Insulinoma staging

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

The staging had been done according to American Joint Cancer Committee (AJCC) 7th edition 2010. Being a pancreatic neuroendocrine tumor, it is also staged by European Neuroendocrine Tumor Society (ENETS). In its new 8th edition of AJCC which is planned to be published on January 1, 2018; AJCC had developed a modified ENETS (mENETS) staging classification.

Staging

American Joint Cancer Committee (AJCC) 7th edition 2010 classification

The staging of malignant insulinoma being a pancreatic neuroendocrine tumor may be classified into several sub types based on American Joint Cancer Committee (AJCC) 7th edition 2010: ^[1]^[2]

Stage	T	N	M
IA	T1	N0	M0
IB	T2	N0	M0
IIA	T3	N0	M0
IIB	T1-3	N1	M0
III	T4	Any N	M0
IV	Any T	Any N	M1

AJCC 2010
T	T1	<2 cm in greatest dimension
	T2	>2 cm in greatest dimension
	T3	Beyond the pancreas but without involvement of the superior mesenteric artery
	T4	Involvement of the celiac axis or superior mesenteric artery (unresectable tumor)
N	N0	No regional lymph node metastasis
N	N1	Regional lymph node metastasis
M	M0	No distant metastasis
M	M1	Distant metastasis

European Neuroendocrine Tumor Society (ENETS) classification:

Being a pancreatic neuroendocrine tumor, it is also staged by European Neuroendocrine Tumor Society (ENETS) as: ^[1]^[2]

Stage	T	N	M
I	T1	N0	M0
IIA	T2	N0	M0
IIB	T3	N0	M0
IIIA	T4	N0	M0
III B	Any T	N1	M0
IV	Any T	Any N	M1

ENETS
T	T1	Tumor limited to pancreas, <2 cm
	T2	Tumor limited to pancreas, 2-4 cm
	T3	>4cm, or invading the duodenum or common bile duct
	T4	Tumor invades adjacent structures
N	N0	No regional lymph node metastasis
N	N1	Regional lymph node metastasis
M	M0	No distant metastasis
M	M1	Distant metastasis

WHO 2010 classification system

WHO classification system combined differentiation and grading characteristics to classify the belligerence of a pancreatic neuroendocrine tumor.
The aggressiveness of tumor was expressed in form of mitotic count and staining of a nuclear antigen called Ki-67: ^[3]^[4]

Grade of tumor	Mitotic Count(Mitoses per 10 high powerfields)	Expression of Ki 67
Grade 1	<2	≤3%
Grade 2	2-10	3-20%
Grade 3	>20	>20%

Grade 1 and 2 tumors were classified as neuroendocrine neoplasm (NET) and grade 3 were classified as neuroendocrine carcinoma (NEC).

In its new 8th edition of AJCC which is planned to be published on January 1, 2018; AJCC had developed a modified ENETS (mENETS) staging classification:^[1]

Stage	T	N	M
IA	T1	N0	M0
IB	T2	N0	M0
IIA	T3	N0	M0
IIB	T1-3	N1	M0
III	T4	Any N	M0
IV	Any T	Any N	M1

mENETS
T	T1	Tumor limited to pancreas, <2 cm
	T2	Tumor limited to pancreas, 2-4 cm
	T3	>4cm, or invading the duodenum or common bile duct
	T4	Tumor invades adjacent structures
N	N0	No regional lymph node metastasis
N	N1	Regional lymph node metastasis
M	M0	No distant metastasis
M	M1	Distant metastasis

References

↑ ^1.0 ^1.1 ^1.2 Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C; et al. (2017). “Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems”. J Clin Oncol. 35 (3): 274–280. doi:10.1200/JCO.2016.67.8193. PMID 27646952.
↑ ^2.0 ^2.1 Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW; et al. (2015). “TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution”. Medicine (Baltimore). 94 (12): e660. doi:10.1097/MD.0000000000000660. PMC 4554009. PMID 25816036.
↑ Bosman, F. T. (2010). WHO classification of tumours of the digestive system. Lyon: International Agency for Research on Cancer. ISBN 978-9283224327.
↑ Sun J (2017). “Pancreatic neuroendocrine tumors”. Intractable Rare Dis Res. 6 (1): 21–28. doi:10.5582/irdr.2017.01007. PMC 5359348. PMID 28357177.

[pmid27646952-1] 1.0 ^1.1 ^1.2 Luo G, Javed A, Strosberg JR, Jin K, Zhang Y, Liu C; et al. (2017). “Modified Staging Classification for Pancreatic Neuroendocrine Tumors on the Basis of the American Joint Committee on Cancer and European Neuroendocrine Tumor Society Systems”. J Clin Oncol. 35 (3): 274–280. doi:10.1200/JCO.2016.67.8193. PMID 27646952.

[pmid25816036-2] 2.0 ^2.1 Yang M, Zeng L, Zhang Y, Wang WG, Wang L, Ke NW; et al. (2015). “TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution”. Medicine (Baltimore). 94 (12): e660. doi:10.1097/MD.0000000000000660. PMC 4554009. PMID 25816036.

[3] Bosman, F. T. (2010). WHO classification of tumours of the digestive system. Lyon: International Agency for Research on Cancer. ISBN 978-9283224327.

[pmid28357177-4] Sun J (2017). “Pancreatic neuroendocrine tumors”. Intractable Rare Dis Res. 6 (1): 21–28. doi:10.5582/irdr.2017.01007. PMC 5359348. PMID 28357177.

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