Endoscopic treatment for early foregut neuroendocrine tumors

Factors associated with gastric and duodenal neuroendocrine tumors: A multicenter case-control study

BACKGROUND AND AIMS

The incidence of gastric and duodenal neuroendocrine tumors (GNET and DNET, respectively) is increasing, however associated factors of these diseases are not well known. Here, we investigated the factors associated with GNET and DNET.

METHODS

Patients with GNET and DNET presenting at eight tertiary referral centers between 2001 and 2020 were included and compared with healthy controls who underwent upper endoscopic screening. Clinical factors and laboratory data were analyzed to determine associated factors of GNET and DNET.

RESULTS

Overall, 396 patients with GNET and 193 patients with DNET were included and compared with 1725 healthy controls. Multivariate analysis showed that age (odds ratio [OR] 0.98), diabetes (OR 1.72), hypertension (OR 1.97), low serum high-density lipoprotein cholesterol (HDL-C) levels (OR 2.54), and past/present H. pylori infection (OR 1.46) were significantly associated with GNET. In contrast, DNET was significantly associated with diabetes (OR 1.80), hypertension (OR 1.68), low serum HDL-C levels (OR 2.29), and past/present H. pylori infection (OR 5.42). In the sex-based subgroup analysis in GNET, current smoking was strongly associated in women (OR 9.85), but not in men.

CONCLUSIONS

This study identified several common metabolic factors associated with GNET and DNET. Additionally, some factors had sex-specific associations.

Efficacy and safety of 177Lu‑DOTATATE in patients with advanced pancreatic neuroendocrine tumours: data from the NETTER-R international, retrospective study

Purpose

NETTER-R aimed to determine the efficacy, safety and tolerability of ¹⁷⁷Lu-DOTATATE in patients with progressive, advanced pancreatic neuroendocrine tumours (panNETs) using retrospective real-world data from multiple sites.

Methods

This international study retrospectively included patients with panNETs treated with ¹⁷⁷Lu-DOTATATE. The primary endpoint was progression-free survival (PFS) by Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1). Secondary endpoints included overall survival (OS), safety and tumour response.

Results

In total, 110 patients with panNETs were studied; 65.5% received a cumulative dose of ¹⁷⁷Lu-DOTATATE 29.6 GBq ± 10% (median: 7.4 GBq). In 62 patients with available RECIST v1.1 tumour response, the median PFS was 24.8 months (95% confidence interval [CI]: 17.5–34.5), and the objective response rate was 40.3% (95% CI: 28.1–53.6); all responses were partial. With a median follow up of 24.5 months (range: 2.0–123.4 months) after the first cycle of ¹⁷⁷Lu-DOTATATE, the median OS in the full analysis set (n = 110) was 41.4 months (95% CI: 28.6–50.2). PFS (hazard ratio [HR]: 3.672; p = 0.0009) and OS (HR: 3.360; p < 0.0001) were longer in patients who received no chemotherapy prior to ¹⁷⁷Lu-DOTATATE than those who did. No treatment-emergent adverse events (TEAEs) led to treatment discontinuation. Grade 3 anaemia, lymphopenia and thrombocytopenia occurred in 0.9%, 5.4% and 0.9% of patients, respectively. No acute leukaemia or myelodysplastic syndrome was reported. Six patients (5.5%) had renal TEAEs. All renal grade ≥ 3 events were transient and did not lead to treatment modification.

Conclusions

These results reinforce the role of ¹⁷⁷Lu-DOTATATE for the treatment of patients with advanced, somatostatin receptor-positive panNETs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-022-05771-3.

Gastric Neuroendocrine Tumor Mimicking Gastrointestinal Stromal Tumor: A Case Report

Gastric neuroendocrine tumors (NETs) are rare lesions that arise from enterochromaffin-like cells of the gastric mucosa. Gastric NETs are classified into 3 types of NETs and poorly differentiated neuroendocrine cancers. Most gastric NETs usually present as hemispherical, yellowish, polypoid lesions with a central depression and often as subepithelial tumors (SETs) because they are confined within the submucosal layer. Here, we report a case of gastric NET presenting as SET mimicking a gastrointestinal stromal tumor (GIST). Endoscopy revealed a 2.3-cm-sized SET with intact surface mucosa, and endoscopic ultrasonography showed a homogeneous hypoechoic lesion with a well-circumscribed margin. Typical features of gastric NET, such as yellowish mucosal changes or central ulceration, were not observed. GIST was suspected, and a laparoscopic wedge resection was performed. The final diagnosis was gastric NET with grade 2 differentiation.

Incidence, treatment, and survival analysis in esophageal neuroendocrine carcinoma population

BACKGROUND

As a subtype of esophageal neuroendocrine neoplasms (ENENs), esophageal neuroendocrine carcinoma (ENEC) is rare. ENEC can be poorly differentiated and highly aggressive. This study aims to illustrate the incidence, treatment, and prognosis of ENEC by using a population-based database.

METHODS

We collected clinicopathological data [1975-2016] of ENEC, esophageal adenocarcinoma (EACA), and esophageal squamous cell carcinoma (ESqCC) from the Surveillance, Epidemiology and End Results (SEER) database, and analyzed their incidence, treatment, and prognosis.

RESULTS

A total of 60,238 cases were in our study cohort, including ENEC (n=686), EACA (n=26,575), and ESqCC (n=32,977). The incidence of ENEC in 2016 was 0.044 per 100,000 persons. The tumor grade of ENEC was significantly higher than that of EACA and ESqCC (P<0.001). Both cancer-specific survival (CSS) and overall survival (OS) of ENEC were significantly worse than those of EACA and ESqCC (P<0.001). Kaplan-Meier analysis showed significant improvement of CSS and OS by surgery, radiotherapy, and chemotherapy (all P<0.001). Besides, compared with monotherapies, combinational therapies brought more benefits to both CSS and OS of patients with ENEC.

CONCLUSIONS

Our population-based evidence revealed that ENEC, as a rare cancer, had a worse prognosis, compared with EACA and ESqCC. Surgery, chemotherapy, and radiotherapy can all improve the prognosis of ENEC patients. Combinational therapy can yield a better prognosis than monotherapy.

Prognostic role of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in patients with midgut neuroendocrine tumors undergoing resective surgery

AIM

Several studies demonstrated the prognostic value of the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and platelet-to-white blood cells ratio (PWR) in different types of tumors. However, there is no information about a possible role of NLR, PLR and PWR as predictor of presence of metastasis or multifocal disease in patients undergoing surgery with curative intent for midgut NET. The aim of our study was to test the role of preoperative NLR, PLR and PWR as predictors of patients undergoing surgery with curative intent for midgut NET.

METHODS

We retrospectively enrolled seven foregut, 35 midgut and six hindgut NET patients with gastrointestinal neuroendocrine tumors operated in our Units from January 2005 to June 2016. Details about preoperative laboratory data, surgical operation, histology and follow-up were retrieved. Non-parametric statistics, ROC curve analysis and survival analysis were used.

RESULTS

NLR was significantly higher in patients with distant metastasis (p = 0.04). The ROC curve analysis indicated that a threshold value of NLR of 2.6 predicted the presence of peritoneal metastasis with a specificity of 100% and a sensitivity of 71% and an overall accuracy of AUC = 0.81 (95%CI: 0.59-0.94), p = 0.05. PLR and PWR was not be associated to metastasis but tended to be associated to multifocal disease.

CONCLUSION

In patients with midgut NET, an impaired adaptive immune response, as suggested by a high NLR ratio, was associated to the presence of distant metastasis and in particular of peritoneal metastasis. This information may be helpful when planning the treatment of a patient with a midgut NET.

Metastatic neuroendocrine tumor of the esophagus with features of medullary thyroid carcinoma

A 41-year-old female presented with a pedunculated mass in the upper esophagus and bilateral lymphadenopathy. Biopsies suggested a neuroendocrine tumor, possibly carcinoid, and ensuing imaging revealed cervical lymph node metastases. The esophageal mass was removed endoscopically and discovered by pathologists to closely resemble medullary thyroid carcinoma (MTC) on immunohistochemistry staining. Following surgery, further work up demonstrated very high serum calcitonin levels, suggestive of medullary thyroid carcinoma, however the thyroid gland was normal on ultrasound. The patient underwent a neck dissection to remove the lymph node metastases and subsequently her calcitonin levels dropped to 0 ng/mL, indicating remission. It appears that the primary tumor was not in the thyroid, but in the cervical esophagus. The thyroid has appeared normal on multiple ultrasounds without any detectable nodules or masses. This is quite a unique case because this patient presented with a tumor resembling medullary carcinoma of the thyroid that presented as a pedunculated mass in the cervical esophagus. The actual final diagnosis of this mass in the cervical esophagus was neuroendocrine tumor (NET), consistent with a carcinoid tumor, not ectopic MTC. This case report highlights that calcitonin-secreting tumors outside the thyroid should not lead to erroneous recommendations for thyroidectomy.

The Risk Factors for Metastasis in Non-Ampullary Duodenal Neuroendocrine Tumors Measuring 20 mm or Less in Diameter

BACKGROUND/AIMS

The treatment strategy for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤20 mm in diameter has not been established. In this study, we aimed to evaluate the detailed characteristics of NAD-NETs ≤20 mm in diameter to clarify the risk factors of subsequent metastasis.

METHODS

The patients with NAD-NETs ≤20 mm in diameter who had been treated at 12 institutions between 1992 and 2013 were enrolled. Clinical records were retrieved, and histopathological findings of all cases were centrally reviewed by 2 pathologists.

RESULTS

We studied 49 patients with a mean follow-up period of 66.5 months. Thirty-five patients were initially treated with endoscopic resection (ER), and 14 with surgery. A univariate analysis revealed the ORs and 95% CIs of the risk factors for metastasis were lymphovascular invasion (12.5 [2.01-77.9]), multiple tumors (9.75 [1.46-65.4]), a tumor size of 11-20 mm (6.67 [1.21-36.6]), and World Health Organization grade G2 (7.13 [1.16-43.9]). Five-year overall and disease-specific survival rates were 86.1 and 97.2%, respectively.

CONCLUSION

This is the first study to demonstrate the risk factors of metastasis in NAD-NETs ≤20 mm in diameter. These findings may be helpful for determining the appropriate therapeutic approach and the clinical strategy of treatment following ER.

Correlation of Ki-67 indices from biopsy and resection specimens of neuroendocrine tumours

INTRODUCTION Neuroendocrine tumours (NETs) are a heterogeneous group of tumours with a highly variable presentation and prognosis. Management decisions are complex. Ki-67 levels in tissue samples are a key indicator used to grade tumours and guide treatment. This study assessed whether the Ki-67 index and tumour grade generated from tissue samples correlated with that assessed in resection specimens. METHODS This was a retrospective cohort analysis of all patients who had both a tissue sample and a resection specimen analysed in our trust, a tertiary referral centre, during 2012 and 2013. RESULTS Data from 36 patients were reviewed. Ki-67 indices from tissue samples and resection specimens showed strong correlation (r=0.95, p<0.001). Tumour grading was the same in the tissue sample and resection specimens for 22 patients (61.1%). In four patients (11.1%), the tissue sample overestimated the grade while in ten (27.8%), the sample underestimated the grade. CONCLUSIONS In most cases, the Ki-67 index and tumour grade from the tissue sample matched that of the resection specimen. However, in nearly 40% of cases, the tissue sample grading did not match the resection tumour grading. In the majority of these, the tissue sample underestimated disease activity. A low Ki-67 index in a tissue sample should therefore be taken as provisional and should not, in isolation, persuade clinicians to choose a more conservative treatment approach if there is clinical, biochemical or radiological evidence suggestive of a more aggressive disease pathology.

Neuroendocrine carcinoma of the esophagus: clinical characteristics and prognostic evaluation of 49 cases with surgical resection

BACKGROUND

The clinicopathological features and optimum treatment of esophageal neuroendocrine carcinoma (NEC) are hardly known due to its rarity. Therefore, we conducted a retrospective study to analyze the clinical characteristics and prognosis of patients with surgically resected esophageal NEC.

METHODS

We collected clinicopathological data on consecutive limited disease stage esophageal NEC patients who underwent esophagectomy with regional lymphadenectomy in West China Hospital from January 2007 to December 2013.

RESULTS

A total of forty-nine patients were analyzed retrospectively. The mean age of the patients was 58.4±8.2 years with male predominance. Fifty-five percent of the esophageal NEC were located in the middle thoracic esophagus. Histologically, 28 (57.1%) patients were found to be small cell NECs. Fifty-one percent of the patients were found to have lymph node metastasis. According to the 2009 American Joint Committee on Cancer (AJCC) staging system for esophageal squamous cell carcinoma, 9 patients were at stage I, 21 patients stage II, and 19 patients stage III. Twenty-six patients (53.1%) received adjuvant therapy. After a median follow-up of 44.8 months [95% confidence interval (CI), 35.2-50.4 months], the median survival time of the patients was 22.4 months (95% CI, 14.0-30.8 months). The 1-year and 3-year survival rates for the whole cohort patients were 74.9% and 35.3%, respectively. In univariate analysis, TNM staging, lymph node metastasis and adjutant therapy significantly influenced survival time. In multivariate analysis, TNM staging was the only independent prognostic factor.

CONCLUSIONS

Esophageal NEC has a poor prognosis. The 2009 AJCC TNM staging system for esophageal squamous cell carcinoma may also fit for esophageal NEC. Surgery combined with adjuvant therapy may be a good option for treating limited disease stage esophageal NEC. Further prospective studies defining the optimum therapeutic regimen for esophageal NEC are needed.

Increasing incidence of duodenal neuroendocrine tumors: Incidental discovery of indolent disease?

BACKGROUND

There has been a marked increase in the recognized incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Studies have often combined duodenal neuroendocrine tumors (D-NETs) with other small bowel GEP-NETs. As a result, the natural history and clinical ramifications of these D-NETs is poorly understood.

METHODS

Patients diagnosed with duodenal "carcinoid" tumors from 1983 to 2010 were identified in the Surveillance Epidemiology and End Results tumor registry.

RESULTS

A total of 1,258 patients were identified. The mean age was 64 years. The majority of patients were male (55.6%), white (55.6%), and had stage I disease (66.2%). Patients meeting inclusion criteria were divided into 2 cohorts: (i) era 1 patients diagnosed with GEP-NETs from 1983 to 2005, and (ii) era 2 those diagnosed from 2005 to 2010. There was a clear increase in the incidence rate of D-NETs from 0.27 per 100,000 in 1983 to 1.1 per 100,000 in 2010 (P < .001). Comparison of patients from the different eras revealed that those in era 2 were more likely than era 1 to present with stage I disease (69.9 vs 57.5%; P < .01) and less likely to present with late-stage disease. The 5-year, disease-specific survival improved for era 2 patients compared with era 1 (89.3 vs 85.2%; P = .05); however, multivariate analysis demonstrated that stage but not era was associated with disease-specific survival.

CONCLUSION

Prognosis for D-NETs, in contrast with other small bowel NETs, is excellent. There has been a steady increase in the recognized incidence of D-NETs, coincident with the migration to earlier disease stage and improved disease-specific survival.