Surgical management of pulmonary large cell neuroendocrine carcinomas: a 10-year experience

Neoadjuvant immunochemotherapy for pulmonary large-cell neuroendocrine carcinoma: case report

BACKGROUND

Pulmonary large-cell neuroendocrine carcinoma (pLCNEC) represents a rare malignancy characterized by its aggressive behavior and a notably high recurrence rate. Remarkably, there is currently no established standard treatment protocol for this condition.

CASE DESCRIPTION

In this report, we present an intriguing case of pLCNEC diagnosed at clinical-stage IIB. This case involves a 64-year-old man with a smoking history spanning four decades. In our approach, we initiated a course of neoadjuvant chemotherapy in combination with pembrolizumab, administered for two cycles prior to surgical resection. This innovative treatment strategy resulted in a significant pathological response, culminating in a major pathological remission (MPR). As of the time of composing this report, the patient has been diligently monitored for 39 months post-surgery, exhibiting no indications of recurrence, and has demonstrated exceptional tolerance to the entire treatment regimen.

CONCLUSIONS

We have first reported a clinically successful case of neoadjuvant combination chemotherapy with pembrolizumab in the treatment of pLCNEC. This case offers promising clinical insights and suggests that this therapeutic approach could be a viable option for managing pLCNEC.

Pulmonary large cell neuroendocrine carcinoma (LCNEC): a population-based study addressing recent molecular-genetic advances and emerging therapeutic approaches

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) of the lung is a rare, aggressive cancer most commonly found in the lungs but not exclusively, with a worse prognosis than non-small cell lung carcinomas. Currently, LCNEC patients are treated using small cell and non-small cell protocols. This study aims to use the SEER database to identify demographic, clinical, pathological, and therapeutic factors affecting the prognosis and survival of patients with LCNEC of the lung.

METHODS

Demographic, clinical, and management data of patients with lung LCNEC were extracted from the SEER database for the period 2000-2018.

RESULTS

In the USA, LCNEC has a higher incidence in elderly white men: M:F ratio = 1.2:1, Caucasian: 83.3%, mean age: 67 ± 10.2 years. The most common treatment modality was chemotherapy only: 29.2%, followed by surgery: 21.5% (but in this group the statuses of chemotherapy were unknown), and combination surgery/chemotherapy: 8.8%. The overall and cause-specific 5-year survival was 17.5% (95% CI 16.3-18.8) and 21.9% (95% CI 20.5-23.4), respectively. By treatment, the best 5-year survival was for surgery alone (48%), followed by multimodality therapy (chemo + surgery + radiation) at 35% (95% CI 27-43). Age > 60 years, male gender, size > 7 cm, and nodal and liver metastasis were independent risk factors associated with increased mortality.

CONCLUSION

Lung LCNEC is an aggressive neoplasm most common in older white males that presents at an advanced stage despite small primary tumors. Most patients die within 2 years. The best predictor of survival is surgery with chemotherapy. Given its dismal prognosis, new treatment guidelines are needed for this aggressive cancer.

Lung Large Cell Neuroendocrine Carcinoma: A Population-Based Retrospective Cohort Study

BACKGROUNDS

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rarely high-grade neuroendocrine carcinoma of the lung with features of both small cell and non-small cell lung cancer. In this study, we aim to construct a prognostic nomogram that integrates the clinical features and treatment options to predict disease-specific survival (DSS).

METHODS

A total of 713 patients diagnosed with LCNEC were from the US National Cancer Institute's Surveillance Epidemiology and End Results (SEER) registry between 2010-2016. Cox proportional hazards analysis was conducted to choose the significant predictors of DSS. External validation was performed using 77 patients with LCNEC in the West China Hospital Sichuan University between 2010-2018. The predictive accuracy and discriminative capability were estimated by the concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve. The clinical applicability of the nomogram was verified through the decision curve analysis (DCA). Additionally, we conducted a subgroup analysis of data available in the external cohort that may impact prognosis but was not recorded in the SEER database.

RESULTS

Six independent risk factors for DSS were identified and integrated into the nomogram. The nomogram achieved good C- indexes of 0.803 and 0.767 in the training and validation group, respectively. Moreover, the calibration curves for the probability of survival showed good agreement between prediction by nomogram and actual observation in 1-, 3- and 5-year DSS. The ROC curves demonstrated the prediction accuracy of the established nomogram (all Area Under Curve (AUC) > 0.8). DCA exhibited the favorable clinical applicability of the nomogram in the prediction of LCNEC survival. A risk classification system was built which could perfectly classify LCNEC patients into high-, medium- and low-risk groups (p < 0.001). The survival analysis conducted on the West China Hospital cohort indicated that whole brain radiation therapy (WBRT), prophylactic cranial irradiation (PCI), surgical procedures, tumor grade, Ki-67, and PD-L1 expression were not significantly associated with DSS.

CONCLUSION

This study has effectively developed a prognostic nomogram and a corresponding risk stratification system, which demonstrate promising potential for predicting the DSS of patients with LCNEC.

The Surgical Management of Lung Neuroendocrine Neoplasms

This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma.

Pulmonary Large Cell Neuroendocrine Carcinoma

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rare subtype of malignant pulmonary tumor. The incidence rate of LCNEC was reported to be 0.3%–3% in lung cancers. Although LCNEC is classified as non-small cell lung cancer (NSCLC), it is more aggressive and malignant than other NSCLC, and its biological behavior is similar to that of small cell lung cancer (SCLC). Most of the LCNEC patients are elderly smoking male and the clinical manifestations are not specific. The imaging manifestations of the tumors are often located in the periphery and the upper lobes, and the enlargement of mediastinal or hilar lymph nodes is common. The diagnosis is mainly based on pathology by the histological features and immunohistochemistry (IHC). Specific neuroendocrine markers such as chromogranin A (CgA), synaptophysin (Syn) and CD56 are usually diffusely positive in LCNEC, and found that insulinoma-associated protein (INSM1) and high rate of Ki-67 are helpful for diagnosis. More differential diagnoses also increase the difficulty of correctly diagnosing LCNEC. The rise of LCNEC molecular typing in recent years may be helpful for diagnosis and subsequent treatment. This review focuses on the epidemiological features, imaging studies, pathology, diagnosis, treatment, and prognosis of LCNEC.

Large Cell Neuroendocrine Carcinoma of the Lung: A Case Series of 14 Cases

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rare subtype of neuroendocrine tumor, presenting with very aggressive behavior and a poor prognosis. The diagnosis is difficult and requires histological confirmation of the neuroendocrine nature by an immunohistochemical study on a biopsy sample. We retrospectively studied a series of 14 patients from the pneumology department of the Mohammed VI University Hospital of Oujda, Morocco, over a period of five years (from April 2017 to March 2021). The average age was 63.41 years (45-80 years). All our patients were male and smokers. The clinical signs were dominated by deterioration in general condition and dyspnea. Bronchoscopy was performed in 92% of patients, with neoplastic stenosis being the main found aspect, in 35% of cases. The histological diagnosis was obtained by bronchoscopy in 50% of cases. In the remaining cases, it was carried by CT-guided transparietal biopsy in 28% of cases, pleural biopsy in 7% of cases, biopsy of a metastatic site in 7% of cases and finally thoracoscopy with pleural biopsy in the remaining 7% of cases. Therapeutically, no patient received surgical treatment and three patients were put on palliative treatment. The positive diagnosis is often late, which makes the prognosis bad and the therapeutic possibilities limited. Hence the importance of strategies for the prevention of tobacco control and early detection in population at risk.

Different Characteristics and Survival between Surgically Resected Pure and Combined Pulmonary Large Cell Neuroendocrine Carcinoma

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) is a rare high-grade neuroendocrine carcinoma of the lung. Little is known about the differences between the pure and combined LCNEC subtypes, and thus we conducted this study to provide more comprehensive insight into LCNEC.

METHODS

We reviewed 221 patients with pure LCNEC (P-LCNEC) and 120 patients with combined LCNEC (C-LCNEC) who underwent pulmonary surgery in our hospital to compare their clinical features, driven genes' status (EGFR/ALK/ROS1/KRAS/BRAF), and adjuvant chemotherapy regimens. Propensity score matching (PSM) was applied to reduce selection bias.

RESULTS

The P-LCNEC group included a higher proportion of males and smokers than the C-LCNEC group. Furthermore, the C-LCNEC group had higher incidences of visceral pleural invasion (VPI), EGFR mutation and ALK rearrangement compared with the P-LCNEC group. Expression of neuroendocrine markers (CD56, CGA, and SYN) and recurrence patterns were not significantly different between the two groups. The P-LCNEC group had better disease-free survival (DFS) and overall survival (OS) compared with the C-LCNEC group (median DFS: 67.0 vs. 28.1 months, p = 0.021; median OS: 72.0 vs. 45.0 months, p = 0.001), which was further confirmed by the PSM method (p = 0.004 and p < 0.001, respectively). Adjuvant chemotherapy was also an independent factor for DFS and OS. Subgroup analysis found that regardless of whether it was for the entire LCNEC group or the P- and C-LCNEC subtypes, the small cell lung cancer (SCLC) regimens presented with superior survival compared with the non-small cell lung cancer (NSCLC) regimens.

CONCLUSION

P-LCNEC was associated with more favorable prognosis compared with C-LCNEC. SCLC-based adjuvant chemotherapy was more appropriate for LCNEC patients than NSCLC-based regimens, regardless of whether they were the pure or combined LCNEC subtypes. C-LCNEC patients may be the potential beneficiary of targeted therapy.

Complete remission of combined pulmonary large cell neuroendocrine carcinoma: a case report

Pulmonary large cell neuroendocrine carcinoma (LCNEC), which accounts for approximately 1% of all lung cancers, is a rare and highly aggressive malignancy with a poor prognosis. Therefore, it is important to devise an effective treatment strategy. In the treatment of locally advanced complex LCNEC, it is unique to first administer radiotherapy combined with albumin-bound paclitaxel plus carboplatin, followed by durvalumab for immune maintenance treatment after concurrent radiotherapy and chemotherapy to achieve complete remission. We report a 54-year-old man who smoked and who felt chest tightness for 2 weeks and was diagnosed as having combined pulmonary LCNEC. For patients with locally advanced pulmonary LCNEC, chemoradiotherapy increases overall survival. After surgical resection and chemoradiotherapy, our patient achieved complete remission. Durvalumab was then started to consolidate the treatment. After six courses of immune maintenance therapy, the patient developed grade 2 immune-related pneumonitis and took prednisone orally until the symptoms resolved, and then reached complete remission again. The patient achieved complete remission, which was a challenge with this rare carcinoma, through albumin-bound paclitaxel plus platinum-based chemotherapy combined with radiotherapy and durvalumab for immune maintenance therapy. This approach may provide a treatment option for locally advanced combined pulmonary LCNEC.

Comparative Study of Pulmonary Combined Large-Cell Neuroendocrine Carcinoma and Combined Small-Cell Carcinoma in Surgically Resected High-Grade Neuroendocrine Tumors of the Lung

Objectives

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) and small-cell lung cancer (SCLC) are both classified as pure and combined subtypes. Due to the low incidence and difficult diagnosis of combined LCNEC (C-LCNEC) and combined SCLC (C-SCLC), few studies have compared their clinical features and prognosis.

Materials and Methods

We compared the clinical features, mutation status of driver genes (EGFR, ALK, ROS1, KRAS, and BRAF), and prognosis between C-LCNEC and C-SCLC. Univariate and multivariate Cox regression analyses were applied for survival analysis.

Results

We included a total of 116 patients with C-LCNEC and 76 patients with C-SCLC in the present study. There were significant differences in distribution of smoking history, tumor location, pT stage, pN stage, pTNM stage, visceral pleural invasion (VPI), and combined components between C-LCNEC and C-SCLC (P<0.05 for all). C-SCLC was more advanced at diagnosis as compared to C-LCNEC. The incidence of EGFR mutations in C-LCNEC patients was higher than C-SCLC patients (25.7 vs. 5%, P=0.004). We found that tumor size, pN stage, peripheral CEA level, and adjuvant chemotherapy were independently prognostic factors for DFS and OS in C-LCNEC patients, while peripheral NSE level, pT stage, pN stage, VPI and adjuvant chemotherapy were independently associated with DFS and OS for C-SCLC patients (P<0.05 for all). Propensity score matching with adjustment for the confounders confirmed a more favorable DFS (P=0.032) and OS (P=0.019) in patients with C-LCNEC in comparison with C-SCLC patients upon survival analysis.

Conclusions

The mutation landscape of driver genes seemed to act in different way between C-SCLC and C-LCNEC, likely by which result in clinical phenotype difference as well as better outcome in C-LCNEC.

Frequency of Neuroendocrine Tumor Studies: Using Latent Dirichlet Allocation and HJ-Biplot Statistical Methods

Background: Neuroendocrine tumors (NETs) are severe and relatively rare and may affect any organ of the human body. The prevalence of NETs has increased in recent years; however, there seem to be more data on particular types, even though, despite the efforts of different guidelines, there is no consensus on how to identify different types of NETs. In this review, we investigated the countries that published the most articles about NETs, the most frequent organs affected, and the most common related topics. Methods: This work used the Latent Dirichlet Allocation (LDA) method to identify and interpret scientific information in relation to the categories in a set of documents. The HJ-Biplot method was also used to determine the relationship between the analyzed topics, by taking into consideration the years under study. Results: In this study, a literature review was conducted, from which a total of 7658 abstracts of scientific articles published between 1981 and 2020 were extracted. The United States, Germany, United Kingdom, France, and Italy published the majority of studies on NETs, of which pancreatic tumors were the most studied. The five most frequent topics were t_21 (clinical benefit), t_11 (pancreatic neuroendocrine tumors), t_13 (patients one year after treatment), t_17 (prognosis of survival before and after resection), and t_3 (markers for carcinomas). Finally, the results were put through a two-way multivariate analysis (HJ-Biplot), which generated a new interpretation: we grouped topics by year and discovered which NETs were the most relevant for which years. Conclusions: The most frequent topics found in our review highlighted the severity of NETs: patients have a poor prognosis of survival and a high probability of tumor recurrence.

Successful salvage of recurrent leptomeningeal disease in large cell neuroendocrine lung cancer with stereotactic radiotherapy

A 70-year old male with stage I large cell neuroendocrine carcinoma (LCNEC) of the lung underwent resection of a metachronous 5 cm brain metastasis and received postoperative hypofractionated stereotactic radiotherapy (hfSRT). Five sequential nodular leptomeningeal metastases up to 5.3 cm in diameter were diagnosed on MRI within 10 months and were treated with SRT. Currently the patient has no evidence of intracranial disease 24 months after last irradiation without chemotherapy or whole brain radiotherapy. This is the first report of sustained complete remission of multiple large leptomeningeal metastases achieved with hfSRT, highlighting this brain-sparing approach in selected patients with LCNEC lung cancer.

Management of Large Cell Neuroendocrine Carcinoma

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive cancer with a dismal prognosis. The majority of cases occur in the lung and the gastrointestinal tract; however, it can occur throughout the body. Recently advances in the understanding of the molecular underpinnings of this disease have paved the way for additional novel promising therapies. This review will discuss the current best evidence for management of LCNEC and new directions in the classification and treatment of this rare disease.

METHODS

We performed a PubMed search for "Large cell neuroendocrine carcinoma" and "High grade neuroendocrine carcinoma." All titles were screened for relevance to the management of LCNEC. Papers were included based on relevance to the management of LCNEC.

RESULTS

Papers were included reviewing both pulmonary and extra pulmonary LCNEC. We summarized the data driven best practices for the management of both early and advanced stage LCNEC. We describe emerging therapies with promising potential.

DISCUSSION

LCNEC are rare and aggressive neoplasms. In advanced disease, the historical regimen of platinum based therapy in combination with etoposide or irinotecan remains among the commonly used first line therapies, however for extra thoracic LCNEC regimens like FOLFOX, FOLFOIRI and CAPTEM can also be used. Further effective and safe treatment options are desperately needed. Recently, new advances including a new understanding of the genetic subcategories of LCNEC and immunotherapy agents may guide further treatments.

Survival and prognosis of lung large cell neuroendocrine carcinoma

INTRODUCTION

Only a few large-scale studies have focused on large cell neuroendocrine carcinoma, a rare type of pulmonary malignancy, and uniform diagnostic criteria and standardized treatments are lacking. This study aimed to assess the treatment outcomes and factors influencing patients' prognosis with large cell neuroendocrine carcinoma.

METHODS

The data of 55 patients with pathologically confirmed large cell neuroendocrine carcinoma, treated at our hospital from January 2013 to January 2018, were collected. Relationships between clinical characteristics, diagnoses, treatment outcomes, and prognoses were retrospectively analyzed.

RESULTS

Patients were followed for a median of 18.5 (0.5-41.0) months. Thirty-four patients died before the final follow-up, resulting in a median overall survival of 17.9 (0.5-36.0) months, with 1-, 2-, and 3-year survival rates of 69.1%, 23.6%, and 1.8%, respectively. Single-factor analysis identified gender (P=0.036), smoking history (P=0.008), obstructive atelectasis (P=0.032), regional lymph node metastasis (P=0.020), and treatment selection (P=0.000) as factors influencing overall survival. Multifactor analysis identified treatment selection as an independent survival prognostic factor. Particularly, significant differences were observed between the combination therapies (surgery+chemotherapy, surgery+radiotherapy, surgery+radiotherapy+chemotherapy, and concurrent chemoradiotherapy) and single-therapy approaches (chemotherapy or radiotherapy alone; P<0.001), but not among the combination therapies (P=0.216).

DISCUSSION

Male patients with large cell neuroendocrine carcinoma with a history of smoking, obstructive atelectasis, and regional lymph node metastasis have a particularly poor prognosis. Our observation of the treatment approach as an independent survival prognostic factor suggests that combination therapies may yield survival benefits to patients.

Large Cell Neuro-Endocrine Carcinoma of the Lung: Current Treatment Options and Potential Future Opportunities

Large-cell neuroendocrine carcinomas of the lung (LCNECs) are rare tumors representing 1-3% of all primary lung cancers. Patients with LCNEC are predominantly male, older, and heavy smokers. Histologically, these tumors are characterized by large cells with abundant cytoplasm, high mitotic rate, and neuroendocrine immunohistochemistry-detected markers (chromogranin-A, synaptophysin, and CD56). In 2015 the World Health Organization classified LCNEC as a distinct subtype of pulmonary large-cell carcinoma and, therefore, as a subtype of non-small cell lung carcinoma (NSCLC). Because of the small-sized tissue samples and the likeness to other neuroendocrine tumors, the histological diagnosis of LCNEC remains difficult. Clinically, the prognosis of metastatic LCNECs is poor, with high rates of recurrence after surgery alone and overall survival of approximately 35% at 5 years, even for patients with early stage disease that is dramatically shorter compared with other NSCLC subtypes. First-line treatment options have been largely discussed but with limited data based on phase II studies with small sample sizes, and there are no second-line well defined treatments. To date, no standard treatment regimen has been developed, and how to treat LCNEC is still on debate. In the immunotherapy and targeted therapy era, in which NSCLC treatment strategies have been radically reshaped, a few data are available regarding these opportunities in LCNEC. Due to lack of knowledge in this field, many efforts have been done for a deeper understanding of the biological and molecular characteristics of LCNEC. Next generation sequencing analyses have identified subtypes of LCNEC that may be relevant for prognosis and response to therapy, but further studies are needed to better define the clinical impact of these results. Moreover, scarce data exist about PD-L1 expression in LCNEC and its predictive value in this histotype with regard to immunotherapy efficacy. In the literature some cases are reported concerning LCNEC metastatic patients carrying driver mutations, especially EGFR alterations, showing targeted therapy efficacy in this setting of disease. Due to the rarity and the challenging understanding of LCNEC, in this review we aim to summarize the management options currently available for treatment of LCNEC.

Survival outcomes of surgery in patients with pulmonary large-cell neuroendocrine carcinoma: a retrospective single-institution analysis and literature review

Background

Pulmonary large-cell neuroendocrine carcinoma (pLCNEC) is a very rare malignancy originating from the lung and bronchus, and its biological behaviour, clinical diagnosis, treatment and prognosis are poorly understood. Thus, the clinical characteristics and surgical treatment-related prognostic factors of this rare disorder must be explored.

Results

The clinical data of 59 patients (48 males and 11 females) who were treated by surgery and diagnosed with pLCNEC by postoperative pathology at Peking Union Medical College Hospital from April 2004 to April 2019 were analysed retrospectively. The median patient age was 62 years (38–79 years), and the median duration of disease was 2 months (0.5–18 months). Compared with other lung malignancies, pLCNEC lacks specific clinical symptoms and imaging features, and preoperative biopsy pathology is often insufficient to confirm the diagnosis. The corresponding numbers of patients who were classified into stages I, II, III and IV according to the postoperative pathological tumour-nodal-metastasis stage were 25, 12, 15 and 7, respectively. The median overall survival was 36 months (0.9–61.1 months). The 1-year, 3-year and 5-year survival rates were 76.3%, 49% and 44.7%, respectively. The tumour stage exerted a significant effect on survival (Cox multivariate analysis p < 0.05).

Conclusions

For patients with resectable pLCNEC, multidisciplinary therapy based on surgery may have good survival benefits, and tumour stage is an independent risk factor for the prognosis of pLCNEC.

Neoadjuvant Therapy for Neuroendocrine Neoplasms: Recent Progresses and Future Approaches

Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors, their treatment being challenging and requiring a multidisciplinary approach. Though the only curative treatment is surgery, up to 50% of patients are diagnosed with metastatic disease. In the last years, neoadjuvant chemo(radio)therapy has become part of the standard of care in the treatment of different cancer types. However, evidence of its efficacy and safety in NEN patients has not yet been confirmed in the literature. The aim of the present review is to perform an extensive review of the scientific evidence for neoadjuvant therapy in patients with gastroenteropancreatic and thoracic NENs.

A Population-Based Systematic Clinical Analysis With a Single-Center Case Series of Patients With Pulmonary Large Cell Neuroendocrine Carcinoma

BACKGROUND AND OBJECTIVES

This study aims to conduct an updated systematic analysis of patients with pulmonary large cell neuroendocrine carcinoma (PLCNC) in recent decades, concerning incidence and mortality trends, demographics, treatments, survival and death causes.

METHODS

Patients who were diagnosed with PLCNC at the Peking Union Medical College Hospital (PUMCH) between 2000 to 2020 were retrospectively analyzed. The population-based Surveillance, Epidemiology, and End Results (SEER) database were also retrieved. Frequencies and average annual age-adjusted rates (AAR) of PLCNC patients were calculated and analyzed by Joint-point regression. Univariate and multivariate Cox regression were used for identifying prognostic factors. Predictive nomograms for overall survival (OS) and cancer-specific survival (CSS) were developed and then validated by calculating C-index values and drawing calibration curves. Survival curves were plotted using the Kaplan-Meier method and compared by log-rank test. Causes of death were also analyzed by time latency.

RESULTS

A total of 56 PLCNC patients of the PUMCH cohort were included. Additionally, the PLCNC patients in the SEER database were also identified from different subsets. The AAR from 2001 to 2017 were 3.21 (95%CI: 3.12-3.30) per million. Its incidence and mortality rates in PLCNC patients increased at first but seemed to decline in recent years. Besides TNM stage and treatments, older age and male gender were independently associated with poorer survival, while marital status only affected CSS other than OS. The nomograms for OS and CSS presented great predictive ability and calibration performance. Surgery gave significantly more survival benefits to PLCNC patients, and chemotherapy might add survival benefits to stage II-IV. However, radiation therapy seemed to only improve stage III patients' survival.

CONCLUSIONS

This study supported some previous studies in terms of incidence, survival, and treatment options. The mortality rates seemed to decline recently, after an earlier increase. Among PLCNC patients, most of the deaths occurred within the first five years, while other non-PLCNC diseases increased after that. Thus, careful management and follow-up of other comorbidities are of equal importance. Our study may partly solve the dilemma caused by PLCNC's rarity and inspire more insights in future researches.

Outcomes for Surgery in Stage IA Large Cell Lung Neuroendocrine Compared With Other Types of Non-Small Cell Lung Cancer: A Propensity Score Matching Study Based on the Surveillance, Epidemiology, and End Results (SEER) Database

Background

Pulmonary large cell neuroendocrine cancer (LCNEC) is commonly classified as non-small cell lung cancer (NSCLC). Even for stage I disease, after surgery the survival is always poor, but clinical research on LCNEC is scant and always with unsatisfying sample sizes. Thus, we conduct the first study using the Surveillance, Epidemiology, and End Results (SEER) database to compare survival after surgery between stage I LCNEC and other types of NSCLC.

Methods

From 2004 to 2016, 473 patients with stage IA LCNEC, 17,669 patients with lung adenocarcinoma (LADC) and 8,475 patients with lung squamous cell cancer (LSCC), all treated with surgery were identified. In addition, 1:1 PSM was used, and overall (OS) and cancer-specific survival (CSS) between groups were compared.

Results

The 5-year OS rates and CSS rates for LCNEC were 52.5% and 81.5%, respectively. Overall, both OS and CSS were significantly superior for stage IA LADC than LCNEC (for OS: HR 0.636, 95% CI 0.568-0.712; for CSS: HR 0.688, 95% CI 0.561–0.842, LCNEC as reference), while comparable for LSCC with LCNEC (for OS: HR 0.974, 95% CI 0.869–1.091; for CSS: HR 0.907, 95% CI 0.738–1.115). PSM generated 471 pairs when LCNEC was compared with LADC and both OS and CSS were significantly better in LADC than LCNEC (for OS: HR 0.580, 95% CI 0.491–0.686; for CSS: HR 0.602, 95% CI 0.446–0.814). Of note, for the subgroup of patients ≤ 65 years old, HRs for both OS and CSS were lower (for OS: HR 0.470; for CSS: HR 0.482). As for comparison between LCNEC and LSCC, PSM generated 470 pairs. Differently, only CSS was significantly superior in LSCC than LCNEC (HR 0.563, 95% CI 0.392–0.807), while OS was not. Further grouping by age showed only CSS between two groups for patients with age ≤ 65 years old was significantly different (P = 0.006).

Conclusions

We report the first survival comparison after surgery between stage IA LCNEC and other types of NSCLC by SEER database and PSM. Our results demonstrated after surgery, stage IA LCNEC was worse in survival, especially compared to LADC. Extra clinical care should be paid, especially for younger patients. More studies investigating adjuvant therapy are warranted.

CDX2 Expression and Prognostic Factors of Resectable Pulmonary Large Cell Neuroendocrine Carcinoma

Background and Aim:

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rare neoplasm, and its clinical features and management are still limited. We evaluated the clinicopathological factors, including CDX2 immunohistochemical expression, to predict survival in patients with LCNEC.

Patients and Methods:

In all, 50 patients with LCNEC who underwent surgery at 4 institutes between 2001 and 2017 were included. Clinicopathological characteristics were evaluated for prognostic factors and statistically analyzed by Kaplan-Meier curve with a log-rank test or Cox regression models. We used immunohistochemical (IHC) analysis to determine the expressions of CDX2 and compared them with clinicopathological factors and survival.

Results:

Sixteen of the 50 cases (32%) were CDX2 positive. No correlation was found between the CDX2 expression by IHC and clinicopathological factors. Multivariate analysis identified adjuvant chemotherapy (hazard ratio [HR] =2.86, 95% confidence interval [CI] = 1.04-8.16, P = .04) and vascular invasion (HR = 4.35, 95% CI = 1.21-15.63, P = .03) as being associated with a significantly worse rate of recurrence-free survival.

Conclusion:

CDX2 was expressed in 1/3 of LCNEC but not associated with prognostic factor. Adjuvant chemotherapy and vascular invasion were associated with a negative prognostic factor of LCNEC.

Factors associated with treatment receipt and overall survival for patients with locally advanced large cell neuroendocrine carcinoma of the lung: A National Cancer Database analysis

PURPOSE

Large cell neuroendocrine carcinoma (LCNEC) is a rare pulmonary malignancy with clinicopathologic features of both non-small cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). Given the paucity of available data regarding LCNEC management, we queried the National Cancer Database (NCDB) to describe trends in management, identify predictors of treatment receipt, and compare outcomes in patients receiving chemotherapy (ChT) and chemoradiotherapy (CRT).

METHODS

We identified patients with locally advanced (Stage III) LCNEC of the lung treated with definitive ChT or CRT between the years of 2004-2015. Odds ratios were calculated to determine predictors of CRT receipt. Multivariable cox regression was used to determine predictors of overall survival.

RESULTS

Using the above criteria, 5797 patients were identified, 54 % of whom received CRT (n = 3153) while 46 % (n = 2644) received ChT alone. Most patients had T4 (35 %) and N2 (59 %) disease. Median overall survival was 11.9 months (11.3-12.6) in patients receiving ChT compared to 16.1 months (15.4-16.9) in patients receiving CRT (p < 0.0001). Overall survival at 1, 3, and 5 years was 50 %, 20 %, and 13 % versus 60 %, 27 %, and 18 %, in patients receiving ChT and CRT, respectively. Older patients and those with higher comorbidity scores were less likely to receive CRT; whereas patients with higher education level, treatment receipt at an academic/research program facility, N2 disease, and later treatment year were more likely to receive CRT. On multivariable analysis, older age, greater comorbidity score, presence of N2 disease, and presence of T4 disease were all associated with decreased OS. CRT receipt was an independent predictor of increased overall survival.

CONCLUSIONS

Definitive CRT was an independent predictor of increased overall survival in patients with locally advanced LCNEC of the lung. Findings from our study may help guide potential areas of future investigation to help define an ideal treatment approach for LCNEC.

Large Cell Neuroendocrine Tumor Size >3 cm Negatively Impacts Long-Term Outcomes After R0 Resection

BACKGROUND

Minimal knowledge exists regarding the outcome, prognosis and optimal treatment strategy for patients with pulmonary large cell neuroendocrine carcinomas (LCNEC) due to their rarity. We aimed to identify factors affecting survival and recurrence after resection to inform current treatment strategies.

METHODS

We retrospectively reviewed 72 patients who had undergone a curative resection for LCNEC in 8 centers between 2000 and 2015. Univariable and multivariable analyses were performed to identify the factors influencing recurrence, disease-specific survival and overall survival. These included age, gender, previous malignancy, ECOG performance status, symptoms at diagnosis, extent of resection, extent of lymphadenectomy, additional chemo- and/or radiotherapy, tumor location, tumor size, pT, pleural invasion, pN and pStage.

RESULTS

Median follow-up was 47 (95%CI 41-79) months; 5-year disease-specific and overall survival rates were 57.6% (95%CI 41.3-70.9) and 47.4% (95%CI 32.3-61.1). There were 22 systemic recurrences and 12 loco-regional recurrences. Tumor size was an independent prognostic factor for systemic recurrence [HR: 1.20 (95%CI 1.01-1.41); p = 0.03] with a threshold value of 3 cm (AUC = 0.71). For tumors ≤3 cm and >3 cm, 5-year freedom from systemic recurrence was 79.2% (95%CI 43.6-93.6) and 38.2% (95%CI 20.6-55.6) (p < 0.001) and 5-year disease-specific survival was 60.7% (95%CI 35.1-78.8) and 54.2% (95%CI 32.6-71.6) (p = 0.31), respectively.

CONCLUSIONS

A large proportion of patients with surgically resected LCNEC will develop systemic recurrence after resection. Patients with tumors >3 cm have a significantly higher rate of systemic recurrence suggesting that adjuvant chemotherapy should be considered after complete resection of LCNEC >3 cm, even in the absence of nodal involvement.

Double-edged role of radiotherapy in patients with pulmonary large-cell neuroendocrine carcinoma

Purpose: Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is classified as non-small-cell lung cancer, but has characteristics similar to small-cell lung cancer. This study was performed to evaluate the effect of surgery and radiotherapy on patients with LCNEC. Materials and Methods: We analyzed 1,619 patients with stage I-III LCNEC, identified from the Surveillance, Epidemiology, and End Results database, diagnosed from 2000 to 2013. The Kaplan-Meier analysis and the Cox proportional hazard model were used to study patient prognosis. Results: Overall, 869 (53.7%) stage I LCNEC patients, 203 (12.5%) stage II patients, and 547 (33.8%) stage III patients were included in the analysis. Various surgery types were all associated with higher overall survival (OS) and lung cancer-specific survival (LCSS) than no surgery, with the following HRs: 0.334 (OS) and 0.279 (LCSS) for lobectomy, 0.468 (OS) and 0.416 (LCSS) for partial/wedge/segmental resection, and 0.593 (OS) and 0.522 (LCSS) for pneumonectomy (all p < 0.05). OS and LCSS of stage I and II LCNEC patients were not improved by radiotherapy (stage I: OS p = 0.719, LCSS p = 0.557; stage II: OS p = 0.136, LCSS p = 0.697). However, in stage III patients, radiotherapy significantly improved both OS and LCSS (p < 0.001). Following multivariate analysis, increased age, male patients, radiotherapy and diagnosed at stage II or III were all independent risk factors for LCNEC (all p < 0.05). Conclusion: Lobectomy had the best outcome for OS and LCSS in stage I-II LCNEC. For stage III LCNEC patients, radiotherapy can significantly improve survival time. However, in LCNEC patients undergoing surgery, radiotherapy may reduce survival time.

Neuroendocrine marker staining pattern categorization of small-sized pulmonary large cell neuroendocrine carcinoma

Background

The aim of this study was to identify subgroups with good or bad prognosis in patients with pulmonary large cell neuroendocrine carcinoma (LCNEC) based on immunostaining patterns with neuroendocrine markers and compare them with small cell lung carcinoma (SCLC).

Methods

From January 2001 to December 2017, of all patients with resected LCNEC and SCLC, we selected patients whose pathological tumor sizes were ≤30 mm in diameter (defined as small‐sized tumors) and who underwent complete resection with lymphadenectomy. We classified patients with small‐sized LCNEC (sLCNEC) into two subgroups based on immunostaining patterns with three neuroendocrine markers (chromogranin A, synaptophysin, and NCAM) and compared them to small‐sized SCLC (sSCLC).

Results

A total of 48 patients with sLCNEC and 39 patients with sSCLC were enrolled. Of 48 patients with sLCNEC, 21 were categorized as the small‐sized triple‐positive group (sTP), whose patients were positive for the three neuroendocrine markers, and 27 patients were categorized as the small‐sized nontriple‐positive group (sNTP), whose patients were not positive for all three neuroendocrine markers. The percentage of lymph node metastasis was significantly lower in sNTP than in sTP and sSCLC. There was no significant difference in overall survival, but recurrence‐free survival (RFS) and tumor‐specific survival (TSS) were significantly poorer in sTP and sSCLC than in sNTP. Multivariate analysis revealed sTP and sSCLC were independent prognostic factors for poorer RFS and TSS than those of sNTP.

Conclusions

The sNTP subgroup had a good prognosis and the sTP subgroup a poor prognosis. There were some similarities in clinicopathological features between sTP and sSCLC.

F-FDG Uptake Is Predictive of Poor Survival After Surgery for Large-CellNeuroendocrine-Carcinomas of The Lung: A Bicentric Analysis

Introduction: Large cell neuroendocrine carcinoma (LCNEC) represents a relatively rare and poorly studied entity whose management is not clearly established. The aim of this study was to explore the relationship between preoperative 18F-FDG-PET results, pathological features and long-term survival in a large surgical cohort of LCNEC. Methods: From 06/08 to 06/17, the clinical, radiometabolic, pathological and surgical aspects of 121 LCNEC-patients surgically treated in 2 tertiary centers were retrieved. A Cox regression model was used to identify predictors of survival and Kaplan-Meier method to summarize overall survivals. Results: Mean age and male/female ratio were 63.4±8.3 and 3:1, respectively. The main clinical, radiometabolic and surgical characteristics are reported in Tab.1. Most patients were active/former smokers and presented symptoms at diagnosis. 18FDG-PET/Scan was performed in 65 patients (53.7%) with a mean SUVmax of 10.1 (SD±4.6). Higher SUVmax values (SUVmax >10) were detected in tumors with larger size (p=0.004), advanced p-Stages (p=0.019), presenting necrosis (p=0.077) and with positive staining for CD56 (p=0.025) and TTF-1 (0.063). After surgery (R0 in 91% of cases), 52 (43%) patients had pStage-I while about 35% of patients presented with N1-2 disease. Median, 3-yrs and 5-yrs overall survival was 40 months, 52.2% and 44.6%, respectively. At univariate analysis, the survival was significantly influenced by SUVmax values (p=0.009) and by the presence of vascular invasion at pathological examination (p=0.024). Multivariate analysis showed as the FDG-SUVmax was the only independent variable affecting long-term survival (HR:2.86;C.E.: 1.09-7.47;p=0.032). Conclusions: Patients underwent surgical resection for LCNEC of the lung experienced a poor prognosis (5-yrs survival = 44.6% in this study). High-level FDG accumulation (SUVmax >10) correlates with pathological features and results to be independently predictive of poor survival after surgery. This parameter should be taking into account when planning the best strategy of care.

Lung Large Cell Neuroendocrine Carcinoma: An Analysis of Patients from the Surveillance, Epidemiology, and End-Results (SEER) Database

Background

The aim of this study was to assess the incidence, clinicopathologic characteristics, prognostic factors, and treatment outcomes in lung large cell neuroendocrine carcinoma (LCNEC).

Material/Methods

Patients diagnosed with lung LCNEC between 2000 and 2013 were identified using the Surveillance, Epidemiology, and End-Results database. Kaplan–Meier methods and univariate and multivariate analyses were used for statistical analysis.

Results

A total of 2097 patients were identified. The total age-adjusted incidence rate of lung LCNEC was 0.3/100 000, with a rise in incidence over the study period. The 5-year lung cancer-specific survival (LCSS) and overall survival (OS) were 20.7% and 16.7%, respectively. Multivariate analysis indicated that age ≥65 years, male sex, advanced tumor stage, advanced nodal stage, not undergoing surgery. and not undergoing chemotherapy were independent adverse indicators for survival outcomes. After stratification by tumor stage, undergoing surgery was associated with more favorable LCSS and OS compared with those without surgery, regardless of tumor stage.

Conclusions

LCNEC is a rare lung cancer subtype with a dismal prognosis. Primary surgical treatment has significant survival benefits, even for stage IV patients. The optimal treatment strategies for lung LCNEC require further investigation.

Treatment outcomes and incidence of brain metastases in pulmonary large cell neuroendocrine carcinoma

INTRODUCTION

Large cell neuroendocrine carcinoma (LCNEC) is a rare type of high-grade pulmonary neuroendocrine tumor. The study objective is to investigate its survival outcomes, incidence of brain metastases, and patterns of recurrence.

METHODS

This is a single center study of patients with pathologic diagnosis of pulmonary LCNEC. Patient data were collected retrospectively and analyzed, including survival, incidence of brain metastases, and patterns of recurrence.

RESULTS

Of 87 patients (stages I: 24, II: 14, III: 23, IV: 26), 52 were managed curatively and 35 palliatively. The median follow-up time was 17.3 months (range 0.6-89.5) for those treated with curative intent and 7.0 months (range 0.1-28.6) for those treated palliatively. The 2- and 5-year overall survival (OS) rates are 48.4% and 25.5% for the curative group, with a median OS of 13.5 months. In the palliative group, the OS are 30.8% at 1 year and 6.8% at 2 years, with a median OS of 7.0 months. Thirty-eight of 52 (73%) patients treated with curative intent had disease relapse, with the common sites being regional lymph nodes (20), brain (18), bones (11), and liver (9). The incidence of brain recurrence among those managed curatively are 21.4% and 41.3%, respectively at 1 and 2 years. Of 18 patients experiencing brain metastases, 14 developed them as part of a first relapse.

CONCLUSIONS

LCNEC's survival outcomes are poor. The incidence of brain metastases is higher than what is observed for other types of nonsmall cell lung cancers. Prophylactic cranial irradiation should be investigated as a means of improving outcomes.

PD-L1 expression in large cell neuroendocrine carcinoma of the lung

OBJECTIVES

Large cell neuroendocrine carcinoma of the lung (LCNEC) is associated with an unfavorable prognosis and only few patients are eligible for surgery. In most patients, chemotherapy is recommended alone or in addition to resection. Novel immunotherapies blocking the PD-L1 pathway have been introduced into therapeutic regimens for NSCLC with great success. In order to evaluate a possible efficacy of an anti-PD-L1 therapy, we analyzed the frequency of PD-L1 expression in LCNEC.

MATERIAL AND METHODS

We retrospectively reviewed data from 76 patients with LCNEC treated in our institution between 1998 and 2010. The expression of PD-L1 was examined on the tumor cells and the tumor surrounding tissue by immunohistochemistry. An expression of >1% was considered as positive. Statistical analysis was performed to determine significant predictors for survival.

RESULTS

56 of 76 patients with LCNEC were treated with a potentially therapeutic surgical approach. Tumor-specific survival (TSS) of the entire cohort was 29% at five years. 17 patients (22.3%) had PD-L1 positive tumors and 12 of these had no additional PD-L1 expression in the adjacent immune cell infiltrate. Tumor-flanking immune cells were found PD-L1 positive 28 patients; 16 of these had no additional expression on the tumor cells. The most considerable difference in survival was found when comparing patients with isolated PD-L1 expression on tumor cells and PD-L1 negative immune cell infiltrate to their counterpart (positive immune-cell infiltrate and PD-L1 negative tumor cell surface; 5-year TSS: 0% vs. 60%; p < 0.017).

CONCLUSION

PD-L1 expression in LCNEC was associated with poorer survival whereas PD-L1 expression in the tumor microenvironment seemed to have a beneficial effect. Therapeutic approaches have to be evaluated in future.

The role of surgery in high grade neuroendocrine tumours of the lung

High grade lung neuroendocrine tumours are a heterogeneous subtype of pulmonary cancers including small cell lung cancer (SCLC) and large-cell neuroendocrine carcinoma (LCNEC). LCNEC represents approximately 2-3% of lung cancers, whereas SCLC represents 15-20% of lung cancers. Patients with SCLC and LCNEC have a poor prognosis compared with patients with non-small cell lung cancer (NSCLC). LCNEC is treated with primary surgical resection in stages I-II, which is similar to other NSCLCs. Neo-adjuvant treatment in stage III is similar to NSCLC but has not been well studied. LCNEC tumours have an unfavourable prognosis in higher stages but a more favourable prognosis in earlier stages. Surgery plays a minor role in treatment of SCLC because tumours are often locally advanced or have metastasized at the time of presentation and treatment relies on chemo- or chemoradiotherapy. However, patients with limited cancer may demonstrate better disease control upon surgical treatment. The resection rate of limited disease (LD) SCLC is low (1-6%), but 5-year survival rates of 31-42% after surgical resection are encouraging and are significantly higher than the survival rates of comparable patients that did not have surgery. Curing SCLC in stage I is reported in up to 66% of cases. Local treatment with either resection or radiotherapy alone is followed by high rates of locoregional and distant recurrences, so preoperative or adjuvant treatment is recommended. Here, we summarise the similarities and differences of SCLC and LCNEC and highlight the role of surgery in the treatment of SCLC and LCNEC and its effect on local recurrence prevention.

Update on large cell neuroendocrine carcinoma

High-grade neuroendocrine carcinomas of the lung are classified into two categories: large cell neuroendocrine carcinoma (LCNEC) and small cell lung carcinoma (SCLC). While typical cases of LCNEC are morphologically distinct from SCLC, the differentiation between LCNEC and SCLC can be challenging in some cases. In fact, there are borderline high-grade neuroendocrine carcinomas that morphologically fall between LCNEC and SCLC. Growing evidence suggests that LCNEC is a histologically and biologically heterogeneous group of tumors. Molecular profiling with next-generation sequencing (NGS) has revealed a few biologically distinct subsets of LCNEC. Of those, the SCLC-like subset is characterized by concurrent inactivating mutations in TP53 and loss of RB1 that are typically seen in SCLC, whereas the non-small cell lung cancer (NSCLC)-like subset frequently harbors molecular alterations that are usually seen in NSCLC. Furthermore, the SCLC-like subset exhibits morphologic features of SCLC, and NSCLC-like morphology predominates in the NSCLC-like subset, although there was a substantial overlap in morphologic features between these subsets. As for the treatment of LCNEC, surgery is advocated for early stage tumors, but surgery alone does not appear to be sufficient and adjuvant chemotherapy, consisting of platinum/etoposide, likely prevents recurrence in patients with completely resected LCNEC. For advanced disease, there have been conflicting reports as to whether LCNEC responds to chemotherapeutic regimens in the similar manner to SCLC rather than NSCLC, and the heterogeneous biology of LCNEC may contribute in part to the discrepant results. A further understanding of the biology of LCNEC will lead to novel approaches to clinical managements of patients with LCNEC.

Improvement in TNM staging of pulmonary neuroendocrine tumors requires histology and regrouping of tumor size

OBJECTIVE

Neuroendocrine tumors of the lung are currently staged with the 7th edition TNM non-small cell lung cancer staging system. This decision, based on data analysis without data on histology or disease-specific survival, makes its applicability limited. This study proposes a specific staging system for these tumors.

METHODS

We retrospectively analyzed 510 consecutive patients (female/male, 313/197; median age, 61 years; interquartile range, 51-70) undergoing lung resection for a primary neuroendocrine tumor between 2000 and 2015 in 8 centers. Multivariable analysis was performed using a Cox proportional hazard model to identify factors associated with disease-specific survival. A new staging system was proposed on the basis of the results of this analysis. Kaplan-Meier disease-specific survival was analyzed by stage using the proposed and the 7th TNM staging system.

RESULTS

Follow-up was completed in 490 of 510 patients at a median of 51 months (interquartile range, 18-99). Histology (G1-typical carcinoid vs G2-atypical carcinoid vs G3-large-cell neuroendocrine carcinoma) and pT were independently associated with survival, but pN was not. After regrouping histology and pT, we proposed the following staging system: IA (pT1-2G1), IB (pT3G1, pT1G2), IIA (pT4G1, pT2-3G2, pT1G3), IIB (pT4G2, pT2-3G3), and III (pT4G3). The 5-year survivals were 97.9%, 81.0%, 69.1%, 51.8%, and 0%, respectively. By using the 7th TNM, 5-year survivals were 95.0%, 92.3%, 67.7%, 70.9%, and 65.1% for stage IA, IB, IIA, IIB, and III, respectively.

CONCLUSIONS

Incorporating histology and regrouping tumor stage create a unique neuroendocrine tumor staging system that seems to predict survival better than the 7th TNM classification.

Pulmonary Large-Cell Neuroendocrine Carcinoma: From Epidemiology to Therapy

Lung neuroendocrine tumors are a heterogeneous subtype of pulmonary cancers representing approximately 20% of all lung cancers, including small-cell lung cancer (SCLC) and large-cell neuroendocrine carcinoma (LCNEC). The frequency appears to be approximately 3% for LCNEC. Diagnosis of LCNEC requires attention to neuroendocrine features by light microscopy and confirmation by immunohistochemical staining for neuroendocrine markers. Both SCLC and pulmonary LCNEC are high-grade and poor-prognosis tumors, with higher incidence in males and smokers and peripheral localization. LCNEC is very rare, and the precise diagnosis on small specimens is very difficult, so we have still too few data to define a standard of treatment for pulmonary LCNECs. Data of literature, most based on retrospective analysis, indicated a poor 5-year overall survival, with a high incidence of recurrence after surgery, even in stage I disease. Primary surgery should be the first option in all operable patients because there is no validate therapeutic approach for LCNEC due to lack of clinical trials in this setting. Neoadjuvant platinum-based regimens remain only an option for potentially resectable tumors. In advanced stages, SCLC-like chemotherapy seems the best option of treatment, with a good response rate but a poor overall survival (from 8 to 16 months in different case series). New agents are under clinical investigation to improve LCNEC patients' outcome. We reviewed all data on treatment options feasible for pulmonary LCNEC, both for localized and extensive disease.

Diagnosis and treatment of bronchopulmonary neuroendocrine tumours: State of the art

Bronchopulmonary neuroendocrine tumours (BP-NET) are a heterogeneous population of neoplasms with different pathology, clinical behaviour and prognosis compared to the more common lung cancers. The management of BP-NET patients is largely based on studies with a low level of evidence and extrapolation of data obtained from more common types of neuroendocrine tumours. This review reflects our view of the current state of the art of diagnosis and treatment of patients with BP-NET.

A marked response to icotinib in a patient with large cell neuroendocrine carcinoma harboring an EGFR mutation: A case report

The present study reports the case of an 84-year-old male with primary pulmonary large cell neuroendocrine carcinoma (LCNEC) harboring an epidermal growth factor receptor (EGFR) gene mutation that exhibited a long-lasting response to the EGFR-tyrosine kinase inhibitor (EGFR-TKI) icotinib. The patient had an extensive smoking history, a poor performance status, and presented with an irregular mass in the middle lobe of the right lung on computed tomography (CT) and an enlarged left supraclavicular lymph node on physical examination. Right middle lobe bronchial brushing during fiberoptic bronchoscopy identified poorly-differentiated cancer cells. The left supraclavicular lymph node was biopsied and a diagnosis of metastatic LCNEC was determined. Furthermore, an EGFR exon 19 deletion was identified by DNA sequencing. Following diagnosis, icotinib was administered at a dose of 125 mg three times a day. Chest CT scans were performed after 1 month of treatment, which indicated that the tumor was in partial remission. This marked response to icotinib lasted for 8 months. Thus, the present case illustrates the possibility of identifying EGFR mutations in LCNEC and indicates that EGFR-tyrosine kinase inhibitors may be an alternative treatment strategy for patients with LCNEC harboring activating EGFR mutations.

Predictors of survival after operation among patients with large cell neuroendocrine carcinoma of the lung

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) represents a rare entity in non-small cell lung cancer, with only partially understood biology and poor survival. A diagnosis is difficult to obtain on the basis of small biopsy specimens, but surgical procedures may be indicated in only a small fraction of patients. The aim of this study was to assess the clinical and immunohistochemical features of patients with LCNEC to identify predictors of outcome and long-term survival.

METHODS

The clinical and pathologic data of 57 surgical patients with LCNEC between March 2003 and December 2012 were retrospectively reviewed. The tumor specimens were examined for expression of neuronal specific enolase, synaptophysin, CD 56, chromogranin-A, and the somatostatin receptor by immunohistochemistry. Statistical analysis was performed to determine significant predictors for overall survival and recurrence-free survival.

RESULTS

Fifty-seven patients (41 men, 16 women) underwent thoracic operations with curative intent. Complete resection was achieved in 91% of cases. The results of staining for CD56, synaptophysin, neuronal specific enolase, chromogranin-A, and somatostatin were positive in 86%, 81%, 68%, 61%, and 21%, respectively. Recurrence occurred in 28 patients (49%). Overall survival and recurrence-free survival were 50% and 45%, respectively, after 3 years. Advanced nodal status (N1, p < 0.025; N2, p < 0.02) and simultaneous expression of CD56 and chromogranin-A (p < 0.04) were significantly associated with poorer outcome.

CONCLUSIONS

LCNEC is a rare neuroendocrine pulmonary malignancy that is associated with poor prognosis and high recurrence rates. Surgical treatment can achieve satisfactory results in selected cases. Neuroendocrine marker profiles may predict prognosis and may influence the decision for adjuvant therapy or follow-up intervals.

A retrospective analysis of the clinicopathological characteristics of large cell carcinoma of the lung

The aim of the present study was to analyze and summarize the clinicopathological characteristics of large-cell lung carcinoma (LCLC) of the lung, in order to improve the definite diagnosis rate of LCLC. Clinicopathological data of 174 patients with LCLC, confirmed pathologically, were retrospectively reviewed. The 174 cases of LCLC accounted for 5.7% of the total lung cancer cases during the corresponding time period at the Affiliated Cancer Hospital of Tianjin Medical University (Tianjin, China), among which there were 131 males and 43 females with an average age of 61.4 years. The postoperative pathological diagnosis of the 174 cases showed 80 cases of classic LCLC, 64 cases of large cell neuroendocrine carcinoma (LCNEC), six cases of combined LCNEC, 19 cases of basaloid carcinoma, three cases of clear cell carcinoma and two cases of lymphoepithelioma-like carcinoma. Of the total 174 LCLC cases, 96 patients exhibited lymph node metastasis. LCLC is a highly aggressive malignancy with a high tendency of invasion and metastasis, although the incidence rate is low. A definite diagnosis of LCLC primarily relies on the pathological diagnosis. Each subtype of LCLC has its own pathomorphological and immunohistochemical characteristics.

Treatment options for patients with large cell neuroendocrine carcinoma of the lung

Large cell neuroendocrine carcinoma (LCNEC) of the lung is categorized as a variant of large cell carcinomas, and LCNEC tumors display biological behaviors resembling those of small cell lung carcinomas and features of high-grade neuroendocrine tumors. Because patients with LCNEC have a poor prognosis, surgery alone is not sufficient. Multimodality therapies, including adjuvant chemotherapy, appear promising for improved prognosis in patients with LCNEC. In this review article, we discuss treatment options for patients with LCNEC of the lung.

High grade neuroendocrine lung tumors: pathological characteristics, surgical management and prognostic implications

Among non-small cell lung cancers (NSCLC), large cell carcinoma (LCC) is credited of significant adverse prognosis. Its neuroendocrine subtype has even a poorer diagnosis, with long-term survival similar to small cell lung cancer (SCLC). Our purpose was to review the surgical characteristics of those tumors. The clinical records of patients who underwent surgery for lung cancer in two French centers from 1980 to 2009 were retrospectively reviewed. We more particularly focused on patients with LCC or with high grade neuroendocrine lung tumors. High grade neuroendocrine tumors were classified as pure large cell neuroendocrine carcinoma (pure LCNEC), NSCLC combined with LCNEC (combined LCNEC), and SCLC combined with LCNEC (combined SCLC). There were 470 LCC and 155 high grade neuroendocrine lung tumors, with no difference concerning gender, mean age, smoking habits. There were significantly more exploratory thoracotomies in LCC, and more frequent postoperative complications in high grade neuroendocrine lung tumors. Pathologic TNM and 5-year survival rates were similar, with 5-year ranging from 34.3% to 37.6% for high grade neuroendocrine lung tumors and LCC, respectively. Induction and adjuvant therapy were not associated with an improved prognosis. The subgroups of LCNEC (pure NE, combined NE) and combined SCLC behaved similarly, except visceral pleura invasion, which proved more frequent in combined NE and less frequent in combined SCLC. Survival analysis showed a trend toward a lower 5-year survival in case of combined SCLC. Therefore, LCC, LCNEC and combined SCLC share the same poor prognosis, but surgical resection is associated with long-term survival in about one third of patients.

Neuroendocrine tumors of the lung

Neuroendocrine tumors may develop throughout the human body with the majority being found in the gastrointestinal tract and bronchopulmonary system. Neuroendocrine tumors are classified according to the grade of biological aggressiveness (G1-G3) and the extent of differentiation (well-differentiated/poorly-differentiated). The well-differentiated neoplasms comprise typical (G1) and atypical (G2) carcinoids. Large cell neuroendocrine carcinomas as well as small cell carcinomas (G3) are poorly-differentiated. The identification and differentiation of atypical from typical carcinoids or large cell neuroendocrine carcinomas and small cell carcinomas is essential for treatment options and prognosis. Pulmonary neuroendocrine tumors are characterized according to the proportion of necrosis, the mitotic activity, palisading, rosette-like structure, trabecular pattern and organoid nesting. The given information about the histopathological assessment, classification, prognosis, genetic aberration as well as treatment options of pulmonary neuroendocrine tumors are based on own experiences and reviewing the current literature available. Most disagreements among the classification of neuroendocrine tumor entities exist in the identification of typical versus atypical carcinoids, atypical versus large cell neuroendocrine carcinomas and large cell neuroendocrine carcinomas versus small cell carcinomas. Additionally, the classification is restricted in terms of limited specificity of immunohistochemical markers and possible artifacts in small biopsies which can be compressed in cytological specimens. Until now, pulmonary neuroendocrine tumors have been increasing in incidence. As compared to NSCLCs, only little research has been done with respect to new molecular targets as well as improving the classification and differential diagnosis of neuroendocrine tumors of the lung.