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Helderman NC, Suerink M, Kilinç G, van den Berg JG, Nielsen M, Tesselaar MET. Relation between WHO Classification and Location- and Functionality-Based Classifications of Neuroendocrine Neoplasms of the Digestive Tract. Neuroendocrinology 2023; 114:120-133. [PMID: 37690447 PMCID: PMC10836754 DOI: 10.1159/000534035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
Practice of neuroendocrine neoplasms (NENs) of the digestive tract, which comprise of a highly diverse group of tumors with a rising incidence, faces multiple biological, diagnostic, and therapeutic issues. Part of these issues is due to misuse and misinterpretation of the classification and terminology of NENs of the digestive tract, which make it increasingly challenging to evaluate and compare the literature. For instance, grade 3 neuroendocrine tumors (NETs) are frequently referred to as neuroendocrine carcinomas (NECs) and vice versa, while NECs are, by definition, high grade and therefore constitute a separate entity from NETs. Moreover, the term NET is regularly misused to describe NENs in general, and NETs are frequently referred to as benign, while they should always be considered malignancies as they do have metastatic potential. To prevent misconceptions in future NEN-related research, we reviewed the most recent terminology used to classify NENs of the digestive tract and created an overview that combines the classification of these NENs according to the World Health Organization (WHO) with location- and functionality-based classifications. This overview may help clinicians and researchers in understanding the current literature and could serve as a guide in the clinic as well as for writing future studies on NENs of the digestive tract. In this way, we aim for the universal use of terminology, thereby providing an efficient foundation for future NEN-related research.
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Affiliation(s)
- Noah C Helderman
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Manon Suerink
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gül Kilinç
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - José G van den Berg
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maartje Nielsen
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Margot E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Constantin M, Petrescu L, Mătanie C, Vrancianu CO, Niculescu AG, Andronic O, Bolocan A. The Vermiform Appendix and Its Pathologies. Cancers (Basel) 2023; 15:3872. [PMID: 37568688 PMCID: PMC10417615 DOI: 10.3390/cancers15153872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
The vermiform appendix is a muscular cylindrical structure originating near the junction of the cecum and ileum, averaging 9 cm (5-35 cm) in size. As the most mobile viscera, it can adopt several positions, the most common being the retrocecal position. Perceived as an atavistic organ lacking physiological relevance, the vermiform appendix appears to be involved in immune function, serving in the maturation of B lymphocytes and the production of immunoglobulin A, in endocrine function, excreting amines and hormones in the 2-3 mL of mucus secreted daily, and in digestive function, by storing beneficial bacteria from where they can recolonize the colon. With a lumen of about 6 mm, the vermiform appendix has a reduced storage capacity, so any blockage of the appendix with fecoliths (fecaliths), seeds derailed from the colon, or enlarged lymph nodes prevents drainage and intraluminal accumulation of secreted mucus. Unable to relax, the appendix wall severely limits its intraluminal volume, so mucus accumulation leads to inflammation of the appendix, known generically as appendicitis. In addition, the vermiform appendix may be the site of the development of neoplastic processes, which may or may not involve mucus production, some of which can significantly affect the standard of living and ultimately lead to death. In general, mucinous tumors may have a better prognosis than non-mucinous tumors. This review takes a comprehensive path, starting by describing the anatomy and embryology of the vermiform appendix and further detailing its inflammatory pathologies, pathologies related to congenital anomalies, and appendix tumors, thus creating an up-to-date framework for better understanding, diagnosis, and treatment of these health problems.
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Affiliation(s)
- Marian Constantin
- Institute of Biology of Romanian Academy, 060031 Bucharest, Romania;
- The Research Institute of the University of Bucharest, ICUB, 050095 Bucharest, Romania;
| | - Livia Petrescu
- Department of Anatomy, Animal Physiology and Biophysics, DAFAB, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (L.P.); (C.M.)
| | - Cristina Mătanie
- Department of Anatomy, Animal Physiology and Biophysics, DAFAB, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (L.P.); (C.M.)
| | - Corneliu Ovidiu Vrancianu
- The Research Institute of the University of Bucharest, ICUB, 050095 Bucharest, Romania;
- Microbiology—Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- National Institute of Research and Development for Biological Sciences, 296 Splaiul Independentei, District 6, 060031 Bucharest, Romania
| | - Adelina-Gabriela Niculescu
- The Research Institute of the University of Bucharest, ICUB, 050095 Bucharest, Romania;
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Politehnica University of Bucharest, 011061 Bucharest, Romania
| | - Octavian Andronic
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.A.); (A.B.)
| | - Alexandra Bolocan
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.A.); (A.B.)
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Shibahara Y, Krzyzanowska M, Vajpeyi R. Appendiceal Well-Differentiated Neuroendocrine Tumors: A Single-Center Experience and New Insights into the Effective Use of Immunohistochemistry. Int J Surg Pathol 2022; 31:252-259. [PMID: 35491663 PMCID: PMC10101181 DOI: 10.1177/10668969221095172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Appendiceal well-differentiated neuroendocrine tumor is the most common histological type of appendiceal tumor. The majority of tumors are found incidentally at the tip of the appendix, with few exceptions. Due to its primarily indolent nature, this entity presents unique pathological challenges, particularly in the appropriate use of immunohistochemistry which this study aims to clarify. Patients and methods. Patients diagnosed at University Health Network (Canada) between 2005–2019 were selected and reviewed. Results. We identified 70 patients and sex distribution was female 60%; median age 36.5 years. Among them, 63 patients underwent appendectomy, and seven had initial right hemicolectomy for non-appendix lesions. Mean tumor size was 5.0 mm. Tumor extent was submucosa (15%); muscularis propria (34%); subserosa or mesoappendix (42%); visceral peritoneum (8%). All were clinically non-functional and negative for nodal and distant metastasis. Ninety percent of tumors were WHO Grade 1; 10% were WHO Grade 2. Immunohistochemically, an average of six stains were performed per patient. Nearly all tumors were positive for chromogranin A, synaptophysin, CAM5.2, and CDX2. MIB-1 staining was < 3% in 58/63 tumors. Other immunohistochemical stainings performed were hormonal markers (serotonin, glucagon, pancreatic peptide, peptide YY). Subsequent right hemicolectomy was performed on five patients. All were followed up (median 4 years 8 months), and all were alive without recurrence except for one patient who died of another comorbidity. Conclusion. Tumors that are small, localized, and of low grade can be reasonably exempt from an extensive immunohistochemical panel in the absence of non-typical clinical and morphological features.
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Affiliation(s)
- Yukiko Shibahara
- Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Pathology, Kitasato University, Sagamihara, Japan
| | - Monika Krzyzanowska
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Management and Evaluation, Institute of Health Policy, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
| | - Rajkumar Vajpeyi
- Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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Saponjski J, Macut D, Sobic-Saranovic D, Ognjanovic S, Bozic Antic I, Pavlovic D, Artiko V. Somatostatin receptor scintigraphy in the follow up of neuroendocrine neoplasms of appendix. World J Clin Cases 2020; 8:3697-3707. [PMID: 32953846 PMCID: PMC7479554 DOI: 10.12998/wjcc.v8.i17.3697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Neuroendocrine tumors of appendix (ANETs) known as carcinoids, are rare endocrine neoplasms originated from enterochromaffin cells of gastrointestinal tract. ANETs are the third most frequent (16.7%) gastrointestinal neuroendocrine tumors, with the incidence of 0.08-0.2 cases/100000 during one year. Incidental ANETs occur in 0.2%-0.7% of emergency surgical resections because of suspected appendicitis which is usually the first manifestation of ANET. Although there are a lot of papers about application of somatostatin receptor scintigraphy in gastrointestinal neuroendocrine tumors, there are very rare sporadic cases described about ANETs particularly.
AIM To establish the role of somatostatin receptor scintigraphy (SRS) in the management of patients with neuroendocrine tumors of appendix (ANET).
METHODS The total of 35 patients was investigated, 23 females and 12 males, average age (43.7 ± 17.3 years). All patients had histological diagnosis of ANET (34 carcinoids of appendix and one tubular carcinoid). Majority of tumors have been found incidentally during surgery of: Acute appendicitis (n = 15), perforated appendicitis (n = 2), ileus (n = 3), hysterectomy (n = 3), ruptured ovarian cyst (n = 2), caecal volvulus (n = 1), while 9 patients had diagnosis of appendiceal tumor before the surgery. Seventeen patients had tumor grade (G) G1, 12 G2 and 6 G3. The right hemicolectomy was performed in 13, while the rest of the patients had appendectomy only. SRS was done early (2 h) and late (24 h) after i.v. application of 740 MBq technetium-99m ethylenediamine-N, N'-diacetic acid Hydrazinonicotinyl-Tyr3-Octreotide (technetium-99m-Tektrotyd, Polatom, Poland). SRS was performed for restaging in all the patients after surgery.
RESULTS There were 12 true positive (TP), 19 true negative, 3 false positive and 1 false negative SRS result. Sensitivity of the method was 92.31%, specificity was 86.36%, positive predictive value was 80.00%, negative predictive value was 95.00% and accuracy 88.57%. Receiver operating characteristics analysis showed that SRS scintigraphy is a good test for detection TP cases [area under the curve of 0.850, 95% confidence interval (CI): 0.710-0.990, P < 001]. Single photon emission computed tomography contributed diagnosis in 7 TP findings. In 10 patients Krenning score was 4 and in 2 was 3. In 8 patients SRS significantly changed the management of the patients (in two surgery was repeated, in 4 somatostatin analogues and in two peptide receptor radionuclide therapy). Median progression-free survival in SRS positive patients was 52 months (95%CI: 39.7-117.3 mo) while in SRS negative patients it was 60 months (95%CI: 42.8-77.1 mo), without statistically significant difference between the two groups (P = 0.434).
CONCLUSION In conclusion, our results confirmed the value of SRS in the follow-up of the patients with ANET after surgery, if recurrences or metastases are suspected.
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Affiliation(s)
- Jelena Saponjski
- Center for Nuclear Medicine, Clinical Center of Serbia, Belgrade 11000, Serbia
| | - Djuro Macut
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Dragana Sobic-Saranovic
- Center for Nuclear Medicine Clinical Center of Serbia, Faculty of Medicine University of Belgrade, Belgrade 11000, Serbia
| | - Sanja Ognjanovic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Ivana Bozic Antic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | | | - Vera Artiko
- Center for Nuclear Medicine Clinical Center of Serbia, Faculty of Medicine University of Belgrade, Belgrade 11000, Serbia
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McNamara D, Raymond B. Sixty-One-Year-Old Female With Metastatic Poorly Differentiated Carcinoma of the Appendix With Omental Metastasis. Cureus 2020; 12:e8688. [PMID: 32699687 PMCID: PMC7370669 DOI: 10.7759/cureus.8688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Neuroendocrine tumors (NETs) are rare tumors that are often asymptomatic and were once considered benign. A specific subtype that we will dive into in this article is appendiceal neuroendocrine tumors (ANETS). ANETs are the most common tumors located within the appendix. Most often, they present as acute appendicitis and are found incidentally on pathology reports status post appendectomy. The objective of this article is to show that even though most of the ANETs are benign and fully treated via surgery, ANETs still have the potential to become malignant and metastasize. Our patient fits the common features seen in ANETS. She is a middle-aged woman with vague abdominal pain and no clear diagnosis on gastrointestinal (GI) workup. Computed tomography (CT) confirmed appendicitis, and pathology reports status post-surgery confirmed stage IV, pT4, Nx, M1 - poorly differentiated neuroendocrine carcinoma of the appendix with omental metastases.
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Aggarwal N, Bhargava A. Appendiceal mucocele secondary to torsion in an asymptomatic patient. J Surg Case Rep 2019; 2019:rjz241. [PMID: 31428310 PMCID: PMC6693393 DOI: 10.1093/jscr/rjz241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 12/11/2022] Open
Abstract
Torsion of the appendix associated with an appendiceal mucocele is extremely rare with just a few published cases. To our knowledge, we report the first case of appendiceal mucocele secondary to torsion in an asymptomatic patient. In this case, numerous adhesions were found attaching the tip of the appendix mucocele to the peritoneum contributing to torsion as well as a lack of evidence for appendiceal neoplasm. Complications of appendiceal mucocele include obstruction, intussusception and pseudomyxoma peritonei, which has a particularly poor prognosis. Clinicians should, therefore, consider prompt surgical resection for definitive histopathological diagnosis and management.
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Affiliation(s)
- Nikhil Aggarwal
- Department of Surgery, King George Hospital, Ilford, Essex, UK
| | - Aman Bhargava
- Department of Surgery, King George Hospital, Ilford, Essex, UK
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Elkbuli A, Sanchez C, McKenney M, Boneva D. Incidental neuro-endocrine tumor of the appendix: Case report and literature review. Ann Med Surg (Lond) 2019; 43:44-47. [PMID: 31194114 PMCID: PMC6551463 DOI: 10.1016/j.amsu.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 05/27/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Neuroendocrine tumors (NETs) are neoplasms that arise from neuroendocrine cells that have properties of both neuronal and endocrine cells. NETs are most common in the small intestine, rectum, and the appendix and frequently termed carcinoid. PRESENTATION OF CASE A 30-year-old male presented with abdominal pain and tenderness in the RLQ. Computerized tomography revealed findings consistent with acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy for an acutely inflamed appendicitis. Histopathological examination, showed a 0.5 cm well-differentiated neuroendocrine tumor of the distal appendix, with clear margins. The mitotic rate was <2 mitoses/10 high power field. Following guidelines, no further procedures were performed and follow-up one week later was uneventful. DISCUSSION Appendectomy for the treatment of appendiceal NETs smaller than 1 cm has been recommended as the treatment of these neoplasms by the guidelines set by The North American Neuroendocrine Society (NANETS). NANETS recommends right hemicolectomy for tumors originating at the base of the appendix, for tumors >2 cm in size, if there is evidence of lymphovascular or meso-appendiceal invasion, with mesenteric lymph node metastases, or for intermediate or high-grade tumors. CONCLUSION We present the case of a 30-year old male that presented with an appendiceal, well-differentiated NET that manifested as appendicitis and laparoscopic appendectomy was performed. The appendix was resected with clear margins. Given appropriate markers appendectomy can be curative.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Carol Sanchez
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
- University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
- University of South Florida, Tampa, FL, USA
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