\ ,.. <·
`
`_. ' I'·;
`. '_.1'._
`• .- .c"'· t"
`·.*' .
`\,~:,5_: '
`·(cid:173),;
`
`Fig. 4.22 Somatostatinoma. A Tumour with glandular architecture and psammoma bodies producing somatostatin as shown by immunophenotyping . B Psammo"
`body at transmission electron microscopy level. The psammoma body shows a coral-like configuration. There is an electron-dense central portion surrounded .
`a paler peripheral area with needle-like crystal structures arranged radially.
`
`Tumour spread and staging
`Because somatostatinomas are general(cid:173)
`ly large by the time they are detected ,
`nearly two-thirds have already metasta(cid:173)
`sized to the regional lymph nodes or the
`liver {105,20451
`
`Histopathology
`Somatostatinomas share histologic fea(cid:173)
`tures with other pancreatic endocrine
`tumours. In contrast to duodenal somato(cid:173)
`statin producing tumours, they often lack
`formation and
`the prominent gland
`psammoma bodies.
`Somatostatinomas usually show fairl y
`uniform histochemical reactions. The
`tumou r cells are uniformly non-argentaf(cid:173)
`fin and show argyrophilia only with the
`Hellerstrom-Hellman technique that is
`selecti ve
`for somatostatin-producing
`cells . Some tumours may show focal
`Grimelius-positive argyrophili a in a small
`number of cells.
`
`Immunohistochemistry
`Synaptophysin is strongly and diffusely
`positive in almost all tumour cells, while
`chromogran ins are
`less consi stently
`expressed. Stains for somatostatin show
`an intense immunoreac tivity in a domi-
`
`nant population of the tumour cells.
`Cytoplasmic staining for such products
`as ACTH, ca lcitonin, insulin, glucagon,
`etc. may be found in a variable. but small
`proportion of the tumour cells and may
`correlate with the focal Grimelius-positive
`argyrophilia seen in those tumours {292 ,
`464 ,776 1
`
`Electron microscopy
`The tumour cells contain large numbers
`of
`intracytoplasmic membrane-bound
`neurosecretory granules in which two
`distinct populations can be identified .
`The majority of the secretory granules
`are large (range of diameter 250-450
`nm), round and moderately electron(cid:173)
`dense. The second subset consists of
`smaller granules (range of diameter 150-
`300 nm), with somewhat denser cores.
`
`Precursor lesions
`Somatostatinomas have not been associ(cid:173)
`ated with any precursor lesion.
`
`Somatic genetics
`Very
`is available on
`little information
`somatic genetic alterations in these rare
`tumou rs. One tumour listed as somato(cid:173)
`statinoma, analyzed by CG H showed a
`
`loss of chromosome X and gains of cl'i·
`mosomes 7, 11 , 14 and 18pter-q 1 •
`{21541 and a second exhibited all( :
`loss together with a somatic mutation
`MEN1{7501 .
`
`Genetic susceptibility
`h2
`Pancreatic
`somatostatinomas
`occasionally been reported in patie,
`with MEN 1 { 1878). Von Hippei-Linc
`syndrome (1389 1 and in a small subse
`NF1 patients {22171
`
`Prognosis and predictive factors
`As somatostatinomas are usually Ia·· · ·
`tumours, most are considered endocr .
`tumours of uncertain behaviour or v .. -
`differentiated endocrine carcinomas. 1·
`largest experience with these uncomr~
`endocrine tumours estimates a 75 .2 ~.
`year survival overall, with a 59.9%
`patients with and 100% of the patiE
`without metastases {20911 . Howeve'
`retrospect not all of the se cases r•
`have been functioning tumours.
`
`190
`
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`Exhibit 1012
`Page 021
`
`

`
`Gastrinoma
`
`P Komminoth
`A. Perren
`K. Oberg
`G. Rindi
`
`C. Bordi
`G. Kloppel
`PU Heitz
`
`:efinition
`CJaStrinoma IS a functionally active and
`;ually malignant endocrine tumour with
`1nical symptoms due to inappropriate
`x retion of gastrin (Zollinger Ellison syn-
`ome; ZES) 120941 Tumours with
`'munohistochemical expression of gas(cid:173)
`n but without evidence of ZES should
`Jt be designated gastrinomas. Two
`pes of gastrinomas can be distin-
`cJished , sporadic , non-familial gastrino(cid:173)
`a with ZES ("'80% of cases) , and famil-
`1 gastrinoma with ZES in the setting of
`lEN 1 ("'20%).
`
`GD-0 code
`·astrin cell tumour
`8 153/1
`astrin cell tumour, malignant
`8 153/3
`
`Synonyms and historical annotation
`:icerogenic tumours. The syndrome was
`:Jmed after R.M. Zollinger and EH
`llison who first described the associa(cid:173)
`on between "islet cell tumours" and
`.1cerogenic disease in 1955 /24981 The
`c~ ep tid e hormone gastri n was isolated by
`' A. Gregory et al. in 1960 1771) and the
`.athogenesis of ZES was elucidated in
`' 964 /5561
`
`Epidemiology
`he majority of patients with ZES suffer
`'Om a gastrinoma of the pancreas or
`luodenum. Gastrinomas are relatively
`ommon functionally active endocrine
`'Jmour of the pancreas accounting for
`ibout 20% of cases , second in frequen-
`
`In some
`cy only to insulinomas (858)
`series they are approximately half as
`common as insulinomas 1255,858,11111.
`whereas in other series gastrinomas and
`insulinomas have a s1milar incidence
`(5771. In the United States. approximate(cid:173)
`ly 0.1% of patients with duodenal ulcers
`have evidence of ZES /577)
`The reported incidence of gastrinomas is
`between 0.5-4 per million population per
`year 1255,463,987 ,2094). ZES is more
`common in males than in females wi th a
`ratio of 3 2. The mean age at the onset of
`symptoms is 38 years (range 7-83 years)
`in some series /556 ,2398) and 50 years
`(range 45-51 years) in others 1220,281 ,
`1001 '1802,21141.
`
`Etiology
`Th e etiology and pathogenesis of spo(cid:173)
`radic gastrinomas are unknown. App roxi(cid:173)
`mately 20% of gastrinomas are part of
`MEN 1. No other risk factors are known.
`
`Localization
`Substantial variation has occurred in the
`distribution of pancreatic versus non(cid:173)
`pancreatic gastrinomas with the passing
`of time, possibly related to the refinement
`of cl inical and pathological (immunohis(cid:173)
`tochemical) diagnostic procedures .
`Indeed, the collection of 800 cases in the
`Zollinger-EI Iison Tumour Registry up to
`1973 demonstrtated localization of gas(cid:173)
`the pancreas in 53% of
`trinomas to
`patients and
`to
`the duodenum and
`jejunum in 13% (644)
`In contrast, the
`recent experience of a large reference
`
`center in the United States revealed an
`overall incidence of pancreatic localiza(cid:173)
`tion of 24% with a drop to 14% in spo(cid:173)
`rad ic cases whereas a duodenal local(cid:173)
`ization was found in 49% of cases (47 %
`in sporadic ones) 11619).
`Pancreatic gastrinomas more frequently
`occ ur
`in
`the head of
`the gland
`(515 ,21 09) More than 90% of duodenal
`gastrinomas are located in the first and
`second parts of the duodenum and limi(cid:173)
`ted to the submucosa in 54% of patients
`12227) The anatomical area comprising
`the head of the pancreas, the superior
`and descending portion of the duode(cid:173)
`num and the relevant lymph nodes has
`been called the "gastrinoma triang le"
`since it harbors the vast majority of these
`tumours (926 , 1002,1617, 1618,2109)
`Other primary sites of gastrinomas are
`increasingly (1619),
`being
`identified
`including stomach, jejunum , biliary tract,
`liver, kidney, mesentery and heart (62,
`374,709,123 7,1416, 1616,2109,2236)
`Some peripancreatic and periduodenal
`lymph node gastrinomas are thought to
`represent primary tumours rather than
`metastases from an occult primary in the
`duodenum 1184,477,2409) and some
`patients have been cured after resection
`of the tumourous lymph nodes (51 , 161 7 ,
`1618). This hypothesis of primary lymph
`node gastrinomas has been challenged
`1515,2235) . In two recent studies, howev(cid:173)
`er, neuroendocrine and gastrin express(cid:173)
`ing cells were identified in peripancreat(cid:173)
`ic and duodenal lymph nodes of patients
`without neuroendocrine tumours, provid-
`
`.- J .
`\ !
`
`A
`8
`Fig. 4.23 Malignant gastrinoma. A Ill-defined gastrinoma in the head of the pancreas invading the papilla
`Vater and the duodenal wall. 8 Large, malignant gastrinoma with areas of necrosis and fibrosis.
`
`Fig. 4.24 Liver metastasis of a gastrinoma. High pro (cid:173)
`liferative index IKi-67 labeling).
`
`191
`
`Roxane Labs., Inc.
`Exhibit 1012
`Page 022
`
`

`
`;
`i
`
`•
`
`•
`;•·
`
`r·
`r
`
`:.
`
`.. ..
`
`·. . ~··
`
`' " .
`
`'
`
`., . '•
`
`. ·-.
`
`~ ... ,
`
`·'.
`
`::f '
`··' ,.· ..
`
`~~.;: ··.·. I
`
`' ,
`
`ing evidence that these embryonic rests
`might be precursors of nodal gastrino(cid:173)
`mas (875, 1726) Still, gastrinomas aris(cid:173)
`ing from
`lymph nodes are extremely
`uncommon. The diagnosis can be made
`only after exclusion of a primary gastri(cid:173)
`noma at another localization . Rarely,
`ovarian or pancreatic mucinous cystade(cid:173)
`nomas or -carcin omas may secrete
`enough gastrin to cause ZES (211, 1406)
`
`Clinical features
`Signs and symptoms
`Most patients with gastrinomas suffer
`from typical duodenal ulcer at presenta(cid:173)
`tion, but about 20% have no ulcer. In
`almost every patient the initial symptom s
`are caused by gastri c acid hypersecre(cid:173)
`tion. Abdominal pain from either peptic
`ulcer disease or gastroesophageal reflux
`disease remains
`the most co mmon
`symptom occurring in more than 75% of
`patients Diarrhoea initially may be the
`only symptom in 10-15% and occurs with
`abdom1n al pain 1n about 50% of pat1ents .
`
`Diarrhoea is caused by high gastric acid
`output in the duodenum, thereby neutral(cid:173)
`izing the pancreatic enzymes necessary
`for digestion. This will cause malabsorp(cid:173)
`tion . In late stages of the disease symp(cid:173)
`toms may be caused by the tumour itself,
`e.g . right upper quadrant abdominal
`pain and weight loss
`than 90% of
`In early studie s more
`patients with gastrinoma and
`the
`Zollinger-EIIison syndrome at presenta(cid:173)
`tion had a peptic ulcer and in more th an
`25% the ulcers were multiple or in unusu(cid:173)
`al locations. Past patients frequently pre(cid:173)
`sented with complications or severe pep(cid:173)
`tic ulcer disease (e. g. bleeding , perfora(cid:173)
`tion,
`oesophageal
`strictures)
`and
`although this is less common today it sti ll
`occurs .
`
`Imaging
`Endoscopic ultrasonography is the most
`sensitive method to demonstrate small
`gastrinomas of the pancreas and duode(cid:173)
`num . Extrapan creat1c and metastatiC
`
`lesions can be detected by ultrasonog;
`phy, CT scan , MRI. Most recently, soma
`stalin receptor scintigraphy and PET-sc 1
`have proven to be the most sensil!
`methods to demonstrate gastrinom. :
`The sensitivity is about 70% and spec1i•
`ty 85%. It is even higher for metasln
`liver disease. with a sensitivity of 92% 2' .·
`a specificity of 90-1 00%.
`
`Diagnostic procedures
`If the gastric pH is below 2.5 and ' ·~
`serum gastrin concentration abc
`1 ,000 picogram per ml (normal < 1
`picogram per ml) the diagnosis of ZE ~ "'
`confirmed and no other diagnostic sl•,
`ies are actually needed . Unfortunat·
`the majority (40-50%) of patients pr•
`concentrat i( · .s
`ent
`serum
`gastrin
`between 100 and 500 picogram per '
`In these patients a secretin test sho ; d
`be performed in addition to a determ>
`lion of basal acid and pentagastrin s'' ·
`ulated acid output Most patients 1.
`• '
`ZES have a basal ac1d output abovr
`
`192
`
`Roxane Labs., Inc.
`Exhibit 1012
`Page 023
`
`

`
`per hour 1f they have not
`evious acid-reductive surgery. The
`cretin test is consi(jered
`when
`: increase 1n serum gastrin over the
`utreatment value is more than 200
`:ogram per mi.
`
`1acroscopy
`Jst sporadic gastrinomas are
`nours. In the pancreas tumours are
`,ually well-circumscnbed, non-encap(cid:173)
`ilated and their diameter generally
`;ceeds 2 em. Their texture varies from
`;It to firm depending on the amount of
`Jrous stroma. Multiple pancreatic
`mours are more common 1n patients
`th MEN 1 associated ZES (1748) How(cid:173)
`;er, most of these MEN associated
`mours exhibit
`immunoreactivity
`for
`'"Ptides other than gastrin and, thus, are
`Jt causative of ZES (229,1748).
`: the duodenum most gastrinomas are
`in diameter. Micro(cid:173)
`ss
`than 1 em
`astrinomas ( <0.5 em) are easily over(cid:173)
`·oked. The size of the tumours is not
`'lated to the severity of hormonally
`:duced symptoms. Duodenal gastrino(cid:173)
`las appear as well circumscribed, soft.
`Jrey to yellow, often polypoid tumours
`;ith or without ulcerated overlying
`1ucosa. In older series 13% of tumours
`;ere multiple
`(266). Multiplicity of
`Jmours, however, is
`indicative for an
`,ssociated MEN 1 syndrome ( 1128,
`: 129)
`
`rumour spread and staging
`Juodenal gastrinomas can metastasize
`1hile still very small, and give rise to
`)araduodenal lymph node metastases.
`·;hich may be larger than the primary. It
`··as, therefore, been suggested that the
`:a-called lymph node gastrinomas are
`netastases of occult duodenal micro(cid:173)
`Jastrinomas (515,2235). The exact per(cid:173)
`;entage of malignant gastrinomas
`is
`mclear. In early studies 60-90% of gas(cid:173)
`rnnoma patients had metastatic disease
`tlt the time of diagnosis but in recent
`stud1es the percentage has dropped to
`34% (range 13-52%) probably due to
`c::arlier diagnosis ( 1 002). Metastases to
`the liver generally occur late and are only
`seen in a small percentage of patients at
`rhe time of surgery, mostly in
`vvith with pancreatic tumours 14 77,515,
`2110)
`system that
`So far there is no
`specifically applies to gastrinomas
`Pancreatic endocrine tumours).
`
`80
`
`60
`
`40
`
`20
`
`0
`
`-20
`
`-40
`
`-60
`
`1p- 3p- 4+ 5+ 6q- 7+ 9p+ 9q+ 10-11p-11q- 12+ 14q+17+ 18q-20q+
`
`Fig. 4.26 Analysis of chromosomal alterations of gastrinomas, using CGH. Chromosomal gains are prominent
`on chromosomes 7, 9p, 9q and 17, while chromosomal losses are shown in 3p, 6q and 11 q.
`
`Histopathology
`The histopathological findings of gastri(cid:173)
`nomas. either pancreatic or extrapancre(cid:173)
`atic, almost invariably correspond to
`those of well differentiated endocrine
`tumours according to the WHO classifi(cid:173)
`cation (2097) As with other pancreatic
`endocrine tumours malignancy cannot
`in most
`be predicted histologically
`instances, except in the rare tumours in
`which angioinvasion or infiltration of peri(cid:173)
`pancreatic tissues can be documented
`12094). The growth fraction of gastrino(cid:173)
`mas was found to be similar to that of
`other functioning but lower than that of
`non-functioning pancreatic endocrine
`tumours whereas a MIB-1 index > 10%
`was invariably associated with develop(cid:173)
`ment of metastases 1391 ).
`Due to their substantial differences pan(cid:173)
`creatic and extrapancreatic gastrinomas
`the
`are described separately as are
`histopathological features of extratu(cid:173)
`moural pancreatic tissue.
`
`Pancreatic gastrinomas
`The histological arrangement of pancre(cid:173)
`atic gastrinomas has no distinctive fea(cid:173)
`tures with respect to other functioning or
`non-functioning differentiated endocrine
`tumours of the pancreas. The early
`observation of an abundance of glandu(cid:173)
`lar like structures 1773) was not con(cid:173)
`firmed by further studies. Actually, pan(cid:173)
`creatic gastrinomas are predominantly
`arranged in a mixed trabecular and solid
`pattern with
`amount of interven(cid:173)
`ing stroma. Tumours with pure,
`form/ribbon pattern, especially if multi-
`
`pie. are likely to be accompanying neo(cid:173)
`plasms that are shown by immunohisto(cid:173)
`chemistry to produce nongastrin hor(cid:173)
`mones, mostly glucagon and/or pancre(cid:173)
`atic polypeptide 1229, 1748). Necrosis is
`uncommon in gastrinomas. Tumour cells
`tend to show regular round or ovoid
`nuclei with minimal atypia and well-rep(cid:173)
`resented cytoplasm with faint eosiniphilic
`granularity. Mitoses are infrequent.
`Immunohistochemistry Although gastri(cid:173)
`noma may react with Grimelius silver
`stain or with a number of general neu(cid:173)
`roendocrine markers. the conclusive evi(cid:173)
`dence for the diagnosis is provided by
`gastrin
`immunohistochemistry, which
`may react diffusely in most tumour cells
`or in discrete cells or cell clusters. In
`cases in which the tumours are mostly or
`entirely unreactive to gastrin antiserum,
`the use of a panel of antibodies directed
`against specific sequences of the gastrin
`molecule may be necessary. Detection of
`gastrin mRNA by in situ hybridization is
`recommended in tumours in which con(cid:173)
`stitutive secretion of the hormone results
`in undetectable or absent gastrin storage
`in tumour cells.
`Electron microscopy Showing varying
`proportions of cells either devo1d of gran(cid:173)
`ules or with nondiagnostic granules
`1431), EM has virtually no diagnostic rel(cid:173)
`evance.
`
`Duodenal gastrinomas
`These tumours are mostly confined to the
`mucosa and submucosa and their pre-
`. dominant patterns include broad trabec(cid:173)
`ulae and glandular-like structures.
`
`93
`
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`Page 024
`
`

`
`(38%) than
`ones (60-70'
`recent stud:<
`(960.20981 However,
`reported a more than 50%
`rate of duodenal gastrinomas (17 4:
`2227). It may be that the reported le'
`malignant behaviour of duodenal gastr
`nomas is only due to the earlier deter
`tion. The same holds true for the pt·
`posed lower malignancy rate of duod•
`nal gastrinornas in MEN 1
`In
`the progression of gastrin,
`mas is relatively slow with a combined :
`year survival rate of 65% (62-75%) at
`10-year survival rate of 51% (47-53')
`( 10021. Even with metastatic disease
`survival of 46% (lymph noc
`1
`metastases) and 40% (liver metastase
`has been reported. Patients with cor'
`plete tumour resection have excellent
`and 1 0-year survival rates (90-1 00'/,
`Again, patients with pancreatic tumou
`have a worse prognosis than those w1
`primary tumours in the duodenum ( 1'
`year survival 9% versus 59%)
`The rate of tumour related death
`aggressive forms of gastrinornas rangt
`from 38% in MEN 1 cases
`01 to 62
`in sporadic cases (2163}
`There are no established markers to pr,
`diet the brological behaviour of gastrin
`mas. However, some have found th
`Her2/neu amplification and overexprE
`sion of EGF and hepatocyte growth fa
`tor (HGF) are associated with aggressr.,
`growth (735,1707).
`
`Gastrin immurlo(cid:173)
`intense and diffuse
`w!rereas electron mrcroscopy shows
`more abundant and typical G cell gran(cid:173)
`ules
`
`Non-tumour pancreatic tissue.
`Islet cell
`and nesidioblasto(cid:173)
`, buddrng off of islet cell clusters
`sis
`from ductal pancreatic epithelium) is fre(cid:173)
`quently encountered in the pancreas of
`(431 ,2094f. Gastrin
`gastrinoma
`has never been convincingly demon-
`strated in these lesions that may possibly
`on the trophic effect of tumour
`hypergastrinaemia. A mer(cid:173)
`study of the PP-rich pancreat(cid:173)
`of ventral embryological origin
`with sporadic gastrinomas
`rn
`showed pronounced PP cell hyperplasia,
`possibly as a manifestation of a more dif(cid:173)
`fuse disorder of PP cells in this condrtion
`(14141
`
`Histogenesis
`Gastrin gene expression in endocrine
`pancreas of mammals is restricted to
`fetal irfe (2401, and gastrin-containing G(cid:173)
`celis are normally not encountered in the
`postnatal human pancreas. Therefore
`gastrinomas are considered
`tumours. whereas gastrinomas
`from the duodenum. jejunum or
`stomach. where G-cells are normally
`found, are consrdered
`tumours.
`Srmiiar
`to all pancreatrc endocrine
`tumours the histogenesis of gastrino111a
`is uncertain.
`
`Somatic genetics
`The number of gastrinomas investigated
`by molecular methods is relatively small
`and the majority of these studies have
`focused on tne mutational state and allel(cid:173)
`ic loss of the MEN1 gene on 11q13.
`Furthermore. many studies did not clear(cid:173)
`ly separate between pancreatic and duo(cid:173)
`denal tumours and, thus, the results
`might not be
`fully
`Comprled results of CGH studres on 9
`revealed Ural
`chromosomal alterations are less often
`present than rn OHler types of
`endocrrne tumours (rncludrng insulino(cid:173)
`mas) wrth the
`of losses of 3p
`wh:ch occur more frequently
`1
`(?1CJ'-J ?107 ?1fi-1 ?!190) The r8lP~ nt
`a:l,;l:c losses at 11q13 and mutatrons of
`he MEN 1 gerre are H:e
`o1 ali oar ·
`
`been found in 90% (28/31) and 37%
`( 19/51) of tumours,
`(750,
`
`gastrino(cid:173)
`mutations in primary
`mas are mostly located in exon 2 and in
`duodenal tumours they are mainly found
`I
`in other exons of
`the gene
`Mutations of other genes have not been
`described.
`
`Genetic susceptibility
`Approx 20-25% of patients
`from ZES have MEN 1 1100220941 The
`of MEN 1 in patients with
`gastrin producing tumours of the duode(cid:173)
`num and upper jejunum has been report(cid:173)
`to be 5.3% 120931 Pancreatic
`ed
`endocrine tumours in the setting of VHL
`disease consistently lack gastrin immu(cid:173)
`noreactivity ( 13571.
`
`Prognosis and predictive factors
`Gastrinomas show a high risk of malig(cid:173)
`nant behaviour independent of size and
`should therefore be classified as tumours
`with uncertain behaviour or as well-differ(cid:173)
`entiated endocrine carcinomas when
`gross invasion and/or metastases are
`present. Gastrinomas in
`with
`liver metastases seem to behave more
`aggressively than those with lymph node
`metastases only (477,21101 and regional
`lymph node metastases appear to have
`little influence on the overall survival of
`suffering from ZES (477,23651
`The risk for liver metastases rncreases
`with tumour size and pancreatic location
`of the primary. It rs low in MEN 1
`Thus. the frequency of liver metastases is
`30% in patients with pancreatic gastrino(cid:173)
`mas and 3% in patients with duodenal
`tumours (20941 The growth rate of
`hepatic metastases as revealed by mod(cid:173)
`ern. sensitive imaging studies. also has
`important predictive relevance.
`It has
`been used to separate aggressive from
`non-aggressive variants of gastrinomas.
`the
`former showing a
`tumour size
`increase of at least 50% in volume per
`in MEN 1 cases
`month (21631
`( 7101) and the latter no or lower
`In
`of the occurrence of liver metas-
`tases also rn the group of indolent
`nomas.
`tumour related deaths were
`almost
`confined to the aggres(cid:173)
`SIVe growth group (710,21631 Meta(cid:173)
`stasAs to other organs such RS
`lung
`
`Roxane Labs., Inc.
`Exhibit 1012
`Page 025
`
`

`
`VIPoma
`
`·)efinition
`• VIPoma is a functionally active and
`,sually malignant endocrine tumour, aris(cid:173)
`in
`the pancreas, which
`" g mostly
`,ecretes mainly vasoactive intestinal
`:eptide (VIP). VIP-secreting tumours
`· ave been associated with the watery
`:iarrhoea syndrome. Additional sub(cid:173)
`ranees produced by VIPomas, possibly
`ontributing to the clinical syndrome,
`r 1clude peptide histidine methionine
`~)HM), pancreatic polypeptide (PP),
`.eurotensin, and others.
`
`:co-o code
`. IP-producing tumour
`
`.liP-producing carcinoma,
`l iPoma, malignant
`
`8155/3
`
`8155/1
`
`Synonyms
`,11Pomas have also been referred to as
`Jiarrhoeogenic tumours of the pancreas
`·:nd islet cell tumours of the pancreas
`·;ith watery diarrhoea (2094). The syn(cid:173)
`!rome associated with VIPomas, origi-
`, :ally known as Verner-Morrison syn(cid:173)
`.Jrome
`recognizing
`its discoverers
`2312), has also been called pancreatic
`· ;holera ! 1437) and WDHA (watery diar(cid:173)
`·rloea, hypokalemia, achlorhydria) syn(cid:173)
`•!rome (1410).
`
`Epidemiology
`•' ancreatic VIPomas constitute about
`'10% of diarrheogenic neoplasms and 3-
`3% of all endocrine tumours in the pan-
`
`creas (1111) . Approximately 50% of pan(cid:173)
`creatic VIPomas are malignant (metasta(cid:173)
`tic) at the time of diagnosis (2090).
`Females are affected more often than
`males and the age of the patients ranges
`from 19-79 years (mean: 48 years)
`(294, 1539). By contrast, two thirds of the
`neurogenic V!Pomas are found in paedi(cid:173)
`atric patients ! 1036, 1349). VIPomas are
`not familial, except for some tumours
`associated with MEN 1 (949, 1649)
`
`Etiology
`With the exception of those associated
`with the MEN 1, no etiologic factors are
`known for VIPomas .
`
`Localization
`VIPomas are located in the pancreas in
`about 80% and outside the pancreas in
`the remaining 20% (2094) . Pancreatic
`VIPomas are located more often in the
`tail (47%) than in the head (23%) or the
`body (19%) (294, 1111 , 1649) Extrapan(cid:173)
`creatic VIP-secreting epithelial tumours
`are exceedingly rare and include lesions
`in the small intestine (294). oesophagus
`(2360). and kidney (808). Neurogenic
`tumours such as ganglioneuromas, gan(cid:173)
`glioneuroblastomas, neuroblastomas ,
`and phaeochromocytomas constitute the
`bulk of the extrapancreatic VIP secreting
`tumours and are located more common(cid:173)
`ly in the retroperitoneum (65%) than in
`the mediastinum (35%) (1126,2094).
`
`Fig. 4.27 VIPoma. A Large multinodular tumour with partly visible capsule and some necrotic and fibrotic
`areas . B Multiple liver metastases.
`
`J. Lechago
`E.J.M. Speel
`A Perren
`M. Papotti
`
`Clinical features
`Signs and symptoms
`The Verner-Morrison syndrome is char(cid:173)
`acterized by Watery Diarrhoea, Hypo(cid:173)
`kalaemia and Achlorhydria or more often
`hypochlorhydria
`(WDHA
`synd rome)
`! 1538,2313). The secretory diarrhoea
`ranges between 0.5-6.0 litres per 24
`hours and is usually the most prominent
`symptom at presentation. It results in
`severe loss of potassium and bicarbon(cid:173)
`ate, which, in turn, lead to metabolic aci(cid:173)
`dosis and dehydration. Additional fea(cid:173)
`tures include hypercalcaemia with nor(cid:173)
`mal parathormone
`levels, hypergly(cid:173)
`caemia, and occasionally flushing of the
`face and the chest. Rare instances of
`tetany have been reported , explained by
`hypomagnesaemia with normal or elevat(cid:173)
`ed calcium levels (949, 1163).
`
`Imaging
`As in other endocrine tumours of the pan(cid:173)
`creas, ultrasound, CT-scan , MRI , octre(cid:173)
`oscan and PET-scan are the methods
`currently utilized to localize pancreatic
`VIPomas and their metastases.
`
`VIP in plasma
`Plasma VIP assay should be carried out
`to confirm the VIPoma diagnosis, a level
`above 60 pmoi/L being virtually diagnos(cid:173)
`tic. Additional corroboration may be
`afforded by evaluation of plasma PHM
`levels, as this peptide is more resistant to
`proteolysis than VIP (202).
`
`Macroscopy
`Pancreatic VIPomas do not present gross
`features that distinguish them from other
`endocrine tumours. These neoplasms are
`generally solitary, except in rare cases
`associated with MEN 1. They appear as
`sharply demarcated, but unencapsulated,
`masses ranging between 2-20 em in max(cid:173)
`imum diameter (median diameter: 4.5
`em). The cut surface is variable, generally
`pink-tan or grey, and may display focal
`haemorrhage ,
`fibrous
`septa,
`cystic
`change, or even gross calcifications
`! 1552, 1649) Most VIP-producing neuro(cid:173)
`genic tumours are encapsulated ! 2094).
`
`Roxane Labs., Inc.
`Exhibit 1012
`Page 026
`
`

`
`Fig. 4.28 VIPoma. Trabecular and gyriform architecture and partly peripheral palisading of nuclei.
`
`Tumour spread and staging
`Metastatic spread of VIPomas is found in
`about one-half of the pancreatic tumours
`at the time of diagnosis !1538,20941.
`Metastases are more commonly found in
`the liver (haematogenous spread) than in
`the regional
`lymph nodes (lymphatic
`Indeed, vascular
`spread) /294,20901
`and perineural permeation is found at the
`periphery of one-half of the pancreatic
`VIPomas, generally in association with
`metastatic spread (2094). So far there is
`no staging system
`that specifically
`applies to VIPomas (see Pancreatic
`endocrine tumours).
`
`Histopathology
`The microscopic appearance of pancre(cid:173)
`atic VIPomas does not present distin(cid:173)
`guishing traits. The tumour cells are
`rounded or polygonal, with a moderate
`amount of well-demarcated, faintly gran(cid:173)
`ular. eosinophilic cytoplasm. The nuclei
`may be regular, but often exhibit mild to
`occasionally moderate pleomorphism
`they may be hyperchromatic or display a
`stippled chromatin pattern, and nucleoli
`are inconspicuous (294,20941. Even sig(cid:173)
`nificant nuclear atypia does not have
`prognostic significance applicable to a
`grading system The mitotic count is usu-
`
`ally low ( <2 per 10 HPF), even in ma'
`nant tumours, although rn about 12%
`the tumours it may be relatively high a
`include the presence of atypical mitm
`!20941. The tumour cells grow in
`organoid fashion and may be arran9
`in solid, trabecular and tubuloacmar ~·
`terns. The
`stroma var
`widely, ranging from delicate fibrovas
`lar septa to broad. richly vasculari1
`collagenous bands 1294,20941. Oc
`sronal examples of calcrum !15521
`amyloid deposits
`!4351 have br
`reported. the latter being of the islet ar
`loid polypeptide (lAPP: amylin) variel\
`
`Fig. 4.29 V!Poma. A Production of VIP by a
`
`196
`
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`Exhibit 1012
`Page 027
`
`

`
`nmunohistochemistry
`eneric endocrine markers. such as
`,naptophysin, chromogranins and oth(cid:173)
`s are posit1ve in more than 90% of the
`mours
`In multiple studies, VIP has
`3en immunolocalized in 87% of diar-
`tumours. peptide histidine
`ethionine (PMH). a flanking sequence
`:[hin the VIP precursor polypeptide, in
`7 %, PP in 53%. GH-releasing hormone
`50%. and the alpha chain of hCG in
`l% 1294,1649,2094,20951. Other pan(cid:173)
`ieatic hormones are expressed in less
`•an 20% of the tumours, and the gastrin(cid:173)
`lated peptide ghrelin has been found
`cently in one VIPoma 123281 All but
`oe 4 somatostatin receptor subtypes
`we been demonstrated in
`individual
`:Pomas 11681,18151.
`
`:Jectron microscopy
`/hereas the ultrastructure of pancreatic
`:>d neurogenic VIPomas has been char(cid:173)
`. :;terized in numerous publications 11,
`)4,631, 16491,
`including the use of
`1munoelectron microscopy, such tech(cid:173)
`•ques are not essential lor diagnosis.
`
`<~'recursor lesions
`for
`:o precursor lesions are known
`!Pomas. Whereas early reports attrib(cid:173)
`.ted some cases of WDHA syndrome to
`let cell hyperplasia 123131, such asso(cid:173)
`•ation has not been reported
`in
`the
`"cent literature (2094
`
`;·fistogenesis
`the pancreatic
`lle histogenesis of
`IPomas is obscure since, as pointed out
`:bove, no normal or neoplastic islet cells
`:ppear to produce VIP. A somewhat per(cid:173)
`~rexing finding is that, in spite of the exis(cid:173)
`. ?nee of VIP-containing neurons in the
`ormal pancreas, all neurogenic tumours
`•ssociated with VIP-hypersecretion so
`1r !lave been extrapancreatic (12381.
`
`80
`
`60
`
`40
`
`20
`
`0
`
`-20
`
`-40
`
`-60
`
`1p- 3p- 4+ 5+ 6q- 7+ 9p+9q+ 10-11p-11q-12+14q+17+18q-20q+
`
`Fig. 4.30 Analysis of chromosomal alterations of VIPomas, using CGH. Chromosomal gains are shown on
`chromosomes 5, 7 and 17 while losses occur predominantly on lp, llp and llq.
`
`Somatic genetics
`The CGH data on nine examined
`VIPomas exhibited frequent chromoso(cid:173)
`mal gains and losses involving various
`chromosomes in all but one. The chro(cid:173)
`mosomal loci involved were similar to
`those of other malignant pancreatic
`endocrine tumours. However, LOH analy(cid:173)
`sis revealed a higher frequency of corre(cid:173)
`sponding allelic imbalances 12105,2107,
`2490}
`MEN1 mutations have been found in 4 of
`9 examined sporadic VIPomas 195,
`2018) No mutations could be identified
`in the genes VHL, PTEN, SOHD and
`OPC4/382, 1721, 1722}.
`
`Genetic susceptibility
`VIPomas are very rarely associated with
`MEN 1 1949, 1649). No association has
`been described with VHL or NF1.
`
`Prognosis and predictive factors
`As outlined in
`the
`Introduction, most
`VIPomas confined to the pancreas are
`
`classified as well-differentiated endo(cid:173)
`crine tumours with uncertain behaviour .
`Those exhibiting metastatic activity fall
`into the well dillerentiated endocrine car(cid:173)
`cinoma variety. Poorly differentiated,
`small cell (high grade) endocrine carci(cid:173)
`nomas have not been reported in associ(cid:173)
`ation with the VIPoma syndrome.
`After treatment, a meta-analysis study
`reported a 59.6% 5-year survival lor
`patients with metastases and 94.4% for
`patients without metastases 120901.
`Little is known with respect to the prog(cid:173)
`nosis of VIPomas in particular. It is under(cid:173)
`stood that, like most endocrine tumours
`of the pancreas, VIPomas tend to have
`an indolent biological behaviour, even
`when metastatic 118581 The massive
`diarrhoea with ensuing electrolyte imbal(cid:173)
`ance associated with these tumours may
`initially pose a higher threat to
`the
`patient's life than the growth and spread
`of the tumour itself. No histopathologic
`criteria lor prognosis have been devel(cid:173)
`oped so tar.
`
`197
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`Exhibit 1012
`Page 028
`
`

`
`Serotonin-secreting tumour
`
`R.Y. Osamura
`K. Oberg
`E.J.M. Speel
`M. Volante
`A. Perren
`
`Definition
`A serotonin-secreting tumour is a usually
`malignant neoplasm of the pancreas that
`may become functionally active (syn(cid:173)
`dromic) only after metasta