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Abstract: Renal hilum is a very rare location for primary adrenocortical adenoma or pheochromocytoma. We report 68 Ga-DOTATATE PET/CT findings of primary renal hilar adrenocortical adenoma in one patient and 68 Ga-DOTATATE PET/MR findings of pheochromocytoma in another patient., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Endocrine organs are metastatic targets for several primary cancers, either through direct extension from nearby tumour cells or dissemination via the venous, arterial and lymphatic routes. Although any endocrine tissue can be affected, most clinically relevant metastases involve the pituitary and adrenal glands with the commonest manifestations being diabetes insipidus and adrenal insufficiency respectively. The most common primary tumours metastasing to the adrenals include melanomas, breast and lung carcinomas, which may lead to adrenal insufficiency in the presence of bilateral adrenal involvement. Breast and lung cancers are the most common primaries metastasing to the pituitary, leading to pituitary dysfunction in approximately 30% of cases. The thyroid gland can be affected by renal, colorectal, lung and breast carcinomas, and melanomas, but has rarely been associated with thyroid dysfunction. Pancreatic metastasis can lead to exo-/endocrine insufficiency with renal carcinoma being the most common primary. Most parathyroid metastases originate from breast and lung carcinomas and melanoma. Breast and colorectal cancers are the most frequent ovarian metastases; prostate cancer commonly affects the testes. In the presence of endocrine deficiencies, glucocorticoid replacement for adrenal and pituitary involvement can be life saving. As most metastases to endocrine organs develop in the context of disseminated disease, surgical resection or other local therapies should only be considered to ameliorate symptoms and reduce tumour volume. Although few consensus statements can be made regarding the management of metastases to endocrine tissues because of the heterogeneity of the variable therapies, it is important that clinicians are aware of their presence in diagnosis.

A 45-year-old woman was diagnosed as having multiple endocrine neoplasia type 2A in 2014. She had bilateral pheochromocytoma, medullary thyroid carcinoma and biopsy-proven cutaneous lichen amyloidosis in the interscapular area. She underwent bilateral adrenalectomy; following which, she achieved clinical and biochemical remission. She was planned for total thyroidectomy at a later date; however, she was lost to follow-up. She presented to us again in December 2016 with abdominal pain. Examination revealed hypertension with postural drop. Positron emission tomography scan showed Ga 68 and fluorodeoxyglucose (FDG)-avid suprarenal, hepatic, peritoneal and mesenteric masses with abdominal lymph nodes. Twenty-four-hour urinary metanephrines/normetanephrines were elevated. Serum calcitonin was as high as it was 2-1/2 years ago. Ultrasonography-guided fine-needle aspiration cytology (FNAC) from the liver mass revealed neuroendocrine cells that did not stain for calcitonin. Hence, a diagnosis of metastatic pheochromocytoma was made. She underwent total thyroidectomy and was started on cyclophosphamide, vincristine, dacarbazine-based chemotherapy regimen., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

There are three types of breast cancer recurrence which can occur after initial treatment: local, regional, and distant. Distant metastases are more frequent than local and regional recurrences. It usually occurs several years after the primary breast cancer, although it is sometimes diagnosed at the same time as the primary breast cancer. Although the common distant metastases are bone, lung and liver, breast cancer has the potential to metastasize to almost any region of the body. Early detection and treatment of distant metastases improves the prognosis, therefore radiologists and clinicians should recognize the possibility of metastasis from breast cancer and grasp the imaging characteristics. In this report, we demonstrate the imaging characteristics of metastases from breast cancer to uncommon sites.

Objective: Imaging with (68)Ga-labeled 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-octreotide analogs has become an important modality in patients with neuroendocrine tumors (NETs). In addition to high uptake in NET lesions, prominent physiologic radiotracer activity has been reported in the pituitary gland, pancreas, adrenal glands, liver, and spleen, and faint activity has been reported in the thyroid and gastrointestinal tract. This article describes previously unknown sites of 68Ga-DOTA-1-NaI3-octreotide (NOC) uptake unrelated to NETs., Materials and Methods: One hundred eighty-two patients (96 female and 86 male patients; age range, 4-89 years) with documented (n=156) or suspected (n=26) NETs underwent 207 68Ga-DOTA-NOC PET/CT studies. Studies were retrospectively reviewed for the presence, intensity, and localization of foci of increased uptake that were further correlated with findings on additional imaging studies and clinical follow-up for a period of 4-32 months., Results: Uptake of 68Ga-DOTA-NOC not identified as NET or known physiologic activity was detected in 297 sites with confirmation in 149 of 207 studies (72%). The most common location of non-NET-related 68Ga-DOTA-NOC-avid sites was in small lymph nodes, followed by prostate, uterus, breasts, lungs, brown fat, musculoskeletal system, and other sites, including oropharynx, pineal body, thymus, aortic plaque, genitalia, surgical bed, and subcutaneous granuloma. Intensity of uptake in non-NET-related 68Ga-DOTA-NOC-avid sites ranged in maximum standardized uptake value from 0.8 to 10.5., Conclusion: Previously unreported benign sites of 68Ga-DOTA-NOC uptake were found in the majority of studies, suggesting the presence of somatostatin receptors in physiologic variants or processes with no evidence of tumor. Knowledge of increased tracer uptake in non-NET-related sites is important for accurate interpretation and for avoiding potential pitfalls of 68Ga-DOTA-NOC PET/CT.

Unlabelled: The aim of the study was to evaluate the effectiveness of intraoperative ultrasonography (IOUS) during operations of endocrine glands tumors., Material and Methods: The study was conducted in patients who underwent endocrine operation in Department of Endocrine, General and Vascular Surgery, Medical University in Łódź in 2008-2011., Results: Patients with thyroid cancer recurrences:in study group we managed shorter lesion access time (10 ± 4.47 min vs 16.78 ± 8.9 min; p=0.04). Time of surgery was also shorter in study group (75 ± 30.17 minvs 85,71 ± 38.92 min), but it was not significant (p=0.46). The use of IOUS did not affect the hospitalization time (2.91 ± 1.64 days vs 3 ± 1.66 days; p=0.820), intraoperative blood loss (45.45 ± 105.96 ml vs 40 ± 82.89 ml; p=0.972) and the rate of intraoperative complications (1/11 - 9.09% vs 2/14 - 14.29%; p=1). Patients with primary hyperparathyroidism: the time of surgery (58 ± 22.74 min vs 65 ± 19.6 min; p=0.336) and the lesion access time (13.33 ± 7,94 min vs 17.25 ± 8.19 min; p=0.169) were shorter in study group. Hospitalization time was longer in study group (6.13 ± 5.3 days vs 4.45 ± 4.58 days; p=0.079). The rate of intraoperative complications was higher in study group (3/15 - 20% vs 2/20 - 10%; p=0.631). None of this results were statistically significant (p≤0.05). Patients who underwent open adrenalectomy: in study group we managed significantly shorter time of surgery (70 ± 44.35 min vs 80.12 ± 29.60 min; p=0.033) and shorter lesion access time (12 ± 8.88 min vs 17.37 ± 7.42 min; p=0.045). The use of IOUS did not affect the hospitalization time (5.6 ± 1.65 days vs 6.35 ± 2.38 days; p=0.429), intraoperative blood loss (110 ± 164.65 ml vs 172.5 ± 226.35 ml; p=0.442) and rate of intraoperative complications (0/10 vs 1/40; p=1). Patients who underwent videoscopicadrenalectomy: in study group we managed to get shortertime of surgery (89.44 ± 27.11 min vs 109.12 ± 33.88 min; p=0.034) and shorter lesion access time (28.61 ± 14.93 min vs 45.98 ± 20.44 min; p=0.002). Intraoperative blood loss was also significantly lower in study group (86.11 ± 157 ml vs 169.27 ± 201.04 ml; p=0.037). The use of IOUS did not affect the hospitalization time (4.39 ± 3.27 days vs 3.83 ± 3.67 days; p=0.227), the rate of intraoperative complications (0/18 vs. 2/41; p=1) and the conversion rate (2/20-10% vs. 5/46- 10.87%; p=1)., Conclusions: 1.During adrenalectomies this technique facilitates finding the pathological lesion shortening the time of access to the tumor and procedure duration. 2. IOUS is useful for determining the tumor relationship with the surrounding anatomical structures. 3. IOUS isa useful technique in the assessment of adrenal tumor infiltration of vena cava. 4. The use of IOUS allows the surgeon to assess anatomical relationships in the real time, after incision and retraction of tissues. 5. During operations of thyroid cancer recurrences using this technique makes easier to find a lesion in the operated area and it is possible to asses radical of surgery. 6. The use of IOUS allows to find pathological parathyroid glands inside thyroid gland. 7. IOUS is useful in the detection of thyroid pathology during parathyroidectomy.

We report a case of concomitant pancreatic endocrine neoplasm (PEN) and intraductal papillary mucinous neoplasm (IPMN). A 74-year-old man had been followed-up for mixed-type IPMN for 10 years. Recent magnetic resonance images revealed an increase in size of the branch duct IPMN in the pancreas head, while the dilation of the main pancreatic duct showed minimal change. Although contrast-enhanced computed tomography and magnetic resonance imaging did not reveal any nodules in the branch duct IPMN, endoscopic ultrasound indicated a suspected nodule in the IPMN. A malignancy in the branch duct IPMN was suspected and we performed pylorus-preserving pancreatoduodenectomy with lymphadenectomy. The resected specimen contained a cystic lesion, 10 x 10 mm in diameter, in the head of the pancreas. Histological examination revealed that the dilated main pancreatic duct and the branch ducts were composed of intraductal papillary mucinous adenoma with mild atypia. No evidence of carcinoma was detected in the specimen. Incidentally, a 3-mm nodule consisting of small neuroendocrine cells was found in the main pancreatic duct. The cells demonstrated positive staining for chromogranin A, synaptophysin, and glucagon but negative staining for insulin and somatostatin. Therefore, the 3-mm nodule was diagnosed as a PEN. Since the mitotic count per 10 high-power fields was less than 2 and the Ki-67 index was less than 2%, the PEN was pathologically classified as low-grade (G1) according to the 2010 World Health Organization (WHO) criteria. Herein, we review the case and relevant studies in the literature and discuss issues related to the synchronous occurrence of the relatively rare tumors, PEN and IPMN.

Germ cell tumors (GCTs) may occur in both children and adults and include a broad array of histologic subtypes, such as teratoma, seminoma (known as dysgerminoma in the ovary and germinoma in the pineal gland), choriocarcinoma, yolk sac tumor, embryonal cell carcinoma, and mixed GCT. In adults, GCTs occur most commonly in the gonads. In children, sacrococcygeal tumors predominate. Teratomas are a common form of GCT. They are defined histologically as containing tissues derived from all 3 germ cell layers: ectoderm, mesoderm (most teratomas contain fat, an imaging hallmark, which is a mesodermal derivative), and endoderm. Teratomas are also classified as mature or immature, depending on the degree of differentiation of its components, and in adults, immature tumors are more likely to exhibit malignant behavior., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Purpose: Positron emission tomography (PET) using 6-[18F]fluoro-L-dihydroxyphenylalanine (18F-dopa) has an excellent sensitivity to detect carcinoid tumour lesions. 18F-dopa tumour uptake and the levels of biochemical tumour markers are mediated by tumour endocrine metabolic activity. We evaluated whether total 18F-dopa tumour uptake on PET, defined as whole-body metabolic tumour burden (WBMTB), reflects tumour load per patient, as measured with tumour markers., Methods: Seventy-seven consecutive carcinoid patients who underwent an 18F-dopa PET scan in two previously published studies were analysed. For all tumour lesions mean standardised uptake values (SUVs) at 40% of the maximal SUV and tumour volume on 18F-dopa PET were determined and multiplied to calculate a metabolic burden per lesion. WBMTB was the sum of the metabolic burden of all individual lesions per patient. The 24-h urinary serotonin, urine and plasma 5-hydroxindoleacetic acid (5-HIAA), catecholamines (nor)epinephrine, dopamine and their metabolites, measured in urine and plasma, and serum chromogranin A served as tumour markers., Results: All but 1 were evaluable for WBMTB; 74 patients had metastatic disease. 18F-dopa PET detected 979 lesions. SUVmax on 18F-dopa PET varied up to 29-fold between individual lesions within the same patients. WBMTB correlated with urinary serotonin (r=0.51) and urinary and plasma 5-HIAA (r=0.78 and 0.66). WBMTB also correlated with urinary norepinephrine, epinephrine, dopamine and plasma dopamine, but not with serum chromogranin A., Conclusion: Tumour load per patient measured with 18F-dopa PET correlates with tumour markers of the serotonin and catecholamine pathway in urine and plasma in carcinoid patients, reflecting metabolic tumour activity.

Unlabelled: Preclinical studies have indicated that somatostatin receptor (sst)-expressing tumors demonstrate higher uptake of radiolabeled sst antagonists than of sst agonists. In this study, we evaluated whether imaging with sst antagonists was feasible in patients., Methods: Biodistribution and tumor uptake of the sst antagonist (111)In-DOTA-pNO(2)-Phe-c(DCys-Tyr-DTrp-Lys-Thr-Cys)DTyrNH(2) ((111)In-DOTA-BASS) were studied in 5 patients with metastatic thyroid carcinoma or neuroendocrine tumors. Findings were compared with (111)In-pentetreotid ((111)In-DTPA-octreotide) scan., Results: No adverse effects of (111)In-DOTA-BASS (20 μg) were observed. (111)In-DOTA-BASS detected 25 of 28 lesions, whereas (111)In-DTPA-octreotide detected only 17 of 28 lesions. In the same patient, (111)In-DOTA-BASS showed higher tumor and lower renal uptake than (111)In-DTPA-octreotide (3.5 ± 2.8 percentage injected activity [%IA] vs. 1.0 ± 0.99%IA and 1.5 ± 0.3 %IA vs. 2.3 ± 0.7 %IA) at 4 h after injection., Conclusion: Imaging of neuroendocrine tumors with sst antagonists is clinically feasible. The favorable human biodistribution data suggest that sst antagonists could significantly affect peptide receptor-mediated imaging and therapy.

Objective: The purpose of this prospective study was to compare the performance of (111)In-octreotide somatostatin receptor scintigraphy (SRS) and (18)fluorodesoxyglucose positron emission tomography (FDG-PET) in aggressive well-differentiated endocrine carcinoma (WDEC) defined by a high Ki67 (≥10%)., Methods: Eighteen consecutive patients explored in a single hospital between November 2003 and 2008 for high Ki67 (≥10%) WDEC were prospectively included. WDEC were sporadic in 17 cases and secreting in 16 cases. FDG-PET, SRS, and computed tomography (CT) were performed within a maximum of 3 months and reviewed by two independent readers. For each patient, an analysis per organ and lesion was performed. Both the results of conventional imaging and the highest number of metastatic organs and distinct lesions visualized by all imaging methods including SRS, FDG-PET, and thoraco-abdomino-pelvic CT were considered for the determination of the standard. Correlation between tumor slope and maximum standardized uptake value, Ki67 value, and grade of uptake at SRS was evaluated., Results: FDG-PET, SRS, and CT showed at least one lesion in 18 (100%), 15 (83%), and 17 (94%) patients, respectively. A total of 254 lesions were diagnosed in 59 organs. FDG-PET, SRS, and CT detected 195 (77%), 109 (43%), and 195 (77%) lesions in 53 (90%), 30 (51%), and 39 (66%) organs, respectively. FDG-PET, compared to SRS, detected more, the same as, and less lesions in 14 (78%), one (6%), and three (17%) patients, respectively. A statistical trend was found between Ki67 value and tumor slope (P = 0.07). Median survival after diagnosis was 25 months (range, 6-71 months)., Conclusion: These results suggest that FDG-PET is more sensitive than the SRS for high Ki67 WDEC staging.

The management of gastroenteropancreatic endocrine tumors is greatly linked to the localization of primary tumor. Morphological imaging methods are thus necessary. However, the expression of somatostatin receptors in endocrine tumors makes their detection possible thanks to radiolabeled somastotatin analogs. [(111)In-DTPA] octreotide is the main radiolabeled analog for somatostatin receptor scintigraphy. Positron emission tomography uses other tracers and currently allows improvement of the diagnosis and the tumoral staging. It also allows to affect the therapeutic management. A further step is about to be taken as far as the therapy of endocrine tumors is concerned with the peptide receptor radionuclide therapy. Those therapies are now being offered in some European and American centers for progressive metastatic tumors. Their place in the therapeutic strategy has to be defined, especially in comparison to targeted therapy. The sudden and delayed adverse events as well as the current legislation on the use of radioactive therapy-aimed products have limited their development in France so far., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Poorly differentiated endocrine carcinoma (PDEC) of the pancreas is a rare and aggressive tumor. First-line treatment is commonly a combination of etoposide and cisplatin, but there is no consensus regarding further treatment recommendations. In this report, we describe a case of pancreatic PDEC treated with gemcitabine as third-line chemotherapy. A 62-year-old man with pancreatic PDEC was administered etoposide plus cisplatin as first-line treatment; he then received irinotecan for tumor relapse. However, because irinotecan induced ileus in this patient, we chose gemcitabine as third-line chemotherapy. After two cycles of gemcitabine (1000 mg/m(2) on days 1, 8 and 15 every 4 wk), a partial tumor response was noted by computed tomography (approximately 68% reduction in tumor size). Our patient survived for 15 mo after diagnosis. This is a rare case of unresectable pancreatic PDEC, which showed a partial response to gemcitabine after the failure of two other regimens. Gemcitabine could be an effective treatment option for pancreatic PDEC that is resistant to other treatments.

Mixed acinar-endocrine carcinoma (MAEC) of the pancreas is extremely uncommon. We report here a rare case of MAEC of the pancreas presenting as watery diarrhea. This is the first report in the English-language literature that describes the imaging findings of MAEC of the pancreas, including computed tomography (CT), magnetic resonance (MR) imaging, and MR cholangiopancreatography features.

Purpose: In detecting pheochromocytoma (PHEO), positron emission tomography (PET) with the radiolabelled amine precursor (18)F-fluorodihydroxyphenylalanine ((18)F-DOPA) offers excellent specificity, while computed tomography (CT) provides high sensitivity and ability to localize lesions; therefore, the combination of these modalities could be advantageous in this setting. The aim of this study was to investigate whether combined (18)F-DOPA PET/CT more accurately detects and localizes PHEO lesions than does each modality alone., Methods: (18)F-DOPA PET, CT and (18)F-DOPA PET/CT images of 25 consecutive patients undergoing diagnostic scanning of suspected sporadic or multiple endocrine neoplasia type 2 syndrome-associated PHEO were reviewed retrospectively in randomized sequence. Two blinded observers scored the images regarding the likelihood of PHEO being present and localizable. Results were correlated with subsequent clinical history and, when available, histology., Results: Of the 19 lesions detected by all three modalities, PET identified each as positive for PHEO, but was unable to definitively localize 15 of 19 (79%). CT could definitively localize all 19 lesions, but could not definitively diagnose or exclude PHEO in 18 of 19 (95%) lesions. Furthermore, CT falsely identified as negative for PHEO one lesion which was judged to be positive for this tumor by both PET and PET/CT. Only in PET/CT scans were all 19 lesions accurately characterized and localized. On a per-patient basis, the sensitivity of (18)F-DOPA PET/CT for PHEO was 100% and the specificity 88%, with a 100% positive predictive value and an 88% negative predictive value., Conclusion: (18)F-DOPA PET/CT more accurately diagnoses and localizes adrenal and extra-adrenal masses suspicious for PHEO than do (18)F-DOPA PET or CT alone.

Functional information provided by PET tracers together with the superior image quality and the better data quantification by PET technology had a changing effect on the significance of nuclear medicine in medical issues. Recently introduced hybrid PET/CT systems together with the introduction of novel PET radiopharmaceuticals have contributed to the fact that nuclear medicine has become a growing diagnostic impact on endocrinology. In this review imaging strategies, different radiopharmaceuticals including the basic mechanism of their cell uptake, and the diagnostic value of PET and PET/CT in endocrine tumours except differentiated thyroid carcinomas will be discussed., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Endocrine tumors comprise a range of benign and malignant conditions that produce a spectrum of clinical symptoms and signs depending on the specific hormones they produce. The symptoms and presentations of these tumors are often independent of their size and location. Because of their expression of cell membrane receptors or production of specific types of hormones or peptides, endocrine tumors can be identified with functional radionuclide imaging much more readily compared to standard cross-sectional imaging. In recent years, 18F-fluoro-deoxy- D-glucose positron emission tomography (18F-FDG-PET) has emerged as a useful tool for diagnosing and assessing many tumors. In this review we describe how PET, using 18F-FDG and other radiopharmaceuticals can be useful in the diagnosis and management of a wide range of endocrine tumors.

Unlabelled: The treatment of metastatic neuroendocrine tumors depends on the aggressiveness of the disease. We wanted to know whether (18)F-FDG PET and somatostatin receptor scintigraphy (SRS) can predict early disease progression and patient survival., Methods: We undertook a prospective study of patients with metastatic neuroendocrine tumor diagnosed between September 2003 and January 2006. After obtaining signed informed consent from the patients, we performed CT, SRS, and (18)F-FDG PET and reviewed histologic data. CT was repeated every 3 mo to assess the risk of early progressive disease (first 6 mo), progression-free survival, and overall survival., Results: Thirty-eight patients (mean age, 60 +/- 15 y) were included. Histologically, 4 patients had a high-grade and 34 a low-grade tumor. The results of (18)F-FDG PET and SRS were positive in 15 and 27 patients. The 2-y overall survival and progression-free survival were 73% and 45%; 16 patients had early progressive disease. Most (18)F-FDG PET-positive patients had early progressive disease (14/15, vs. 2/23 (18)F-FDG PET-negative patients), and most SRS-negative patients had early progressive disease (9/11, vs. 7/27 SRS-positive patients); (18)F-FDG PET gave excellent negative and positive predictive values of 91% and 93%; (18)F-FDG PET results correlated with progression-free survival (P < 0.001) and overall survival (P < 0.001) even when only low-grade tumors were considered. SRS was associated with progression-free survival (P < 0.001) and overall survival (P < 0.03). At multivariate analysis, only (18)F-FDG PET was predictive of progression-free survival., Conclusion: (18)F-FDG PET exhibits excellent predictive values for early tumor progression. (18)F-FDG PET and SRS results correlate with progression-free survival and overall survival even for histologically low-grade tumors. These explorations could be included in the initial work-up for metastatic neuroendocrine tumor.

The cytologic findings of a clear-cell pancreatic endocrine neoplasm (PEN) diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) occurring in a 29-year-old man with von Hippel-Lindau (VHL) syndrome are described. Imaging studies showed multiple pancreatic masses and cysts, a single liver lesion, and pulmonary and renal cysts. Cytologic features of this clear-cell PEN included the presence of large sheets and rounded clusters of polygonal neoplastic cells with relatively abundant cytoplasm containing numerous, small, sharply-demarcated vacuoles that occasionally indented nuclei and gave the cells a "frothy" appearance. Mild anisonucleosis was present and nucleoli were visible. Rare single cells and stripped nuclei were seen. Small vessels transgressed tumor cell sheets. These cytologic findings are distinct from those of typical endocrine neoplasms, and bear resemblance to the cytologic features of renal cell carcinoma metastatic to the pancreas. To the best of our knowledge, this is the first detailed report of the EUS-FNA cytologic findings of a clear-cell PEN associated with VHL syndrome. We believe that the distinctive and characteristic cytologic features, together with immunohistochemical studies, can allow a preoperative cytologic diagnosis of this highly unusual pancreatic lesion and avoid possible confusion with other clear-cell neoplasms in the pancreas, particularly metastatic renal cell carcinoma., ((c) 2009 Wiley-Liss, Inc.)

Context and Objectives: Fluorodihydroxyphenylalanine-(18F) (FDOPA) positron emission tomography (PET) is a recent imaging modality used to localize endocrine tumors. This study was conducted to evaluate the impact of FDOPA-PET on the management of patients referred for carcinoid or noncarcinoid digestive tumors and the clinical relevance of the treatment decisions based on this examination., Methods and Patients: Between March 2002 and December 2006, 101 FDOPA-PET examinations were performed in 78 adult patients for follow-up of histologically documented carcinoid tumor of the ileum (23 patients) or noncarcinoid digestive tumor (26 patients) or to screen for occult digestive endocrine tumors (29 patients). More than one FDOPA-PET examination was performed in 12 patients. The impact of FDOPA PET was evaluated on a per-patient basis by means of a questionnaire completed by the referring physician, and the relevance of the treatment decision was assessed on the basis of follow-up data., Results: The survey response rate was 91% (71 of 78). The overall impact rate of FDOPA-PET on patient management was 25% (18 of 71). The greatest impact was observed for carcinoid tumors (50%: 11 of 22) and was clinically relevant in every case, followed by occult endocrine tumors (16%: four of 25), and was clinically relevant in three of the four cases, and noncarcinoid tumors (13%: 3 of 22), clinically relevant in only one case., Conclusion: FDOPA-PET appears to be a major tool for the management of carcinoid tumors with excellent diagnostic performances and induced relevant changes in patient management. FDOPA-PET was less sensitive and less useful for the management of noncarcinoid tumors.

The role of PET in the assessment of endocrine tumours has been, until recently, restricted to the use of (18)F-fluoro-deoxy-D-glucose ((18)F-FDG). Being a marker of metabolically active lesions that show high grading and low differentiation, FDG is not ideal for this purpose since the majority of endocrine tumours are slow growing and highly differentiated. It is however useful when dedifferentiation takes place and provides excellent prognostic information. A number of hormone precursors and amino acids are labelled with (11)C and used successfully in the management of parathyroid, adrenal and pituitary tumours. However, the short half-life of (11)C radiopharmaceuticals restricts their use to centres with access to an on-site cyclotron, while the high cost of production may limit their use to research purposes. A promising new positron-emission tomography (PET) tracer is Gallium-68 obtained by elution from a long shelf-life generator that makes it economic and cyclotron-independent. Its short half-life and flexible labelling ability to a wide range of peptides and antibodies makes it ideal for PET imaging. In addition to imaging GEP-NETs and phaeochromocytoma, it has the potential to be used in a wider range of endocrine tumours.

Somatostatin receptors (sst), somatostatin (SS) and cortistatin (CST) are widely expressed in the various systems in the human and rodent organisms and are "responsible" for maintaining homeostasis, which is essential for survival. Because of their broad expression pattern sst, SS and CST interactions may play regulatory roles in both physiology and pathophysiology in mammalian organisms. SS analogue treatment strategies as well as the use of SS analogues for diagnostic purposes have been established in diseases of different origins. This review focuses on the currently determined role for SS analogues in today's clinical practice and the potential clinical prospects for SS, CST and sst interactions in the future, with a focus on neuroendocrine and non-neuroendocrine tumours and immune-mediated diseases. Moreover, the role of new SS analogues and new insights in sst physiology will be discussed.

Purpose: Well-differentiated metastatic endocrine carcinomas are difficult to manage because of variable disease outcome. New prognostic factors are required. These tumors overexpress somatostatin receptors (sst), implying the use of somatostatin analogs for tumor localization by somatostatin receptor scintigraphy using indium-111-pentetreotide ((111)In-pentetreotide) and for medical treatment. The aim of the present study was to evaluate the correlation between (111)In-pentetreotide scintigraphy, sst receptor expression, and prognosis., Patients and Methods: Between 1994 and 2002, 48 consecutive patients with well-differentiated endocrine carcinomas and a negative (111)In-pentetreotide scintigraphy were retrospectively paired according to sex, age, and tumor localization with 50 patients with well-differentiated endocrine carcinomas and a positive tracer uptake at (111)In-pentetreotide scintigraphy. Overall survival and expression of sst1 to sst5 receptors by immunohistochemistry were assessed., Results: The lack of tracer uptake at the (111)In-pentetreotide scintigraphy seemed to be a poor prognostic factor (P = .007) for overall survival by Kaplan-Meier test and in multivariate analysis; age and absence of clinical secretory syndrome also seemed to be poor prognostic factors. The tracer uptake (positive (111)In-pentetreotide scintigraphy) correlated with the tumor expression of somatostatin receptor sst2 (P < .001) but not with that of sst1, sst3, sst4, or sst5. In a bivariate analysis, lack of sst2 expression also significantly correlated with poor prognosis., Conclusion: We demonstrate the prognostic value of (111)In-pentetreotide scintigraphy in well-differentiated malignant endocrine tumors. In these tumors, sst2 somatostatin receptor expression correlates with both tracer uptake and a better prognosis.

Purpose: The aim of this study was to investigate (a) in vitro the relationship between [(18)F]fluorocholine ([(18)F]FCH) uptake and cell growth in endocrine cell lines and (b) in vivo the uptake of [(18)F]FCH by tumoral sites in an animal model of metastasized endocrine tumor., Methods: In vitro studies were conducted on three endocrine and two nonendocrine digestive tumoral cell lines. The proliferative ratio was estimated using the 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay. The uptake of [(18)F]FCH and that of [(18)F]fluorodeoxyglucose ([(18)F]FDG) were measured before and after cytotoxic therapy. [(18)F]FCH biodistribution was studied in nude mice and in an endocrine xenografted mice model., Results: The [(18)F]FCH uptake in tumoral cell lines was related to their proliferative capacities as measured by the MTT assay in basal conditions. After cytotoxic therapy, the IC(50) values calculated with the [(18)F]FCH incorporation test were very close to those determined with the MTT assay. Biodistribution studies showed that [(18)F]FCH was predominantly concentrated in the liver and kidney of nude mice. In the STC-1 xenografted animal model, the uptake of [(18)F]FCH in the primary tumor was only 1.1%. On autoradiography and micro-positron emission tomography, there was no uptake of [(18)F]FCH in liver metastases but there was a significant uptake of [(18)F]FDG., Conclusions: In vitro studies suggested that the incorporation of [(18)F]FCH in endocrine tumor cell lines was related to their growth capacities; however, in vivo studies conducted in an endocrine xenografted animal model showed an uptake of [(18)F]FCH in hepatic metastases lower than that in normal liver cells. An influence of the microenvironment or a competition phenomenon for [(18)F]FCH uptake between normal liver and endocrine tumor cells cannot be excluded.

Clinically inapparent masses, or 'incidentalomas' of the endocrine glands are increasingly common owing to continued advancements in medical imaging. Incidentalomas of the adrenal glands have received substantial attention in the literature, whereas lesions of the thyroid and endocrine pancreas, though frequently encountered in the clinic, have received relatively little attention. We review the detection and subsequent management of incidentalomas of the thyroid, adrenal and pancreas, with specific attention paid to the mode of detection and risk stratification of lesions.

Unlabelled: The aim of this study was to evaluate whether (18)F-fluorodihydroxyphenylalanine ((18)F-FDOPA) PET is accurate for the diagnosis and follow-up of any type of well-differentiated digestive endocrine tumor and to assess its performance compared with standard somatostatin receptor scintigraphy (SRS) using (111)In-pentetreotide., Methods: We reviewed the results of 33 evaluable (18)F-FDOPA PET and (111)In-pentetreotide SRS examinations performed between March 2002 and September 2005 in 30 patients referred for documented well-differentiated digestive endocrine tumor., Results: The sensitivity and accuracy of (18)F-FDOPA PET were significantly better for carcinoid tumors (defined according to the World Health Organization 2000 classification) (n = 19) than for noncarcinoid tumors (n = 14)-that is, 93% versus 25% for sensitivity (P < 0.01) and 89% versus 36% for accuracy (P < 0.01), respectively. In contrast, the performances of (111)In-pentetreotide SRS did not differ according to the carcinoid or noncarcinoid type of the primary endocrine tumor-that is, 81% versus 75% for sensitivity and 79% versus 71% for accuracy, respectively. In carcinoid tumors, comparison between (18)F-FDOPA PET and (111)In-pentetreotide SRS showed that (18)F-FDOPA PET more accurately evaluated the extent of disease than (111)In-pentetreotide SRS. (111)In-Pentetreotide SRS did not reveal any additional lesions in any case. Conversely, in noncarcinoid tumors, the extent of the disease was more accurately evaluated in all cases by (111)In-pentetreotide SRS than by (18)F-FDOPA PET., Conclusion: This preliminary study emphasizes the importance of a precise histologic characterization of well-differentiated digestive endocrine tumor to select the best radiopharmaceutical. (18)F-FDOPA PET appears to be useful in carcinoid tumors and could become the first-line scintigraphic imaging modality for these tumors, but (111)In-pentetreotide SRS appeared to be a better first-line scintigraphic imaging modality for noncarcinoid digestive tumors.

Somatostatin receptor scintigraphy (SRS) is a very valuable imaging technique for visualisation of a diversity of neuroendocrine tumours. The sensitivity for localisation of carcinoid tumours is high, but somewhat lower for other neuroendocrine tumours. The methodology, multiple clinical aspects and limitations of the examination are described. The value of the method in patients with non-neuroendocrine tumours has yet to be established. The development of new radio-labelled somatostatin analogues for diagnosis and treatment is briefly discussed.

Positron emission tomography (PET) supplies a range of labelled compounds to be used for the characterization of tumour biochemistry. Some of these have proved to be of value for clinical diagnosis, treatment follow-up, and clinical research. (18)F-fluorodeoxyglucose PET scanning is now a widely accepted imaging approach in clinical oncology, reflecting increased expression of glucose transporters in cancerous tissue. This tracer, however, does not show sufficient uptake in well-differentiated tumours such as neuroendocrine tumours. Endocrine tumours have the unique characteristics of taking up and decarboxylating amine precursors. These so-called APUD characteristics offer highly specific targets for PET tracers. Using this approach, radiopharmaceuticals such as [(11)C]-5-hydroxytryptophan and [(11)C]-L-dihydroxyphenylalanine for localization of carcinoid and endocrine pancreatic tumours, 6-[(18)F]-fluorodopamine and [(11)C]-hydroxyephedrine for phaeochromocytomas, and [(11)C]-metomidate for adrenal cortical tumours have been developed. Functional imaging with PET using these compounds is now being employed to complement rather than replace other imaging modalities. Development of new PET radiopharmaceuticals may in the future allow in vivo detection of tumour biological properties, such as malignant potential and responsiveness to treatment.

This article provides an update on functional imaging approaches for diagnostic localization of endocrine tumors, with emphasis on positron emission tomography (PET). [18F]Fluorodeoxyglucose PET scanning is now a widely accepted imaging approach in clinical oncology. Benefits include improved patient outcome facilitated by staging and monitoring of disease and better treatment planning. [18F]Fluorodeoxyglucose PET is also useful in some endocrine tumors, particularly in recurrent or metastatic thyroid cancer where the degree of accumulation of the radionuclide has prognostic value. However, this imaging approach does not take full advantage of the unique characteristics of endocrine tumors. Endocrine tumor cells take up hormone precursors, express receptors and transporters, and synthesize, store, and release hormones. These characteristics offer highly specific targets for PET. Radiopharmaceuticals developed for such approaches include 6-[18F]fluorodopamine, and [11C]hydroxyephedrine for localization of pheochromocytomas, [11C]5-hydroxytryptophan and [11C]L-dihydroxyphenylalanine for carcinoid tumors, and [11C]metomidate for adrenocortical tumors. These functional imaging approaches are not meant to supplant conventional imaging modalities but should be used conjointly to better identify specific characteristics of endocrine tumors. This represents a relatively new and evolving approach to imaging that promises to answer specific questions about the behavior and growth of endocrine tumors, their malignant potential, and responsiveness to different treatment modalities.

With the in vivo demonstration of somatostatin-receptor- positive tumors in patients using a radiolabeled somatostatin analog, peptide receptor scintigraphy became available some 15 yr ago. Octreoscan is a radiopharmaceutical with proven clinical importance in the visualization of somatostatin-receptor-positive tumors, and the overall sensitivity of somatostatin receptor imaging is high. In a number of neuroendocrine tumor types, as well as in Hodgkin's disease, inclusion of somatostatin receptor imaging in the localization or staging procedure may be very rewarding. The value of somatostatin receptor imaging in patients with other tumors, like breast cancer, or in patients with granulomatous diseases, has to be established.

Background: In patients with digestive endocrine tumours, complete pre-operative staging is essential in planning proper management and evaluating treatment efficacy. To date, somatostatin receptor scintigraphy (SRS) is considered the 'gold standard' imaging procedure, and very few data are available concerning the use of helical computed tomography (hCT). This study aimed to determine the diagnostic accuracy and the ability to modify the surgical management of hCT, alone or combined with SRS., Patients and Methods: Sixty patients were staged before surgery by hCT, SRS and tumour markers, and included in group 1 if suitable for radical surgery, otherwise in group 2. All patients underwent laparotomy followed by subsequent re-staging., Results: SRS sensitivity was 77%, 48% and 67% for primary, lymph-node and liver lesions, respectively. hCT sensitivity was 94%, 69% and 94% for primary, lymph-node and liver lesions, respectively (P = 0.02 versus SRS, for liver lesions). During pre-operative evaluation, hCT correctly staged 92% and SRS 75% of patients (P = 0.02). hCT provided additional information in 17% of patients., Conclusions: Since hCT has been shown to be extremely accurate, providing essential information for the planning of surgical treatment compared with that of SRS, both techniques should be used in the pre-operative work-up of digestive endocrine tumours.

Positron emission tomography (PET) is considered one of the most effective nuclear medicine imaging modality in oncology. In many types of malignant tumours PET has proven to be high sensitive in detecting both primary neoplasm and metastatic disease both before therapy for staging purposes and after surgery, radiotherapy and chemotherapy during follow-up. In particular, PET showed high accuracy in differentiating post-treatment scar from viable tumoural tissue and high sensitivity in visualising very small metastatic foci as those in normal-sized (less than 1 cm in diameter) lymph nodes. A large variety of positron emitter tracers have been produced for PET imaging: the most widely used tracer in clinical oncology is 18F-fluoro-2-deoxy-D-glucose (18F-FDG). Deoxy-glucose (DG) is a glucose analog that enters the cell using specific transmenbrane carrier proteins (especially GLUT-1). Once within the cytoplasm, DG is phosphorylated to FG-6-phosphate but does not appear to be further metabolised. In most malignant tumours there is an increase of the glycolityc metabolism which accounts for an increase of the FDG uptake. However, the metabolic cellular activity can be only slightly increased or even normal in well differentiated and slow growing tumours as some endocrine neoplasms. In the present review, the clinical usefulness and limits of PET imaging are discussed in the management of patients with endocrine tumors.

Pancreatic endocrine tumors are rare neoplasms. It is important to distinguish them from the more common ductal adenocarcinoma of the pancreas because they are slowly progressive and specific treatments are available. The CT findings of pancreatic endocrine tumors usually vary according to the functioning or nonfunctioning status. In this article, the authors illustrate typical and atypical CT findings of pancreatic endocrine tumors with radiopathologic correlations and give examples of other pancreatic conditions mimicking pancreatic endocrine tumors.

Introduction: Extraadrenal pheochromocytomae represent 17-18% of pheochromocytomae, 85% of which are located infradiaphragmaticaly and generally wherever there is cromaffin tissue, as in this case, located at the organ of Zuckerkand. They can also appear in the context of family syndromes, i.e. phacomatosis and MEN (IIA and IIB)., Clinical Case: The authors present a case of pheochromocytoma located in the organ of Zuckerkand, diagnosed in the course of uncontroled HBP. Diagnosis was achieved by metanephrine determinations and radiological tests (ultrasound, CAT and MIBG). This patient was surgically treated by exeresis of the lession previous alpha and beta adrenergic blockade with phenoxybenzamine and propanolol. Currently this patient is asymptomatic with normal blood pressor and metanephrines blood levels., Discussion: Extraadrenal pheochromocytomae are usually located in superior paraaortic infradiaphragmatic region. The grade of malignancy must be established by histopathological findings, local recidives and metastasis. After clinical suspicion and the finding of a retroperitoneal mass with ultrasound, CAT and/or MRI, MIBG must be performed to confirm the diagnosis as well as to leave out possible tumours at distance. Treatment is surgery previous blockade of cathecolamines secretion by the preoperative administration of alpha blockers, with or without beta blockers.

Neuroendocrine tumours can be visualized by several nuclear medicine modalities based on different mechanisms of cellular uptake. The most widely used radiopharmaceutical are the metaiodobenzylguanidine (123I/131I MIBG) and pentetreotide (111In pentetreotide). The first tracer follows the metabolic pathway of norephinephrine while the second one binds to somatostatin receptors which are expressed with high intensity on the neuroendocrine tissue. Some radiopharmaceuticals (Anti-CEA, Anti-CgA, Anti-GD2 monoclonal antibodies) have today only an experimental value, others such as 99mTc(V)DMSA had in the past very limited indications (medullary thyroid cancer) but at present their production is going to be stopped. An interesting series of new peptides showing a great affinity for the receptors/structures expressed by the neuroendocrine tissue is under evaluation in order to obtain a better tumour specificity. Among the positron-emitting radiopharmaceuticals, the 18F-fluorodeoxyglucose (FDG), in spite it is considered the most widely used tracer for clinical PET in oncology, did not show a satisfactory uptake in the well differentiated neuroendocrine tissues. On the contrary 18F-FDG is the best radiopharmaceutical to visualize those rare poorly differentiated neurondocrine tumours with a high proliferative index. For this reason also in this area, new radiopharmaceuticals have been studies and developed. A serotonin precursor 5-hydroxytryptophan (5-HTP) labelled with 11C has shown an increased uptake in carcinoids. Another radiopharmaceutical in development for PET is 11C L-DOPA which seems to be useful in visualizing endocrine pancreatic tumours. 18F-DOPA whole body PET may be a more promising imaging approach. Aim of this review is to summarize the potential of nuclear medicine techniques in the diagnosis of neuroendocrine tumours and to stresses the renewed role of nuclear medicine in the management of this disease.

Helical CT evaluation of the abdomen and pelvis can be challenging in the cancer patient. This pictorial essay illustrates the important sites of neoplastic dissemination in the abdomen and pelvis. We will emphasize the classic CT appearance of several selected sites and indicate, where appropriate, the primary lesions usually associated with each.

Unlabelled: The clinical value of a novel technology of combined transmission and emission tomography (TET) was assessed in patients with endocrine tumors., Methods: TET technology, which combines simultaneous acquisition of SPECT and CT images, using the same imaging device, allows correct fusion of images of both modalities. TET was performed on 27 patients with known or suspected endocrine tumors. The radiopharmaceuticals used for the emission part of the study were chosen according to the tumor type: (111)In-octreotide for patients with neuroendocrine tumors (n = 10), (99m)Tc-sestamibi for patients with primary hyperparathyroidism (n = 8), (131)I for patients with thyroid cancer (n = 4), and (123)I-metaiodobenzylguanidine and (75)Se-cholesterol for patients with adrenal masses (n = 3 and n = 2, respectively). The additional information provided by TET compared with scintigraphy was assessed for both image interpretation and clinical utility., Results: TET did not provide any additional data in 16 patients (59%), including 5 patients with normal scintigraphy. In 11 patients (41%) with abnormal SPECT findings, TET improved image interpretation by providing a better anatomic localization of SPECT-detected lesions. It showed unsuspected bone involvement in 4 patients, it identified the organs involved and the relationship of the lesions to neighboring structures in 5 patients, and it differentiated physiologic uptake from tumor uptake in 2 patients. TET provided additional information of clinical value in 9 patients (33%). It assisted in better planning of surgery in 2 patients with neuroendocrine tumors and in 2 patients with ectopic parathyroid adenomas. It changed the treatment approach in 2 patients with neuroendocrine tumors and 1 patient with thyroid carcinoma, and it altered prognosis in 2 patients with thyroid malignancy., Conclusion: TET enhances the already unique role of nuclear medicine procedures in the assessment and management of patients with endocrine neoplasms.

Cystic endocrine tumors of the pancreas are rare and raise difficult clinical problems. Our aims were to reevaluate the diagnostic and therapeutic strategy and to assess their histopathologic characteristics. Thirteen cystic endocrine tumors diagnosed in 10 patients were included. Clinical, radiologic, and pathologic data were reviewed. There were 6 male and 4 female patients (median age, 46 yrs). Six patients had evidence of multiple endocrine neoplasia type 1 (MEN1) disease. Four had a functional endocrine syndrome. Ten tumors were visible on imaging studies. The most suggestive radiologic features were the existence of a peripheral hypervascular rim (10 cases) and images of cyst into cyst (two cases). On gross and histologic examinations, two distinct types were present. Macrocystic tumors (six cases) were unilocular and limited by a thick wall containing nests of tumor cells. Microcystic tumors (seven cases) were characterized by the presence of multiple cystic spaces directly lined by tumor cells. Surgical resection was performed in all cases. Three patients had lymph node metastases at the time of diagnosis. One patient is dead with metastatic dissemination. The others are alive without recurrence or metastasis. The diagnosis of endocrine tumor must be considered for any pancreatic cyst discovered in a patient with a history of MEN1 syndrome or with clinical features suggestive of this syndrome. Cystic pancreatic endocrine tumors must be treated by surgical resection because of their possible malignant evolution.

The contribution of nuclear medicine to the diagnosis and treatment of endocrine malignancy is increasing. Advances in molecular biology offer new opportunities for tumour targeting via surface receptor recognition and tumour-specific metabolic markers. Imaging the biodistribution of these markers allows quantitative, in vivo characterization of tumour function. There is growing interest in the therapeutic potential of nuclear medicine targeting, substituting therapeutic beta-emitting radionuclides for the gamma-emitters used in diagnostic imaging. Limited clinical experience supports the rationale of this approach in patients with inoperable or disseminated disease and controlled trials are in progress. This chapter outlines the place of nuclear medicine techniques in the routine management of endocrine malignancy and explores areas for further development., (Copyright 2001 Harcourt Publishers Ltd.)

Neuroendocrine tumors are characterized by the expression of different peptides and biogenic amines. These rare tumors tend to grow slowly and are notoriously difficult to localize, at least in the early stages. Surgical removal is the only definitive therapeutic option for neuroendocrine tumors and relief from hyperfunctional status. The effectiveness of surgical treatment is invariably dependent upon the complete surgical excision of all tumor tissue, because microscopic and occult disease not readily seen by the surgeon may remain in situ, leading to shortened survival. Therefore, pre- and intraoperative localization of the primary as well as of metastatic tumors is of utmost importance. Radioguided surgery (RGS) is an intraoperative technique that enables the surgeon to localize radiolabelled tissue based on the characteristics of the various tissues. Concerning gastroenteropancreatic tumors (GEP), intraoperative gamma probe examination is able to reveal small tumor sites accumulating (111In-DTPA-D-Phe1)-pentetreotide more efficiently (> 90%) than somatostatin receptor scintigraphy (68%-77%), because lesions with a size smaller than 5 mm in greatest dimension could be identified. Furthermore, RGS identified 57% more lesions when compared to the "palpating finger" of the surgeon. In medullary thyroid cancer (MTC), surgical removal of the tumor is the first and most efficient treatment of the disease. Persistent or increasing serum calcitonin and carcinoembryonic antigen (CEA) levels imply tumor recurrence after thyroid ablation. For imaging recurrent MTC many radiopharmaceuticals have been used to visualize tumor sites, but none of them has shown excellent sensitivity. Preoperative somatostatin receptor scintigraphy and intraoperative RGS in patients with recurrent MTC demonstrate only part of the tumor sites and cannot visualize small tumor sites (less than 10 mm). In comparison, RGS using 99mTc(V)-DMSA detects metastases with a size of 5 mm in diameter, whereas the "palpating finger" of the surgeon localized metastases with a size of more than 1 cm in diameter. In patients with recurrent MTC, intraoperative gamma probe examination is able to localize over 30% more tumor lesions when compared with conventional preoperative imaging modalities and surgical findings. MIBG scintigraphy is the most sensitive technique for the detection and staging of neuroblastoma (sensitivity 92%; specificity nearly 100%). Intraoperative RGS with iodine labelled MIBG has been developed to improve the definition of tumor limits or to localize small, nonpalpable tumors. Comparison of 123I- and 125I-labelled MIBG revealed a sensitivity of 91% and 92%, respectively; the specificity of 125I (85%) was significantly higher than that of 123I (55%). In addition to scintigraphy of the adrenal glands by precusors of adrenal hormones, imaging with a radiolabelled somatostatin analogue is possible; however, (111In-DTPA-D-Phe1)-pentetreotide is not specific for any adrenal disease or function and the relatively high radioligand accumulation in the kidneys limited the use for detection of tumors in the area of the adrenal glands.

Unlabelled: Around 30% of the gastroenteropancreatic endocrine tumors (GPET) cannot be preoperatively identified by the common diagnostic imaging techniques. The aim of this retrospective study was to present our experience in the diagnosis and localization of GPET by endoscopic ultrasonography (EUS) performed prior to surgery and compare this with a review of the literature., Patients and Methods: Twenty patients suspected of having specific hormonal syndromes were correlatively explored with US, CT, MR, angiography, octreoscan and radial EUS with Olympus GFUM3/EUM3 and GF-UM20/EUM 20 and 30. Eleven cases were males (55%) and 9 (45%) females with a mean age of 60 years (range: 40-80 years). Of the 20 patients, 14 had endocrine 16 tumors in the pancreas and 6 tumors in the gastrointestinal tract. In 6 patients no tumors were found and were therefore used as a control group. Of the 20 patients, 14 underwent surgery confirming the existence of GPET in 12 cases., Results: The diagnostic sensitivity and precision of the EUS were of 75 and 78%, respectively, with these percentages being higher to those obtained with other imaging techniques. The specificity was 83%. All these values were slightly lower than the mean obtained on review of the literature. Two pancreatic tumors of less than or equal to 1 cm were detected which had not been previously diagnosed with US, CT and MR. In two cases the exact situation was not determined. Echo-endoscopic exploration of the pancrease could not be completely performed in two cases (10%), one pancreatic carcinoma and one double pancreatic gastrinoma which was gastrectomized. Endoscopic ultrasonography is a good preoperative technique for detecting GPET and in the evaluation of small sized tumors it may surpass other imaging techniques. The usefulness of EUS as a second exploration following US has been suggested for the diagnosis and localization prior to surgery.

The instruments, techniques, clinical applications and results, advantages and limitations of intraoperative ultrasound (IOUS) and laparoscopic ultrasound (LUS) in general surgical oncology are presented based on our experiences and review of publications. IOUS provides remarkable benefits in acquisition of accurate diagnostic information, particularly in tumor staging and resectability, and thereby in intraoperative decision making during hepatobiliary, pancreatic, and endocrine surgery. In addition, various surgical procedures are guided or assisted by IOUS. A latest modality of IOUS is LUS, which can provide similar valuable information and compensate for the limitation of laparoscopy. LUS will demonstrate great promise as an adjunct to laparoscopic exploration or surgery.

Purpose: To determine the clinical course and outcome of patients undergoing pulmonary resection for metastatic endocrine tumors., Methods: Retrospective review of 47 patients with known endocrine tumors and pulmonary metastases who were evaluated for surgical resection between 1975 and 1996., Results: Tumors evaluated included the following: carcinoid (16), thyroid (12), pancreatic adenocarcinoma (10), adrenocortical carcinoma (6), pheochromocytoma (2), and parathyroid (1). Thirty-three patients were asymptomatic. Hormone secretion was noted in five patients. Twenty-five patients, who had isolated lung metastases, good control of the primary tumor, and no medical contraindication had surgical resection. The number of pulmonary nodules was not a limiting factor as long as all disease could be resected with adequate residual pulmonary function. CT was successful in directing resection in all patients. Twenty-six operations were performed in 25 patients and 22 patients were treated medically. Wedge resection was performed for lesions <2 cm (15), and lobectomy for larger or multiple nodules (10). Four patients had bilateral nodules resected. There was no operative mortality and no major complications. Actuarial 5-year survival was 61% for surgically treated patients. Independent predictors of poor survival included positive mediastinal lymph nodes at time of surgery (p=0.004) and shorter disease-free interval (p=0.01). At a median of 6.7+/-1.2 years, six patients have developed radiographic appearance of a recurrence. A single patient with recurrent Hürthle cell cancer has had a successful reresection. The remaining patients have received chemotherapy. No patient with pancreatic carcinoma or adrenocortical carcinoma was a candidate for resection. All medically treated patients died within 6 months., Conclusion: Patients with endocrine tumors and pulmonary metastases are usually asymptomatic, their conditions are diagnosed accurately with CT, and they can achieve long-term survival comparable to other tumors (sarcoma) after pulmonary metastasectomy., Clinical Implications: Patients with carcinoid, thyroid, pheochromocytoma, and parathyroid tumors with pulmonary metastases should undergo surgical resection if there is the following: (1) no evidence of extrathoracic disease; (2) good control of the primary tumor; (3) no medical contraindications for surgery; and (4) pulmonary function that can tolerate resection of all documented disease. The role of adjuvant chemotherapy in patients with positive lymph nodes needs further study.