Intrahepatic bile duct mixed adenoneuroendocrine carcinoma: a case report and review of the literature

Relation between WHO Classification and Location- and Functionality-Based Classifications of Neuroendocrine Neoplasms of the Digestive Tract

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.

Neuroendocrine Component in Extrahepatic Cholangiocarcinoma is Associated with Better Survival: Data from the SEER Study

INTRODUCTION

This study was performed to evaluate the prognostic value of the neuroendocrine component in patients with extrahepatic cholangiocarcinoma (EHCC).

METHODS

Cases with EHCC derived from the SEER database were retrospectively reviewed and analyzed. The clinicopathological features and long-term survival were compared between patients with neuroendocrine carcinoma (NECA) and those with pure adenocarcinoma (AC).

RESULTS

A total of 3277 patients with EHCC were included (62 patients with NECA and 3215 patients with AC). T stage (P = 0.531) and M stage (P = 0.269) were comparable between the two groups. However, lymph node metastasis was more frequently detected in NECA (P = 0.022). NECA was correlated with more advanced tumor stage than pure AC (P < 0.0001). Inconsistent differentiation status was also observed between the two groups (P = 0.001). The proportion of patients who received surgery was significantly higher in the NECA group (80.6% vs 62.0%, P = 0.003) while chemotherapy was more frequently performed among patients with pure AC (45.7% vs 25.8%, P = 0.002). Comparable incidence of radiotherapy was acquired (P = 0.117). Patients with NECA shared a better overall survival than those with pure AC (P = 0.0141), even after matching (P = 0.0366). The results of univariate and multivariate analyses indicated that the neuroendocrine component was a protective factor as well as an independent prognostic factor for overall survival (HR < 1, P < 0.05).

CONCLUSION

Patients with EHCC with a neuroendocrine component shared a better prognosis than those with pure AC, and NECA could serve as a favorable prognostic factor for overall survival. Considering various unprovided but potentially confounding factors, future more well-conducted research is required.

Cholangiocarcinoma: A diagnostic dilemma on cytology

BACKGROUND

Cholangiocarcinoma is a relatively rare form of adenocarcinoma which may resemble adenocarcinoma of pancreatobiliary origin or adenocarcinomas from many other sites in the body. As a result, its diagnosis relies mainly on clinical history and morphology.

CASE

A 64-year-old male with cirrhosis and worsening liver failure underwent fine needle aspiration of a radiologically detected liver mass. Cytological material showed a monomorphic population of cells arranged singly and in clusters, reminiscent of a neuroendocrine tumour (NET). Cell block morphology added to the diagnostic dilemma by showing a delicate vasculature among the tumour cells. Immunohistochemistry on the cell block revealed that cells were positive for CK7 and CK19 and negative for synaptophysin and chromogranin, thereby pointing towards a pancreatobiliary origin for the tumour and excluding an NET.

CONCLUSION

In the case of liver aspirates, even when encountering confusing morphological entities, it is imperative to keep in mind the possibility of a rare neoplasm such as cholangiocarcinoma. In the absence of core needle biopsy, cell block sections prepared from aspirated material can provide appreciable immunohistochemistry results to resolve the diagnostic dilemma.

Hepatocellular carcinoma with biliary and neuroendocrine differentiation: A case report

BACKGROUND

Liver tumors with dual differentiations [combined hepatocellular carcinoma (HCC) and cholangiocarcinoma] are common. However, liver tumors that exhibit hepatocellular, biliary, and neuroendocrine differentiation are exceedingly rare, with only three previous case reports in the literature.

CASE SUMMARY

A 65-year-old female with a previous history of hepatitis C and a distant history of low grade, well-differentiated rectal neuroendocrine tumor was found to have two liver lesions in segment 4 and segment 7 on imaging. Serum alpha-fetoprotein and chromogranin A were elevated. Biopsy of the larger lesion in segment 4 revealed a high-grade tumor, with morphologic and immunohistochemical features of a neuroendocrine tumor. Given the previous history of rectal neuroendocrine tumor, imaging investigation, serologic markers, and biopsy findings, metastatic neuroendocrine tumor was considered. Subsequent regional resection of these hepatic lesions revealed the segment 4 lesion to be a HCC with additional biliary and neuroendocrine differentiation and the segment 7 lesion to be a cholangiocarcinoma with neuroendocrine differentiation. Follow-up of the patient revealed disease recurrence in the dome of the liver and metastasis in retro-pancreatic lymph nodes. The patient eventually expired due to complications of chemotherapy.

CONCLUSION

HCC cases with additional biliary and neuroendocrine differentiation are exceedingly rare, posing a diagnostic challenge for clinicians and pathologists.

Secondary Nasopharyngeal Mixed Adenoneuroendocrine Carcinoma After Radical Radiotherapy for Nasopharyngeal Carcinoma: A Rare Case and Literature Review

The incidence of primary mixed adenoneuroendocrine carcinoma (MANEC) is rapidly increasing. MANEC mainly arises from the gastrointestinal tract, but occasionally it occurs as a pathological type of second primary malignancy (SPM). These SPMs can occur in the nasopharynx. Herein we describe the case of a first secondary nasopharyngeal MANEC that was detected 20 years after radical radiotherapy for nasopharyngeal carcinoma. The patient was a 50-year-old man who was admitted to our hospital after experiencing 1 month of left nasal congestion and ipsilateral tinnitus caused by a nasopharyngeal mass that was detected via physical examination and magnetic resonance imaging. A biopsy specimen from this nasopharyngeal lesion led to a histopathological diagnosis of recurrent nasopharyngeal carcinoma. He underwent high-dose palliative radiotherapy, followed by a course of gemcitabine–cisplatin-based adjuvant chemotherapy. These treatments failed to achieve local control of the tumor, and progressive left earache emerged. Another two forceps biopsies of the external auditory canal mass were conducted, and immunohistochemical testing for adenocarcinoma and neuroendocrine carcinoma markers including CK7, CK8, CK18, carcinoembryonic antigen, synaptophysin, chromogranin A, and CD56 was conducted. The diagnosis of MANEC was ultimately confirmed 5 months after the first visit, and one additional cycle of chemotherapy was subsequently performed. The patient died of hepatic metastases 8 months after the final diagnosis. Knowledge of this rare case will raise awareness of MANEC as a new pathological type of SPM originating in the nasopharynx, which will reduce delays and promote early diagnosis.

Clinicopathological features and prognostic factors associated with gastroenteropancreatic mixed neuroendocrine non-neuroendocrine neoplasms in Chinese patients

BACKGROUND

The incidence of mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) is low. To improve our understanding of this rare tumor type and optimally guide clinical treatment, associated risk factors, clinical manifestations, and prognosis must be explored.

AIM

To identify risk factors that influence the prognosis of patients with gastroenteropancreatic MiNEN (GEP-MiNEN).

METHODS

We retrospectively analyzed the clinical data of 46 patients who were diagnosed with GEP-MiNEN at the First Affiliated Hospital of Bengbu Medical College (Anhui, China) between January 2013 and December 2017. Risk factors influencing the prognosis of the patients were assessed using Kaplan-Meier curves and cox regression models. We compared the results with 55 randomly selected patients with gastroenteropancreatic GEP neuroendocrine tumors, 47 with neuroendocrine carcinomas (NEC), and 58 with poorly differentiated adenocarcinoma.

RESULTS

Among the 46 patients with GEP-MiNEN, thirty-five had gastric tumors, nine had intestinal tumors (four in the small intestine and five in the colon and rectum), and two had pancreatic tumors. The median age of the patients was 66 (41-84) years, and the male-to-female ratio was 2.83. Thirty-three (71.7%) patients had clinical stage III and IV cancers. Distant metastasis occurred in 14 patients, of which 13 had metastasis to the liver. The follow-up period was 11-72 mo, and the median overall survival was 30 mo. Ki-67 index ≥ 50%, high proportion of NEC, lymph node involvement, distant metastasis, and higher clinical stage were independent risk factors affecting the prognosis of patients with GEP-MiNEN. The median overall survival was shorter for patients with NEC than for those with MiNEN (14 mo vs 30 mo, P = 0.001), but did not significantly differ from those with poorly differentiated adenocarcinoma and MiNEN (30 mo vs 18 mo, P = 0.453).

CONCLUSION

A poor prognosis is associated with rare, aggressive GEP-MiNEN. Ki-67 index, tumor composition, lymph node involvement, distant metastasis, and clinical stage are important factors for patient prognosis.

Neuroendocrine neoplasms of the biliary tree, liver and pancreas: a pathological approach

Neuroendocrine neoplasms of the pancreatobiliary tract and liver are a heterogeneous group that encompass a spectrum of entities with distinct morphological, biological and clinical features. Although in the various anatomical sub-sites of this region they show specific characteristics, these tumors, as a whole, share several etiological and clinical aspects. This review systematically addresses NENs arising in the extrahepatic bile ducts, gallbladder, liver and pancreas, with the principal aim of pinpointing essential diagnostic and classification issues. In addition, the section on hepatic NENs has been expanded to include metastatic disease of unknown primary site.

Mixed adenoneuroendocrine carcinoma of the hepatic bile duct: a case report and review of the literature

Background

The World Health Organization's updated classification of digestive system neuroendocrine tumors in 2010 first proposed the classification of mixed adenoneuroendocrine carcinoma (MANEC). The incidence of biliary malignant tumors with neuroendocrine tumors accounts for less than 1% of all neuroendocrine tumors. Moreover, the incidence of hilar bile duct with MANEC is very rare.

Case presentation

A 65-year-old female patient came to our hospital for repeated abdominal pain for more than 4 months and skin sclera yellow staining for 1 week. Contrast-enhanced computed tomography imaging and magnetic resonance results suggested a hilar tumor for Bismuth-Corlette Type II. The patient underwent radical surgery for hilar cholangiocarcinoma. Finally, the patient was diagnosed with hilar bile duct MANEC, staged 1 (pT1N0M0) based on the eighth edition of the AJCC. Histopathology showed that the tumor was a biliary tumor with both adenocarcinoma and neuroendocrine carcinoma. No evidence of recurrence and metastasis after 20 months of follow-up.

Conclusions

We first reported a MANEC that originated in the hilar bile duct. As far as we known, there were few reports of biliary MANEC, and the overall prognosis was poor. We also found that the higher the Ki-67 index, the worse the prognosis of this type of patient. Radical surgery is the most effective treatment.

Mixed adenoneuroendocrine carcinoma of the extrahepatic bile duct: a case report

Background

The concept of mixed adenoneuroendocrine carcinoma (MANEC) was introduced in the 2010 World Health Organization classification of digestive neuroendocrine neoplasms. Bile duct invasion by MANEC is exceptionally rare. We herein report a case of MANEC with invasion of multiple bile ducts.

Case presentation: A 60-year-old man presented with a 7-day history of upper abdominal pain, and a mass in the cystic duct was suspected based on computed tomography findings. The patient underwent resection of the extrahepatic bile ducts with concomitant radical lymphadenectomy and Roux-en-Y cholangiojejunostomy. Large cell neuroendocrine carcinoma was detected in a component of the resected tumor. According to the pathological and immunohistochemical features of the tumor, the final histopathological diagnosis was a biliary MANEC, tumor stage T2N0M1 (Stage IIIC). The patient recovered uneventfully and was discharged from the hospital 10 days after surgery.

Conclusions

We have described a rare case of extrahepatic MANEC invading multiple bile ducts, with particular emphasis on the physician’s awareness of MANEC and its optimal treatment. MANEC arising from extrahepatic bile ducts is rare, and surgical resection is the most effective treatment method.

Appendiceal Mixed Adeno-Neuroendocrine Carcinoma: A Population-Based Study of the Surveillance, Epidemiology, and End Results Registry

INTRODUCTION

Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare pathological diagnosis recently defined by the World Health Organization (WHO) in 2010. Prior to the definition by the WHO, tumors with both adenocarcinoma and neuroendocrine components were given multiple pathological designations making it difficult to characterize the disease. The aim of our study is to better characterize MANEC to better understand its natural history to influence patient care and positively impact outcomes.

MATERIALS AND METHODS

The surveillance, epidemiology, and end results program database was queried for all patients aged 18 years or older between 1973 and 2012 who had the diagnosis composite carcinoid (n = 249) of the appendix. Composite carcinoid tumors refer to tumors that have both adenocarcinoma and carcinoid tumor components present, consistent with that pathological diagnosis MANEC. For comparison, the database was also queried for carcinoid tumor of the appendix (n = 950), signet ring cell carcinoma of the appendix (n = 579), and goblet cell carcinoid (GCC) tumors of the appendix (n = 944). The data were retrospectively reviewed, and clinicopathological characteristics, treatment regimens, and survival data were obtained.

RESULTS

The median age of diagnosis of MANEC tumors was 58 years of age. Eighty percent of patients were White, and 49% were female. Fifty-four percent of patients underwent hemicolectomy and 31% had partial/subtotal colectomy as their surgical management. Median overall survival for MANEC was 6.5 years (95% CI 4.5-9.7), which was statistically significantly shorter (p < 0.0001) in comparison to 13.8 years (95% CI 12.1-16.5) for GCC, 2.1 years (95% CI 1.8-2.3) for signet ring cell carcinoma, and 39.4 years (95% CI 37.1-NA) for carcinoid tumors.

DISCUSSION

MANEC is a more aggressive clinical entity than both GCC of the appendix and carcinoid tumors of the appendix. Based on these findings, patients with MANEC tumors should undergo aggressive multidisciplinary cancer management.