Endocrine tumours of the pancreas
Endocrine tumours of the pancreas arise from the pancreatic islet cells and include some distinct tumours that match the cell type of origin.
Pancreatic endocrine tumours have commonly been referred to as "islet cell tumours", referring to the islets of Langerhans, from which they were thought to derive. It has since been shown that these tumours derive from ductal pluripotent stem cells, and "endocrine tumour" is now preferred 3.
Most tumours are isolated. 1-2% are associated with the multiple endocrine neoplasia type I (MEN I), which is characterised by the triad of parathyroid, pituitary, and pancreatic lesions.
Overall, pancreatic endocrine tumours have an incidence of 0.001% and account for 1-2% of pancreatic neoplasms. They occur most commonly at ages 30-60, with no clear gender predilection.
Syndromic tumours tend to present earlier, with clinical signs and symptoms related to their cell type and biological activity.
- insulinoma: Whipple's triad
- gastrinoma: Zollinger-Ellison syndrome
- glucagonoma: 4D syndrome
- non-functioning tumours: tend to present late, similar to pancreatic adenocarcinomas
Non-syndromic tumours tend to present later and are often larger in size.
These tumours can broadly be divided according to whether or not they secrete enough active compounds to be syndromic or not:
- syndromic tumours
- non-syndromic tumours: 3rd most common
Individual functional tumours are discussed in more detail separately.
The term "syndromic" is preferred over "functioning" since it is becoming increasingly clear that most tumours are functional (i.e. produce hormones), but either do not produce enough hormone or produce an ineffective variant of the hormone, so that they may not produce a clinical syndrome.
Neuroendocrine tumours are classified histologically by the presence of neurosecretory granules, which stain positively for:
- Gremilius stains
- neuron-specific enolase
Overall these endocrine tumours of the pancreas tend to be highly vascular and well circumscribed, often displacing adjacent structures. They can demonstrate calcific or cystic change.
- well-circumscribed with smooth margins
- round or oval
Liver metastases may be hyperechoic or targetoid.
- tend to be homogenous and well circumscribed
- may appear heterogeneous and contain areas of cystic or necrotic change
- can occasionally manifest as primarily cystic lesions and are distinguishable from other cystic neoplasms by their hypervascular rim
Since usually have a distinct capsule which means they displace rather than invade surrounding structures as they grow in size. As a result, they less frequently present with biliary obstruction, which is a classic mode of presentation for pancreatic adenocarcinomas.
Endocrine tumours of the pancreas show peak contrast enhancement in the early arterial phase (25-35 secs) rather than in late arterial phase (35-45 secs) which is normally used for pancreatic imaging. This is particularly important when considering that small lesions may be missed in late arterial phase when the tumour will appear isointense with enhancing pancreatic parenchyma.
75% of patients with neuroendocrine tumours have metastatic disease at presentation, most commonly in the liver and less frequently in bone.
Sensitivity is similar to CT
- T1: hypointense relative to pancreas
- T2: typically hyperintense relative to pancreas, but there is a range of signal intensities
- T1 C+ (Gad): hyperintense/hypervascular relative to pancreas
May be useful to localise or confirm a functioning tumour and look for metastases.
- planar or SPECT
- sensitivity is ~80%, although limited by the somatostatin receptor characteristics of the tumour
- reported sensitivity is highest with gastrinomas >2 cm
- reported sensitivity is lowest with insulinomas
- sensitivity limited unless poorly-differentiated
Treatment and prognosis
If diagnosed early enough (before metastases), then complete surgical resection may be curable. Even patients with advanced disease can have reasonable long-term survival. Biological behaviour also depends on the cell of origin:
- insulinoma: 10% malignant
- gastrinoma: 60% malignant
- glucagonoma: 80% malignant
- VIPoma: 75% malignant
- somatostatinoma: 75% malignant
- non-functional: 85-100% malignant
- metastasis to the spleen (e.g. renal cell carcinoma)
- intrapancreatic splenule (if in the tail of the pancreas)
- mostly-solid serous cystadenoma
- cystic neoplasm (cystic pancreatic mass differential diagnosis)
- solid neoplasm
- nonepithelial pancreatic neoplasms
pancreatitis (mnemonic for the causes)
- gallstone pancreatitis
- interstitial oedematous pancreatitis
- necrotising pancreatitis
- haemorrhagic pancreatitis
- revised Atlanta classification of acute pancreatitis
- chronic pancreatitis
- Ascaris-induced pancreatitis
- tropical pancreatitis
- autoimmune pancreatitis
- emphysematous pancreatitis
- hereditary pancreatitis
- pancreatitis associated with cystic fibrosis
- segmental pancreatitis
- acute pancreatitis
- pancreatic atrophy
- pancreatic lipomatosis
- pancreatic trauma
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