Insulinoma staging: Difference between revisions

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__NOTOC__
__NOTOC__
{{Insulinoma}}
{{Insulinoma}}
{{CMG}}{{AE}}{{PSD}}
{{CMG}}; {{AE}}{{ADS}}
==Overview==
==Overview==
According to The American Joint Committee on Cancer (AJCC), there are four stages of insulinoma based on the TNM staging sysytem.
The staging had been done according to American Joint Cancer Committee (AJCC) 7th edition 2010. Being a [[pancreatic neuroendocrine tumor]], it is also staged by European Neuroendocrine Tumor Society (ENETS). 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.
 
==Staging==
==Staging==
According to The American Joint Committee on Cancer (AJCC), there are four stages of insulinoma based on the TNM staging sysytem:<ref>Stage Information for Pancreatic Neuroendocrine Tumors (Islet Cell Tumors). http://www.cancer.gov/types/pancreatic/hp/pnet-treatment-pdq#section/_199</ref>
=== [[American Joint Committee on Cancer|American Joint Cancer Committee]] ([[AJCC]]) 7th edition 2010 classification ===
===TNM Classification===
The staging of [[malignant]] insulinoma being a [[pancreatic neuroendocrine tumor]] may be classified into several sub types 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"
| 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]]
|-
|}


{| class="wikitable"
=== European Neuroendocrine Tumor Society (ENETS) classification: ===
! style="font-weight: bold;" | T
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>
! style="text-align: center; font-weight: bold;" | Primary Tumor
{| class="wikitable" align="right"
| 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="font-weight: bold;" | Tx
| style="background:#DCDCDC;" align="center" + |I
| style="text-align: center;" | Primary tumor cannot be assessed
| style="background:#F5F5F5;" + |T1
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | T0
| style="background:#DCDCDC;" align="center" + |IIA
| style="text-align: center;" | No evidence of primary tumor
| style="background:#F5F5F5;" + |T2
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | Tis
| style="background:#DCDCDC;" align="center" + |IIB
| style="text-align: center;" | Carcinoma in situ
| style="background:#F5F5F5;" + |T3
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | T1
| style="background:#DCDCDC;" align="center" + |IIIA
| style="text-align: center;" | Tumor limited to the pancreas, ≤2 cm in greatest dimension
| style="background:#F5F5F5;" + |T4
| style="background:#F5F5F5;" + |N0
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | T2
| style="background:#DCDCDC;" align="center" + |III B
| style="text-align: center;" | Tumor limited to the pancreas, >2 cm in greatest dimension
| style="background:#F5F5F5;" + |Any T
| style="background:#F5F5F5;" + |N1
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | T3
| style="background:#DCDCDC;" align="center" + |IV
| style="text-align: center;" | Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery
| style="background:#F5F5F5;" + |Any T
| style="background:#F5F5F5;" + |Any N
| style="background:#F5F5F5;" + |M1
|}
{| class="wikitable" style="text-align:center"
| colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |'''ENETS'''
|-
! rowspan="4" style="background:#DCDCDC;" align="center" + | T
| 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
|-
| style="background:#DCDCDC;" align="center" + |T3
| style="background:#F5F5F5;" + |>4cm, or invading the [[duodenum]] or [[common bile duct]]
|-
| style="background:#DCDCDC;" align="center" + |T4
| style="background:#F5F5F5;" + |[[Tumor]] invades adjacent structures
|-
! 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]]
|-
|-
| style="font-weight: bold;" | T4
| style="text-align: center;" | Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)
|}
|}


{| class="wikitable"
=== [[WHO]] 2010 classification system ===
! N
*WHO classification system combined differentiation and grading characteristics to classify the belligerence of a [[pancreatic neuroendocrine tumor]].
! Regional Lymph Nodes
*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'''
|-
|-
| '''NX'''
| style="background:#DCDCDC;" align="center" + |Grade 1
| Regional lymph nodes cannot be assessed
| style="background:#F5F5F5;" + |<2
| style="background:#F5F5F5;" + |≤3%
|-
|-
| '''N0'''
| style="background:#DCDCDC;" align="center" + |Grade 2
| No regional lymph node metastasis
| style="background:#F5F5F5;" + |2-10
| style="background:#F5F5F5;" + |3-20%
|-
| style="background:#DCDCDC;" align="center" + |Grade 3
| style="background:#F5F5F5;" + |>20
| style="background:#F5F5F5;" + |>20%
|-
|-
| '''N1'''
| Regional lymph node metastasis
|}
|}
*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>


{| class="wikitable"
{| class="wikitable" align="right"
! style="font-weight: bold;" | M
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Stage'''
! Distant Metastases
| 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="font-weight: bold;" | M0
| style="background:#DCDCDC;" align="center" + |III
| No distant metastasis
| style="background:#F5F5F5;" + |T4
| style="background:#F5F5F5;" + |Any N
| style="background:#F5F5F5;" + |M0
|-
|-
| style="font-weight: bold;" | M1
| style="background:#DCDCDC;" align="center" + |IV
| Distant metastasis
| style="background:#F5F5F5;" + |Any T
| style="background:#F5F5F5;" + |Any N
| style="background:#F5F5F5;" + |M1
|}
|}
 
{| class="wikitable" style="text-align:center"
===Anatomic Stage/Prognostic Groups===
| colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" coolspan="4" + |'''mENETS'''
{| class="wikitable"
! style="font-weight: bold;" | Stage
! style="font-weight: bold;" | T
! style="font-weight: bold;" | N
! style="font-weight: bold;" | M
|-
|-
| style="font-weight: bold;" | 0
! rowspan="4" style="background:#DCDCDC;" align="center" + |T
| Tis
| style="background:#DCDCDC;" align="center" + |T1
| N0
| style="background:#F5F5F5;" + |[[Tumor-associated calcium signal transducer 1|Tumor]] limited to [[pancreas]], <2 cm
| M0
|-
|-
| style="font-weight: bold;" | IA
| style="background:#DCDCDC;" align="center" + |T2
| T1
| style="background:#F5F5F5;" + |[[Tumor]] limited to [[pancreas]], 2-4 cm
| N0
| M0
|-
|-
| style="font-weight: bold;" | IB
| style="background:#DCDCDC;" align="center" + |T3
| T2
| style="background:#F5F5F5;" + |>4cm, or invading the [[duodenum]] or [[common bile duct]]
| N0
| M0
|-
|-
| style="font-weight: bold;" | IIA
| style="background:#DCDCDC;" align="center" + |T4
| T3
| style="background:#F5F5F5;" + |[[Tumor]] invades adjacent structures
| N0
| M0
|-
|-
| rowspan="3" style="font-weight: bold;" | IIB
! rowspan="2" style="background:#DCDCDC;" align="center" + | N
| T1
| style="background:#DCDCDC;" align="center" + |N0
| N1
| style="background:#F5F5F5;" + |No regional [[lymph node]] metastasis
| M0
|-
|-
| T2
| style="background:#DCDCDC;" align="center" + |N1
| N1
| style="background:#F5F5F5;" + |Regional [[lymph node]] metastasis
| M0
|-
|-
| T3
! rowspan="2" style="background:#DCDCDC;" align="center" + | M
| N1
| style="background:#DCDCDC;" align="center" + |M0
| M0
| style="background:#F5F5F5;" + |No distant [[metastasis]]
|-
|-
| style="font-weight: bold;" | III
| style="background:#DCDCDC;" align="center" + |M1
| T4
| style="background:#F5F5F5;" + |Distant [[metastasis]]
| Any N
| M0
|-
|-
| style="font-weight: bold;" | IV
| Any T
| Any N
| M1
|}
|}


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Latest revision as of 15:07, 5 December 2017

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

Overview

The staging had been done according to American Joint Cancer Committee (AJCC) 7th edition 2010. Being a pancreatic neuroendocrine tumor, it is also staged by European Neuroendocrine Tumor Society (ENETS). 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.

Staging

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

The staging of malignant insulinoma being a pancreatic neuroendocrine tumor may be classified into several sub types based on American Joint Cancer Committee (AJCC) 7th edition 2010: [1][2]

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: [1][2]

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: [3][4]
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:[1]
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. ↑ 1.0 1.1 1.2 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.
  2. ↑ 2.0 2.1 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.
  3. ↑ Bosman, F. T. (2010). WHO classification of tumours of the digestive system. Lyon: International Agency for Research on Cancer. ISBN 978-9283224327.
  4. ↑ Sun J (2017). "Pancreatic neuroendocrine tumors". Intractable Rare Dis Res. 6 (1): 21–28. doi:10.5582/irdr.2017.01007. PMC 5359348. PMID 28357177.

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