Neurofibromatosis 1 Presenting with Multiple Duodenal GistsAssociated with a Somatostatin-Producing D Cell Neoplasm

Giovanni Serio & Clementina Zampatti &Andrea Ballabio & Riccardo Ricci & Maurizio Martini &Francesco Zurleni

Published online: 7 April 2013# Springer Science+Business Media New York 2013

Abstract The co-existence of a duodenal somatostatin-producing D cell neoplasm and multiple duodenal gastroin-testinal stromal tumours (GISTs) in a 61-year-old womanwith neurofibromatosis type 1 is reported. Histologically,the D cell neoplasm showed a glandular pattern withpsammoma bodies and was metastatic to regional lymphnodes and liver at the time of surgery. Tumour cells weremonomorph and showed intense and diffuse immunoreac-tivity for somatostatin, focal positivity for calcitonin, whilewere negative for other gastroenteropancreatic hormonesincluding insulin, glucagon, pancreatic polypeptide, seroto-nin and gastrin. Four submucosal and subserosal GISTs,ranging from 5 to 15 mm in diameter, were composed ofuniform spindle-shaped cells lacking mitoses and containednumerous skeinoid fibres. The tumours were positive forCD117, DOG1, vimentin and CD34 and did not have KIT orPDGFRA mutations. The clinical and pathological impor-tance of this unusual association is discussed.

Keywords Somatostatinoma . GIST . Neurofibromatosis 1

Introduction

Neurofibromatosis type 1 (NF1) is a relatively common auto-somal dominant trait with a rate of occurrence of about 1 in3,000 in Western population [1]. In approximately half ofnewly diagnosed cases, there is not a positive family history,and the occurrence of these sporadic diseases results fromnon-inherited new mutations [2]. The gene for NF1 has beenidentified in the pericentromeric region of the long arm ofchromosome 17 [3] and encodes a GPTase-activating proteinnamed neurofibromin, that regulates the activity of the p21product of the ras oncogene [4]. This gene functions in part asa tumour suppressor gene and plays an important role incontrolling cell proliferation and differentiation. Therefore,apart from the classical triad of café au lait spots, multipleneurofibromas and Lisch nodules, the clinical features of theNF1 are variable by occurrence of a wide variety of tumours.

Gastrointestinal involvement in NF1 is well recognised[5]. It occurs in three main forms: (1) hyperplastic/dysplasticlesions of the gut neural tissue and its supporting structures,(2) multiple mesenchymal tumours and (3) duodenalsomatostatin-producing D cell tumours of the periampullaryregion. Although some of these gastrointestinal mesenchy-mal tumours are peripheral nerve sheath tumours [6], wenow know that most of them show the immunophenotypicprofile of the CD117-positive interstitial cell of Cajal (ICC),known as the gastrointestinal pacemaker cell (GIPAC) [7,8]. This fact has suggested either an origin of these neo-plasms from such cell or an immunophenotypic differentia-tion along this line. Therefore, they were called ICC orGIPAC tumours [7, 8]. These tumours are now definedas gastrointestinal stromal tumours (GISTs), a term orig-inally coined by Mazur and Clark in 1983 [9, 10].Duodenal somatostatin-producing D cell tumour is a

G. Serio (*) : C. ZampattiOperative Unit of Anatomic Pathology, Azienda Ospedaliera“Ospedale di Circolo” di Busto Arsizio, Via A. da Brescia 1,21052 Busto Arsizio, Italye-mail: gserio@aobusto.it

A. Ballabio : F. ZurleniOperative Unit of Surgery, Azienda Ospedaliera “Ospedale diCircolo” di Busto Arsizio, Busto Arsizio, Italy

R. Ricci :M. MartiniInstitute of Anatomic Pathology, Università Cattolica del SacroCuore, Policlinico Gemelli, Roma, Italy

Endocr Pathol (2013) 24:100–105DOI 10.1007/s12022-013-9239-x

rare endocrine neoplasm which is distinguished from thepancreatic counterpart by its frequent association withNF1 and by the absence of the somatostatinoma syn-drome [11].

We describe a very uncommon case of NF1 presentingwith an association of multiple duodenal GISTs with aduodenal D cell tumour. As far as we know, there are onlytwo reports [12, 13] describing this unusual combination.We think that the identification of this unusual associationmay provide the first clue to the diagnosis of NF1.

Case Report

Clinical Findings

A 61-year-old-womanwith multiple cutaneous neurofibromaswas admitted in November 1998 to Busto Arsizio Hospitaldue to a 5-month history of watery vomiting and weight loss(4 kg). Past medical history included no familial NF1 diag-nosed 20 years before, diphtheria and persistent dyspepsia.Findings at physical examination were: multiple cutaneousneurofibromas, several café au lait spots and cardiac systolicmurmur. Laboratory data were within normal limits except forraised serum level of calcitonin (29.2 pg/ml; normal level, 0–10 pg/ml). Oesophagogastroduodenoscopy revealed a steno-sis of the second portion of the duodenum with dilatation ofthe upper tract. A computed tomography (CT) scan showed aduodenal intramural mass (Fig. 1) and multiple metastases toregional lymph nodes. At endoscopic ultrasonography, thetumour measured 28 mm in diameter and infiltrated the headof the pancreas (Fig. 2). A duodenopancreatectomy (accordingto Whipple’s procedure) was performed. During the operation,a small nodule of the liver was found and enucleated. Thepatient’s postoperative course was satisfactory and she was

discharged 20 days postoperative on somatostatin long-actinganalog therapy. The patient died of metastatic liver disease,5 years after surgery.

Pathological Findings

The resected specimen showed a duodenal solid firm mass,25 mm in diameter, in the ampullary region invading thehead of the pancreas. In addition, two submucosal and twosubserosal white nodules, measuring from 5 to 15 mm indiameter were also found. These tumours were located from3 to 11 cm distal to the main neoplasm.

Histological investigation disclosed that the ampullary le-sion was a duodenal somatostatin-producing D cell tumourwith distinctive morphological and immunocytochemical fea-tures (Fig. 3). Tumour was composed of monomorphic glan-dular or tubular structures lined by epithelial cells withabundant, eosinophilic, granular cytoplasm. Nuclei weresmall, vesicular, basally located and containing small nucleoli.Mitotic figures were scarce (less than 1 per 10 high powerfields) and proliferative index by Ki-67 was 1 %. The tumourwas diagnosed as NET G1 according to the recent WHOclassification of gastroenteropancreatic endocrine tumours.Glandular lumina often contained eosinophilic and PAS-positive-diastase-resistant homogeneous secretions. In somesections, numerous psammoma bodies were seen either withinglandular lumina or in connective tissue septa. Foci of solidand trabecular growth patterns, typical of well-differentiatedendocrine tumours, were also present. The tumour was clearlyinvasive infiltrating, through the duodenal submucosa and theunderlying muscularis propria, the pancreas and theperipancreatic tissues. In addition, foci of necrosis and inva-sion of blood vessels and perineural spaces were observed.Metastases were found in 11 of 29 regional lymph nodes andin the liver (the enucleated nodule). Immunocytochemical

Fig. 1 Abdominal CT scan showing a tumour in the second part of theduodenum (arrows)

Fig. 2 Endoscopic US detecting the mass

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stainings, performed using the streptavidin–biotin–peroxidasemethod, were positive for general endocrine markers such aschromogranin A, synaptophysin and neuron-specific enolase(NSE). In addition, tumour cells were mostly reactive forsomatostatin and occasionally for calcitonin while were neg-ative for insulin, glucagon, pancreatic polypeptide, serotoninand gastrin.

Histological examination of the subserosal and submu-cosal nodules revealed that they were mesenchymal tumoursshowing the immunohistochemical profile of the ICC(Fig. 4). These tumours appeared well circumscribed withexpandingmargins and surrounded by a fibrous pseudocapsule.Histologically, they were composed of well-differentiated spin-dle cells arranged in multiple interwoxven bundles withoutdefinite neurogenic or myogenic differentiation. Varying sized,irregular-shaped eosinophilic hyaline extracellular deposits,designated as “skeinoid fibres” [14], were also present adja-cent to spindle cells. Mitotic figures and necrosis were absent.Immunohistochemically, all tumours were diffusely positivefor c-kit (CD117), DOG1 and vimentin and focally immuno-stained for CD34, while they were negative for S-100 protein,desmin and muscle specific actin (HHF-35). A positivestaining for NSE and PGP 9.5 was also seen in scattered cells.They were diagnosed as GISTs, risk “very low” or “none”[10]. KIT and plateled-derived growth factor receptoralpha (PDGFRA) mutational analysis was performed inthree GISTs, as described elsewhere [15, 16]. We foundwild-type sequences in KIT exons 9, 11, 13 and 17 andin PDGFRA exons 12, 14 and 18 of all investigatedGISTs.

Interestingly, multifocal ICC hyperplasia was observed inthe wall adjacent to tumours.

Discussion

The most noteworthy findings of the present case of NF1 arethe presence of multiple duodenal GISTs associated with aduodenal D cell tumour. Mesenchymal tumours are the mostcommonly reported gastrointestinal manifestations of NF1.Usually, they become clinically apparent many years afterthe appearance of the typical cutaneous lesions [5]. GISTs inNF1 are morphologically indistinguishable from their

a b

c d

Fig. 3 Portion of duodenal wallwith extensive involvement bysomatostatin-producing D celltumour (a; H&E, ×40), showinga distinctive glandular pattern ofgrowth with psammoma bodies(b; H&E, ×250). Tumour cellswere diffusely positive forsomatostatin (c; immunostain,×200), and focally for calcitonin(d; immunostain, ×400)

a

b

Fig. 4 GIST showing prominent eosinophilic hyaline skeinoid fibres(a; H&E, ×250). Tumour cells were diffusely positive for c-kit(CD117; b; immunostain, ×200)

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counterparts that arise sporadically, with which share thesame difficulties in histological classification. In past re-ports, they have been designated with various names includ-ing neurofibromas of both localised [17] and plexiform type[18], malignant schwannomas [19, 20], leiomyomas [21],leiomyosarcomas [22] and GAN tumours [23] as describedby Herrera et al. [24], despite most of the tumours describedshowed no convincing evidence of neural or muscle differ-entiation either on immunohistochemistry or electron mi-croscopy. The usual benign clinical course of the smallintestinal stromal tumours with skeinoid fibres, especiallymultiple, found in NF1 setting has been known since a longtime [25, 26]. The understanding of the GIST histogenesisindicate that they represent a biologically distinctive groupof tumours, characterised by the immunohistochemical ex-pression of the c-kit (CD117) proto-oncogene product,DOG1 gene product and CD34 [7, 8, 27]. CD34, DOG1and c-kit proteins have been shown to be markers of ICCs[27, 28], which are a special type of stromal cells present inthe myenteric and submucosal plexuses. They are interca-lated between autonomic nerve fibres and muscle cells ofthe gut wall, where they form a complex cell network. ICCsare now considered as pacemaker for peristaltic movementsof the gastrointestinal tract [29]. Because of the sharedexpression of c-kit and CD34 proteins, Kindblom et al. [8]have introduced the unifying concept of gastrointestinalpacemaker cell tumours (GIPACTs) to indicate stromal tu-mours, including GANTs, showing phenotypic similaritieswith ICCs. In two reports, mesenchymal tumours associatedwith NF1 were called GIPACTs [30, 31], and they corre-spond to GISTs. The present study reconfirms this findingbesides to emphasise the close link between such tumours andNF1. Most sporadic GISTs have a constitutive activation of c-kit or PDGFRA [32, 33]. Kinoshita et al. [34], finding no c-kitmutations in any of the GISTs he observed in NF1 patients,suggested that the pathogenesis of NF1-associated GISTs maybe different from that of non-NF1 patients. This hypothesiswas later confirmed by the finding of somatic inactivation ofthe wild-type NF1 gene in GISTs from NF1 patients [33],similar to the known “two-hit” mechanism determining neu-rofibromas in the same clinical setting [35]. In our case no

mutations were found in KIT exons 9, 11, 13 and 17 and inPDGFRA exons 12, 14 and 18 of the three investigatedGISTs,as expected in a NF1 setting.

The clinical feature of particular interest in our case is thecoexistence of multiple GISTs with duodenal D cell tumour.The first example of this concomitant association occurring ina patient with NF1 has been described by Usui et al. [12].Successively, another case has been described, although as ameeting report [13]. Therefore, the case reported here can beregarded as the third (Table 1). In all cases described, patientswere female with an average age of 59 years (range, 53–64 years). The duodenal somatostatin-producing D celltumour was malignant in only one case (our case).GIST tumours were always multiple. Interestingly, intwo cases hyperplastic features of ICCs were observedin the adjacent muscular layer.

A non-random link between NF1 and duodenal carcinoidhas been recognised since 1982 [36–38], and so far, about 30examples have been reported either alone or more rarely inassociation with pheochromocytoma [37–40]. All arose at, orclose to, the ampulla of Vater and, histologically, showed adistinctive glandular architecture, which could lead to confu-sion with exocrine adenocarcinoma. In many tumours lami-nated calcified basophilic structures resembling psammomabodies were present, mainly in the lumina of the glandularstructures. Glandular pattern and psammoma bodies are un-common features of endocrine tumour. Therefore, this com-bination makes this tumour type an easily identifiable entity.In addition, except two cases containing amyloid, one ofwhich producing gastrin [41] and the other calcitonin [42],all tumours immunohistochemically investigated elaboratedsomatostatin. Despite this fact, clinical manifestations due tosomatostatin hypersecretion were unusual. In the present case,a moderate number of tumour cells were also reactive forcalcitonin. The increased serum level of this hormone notedin our patient was possibly related to this feature.

Duodenal D cell tumour can behave in a clinically ma-lignant fashion with regional lymph nodes and liver metas-tases, and death as a direct result of tumour spread mayoccur as in our patient. Because it also arises sporadically inpatients without neurofibromatosis, an accurate histological

Table 1 Clinicopathological features of patients with NF1 presenting with multiple GISTs and duodenal somatostatin-producing D cell tumour

Age Sex D cell tumour GIST ICC hyperplasia Therapy Follow-up References

Ø Metastases Ø Number

64 F 1.5 No 0.5–3 Multiplea Not reported Resection 1 year, alive [12]

53 F 1.3 No 0.4, 0.7 2 Yes Resection n.k. [13]

61 F 2.5 Liver nodes 0.5, 1.5 4 Yes Resection DOD, 5 years Present case

F female, Ø diameter in centimetres, ICC interstitial cell of Cajal, n.k. not known, DOD died of diseasea Gastric, duodenal and jejunal

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distinction from adenocarcinoma of the periampullary re-gion is of both pathological and clinical relevance.

In conclusion, we have reported an additional case of aparticular manifestation of NF1 presenting with multipleduodenal GISTs and a somatostatin-producing D cell tu-mour, with the conviction that it may be of considerableclinical significance and proven to be more common thanhas been thought.

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