Ruszniewski P, Belghiti J, Sauvanet A. Sporadic nonfunctioning pancreatic neuroendocrine tumors: prognostic significance of incidental diagnosis. Surgery. 2014 Jan;155(1):13-21. doi: 10.1016/j.surg.2013.08.007. Epub 2013 Nov 12. |
| 21683859 | Background | Bettini R, Partelli S, Boninsegna L, Capelli P, Crippa S, Pederzoli P, Scarpa A, Falconi M. Tumor size correlates with malignancy in nonfunctioning pancreatic endocrine tumor. Surgery. 2011 Jul;150(1):75-82. doi: 10.1016/j.surg.2011.02.022. |
| 21576607 | Background | Haynes AB, Deshpande V, Ingkakul T, Vagefi PA, Szymonifka J, Thayer SP, Ferrone CR, Wargo JA, Warshaw AL, Fernandez-del Castillo C. Implications of incidentally discovered, nonfunctioning pancreatic endocrine tumors: short-term and long-term patient outcomes. Arch Surg. 2011 May;146(5):534-8. doi: 10.1001/archsurg.2011.102. |
| 24074416 | Background | Cherenfant J, Stocker SJ, Gage MK, Du H, Thurow TA, Odeleye M, Schimpke SW, Kaul KL, Hall CR, Lamzabi I, Gattuso P, Winchester DJ, Marsh RW, Roggin KK, Bentrem DJ, Baker MS, Prinz RA, Talamonti MS. Predicting aggressive behavior in nonfunctioning pancreatic neuroendocrine tumors. Surgery. 2013 Oct;154(4):785-91; discussion 791-3. doi: 10.1016/j.surg.2013.07.004. |
| 23986355 | Background | Partelli S, Gaujoux S, Boninsegna L, Cherif R, Crippa S, Couvelard A, Scarpa A, Ruszniewski P, Sauvanet A, Falconi M. Pattern and clinical predictors of lymph node involvement in nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs). JAMA Surg. 2013 Oct;148(10):932-9. doi: 10.1001/jamasurg.2013.3376. |
| 22261872 | Background | Falconi M, Bartsch DK, Eriksson B, Kloppel G, Lopes JM, O'Connor JM, Salazar R, Taal BG, Vullierme MP, O'Toole D; Barcelona Consensus Conference participants. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms of the digestive system: well-differentiated pancreatic non-functioning tumors. Neuroendocrinology. 2012;95(2):120-34. doi: 10.1159/000335587. Epub 2012 Feb 15. No abstract available. |
| 24057286 | Background | Gaujoux S, Partelli S, Maire F, D'Onofrio M, Larroque B, Tamburrino D, Sauvanet A, Falconi M, Ruszniewski P. Observational study of natural history of small sporadic nonfunctioning pancreatic neuroendocrine tumors. J Clin Endocrinol Metab. 2013 Dec;98(12):4784-9. doi: 10.1210/jc.2013-2604. Epub 2013 Sep 20. |
| 23102679 | Background | Lee LC, Grant CS, Salomao DR, Fletcher JG, Takahashi N, Fidler JL, Levy MJ, Huebner M. Small, nonfunctioning, asymptomatic pancreatic neuroendocrine tumors (PNETs): role for nonoperative management. Surgery. 2012 Dec;152(6):965-74. doi: 10.1016/j.surg.2012.08.038. Epub 2012 Oct 24. |
| 26131843 | Background | Jung JG, Lee KT, Woo YS, Lee JK, Lee KH, Jang KT, Rhee JC. Behavior of Small, Asymptomatic, Nonfunctioning Pancreatic Neuroendocrine Tumors (NF-PNETs). Medicine (Baltimore). 2015 Jul;94(26):e983. doi: 10.1097/MD.0000000000000983. |
| 26597365 | Background | Sadot E, Reidy-Lagunes DL, Tang LH, Do RK, Gonen M, D'Angelica MI, DeMatteo RP, Kingham TP, Groot Koerkamp B, Untch BR, Brennan MF, Jarnagin WR, Allen PJ. Observation versus Resection for Small Asymptomatic Pancreatic Neuroendocrine Tumors: A Matched Case-Control Study. Ann Surg Oncol. 2016 Apr;23(4):1361-70. doi: 10.1245/s10434-015-4986-1. Epub 2015 Nov 23. |
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| 33425946 | Derived | Partelli S, Ramage JK, Massironi S, Zerbi A, Kim HB, Niccoli P, Panzuto F, Landoni L, Tomazic A, Ibrahim T, Kaltsas G, Bertani E, Sauvanet A, Segelov E, Caplin M, Coppa J, Armstrong T, Weickert MO, Butturini G, Staettner S, Boesch F, Cives M, Moulton CA, He J, Selberherr A, Twito O, Castaldi A, De Angelis CG, Gaujoux S, Almeamar H, Frilling A, Vigia E, Wilson C, Muffatti F, Srirajaskanthan R, Invernizzi P, Lania A, Kwon W, Ewald J, Rinzivillo M, Nessi C, Smid LM, Gardini A, Tsoli M, Picardi EE, Hentic O, Croagh D, Toumpanakis C, Citterio D, Ramsey E, Mosterman B, Regi P, Gasteiger S, Rossi RE, Smiroldo V, Jang JY, Falconi M. Management of Asymptomatic Sporadic Nonfunctioning Pancreatic Neuroendocrine Neoplasms (ASPEN) </=2 cm: Study Protocol for a Prospective Observational Study. Front Med (Lausanne). 2020 Dec 23;7:598438. doi: 10.3389/fmed.2020.598438. eCollection 2020. |