Prognostic value of tumor-to-parenchymal contrast enhancement ratio on portal venous-phase CT in pancreatic neuroendocrine neoplasms

OBJECTIVES

We aimed to evaluate the prognostic value of tumor-to-parenchymal contrast enhancement ratio on portal venous-phase CT (CER on PVP) and compare its prognostic performance to prevailing grading and staging systems in pancreatic neuroendocrine neoplasms (PanNENs).

METHODS

In this retrospective study, data on 465 patients (development cohort) who underwent upfront curative-intent resection for PanNEN were used to assess the performance of CER on PVP and tumor size measured by CT (CT-Size) in predicting recurrence-free survival (RFS) using Harrell's C-index and to determine their optimal cutoffs to stratify RFS using a multi-way partitioning algorithm. External data on 184 patients (test cohort) were used to validate the performance of CER on PVP in predicting RFS and overall survival (OS) and compare its predictive performance with those of CT-Size, 2019 World Health Organization classification system (WHO), and the 8th American Joint Committee on Cancer staging system (AJCC).

RESULTS

In the test cohort, CER on PVP showed C-indexes of 0.83 (95% confidence interval [CI], 0.74-0.91) and 0.84 (95% CI, 0.73-0.95) for predicting RFS and OS, respectively, which were higher than those for the WHO (C-index: 0.73 for RFS [p = .002] and 0.72 for OS [p = .004]) and AJCC (C-index, 0.67 for RFS [p = .002] and 0.58 for OS [p = .002]). CT-Size obtained C-indexes of 0.71 for RFS and 0.61 for OS.

CONCLUSIONS

CER on PVP showed superior predictive performance on postoperative survival in PanNEN than current grading and staging systems, indicating its potential as a noninvasive preoperative prognostic tool.

KEY POINTS

• In pancreatic neuroendocrine neoplasms, the tumor-to-parenchymal enhancement ratio on portal venous-phase CT (CER on PVP) showed acceptable predictive performance of postoperative outcomes. • CER on PVP showed superior predictive performance of postoperative survival over the current WHO classification and AJCC staging system.

Cutaneous metastasis on the nasal tip: first clinical sign of pulmonary carcinoid tumor

Skin metastases are rare and may occur in the context of a known metastatic disease or be the first clinical sign of an underlying primary tumor. In the case of carcinoid neoplasms, determining whether the cutaneous tumor is primary or secondary and identifying the tumor origin in metastatic cases is not always an easy task. This is the report of a case of cutaneous metastasis presenting as the first clinical manifestation of a previously unknown pulmonary carcinoid tumor, including the discussion of histopathological and immunohistochemical findings that allowed an adequate diagnosis of the tumor etiology and reinforces the importance for dermatologists and dermatopathologists to be familiar with these findings.

Hepatic neuroendocrine neoplasm: imaging patterns

Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors with distinct morphological and biological manifestations, the liver being the main organ affected by its metastases. However, primary hepatic involvement is quite rare. Hepatic NENs can have a variety of radiological presentation forms and can therefore mimic other lesions, making their diagnosis challenging. Nonetheless, certain imaging aspects allow NENs to be included among the main differential diagnoses of hepatic lesions and can guide the search for an extrahepatic primary site when the probable diagnosis is metastases.

Primary carcinoid tumor in the external auditory canal

A 39-year-old man visited the department of otolaryngology due to an ongoing hearing disturbance that had lasted for 1 year. Temporal bone computed tomography revealed soft tissue density nearly obliterating the left external auditory canal (EAC). The mass was composed of sheets of round tumor cells containing moderate amounts of fine granular cytoplasm and salt and pepper chromatin. Neither mitosis nor necrosis was found. The Ki-67 proliferation index was less than 2%. Cells were positive for CD56 and synaptophysin but negative for chromogranin, cytokeratin (CK) 20, and CK7. Based on these findings, the tumor was diagnosed as a carcinoid tumor, well differentiated neuroendocrine carcinoma, grade 1 (G1) according to current World Health Organization (WHO) classification of head and neck tumors; and a neuroendocrine tumor, G1 according to neuroendocrine neoplasm (NEN)-2018 WHO standard classification. He remained free of local recurrence and metastasis after 20 months of follow up. To date, only six cases of primary NENs in the EAC have been reported. Metastatic tumor should be included in the differential diagnoses. Because of its rarity, the prognosis and treatment have not yet been clarified.

[Gastric mixed adenoneuroendocrine carcinoma: a clinicopathological analysis of 36 cases]

Objective: To investigate the clinicopathological characteristics of gastric mixed adenoneuroendocrine carcinoma (MANEC). Methods: The clinical and pathologic data of 36 cases of gastric MANEC collected from January 2011 to December 2018 in the Department of Pathology, Fujian Provincial Hospital were retrospectively analyzed. Light microscopy and EnVision immunohistochemical (IHC) staining were used in the study. The results were compared with 40 cases of gastric neuroendocrine carcinoma collected within the same period. Results: The 36 cases were collected, there were 29 males and 7 females. The patients' age ranged from 43 to 87 years (mean 66 years). The tumor diameter ranged from 1.0 to 9.0 cm (mean 5.0 cm). Clinical staging showed that four cases were at T1+T2 stages and 32 cases were at T3+T4 stages. The main clinical manifestations were upper abdominal pain, abdominal distension and dysphagia. Complete follow-up data were obtained in 20 (eleven living and nine dead) patients. Pathologic analysis showed that all tumors were composed of neuroendocrine carcinoma and adenocarcinoma and each of the components was more than 30%. IHC staining showed that CK was expressed in adenocarcinoma; whereas the neuroendocrine carcinoma mainly expressed CD56 and Syn. There was no significant difference in age, sex, T stage and prognosis between gastric MANEC and gastric neuroendocrine carcinoma(P>0.05). Gastric neuroendocrine carcinoma predominantly occurred in the esophagogastric junction and the gastric body but only rarely in the gastric antrum; gastric MANEC mainly occurred in the esophagogastric junction and the gastric antrum but rarely in the gastric body. Gastric MANEC was more prone to lymph node metastasis than gastric neuroendocrine cancer(P<0.05). Conclusions: Most of the gastric MANEC patients are middle-aged and elderly males, and the tumors predominantly occur in the esophagogastric junction and the gastric antrum. Most of the patients are found to have higher stages, and most of them have lymph node metastases and poor prognosis.

Large Cell Neuroendocrine Carcinoma of the Extrahepatic Bile Duct

Primary neuroendocrine tumors originating from the extrahepatic bile duct are rare. Among these tumors, large cell neuroendocrine carcinomas (NECs) are extremely rare. A 59-year-old man was admitted to Sanggye Paik Hospital with jaundice that started 10 days previously. He had a history of laparoscopic cholecystectomy, which he had undergone 12 years previously due to chronic calculous cholecystitis. Laboratory data showed abnormally elevated levels of total bilirubin 15.3 mg/dL (normal 0.2-1.2 mg/dL), AST 200 IU (normal 0-40 IU), ALT 390 IU (normal 0-40 IU), and gamma-glutamyl transferase 1,288 U/L (normal 0-60 U/L). Serum CEA was normal, but CA 19-9 was elevated 5,863 U/mL (normal 0-37 U/mL). Abdominal CT revealed a 4.5 cm sized mass involving the common bile duct and liver hilum and dilatation of both intrahepatic ducts. Percutaneous transhepatic drainage in the left hepatic duct was performed for preoperative biliary drainage. The patient underwent radical common bile duct and Roux-en-Y hepaticojejunostomy for histopathological diagnosis and surgical excision. On histopathological examination, the tumor exhibited large cell NEC (mitotic index >20/10 high-power field, Ki-67 index >20%, CD56 [+], synaptophysin [+], chromogranin [+]). Adjuvant concurrent chemotherapy and radiotherapy were started because the tumor had invaded the proximal resection margin. No recurrence was detected at 10 months by follow-up CT.

Combined Hepatocellular Carcinoma and Neuroendocrine Carcinoma with Ectopic Secretion of Parathyroid Hormone: A Case Report and Review of the Literature

Primary combined hepatocellular carcinoma (HCC) and neuroendocrine carcinoma is a rare entity, and so is hypercalcemia due to ectopic parathyroid hormone (PTH) secretion by tumor. A 44-year old man with hepatitis B virus associated chronic liver disease presented with a hepatic mass. Hemihepatectomy discovered the mass as combined HCC and poorly differentiated cholangiocarcinoma. During adjuvant chemoradiation therapy, he presented with nausea, and multiple systemic metastases were found. Laboratory tests revealed hypercalcemia with markedly elevated PTH and neuron specific enolase. Parathyroid scan showed normal uptake in parathyroid glands, suggestive of ectopic PTH secretion. Subsequently, immunohistochemistry of neuroendocrine marker was performed on the primary lesion, and confirmed the neuroendocrine differentiation in non-HCC component. The patient died 71 days after surgery. This report may suggest the possibility of ectopic PTH secretion by neuroendocrine carcinoma of hepatic origin causing hypercalcemia. Caution for neuroendocrine differentiation should be exercised when diagnosing poorly differentiated HCC.

[Neuroendocrine carcinoma of cervix: a clinicopathologic study of 82 cases]

Objective: To investigate the clinicopathological characteristics and prognostic factors of neuroendocrine carcinoma (NEC) of the cervix. Methods: Eight-two patients diagnosed as NEC of cervix from 2008 to 2016 at West China Second University Hospital were analyzed retrospectively including HE slide review, immunohistochemistry and HPV genotyping. Survival analysis was performed using Kaplan-Meier and Cox regression model. Results: The age of the patients ranged from 16 to 75 years with mean age of 43 years. According to International Federation of Gynecology and Obstetrics (FIGO) clinical stage, 52 cases were in stageⅠ, 10 cases in stageⅡ, 14 cases in stage Ⅲ and 6 cases in stage Ⅳ. The tumor size ranged from 0.5 to 6.5 cm, with an average of 3.6 cm. Upon histopathologic review, 74 tumors were classified as small cell carcinoma; 7 tumors as large cell NEC, and 1 as atypical carcinoid. Further evaluation showed 52 cases (63.4%) with deep stromal invasion, 73 cases (89.0%) with lymph-vascular invasion, and 28 cases (34.2%) with pelvic and (or) para-aortic lymph nodes involvement. Immunohistochemical staining showed neuroendocrine markers Syn, CD56, NSE, S-100 protein and CgA were positive in 93.9%, 84.2%, 74.4%, 64.6% and 51.2% of cases, respectively. The results of HPV-DNA detection were positive in 72 cases, high-risk HPV types were 70 cases and 49 cases were HPV18 positive. The median follow-up time was 37 months (range, 6-101 months). Twenty-nine cases were found recurrence or metastasis, including 23 cases of death. The univariate analysis demonstrated that the tumor size, lymph node metastasis, infiltration depth, FIGO stage and whether the lesion confined to the uterus were significant prognostic factors(P<0.05). Cox multivariate analysis showed that lymph node metastasis and FIGO stage were independent prognostic factors of NEC(P<0.05). Conclusions: NEC of the cervix is a highly aggressive malignancy with poor prognosis. The tumor is associated with HPV infection, especially type 18. Small cell NEC is the most common type of cervical NEC. Diagnosis is based on histological and immunohistochemical examination. Lymph node metastasis and FIGO stage are the independent factors affecting prognosis.

A gastric composite tumor with an adenocarcinoma and a neuroendocrine carcinoma: a case report

A 70-year-old woman was admitted to our department with epigastric discomfort and nausea over the duration of 1 month. An esophagogastroduodenoscopy showed the presence of a 1.0×1.0 cm-sized flat lesion with central ulceration at the greater curvature side of the antrum. A biopsy demonstrated the presence of an adenocarcinoma of well differentiated, intestinal type in the stomach. Endoscopic submucosal dissection was done and the diagnosis of a composite neuroendocrine carcinoma with an adenocarcinoma of the stomach was confirmed. We report a case of a gastric composite tumor with an adenocarcinoma and neuroendocrine carcinoma confirmed by endoscopic submucosal dissection with a review of the literature.

Morphologic analysis of pulmonary neuroendocrine tumors

Background

Few studies on how to diagnose pulmonary neuroendocrine tumors through morphometric analysis have been reported. In this study, we measured and analyzed the characteristic parameters of pulmonary neuroendocrine tumors using an image analyzer to aid in diagnosis.

Methods

Sixteen cases of typical carcinoid tumor, 5 cases of atypical carcinoid tumor, 15 cases of small cell carcinoma, and 51 cases of large cell neuroendocrine carcinoma were analyzed. Using an image analyzer, we measured the nuclear area, perimeter, and the major and minor axes.

Results

The mean nuclear area was 0.318±0.101 µm² in typical carcinoid tumors, 0.326±0.119 µm² in atypical carcinoid tumors, 0.314±0.107 µm² in small cell carcinomas, and 0.446±0.145 µm² in large cell neuroendocrine carcinomas. The mean nuclear circumference was 2.268±0.600 µm in typical carcinoid tumors, 2.408±0.680 µm in atypical carcinoid tumors, 2.158±0.438 µm in small cell carcinomas, and 3.247±1.276 µm in large cell neuroendocrine carcinomas. All parameters were useful in distinguishing large cell neuroendocrine carcinoma from other tumors (p=0.001) and in particular, nuclear circumference was the most effective (p=0.001).

Conclusions

Pulmonary neuroendocrine tumors showed nuclear morphology differences by subtype. Therefore, evaluation of quantitative nuclear parameters improves the accuracy and reliability of diagnosis.

Clinicopathological analysis of 21 thymic neuroendocrine tumors

BACKGROUND

Thymic neuroendocrine carcinomas (NECs) are uncommon, for which there is no established information available because of a limited number of epidemiological study in Asia.

METHODS

We reviewed 21 cases of surgically resected thymic NECs, and evaluated their pathological and clinical features.

RESULTS

It showed male predominance (male/female ratio, 15/6) with wide age range from 20 to 72 years (mean age, 49 years). All 21 cases were divided into two types according to the World Health Organization criteria: atypical carcinoid (n=18) and large cell NEC (n=3). Three cases of atypical carcinoid (AC) were associated with ectopic Cushing's syndrome. All the patients (3/3) with large cell NEC (3/3) and 16.7% (3/18) of those with AC died of tumor progression. Common sites of metastasis included lung, lymph node, brain, lumbar spine, mediastinum, bone, and liver.

CONCLUSIONS

In conclusion, thymic neuroendocrine tumors carry a poor prognosis. Regarding the tumor classification, our results showed that a vast majority of carcinoids in the thymus correspond to ACs. In addition, our results also indicate that typical carcinoid is a very rare entity. Some cases of AC exhibited a large size, solid pattern and they showed aggressive clinical behavior, which highlights the spectrum of histologic appearances of thymic NECs.