Neuroendocrine tumors of the stomach: chemotherapy with cisplatin plus irinotecan is effective for gastric poorly-differentiated neuroendocrine carcinoma

Unusual endoscopic findings of gastric neuroendocrine tumor

Gastric neuroendocrine tumor (NET) is sometimes found as a submucosal tumor on upper gastrointestinal endoscopy. Gastric NET with malignant profile and neuroendocrine carcinoma (NEC) show various forms which are difficult to distinguish from gastric cancer and other disease. We report a case of a cauliflower-shaped NET of the stomach. A 61-year-old man was referred to our hospital with a complaint of abdominal fullness. Upper gastrointestinal endoscopic examination revealed an unusual, whitish cauliflower-shaped tumor that belongs to Borrmann type I on the lesser curvature of the gastric antrum. Histological examination of the biopsy specimen revealed NET G2, because the tumor cells were CD56- and synaptophysin-positive by immunohistochemical analysis. A distal gastrectomy with D2 lymphadenectomy was performed. A recurrence in the liver was revealed by follow up computed tomography after 11 months from operation. Combined chemotherapy with irinotecan (CPT-11) plus cisplatin (CDDP) was treated. The patient achieved a partial response, but he died after 31 months from gastrectomy. There is no independent, large-scaled prospective study and no standard treatment for gastric NETs with distant metastases. Our case is reported with a literature review of the treatment of metastatic gastric NET G2.

Post-first-line FOLFOX chemotherapy for grade 3 neuroendocrine carcinoma

There is no standard for second-line chemotherapy in poorly differentiated grade 3 neuroendocrine carcinoma (G3-NEC) patients. We analyzed the antitumor efficacy of 5-fluorouracil and oxaliplatin (FOLFOX) chemotherapy in this population. A single-center retrospective analysis of consecutive G3-NEC patients treated with FOLFOX chemotherapy after failure of a cisplatinum-based regimen between December 2003 and June 2012 was performed. Progression-free survival (PFS), overall survival (OS), response rate, and safety were assessed according to RECIST 1.1 and NCI.CTC v4 criteria. Twenty consecutive patients were included (seven males and 13 females; median age 55; range 23-87 years) with a performance status of 0-1 in 75% of them. Primary location was gastroenteropancreatic in 12, thoracic in four, other in two, and unknown in two patients. There were 12 (65%) large-cell and 7 (30%) small-cell G3-NEC tumors, and 1 (5%) unknown. All patients had distant metastases. Twelve (60%) patients received FOLFOX as second-line treatment and 8 (40%) as third-line treatment or later and the median number of administered cycles was 6 (range 3-14). The median follow-up was 19 months. Median PFS was 4.5 months. Among the 17 evaluable patients, five partial responses (29%), six stable diseases (35%), and six progressive diseases (35%) were observed. Median OS was 9.9 months. Main Grade 3-4 toxicities were neutropenia (35%), thrombopenia (20%), nausea/vomiting (10%), anemia (10%), and elevated liver transaminases (10%). Our results indicate that the FOLFOX regimen could be considered as a second-line option in poorly differentiated G3-NEC patients after cisplatinum-based first-line treatment but warrant further confirmation in future larger prospective studies.

Neuroendocrine Carcinomas of the Gastroenteropancreatic System: A Comprehensive Review

To date, empirical literature has generally been considered lacking in relation to neuroendocrine carcinomas (NECs), the highly malignant subgroup of neuroendocrine neoplasms. NECs are often found in the lungs or the gastroenteropancreatic (GEP) system and can be of small or large cell type. Concentrating on GEP-NECs, we can conclude that survival times are poor, with a median of only 4–16 months depending on disease stage and primary site. Further, this aggressive disease appears to be on the rise, with incidence numbers increasing while survival times are stagnant. Treatment strategies concerning surgery are often undecided and second-line chemotherapy is not yet established. After an analysis of over 2600 articles, we can conclude that there is indeed more empirical literature concerning GEP-NECs available than previously assumed. This unique review is based on 333 selected articles and contains detailed information concerning all aspects of GEP-NECs. Namely, the classification, histology, genetic abnormalities, epidemiology, origin, biochemistry, imaging, treatment and survival of GEP-NECs are described. Also, organ-specific summaries with more detail in relation to disease presentation, diagnosis, treatment and survival are presented. Finally, key points are discussed with directions for future research priorities.

Chemotherapy for advanced poorly differentiated pancreatic neuroendocrine carcinoma

Pancreatic neuroendocrine carcinoma (P-NEC) resembles small cell lung carcinoma in its biologic and clinical features, such as rapid growth and relatively high sensitivity to platinum-based chemotherapy. And, etoposide plus cisplatin (EP) or irinotecan plus cisplatin (IP), recommended by guidelines for the treatment of small cell lung carcinoma, has also been widely used for the treatment of unresectable NEC. Both regimens have been demonstrated to show favorable efficacy and have been acknowledged as de facto standard regimens for unresectable NEC, although it remains unclear which of the two regimens might yield more favorable outcomes. Therefore, a phase III trial of EP vs. IP has been planned for unresectable gastrointestinal, hepatobiliary or pancreatic NEC by the Japan Clinical Oncology Group. For patients with unresectable NEC who are refractory or intolerant to these regimens, no standard regimens have been established. Everolimus, an mTOR inhibitor, is likely to be effective in such patients, as there have been sporadic reports of the usefulness of everolimus in the treatment of P-NEC. A multicenter phase II trial is underway to elucidate the efficacy and safety of everolimus in patients with P-NEC who are refractory or intolerant to EP or IP.

Prognostic significance of neuroendocrine components in gastric carcinomas

BACKGROUND

Gastric neuroendocrine carcinomas (NECs) and mixed adenoneuroendocrine carcinomas (MANECs) are aggressive tumours but the prognostic significance of a neuroendocrine component in <30% of the tumour remains unclear. Here, the implication of neuroendocrine components in gastric carcinomas was assessed according to proportion.

METHODS

Surgically resected primary gastric carcinomas with neuroendocrine morphology (NEM; n=88) from 2000 to 2012 at Asan Medical Center were retrospectively reviewed. Neuroendocrine differentiation (NED) was defined as immunopositivity for one of three neuroendocrine markers (synaptophysin, chromogranin or CD56) within the NEM area. To validate the prognostic significance of NED, these cases were compared with 650 randomly selected gastric adenocarcinomas without NEM from the same time period.

RESULTS

Gastric carcinomas with NEM were reclassified as NEC (⩾70% NED, n=47), MANEC (30-70% NED, n=10), gastric carcinoma with 10-30% NED (GCNED, n=8) and carcinoma with <10% NED (n=23). The survival rates of patients with ⩾10% NED were significantly poorer than those with <10% NED but no survival difference was observed between NEC and MANEC. In univariate analyses, older age (⩾60years), larger tumour size (⩾4cm), advanced stage group, ⩾10% NED and lymphovascular or perineural invasion were indicative of a poor prognosis. Stage group and ⩾10% NED remained as independent prognostic factors by multivariate analysis.

CONCLUSIONS

A minor proportion (10-30%) of NED should not be overlooked in gastric carcinomas with NEM. NED should be carefully evaluated to predict patient outcomes and plan optimal additional therapies.

Multicenter retrospective analysis of systemic chemotherapy for advanced neuroendocrine carcinoma of the digestive system

This study analyzed outcomes of systemic chemotherapy for advanced neuroendocrine carcinoma (NEC) of the digestive system. Clinical data from 258 patients with unresectable or recurrent NEC of the gastrointestinal tract (GI) or hepato-biliary-pancreatic system (HBP), who received chemotherapy, were collected from 23 Japanese institutions and analyzed retrospectively. Patients had primary sites in the esophagus (n = 85), stomach (n = 70), small bowel (n = 6), colorectum (n = 31), hepato-biliary system (n = 31) and pancreas (n = 31). Median overall survival (OS) was 13.4 months the esophagus, 13.3 months for the stomach, 29.7 months for the small bowel, 7.6 months for the colorectum, 7.9 months for the hepato-biliary system and 8.5 months for the pancreas. Irinotecan plus cisplatin (IP) and etoposide plus cisplatin (EP) were most commonly selected for GI-NEC and HBP-NEC. For patients treated with IP/EP (n = 160/46), the response rate was 50/28% and median OS was 13.0/7.3 months. Multivariate analysis among patients treated with IP or EP showed that the primary site (GI vs HBP; hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.35-0.97) and baseline serum lactate dehydrogenase levels (not elevated vs elevated; HR 0.65, 95% CI 0.46-0.94) were independent prognostic factors for OS, while the efficacy of IP was slightly better than for EP (HR 0.80, 95% CI 0.48-1.33; P = 0.389). IP and EP are the most common treatment regimens for NEC of the digestive system. HBP primary sites and elevated lactate dehydrogenase levels are unfavorable prognostic factors for survival. A randomized controlled trial is required to establish the appropriate chemotherapy regimen for advanced NEC of the digestive system. This study was registered at UMIN as trial number 000005176.

Review article: the investigation and management of gastric neuroendocrine tumours

BACKGROUND

Gastric carcinoids (GCs) or neuroendocrine tumours (NETs) are increasingly identified at endoscopy, and account for 0.6-2% of all gastric polyps identified. The SEER database in the US has demonstrated a rising incidence of gastric NETs amongst all NETs; from 2.2% between 1950 and 1969 to 6.0% between 2000 and 2007.

AIM

To review the literature and assist clinicians in managing patients with GCs.

METHODS

A literature search was conducted through MEDLINE using search terms: gastric, carcinoid, neuroendocrine tumour, therapy, endoscopy, mucosal resection, submucosal dissection. Relevant articles were identified through manual review. The reference lists of these articles were reviewed to include further appropriate articles.

RESULTS

There are three types of GCs with important epidemiological, pathophysiological, histological and endoscopic differences that affect prognosis and management. Type 1 and 2 GCs develop in the context of hypergastrinaemia that originates from achlorhydria in atrophic gastritis and a gastrinoma, respectively. Type 3 GCs occur sporadically and independent of gastrin. The histological type, grade and Ki67 index are used to determine prognosis and direct clinical management. Type 1 GCs >1 cm in size and type 2 GCs should be assessed for invasion beyond the submucosa with EUS prior to endoscopic resection with EMR or ESD. Type 3 GCs should be managed as per recommendations for gastric adenocarcinoma. The treatment of advanced disease is multimodal.

CONCLUSIONS

Patients with gastric carcinoids should be discussed in a specialist neuroendocrine tumour multidisciplinary meeting to ensure all treatment options are explored in localised and advanced disease. Areas of controversy exist that need further research.

Multiple scalp metastases from colonic neuroendocrine carcinoma: case report and literature review

Background

Colonic neuroendocrine neoplasms (NENs) are relatively rare tumors with an incidence rate of 0.11–0.21/100,000. NENs account for approximately 0.4% of colorectal neoplasms. Cutaneous metastases of colonic neuroendocrine carcinomas (NECs) are very infrequent, while cases of scalp metastasis are even fewer. Cutaneous metastases are more rare than visceral metastases and usually develop later; therefore, cutaneous metastases as initial distant metastases can be easily overlooked. This is the second case report of a colonic NEC with scalp metastasis. Compared with the previous case, in this instance scalp metastasis developed before visceral metastasis, and the cutaneous lesions were confined to the scalp alone.

Case presentation

A 62-year-old Chinese man, who had undergone radical surgery for a “locoregional” colonic NEC one and half months before, came to our hospital for adjuvant chemotherapy. We found multiple scalp nodules during physical examination. Moreover, these nodules had occurred and had not been detected prior to the patient undergoing radical surgery. The scalp nodules proved to be metastases from colonic NEC as determined using pathological and immunohistochemical examinations following lumpectomy. After one and half months, visceral metastases were detected in this patient. Ultimately, the patient died two months later.

Conclusions

In this report an unusual case of a colonic NEC with initial distant metastasis confined to the scalp is presented. This case is unusual because of the development of cutaneous metastasis before visceral metastasis. The scalp metastasis were initially overlooked, leading to inaccurate staging and radical surgery that was not curative. This demonstrates that distant metastasis can occur during the early phase of tumor growth in these aggressive lesions. Thus, the possibility of distant metastases should be assessed in the initial work up to avoid mistaken clinical staging especially when distant metastases occur only in skin.

Neuroendocrine carcinoma of the stomach: A case report

Neuroendocrine carcinoma (NEC) is a rare tumor, comprising < 1% of stomach cancers. A 55-year-old woman was referred to our hospital with biopsy-proven gastric cancer. A shallow ulcerative lesion was detected in the lesser curvature of the lower body. It was suspected to be early gastric cancer IIA + IIC type. Thus, endoscopic submucosal dissection was performed. She was subsequently diagnosed with NEC, which is aggressive and carries a poor prognosis. We conducted a radical resection and a laparoscopic-assisted distal gastrectomy. The tumor had infiltrated the subserosal layer and 6/42 lymph nodes were involved. The mitotic index was 16/10 high power fields and the Ki-67 labeling index was 26%-50%. The final diagnosis of NEC was made according to the World Health Organization 2010 criteria. She was suspected of having jumping metastasis to the proximal margin. The patient was treated with an oral anticancer drug (5-flurouracil based drug) for 2 years. The patient has been followed up for 3 years without recurrence.

A retrospective review of 126 high-grade neuroendocrine carcinomas of the colon and rectum

BACKGROUND

High-grade neuroendocrine carcinomas (HGNECs) of the colon and rectum are rare, constituting less than 1 % of colorectal cancers. The purpose of this study was to identify the natural history and oncologic outcomes of this disease, describe the use of surgery, and determine the clinical and pathological factors associated with outcomes.

METHODS

Following Institutional Review Board approval, patients with HGNEC were identified from our institutional database. Patient charts and pathology reports were analyzed retrospectively for clinical and pathological factors.

RESULTS

A total of 126 patients with a median follow-up of 9 months were identified. Median survival was 13.2 months, and 85 (67 %) patients had metastatic disease at diagnosis. Three-year overall survival (OS) was 5 and 18 % for patients with and without metastatic disease, respectively. Factors associated with improved OS on multivariable analysis were absence of metastatic disease and presence of an adenocarcinoma component within the tumor. In patients with metastatic disease, response to chemotherapy was the only factor associated with survival. In patients with localized disease, an adenocarcinoma component within the tumor was the only factor associated with survival. Resection of tumor was not associated with survival in either localized or metastatic disease.

CONCLUSION

High-grade colorectal NECs are extremely aggressive tumors with poor prognosis. Patients appear to have a marginally better prognosis if they present without metastatic disease, have an adenocarcinoma component within their tumor, or respond to chemotherapy. Surgery, particularly in the presence of metastatic disease, may not offer a survival benefit for the majority of patients.

Gastroduodenal intussusception caused by a gastric collision tumor consisting of adenocarcinoma and neuroendocrine carcinoma

Adenocarcinoma is the most common histological type of gastric tumor. Gastric tumor arising from collision of an adenocarcinoma with a neuroendocrine carcinoma is extremely rare. Moreover, this uncommon gastric collision tumor in our case had prolapsed into the duodenum. A 77-year-old woman was admitted to our hospital complaining of vomiting and severe weight loss. Abdominal X-ray showed gastric distension, and computed tomography revealed a duodenal giant mass spreading from the bulb to the horizontal part of the duodenum. Upper gastrointestinal endoscopy was not helpful in confirming the diagnosis of the tumor. We suspected duodenal malignant tumor and performed laparotomy. The operative findings indicated that the gastric antrum was deeply invaginated into the duodenum because of the gastric tumor. Partial resection of the stomach and duodenum was performed because the tumor was irreducible. Intraoperative diagnosis of the frozen section was well-differentiated adenocarcinoma and undifferentiated carcinoma. Additional distal gastrectomy with lymphadenectomy was performed. We herein report the first case of gastroduodenal intussusception caused by a gastric collision tumor consisting of well-differentiated adenocarcinoma and poorly differentiated neuroendocrine carcinoma.

Classification, clinicopathologic features and treatment of gastric neuroendocrine tumors

Gastric neuroendocrine tumors (GNETs) are rare lesions characterized by hypergastrinemia that arise from enterochromaffin-like cells of the stomach. GNETs consist of a heterogeneous group of neoplasms comprising tumor types of varying pathogenesis, histomorphologic characteristics, and biological behavior. A classification system has been proposed that distinguishes four types of GNETs; the clinicopathological features of the tumor, its prognosis, and the patient’s survival strictly depend on this classification. Thus, correct management of patients with GNETs can only be proposed when the tumor has been classified by an accurate pathological and clinical evaluation of the patient. Recently developed cancer therapies such as inhibition of angiogenesis or molecular targeting of growth factor receptors have been used to treat GNETs, but the only definitive therapy is the complete resection of the tumor. Here we review the literature on GNETs, and summarize the classification, clinicopathological features (especially prognosis), clinical presentations and current practice of management of GNETs. We also present the latest findings on new gene markers for GNETs, and discuss the effective drugs developed for the diagnosis, prognosis and treatment of GNETs.

Combination of irinotecan and a platinum agent for poorly differentiated neuroendocrine carcinomas

Extrapulmonary poorly differentiated neuroendocrine carcinoma (PDNEC) is a rare and highly aggressive neoplasm for which the optimal chemotherapy remains unclear. The objective of this study was to evaluate the outcomes of patients with PDNEC treated with cisplatin and irinotecan (IP) and perform a review of the literature. From 2008 to 2012, patients with advanced PDNEC (Ki67≥20%) who received the IP combination were selected for analysis. Radiologic responses were determined through Response Evaluation Criteria In Solid Tumors criteria. Twenty-eight patients were included. The median age at diagnosis was 57 years and the most common presentation was pancreatic PDNEC. Twenty-five patients (89%) received chemotherapy with cisplatin and irinotecan and three received carboplatin and irinotecan. Forty-six percent of the patients achieved objective response and the median time to tumor progression was 3.7 months. The median overall survival was 11.7 months. Thirteen patients (46%) had treatment interruptions or dose reductions due to grade 3/4 toxicity. This retrospective cohort of advanced extrapulmonary PDNEC patients suggests that the IP combination is feasible and resulted in similar response rate and median survival to other treatments previously reported.

Feasibility and efficacy of combined cisplatin plus irinotecan chemotherapy for gastroenteropancreatic neuroendocrine carcinomas

No standard treatment is currently available for gastroenteropancreatic neuroendocrine carcinomas (GEP-NEC). Therefore, we conducted this study to evaluate the effect of the combination of irinotecan and cisplatin in the treatment of GEP-NECs. Clinical data of 16 locally advanced or metastatic GEP-NEC patients treated with irinotecan plus cisplatin regimen in our center from September 2009 to August 2011 were reviewed. The regimen included 2-week cycles of 180 mg/m(2) irinotecan and 50 mg/m(2) cisplatin on day 1. Median age was 57 years. The overall response rate was 57.1%, with a disease control rate of 78.6%. One patient achieved pathologic complete response and underwent esophagectomy after chemotherapy. Two patients who had gotten progressive disease were given sequential octreotide long-acting release (LAR) treatment and got disease progression again within 1 month. Six patients who achieved disease control received octreotide LAR as maintenance treatment. The total number of cycles of octreotide was 41, with a median of 4.5 (3-20 cycles). The progression-free survival was 5.5 months, with overall survival of 10.6 months. Grades 3-4 hematological adverse events (AEs) occurred in 10 patients (62.5%) and 3 patients (18.7%) suffered grades 3-4 non-hematological AEs; no patient died of AEs. The irinotecan plus cisplatin chemotherapy is moderately effective and tolerable well tolerated in advanced or metastatic GEP-NEC patients; octreotide LAR may be a good maintenance treatment and should be considered as a treatment option for these patients in the future.

Rare neuroendocrine tumours: results of the surveillance of rare cancers in Europe project

Because of the low incidence, and limited opportunities for large patient volume experiences, there are very few relevant studies of neuroendocrine tumours (NETs). A large population-based database (including cancer patients diagnosed from 1978 to 2002 and registered in 76 population-based cancer registries [CRs]), provided by the project 'surveillance of rare cancers in Europe' (RARECARE) is used to describe the basic indicators of incidence, prevalence and survival of NETs, giving a unique overview on the burden of NETs in Europe. NETs at all cancer sites, excluding lung, were analysed in this study. In total over 20,000 incident cases of NETs were analysed and a data quality check upon specific NETs was performed. The overall incidence rate for NETs was 25/1,000,000 and was highest in patients aged 65 years and older with well differentiated endocrine carcinomas (non-functioning pancreatic and gastrointestinal) (40 per 1,000,000). We estimated that slightly more than 100,000 people were diagnosed with NETs and still alive in EU27 at the beginning of 2008. Overall, NETs had a 5 year relative survival of 50%; survival was low (12%) for poorly differentiated endocrine carcinoma, and relatively high (64%) for well differentiated carcinoma (not functioning of the pancreas and digestive organs). Within NETs, endocrine carcinoma of thyroid gland had the best 5-year relative survival (82%). Because of the complexity and number of the different disciplines involved with NETs (as they arise in many organs), a multidisciplinary approach delivered in highly qualified reference centres and an international network between those centres is recommended.

Neuroendocrine carcinoma of the stomach: clinicopathological and immunohistochemical evaluation

Neuroendocrine carcinoma (NEC) of the stomach is an uncommon disease. Because of its rarity, the clinicopathological features are unclear, and there is no consensus on the optimal treatment strategy. This study included five consecutive patients with gastric NEC who underwent surgery from July 2001 to August 2011. Clinical presentation, tumor location, tumor morphology and size, pathology and immunohistochemistry results, and treatment outcome were analyzed retrospectively and discussed. The study cohort of four men and one woman ranged in age from 52 to 84 years, with a median age of 72 years. Positive rates of neuroendocrine markers were 40 % for chromogranin A, 60 % for synaptophysin, 60 % for CD56, 40 % for neuron-specific enolase, and 100 % for p53 protein. Median number of lymph node metastases per patient was 10, with severe lymphatic and venous infiltration, and high Ki-67 labeling index (60-90 %) reported for all patients. Median tumor size was 6 cm. Stage IV disease was diagnosed in three patients; the other two patients showed stage IIIA tumors. After a mean follow-up of 29.8 months, two of the five patients had died of the disease. Although rare, gastric NECs deserve particular attention because of their strong malignant potential associated with an extremely poor prognosis. Such carcinomas demand an aggressive surgical approach followed by chemotherapy and multimodality adjuvant therapy.

Current concepts on gastric carcinoid tumors

Gastric carcinoid tumors (GCs) are rare lesions representing less than 10% of carcinoid tumors and less than 1% of all stomach neoplasms. There are three distinct types of gastric carcinoids; type I includes the vast majority (70–85%) of these neoplasms that are closely linked to chronic atrophic gastritis. Type II which accounts for 5–10 %, is associated with Zollinger-Ellison syndrome and often occurs in the context of multiple endocrine neoplasia type 1. Type III, finally, represents 15–25% of gastric carcinoids and is characterized by a far more aggressive course. The optimal clinical approach to GCs remains to be elucidated, depending upon type, size, and number of carcinoids. While there is universal agreement about the surgical treatment of type III GCs, current options for type I and II include simple surveillance, endoscopic polypectomy, surgical excision associated with or without surgical antrectomy, or total gastrectomy. Moreover, the introduction of somatostatin analogues could represent another therapeutic option.

Genetics and molecular pathology of gastric malignancy: Development of targeted therapies in the era of personalized medicine

Gastric malignancy constitutes a major cause of cancer deaths worldwide. Despite recent advances in surgical techniques combined with neoadjuvant chemotherapy and radiotherapy approaches, patients with advanced disease still have poor outcomes. An emerging understanding of the molecular pathways that characterize cell growth, cell cycle, apoptosis, angiogenesis, invasion and metastasis has provided novel targets in gastric cancer therapy. In this review, recent advances in the understanding of molecular tumorigenesis for common gastric malignancies are discussed. We also briefly review the current targeted therapies in the treatment of gastric malignancies. Practical insights are highlighted including HER2 testing and target therapy in gastric adenocarcinoma, morphologic features and molecular signatures of imatinib-resistance GISTs, and recent investigations aimed at tumor-specific therapy for neuroendocrine tumors.

Chemotherapy in gastroenteropancreatic (GEP) neuroendocrine carcinomas (NEC): a critical view

Neuroendocrine tumors (NET) are classified according to the Ki67 in low-intermediate grade (Ki67<20%) and high grade (Ki67>20%). The NET of the latter group are also known as neuroendocrine carcinoma (NEC), and their prognosis is dismail. While in the former group biotherapy and radionuclide therapy can be proposed, chemotherapy represents the only treatment usually proposed for NEC. Cisplatin/etoposide combination is usually chosen based on the rationale that NEC are clinically similar to small cell lung cancer. However, evidence for cisplatin/etoposide in NEC is poor and controversial, and different schedules and response rate have been published so far. These aspects, combined with the heterogeneous characteristics of NEC, prompt us to have some doubt in considering cisplatin/etoposide as the gold standard. Some evidence exists that carboplatin can be used instead of cisplatin and irinotecan instead of etoposide without reducing efficacy. Furthermore other drugs, as gemcitabine, oxaliplatin or temozolomide can be evaluated in NEC with non-neuroendocrine component or in mixed adenoneuroendocrine carcinomas. NEC are a category of NET that should be deeply studied to verify if the response to cisplatin/etoposide is homogeneous related to the different Ki67, different morphology and/or different primary site.

Endocrine carcinoma of the stomach: clinicopathological analysis of 27 surgically treated cases in a single institute

BACKGROUND

Gastric endocrine carcinoma (EC) is an uncommon tumor of the stomach and the clinical features are not well known. Additionally, the classification and staging systems of this tumor are not yet unified worldwide. In this study, we reviewed 27 patients with gastric EC to evaluate the clinicopathological characteristics of this tumor.

METHODS

We retrospectively reviewed 27 patients with gastric EC among 6466 patients who had undergone gastrectomy between 1986 and 2008 at our institute. Clinicopathological features including immunohistochemistry of Ki-67 were investigated to evaluate the malignant potential of the tumor. Furthermore, survivals were compared between the 7th edition of the International Union Against Cancer (UICC)-TNM (7th TNM) classification for gastric cancer (GC) and the new TNM classification for foregut neuroendocrine tumors (NET).

RESULTS

The median survival of the patients was 19.0 months. The 5-year survival rate was 100% in pathological stage (pStage) I, 40% in pStage II, 38% in pStage III, and 11% in pStage IV according to the 7th TNM classification for GC. Survivals by stage showed great difference between the 7th TNM classification for GC and the new TNM classification for foregut NET, but each system correlated with survival. The Ki-67 labeling index was more than 20% in most of the patients. Univariate analysis revealed that maximum tumor diameter, tumor depth, lymph node metastasis, lymphatic invasion, pStage, and curability had significant correlations with survival.

CONCLUSION

Early detection and curative operations are essential for improving the prognosis of gastric EC. However, some adjuvant chemotherapies are required for advanced-stage tumors. Classification and staging systems may need to be unified worldwide for further analysis.

Immunohistochemical consistency between primary tumors and lymph node metastases of gastric neuroendocrine carcinoma

Background

Gastric neuroendocrine carcinoma (G-NEC) is a rare, highly malignant tumor that exhibits aggressive growth leading to vascular invasion, distant metastasis and extremely poor prognosis. We studied the clinicopathological findings of seven patients at our institute to better under this disease.

Methods

Seven cases of G-NEC were identified among 1,027 cases of gastric carcinoma that underwent gastrectomy at Kansai Rousai Hospital between 2002 and 2010. We studied the pathological and immunohistochemical features of gastric neuroendocrine carcinomas at both the primary site and metastatic lymph nodes.

Results

The mean patient age was 73 years (range 63 to 86 years). There were no females in this series. The final staging was Stage I in one case, Stage II in two, Stage III in two and Stage IV in two. A total of 31 metastatic lymph nodes were found in these patients. This study revealed that the ratio of neuroendocrine cells was similar between the primary and metastatic sites, which tended to show the same expression patterns of neuroendocrine markers.

Conclusions

Metastatic lymph nodes showed heterogeneous immunohistochemical expression patterns similar to the primary sites. G-NEC is far advanced at diagnosis and rapidly reaches the lymph nodes retaining its heterogeneity, carrying a worse prognosis than common gastric cancer.

Mini abstract

G-NEC grows rapidly and metastasizes to the lymph nodes, retaining its pathological and immunohistochemical heterogeneity even at the metastatic sites.

Primary small cell carcinoma of the stomach: an experience of two decades (1990-2011) in a Chinese cancer institute

BACKGROUND

Primary gastric small cell carcinoma (GSCC) is a rare and aggressive disease for which the standard treatment has not been established. The objective of this study is to investigate the clinical characteristics and survival.

METHODS

All cases of GSCC treated at our institute from January 1990 to December 2011 were reviewed and analyzed retrospectively. Statistical analyses were performed using Fisher's exact test.

RESULTS

A total of 19 patients from 11,603 cases (0.16%) of all gastric cancers treated during this period were identified. The median age was 61 years and the patients were predominantly men. Using the latest AJCC Staging Criteria, the majority of the patients (68.4%) were Stage III. All patients underwent surgery. The median overall survival time (MST) was 19.5 months (95% CI 17.5-21.6 months). The 1-, 3-, and 5-year overall survival rates were 77.3%, 44.2%, and 22.1%, respectively. The MST of 48.5 months for cases who received postoperative adjuvant chemotherapy was superior to that of 19.0 months for cases who did not (P = 0.026).

CONCLUSIONS

Our data indicate that GSCC patients can be treated effectively with combined modality of treatment, despite the aggressive nature of GSCC. Systemic therapy, based on chemotherapy with surgery, is recommended.

Medical treatment of gastroenteropancreatic neuroendocrine tumors

Treatment of the clinically and prognostically heterogeneous neuroendocrine neoplasms (NEN) should be based on a multidisciplinary approach, including surgical, interventional, medical and nuclear medicine-based therapeutic options. Medical therapies include somatostatin analogues, interferon-α, mTOR inhibitors, multikinase inhibitors and systemic chemotherapy. For the selection of the appropriate medical treatment the hormonal activity, primary tumor localization, tumor grading and growth behaviour as well as the extent of the disease must be considered. Somatostatin analogues are mainly indicated in hormonally active tumors for symptomatic relief, but antiproliferative effects have also been demonstrated, especially in well-differentiated intestinal NET. The efficacy of everolimus and sunitinib in patients with pancreatic neuroendocrine tumors (pNET) has been demonstrated in large placebo-controlled clinical trials. pNETs are also chemosensitive. Streptozocin-based chemotherapeutic regimens are regarded as current standard of care. Temozolomide in combination with capecitabine is an alternative that has shown promising results that need to be confirmed in larger trials. Currently, no comparative studies and no molecular markers are established that predict the response to medical treatment. Therefore the choice of treatment for each pNET patient is based on individual parameters taking into account the patient’s preference, expected side effects and established response criteria such as proliferation rate and tumor load. Platin-based chemotherapy is still the standard treatment for poorly differentiated neuroendocrine carcinomas. Clearly, there is an unmet need for new systemic treatment options in patients with extrapancreatic neuroendocrine tumors.

Advanced gastric neuroendocrine carcinoma with an adenocarcinoma component

In the present study, we observed that the adenocarcinoma component in the mucosa was continuous with neuroendocrine carcinoma (NEC) in the deeper layers; this suggests the normal course of NEC carcinogenesis at the histological level. A 72-year-old man was admitted to our hospital with a chief complaint of tarry stools. Endoscopic examination of the upper gastrointestinal tract revealed a 2-cm tumor, with a deep central depression, surrounded by a smooth elevated area, in the middle of the stomach body. A biopsy showed that the tumor was a moderately differentiated gastric adenocarcinoma. The patient underwent total gastrectomy and standard lymph node dissection. The resected tumor was a 3.5 × 2.5 cm type 2 lesion. It comprised two elements at the histological level: (i) a moderately differentiated adenocarcinoma in the superficial portion of the mucous membrane layer, and (ii) NEC-like cells with dark, round nuclei and scant cytoplasm, presenting a solid and trabecular pattern, in the submucosal and muscularis propria layers. Immunohistochemical findings showed that the NEC-like cells were diffusely positive for chromogranin A, synaptophysin, neural cell adhesion molecule, and neuron-specific enolase, but were negative for carcinoembryonic antigen. The Ki-67 labeling index was 95%. The final pathological diagnosis was gastric NEC with an adenocarcinoma component and a high cellular proliferative potential.