今日の臨床サポート

小腸腫瘍

著者: 須並英二 杏林大学医学部 消化器・一般外科

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2022/10/26
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
須並英二 : 特に申告事項無し[2022年]
監修:杉原健一 : 講演料(大鵬薬品工業)[2022年]

改訂のポイント:
  1. 小腸癌に関する疫学を追加した。
  1. NETの分類を更新した。
  1. NETの治療法を更新した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 小腸腫瘍の頻度は全消化管腫瘍のおよそ3~6%、全消化管悪性腫瘍のおよそ1~3%にすぎず、人口あたりの統計でも10万人あたり1人以下の発生率であり、非常にまれな疾患である。
  1. 小腸には40種類以上の腫瘍性病変が発生し得るが、およそ2/3は悪性とされている。
  1. 小腸悪性腫瘍としては、腺癌、悪性リンパ腫、平滑筋肉腫(GIST)、神経内分泌腫瘍などが認められるが、わが国では欧米に比較し神経内分泌腫瘍の占める割合は低い。
  1. カプセル内視鏡やダブルバルーン内視鏡の登場により、小腸腫瘍の診断は急速に進歩したが、小腸腫瘍は腫瘍が増大し症状が現れてから診断されることが依然として多い。
  1. 米国の統計では小腸悪性腫瘍の新規発生数は2012年までは増加傾向であったが2013年以降は横ばいとなっている[1]
 
 
  1. 治療は小腸癌、小腸神経内分泌腫瘍、GISTは原則として手術が第1選択であるが、悪性リンパ腫に対しては手術は限局性のものに限られる。
 
  1. 小腸腫瘍の疫学
  1. 小腸腫瘍が疑われる際には、その頻度に関する知識も重要である。小腸悪性腫瘍の疫学的報告は日本と欧米では若干の相違があり、さらに今後、小腸ダブルバルーン内視鏡やカプセル内視鏡の進歩・普及により、その頻度に関する報告は変化する可能性がある。
  1. わが国の集計では、1990年代に小腸悪性腫瘍481例に関する検討で、小腸腺癌32.6%、悪性リンパ腫30.4%、GIST29.1%、カルチノイド(神経内分泌腫瘍)1.7%という報告がなされている[2]が、ダブルバルーン内視鏡導入後の統計では、小腸腫瘍全体144症例に関する検討で、悪性リンパ腫22%、GIST19%、小腸癌10%カルチノイド(神経内分泌腫瘍)3%と報告されている[3]
  1. 一方海外では、米国での67,843症例の検討で、カルチノイド(神経内分泌腫瘍)38%、癌37%、悪性リンパ腫17%、GIST8%と報告されており、わが国では欧米に比較し、神経内分泌腫瘍の頻度が低い傾向が認められる[4]
 
  1. 小腸腺癌の疫学
  1. 小腸癌は近年の報告では全小腸腫瘍の約10%を占めるとされる。発生部位としては、空腸53%、回腸46%とやや空腸に多く、空腸ではトライツ靱帯から50cm以内の近位空腸に76%が発生し、回腸ではBauhin弁から50cm以内の回腸末端に76%が発生していた[5]
  1. 症状としては、腹痛が48%、次いで嘔気・嘔吐などの腸閉塞関連が28%、貧血10%、下血・黒色便5%、便潜血陽性5%など消化管出血関連がそれらに次いで認められている[5]
  1. 術前に診断のついた症例は約4割と報告され、早期癌の占める割合は11%と未だに多くはない[5]
 
  1. 小腸神経内分泌腫瘍の疫学
  1. 消化管神経内分泌腫瘍のなかで小腸神経内分泌腫瘍の占める割合は、欧米では25~45%であるが、わが国では約4%程度と比較的まれであり、わが国の特殊性が示されている[6]。部位的には、回腸および回腸終末部に約90%が発生していた[7]
  1. 神経内分泌腫瘍で産生されるセロトニンなどの物質により、皮膚紅潮や喘息様発作などが引き起こされることをカルチノイド症候群といい、神経内分泌腫瘍の特徴的症状の1つである。小腸神経内分泌腫瘍では約10%に認められる[8]
  1. 小腸神経内分泌腫瘍のリンパ節転移頻度は高く、海外のデータでは直径1cm以下のものでも40%強に転移を認め、1~2cmになると80%を超えるという報告もある[9]。本邦のデータでは直径5mm以下のものでも17.2%、1cm以下のもので30.2%に、1~2cmになると34.2%、2cmをこえると53.3%に転移を認めたという報告もある。5年生存率は50~60%(進行度によって変わる;局所のみ75%、リンパ節転移あり60%、肝転移あり20~35%程度)との報告がある[9]
問診・診察のポイント  
  1. 小腸腫瘍は他疾患の精査中に偶然指摘される場合もあるが、何らかの症状を呈することが契機となり診断されることが多い。

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文献 

Keigo Mitsui, Shu Tanaka, Hironori Yamamoto, Tsuyoshi Kobayashi, Akihito Ehara, Tomonori Yano, Hidemi Goto, Hiroshi Nakase, Shinji Tanaka, Toshiyuki Matsui, Mitsuo Iida, Kentaro Sugano, Choitsu Sakamoto
Role of double-balloon endoscopy in the diagnosis of small-bowel tumors: the first Japanese multicenter study.
Gastrointest Endosc. 2009 Sep;70(3):498-504. doi: 10.1016/j.gie.2008.12.242. Epub 2009 Jun 24.
Abstract/Text BACKGROUND: The early diagnosis of small-bowel tumors (SBT) was a difficult task until the advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) allowed access to the disease site. However, although CE and DBE have greatly simplified the task, DBE studies have yet to provide sufficient data on the diagnosis and outcome of patients with SBTs.
OBJECTIVE: To determine the efficacy of DBE examination in the detection and diagnosis of SBT.
DESIGN: A retrospective analysis of cross-sectional case series.
SETTING: Seven major medical centers in Japan.
PATIENTS: The first 1035 consecutive DBE cases at these major Japanese centers since the introduction of DBE.
MAIN OUTCOME MEASUREMENTS: The percentage of subjects with SBT and a diagnosis of SBT, their indications for DBE, and diagnostic and therapeutic DBE procedures carried out for SBT.
RESULTS: SBTs were identified in 144 of 1035 subjects (13.9%) who underwent DBE between September 2000 and December 2005. For subjects with SBT, the most common indication for DBE was the suspected presence of a SBT (61/144 [42.4%]). For subjects without SBT, the most common indication was obscure GI bleeding (OGIB) (419/891 [47.0%]). Malignant lymphoma and GI stromal tumor (GIST) were the most frequent (31/144 [21.5%]) and the second-most frequent SBTs (27/144 [18.8%]), respectively, in this database. We also performed 85 biopsies and 45 therapeutic procedures for the evaluation and treatment of SBTs in 144 patients. Although complications were encountered in 5.3% of cases (14/266 sessions), none of these were life threatening in the present study.
CONCLUSION: DBE proved a valuable tool for the detection and diagnosis of SBTs, especially when tumors were suspected. Biopsies and therapeutic procedures were also possible in most of these patients, which directed our management of the disease.

PMID 19555947
Karl Y Bilimoria, David J Bentrem, Jeffrey D Wayne, Clifford Y Ko, Charles L Bennett, Mark S Talamonti
Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years.
Ann Surg. 2009 Jan;249(1):63-71. doi: 10.1097/SLA.0b013e31818e4641.
Abstract/Text BACKGROUND: Previous studies have shown an increasing incidence of small bowel tumors in the United States. Our objective was to assess this increase by examining changes in histology-specific incidence, treatment, and survival.
METHODS: Patients with small bowel malignancies were identified from the National Cancer Data Base (NCDB, 1985-2005) and the Surveillance Epidemiology and End Results (SEER, 1973-2004) database. Age-adjusted incidence rates were calculated using SEER. Treatment and survival trends over time were examined using the National Cancer Data Base. Regression models were developed to assess survival over time.
RESULTS: Sixty-seven thousand eight hundred forty-three patients were identified with small bowel malignancies: 37.4% carcinoid, 36.9% adenocarcinomas, 8.4% stromal tumors, and 17.3% lymphomas. From 1973 to 2004, the incidence of carcinoid tumors increased more than 4-fold (2.1 to 9.3 per million), whereas changes in adenocarcinomas, stromal tumors, and lymphomas were less pronounced. From 1985 to 2005, utilization of surgery increased significantly for carcinoid tumors from 78.8% to 87.4% (P < 0.0001). Adjuvant chemotherapy utilization for adenocarcinoma increased from 8.1% in 1985 to 23.8% in 2005 (P < 0.0001). Treatment over time was generally unchanged for lymphoma and stromal tumors. Five-year survival after resection remained unchanged over time for all histologic subtypes even after adjusting for changes in patient demographics, tumor characteristics, and treatment approaches.
CONCLUSIONS: The overall incidence of small intestine malignancies has increased considerably, primarily because of carcinoid tumors which are now the most common small bowel cancer. With current treatments, survival has remained relatively unchanged over the last 20 years. Novel therapeutic options need to be investigated.

PMID 19106677
Janice L Pasieka
Carcinoid tumors.
Surg Clin North Am. 2009 Oct;89(5):1123-37. doi: 10.1016/j.suc.2009.06.008.
Abstract/Text Carcinoid tumors, which arise from the enterochromaffin cells of the gastrointestinal tract, encompass a diverse group of neoplasms. Once thought to be "carcinoma-like," these neoplasms exhibit a biologic behavior that varies from an indolent, benign course to an aggressive, rapidly progressive, and deadly disease. Today the term carcinoid is reserved for neuroendocrine tumors arising from the small bowel or neuroendocrine tumors that can cause carcinoid syndrome. This newer terminology has yet to be universally adopted, adding to the confusion in the literature. For the general surgeon there are several "carcinoid" tumors that he or she must be familiar with because many of these lesions are encountered during emergency laparotomies or incidentally discovered during investigation for vague abdominal pain. This review focuses on the gastrointestinal neuroendocrine tumors that general surgeons are likely to encounter during their career.

PMID 19836488
B Stinner, O Kisker, A Zielke, M Rothmund
Surgical management for carcinoid tumors of small bowel, appendix, colon, and rectum.
World J Surg. 1996 Feb;20(2):183-8.
Abstract/Text Carcinoid tumors occur most frequently in the gastrointestinal tract. Despite their ability to produce hormones, most of the midgut and hindgut carcinoids covered in this study are clinically silent, and the diagnosis is often not made before emergency surgery or evaluation for liver metastases. Because the rate of lymph node involvement and the prognosis of carcinoid tumors depend on their site and size, surgery refers to these two factors too. Lymph node metastases are most commonly found with small bowel carcinoids (20-45%), providing the rationale for an extended resection including the adjacent lymph node drainage area. Carcinoid tumors of the appendix < 1 cm in diameter rarely metastasize, simply requiring appendectomy for treatment. Lesions > 2 cm should be treated by right hemicolectomy because of their approximately 30% risk of lymph node metastases. Resection should always be done for carcinoid tumors of the colon resection as for adenocarcinomas. Rectal carcinoids < 2 cm rarely metastasize, directing the conclusion that for these smaller lesions local excision is sufficient; for lesions >2 cm a standard cancer resection should be performed provided distant metastases are absent. In general, the younger the patient or the larger the primary tumor, the more aggressive the treatment should be.

PMID 8661815
S A C van Tuyl, E J Kuipers, R Timmer, M F J Stolk
Video capsule endoscopy: procedure, indications and diagnostic yield.
Neth J Med. 2004 Jul-Aug;62(7):225-8.
Abstract/Text Video capsule endoscopy (VCE) is a new noninvasive imaging technique for the complete small bowel. It provides good to excellent visualisation of the mucosa of the small bowel and has a high diagnostic yield in selected patients with gastrointestinal blood loss of suspected small bowel origin and in patients with Crohn's disease. In comparison with small bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Although VCE is becoming increasingly popular, good studies on its clinical implications and application are only just emerging. In this paper we review the possibilities and limitations of clinical application of VCE.

PMID 15554596
Tetsuya Nakamura, Akira Terano
Capsule endoscopy: past, present, and future.
J Gastroenterol. 2008;43(2):93-9. doi: 10.1007/s00535-007-2153-6. Epub 2008 Feb 29.
Abstract/Text A capsule endoscope is a swallowable wireless miniature camera for getting images of the gastrointestinal (GI) mucosa. The initial capsule endoscope model was developed by Given Imaging and approved in Western countries in 2001. Before the introduction of capsule endoscopy (CE) and double-balloon endoscopy (DBE), there was no effective modality for the evaluation and management of patients with obscure GI bleeding. Obscure GI bleeding is defined as bleeding of unknown origin that persists or recurs after a negative initial or primary endoscopy (colonoscopy or upper endoscopy) result. The first capsule endoscope model, which is now regarded as a first-line tool for the detection of abnormalities of the small bowel, was the PillCam SB. It was approved in Japan in April 2007. The main indication for use of the PillCam SB is obscure GI bleeding. Almost the only complication of CE is capsule retention, which is the capsule remaining in the digestive tract for a minimum of 2 weeks. A retained capsule can be retrieved by DBE. There are some limitations of CE in that it cannot be used to obtain a biopsy specimen or for endoscopic treatment. However, the combination of a PillCam SB and DBE seems to be the best strategy for management of obscure GI bleeding. Recently, several new types of capsule endoscope have been developed, such as Olympus CE for the small bowel, PillCam ESO for investigation of esophageal diseases, and PillCam COLON for detection of colonic neoplasias. In the near future, CE is expected to have a positive impact on many aspects of GI disease evaluation and management.

PMID 18306982
Mark S Talamonti, Laura H Goetz, Sambasiva Rao, Raymond J Joehl
Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management.
Arch Surg. 2002 May;137(5):564-70; discussion 570-1.
Abstract/Text HYPOTHESIS: This study was done to review the clinical presentation, surgical management, pathologic features, and prognostic factors for primary small-bowel cancers.
DESIGN: Retrospective case series.
SETTING: Tertiary care, university hospital.
PATIENTS: One hundred twenty-nine patients were surgically treated between January 1, 1977, and December 31, 2000. There were 73 men and 56 women, with a median age of 55 years (age range, 19-82 years). Median follow-up was 36 months.
MAIN OUTCOME MEASURES: Presenting symptoms and signs, operations performed, and surgical pathologic features were analyzed and survival curves were generated.
RESULTS: Clinical findings included abdominal pain (63%), vomiting (48%), weight loss (44%), and gastrointestinal tract bleeding (23%). The distribution of tumors by histological features was as follows: adenocarcinoma (33%), carcinoid tumor (29%), lymphoma (19%), and sarcoma (19%). Cumulative 5-year survival rate was 37% in the adenocarcinoma group, 64% in the carcinoid tumor group, 29% in the lymphoma group, and 22% in the sarcoma group. Significant prognostic predictors of overall survival for the entire cohort and for each tumor subtype included complete resection and American Joint Committee on Cancer tumor stage (P<.05). Patient age, tumor location, histological grade, and use of chemotherapy and radiation therapy did not significantly influence survival. Curative resections were accomplished in 83 patients (64%) with a median survival of 37 months compared with 46 patients undergoing incomplete or palliative resections with a median survival of 10 months (P<.05). Adjacent organ resection was required in 18 (22%) of the 83 patients undergoing potentially curative resections. The median time to recurrence was 16 months. Twenty-one patients (16%) developed associated primary cancers.
CONCLUSIONS: Aggressive surgical resection in an attempt to achieve complete tumor removal seems warranted. Despite complete resections, patients with high-stage tumors remain at risk for recurrence.

PMID 11982470
Yutaka Ogata, Keizo Yamaguchi, Teruo Sasatomi, Shinji Uchida, Yoshito Akagi, Kazuo Shirouzu
[Treatment and outcome in small bowel cancer].
Gan To Kagaku Ryoho. 2010 Aug;37(8):1454-7.
Abstract/Text In adenocarcinoma of the small intestine, delays in diagnosis are frequent, and the majority of patients present with advanced- stage disease and either lymph node involvement or distant metastatic disease. Surgical resection is a mainstay in treatment of this disease, but the role of adjuvant therapy is unclear. Recent retrospective and prospective studies have helped to clarify the optimal chemotherapy approach for advanced small bowel adenocarcinoma. The combination of capecitabine and oxaliplatin is reportedly highly effective. Further clinical studies on this rare type of tumor are needed. This article reviews the focuses on recent advances in management. The 72nd Japanese Society for Cancer of the Colon and Rectum have conducted a retrospective review of Japanese patients with adenocarcinoma of the jejunum or ileum. The data indicated that although not statistically significant, there was a trend in median overall survival favoring the chemotherapy for advanced jejunal or ileal adenocarcinoma (17 months vs. 8 months, p=0.114).

PMID 20716869
Ping Lu
Staging and classification of lymphoma.
Semin Nucl Med. 2005 Jul;35(3):160-4. doi: 10.1053/j.semnuclmed.2005.02.002.
Abstract/Text In 2004, new cases of non-Hodgkin's lymphoma in the United States were estimated at 54,370, representing 4% of all cancers and resulting 4% of all cancer deaths, and new cases of Hodgkin's lymphoma were estimated at 7,880. The appropriate staging and management of lymphomas greatly depend on an accurate pathological diagnosis and classification. The recently established Revised European-American Classification of Lymphoid Neoplasms (REAL) and the subsequently adopted and updated World Health Organization (WHO) classification include modern cytogenetic, molecular, and immunologic techniques and knowledge and reach an international consensus on the classification of lymphomas. This classification scheme represents an advance in our understanding of lymphomas and serves as an operative guideline for studying and diagnosing lymphomas. Imaging techniques always have served as staging and monitoring tools for the clinical management of lymphomas. The understanding and adoption of the current classification system is important in refining the role of imaging modalities in the management of specific lymphoma. To help one understand the current classification, this current review gives a brief history of lymphoma classifications and summaries the recent classification schemes, including new entities, clinical staging methods, and clinical prognostic criteria.

PMID 16098289
A Rohatiner, F d'Amore, B Coiffier, D Crowther, M Gospodarowicz, P Isaacson, T A Lister, A Norton, P Salem, M Shipp
Report on a workshop convened to discuss the pathological and staging classifications of gastrointestinal tract lymphoma.
Ann Oncol. 1994 May;5(5):397-400.
Abstract/Text It was considered timely to review the pathological and staging classifications of GI tract lymphoma. This meeting specifically did not address the question of treatment; the management of GI tract lymphoma could perhaps form the basis for a further workshop. The following recommendations were made: to adopt the Isaacson histological classification, that all patients with GI tract lymphoma be investigated uniformly, to record the prognostic factors described above, to use the staging classification shown above. It is hoped that these recommendations will be taken into account in the design of future clinical trials of therapy for GI tract lymphoma.

PMID 8075046
Iris D Nagtegaal, Robert D Odze, David Klimstra, Valerie Paradis, Massimo Rugge, Peter Schirmacher, Kay M Washington, Fatima Carneiro, Ian A Cree, WHO Classification of Tumours Editorial Board
The 2019 WHO classification of tumours of the digestive system.
Histopathology. 2020 Jan;76(2):182-188. doi: 10.1111/his.13975. Epub 2019 Nov 13.
Abstract/Text
PMID 31433515
Tina Binderup, Ulrich Knigge, Annika Loft, Jann Mortensen, Andreas Pfeifer, Birgitte Federspiel, Carsten Palnaes Hansen, Liselotte Højgaard, Andreas Kjaer
Functional imaging of neuroendocrine tumors: a head-to-head comparison of somatostatin receptor scintigraphy, 123I-MIBG scintigraphy, and 18F-FDG PET.
J Nucl Med. 2010 May;51(5):704-12. doi: 10.2967/jnumed.109.069765. Epub 2010 Apr 15.
Abstract/Text UNLABELLED: Functional techniques are playing a pivotal role in the imaging of cancer today. Our aim was to compare, on a head-to-head basis, 3 functional imaging techniques in patients with histologically verified neuroendocrine tumors: somatostatin receptor scintigraphy (SRS) with (111)In-diethylenetriaminepentaacetic acid-octreotide, scintigraphy with (123)I-metaiodobenzylguanidine (MIBG), and (18)F-FDG PET.
METHODS: Ninety-six prospectively enrolled patients with neuroendocrine tumors underwent SRS, (123)I-MIBG scintigraphy, and (18)F-FDG PET on average within 40 d. The functional images were fused with low-dose CT scans for anatomic localization, and the imaging results were compared with the proliferation index as determined by Ki67.
RESULTS: The overall sensitivity of SRS, (123)I-MIBG scintigraphy, and (18)F-FDG PET was 89%, 52%, and 58%, respectively. Of the 11 SRS-negative patients, 7 were (18)F-FDG PET-positive, of which 3 were also (123)I-MIBG scintigraphy-positive, giving a combined overall sensitivity of 96%. SRS also exceeded (123)I-MIBG scintigraphy and (18)F-FDG PET based on the number of lesions detected (393, 185, and 225, respectively) and tumor subtypes. (123)I-MIBG scintigraphy was superior to (18)F-FDG PET for ileal neuroendocrine tumors, and (18)F-FDG PET was superior to (123)I-MIBG scintigraphy for pancreaticoduodenal neuroendocrine tumors. The sensitivity of (18)F-FDG PET (92%) exceeded that of both SRS (69%) and (123)I-MIBG scintigraphy (46%) for tumors with a proliferation index above 15%.
CONCLUSION: The overall sensitivity of (123)I-MIBG scintigraphy and (18)F-FDG PET was low compared with SRS. However, for tumors with a high proliferation rate, (18)F-FDG PET had the highest sensitivity. The results indicate that, although SRS should still be the routine method, (18)F-FDG PET provides complementary diagnostic information and is of value for neuroendocrine tumor patients with negative SRS findings or a high proliferation index.

PMID 20395333
Kazuo Kubota, Momoko Okasaki, Ryogo Minamimoto, Yoko Miyata, Miyako Morooka, Kazuhiko Nakajima, Takashi Sato
Lesion-based analysis of (18)F-FDG uptake and (111)In-Pentetreotide uptake by neuroendocrine tumors.
Ann Nucl Med. 2014 Dec;28(10):1004-10. doi: 10.1007/s12149-014-0900-3. Epub 2014 Sep 2.
Abstract/Text PURPOSE: To characterize the heterogeneity of metastatic neuroendocrine tumor (NET) lesions, we compared the [(18)F]-fluorodeoxyglucose (FDG) uptake and the (111)In-pentetreotide (SRS) uptake for somatostatin receptor scintigraphy using the CT-based fusion imaging techniques of PET/CT and SPECT/CT.
METHODS: Fifteen consecutive patients with NET lesions were examined using both FDG-PET/CT and SRS SPECT/CT prospectively. A total of 45 metastatic NET lesions were evaluated for FDG uptake according to the standardized uptake value (SUV) and for SRS uptake according to the tumor-to-muscle count ratio (T/M ratio); these values were then compared according to the grade of NET (G), also compared to the tumor volume.
RESULTS: Both the SRS uptake and FDG uptake showed no significant correlation to the tumor volume, and suggested no significant artifacts in these data. The T/M ratio for the SRS uptake ranged from 192.7 to 1.9 and exhibited very wide range of distribution. The SUV for the FDG uptake ranged from 13.8 to 0.77 and exhibited narrow range of distribution. The uptake of the two tracers in individual lesions showed an inverse correlation. The G1 + 2 lesions had a higher SRS uptake than the G3 lesions, but the difference was not significant because of the large variation (40.65 ± 48.03, n = 39 vs. 8.66 ± 13.13, n = 6). However, the G1 + 2 lesions had a significantly lower FDG uptake than the G3 lesions (3.52 ± 1.84, n = 39 vs. 10.82 ± 4.50, n = 6). The tracer uptakes varied largely not only in an inter-subject manner, but also in an intra-subject manner.
CONCLUSION: An inverse correlation between SRS uptake and FDG uptake in the metastatic NET lesions observed in this study may be consistent with the opposing ideas of differentiation and proliferation in oncology. The large variations in SRS and FDG uptake by metastatic NET lesions suggest the biological heterogeneity of advanced NET. These results support the idea that combination therapy targeting both receptor-positive cells and proliferating cells may be beneficial from a functional imaging perspective.

PMID 25179521
Stefano Partelli, Detlef K Bartsch, Jaume Capdevila, Jie Chen, Ulrich Knigge, Bruno Niederle, Els J M Nieveen van Dijkum, Ulrich-Frank Pape, Andreas Pascher, John Ramage, Nick Reed, Philippe Ruszniewski, Jean-Yves Scoazec, Christos Toumpanakis, Reza Kianmanesh, Massimo Falconi, Antibes Consensus Conference participants
ENETS Consensus Guidelines for Standard of Care in Neuroendocrine Tumours: Surgery for Small Intestinal and Pancreatic Neuroendocrine Tumours.
Neuroendocrinology. 2017;105(3):255-265. doi: 10.1159/000464292. Epub 2017 Feb 25.
Abstract/Text
PMID 28237989

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