A new endoscopic tumor grading for rectal neuroendocrine tumors: Correlation of vascular pattern with histopathology

INTRODUCTION

The clinical utility of applying endoscopic vascular patterns in rectal neuroendocrine tumor (NET) remains unknown. The aims of this study were to develop a system for utilizing vascular patterns for tumor grade and submucosal invasion depth.

METHODS

We retrospectively included patients diagnosed as well-differentiated rectal NET between March 2015 and February 2024. The entire dataset was divided into evaluation and validation sets. In the evaluation set, the relationship between endoscopic tumor features and tumor grade was explored using a multivariable regression model. Based on the endoscopic vessel characteristics, vascular patterns were established and classified into V1 and V2 types. In the validation set, 104 lesions were used to assess the diagnostic performance of the vascular patterns.

RESULTS

Multivariate analysis demonstrated good association between tumor grade and vascular pattern (13.65 odds ratio; 95 % confidence interval, 2.06-90.58). Vascular patterns exhibited almost perfect inter- and intra-observer agreement (kappa = 0.957). The sensitivity, positive predictive value and accuracy of V1 for predicting grade 1 were 94.5 %, 97.7 and 93.3 %, respectively. Histopathological analysis revealed significantly deeper submucosal invasion depth for V2 than that for V1 lesions (p < 0.001).

CONCLUSIONS

Vascular patterns can help identify tumor grade and assess submucosal invasion depth.

Risk factors for lateral pelvic lymph node metastasis in patients with rectal neuroendocrine tumors: a systematic review and meta-analysis

Background and objective

Lateral pelvic lymph node (LPLN) metastasis is one of the prominent reasons for local recurrence in patients with rectal neuroendocrine tumors (RNETs). The evaluation criteria of lateral lymph node metastasis for patients and the indications and value of lateral pelvic lymph node dissection (LPLD) have been controversial. Total mesorectal excision (TME), a conventional surgical treatment for RNETs, excluding lateral lymph nodes, may be one of the reasons for postoperative local recurrence. This study aimed to analyze the risk factors for LPLN metastasis in patients with RNETs in order to guide surgical methods.

Methods

We searched relevant databases (PubMed, Embase, Medline, Cochrane Library, and Web of Science) for articles published between 1 January 2000 and 1 April 2024 to evaluate the risk factors for LPLN metastasis in patients with RNETs in this meta-analysis.

Results

A total of seven articles with 433 patients were included in this study. The overall results showed that a WHO grade > G1, tumor invasion of the muscularis propria or deeper, lymphovascular invasion (LVI), mesorectal lymph node metastasis (MLNM), and distant metastasis (M1) were significant risk factors for LPLN metastasis in patients with RNETs (P <0.05).

Conclusion

This study identified key risk factors for LPLN metastasis in patients with RNETs, providing guidance for treatment strategies. A comprehensive evaluation of these risk factors and imaging findings is recommended to tailor personalized treatment strategies that optimize survival outcomes and improve quality of life.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024581891.

Construction and evaluation of the prediction model for advanced disease in well-differentiated colorectal neuroendocrine neoplasms less than 2 cm in diameter

Objective

Advanced lesions are often ignored in well-differentiated colorectal neuroendocrine neoplasms (NENs) smaller than 2 cm, and we aimed to develop an effective nomogram for these lesions.

Methods

We extracted data from the Surveillance, Epidemiology, and End Results (SEER) database and used a logistic regression model to identify independent risk factors for advanced disease. All these identified factors were included to construct the prediction model, and the receiver operating characteristic (ROC) curve, calibration plot and DCA curve were utilized to assess the predictive value. The data obtained from the National Cancer Center were utilized for external validation.

Results

In total, 3223 patients were enrolled in the training set, including 2947 (91.4 %) with early disease and 276 (8.6 %) with advanced disease. The logistic analysis showed that age (odds ratio (OR) = 1.486, 95 % confidence interval (CI): 1.102-2.003, P = 0.009), tumor size (OR = 11.071, 95 % CI: 8.229-14.893, P < 0.001), tumor location (OR = 7.882, 95 % CI: 5.784-10.743, P < 0.001) and tumor grade (OR = 1.768, 95 % CI: 1.206-2.593, P = 0.004) were independent variables for advanced disease. All of them were included in the final prediction model. The area under the ROC curve (AUC) was 0.838 (95 % CI: 0.807-0.868). The calibration plot and Hosmer‒Lemeshow test (P = 0.108) indicated favorable consistency between the predicted probabilities and actual probabilities of advanced disease. The Brier score was 0.108, indicating acceptable overall performance. The DCA curve presented a significant clinical net benefit. In the validation set, both the ROC curve and calibration plot exhibited an acceptable discrimination ability (AUC = 0.807 (95 % CI 0.702-0.913) and calibration (Hosmer Lemeshow P = 0.997), respectively.

Conclusions

The prediction model had good value for identifying advanced disease from well-differentiated colorectal NENs smaller than 2 cm.

Treatment indicators and prognostic factors in colorectal neuroendocrine neoplasms and adenocarcinoma with neuroendocrine differentiation: a single center retrospective study

PURPOSE

This study compared survival and metastasis occurrence between colorectal neuroendocrine neoplasms (cNEN) and colorectal adenocarcinoma with neuroendocrine differentiation (cNED) and further explored their prognostic factors and treatment indicators.

METHODS

Patients diagnosed as cNEN and cNED in West China Hospital from January 2009 to December 2020 were enrolled. The diagnosis and metastasis rates were calculated. Univariate and multivariate Cox analyses were conducted for progression-free survival (PFS) in cNEN surgical patients, and generalized linear regression was used for metastatic disease.

RESULT

The study enrolled 435 patients, including 257 neuroendocrine tumors (NET), 52 neuroendocrine carcinomas (NEC), 29 mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN), and 97 NED patients, of whom 202 received local resection, and 233 received radical resection. Metastasis rates were higher in MiNEN and NEC groups compared to other groups (NED: 28.9%, MiNEN: 58.6%, NEC: 65.4%, NET: 8.6%, p < 0.001). The liver is the main metastatic site in cNEN, whereas cNED metastasized to various sites. For NEC and MiNEN patients, colon location (p = 0.002) and T stage > 2 (p = 0.040) were associated with disease progression separately. Independent risk factors for metastatic NET included tumor grade G2/G3 (p < 0.001), colon location (p = 0.001), size ≥ 1 cm (p = 0.005), and CK20 partial positive (p < 0.001).

CONCLUSION

cNEN show high metastatic capacity and are challenging to diagnose. More aggressive treatment and follow-up strategies are necessary for those patients. NET tumor grade higher than G2, size larger than 1 cm, or located in the colon should be managed with radical surgery.

Endoscopic submucosal dissection for rectal neuroendocrine tumours: A multicentric retrospective study

INTRODUCTION

Endoscopic Submucosal Dissection (ESD) has been reported as a feasible and effective treatment for Rectal Neuroendocrine Tumours (R-NETs). However, most of the experience on the topic comes from retrospective tertiary centre from Eastern Asia. Data on ESD for R-NETs in Western centres are lacking.

MATERIALS AND METHODS

This is a retrospective study, including patients who underwent endoscopic resection of R-NETS by ESD between 2015 and 2020 in Western Centres. Important clinical variables such as demographic, size of R-NETs, histological type, presence of lymphovascular invasion or distant metastasis, completeness of the endoscopic resection, recurrence, and procedure related complications were recorded.

RESULTS

40 ESD procedure on R-NETs from 39 patients from 8 centres were included. Mean R-NETs size was 10.3 mm (SD 4.01). Endoscopic en-bloc resection was achieved in 39/40 ESD (97.5 %), R0 margin resection was obtained in 87.5 % (35/40) of the procedures, one patient was referred to surgery for lymphovascular invasion, two procedures (5 %) reported significant episodes of bleeding, whereas a perforation occurred in one case (1/40, 2.5 %) managed endoscopically. Recurrence occurred in 1 patient (2.5 %).

CONCLUSION

ESD is an effective and safe treatment for R-NETs in western centres.

Impact of grade on workup of rectal neuroendocrine tumors: a retrospective cohort study : Grade impact on workup of rectal NETs

BACKGROUND

Rectal neuroendocrine tumors (RNETs) are often discovered on screening colonoscopy. Indications for staging and definitive resection are inconsistent in current guidelines. We evaluated the role of grade in guiding staging and procedural decision-making.

METHODS

Patients with biopsy confirmed RNETs between 2004 and 2015 were reviewed. Baseline characteristics, staging investigations (biochemical and imaging), and endoscopic/surgical treatment were recorded. Associations between grade, preoperative staging, interventions, and survival were determined using Fisher-Freeman-Halton Exact, log-rank, and Kaplan-Meier analysis.

RESULTS

Amongst 139 patients with RNETs, 9% were aged ≥ 75 years and 44% female. Tumor grade was: 73% grade 1 (G1), 18%, grade 2 (G2) and 9% grade 3 (G3). Staging investigations were performed in 52% of patients. All serum chromogranin A and 97% of 24-hour urine 5-hydroxyindoleacetic acid tests were normal. The large majority of staging computed tomography (CT) scans were negative (76%) with subgroup analysis showing no G1 patients with CT identified distant disease compared with 38% of G2 and 50% of G3 patients (p < 0.001). G1 patients were more likely to achieve R0/R1 resections compared to G2 (95% vs. 50%, p < 0.001) and G1 patients had significantly better 5-year overall survival (G1: 98%, G2: 67%, G3: 10%, p < 0.001).

CONCLUSION

Tumor grade is important in preoperative workup and surgical decision-making. Biochemical staging may be omitted but staging CT should be considered for patients with grade ≥ 2 lesions. Anatomic resections should be considered for patients with grade 2 disease.

Palliative primary tumor resection may not offer survival benefits for patients with unresectable metastatic colorectal neuroendocrine neoplasms, one multicenter retrospective cohort study

BACKGROUND

The efficacy of palliative primary tumor resection (PTR) in improving prognosis for patients with unresectable metastatic colorectal neuroendocrine neoplasms (NENs) has not been fully explored.

METHODS

We performed one retrospective cohort study and recruited 68 patients with unresectable metastatic colorectal NENs from two Chinese medical centers between 2000 and 2022. All patients were assigned to PTR group and no PTR group. The clinicopathological manifestation data were carefully collected, and the survival outcomes were compared between the two groups using Kaplan-Meier methods. Propensity score matching (PSM) was conducted to minimize confounding bias. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify prognostic factors.

RESULTS

A total of 32 patients received PTR, and the other 36 patients did not. The median progression-free survival (PFS) and overall survival (OS) times were 4 and 22 months in the whole cohort, respectively. For patients who received no PTR, the median OS was 16 months, and the 1-year OS rate and 3-year OS rate were 56.4% and 39.6%, respectively. For patients who received PTR, the median OS was 24 months, and the 1-year OS rate and 3-year OS rate were 67.9% and 34.1%, respectively. However, the Kaplan-Meier survival curves and log-rank test demonstrated no significant survival difference between the two groups (P = 0.963). Moreover, palliative PTR was also not confirmed as a prognostic factor in subsequent univariable and multivariable Cox proportional hazards regression analyses in both the original and matched cohorts. Only histological differentiation was identified as an independent prognostic factor affecting PFS [hazard ratio (HR) = 1.86, 95% confidence interval (CI): 1.02-3.41, P = 0.043] and OS [HR = 3.70, 95% CI: 1.09-12.48, P = 0.035] in the original cohort.

CONCLUSIONS

Palliative PTR may not offer survival benefits for patients with unresectable metastatic colorectal NENs.

Endoscopic Management of Gastro-Entero-Pancreatic Neuroendocrine Tumours: An Overview of Proposed Resection and Ablation Techniques

A literature search of MEDLINE/PUBMED was conducted with the aim to highlight current endoscopic management of localised gastro-entero-pancreatic NETs. Relevant articles were identified through a manual search, and reference lists were reviewed for additional articles. The results of the research have been displayed in a narrative fashion to illustrate the actual state-of-the-art of endoscopic techniques in the treatment of NETs. Localised NETs of the stomach, duodenum and rectum can benefit from advanced endoscopic resection techniques (e.g., modified endoscopic mucosal resection, endoscopic full thickness resection, endoscopic submucosal dissection) according to centre expertise. Radiofrequency thermal ablation can be proposed as an alternative to surgery in selected patients with localised pancreatic NETs.

Analysis of the Genetic Characteristics and Metastatic Pathways of G1 and G2 Colorectal Neuroendocrine Neoplasms

Objective

G1 and G2 colorectal neuroendocrine neoplasms (NENs) are a group of rare and indolent diseases. We aimed to delineate their genetic characteristics and explore their metastatic mechanisms.

Methods

We used next-generation sequencing technology for targeted sequencing for 54 patients with G1 and G2 colorectal NENs. We delineated their genetic features and compared the genetic characteristics between metastatic NENs and nonmetastatic NENs. Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis was utilized to explore their abnormal pathways and study their potential metastatic mechanisms.

Results

We collected 23 metastatic NENs and 31 nonmetastatic NENs. In the whole cohort, the common mutated genes were NCOR2, BRD4, MDC1, ARID1A, AXIN2, etc. The common copy number variations (CNVs) included amplification of HIST1H3D, amplification of HIST1H3E, and loss of PTEN. The KEGG enrichment analysis revealed that PI3K-Akt, MAPK, and Rap1 were the major abnormal pathways. There were significantly different genetic features between metastatic NENs and nonmetastatic NENs. The metastatic NENs shared only 47 (22.5%) mutated genes and 6 (13.3%) CNVs with nonmetastatic NENs. NCOR2, BRD4, CDKN1B, CYP3A5, and EIF1AX were the commonly mutated genes in metastatic NENs, while NCOR2, MDC1, AXIN2, PIK3C2G, and PTPRT were the commonly mutated genes in nonmetastatic NENs. Metastatic NENs presented a significantly higher proportion of abnormal pathways of cell senescence (56.5% vs 25.8%, P = .022) and lysine degradation (43.5% vs 16.1%, P = .027) than nonmetastatic NENs.

Conclusion

G1 and G2 colorectal NENs are a group of heterogeneous diseases that might obtain an increased invasive ability through aberrant cell senescence and lysine degradation pathways.

Optimising Outcomes and Surveillance Strategies of Rectal Neuroendocrine Neoplasms

Rectal neuroendocrine neoplasms are increasing in incidence, in part due to increased endoscopic procedures being performed for bowel cancer screening. Whilst most of these lesions are low-grade well-differentiated neuroendocrine tumours, they can have a varied clinical behaviour. Frequently, these lesions are incorrectly characterised at endoscopy and, therefore, incompletely excised using standard polypectomy techniques. Furthermore, some cases are not fully staged prior to or post resection. In this article we discuss the endoscopic and surgical options available to improve the likelihood of achieving an R0 resection and the staging procedures that should be used in these NETs. We also review factors that may suggest a higher risk of nodal involvement or recurrence. This information may help determine whether endoscopic or surgical resection techniques should be considered. In cases of R1 resection we discuss the management options available and the long-term surveillance options and when these should be offered to patients.

Clinical outcomes and risk factors associated with poor prognosis after endoscopic resection of 10-20 mm rectal neuroendocrine tumors: a multicenter, retrospective study of 10-year experience

BACKGROUND

The efficacy of endoscopic resection for of 10-20 mm rectal neuroendocrine tumor (NET) remains controversial. We aimed to evaluate the clinical outcomes and risk factors associated with poor prognosis after endoscopic resection of 10-20 mm rectal NET and to determine the optimal treatment.

METHODS

Patients who underwent endoscopic resection for rectal NET in four tertiary hospitals were enrolled, and data on with the clinical outcomes and risk factors related to poor prognosis were retrospectively analyzed.

RESULTS

A total of 105 patients who underwent endoscopic submucosal resection (ESD; n = 65, 61.9%), modified endoscopic mucosal resection (mEMR; n = 31, 29.5%), and conventional EMR (cEMR; n = 9, 8.6%) were enrolled. The mean follow-up period was 41.2 ± 21.9 months. In the morphologic findings, the mean diameter was 11.6 mm (range 10-19); the shape was sessile (50.5%) and mixed type (49.5%), and surface depression was observed in 41.9% of patients. In the histologic findings, 87.6% of patients had G1 and 12.4% G2 tumor grade, and 3.8% of patients had lymphovascular invasion. The overall en bloc and histologically complete (R0) resections were 99.1% and 76.2%, respectively. cEMR was a less-frequently developed R0 resection. In the univariate and multivariate analyses for R0 resection, only surface depression was significantly associated. Regional or distant organs metastasis during follow-up developed in three patients (2.9%) and was significantly associated with female sex, redness, G2 tumor grade, and non-ESD methods.

CONCLUSION

Patients who underwent endoscopic resection of 10-20 mm rectal NET had good prognosis; therefore, endoscopic resection can be considered as the first-line treatment, particularly for 10-14 mm rectal NET. However, the risk factors, such as female sex, redness, G2 tumor grade and non-ESD methods, were associated with regional or distant metastases during follow-up. Therefore, patients with these risk factors should be carefully monitored.

The genetic alterations of rectal neuroendocrine tumor and indications for therapy and prognosis: a systematic review

Neuroendocrine tumors (NETs) are a type of rare tumor that can occur at multiple organs. Rectal NETs are the most common NETs in gastrointestinal tract. Due to the rarity of rectal NETs in rectal cancer, the molecular features and the correlation with patient therapeutic response and prognosis have not been investigated in detail. In this review, we focused on the molecular features, potential therapeutic targets and prognosis of rectal NETs. By summarizing the relevant studies, we established the mutational landscape of rectal NETs and identified a series of large fragment variations. Driver genes including TP53, APC, KRAS, BRAF, RB1, CDKN2A and PTEN were found as the top mutated genes. Large fragment alterations mainly involved known driver genes, including APC, TP53, CCNE1, MYC, TERT, RB1 and ATM. Germline mutations of APC, MUTYH, MSH6, MLH1 and MSH2 associated with Lynch syndrome or FAP were also found in rectal NETs. The BRAF-V600E mutation was reported as an actionable target in rectal NETs, and the combined BRAF/MEK inhibitors were found to be effective targeting BRAF-V600E in advanced or metastatic NETs. The known prognostic risk factors of rectal adenocarcinoma, including a series of demographic and clinicopathological factors were also prognostic factors for rectal NETs. Furthermore, three types of markers, including genetic alterations, protein expression levels and methylation, were also suggested as prognostic factors for rectal NETs. In summary, we established the landscape of mutations and large-fragment alterations of rectal NETs, and identified potential therapeutic targets and a series of prognostic factors. Future studies may focus on the optimization of therapeutic strategies based on potential actionable biomarkers.

Development of novel prediction models for nodal and distant metastasis in G1 and G2 colorectal neuroendocrine tumors

PURPOSE

We aimed to construct novel nomograms for nodal and distant metastasis for patients with G1 and G2 colorectal neuroendocrine tumors (NETs).

METHODS

A training set and validation set were obtained by including G1 and G2 colorectal NET patients from the Surveillance, Epidemiology, and End Results database and the Cancer Hospital Chinese Academy of Medical Science, respectively. The area under curve (AUC) values under receiver operating characteristic (ROC) curves, calibration plots, and the Hosmer‒Lemeshow tests were used to evaluate the discriminability and calibration of nomograms.

RESULTS

In total, 3690 and 172 patients were included in the training set and validation set, respectively. Tumor size, location, and T stage were included in the nomogram predicting nodal metastasis. The AUC values of the nomogram were 0.972 (95% confidence interval (CI): 0.964-0.980) and 0.897 (95% CI: 0.846-0.948) in the training set and validation set, respectively. The calibration plots and Hosmer‒Lemeshow test for the training set (P = 0.999) and validation set (P = 0.537) showed good model calibration. Tumor size, T stage, and N stage were incorporated into the nomogram predicting distant metastasis. The ROC curves demonstrated desirable discrimination both in the training set (AUC = 0.938 (95% CI: 0.921-0.954)) and validation set (AUC = 0.938 (95% CI: 0.890-0.988)). The calibration curves and Hosmer‒Lemeshow test indicated acceptable model calibration both in the training set (P = 0.908) and validation set (P = 0.722).

CONCLUSION

The proposed nomograms may be used as a reliable tool to predict the nodal and distant metastasis in G1 and G2 colorectal NETs.

Comparison of the efficacy of endoscopic submucosal dissection and transanal endoscopic microsurgery in the treatment of rectal neuroendocrine tumors ≤ 2 cm

INTRODUCTION

Currently, complete tumor resection is considered the most effective treatment for rectal neuroendocrine tumors (NETs). Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are recommended for rectalNETs ≤2 cm, but it is not clear which method is better. Thus, we evaluated the efficacy of ESD and TEM in the treatment of rectal neuroendocrine tumors (NETs) ≤ 2 cm.

METHODS

We conducted a single-centre retrospective cohort study between 2010 and 2021 of rectal NETs ≤ 2 cm in 114 patients with long-term follow-up data who were divided into ESD (n=55) and TEM groups (n=59). Our study assessed differences between groups in the complete resection rate of lesions, recurrence rate, surgical complications, procedure time, and length of hospital stay.

RESULTS

The co-primary outcomes were the complete resection rate of lesions and the recurrence rate. Compared to that in the ESD group, the complete resection rate was significantly higher in the TEM group (91.5% vs. 70.9%, p=0.005). The median follow-up time was 22 months in our study, and the follow-up outcomes suggested that the rates of recurrence were 1.8% (1/55) and 6.8% (4/59) in the ESD and TEM groups, respectively, with no significant difference between the two groups. The secondary outcomes of the evaluation were surgical complications, procedural time, and length of hospital stay. The rate of complications (gastrointestinal bleeding and perforation) was low in both the ESD (7.3%, 4/55) and TEM (5.1%, 3/59) groups. No difference in hospitalization duration was observed between the two groups in our study. However, the procedure time was significantly shorter in the ESD group than in the TEM group (27.5 min vs. 56 min, p<0.001).

CONCLUSIONS

Although the rate of complete resection in the TEM group was higher than that in the ESD group, there was no difference in recurrence rates between the two modalities during long-term follow-up. Depending on the qualities of the available hospital resources in the area, one of the two approaches can be adopted.

Novel staging for gastric neuroendocrine neoplasms by incorporating the WHO grading into the TNM staging system

BACKGROUND

The 8th tumor-node-metastasis (TNM) classification of the American Joint Committee on Cancer (AJCC) can be used to estimate the prognosis of gastric neuroendocrine tumor (gNET) and gastric neuroendocrine carcinoma (gNEC) patients but not gastric neuroendocrine neoplasms (gNENs).

METHODS

First, in the SEER (training) dataset, a TNMG system was built by combining the WHO G grade (G1-4; NEC grouped into G4) with the 8th AJCC T (T1-4), N (N0-1), and M (M0-1) stage, which was then validated in a Chinese (validation) cohort.

RESULTS

In all, 2245 gNENs cases from the training dataset and 280 cases from the validation dataset were eligible. The T stage, M stage, and G grade were independent prognostic factors for OS in both datasets (all p < 0.05). The TNMG staging system demonstrated better C-index for predicting OS than the 8th AJCC TNM staging system in both the training (0.87, 95%CI: 0.86-0.88 vs. 0.79, 95%CI: 0.77-0.81) and validation (0.77, 95%CI: 0.73-0.80 vs. 0.75, 95%CI: 0.71-0.79) datasets. The AUC of the 3-year OS for the TNMG staging system was 0.936 and 0.817 in the SEER and validation dataset, respectively; higher than those of the 8th AJCC system (vs. 0.843 and 0.779, respectively). DCA revealed that compared with the 8th AJCC TNM staging system, the TNMG staging system demonstrated superior net prognostic benefit in both the training and validation datasets.

CONCLUSIONS

The proposed TNMG staging system could more accurately predict the 3- and 5-year OS rate of gNENs patients than the 8th AJCC TNM staging system.

Nomogram for Predicting Distant Metastasis of Pancreatic Ductal Adenocarcinoma: A SEER-Based Population Study

(1) Background: The aim of this study was to identify risk factors for distant metastasis of pancreatic ductal adenocarcinoma (PDAC) and develop a valid predictive model to guide clinical practice; (2) Methods: We screened 14328 PDAC patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. Lasso regression analysis combined with logistic regression analysis were used to determine the independent risk factors for PDAC with distant metastasis. A nomogram predicting the risk of distant metastasis in PDAC was constructed. A receiver operating characteristic (ROC) curve and consistency-index (C-index) were used to determine the accuracy and discriminate ability of the nomogram. A calibration curve was used to assess the agreement between the predicted probability of the model and the actual probability. Additionally, decision curve analysis (DCA) and clinical influence curve were employed to assess the clinical utility of the nomogram; (3) Results: Multivariate logistic regression analysis revealed that risk factors for distant metastasis of PDAC included age, primary site, histological grade, and lymph node status. A nomogram was successfully constructed, with an area under the curve (AUC) of 0.871 for ROC and a C-index of 0.871 (95% CI: 0.860-0.882). The calibration curve showed that the predicted probability of the model was in high agreement with the actual predicted probability. The DCA and clinical influence curve showed that the model had great potential clinical utility; (4) Conclusions: The risk model established in this study has a good predictive performance and a promising potential application, which can provide personalized clinical decisions for future clinical work.

Comparison between endoscopic mucosal resection with a cap and endoscopic submucosal dissection for rectal neuroendocrine tumors

Background

The aim of this study is to evaluate and compare the safety and efficacy of endoscopic mucosal resection with a cap (EMR-c) with those of endoscopic submucosal dissection (ESD) for rectal neuroendocrine tumors (R-NETs) ≤ 15 mm in diameter, and to analyze the risk factors of incomplete resection.

Methods

A total of 122 patients who underwent EMR-c or ESD for R-NETs at the Fourth Hospital of Hebei Medical University between February 2007 and December 2020 were invovled in this study. The clinical outcomes of two groups were compared and evaluated.

Results

A total of 122 patients with 128 R-NETs underwent endoscopic resection (EMR-c, 80; ESD, 48). In terms of duration of operation, EMR-c was significantly shorter than ESD (p < 0.001). Univariate analysis and multivariate analysis suggested that tumor diameter ≥ 8 mm was an independent risk factor for incomplete resection in patients with R-NETs in this study.

Conclusions

Both EMR-c and ESD were safe and effective treatments for R-NETs ≤ 15 mm in diameter. In addition, tumor diameter ≥ 8 mm was an independent risk factor for incomplete resection.

Rectal neuroendocrine tumors: Current advances in management, treatment, and surveillance

Rectal neuroendocrine neoplasms (r-NENs) are considered among the most frequent digestive NENs, together with small bowel NENs. Their incidence has increased over the past few years, and this is probably due to the widespread use of endoscopic screening for colorectal cancer and the advanced endoscopic procedures available nowadays. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, well-differentiated r-NENs smaller than 10 mm should be endoscopically removed in view of their low risk of local and distant invasion. R-NENs larger than 20 mm are candidates for surgical resection because of their high risk of distant spreading and the involvement of the muscularis propria. There is an area of uncertainty regarding tumors between 10 and 20 mm, in which the metastatic risk is intermediate and the endoscopic treatment can be challenging. Once removed, the indications for surveillance are scarce and poorly codified by international guidelines, therefore in this paper, a possible algorithm is proposed.

Predicting Distant Metastasis in Young-Onset Colorectal Cancer After Surgery: A Retrospective Study

Background

Although overall colorectal cancer (CRC) cases have been declining worldwide, there has been an increase in the incidence of the CRC among individuals younger than 50 years old, which is associated with distant metastasis (DM) and poor prognosis.

Methods

Young-onset CRC patients' postoperative data were collected from the Surveillance, Epidemiology, and End Results (SEER) database between January 2010 and December 2015. Data from the SEER database were divided into early stage and advanced stage according to whether chemoradiotherapy was recommended in the guidelines. Independent risk factors for DM were explored by using univariate and multivariate logistic regression separately. A predictive model was established and presented as nomogram in the training set of advanced stage. The model was internally verified in testing set and externally validated in a cohort of 145 patients from Zhongnan Hospital of Wuhan University. The accuracy, reliability, and clinical application value were assessed using the receiver operating characteristic curve (ROC), the area under the curve (AUC), calibration curve, and decision curve analysis (DCA), respectively. Different risk subgroups of DM were classified according to the scores of the nomogram in the training set of advanced stage.

Results

A total of 5,584 patients were eligible and enrolled in our study in which 1,277 were in early stage and 4,307 in advanced stage. Preoperative CEA positive was found to be an independent predictor of DM in early stage. Multivariate logistic regression analysis showed that tumor size, degree of differentiation, T stage, N stage, preoperative CEA, and whether radiation or chemotherapy performed were independent risk factors for DM (all, p < 0.05) in advanced stage. Great accuracies were achieved in our nomogram with AUC of 0.801 in training set, 0.811 in testing set, and 0.791 in the validation cohort, respectively. Calibration curves and DCA in internal validation and external validation both showed good stability and clinical utility values.

Conclusions

Preoperative CEA positive was a significant predictor of DM for young-onset CRC patients. A novel nomogram containing clinical and pathological features was established for predicting DM of advanced CRC in patients younger than 50 years old. This tool may serve as an early alert for clinicians to DM and make better clinical treatment regimens.

Long-term outcomes of transanal endoscopic microsurgery for the treatment of rectal neuroendocrine tumors

Background

Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. We aimed to assess the efficacy and safety of TEM in the treatment of rectal neuroendocrine tumors (RNET).

Methods

A retrospective study of patients who had undergone TEM for RNET at our institution between December 2006 and June 2019 was performed. Demographic and tumor characteristics, operative and pathological details, complications, anal function questionnaires, and follow-up data were included.

Results

A total of 144 patients was included. TEM was performed as primary excision in 54 patients, after endoscopic forceps biopsy in 57 patients, and after incomplete resection by endoscopic excision in 33 patients. The median size of all primary tumors was 0.6 cm (range, 0.3–2.0 cm), and the negative resection margin was achieved in 142 (98.6%) patients. Postoperative complications (referring to only bleeding) occurred in 3 (2.1%) patients and was successfully managed with conservative method. After a median follow-up of 75.5 months after surgery, 3 patients died of other causes, and 2 patients suffered metastasis. An anal function questionnaire was posted 24 months after TEM. Among the results, 3 (2.1%) patients complained of major low anterior resection syndrome (LARS), including 1 (0.7%) who suffered from complete incontinence, while 6 (4.2%) patients had minor LARS.

Conclusions

TEM has satisfying long-term outcomes and relatively low anal function disturbance as for the treatment of small RNET. TEM also acts as a preferred salvage treatment for incomplete endoscopic excision.

Tumor Differentiation is the Dominant Prognostic Factor for Patients with Colorectal Neuroendocrine Neoplasms with Distant Metastasis

PURPOSE

Colorectal neuroendocrine neoplasms (NENs) are rare tumors. The prognosis and prognostic factors of metastatic colorectal NENs have not been fully elucidated.

METHODS

We retrospectively enrolled 77 consecutive patients diagnosed with colorectal NENs with synchronous distant metastases between 2000 and 2021. All patients were assigned to the neuroendocrine tumor (NET) group or the neuroendocrine carcinoma (NEC) group based on histological differentiation. Propensity score matching (PSM) was performed to minimize confounding bias. The Kaplan-Meier method was used to calculate the survival rates. Univariate and multivariate logistic regression analyses were performed to identify prognostic factors.

RESULTS

In total, 35 (45.5%) and 42 (54.5%) patients had well-differentiated NETs and poorly differentiated NECs, respectively. The median overall survival (OS) was 26 months for the entire cohort, and the 1-year, 3-year, and 5-year OS rates were 69.4%, 41.4%, and 27.8%, respectively. In the subgroup analysis, the median OS was 62 and 10 months for NETs and NECs, respectively. Univariate analysis demonstrated that patients with a primary tumor located in the colon, ulcerative tumors and poorly differentiated tumors were at higher risk for poorer progression-free survival (PFS) and OS. However, only histological differentiation was identified as an independent factor affecting OS (hazard ratio (HR) = 8.28, 95% confidence interval (CI): 2.98-23.01, P < 0.001) in multivariate analysis. After PSM, histological differentiation was further confirmed as the dominant factor affecting OS (HR = 6.09, 95% CI: 1.96-18.95, P=0.002)).

CONCLUSION

Histological differentiation was the most dominant prognostic factor in patients with metastatic colorectal NENs. Patients with well-differentiated NETs had a good chance of long-term survival.

Risk factors for lymph node metastasis and prognosis in colorectal neuroendocrine tumours

PURPOSE

The detection rate of colorectal neuroendocrine tumours (CR-NETs) is increasing, but their treatment is still controversial. Lymph node metastasis is an important reference index for the selection of treatment. The aim of our study was to investigate the factors associated with lymph node metastasis and prognosis of CR-NETs.

METHODS

The case characteristics of patients with colorectal neuroendocrine tumours from January 2011 to December 2020 were retrospectively analysed, including age, gender, tumour size, tumour location, lymph node metastasis, pathological grade and follow-up.

RESULTS

A total of 195 cases of CR-NETs were included in this study. When 15 mm was used as the cut-off value, the sensitivity, specificity and area under the curve (AUC) of lymph node metastases were 95.9%, 95.2% and 0.986, respectively. Multivariate analysis suggested that tumour size ≥ 15 mm (OR: 30.517, 95% CI: 1.250 ~ 744.996, p = 0.036) and lymphovascular invasion (OR: 42.796, 95% CI: 2.882 ~ 635.571, p = 0.006) were independent risk factors for lymph node metastasis. Age ≥ 56 (HR: 7.434, 95% CI: 1.334 ~ 41.443, p = 0.022) and distant metastasis (HR: 24.487, 95% CI: 5.357 ~ 111.940, p < 0.001) were independent prognostic factors in multivariable analyses.

CONCLUSIONS

When the size of a CR-NET is ≥ 15 mm, the risk of lymph node metastasis is higher, and it is recommended to choose the surgical method carefully. Tumour size and lymphovascular invasion were independent risk factors for lymph node metastasis. Age ≥ 56 and distant metastasis were independent prognostic factors.

Evaluation of radical surgical treatment in the management of 58 locally advanced rectal neuroendocrine neoplasms, one multicenter retrospective study

BACKGROUND

Locally advanced rectal neuroendocrine neoplasms (NENs) are rare, and the therapeutic effects of surgery in improving the prognosis have been questioned in previous reports.

MATERIALS AND METHODS

The research included 58 consecutive patients with locally advanced rectal NENs from three Chinese medical centers between 2000 and 2020. All have received radical surgical treatment. The clinicopathological and survival data were collected. Kaplan-Meier methods and a Cox proportional hazards regression model were used to evaluate the prognosis and identify independent prognostic factors.

RESULTS

All patients were followed up for a median period of 36 (2-125) months. Of the 58 patients, 13 (22.4%) had G1 neuroendocrine tumors (NETs), 15 (25.9%) had G2 NETs, 6 (10.3%) had G3 NETs, and the remaining 24 (41.4%) patients had G3 neuroendocrine carcinomas (NECs). The 1-year and 3-year disease-free survival (DFS) rates were 64.5% and 48.8%, respectively. The 1-year and 3-year overall survival (OS) rates were 90.5% and 75.4%, respectively. Univariate analysis demonstrated that tumor differentiation (p = 0.002), gross morphology (p = 0.009), T stage (p = 0.024), and extramural vascular invasion (p = 0.009) were associated with the OS. The subsequent multivariate analysis confirmed that tumor differentiation [hazard ratio (HR) = 6.002, 95% confidence interval (CI): 1.210-29.767, p = 0.028] and gross morphology (HR = 3.438, 95% CI: 1.038-11.382, p = 0.043) were independent prognostic factors affecting the clinical outcomes.

CONCLUSIONS

Rectal NENs are a heterogeneous group of diseases. The survival benefits obtained from surgery vary widely based on the tumor clinicopathological features. Patients with G3 NECs and ulcerative mass are at high risks of poor prognosis.

Prognosis for Poorly Differentiated, High-Grade Rectal Neuroendocrine Carcinomas

INTRODUCTION

Rectal neuroendocrine carcinomas (rNECs) are poorly characterized and, given their aggressive nature, optimal management is not well-established. We therefore sought to describe clinicopathologic traits, treatment details, and survival patterns for patients with rNECs.

METHODS

Patients captured in the National Cancer Database (NCDB; 2004-2016) with rNECs managed with observation, chemotherapy, or proctectomy ± chemotherapy were considered for analysis.

RESULTS

The inclusion criteria were met by 777 patients. Mean age was 62.4 years, 45% were male, 80% were Caucasian, 40% presented with lymph nodes metastases, and 49% presented with distant metastases. Chemotherapy and surgical resection were administered in 72 and 19% of cases, respectively. Median overall survival (OS) was 0.83 years (1 year, 41%; 3 years, 13%; 5 years, 10%). During the study interval, 659 (85%) patients died, with a median follow-up of 0.79 years. On multivariable analysis, age ≥60 years, male sex, and distant metastases were associated with worse survival; surgical resection and administration of chemotherapy were associated with a reduced risk of death. Among non-metastatic patients treated with surgical resection, administration of chemotherapy was protective, while a positive lymph node ratio (LNR) ≥42% (median value) was associated with an increased risk of death. There was no difference in the number of examined lymph nodes between LNR cohorts.

CONCLUSIONS

Patients with rNECs experience dismal survival outcomes, including those with non-metastatic disease treated with curative-intent surgical resection. Neoadjuvant therapy can serve as a useful biologic test, and surgical resection should be judiciously employed.

Tumor grade 2 as the independent predictor for lymph node metastasis in 10-20 mm sized rectal neuroendocrine tumor

Purpose

Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10-20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10-20 mm sized rectal NET and utilize them to decide upon the treatment strategy.

Methods

Twenty-eight patients with 10-20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (-) groups, and their respective data were analyzed.

Results

Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (-) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17-1,188.64; P=0.010).

Conclusion

Tumor grade 2 was the independent factor predicting LNM in 10-20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Digestive Well-Differentiated Grade 3 Neuroendocrine Tumors: Current Management and Future Directions

Digestive well-differentiated grade 3 neuroendocrine tumors (NET G-3) have been clearly defined since the 2017 World Health Organization classification. They are still a rare category lacking specific data and standardized management. Their distinction from other types of neuroendocrine neoplasms (NEN) not only lies in morphology but also in genotype, aggressiveness, functional imaging uptake, and treatment response. Most of the available data comes from pancreatic series, which is the most frequent tumor site for this entity. In the non-metastatic setting, surgical resection is recommended, irrespective of grade and tumor site. For metastatic NET G-3, chemotherapy is the main first-line treatment with temozolomide-based regimen showing more efficacy than platinum-based regimen, especially when Ki-67 index <55%. Targeted therapies, such as sunitinib and everolimus, have also shown some positive therapeutic efficacy in small samples of patients. Functional imaging plays a key role for detection but also treatment selection. In the second or further-line setting, peptide receptor radionuclide therapy has shown promising response rates in high-grade NEN. Finally, immunotherapy is currently investigated as a new therapeutic approach with trials still ongoing. More data will come with future work now focusing on this specific subgroup. The aim of this review is to summarize the current data on digestive NET G-3 and explore future directions for their management.

Grade G2 Rectal Neuroendocrine Tumor Is Much More Invasive Compared With G1 Tumor

Background

To compare clinicopathologic feature of rectal neuroendocrine tumor (NET) grade G1 with G2 NET.

Methods

Six hundred-one cases of rectal G1 and G2 NETs diagnosed in our center were analyzed.

Results

Of 601 cases of rectal NET, 515 cases were with grade G1 and 86 cases were with grade G2. Median tumor size was 0.7 cm. Compared with G1 NET, G2 tumors were with significantly larger tumor size (0.8 vs 2.2 cm, p < 0.001), less percentages of patients with tumors confined to submucosa (92.6 vs 42.8%, p < 0.001), more frequent presence of microvascular invasion (MVI) (3.6 vs 16.9%, p < 0.001) or peri-neural invasion (PNI) (2.0 vs 24.1%, p < 0.001). Incidence of lymph node and distant metastasis was 5.2 and 2.1% in G1 NET compared with 44.2 and 31.4% in G2 tumor, respectively (p < 0.001). For tumors sized 1–2 cm and confined to submucosa, incidence of lymph node metastasis was 6.1% for G1 NET compared with 21.1% for G2 NET. Status of MVI/PNI was predictive of lymph node metastasis for G2 tumor rather than G1 NET in this subgroup.

Conclusions

Rectal G2 NET was much more invasive with significantly elevated prevalence of lymph node metastasis compared with G1 tumor.

Update on gastroenteropancreatic neuroendocrine tumors

The incidence gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) has dramatically risen over the last three decades, probably due to the increased detection of asymptomatic lesions. The diagnostic work-up for patients with suspected GEP-NENs is based on conventional imaging, endoscopy, pathology, and functional imaging, including 68Gallium-DOTATATE PET and 18F-FDG PET. The choice of the best treatment strategy should be based on the evaluation of tumor-related features and patient's characteristics. A conservative management, consisting of active surveillance or endoscopic resection, has been advocated for patients with small, incidentally discovered, nonfunctioning tumors without features of aggressiveness. On the other hand, surgery with lymphadenectomy, also with a minimally invasive approach, represents the gold standard for the curative treatment of localized disease. Moreover, surgical resection plays an important role also in the context of a multimodal treatment strategy for patients with advanced GEP-NENs. Finally, a wide range of medical therapies, comprising somatostatin analogues, peptide receptor radionuclide therapy, target therapies and several chemotherapy regimens, can be offered to patients with advanced GEP-NENs not amenable of surgical resection, according to the biological and molecular features of their disease.

Prediction of the World Health Organization Grade of rectal neuroendocrine tumors based on CT histogram analysis

OBJECTIVES

To investigate the diagnostic value of contrast-enhanced computed tomography (CECT) histogram analysis in predicting the World Health Organization (WHO) grade of rectal neuroendocrine tumors (R-NETs).

MATERIALS AND METHODS

A total of 61 (35 G1, 12 G2, 10 G3, and 4 NECs) patients who underwent preoperative CECT and treated with surgery to be confirmed as R-NETs were included in this study from January 2014 to May 2019. We depicted ROIs and measured the CECT texture parameters (mean, median, 10th, 25th, 75th, 90th percentiles, skewness, kurtosis, and entropy) from arterial phase (AP) and venous phase (VP) images by two radiologists. We calculated intraclass correlation coefficient (ICC) and compared the histogram parameters between low-grade (G1) and higher grade (HG) (G2/G3/NECs) by applying appropriate statistical method. We obtained the optimal parameters to identify G1 from HG using receiver operating characteristic (ROC) curves.

RESULTS

The capability of AP and VP histogram parameters for differentiating G1 from HG was similar in several histogram parameters (mean, median, 10th, 25th, 75th, and 90th percentiles) (all p < 0.001). Skewness, kurtosis, and entropy on AP images showed no significant differences between G1 and HG (p = 0.853, 0.512, 0.557, respectively). Entropy on VP images was significantly different (p = 0.017) between G1 and HG, however, skewness and kurtosis showed no significant differences (p = 0.654, 0.172, respectively). ROC analysis showed a good predictive performance between G1 and HG, and the 75th (AP) generated the highest area under the curve (AUC = 0.871), followed by the 25th (AP), mean (VP), and median (VP) (AUC = 0.864). Combined the size of tumor and the 75th (AP) generated the highest AUC.

CONCLUSIONS

CECT histogram parameters, including arterial and venous phases, can be used as excellent indicators for predicting G1 and HG of rectal neuroendocrine tumors, and the size of the tumor is also an important independent predictor.

Low-grade Rectal Neuroendocrine Tumor Recurring as Multiple Hepatic Metastasis after Complete Endoscopic Removal: A Case Report

The World Health Organization classified rectal neuroendocrine tumors (NETs) as malignant in 2010 owing to their distant metastasis potential. On the other hand, in cases of small rectal NETs (<10 mm), which have a low risk of metastasis, endoscopic removal is the first-line therapeutic option, and regular surveillance is not recommended. The authors report a case of a small, well-differentiated rectal NET, which recurred as multiple hepatic metastases 5 years after apparent complete removal using endoscopic methods.