Clinical Significance of Metastatic Lymph Nodes in the Gut of Patients with Pure and Mixed Primary Appendiceal Carcinoids

An unusual case of appendicitis due to appendiceal neuroendocrine tumor in a patient: A case report

Appendiceal neuroendocrine tumor (NET) is the most common type of appendiceal cancer and is rare in the pediatric population. The clinical characteristics of this cancer are not specific and are highly similar to those of acute appendicitis. By contrast, acute appendicitis is a common surgical indication that is caused by obstruction of the appendix lumen. With a detection rate of 0.5-1% in all appendectomy specimens, appendiceal NET is rare histopathologically and can easily be missed. However, detecting an appendiceal NET in a patient with appendicitis is highly difficult. Therefore, clinicians must be aware of this much under-reported and rare tumor in children. In the present report, a case was reported, of a 13-year-old female child who initially presented with clinical presentation of acute appendicitis, but was subsequently diagnosed with appendiceal NET by histopathological examination after an emergency appendectomy. Follow-up examination including abdominal enhanced CT and enteroscopy 2 years after surgery revealed normal results.

Size Criteria Is Not Sufficient in Selecting Patients for Local Excision Versus Radical Excision for Rectal Neuroendocrine Tumors >2 cm: A National Cancer Database Analysis

BACKGROUND

Patients with rectal neuroendocrine tumors >2 cm often undergo radical surgery, despite limited data supporting this practice. Five- and 10-year survival rates for these patients have been reported previously as 74.8% and 58.6%.

OBJECTIVE

Overall survival was compared between local excision and radical surgery and pN0 and pN1 within the radical surgery subgroup for rectal neuroendocrine tumors >2 cm. Factors independently associated with survival were identified.

DESIGN

A retrospective, nationwide, multivariate regression analysis was performed.

SETTINGS

Data are from the National Cancer Database (2004-2013).

PATIENTS

Patients with rectal neuroendocrine tumors >2 cm, excluding stages T4 and M1, were included.

MAIN OUTCOME MEASURES

Outcome measures were overall survival and independent risk factors for overall survival based on multivariate regression analysis.

RESULTS

Each group had 178 patients. After local excision, 5- and 10-year overall survival rates were 88% and 72% vs 51% and 42% after radical surgery (p < 0.001). A multivariate Cox proportional hazards model showed similar survival (p = 0.96). Tumor factors independently associated with survival were nodal metastasis (HR = 2.01 (95% CI, 1.01-3.97)), poorly differentiated tumors (HR = 4.82 (95% CI, 1.65-14.01)), and undifferentiated tumors (HR = 9.91 (95% CI, 2.77-35.49)). After radical surgery, patients with and without nodal metastasis had 5-year survival rates of 44% vs 59% (unadjusted p = 0.09; adjusted p = 0.11), with insufficient 10-year survival data.

LIMITATIONS

The study is a retrospective analysis and includes only Commission on Cancer-accredited hospitals. Long-term follow-up was limited. Lymphovascular invasion was missing for a majority of patients analyzed.

CONCLUSIONS

Local excision for select patients with rectal neuroendocrine tumors >2 cm is a viable alternative to radical surgery. Nodal status and tumor grade independently predict survival and should be factored into surgical intervention selection. In higher-risk patients selected for radical surgery, survival was similar between the pN0 and pN1 groups, possibly indicating a benefit of radical surgery for these patients. See Video Abstract at http://links.lww.com/DCR/B455.

EL CRITERIO DE TAMAO NO ES SUFICIENTE PARA SELECCIONAR PACIENTES PARA LA ESCISIN LOCAL VERSUS ESCISIN RADICAL PARA TUMORES NEUROENDOCRINOS RECTALES CM ANLISIS DE UNA BASE DE DATOS NACIONAL DE CANCER

ANTECEDENTES:Los pacientes con tumores neuroendocrinos rectales >2 cm a menudo se someten a cirugía radical, a pesar de los datos limitados que respaldan esta práctica. La supervivencia a cinco y diez años para estos pacientes se había informado anteriormente como 74,8% y 58,6%, respectivamente.OBJETIVO:Se comparó la supervivencia global entre escisión local y cirugía radical, y pN0 y pN1 dentro del subgrupo de cirugía radical para tumores neuroendocrinos rectales >2 cm. Se identificaron factores asociados de forma independiente con la supervivencia.DISEÑO:Se realizó un análisis retrospectivo de regresión multivariante a nivel nacional.AJUSTE:Los datos provienen de la Base de Datos Nacional sobre el cáncer (2004-2013).PACIENTES:Pacientes con tumores neuroendocrinos rectales > 2 cm, excluyendo los estadios T4 y M1.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado fueron la supervivencia general y los factores de riesgo independientes para la supervivencia general según el análisis de regresión multivariante.RESULTADOS:Cada grupo tuvo 178 pacientes. Después de la escisión local, la supervivencia global a cinco y diez años fue del 88% y 72% frente al 51% y el 42% después de la cirugía radical (p <0,001). Un modelo multivariado de riesgos proporcionales de Cox mostró una supervivencia similar (p = 0,96). Los factores tumorales asociados de forma independiente con la supervivencia fueron metástasis ganglionares (HR = 2,01; IC, 1,01-3,97), tumores pobremente diferenciados (HR = 4,82, IC, 1,65-14,01) y tumores indiferenciados (HR = 9,91, IC, 2,77-35,49). Después de la cirugía radical, los pacientes con y sin metástasis ganglionar tuvieron una supervivencia a cinco años del 44% frente al 59%, respectivamente (p no ajustado = 0,09; p ajustado = 0,11), con datos insuficientes de supervivencia a diez años.LIMITACIONES:El estudio es un análisis retrospectivo e incluye solo hospitales acreditados por la Comisión de Cáncer. El seguimiento a largo plazo fue limitado. La mayoría de los pacientes analizados no tenían invasión linfovascular.CONCLUSIONES:La escisión local para pacientes seleccionados con tumores neuroendocrinos rectales >2 cm es una alternativa viable a la cirugía radical. El estado ganglionar y el grado del tumor predicen de forma independiente la supervivencia y deben tenerse en cuenta en la selección de la intervención quirúrgica. En los pacientes de mayor riesgo seleccionados para cirugía radical, la supervivencia fue similar entre los grupos pN0 vs. pN1, lo que posiblemente indica un beneficio de la cirugía radical para estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B455.

Diagnosis and Treatment of Primary Tumors of the Appendix: a Critical Review

INTRODUCTION

The aim of the current paper was to critically collect, select and summarize the evidence regarding diagnosis, treatment and follow up of primary tumors of the appendix.

METHODS

A literature review was performed by search and review of the scientific studies pertaining to the subject of our inquiry.

RESULTS

Recommendations regarding pimary tumors of the appendix were formulated on the basis of the collected evidence. CONCLUSION : Primary tumors of the appendix are rare and a high index of suspicion is required not to miss a potentially life threatening medical condition.

Prognostic significance for colorectal carcinoid tumors based on the 8th edition TNM staging system

The aim of our study was to explore the value of the 8th edition TNM staging system on evaluating the prognosis of colorectal carcinoid. Colorectal carcinoid patients between 1988 and 2015 were selected in the Surveillance, Epidemiology, and End Results Program (SEER) database for analysis. About 4286 patients with colorectal carcinoid tumors were identified, of which were carcinoid tumor NOS (n = 1726), neuroendocrine carcinoma (NEC) (n = 1346) and other carcinoid tumor (OCT) (n = 591). Worsening 10-year CSS rates with increasing N status, M status, and SEER historic stage were demonstrated across all three above groups (all P < .05). In carcinoid tumor NOS, significant differences in CSS were found with increasing combined 8th AJCC stages (P < .001), except for that between stage II and stage III (10-year CSS rate: 82.6% vs 84.3%, P = .68). While combined 8th TNM stage in NEC and OTC exhibited greater separations in CSS despite on-going overlaps between groups. For carcinoid tumor NOS, stage II (HR = 3.37; 95% CI: 0.97-11.76), and stage III (HR = 2.09; 95% CI: 0.51-8.66) conferred no significant difference in CSS compared with stage I, while stage IV had an increasing HR of 5.09 (95% CI: 1.08-24.08). Although combined 8th AJCC stage had a good ability to distinguish 10-year CSS of patients with NEC or OCT, detailed 8th AJCC stage did not seem to be applicable. Detailed 8th AJCC categories of advanced stages in all the three groups conferred increased HRs with overlapping CIs. However, in the early and middle status, HRs did not increase with the increase of stages, or there was no difference in HRs between adjacent stages. Combined 8th TNM stage was not practical for judging the survival outcomes of colorectal carcinoid tumor NOS, especially in patients with stages II and III, but it provided useful prognostic information for NEC and OCT. However, for all carcinoid tumors, the prognostic values of detailed 8th AJCC stage were not enough accurate in the clinic. More optimized staging methods should be developed and validated in the future.

Neuroendocrine Tumors of the Pancreatobiliary and Gastrointestinal Tracts

Incidence of neuroendocrine tumors (NETs) is increasing, including those of the gastroenteropancreatic tract. A proper understanding of the management of this disease has become necessary for the general surgeon. This article addresses current guidelines for diagnosis and localization of NETs, including somatostatin receptor PET. Updated treatment and outcomes of NETs by primary tumor site are discussed as well as those metastatic to the liver.

A Nomogram for Predicting Lymph Nodal Metastases in Patients with Appendiceal Cancers: An Analysis of SEER Database

BACKGROUNDS

Appendiceal cancers are usually diagnosed after appendectomy accidentally. The need for subsequent right hemicolectomy in these patients was determined by the potential risk of regional lymph node (LN) metastasis. Establishing a nomogram to forecast the potential risk of lymph node metastasis of appendiceal cancer could help in the next step of treatment.

METHODS

Patients with appendiceal cancer undergoing surgery was queried in the American cancer database of Surveillance, Epidemiology and End Results database from 2004 to 2016. A nomogram was established based on Logistic regression model.

RESULTS

Finally, 3,075 patients were diagnosed with appendectomy cancer from 2004 to 2016. Among them, there were 2028 (65.9%) cases with negative lymph nodes, 1047 (34.1%) cases with positive lymph nodes. Risk factors associated with lymph node metastasis include age, histological type, tissue grade, T stage, distant metastasis, and tumor size. We drew the ROC curves of the training group（0.754, P < 0.001） and the validation group （0.775, P < 0.001） respectively. C-index values of predictions were 0.772 (95%CI, 0.750-0.793) and 0.776 (95%CI, 0.746-0.807), and Brier score were 0.178 and 0.172 in training and validation group respectively. All of them showed excellent performance of the nomogram in our study.

CONCLUSION

A new nomogram was created to assess the potential risk of LN metastasis in patients of appendiceal cancer by utilizing age, tumor histology, tumor pathologic grade, tumor size, T-stage, and M-stage. The nomogram could provide a strong reference for the right hemicolectomy and facilitate clinic decision.

Appendiceal neuroendrocrine neoplasms: incidentaloma or something we should worry about?

PURPOSE OF REVIEW

To synthesize the current knowledge and guidelines on the management of appendiceal neuroendocrine neoplasms (ANENs).

RECENT FINDINGS

Most recent guidelines are essentially based on heterogeneous retrospective series. With the advent of a more precise classification of neuroendocrine neoplasms, this heterogeneity is rightly criticized and many 'grey areas' are now debated in expert literature. The only way to solve these issues is through the conduct of large prospective multicentre studies, but this seems somewhat utopian, given the rarity of this disease.

SUMMARY

ANENs are rare tumours with a favourable prognosis, and mainly diagnosed in young patients. They are predominantly localized, and diagnosed incidentally on appendectomy. This procedure is curative for the vast majority of patients but ANENs can relapse even a significant time after the first diagnosis. Identifying the risks for recurrence is challenging, with some factors thought to be predictive of nodal involvement. The presence of one or more of these factors justifies an oncological radicalization of the surgical procedure (right hemicolectomy with lymphadenectomy). However, the beneficial impact of this surgical procedure on survival is still unproven.

Poorly differentiated neuroendocrine rectal carcinoma with uncommon immune-histochemical features and clinical presentation with a subcutaneous metastasis, treated with first line intensive triplet chemotherapy plus bevacizumab FIr-B/FOx regimen: an experience of multidisciplinary management in clinical practice

Background

Neuroendocrine tumors (NETs) are heterogeneous, widely distributed tumors arising from neuroendocrine cells. Gastrointestinal (GI)-NETs are the most common and NETs of the rectum represent 15, 2% of gastrointestinal malignancies. Poorly differentiated neuroendocrine carcinomas of the GI tract are uncommon. We report a rare case of poorly differentiated locally advanced rectal neuroendocrine carcinoma with nodal and a subcutaneous metastasis, with a cytoplasmic staining positive for Synaptophysin and Thyroid Transcription Factor-1.

Case presentation

A 72-year-old male presented to hospital, due to lumbar, abdominal, perineal pain, and severe constipation. A whole-body computed tomography scan showed a mass of the right lateral wall of the rectum, determining significant reduction of lumen caliber. It also showed a subcutaneous metastasis of the posterior abdominal wall. Patient underwent a multidisciplinary evaluation, diagnostic and therapeutic plan was shared and defined. The pathological examination of rectal biopsy and subcutaneous nodule revealed features consistent with small-cell poorly differentiated neuroendocrine carcinoma. First line medical treatment with triplet chemotherapy and bevacizumab, according to FIr-B/FOx intensive regimen, administered for the first time in this young elderly patient affected by metastatic rectal NEC was highly active and tolerable, as previously reported in metastatic colo-rectal carcinoma (MCRC). A consistent rapid improvement in clinical conditions were observed during treatment. After 6 cycles of treatment, CT scan and endoscopic evaluation showed clinical complete response of rectal mass and lymph nodes; patient underwent curative surgery confirming the pathologic complete response at PFS 9 months.

Discussion and conclusions

This case report of a locally advanced rectal NEC with an unusual subcutaneous metastasis deserves further investigation of triplet chemotherapy-based intensive regimens in metastatic GEP NEC.

Challenging the Current Risk Factors of Appendiceal Neuroendocrine Neoplasms: Can They Accurately Predict Local Lymph Nodal Invasion? Results from a Large Case Series

BACKGROUND

Appendiceal neuroendocrine neoplasms (ANEN) are uncommon entities, which run mostly an indolent course. Appendicectomy alone is usually curative, except for in a selected group of patients that are deemed to be at risk of loco-regional metastases, in whom a completion right hemicolectomy (RHC) is recommended. The current "Guidelines" criteria for the latter have been controversial, and may result in overtreatment, which is concerning for a young patient population.

OBJECTIVE

The aim of this study is to evaluate the prognostic value of the current criteria in identifying more accurately those at-risk patients.

METHODS

This was a retrospective study of the 263 cases of ANEN referred for advice or management to a tertiary referral unit over a 10-year period. Seventy-two patients underwent RHC, based on criteria, suggested by International Guidelines. Each one of those was assessed to identify whether it correlated with lymph node invasion (LNI) at the RHC surgical specimen.

RESULTS

Tumour grade (p < 0.001), vascular (p = 0.044) and lymph vessel invasion (p < 0.001) were all found to be statistically significant independent risk factors for LNI identified following RHC, whilst tumour size (p = 0.375) and mesoappendiceal invasion (MAI) (p = 0.317) were not statistically significant. However, deep MAI and tumour size >2 cm showed a correlation with each other on LNI positive subgroup analysis. Location in appendiceal base made LNI more likely but again was not significant (p = 0.133).

CONCLUSIONS

Higher tumour grade and lymphovascular invasion should be considered as the most important risk prognosticators. Surprisingly, tumour size was not found to be significant in our cohort. Further international multicentre studies with large numbers of patients are needed to fully validate those data.