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`NOVARTIS EXHIBIT 2096
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`World Health Organization Classification of Tumours
`
`12::
`.73
`
`e 3
`
`International Agency for Research on Cancer (lARC)
`
`Pathology and Genetics of
`Tumours of Endocrine Organs
`
`Lyon, 2004
`
`Edited by
`
`Ronald A. DeLellis
`
`Ricardo V. Lloyd
`
`Philipp U. Heitz
`
`Charis Eng
`
`lARCPress
`
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`World Health Organization Classification of Tumours
`
`Series Editors
`
`Paul Kleihues‘ MD.
`Leslie H. Sobin, M.D.
`
`Pathology and Genetics of Tumours of Endocrine Organs
`
`69008 Lyon, France
`
`Editors Ronald A DeLeilis, MD.
`Ricardo V, Lloyd. MD,
`Philipp U. Heitz. MD.
`Charis Eng, MD, PhD.
`
`Coordinating Editors Wojciech Biernat, MD.
`Janice Sych, PhD.
`
`Conlrol Number Editorial Assistants
`
`iiiiiiiiiiiiiii
`
`mm
`
`3"“‘W
`
`lsabelle Forcier
`
`xasggmsggigm
`
`Vanessa Meister
`Marlen Grassinger
`Sibylle sonng
`
`Illustrations Thomas Odin
`
`Primed by
`
`Team Rush
`89603 Villeurbanne, France
`
`Publisher
`
`iARCPress
`International Agency for
`Research on Cancer (lARC)
`
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`

`This volume was produced in collaboration with the
`
`International Academy of Pathology (IAP)
`
`in the List of Contributors on page 263
`
`The WHO Classification of Tumours of Endocrine Organs
`presented in this book reflects the views of a Working Group that
`convened for an Editorial and Consensus Conference in Lyon, France,
`April 23—26, 2003
`
`Members of the Working Group are indicated
`
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`

`

`Published by lARC Press. International Agency for Research on Cancer.
`150 cours Albert Thomas. F-69008 Lyon. France
`
`© international Agency for Research on Cancer. 2004
`
`Publications of the World Health Organization enjoy copyright protection in
`accordance with the provisions of Protocol 2 of the Universal Copyright Convention.
`‘
`All rights reserved.
`
`The International Agency for Research on Cancer welcomes
`requests for permission to reproduce or translate its publications. in part or in iuiir
`Requests for permission to reproduce figures or charts from this publication should be directed to
`the respective contributor (see section Source of Charts and Photographs).
`
`The designatiOns used and the presentation of the material in this publication do not imply the
`expression of any opinion whatsoever on the part of the Secretariat of the
`World Health Organization concerning the legal status of any country. territory. city.
`or area or of its authorities. or concerning the delimitation of its frontiers or boundaries.
`
`The mention of specific companies or of certain manufacturers‘ products does not imply'
`that they are endorsed or recommended by the World Health Organization in‘ preference to others
`of a similar nature that are not mentioned. Errors and omissions excepted.
`the names of proprietary products are distinguished by initial capital letters.
`
`The authors alone are responsible for the views expressed in this publication.
`
`Enquiries should be addressed to the
`Communications Unit. international Agency for Research on Cancer. 69008 Lyon. France.
`which will provide the latest information on any changes made to the text and plans for new editions.
`
`iSBN 92 832 2416 7 (NLM Classification: WJ TBO)
`
`1. Pituitary gland neoplasms ~ genetics 2. Pituitary gland neoplasms - pathology
`3. Thyroid neoplasms - genetics 4. Thyroid neoplasms. - pathology
`5. Endocrine pancreas neoplasms — genetics 6. Endocrine pancreas neoplasms - pathology
`* 7. Adrenal neoplasms — genetics 8. Adrenal neoplasms - pathology
`1. DeLellis Ronald A.
`II. Series
`
`Format for bibliographic citations:
`DeLeiiis RA. Lloyd R.V.. Heitz P.U.. Eng C. (Eds): World Health Organization
`Classification of Tumours. Pathology and Genetics of Tumours of Endocrine Organs.
`IARC Press: Lyon 2004
`
`mm: Library Cataloguing in Publication Data
`
`Pathology and genetics of tumours of endocrine organs /
`editors RA. DeLellis... [et ai.]
`
`(World Health Organization classification of tumours ‘. 8)
`
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`

`.
`
`‘
`
`.
`
`1
`
`.r
`
`_
`
`.
`
`_I
`
`1
`
`5.x
`
`.
`
`'
`_
`
`Thmours of the Endocrine Pancreas
`
`
`
`,.1
`rm .«1'
`H"
`
`a:
`
`_
`
`_
`-,
`
`I
`
`'
`
`_
`
`"
`
`Tumours of the endocrine pancreas are much less frequent
`than those of the exocrine pancreas and usually have a much
`better prognosis. Hormonesv'secreted by endocrine neoplasms
`include insulin, glucagonf‘ somatostatin. gastrin, vasoactive
`> intestinal polypeptide (VlP), pancreatic polypeptide (PP). sero-
`tonin, ACTH;»and calcitonin. Depending on the peptide hor-
`" . mones produced. they mayicausetdistinct clinical syndromes.
`including liie«threatening' hypoglyoaernla. gastric and/or duct;
`denal ulcers. or dehydration due to diarrhoea,
`'
`- Most pancreatic"neuroendocrine tumours can be surgically
`resected and'this leads to a rapid regression oi clinical’ symp-
`toms, Poorly differentiated neoplasms may be metastatic at the
`time of clinical presentation, and this is associated-with a poor
`prognosis.
`W
`Genetic susceptibility may play an important role. Up to 20% oi
`gastrinomas are associated with the inherited MEN-1 syn-
`drome?
`,
`V'
`
`.9,I“_‘g,“.4flaky,"
`
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`Well»diflerentialed endocrine carcinoma
`Functioning
`
`Insulin'produclng (insulinoma)
`Glucagon-p-roducing‘(glucagonomn)
`Somalosmln-Pwducmg 15001310518000”)
`Gastrin-pFOdUCinQ 193317100013)
`VlP—producing (VIPoma)
`Serotonin producing with carcinuid syndrome
`ACTH producing with Cushing syndrome
`
`N0n~functioning
`
`Poorly-dilleremiaterl endocrine carcinoma —
`small cell carcinoma
`
`Mixed exocrine — endocrine carcinoma
`
`8150/3
`
`8151/3
`8152/3
`3155/3
`3153/3
`8155/3
`8241/3
`8150/3
`
`8150/3
`
`0041/3
`
`8154/3
`
`I Morphology coda oi
`
`the Inlernational Clasmlication of Diseases lor Unnnlugv (ICU-CI)
`
`(664) and the Systemalized Numenclalure 01 Medicine lnnpihsnomedorgl.
`
`WHO histological classification of tumours of the
`
`endocrine pancreas
`
`8150/11
`
`3151/1
`3152/1
`8156/1
`8153/1
`8155/1
`
`8150/0
`
`Non—functioning
`Microadenoma (<05 cm)
`Others
`
`Well~diflerenlialed endocrine tumour
`Functioning
`insulin-producing (insulinomal
`6|ucagon.pmduc.ng [giucagonoma)
`Somatostatin‘producing lsomatustatinoma)
`Gastrin-prodncing (gastrinoma)
`V|P~prodncing lVIPoma)
`Others
`
`Behaviour is coded /0 lor benign tumours, [3 lor malignanttumours, and /l for borderline or uncertain behaviour,
`
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`Ensulinoma
`
`P. Komminoth
`
`A. Eerren
`K. Oberg
`
`G. Hindi
`Ph.U. Heitz
`G. Kipppel
`
`definition
`insulinoma is a functionally active and
`zinmonly benign endocrine tumour of
`a). panCreas with evidence of B-cell dif-
`lentialion and clinical symptoms of
`.xpoglycaemia due to inappropriate
`acretion of insulin
`
`iCD-O code
`.,-:.ulin producing tumour
`
`8151/1
`“sulin producing carcinoma
`8151/3
`
`Synonyms
`elated. but not universally applicable
`.irms for these tumours include “func-
`ainlng beta-cell
`tumour".
`"insulin pro—
`-iucing pancreatic endocrine tumour“ or
`nsulin producing islet cell tumour".
`Eymptoms of hypoglycaemia due to
`appropriate secretion of
`insulin were
`irst described by Harris in 1924 |836j
`‘ilid
`three years later
`the association
`between insulin secreting pancreatic
`-:ndocrine tumours and hypoglycaemia
`.ras reported by Wilder er al {2386].
`
`Epidemiology
`insulinomas are the most frequent of all
`aunctioning
`pancreatic
`endocrine
`tumours
`(see Pancreatic
`endocrine
`tumours) |1154j1874j The incidence of
`-nsulinoma was reported to be 2-4
`patients per million population per year
`il207,2012j.
`Insulinomas have been
`diagnosed in all age groups but rarely
`occur below the age of 15. The highest
`
`Fig. 4.10 Abdominal CT of a patient with a small
`insulinoma larrowl.
`
`categories: neurological symptoms and
`the autonomic nervous system response.
`The most Common and convincing
`symptoms result from neuroglucopenia,
`followed by the catecholamine response.
`Most prominent are symptoms of central
`nervous system dyslunction including
`dlplopia,
`blurred
`vision,
`contusion,
`abnormal behaviour and amnesia. Some
`patients may develop loss of conscious
`ness and coma or even permanent brain
`damage. Sometimes the patients also
`present with focal seizures. When trig—
`gered by hypoglycaemia the release of
`calecholamines
`produce
`symptoms
`such as sweating, weakness, hunger.
`tremor, nausea, anxiety and palpitation.
`These symptoms, although highly sug~
`gestive, are not pathognomonic for hypo»
`glyoaemia and a low blood glucose level
`must be demonstrated during their
`occurrence. The Whipple triad includes:
`(1) symptoms of hypoglycaemia.
`(2)
`
`183
`
`incidence is lound between 40-60 years.
`Approximately 10% oi
`the patients are
`younger than 20 years and 10% older
`than 60 [603.714.2011.2120j. Females
`seem to be slightly more frequently
`affected (1.5:1 ratio)
`in most reported
`series
`[682.714.729.12552011,2012.
`2295].
`
`Etiology
`The etiology and pathogenesis of insuli-
`nomas are unknown. No risk factors have
`been associated with these tumours.
`Embryologlcally. pancreatic
`tumours
`arise from similar precursor cells as pan-
`creatic islet cells which are derived from
`the endoderm [1253}. The results of a
`recent clonality study on pancreatic
`endocrine tumours are consistent with
`the hypothesis that these tumours prima‘
`rily might be polyclonal or oligocl'onal
`neoplasms which are eventually out-
`grown by a more aggressive cell clone
`that may give rise to invasive growth
`and/or metastasis [1724].
`
`Localization
`The majority of insulinomas are located in
`the pancreas or are directly attached to
`it. Ectopic (extrapancreatic) insulinomas
`with symptoms 01 hypoglycaemia are
`extremely rare (1.8%) and are most com-
`monly lound in
`the duodenal wall
`[627,2120l. Other
`reported locations
`include the ileum, jejunum, gastric wall,
`hilus oi
`the spleen, gastrosplenic liga-
`ment.
`lung. cervix and ovary [11.1075,
`1124.1714.2017.2036.2458j.
`Compiled data indicate that insulinomas
`are equally distributed between the
`head. body and tail of the pancreas with
`a slight predominance in the head and
`tail
`region
`[516.827.925.154221201.
`Approximately 85% of insulinomas ‘occur
`singly. 613% are multiple and 46% are
`associated with MENl {516,682,714,
`72912552011.2120.2295l.
`
`Clinical features
`Signs and symptoms
`Patients with insulinoma manifest symp-
`toms that can be grouped into two major
`
`Fig. 4.11 Octreoscan of a patient with an endocrine
`tumour of the ileum. Note paraaortal metastases
`(arrows) and iniraclavicular lymph node metas-
`tases (arrowhead). The latter were confirmed by
`cytology.
`
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`

`cells and proinsulin in the perinuclera
`
`Histopathology
`lnsulinomas exhibit four main histologica:
`patterns including a solid.
`trabeculas
`gland-like (tubular or acinar)
`tumOU'
`growth and mixed forms (858.1154;
`Larger tumours are encapsulated but tht
`capsule is usually incomplete. Smalle-
`tumours
`and microadenomas
`(set
`Nonfunctionlng tumours. microadenc-
`mas, others) are rarely encapsulated
`Tumour cells frequently exhibit a blantv
`cytology and cells with large. pleomor
`phic nuclei are rare. If present, these tee:
`tures are not predictive ol malignar
`behaviour. A relatively uncommon. bi.z
`characteristic finding in insulinomas t
`the deposition of amyloid. Its major con'
`ponenl
`is
`islet amyloid polypeptid:
`(lAPP) or amylin. that can be Visualizer
`by immunohistochemistry (2388}. Calc
`fications and inlracytoplasmatic pigmer;
`may rarely be seen in
`insulinoma:
`{957.2405}.
`
`"
`
`: “vi-‘75
`I.
`--~v, ~.,.~.
`W”. "(‘3'
`, 1;.
`-u
`
`" H
`
`lmmunohistochemistry
`Almost all insulinomas exhibit immunore
`activity lor
`insulin and proinsulin, The
`intensity and extent of this immunoreac
`tivity. however. does not correlate will
`circulating insulin levels. Strong positivit~
`for
`insulin at the secretory pole of
`in.
`
`184
`
`cystic changes are uncommon and most
`often restricted to large tumours.
`Insulinomas producing a hypoglycaemit-
`syndrome in MENi patients are usually
`larger than 1 cm, Microadenomas.
`'ie.
`tumours below 0.5 cm in diameter. with
`insulin expression. no matter how numer
`ous they are, seem to remain functionally
`silent [1114]. This implies that the insuli-
`nomas in MENi patients are among the
`grossly apparent and palpable pancreat-
`ic tumours.
`if
`there are several
`large
`tumours usually only one of them is an
`inaulinoma.
`
`Tumour spread and staging
`Malignant insulinomas may show gross
`local invasion of peripancreatic fatty tis-
`sue and/or adjacent organs such as the
`duodenum or the spleen. The first metas
`tases are usually found in regional lympl.
`nodes (peripancreatic, coeliac. perlaor»
`tic) and the liver. Spread to other distant
`sites is unusual. So far there is no staging
`system that specifically applies to insuli-
`nomas
`(see
`Pancreatic
`endocrine.
`tumours).
`
`Fig. 4.12 A Insulinoma. The tumour is small. sharply demarcated. B Malignant insulinoma invading the
`spleen. Numerous small liver metastases are present.
`
`from factitlous hyperinsulinaemia, In gen-
`eral. 80-85% of all insulinomas are diag—
`nosed
`by
`thesa measurements.
`Inappropriately high plasma insulin lev-
`els. during 48-72 hour lasting.
`is also
`regarded as a sensitive diagnostic test,
`Alternatively. C-peplide suppression is
`also a valuable screening or confirmato—
`ry test for insulinoma.
`
`Macroscopy
`Grossly.
`insulinomas are wall—circum-
`scribed tumours. softer
`than the sur—
`rounding pancreatic parenchyma and
`have. a red«brown cut surface. Tumours
`with abundant stroma or amyloid are
`firmer. insulinomas are trequently discov—
`ered while still small with 75% of
`the
`tumours measuring 0.5-2 cm in diameter
`and less than2 g in weight, The reported
`diameter ranges from O 541 cm {1154}.
`Tumour size is unrelated to severity of
`symptoms. Degenerative. necrotic and
`
`.
`_
`-: was“.
`I
`-
`'
`'
`f v it“!«My—3‘.
`Exam-u r» ~.,-_
`".t «L We"!
`.5: to ‘
`
`I1
`
`plasma glucose levels <3.0 mmol per
`hire; and (3)
`relief of symptoms with
`administration of glucose [16202010.
`2l20, 2497].
`
`Imaging
`Transabdominal ultrasonography yields
`a sensitivity of 20~65% in various series.
`CT scan 25-60%. angiography 35-75%.
`and lntraoperative ultrasonography 90-
`lOO%. More specific methods include
`octreoscan and PET~scan
`
`Diagnostic procedures
`Determination of plasma insulin and
`proinsulln concentrations by radioim-
`munoassay has greatly facilitated and
`simplified the diagnosis of
`insulinoma.
`Usually insulin. proinsulin, C-peptide and
`blood glucose are measured together to
`demonstrate an inappropriately high
`secretion of
`insulin in relation to blood
`glucose and to distinguish endogenous
`
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`-.
`
`.
`
`.,
`
`185
`
`".
`2’
`-
`~
`.
`as?”
`L’
`'.-‘u~.w:s
`-
`.
`' a-
`Fig. 4.14 A lnsulinoma with trabeculer architecture. 8 Insulinoma. Strains-containing amyloid. c Amyloid Visualized by Congo red staining. D lnsulinoma, highly
`iifferentiated, trabecular architecture. Proinsulin localized to the paranuclear Golgi area. Antibody specific for proinsuiin. E Insulin predominantly localized at a
`cemetery pole of the tumour cells. F lnsulinoma with a trabecuiar growth pattern. Localization of insulin at the secretory pole of the tumour cells and partly within
`he cytOplasm. Antibody to insulin. 6 mHNA for insulin visualized by in-situ hybridization. H Proinsuiin is partly located in the paranuclear Golgi area but also in the
`cytoplasm and at the secretory pole of the tumour cells Proinsulin is secreted together with insulin in these tumours. Antibody specific for proinsulin.
`l Insulin is
`'zicalized within the entire cytoplasm and at the secretory pole of the cells.
`
`- :gion, is. the Golgi region can be seen
`.1 some highly differentiated insulinomas.
`-.lore often. however. an abnormal stain-
`lg pattern for insulin and proinsulin is
`riund [1871,1872]. About 50% of insuli-
`iomas
`are multihormonal.
`In
`such
`"Irnours
`insulin
`positive
`cells
`are
`admixed with cells expressing glucagcn.
`:omatostatin, pancreatic polypeptide or
`other hormones [1154}.
`
`immunohistochemical
`iseful additional
`‘narkers for the classification of insulino~
`I'ias are MlB-t
`(to assess proliferation
`'idex), CD31 (to visualize angioinvasion)
`ind somatostatin receptor subtypes
`1681].
`in cases with non-detectable
`.tsulin by immunohislochemistry in-situ
`‘ybridizalion may be helpful
`to identify
`.isulin mFtNA in tissue sections {2106}.
`
`Electron microscopy
`There are several classifications of insuli-
`nomas based on the ultrastructrural
`shape of their secretory granules 1174,
`429.430.2164}. However.
`as
`it has
`become more and more obvious that
`insulinomas are extremely heteroge-
`neous. containing poorly and well-granu-
`lated cells in the same tumour. the use of
`these classifications is limited. in a more
`recent study it was demonstrated that the
`pathophysiology of
`insulinomas is less
`likely caused by decreased storage
`capacity for insulin, as proposed earlier,
`than by impaired conversion of proinsulin
`to insulin [1873}.
`
`Precursor lesions
`No definite precursor lesion has been
`identified for insulinoma. Proliferation of B
`
`cells ([5 cell hyperplasla. nesidioblasto-
`sis),
`in patients with persistent hyperin-
`sulinaemic hypoglyoaemia cannot be
`considered a precursor lesion of insuli-
`noma because it is genetically different
`(2006i.
`
`v
`Histogenesis
`The histogenesis of insulinoma is uncer-
`tain {1835). Ductai proliferation may
`sometimes be associated with insulino-
`may, suggesting a potential duct cell ori—
`gin. Alternatively. an islet origin of B cell
`tumours is suggested by histology in
`MENt patients [2094] and is supported
`by observations that
`transgenic mice
`consistently developed islet B-cell hyper-
`plasia, dysplasia and insulihomas. in the
`absence of ductuloinsular proliferation
`[815.1834,1835,1837}.
`
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`

`emogfl
`
`a J, ’3’
`
`“ole "
`
`r
`
`’lp— 3p- 4+ 5+ 6q— 7+ 9p+9q+10-11p-11q—12+14q+17+18q-20q+
`
`Fig. 4.15 Summary of the results obtained by CGH analysis of insulinomas. Gains of chromosomal material
`mainly occur on chromosomes 5, 7, 9o, 14:] and 2th while losses are shown on ip, liq, 11 p and liq,
`
`Fig. 4.16 insulinoma. The proliferative index is less
`than 2 "/u. Antibody K'I-67,
`
`identified.
`
`Somatic genetics
`Compiled data from 43 analysed tumours
`indicate that as compared to other pan-
`creatic endocrine tumours.
`insulinomas
`exhibit fewer genomic alterations by CGH
`(see Pancreatic endocrine tumours)
`{2105,210712154. 2490].
`in particular,
`losses of 3p and other malignancy-asso-
`ciated alterations are rare. Losses of so
`and gains of 15q appear to be more tre—
`quently encountered in insulinomas than
`in the other pancreatic endocrine tumour
`types Gains of 9q34 and losses of 1p36
`and 11q appear to be early alterations
`already detectable in tumours smaller
`than 2 cm.
`Despite allelic losses of up to 40% at
`11q13 (the locus of MEN1). somatic
`mutations ol the MEN1 gene appear to
`be rare when compared to the other
`endocrine tumour types. They were iden-
`titled in only 7.7% (5/65) of sporadic
`insulinomas [750,879,153020182105,
`2350,2495l Somatic mutations in other
`genes such as Wit and CDKNZA/p 76
`are only occasionally encountered (1/22
`and 1/9) {1530.1531l.
`
`mas {113311901291}. Risk factors
`insulinomas that are not overtly malig»
`nant include: diameter larger than 2 on:
`high mitotic/MlBt
`index and necros:
`l899lJMalignant
`insulinomas contain a
`higher number of genetic alterations Thiil
`benign tumours
`:21062107], Furthe"
`more,
`it has been shown that losses t,
`chromosomes 3pq and so as well
`2‘.-
`gains of
`i7pq and 20q are associates
`with malignant behaviour {2107]. Th
`involved genes. however. remain to t:
`
`from MEN 1 {2012} Between 10 and 30%
`of the pancreatic endocrine tumours in
`MEN1 patients are associated with
`symptoms of hypoglycaemia due to
`inappropriate insulin secretion 1757.
`1154.1989]. Between 12 and 17% of VHL
`patients develop pancreatic endocrine
`tumours which may show focal
`insulin
`immunoreactivity {1857}. However. most
`of these tumours are clinically non-func-
`troning.
`
`Prognosis and predictive factors
`In contrast to the other types of pancre»
`atic endocrine tumours, the vast majority
`of insulinomas are benign at the time of
`diagnosis [2094]. This may be due in
`part
`to their early detection as they
`already become symptomatic when still
`small {1113,2092}. The percentage of
`malignant
`insulinoma ranges from 2.4-
`179 % with an average of 8.4 % [682.
`714,729,125520112092212022951.
`Malignant insulinomas occur in an older
`age group and are rare in children
`[426.2152l.
`it appears that males are
`more frequently aftected than lemales
`i449i,
`lnsulinomas of less than 2 cm in diame-
`ter without signs of angiolnvasion, gross
`invasion or metastases and showing a
`mitotic rate of <2 mitoses per 10 HPF or
`<2% Ki—67 (or MlBri) staining index are
`considered benign (macroadenomas)
`[2097] There are no immunohislochenii—
`cal markers available which reliably pre—
`dict the biological behaviour of insulino-
`
`Genetic susceptibility
`insulinoma is the second most frequent
`functioning enteropanoreatic tumour
`in
`MEN1 patients after gastrinoma. the lat-
`ter often arising in the duodenum 11250}.
`Rare examples ol insulinomas have also
`been described in patients suffering from
`NF1 l672l. Approximately 4 7% of unse»
`locted patients With insulinomas sutier
`
`186
`
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`

`Glucagonoma
`
`G. Ktoppel
`P. Komminoth
`A. Perren
`
`K. Cberg
`X. Matias—Gum
`PhU. Heitz
`
`Definition
`‘1. glucagonoma is a tunctionally active
`tnd~usually malignant endocrine tumour
`.l the pancreas with evidence of A-cell
`:iiterentiation and clinical symptoms of
`v-ie glucagonoma syndrome. due to
`appropriate secretion of glucagon, and
`noiuding a skin rash (necrolytic migrato<
`/ erythema). stomatitis, mild diabetes
`-re|lilus and weight loss.
`"ancreatic endocrine tumours with A-cell
`:itferentiation but without a glucagono-
`ta syndrome should not be considered
`:lucagonomas. but non-functioning pan—
`reatic endocrine tumours.
`
`tCD—O code
`ilucagon producing tumour
`8152/1
`iiucagon productng carcinoma
`8152/3
`
`Epidemiology
`‘F-lucagonomas represent about 5% of all
`:tinically relevant pancreatic endocrine
`tumours and 843% of
`functioning
`:imours
`(see Pancreatic
`endocrine
`Himours) {2094]. The estimated inci-
`dence of the gtucagonoma syndrome is
`1 per 20 million per year [1771}. Patients
`most often present between the ages oi
`10-70 years (range 1972 years) and
`women are slightly more otten attected
`I 1885}.
`
`Etiology
`Jilucagonomas are occasionally part oi
`t-.-tEN1 [21122355],
`
`187
`
`Clinical teatures
`Signs and symptoms
`syndrome was
`The
`giucagonoma
`in 1974 [1397: but
`described in detail
`had already been observed in 1960
`l752i, The glucagonoma syndrome is
`thought to reflect the catabolic action oi
`excessively elevated glucagon levels
`[883.1397.1771l.
`The most common presenting teature of
`the glucagonoma syndrome is necro/yt/c
`migratory eryrhema found in about 70%
`of all patients. The rash usually starts in
`the groins
`and the perineum and
`migrates to the distal extremities The
`syndrome also includes mild glucose
`intolerance. normochromic normocytic
`anaemia. weight loss. depression. diar-
`rhoea and a tendency to develop deep
`vein thrOmbosis, The skin rash may be
`associated with angular stomatitis. cheili—
`tis. atrophic glossitis. alopecia, onycholy-
`sis. vulvovaginitis and urethritis. The
`cause of
`the rash is still unknown. A
`direct effect of glucagon on the skin,
`prostaglandin release, deficiency of
`amino acids. free fatty acids or zinc have
`been proposed as the underlying mech
`anisms. Marked weight
`loss occurs in
`around 65% at all patients and diabetes
`mellitus is seen in about 50% of
`all
`cases. Normochromic and normocytic
`anaemia occurs in about 1/3 of patients
`and is probably due to direct bone mar—
`row suppression by glucagon or to the
`deficiency of amino acids. Diarrhoea
`occurs In 1/5 of the cases as do psychi-
`atric disturbances. A tendency to venous
`thrombosis is
`increased, occurring in
`around 10-15% of all patients and may
`be life—threatening [53. 201.11852111}.
`
`Localization
`Glucagonomas commonly occur in the
`tail of the pancreas or attached to the
`pancreas {1885}. Extrapancreatic gluca-
`genomes are extremely rare [1852}.
`
`These tumours are usually large at diag—
`nosis unless they occur in patients with
`MEN 1. Somatostatin receptor scintigra~
`phy (octreoscan) is the most sensitive
`localization procedure and also an
`important method for staging of the dis»
`ease. Small tumours may be detected by
`endoscopic ultrasonography.
`
`Diagnostic procedures
`The diagnosis of glucagonoma is made
`on the basis of raised fasting plasma
`glucagon concentration together with
`demonstrable tumour and characteristic
`clinical
`features
`Fasting
`plasma
`glucagon concentration is usually elevat-
`ed 10 to 20 told; however.
`in some
`patients it may be only marginally so.
`Totbutamide or arginine stimulation tests
`may be used to confirm the diagnosis.
`Approximater
`1/5
`of glucagonoma
`patients also have raised tasting plasma
`gastrin concentration.
`
`Macroscopy
`large,
`Most gluca‘gonomas are rather
`solitary pancreatic tumours reaching up
`to 3.5 cm in greatest diameter. The mean
`diameter
`is
`approximately
`7
`cm
`{1885.2094l. The colour of the out sur-
`face is brown«red to pink. and the con-
`sistency is usually sott. Because of their
`large size. degenerative changes, such
`as haemorrhage. necrosis and cystic
`change are frequently seen in these
`tumours.
`
`"i9. 4.17 Glucagonoma syndrome: necrulytic migra-
`tory erythema. From E. Ruttman et al. {1885).
`
`Imaging
`Imaging procedures include helical CT,
`ultrasonography. MRI and somatostatin
`receptor scintigraphy and PET—scan.
`
`Fig. 4.18 Glucagonoma within the head oi the pan—
`creas. The tumour is sharply demarcated.
`
`NOVARTIS EXHIBIT 2096
`Par v. Novartis, IPR 2016-01479
`Page 12 of 33
`
`

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`‘_
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`'7
`‘
`9'
`‘
`;
`.’ W/g
`'
`‘\
`-
`"Lu.
`1;“ ‘
`«£69: v2
`Fig. 4.19 A Glucagonoma with a trabecular architecture, 8 Glucagonoma. intense glucagun production by tumour cells.
`
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`mosomes 4,5,73,12,14,” and 20 while losses occur at 1p. 3p, 6c, 10, Hp & q.
`
`Prognosis and predictive factors
`Approximately 60-70% of glucagonoma
`are already metastatic at
`the time tn
`diagnosis l883.177i.1885}. Even am;
`glucagonomae are considered lumou‘
`of uncertain behaviour or well—differen‘
`ated
`endocrine
`carcinomas
`(SE
`Pancreatic endocrine tumours). Thee.
`tumours tend to grow slowly and patient
`may survive for many years.
`Occasionally.
`in multihormonal tumour.-
`the glucagonoma syndrome may i
`associated with. or followed by. anoth'
`syndrome. such as a hypoglycaem
`syndrome or VlPoma syndrome l33
`1640,2447}.
`
`,
`
`in
`
`k
`
`.
`
`Tumour spread and staging
`As in other endocrine tumours of the pan—
`creas. glucagonomas spread by local
`invasion into surrounding tissues and
`metastasize to the regional lymph nodes
`and the liver. So far there is no staging
`system that
`specifically applies
`to
`glucagonomas (see Pancreatic endo-
`Crine tumours).
`
`Histopathology
`The histological features of glucagono-
`mas do not differ
`fundamentally from
`those of other pancreatic endocrine
`tumours l230.1885.2094l. They do. how-
`ever. show a predominance of a mixed
`trabecuiar-soiid patterns. The tumour
`cells show faintly granular, often abun—
`dant cytoplasm.
`
`Immunohistochemistry
`Glucagonomas often stain weakly for
`glucagon. but also show reactivity for
`peptides derived from proglucagon (gly-
`centin. glucagonvlike peptides 1 and 2)
`[230.806.1885].
`in addition. numerous
`PP immunoreactive cells can often be
`identified. Mitoses are noted infrequently.
`
`Electron microsoopy
`Electron microscopically. glucagonomas
`Show atypical secretory granules {230,
`2355].
`
`Somatic genetics
`CGH reveals
`frequent chromosomal
`gains and losses involving different chro—
`mosomes. Only a small number of
`tumours (12) have been investigated.
`however, and the results may not be rep-
`resentative. The
`chromosomal
`loci
`involved are similar to those involved in
`non—functioning tumours. and gains of
`chromosome 7 are present in up to 80%
`
`188
`
`production seems to be uncommon i
`. pancreatic tum0urs occurring in patienzy
`with von Hippel—Lindau disease {1357},
`
`of cases l2105,2tO7.2154,2490l4 Using
`LOH analysis
`corresponding allelic
`imbalances
`have
`been
`described.
`though with higher frequencies of losses
`at 1p36. 3p25~26, 6q22. qu23 and
`ttq13l120.750.879l.
`Somatic MEN1 mutations were reported
`in 2 of 3 investigated tumours. No muta—
`tions could be identified in the genes
`VHL, PTEN, SDHD and DPC4 {3821721.
`1722].
`
`Genetic susceptibility
`Glucagon-immunoreactive tumours may
`occur in the setting of MENt {1114,1250
`1941],
`In a series of
`tOO pancreatic
`tumours in 28 patients with MEN1,37 dis—
`played glucagon immunoreactivity. and
`one
`patient
`presented with
`the
`glucagonoma
`syndrome
`{1250}.
`in
`MENl, these tumours tend to be multiple
`(59%) and benign (75%)
`[2089}. A
`glucagon-immunoreactive tumour was
`associated with familial adenomatous
`polyposls l2131l.
`in contrast. glucagon
`
`80
`
`60
`
`40
`
`mm
`
`ii
`
`7+ 9p+ 9q+ 10- 11p-11q~12+14q+17+18q-20q+
`4+ 5+ 6q-
`1p- 3p-
`Fig. 4.20 Analysis of genetic alterations of glucagonomas by CGH. Chromosomal gains are frequent on chr't
`
`NOVARTIS EXHIBIT 2096
`Par v. Novartis, IPR 2016-01479
`Page 13 of 33
`
`

`

`Somatostatinoma
`
`Definition
`.A
`somatostatlnoma is a functionally
`rive and usually malignant endocrine
`t .mour with evidence of D—cell differenti-
`_t;on and clinical symptoms reflecting
`we diverse pathophysiologic effects of
`mronic
`inappropriate
`secretion
`of
`.-
`t .matostatin (hypersomatostatinemla:
`2matostatinoma syndrome). Extrapan-
`'zeath endocrine tumours such as those
`t
`~z the duodenum, lung, thyroid and para-
`..tnglra composed either exclusively or
`arredominantly of somatostatin immuno-
`. tacticve cells, but unassociated with the
`tlmatostatinoma
`syndrome
`should
`:erefore be more appropriately desig—
`nated
`as
`somatostatln
`producing
`endocrine tumours (or D-cell tumours).
`
`iCD-O code
`:7omatostatlnoma producing tumour
`8156/1
`Aomatostatinoma producing carcinoma
`8156/3
`
`Historical annotation
`:5somatostatinomas were independently
`described by Ganda et al. {687] and
`Larsson et a1. [1236}.
`
`Epidemiology
`Somatostatlnomas account for between
`i
`to 2% of endocrine tumours of the gas-
`troenteropancreaticohepatic
`(GEPH)
`axis. Duodenal somalostatln producing
`tumours appear to be as common as
`their pancreatic counterparts. Unlike
`other gastrointestinal and pancreatic
`endocrine tumours that may occur at any
`age. somatostatinomas generally arise in
`adults 25-85 years of age. The vast
`majority occur between the fourth and
`sixth decades and are twice as common
`in females as in males {464.2323}.
`
`Etiology
`While some somatostatlnomas are asso—
`ciated with NFi, MENl and Von Hippel-
`Lindau syndromes.
`the etiology of their
`sporadic counterparts is unclear. similar
`to that of endocrine tumours of the GEPH
`axrs.
`
`Clinical features
`Signs and symptoms
`The subtle and nonspecific somatosta‘tin-
`oma syndrome consists of markedly ele-
`vated somatostatin concentrations in
`plasma and/or tumour, diabetes mellitus
`of
`recent onset. hypochlorhydria. gall-
`bladder disease (cholelithlasis, suppres-
`sion of gallbladder motility), diarrhoea,
`steatorrhoea. anaemia and weight
`loss
`[1164]. Although each of
`these syn~
`drornic components can be due to the
`inhibitory effects of somatostatin on the
`secretory activity of various endocrine
`and exocrine cell types and the suppres-
`sion of gallbladder motility, the very exis-
`tence of the somato’statinoma syndrome
`has been questioned on the ground that
`these features are non—specific and very
`common in the older age group in which
`these tumours most often arise.
`
`189
`
`Localization
`Although somalostatinomas may arise
`anywhere within the pancreas, they are
`most commonly located in the head.
`
`Y, Dayal
`K. Oberg
`A. Perren
`P. Komminoth
`
`Imaging
`Uttrasonography is the most sensitive
`method to demonstrate somatostatlnd
`mas of
`the pancreas and duodenum.
`Extrapancreatic and metastatic lesions
`can be detected by ultrasonography, CT
`scan. and MRI. Somatostatin receptor
`scintigraphy and PET-scan have proven
`to be the most sensitive methods to
`demonstrate extrapancreatic and extra-
`duodenal somatostatlnomas.
`
`Diagnostic procedure
`The diagnosis is. confirmed by documen-
`tation of elevated plasma concentrations
`of somatostatin and the presence of the
`somatostatinoma syndrome.
`
`Macroscopy
`irrespective of whether they are pure or
`mixed, somatostatinomas Usually occur
`as solitary, well~circumscribed. but not
`encapsulated. soft. grey-white to yellow-
`tan tumours l2091l,
`that are generally
`large (average diameter 5-6 cm) by the
`time t