Clinicopathologic characteristics and prognosis of gastroenteropancreatic neuroendocrine neoplasms: a multicenter study in South China

Gender impact on pancreatic neuroendocrine neoplasm (PanNEN) prognosis according to survival nomograms

PURPOSE

Personalizing care and outcome evaluation are important aims in the field of NEN and nomograms may represent useful tools for clinicians. Of note, gender difference is being progressively more considered in NEN care, as it may also impact on survival. This systematic review aims to describe and analyze the available nomograms on pancreatic NENs (PanNENs) to identify if gender differences are evaluated and if they could impact on patients' management and prognosis.

METHODS

We performed an electronic-based search using PubMed updated until June 2024, summarizing the available evidence of gender impact on PanNEN survival outcomes as emerges from published nomograms.

RESULTS

34 articles were identified regarding prognostic nomograms in PanNEN fields. The most included variables were age, tumor grade, tumor stage, while only 5 papers (14.7%) included sex as one of the key model variables with a significant impact on patients' prognosis. These 5 studies analyzed a total of 18,920 PanNENs. 3 studies found a significant impact of sex on overall survival (OS), whereas the remaining 2 studies showed no significant impact of sex on OS.

CONCLUSIONS

Gender difference is being progressively more considered in PanNEN diagnosis, care and survival. Nomograms represent a potentially useful tool in patients' management and in outcomes prediction in the field of PanNENs. A key role of sex in the prognosis of PanNENs has been found in few models, while definitive conclusions couldn't be drawn. Future studies are needed to finally establish gender impact on PanNEN prognosis.

Surufatinib combined with transarterial embolization versus surufatinib monotherapy in patients with liver metastatic neuroendocrine tumors: Study protocol for a prospective, randomized, controlled trial

BACKGROUND

More than half of neuroendocrine tumor (NET) patients will experience liver metastasis, and interventional therapy represented by transarterial embolization (TAE) is the main local treatment method. Surufatinib is recommended as a standard systemic treatment for advanced NETs. The efficacy and safety of surufatinib combined with TAE in the treatment of liver metastasis are undetermined. This study was conducted to compare the clinical outcome of surufatinib combined with TAE versus surufatinib monotherapy in liver metastatic NETs.

METHODS

This is a prospective, multicenter, open-label, and randomized controlled trial. Patients diagnosed with liver metastatic NETs will be enrolled. Participants are randomly assigned in a 1:1 ratio to either the experimental group or the control group. Patients will be treated with surufatinib plus TAE in the experimental group, while patients in the control group will receive surufatinib monotherapy. The primary endpoint is progression-free survival (PFS) assessed by a blinded independent image review committee (BIIRC). The secondary endpoints are investigator-assessed PFS, liver-specific objective response rate (ORR), objective response rate (ORR), disease control rate (DCR), overall survival (OS), and incidence of adverse events.

DISCUSSION

This is the first prospective study to investigate the efficacy of surufatinib combined with TAE. We expect this trial to propose a new and effective treatment strategy for liver metastatic NETs.

Epidemiological, Clinical and Biological Hemogram Features in a Cohort of Neuroendocrine Tumor Patients

We conducted a retrospective study based on 55 patients diagnosed with gastroenteropancreatic neuroendocrine tumors (GEP-NETs)-gastric (G-NET), small bowel (SB-NET) and colonic (C-NET), hospitalized and evaluated within the Surgical, Gastroenterology and Internal Medicine Clinics, in The Clinical Emergency County Hospital Craiova, between May 2016 and April 2024. We aimed in this study to analyze the epidemiological aspects and clinical characteristics of patients with GEP-NETs. In our study group, the patients' ages were between 39-82 years, with a mean of 66.40 (±12.46) years. The incidence of GEP-NETs cases in young patients was insignificant low-1 case. 45.46% of all patients lived in urban areas. 16.36% were G-NET, 14,54 were SB-NET and 69.09% were C-NET. The GEP-NETs diagnosis was established by immunohistochemistry features. Also, we observed that the most frequency localization was on the ascending colon, while the rarest on the colon it is located on the transverse colon and the rarest is on the small bowel, in spite of the generally literature data. From the C-NET group, 49.09% have been presented arterial hypertension probable explained by serotonin and dopamine secretion an inflammatory through phenotype expression and just one patient has been presented an erythematous psoriasis, which could be also explained by the same neurotransmitter's involvement as a possible purposed mechanism. The results obtained in our study demonstrate that could be a common profile of GEP-NETs patients through epidemiological general information and clinical characteristics. Also, we demonstrate that, in the last years, the incidence increased for the GEP-NETs.

Lymph node ratio and hematological parameters predict relapse-free survival in patients with high grade rectal neuroendocrine neoplasms after radical resection: a multicenter prognostic study

BACKGROUND

The prognostic nutritional index (PNI), alkaline phosphatase (ALP), and lymph node ratio (LNR) are reportedly related to prognosis. The aim of this study was to elucidate the clinical importance of the LNR and hematological parameters in patients with high grade rectal neuroendocrine neoplasms (HG-RNENs) who were undergoing radical resection.

METHODS

We reviewed the medical records of patients with HG-RNENs from 17 large-scale medical centers in China (January 1, 2010-April 30, 2022). A nomogram was constructed by using a proportional hazard model. Bootstrap method was used to draw calibration plots to validate the reproducibility of the model. Concordance index (C-Index), decision curve analysis (DCA), and time-dependent area under the receiver operating characteristic curve (TD-AUC) analysis were used to compare the prognostic predictive power of the new model with American Joint Committee on Cancer (AJCC) TNM staging and European Neuroendocrine Tumor Society (ENETS) TNM staging.

RESULTS

A total of 85 patients with HG-RNENs were enrolled in this study. In the 45 patients with HG-RNENs who underwent radical resection, PNI ≤ 49.13 (HR: 3.997, 95% CI: 1.379-11.581, P = 0.011), ALP > 100.0 U/L (HR: 3.051, 95% CI: 1.011-9.205, P = 0.048), and LNR > 0.40 (HR: 6.639, 95% CI: 2.224-19.817, P = 0.0007) were independent predictors of relapse-free survival. The calibration plots suggested that the nomogram constructed based on the three aforementioned factors had good reproducibility. The novel nomogram revealed a C-index superior to AJCC TNM staging (0.782 vs 0.712) and ENETS TNM staging (0.782 vs 0.657). Also, the new model performed better compared to AJCC TNM staging and ENETS TNM staging in DCA and TD-AUC analyses.

CONCLUSIONS

LNR, ALP, and PNI were independent prognostic factors in patients with HG-RNENs after radical resection, and the combined indicator had better predictive efficacy compared with AJCC TNM staging and ENETS TNM staging.

Simultaneous rectal neuroendocrine tumors and pituitary adenoma: A case report and review of literature

BACKGROUND

Neuroendocrine tumors (NET) are rare heterogeneous tumors that arise from neuroendocrine cells throughout the body. Acromegaly, a rare and slowly progressive disorder, usually results from a growth hormone (GH)-secreting pituitary adenoma.

CASE SUMMARY

We herein describe a 38-year-old patient who was initially diagnosed with diabetes. During colonoscopy, two bulges were identified and subsequently removed through endoscopic submucosal dissection. Following the surgical intervention, the excised tissue samples were examined and confirmed to be grade 2 NET. 18F-ALF-NOTATATE positron emission tomography-computed tomography (PET/CT) and 68Ga-DOTANOC PET/CT revealed metastases in the peri-intestinal lymph nodes, prompting laparoscopic low anterior resection with total mesorectal excision. The patient later returned to the hospital because of hyperglycemia and was found to have facial changes, namely a larger nose, thicker lips, and mandibular prognathism. Laboratory tests and magnetic resonance imaging (MRI) suggested a GH-secreting pituitary adenoma. The pituitary adenoma shrunk after treatment with octreotide and was neuroendoscopically resected via a trans-sphenoidal approach. Whole-exome sequencing analysis revealed no genetic abnormalities. The patient recovered well with no evidence of recurrence during follow-up.

CONCLUSION

18F-ALF-NOTATE PET/CT and MRI with pathological analysis can effectively diagnose rare cases of pituitary adenomas complicated with rectal NET.

A novel nomogram and risk stratification system predicting the cancer-specific survival of patients with gastric neuroendocrine carcinoma: a study based on SEER database and external validation

BACKGROUND

Gastric neuroendocrine carcinoma (GNEC) is a rare histology of gastric cancer. The retrospective study was designed to construct and validate a nomogram for predicting the cancer-specific survival (CSS) of postoperative GNEC patients.

METHODS

Data for 28 patients from the Hangzhou TCM Hospital were identified as the external validation cohort. A total of 1493 patients were included in the SEER database and randomly assigned to the training group (1045 patients) and internal validation group (448 patients). The nomogram was constructed using the findings of univariate and multivariate Cox regression studies. The model was evaluated by consistency index (C-index), calibration plots, and clinical net benefit. Finally, the effect between the nomogram and AJCC staging system was compared by net reclassification index (NRI) and integrated discrimination improvement (IDI).

RESULTS

Age, gender, grade, T stage, N stage, metastasis, primary site, tumor size, RNE, and chemotherapy were incorporated in the nomogram. The C-indexes were 0.792 and 0.782 in the training and internal verification sets. The 1-, 3-, and 5-year CSS predicted by the nomogram and actual measurements had good agreement in calibration plots. The 1-, 3-, and 5-year NRI were 0.21, 0.29, and 0.37, respectively. The 1-, 3-, and 5-year IDI values were 0.10, 0.12, and 0.13 (P < 0.001), respectively. In 1-, 3-, and 5-year CSS prediction using DCA curves, the nomogram outperformed the AJCC staging system. The nomogram performed well in both the internal and external validation cohorts.

CONCLUSION

We developed and validated a nomogram to predict 1-, 3-, and 5-year CSS for GNEC patients after surgical resection. This well-performing model could help doctors enhance the treatment plan.

Small bowel neuroendocrine tumours - casting the net wide

PURPOSE OF REVIEW

Our aim is to provide an overview of small bowel neuroendocrine tumours (NETs), clinical presentation, diagnosis algorithm and management options. We also highlight the latest evidence on management and suggest areas for future research.

RECENT FINDINGS

Dodecanetetraacetic acid (DOTATATE) scan can detect NETs with an improved sensitivity than when compared with an Octreotide scan. It is complimentary to small bowel endoscopy that provides mucosal views and allows the delineation of small lesions undetectable on imaging. Surgical resection is the best management modality even in metastatic disease. Prognosis can be improved with the administration of somatostatin analogues and Evarolimus as second-line therapies.

SUMMARY

NETs are heterogenous tumours affecting most commonly the distal small bowel as single or multiple lesions. Their secretary behaviour can lead to symptoms, most commonly diarrhoea and weight loss. Metastases to the liver are associated with carcinoid syndrome.

Characteristics and treatment results of patients with gastroenteropancreatic neuroendocrine tumors in a tertiary care centre

BACKGROUND

Gastroenteropancreatic Neuroendocrine tumors (GEP-NET) are rare neoplasms with limited reported data from the Middle East. Our study aims to report the clinicopathological feature, treatment patterns, and survival outcomes of patients with GEP-NET from our part of the world.

METHODS

Medical records of patients diagnosed with GEP-NET between January 2011 and December 2016 at a single center in Saudi Arabia were reviewed retrospectively, and complete clinicopathological and treatment data were collected. Patients' survival was estimated by the Kaplan-Meier method.

RESULTS

A total of 72 patients were identified with a median age of 51 years (range 27-82) and male-to-female ratio of (1.1). The most common tumor location was the pancreas (29.1%), followed by small bowel (25%), stomach (12.5%), rectum (8.3%), colon (8.3%), and appendix (6.9%). Forty-one patients (57%) had well-differentiated grade (G)1, 21 (29%) had G2, and 4 (6%) had G3. In five patients, the pathology was neuroendocrine carcinoma and in one it could not be classified. 54.2% of the patients were metastatic at diagnosis. Forty-two patients underwent surgical resection as primary management while 26 underwent systemic therapy, three patients were put on active surveillance, and one was treated endoscopically with polypectomy. The 5-year overall survival and progression-free survivals were 77.2% and 49%, respectively, for the whole group. Patients with G1 and 2 disease, lower Ki-67 index, and surgically treated as primary management had significantly better survival outcomes.

CONCLUSION

Our study suggests that the most common tumor locations are similar to western reported data. However, there seems to be a higher incidence of metastatic disease at presentation than in the rest of the world.

Surgical Management of G3 Gastroenteropancreatic Neuroendocrine Neoplasms: A Systematic Review and Meta-analysis

BACKGROUND

Grade 3 (G3) gastroenteropancreatic (GEP) neuroendocrine neoplasms (NENs) are rare, aggressive tumors with poor prognosis. The World Health Organization 2017 and 2019 classifications further subdivided G3 NENs into G3 neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). Current guidelines favor medical management in most of these patients, and the role of surgical management is not well defined. We performed a systematic literature review and meta-analysis of surgical management versus nonsurgical management for G3 GEP NENs.

MATERIALS AND METHODS

A PRISMA-compliant systematic review of the MEDLINE, Embase, Scopus, and Cochrane Library databases (end-of-search date: 16 July 2021) was conducted. Individual patient survival data were reconstructed, and random-effects meta-analyses were performed.

RESULTS

Fourteen studies comprising 1810 surgical and 910 nonsurgical patients were systematically reviewed. Publication bias adjusted meta-analysis of 12 studies (1788 surgical and 857 nonsurgical patients) showed increased overall survival (OS) after surgical compared with nonsurgical management for G3 GEP NENs [hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.31-0.53]. Subgroup meta-analyses showed increased OS after surgical management for both pancreatic and gastrointestinal primary sites separately. In another subgroup meta-analysis of G3 GEP NETs (not NECs), surgical management was associated with increased OS compared with nonsurgical management (HR 0.26, 95% CI 0.11-0.61).

CONCLUSIONS

Surgical management of G3 GEP NENs may provide a potential survival benefit in well-selected cases. Further research is needed to define which patients will benefit most from surgical versus nonsurgical management. The current literature is limited by inconsistent reporting of survival outcomes in surgical versus nonsurgical groups, tumor grade, differentiation, primary tumor site, and selection criteria for surgical and nonsurgical management.

Long-term survival in patients with gastroenteropancreatic neuroendocrine neoplasms: A population-based study

BACKGROUND

Gastroenteropancreatic (GEP) neuroendocrine neoplasms (NENs) comprise a group of rare malignant tumours with heterogeneous behaviour. This study aimed to assess long-term survival and prognostic factors associated with survival, in order to optimise counselling.

PATIENTS AND METHODS

This population-based study included all GEP-NENs diagnosed between 1989 and 2016 in the Netherlands, selected from the Netherlands Cancer Registry. Overall survival (OS) and relative survival (RS) were calculated. A Cox Proportional Hazard analysis was used to identify prognostic factors (gender, age, tumour stage, location and treatment) for OS. Analyses were stratified by metastatic disease status and tumour grade.

RESULTS

In total, 9697 patients were included. In grade 1, 2 and 3 non-metastatic GEP-NENs (N = 6544), 5-year OS and RS were 81% and 88%, 78% and 83%, and 26% and 30%, respectively. In grade 1 non-metastatic GEP-NENs 10-year OS and RS were 68% and 83%. In grade 1, 2 and 3 metastatic GEP-NENs (N = 3153), 5-year OS and RS rates were 47% and 52%, 38% and 41%, and 5% and 5%, respectively. The highest (relative) survival rates were found in appendicular and rectal NENs, demonstrating 10-year OS and RS of 87% and 93%, and 81% and 95%, respectively.

CONCLUSIONS

These long-term follow-up data demonstrate significant differences in survival for different grades, tumour stage, and primary origin of GEP-NENs, with the most favourable overall and RS rates in patients with non-metastatic grade 1 appendicular and rectal NENs. This study demonstrates unique long-term OS and RS rates using combined stratification by tumour site, grade and stage.

Survival Analysis in Gastrointestinal Neuroendocrine Carcinoma With Bone Metastasis at Diagnosis

Purpose

Gastrointestinal neuroendocrine carcinoma (NEC) with bone metastasis is rarely reported. The purpose of this study is to explore the prognosis and risk factors of such patients.

Patients and Methods

We retrospectively reviewed patients diagnosed as gastrointestinal NECs with bone metastasis at diagnosis from 2010 to 2016 by using the Surveillance, Epidemiology and End Results (SEER) database. Predictors of overall survival (OS) and cancer-specific survival (CSS) were analyzed by univariable and multivariable Cox analyses. Kaplan–Meier plots were constructed to show the correlation between independent predictors and survival.

Results

A total of 330 gastrointestinal NEC patients with bone metastasis at diagnosis were included for analysis. Over half of patients were male and older than 60 years old. The most common primary site of gastrointestinal NEC with bone metastasis was the pancreas. The prognosis of gastrointestinal NEC with bone metastasis (3-year OS and CSS rates: 16.7 and 17.0%) was very poor. On Cox multivariable analysis, age over 60 years old, no surgery, and lung metastasis were independent predictors of decreased OS and CSS.

Conclusions

We identified three independent factors associated with prognosis among gastrointestinal NEC patients with bone metastasis, namely age, surgery, and lung metastasis. For younger gastrointestinal NEC patients with bone metastasis, surgical resection of primary tumors as well as actively treating lung metastasis might be useful for prolonging survival.

Patterns and predictors of pancreatic neuroendocrine tumor prognosis: Are no two leaves alike?

Pancreatic neuroendocrine tumors (PanNETs) are heterogeneous; thus, individual prognostic prediction is important. Clinicopathological features, like TNM stage, grade, and differentiation, are independent clinical predictors. However, single predictors are insufficient, as patients sharing similar clinicopathological features usually show distinct prognoses. Accordingly, novel nomograms and risk stratifications have been developed for more accurate PanNET prognostic prediction. Moreover, the exploration of molecular mechanisms has identified novel prognostic predictors for PanNET. Multi-analyte assays of molecular biomarkers provide a deeper understanding of PanNET features; however, the priority, and the optimal combination of classic and novel predictors for PanNET prognosis prediction remain unclear. In this review, we summarized the patterns and predictors of PanNET prognosis and discussed their clinical utility; we emphasized that PanNET at different stages have different superior predictor, and that multi-analyte assays are more sensitive than mono-analyte biomarkers. Therefore, combined biomarkers improve the accuracy of surveillance and optimize decision-making in clinical practice.

Risk Factors and Predictive Score Model for Early Recurrence After Curative Surgery in Patients With Poorly Differentiated Gastrointestinal Neuroendocrine Neoplasms

Purpose: Studies on early recurrence in gastrointestinal neuroendocrine carcinoma (NEC) and mixed adenoneuroendocrine carcinoma (MANEC) are lacking and risk factors related to early recurrence are not clear. We evaluated risk factors for early recurrence in such patients and developed a predictive scoring model.

Methods: Patients undergoing curative surgery for GI-NEC or MANEC between January 2010 and January 2019 were included. Early recurrence was defined as recurrence within 12 months after surgery. Risk factors for early recurrence were identified using logistic regression.

Results: Of the 80 included patients, 27 developed early recurrence and 53 had no early recurrence. Independent risk factors associated with early recurrence included tumor location in the midgut/hindgut [odds ratio (OR) = 5.077, 95% confidence interval (CI) 1.058–24.352, p = 0.042], alkaline phosphatase (ALP) >80 (OR = 5.331, 95% CI 1.557–18.258, p = 0.008), and lymph node ratio (LNR) >0.25 (OR = 6.578, 95% CI 1.971–21.951, p = 0.002). Risk scores were assigned to tumor location (foregut, 0; midgut/hindgut, 1), ALP (≤80, 0; >80, 1), and LNR (≤0.25, 0; >0.25, 1). Patients with a high risk (score 2–3) for early recurrence had significantly shorter disease-free survival and overall survival than those with low- (score 0) and intermediate risks (score 1) (both p < 0.001). The novel scoring model had superior predictive efficiency for early recurrence over TNM staging (area under the curve 0.795 vs. 0.614, p = 0.003).

Conclusion: Tumor location, preoperative ALP, and LNR were independent factors associated with early recurrence after curative surgery for GI-NEC or MANEC. The risk scoring model developed based on these three factors shows superior predictive efficiency.

Tumor size and perineural invasion predict outcome of gastric high-grade neuroendocrine neoplasms

A new subcategory, grade 3 neuroendocrine tumors, is incorporated into the grading system of pancreatic neuroendocrine neoplasms in the 2017 WHO classification in order to differentiate grade 3 neuroendocrine tumors from neuroendocrine carcinomas. The 2019 WHO classification extends the concept of grade 3 neuroendocrine tumors to gastrointestinal high-grade neuroendocrine neoplasms. However, there is still limited study focusing on the gastric grade 3 neuroendocrine tumors and gastric neuroendocrine carcinomas. We retrospectively enrolled 151 gastric high-grade neuroendocrine neoplasms patients, who underwent radical resection from January 2007 to December 2015. Clinicopathologic and prognostic features were studied. The Surveillance, Epidemiology, and End Results (SEER) database was used to verify the prognostic determinants found in the Zhongshan cohort. Neuroendocrine carcinomas showed a higher Ki67 index and higher mitotic count than grade 3 neuroendocrine tumors. We identified 109 (72.2%) patients with neuroendocrine carcinomas, 12 (7.9%) patients with grade 3 neuroendocrine tumors, and 30 (19.9%) patients with mixed neuroendocrine-non-neuroendocrine neoplasms. Although neuroendocrine carcinomas demonstrated higher Ki67 index (P = 0.004) and mitoses (P = 0.001) than grade 3 neuroendocrine tumors, their prognosis after radical resection did not demonstrate significant differences (P = 0.709). Tumor size, perineural invasion, and TNM stage were independent prognostic factors of gastric high-grade neuroendocrine neoplasms.

Development and validation of prognostic nomograms for patients with colon neuroendocrine neoplasms

BACKGROUND

Colon neuroendocrine neoplasms (NENs) have one of the poorest median overall survival (OS) rates among all NENs. The American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system-currently the most commonly used prediction model-has limited prediction accuracy because it does not include parameters such as age, sex, and treatment. The aim of this study was to construct nomograms containing various clinically important parameters to predict the prognosis of patients with colon NENs more accurately.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we performed a retrospective analysis of colon NENs diagnosed from 1975 to 2016. Data were collected from 1196 patients; almost half were female (617/1196, 51.6%), and the average age was 61.94 ± 13.05 years. Based on the age triple cut-off values, there were 396 (33.1%), 408 (34.1%), and 392 (32.8%) patients in age groups 0-55 years, 55-67 years, and ≥ 68 years, respectively. Patients were randomized into training and validation cohorts (3:1). Independent prognostic factors were used for construction of nomograms to precisely predict OS and cancer-specific survival (CSS) in patients with colon NENs.

RESULTS

Multivariate analysis showed that age ≥ 68 years, sex, tumor size, grade, chemotherapy, N stage, and M stage were independent predictors of OS. In the validation cohort, the Concordance index (C-index) values of the OS and CSS nomograms were 0.8345 (95% confidence interval [CI], 0.8044-0.8646) and 0.8209 (95% CI, 0.7808-0.861), respectively. C-index also indicated superior performance of both nomograms (C-index 0.8347 for OS and 0.8668 for CSS) compared with the AJCC TNM classification (C-index 0.7159 for OS and 0.7366 for CSS).

CONCLUSIONS

We established and validated new nomograms for more precise prediction of OS and CSS in patients with colon NENs to facilitate individualized clinical decisions.

Tumour grade and primary site predict patterns of recurrence and survival in patients with resected gastroenteropancreatic neuroendocrine tumors

BACKGROUND

Patterns of recurrence help to inform surveillance of patients with resected gastroenteropancreatic neuroendocrine tumors (GEP-NETs).

METHODS

Patients with GEP-NETs in British Columbia, Canada (2004-2015) were reviewed. Associations between tumor characteristics, recurrence and survival were analyzed.

RESULTS

Among 759 patients, 41%, 25%, and 17% had grade 1, 2, and 3 disease, respectively. 387 patients had R0/R1 resections, of which 30% recurred (median 25 months). 5-year incidence of recurrence was 22% (grade 1), 46% (grade 2), and 59% (grade 3) (p < 0.001). Grade predicted distant recurrence (Grade 2 HR 1.89, 95% CI 1.16-3.07; p = 0.011; Grade 3 HR 3.29, 95% CI 1.81-5.99; p < 0.001). Compared to small bowel NETs, pancreas NETs had less peritoneal recurrence (OR 0.15, 95% CI 0.03-0.68, p = 0.014). No patients had isolated pulmonary recurrences.

CONCLUSION

Higher grade tumors and pancreatic NETs require more frequent surveillance. Evidence is limited for pulmonary surveillance.

Prognostic Nomograms to Predict Overall Survival and Cancer-Specific Survival of Patients With Pancreatic Neuroendocrine Tumors: A Population-Based Study

OBJECTIVE

The objective of this research was to construct and validate prognostic nomograms predicting overall survival (OS) and cancer-specific survival (CSS) in patients with pancreatic neuroendocrine tumors (pNETs).

METHODS

We extracted 3787 patients with pNETs from the Surveillance, Epidemiology and End Results database. Nomograms for estimating 3- and 5-year OS and CSS were first established. Then, we used Harrell's Concordance Index, calibration plots, and the area under receiver operating characteristic curve to evaluate the nomograms. The Kaplan-Meier curve was plotted to evaluate the different survival outcomes.

RESULTS

In the multivariate analysis, age, grade, functional status, American Joint Committee on Cancer stage, and surgery were associated with OS and CSS. The established nomograms had good discriminative ability, with a Harrell's Concordance Index of 0.830 for OS and 0.855 for CSS. The calibration plots also revealed good agreement. The area under receiver operating characteristic curve values of the nomograms predicting 3- and 5-year OS and CSS rates were 0.836, 0.816 and 0.859, 0.841, respectively. In addition, Kaplan-Meier curve indicated that patients with higher risk had worse survival outcomes.

CONCLUSIONS

We have proposed and validated the nomograms predicting OS and CSS of pNETs. They can be convenient individualized tools to facilitate clinical decision making.

Concordance Between the Ki-67 Index Cutoff Value of 55% and Differentiation in Neuroendocrine Tumor and Neuroendocrine Carcinoma in Grade 3 Pancreatic Neuroendocrine Neoplasms

OBJECTIVE

In 2017 and 2019, the World Health Organization defined grade 3 neuroendocrine tumors (G3 NETs) and neuroendocrine carcinoma (G3 NEC) in the pancreas. The validity of this classification remains to be verified.

METHODS

Clinical data were collected and analyzed for 39 G3 pancreatic neuroendocrine neoplasms (PanNENs) patients between 2009 and 2018.

RESULTS

The tumor-node-metastasis stage (P = 0.0260), differentiation (P = 0.0115), and Ki-67 index (P = 0.0371) are prognostic factors for G3 PanNENs by Kaplan-Meier survival analysis. Among 39 patients, 18 had a Ki-67 index of less than 55% and well-differentiated morphology (G3 NET) and 16 had a Ki-67 index of 55% or greater and poorly differentiated morphology (G3 NEC). Grade 3 neuroendocrine tumor had a significant better prognosis than G3 NEC (median overall survival time, 25 months [95% confidence interval, 10.854-39.146 months] vs 12 months [95% confidence interval, 6.316-17.684 months], P = 0.0164). Based on Cox regression analyses, tumor-node-metastasis stage (P = 0.016) was identified as the independent prognostic factor for G3 PanNENs.

CONCLUSIONS

The upper Ki-67 index cutoff of 55% might be the best cutoff value to define G3 NETs and G3 NECs for G3 PanNENs. The World Health Organization 2017 and 2019 classification system for G3 PanNENs can identify high-risk patients with G3 PanNENs.

Effects of tumor distance from anal verge on survival outcomes for rectal NENs and lymphatic metastasis risk score for colorectal NENs

OBJECTIVE

To explore whether the distance of rectal neuroendocrine neoplasms from the anal margin has an impact on the prognosis of patients and evaluate lymphatic metastases risk score for colorectal neuroendocrine neoplasms (NENs).

METHODS

Clinical pathological and follow-up data of 71 patients identified as colorectal neuroendocrine neoplasms by pathology from July 2011 to July 2019 were carefully collected.

RESULTS

Among 71 patients with colorectal NENs, most of the tumors were rectal NENs (62 cases). A total of 26 patients were in the presence of lymph node metastasis, and 44 patients had negative lymph nodes. Patients with lesions from the anal margin > 5 cm in rectum have a better prognosis (P = 0.022). Tumor stage (P = 0.034) and grade (P = 0.001) were independent risk predictors of lymphatic metastases. We developed a lymphatic metastasis risk score for rectal NENs, and patients with the score ≥ 7.5 were more likely to develop lymph node metastases (area 0.958, 95% CI 0.903-1.000, P = 0.000) with a sensitivity of 72.2% and a specificity of 97.3%.

CONCLUSION

Patients with lesions from the anal margin > 5 cm and lymphatic metastasis risk score ≥ 7.5 should be treated actively.

Trends of incidence and prognosis of gastric neuroendocrine neoplasms: a study based on SEER and our multicenter research

BACKGROUND

To investigate the recent epidemiological trends of gastric neuroendocrine neoplasms (GNENs) and establish a new tool to estimate the prognosis of gastric neuroendocrine carcinoma (GNEC) and gastric neuroendocrine tumor (GNET).

METHODS

Nomograms were established based on a retrospective study on patients diagnosed with GNENs from 1975 to 2016 in Surveillance, Epidemiology and End Results database. External validation was performed among 246 GNENs patients in Jiangsu province to verify the discrimination and calibration of the nomograms.

RESULTS

The age-adjusted incidence of GNENs has increased from 0.309 to 6.149 per 1,000,000 persons in the past 4 decades. Multivariate analysis indicated independent prognostic factors for both GNEC and GNET including age, distant metastasis and surgical intervention (P < 0.05). In addition, T, N staging and grade were significantly associated with survival of GNEC, while size was a predictor for GNET (P < 0.05). The C-indexes of the nomograms were 0.840 for GNEC and 0.718 for GNET, which were higher than those of the 8th AJCC staging system (0.773 and 0.599). Excellent discrimination was observed in the validation cohorts (C-index of nomogram vs AJCC staging for GNEC: 0.743 vs 0.714; GNET: 0.945 vs 0.927). Survival rates predicted by nomograms were close to the actual survival rates in the calibration plots in both training and validation sets.

CONCLUSIONS

The incidence of the GNENs is increasing steadily in the past 40 years. We established more excellent nomograms to predict the prognosis of GNENs than traditional staging system, helping clinicians to make tailored decisions.

Label-free identification of early gastrointestinal neuroendocrine tumors via biomedical multiphoton microscopy and automatic image analysis

At present, early diagnosis and treatment is the most effective way to treat early gastrointestinal neuroendocrine tumors. Therefore, we attempted to carry out multiphoton imaging of early neuroendocrine tumors because of its ability to label-free image tissue microstructure at the cellular level. Imaging results show that this imaging technique can quickly identify the histopathological changes in mucosa and submucosa caused by tumor invasion. Furthermore, we performed automatic image analysis on SHG images and extracted two optical diagnostic features-collagen density and average intensity, and also found obvious differences in the density as well as average intensity of collagen fibers in tumor microenvironment using a series of quantitative analysis. These findings may further facilitate the development of multiphoton microscopic imaging technique for clinical use.

Value of computed tomography evaluation in pathologic classification and prognosis prediction of gastric neuroendocrine tumors

Background

The study aims to investigate the correlation of CT characteristics with pathological classifications and the prognostic value of CT features in patients with gastric neuroendocrine neoplasms (g-NENs).

Methods

Ninety-one cases of pathologically diagnosed g-NENs, including 15 cases of well-differentiated neuroendocrine tumors (NETs) (G1 and G2) and 76 cases of poor-differentiated neuroendocrine carcinomas (NECs) (G3 and MANEC) were retrospectively studied. All cases were included in correlation analysis of CT characteristics with pathologic grades. Among them, 76 patients who had fulfilled follow-up data were included for overall survival (OS) and disease-free survival (DFS) analysis.

Results

CT characteristics that favor poor differentiation include tumor location (fundus and cardia), larger tumor size (>3.0 cm), infiltrative growth, unclear tumor margin, serosa involvement, ulceration and lymph node metastasis (P<0.05). Most variables had sensitivities >80% and specificities >60% to distinguish NECs from NETs. Through log-rank analysis, it was revealed that serosa involvement, cystic degeneration, necrosis, heterogeneous enhancement and lymph node metastasis led to worse DFS and OS for patients with g-NENs (P<0.05). COX regression analysis showed that serosa involvement and lymph node metastasis were independent risk factor for DFS and OS, respectively, despite of grading, staging and therapeutic choices (P<0.05). Moreover, high Ki-67 index (>55%) in G3 g-NENs is in correlation with serosa involvement and lymph node metastasis; accordingly, patients with higher Ki-67 index had worse 1-year DFS (61.7% vs. 92.3%; P<0.05).

Conclusions

CT characteristics can be useful discriminators and prognostic factors for g-NENs and may help identify G3 g-NEC from G3 g-NEN by revealing its poor differentiation and high invasive potential.

Survival comparison between primary hepatic neuroendocrine neoplasms and primary pancreatic neuroendocrine neoplasms and the analysis on prognosis-related factors

BACKGROUND

Primary hepatic neuroendocrine neoplasms (PHNENs) are extremely rare and few articles have compared the prognosis of PHNENs with other neuroendocrine neoplasms (NENs). This study aimed to investigate the different prognosis between PHNENs and pancreatic NEN (PanNENs) and evaluate the relevant prognosis-related factors.

METHODS

From January 2012 to October 2016, a total of 44 NENs patients were enrolled and divided into two groups according to the primary tumor location which were named group PHNENs (liver; n = 12) and group PanNENs (pancreas; n = 32). Demographic, clinical characteristics and survival data were compared between the two groups with Kaplan-Meier method and log-rank tests. Prognostic factors were analyzed using the Cox regression model.

RESULTS

The overall survival of group PHNENs and group PanNENs were 25.4 ± 6.7 months and 39.8 ± 3.7 months, respectively (P = 0.037). The cumulative survival of group PanNENs was significantly higher than that of group PHNENs (P = 0.029). Univariate analysis revealed that sex, albumin, total bilirubin, total bile acid, aspartate aminotransferase, alkaline phosphatase, α-fetoprotein and carbohydrate antigen 19-9, histological types, treatments and primary tumor site were the prognostic factors. Further multivariate analysis indicated that albumin (P = 0.008), histological types NEC (P = 0.035) and treatments (P = 0.005) were the independent prognostic factors. Based on the histological types, the cumulative survival of patients with well-differentiated neuroendocrine tumor was significant higher than that of patients with poorly differentiated neuroendocrine carcinoma in group PHNENs (P = 0.022), but not in group PanNENs (P > 0.05). According to the different treatments, patients who received surgery had significantly higher cumulative survival than those with conservative treatment in both groups (P < 0.05).

CONCLUSIONS

PHNENs have lower survival compared to PanNENs. Histological types and treatments affect the prognosis. Surgical resection still remains the first line of treatment for resectable lesions and can significantly improve the survival.

A nomogram for individualized estimation of survival among adult patients with adrenocortical carcinoma after surgery: a retrospective analysis and multicenter validation study

Background

Clinical outcome of adrenocortical carcinoma (ACC) varies because of its heterogeneous nature and reliable prognostic prediction model for adult ACC patients is limited. The objective of this study was to develop and externally validate a nomogram for overall survival (OS) prediction in adult patients with ACC after surgery.

Methods

Based on the data from the Surveillance Epidemiology, and End Results (SEER) database, adults patients diagnosed with ACC between January 1988 and December 2015 were identified and classified into a training set, comprised of 404 patients diagnosed between January 2007 and December 2015, and an internal validation set, comprised of 318 patients diagnosed between January 1988 and December 2006. The endpoint of this study was OS. The nomogram was developed using a multivariate Cox proportional hazards regression algorithm in the training set and its performance was evaluated in terms of its discriminative ability, calibration, and clinical usefulness. The nomogram was then validated using the internal SEER validation, also externally validated using the Cancer Genome Atlas set (TCGA, 82 patients diagnosed between 1998 and 2012) and a Chinese multicenter cohort dataset (82 patients diagnosed between December 2002 and May 2018), respectively.

Results

Age at diagnosis, T stage, N stage, and M stage were identified as independent predictors for OS. A nomogram incorporating these four predictors was constructed using the training set and demonstrated good calibration and discrimination (C-index 95% confidence interval [CI], 0.715 [0.679–0.751]), which was validated in the internal validation set (C-index [95% CI], 0.672 [0.637–0.707]), the TCGA set (C-index [95% CI], 0.810 [0.732–0.888]) and the Chinese multicenter set (C-index [95% CI], 0.726 [0.633–0.819]), respectively. Encouragingly, the nomogram was able to successfully distinguished patients with a high-risk of mortality in all enrolled patients and in the subgroup analyses. Decision curve analysis indicated that the nomogram was clinically useful and applicable.

Conclusions

The study presents a nomogram that incorporates clinicopathological predictors, which can accurately predict the OS of adult ACC patients after surgery. This model and the corresponding risk classification system have the potential to guide therapy decisions after surgery.

The prognostic analysis of different metastatic patterns in pancreatic neuroendocrine tumors patients: A population based analysis

OBJECTIVE

To evaluate the prognostic value of pancreatic neuroendocrine tumors (pNETs) with different metastatic patterns.

METHODS

Data of pNETs cases were extracted from the Surveillance, Epidemiology, and End Result (SEER) database. They were classified according to the different metastatic patterns. We utilized chi-square test to compare the clinical and metastasis characteristics among different groups. We used Kaplan-Meier analysis and log-rank testing for survival comparisons. Adjusted HRs with 95% CIs was calculated using Cox regression model to estimate prognostic factors. P < .05 was considered statistically significant.

RESULTS

Among the 3909 patients, liver is the most metastatic organ, and isolated brain metastasis is the least common. At the same time, many patients have had multiple metastases. We studied the overall survival (OS) and cancer-specific survival (CCS) of the groups. OS: Non-organ metastasis: 5-year OS = 77.1%; Bone metastasis: median survival time (MST) = 56 m, 5-year OS = 42.7%; Liver metastasis: MST = 24 m, 5-year OS = 25.5%; Lung metastasis: MST = 14 m, 5-year OS = 33.7%; multiple metastases: MST = 7m, 5-year OS = 12.0%. CCS: Non-organ metastasis: 5-year OS = 84.2%; Bone metastasis: 5-year OS = 52.5%; Liver metastasis: MST = 27 m, 5-year OS = 28.6%; Lung metastasis: MST = 49 m, 5-year OS = 40.1%; multiple metastases: MST = 8 m, 5-year OS = 14.5%. In addition, the results showed that there were all statistical significances between the surgery and the no surgery group (all, P < .001). Multivariate analysis revealed that brain metastasis, multiple metastases, age over 60 years, unmarried, grade III/IV, regional/distant and no surgery were independently associated with decreased OS and CCS.

CONCLUSIONS

pNETs patients without organ metastasis had the best survival outcomes, while multiple had the worst outcomes. There were no significant differences in bone metastasis, liver metastasis and lung metastasis. Surgery was still an option for patients with metastasis.

A novel and validated nomogram to predict overall survival for gastric neuroendocrine neoplasms

BACKGROUND

This study aims to develop and validate an effective nomogram to estimate the individual outcome of patients with Gastric neuroendocrine neoplasms (G-NENs).

METHODS

A total of 260 patients diagnosed with G-NENs at two medical centers were included, with 156 patients allocated as training set and 104 patients as validation. Predictive nomogram was constructed based on multivariate analyses using RMS package in R version. The predictive accuracy and discriminative ability were analyzed by C-index, risk group stratification and calibration curve, which was compared with other predictive systems for G-NENs.

RESULTS

In multivariate analysis, age, Ki-67, mitoses, neutrophil to lymphocyte ratio, serum tumor marker and distant metastasis were significantly associated with overall survival. The constructed prognostic nomogram demonstrated a good calibration and discrimination value with 0.884 and 0.852 C-indices in training and validation dataset. Compare to World Health Organization (WHO) grading system (C-indices=0.760 and 0.732) and American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system (C-indices=0.747 and 0.811), the nomogram displayed a better predictive accuracy.

CONCLUSIONS

The novel prognostic nomogram showed superior predictive value in overall survival of G-NENs. It might be a useful tool for clinicians in estimating individual survival in G-NENs patients.

Consideration of Age Is Necessary for Increasing the Accuracy of the AJCC TNM Staging System of Pancreatic Neuroendocrine Tumors

Purpose: Currently, of the two most common staging systems of pancreatic neuroendocrine tumors (pNETs) one is from the European Neuroendocrine Tumor Society (ENETS) and the other is from the American Joint Committee on Cancer (AJCC). However, there are imperfections in both these staging systems. Patients and methods: Patients were selected retrospectively from the Surveillance Epidemiology and End Results (SEER) database (2004 to 2013). The effect of age on the hazard ratio (HR) was evaluated using restricted cubic splines. The discriminatory power of the staging systems was determined using the concordance index (C-index). Results: A total of 3,034 patients with pNETs were included in the final analyses. The risk of death increased slowly along with age for patients under 60 years of age, but the risk of death rose sharply for those over 60 years of age, forming a mirrored L-shaped survival curve. In the current AJCC tumor-node-metastasis (TNM) staging system, no statistical significance was observed between stages IA and IB (p = 0.105). Patients with stage IIB even had longer OS than patients with IIA, although there was no statistical significance (p = 0.574). The proportion of stage III patients was small (2.7%). In the proposed aTNM staging system, significant survival differences could be observed among stage I, IIA, and IIB (p < 0.001) and the proportion of stage III rose from 2.7 to 25.7%. Conclusion: Our findings suggest that age has a critical influence on the survival of patients with pNETs. Age should be considered as a factor in future staging systems of pNETs.

Clinicopathological features and prognostic validity of the European Neuroendocrine Tumor Society (ENETS) and American Joint Committee on Cancer (AJCC) 8th staging systems in colonic neuroendocrine neoplasms

Purpose

This study aimed to investigate the characteristics of colonic neuroendocrine neoplasms (NENs) and to validate the prognostic value of the European Neuroendocrine Tumor Society (ENETS) and American Joint Committee on Cancer (AJCC) 8th staging systems.

Methods

A total of 167 and 1248 patients with colonic NENs from 12 medical centers across China and from the Surveillance, Epidemiology, and End Results (SEER) cancer registry in the United States, respectively, were reviewed. Patients were staged according to the ENETS and AJCC 8th staging systems.

Results

Clinicopathological features of colonic NENs in the Chinese cohort and SEER cohort were significantly distinct. In both the Chinese cohort and the SEER cohort, colonic neuroendocrine carcinoma (NEC) and mixed adeno‐neuroendocrine carcinoma (MANEC) were more frequent in the midgut than in the hindgut. Tumors originating from the midgut tended to be larger and at a more advanced stage than those from the hindgut. The AJCC 8th staging system and the ENETS system appeared to have similar prognostic ability for colonic NEC/MANEC.

Conclusions

Our study revealed that tumors originating from the midgut and the hindgut shared different clinicopathological features. The AJCC 8th staging system and the ENETS system appeared to have similar prognostic ability for colonic NEC/MANEC.

Systematic review of the use of big data to improve surgery in low- and middle-income countries

Background

Technological advances have led to the generation of large amounts of data, both in surgical research and practice. Despite this, it is unclear how much originates in low‐ and middle‐income countries (LMICs) and what barriers exist to the use of such data in improving surgical care. The aim of this review was to capture the extent and impact of programmes that use large volumes of patient data on surgical care in LMICs.

Methods

A PRISMA‐compliant systematic literature review of PubMed, Embase and Google Scholar was performed in August 2018. Prospective studies collecting large volumes of patient‐level data within LMIC settings were included and evaluated qualitatively.

Results

A total of 68 studies were included from 71 LMICs, involving 708 032 patients. The number of patients in included studies varied widely (from 335 to 428 346), with 25 reporting data on 3000 or more LMIC patients. Patient inclusion in large‐data studies in LMICs has increased dramatically since 2015. Studies predominantly involved Brazil, China, India and Thailand, with low patient numbers from Africa and Latin America. Outcomes after surgery were commonly the focus (33 studies); very few large studies looked at access to surgical care or patient expenditure. The use of large data sets specifically to improve surgical outcomes in LMICs is currently limited.

Conclusion

Large volumes of data are becoming more common and provide a strong foundation for continuing investigation. Future studies should address questions more specific to surgery.

Genetics and Epigenetics of Gastroenteropancreatic Neuroendocrine Neoplasms

Gastroenteropancreatic (GEP) neuroendocrine neoplasms (NENs) are heterogeneous regarding site of origin, biological behavior, and malignant potential. There has been a rapid increase in data publication during the last 10 years, mainly driven by high-throughput studies on pancreatic and small intestinal neuroendocrine tumors (NETs). This review summarizes the present knowledge on genetic and epigenetic alterations. We integrated the available information from each compartment to give a pathway-based overview. This provided a summary of the critical alterations sustaining neoplastic cells. It also highlighted similarities and differences across anatomical locations and points that need further investigation. GEP-NENs include well-differentiated NETs and poorly differentiated neuroendocrine carcinomas (NECs). NENs are graded as G1, G2, or G3 based on mitotic count and/or Ki-67 labeling index, NECs are G3 by definition. The distinction between NETs and NECs is also linked to their genetic background, as TP53 and RB1 inactivation in NECs set them apart from NETs. A large number of genetic and epigenetic alterations have been reported. Recurrent changes have been traced back to a reduced number of core pathways, including DNA damage repair, cell cycle regulation, and phosphatidylinositol 3-kinase/mammalian target of rapamycin signaling. In pancreatic tumors, chromatin remodeling/histone methylation and telomere alteration are also affected. However, also owing to the paucity of disease models, further research is necessary to fully integrate and functionalize data on deregulated pathways to recapitulate the large heterogeneity of behaviors displayed by these tumors. This is expected to impact diagnostics, prognostic stratification, and planning of personalized therapy.

Margin status and long-term prognosis of primary pancreatic neuroendocrine tumor after curative resection: Results from the US Neuroendocrine Tumor Study Group

BACKGROUND

The impact of margin status on resection of primary pancreatic neuroendocrine tumors has been poorly defined. The objectives of the present study were to determine the impact of margin status on long-term survival of patients with pancreatic neuroendocrine tumors after curative resection and evaluate the impact of reresection to obtain a microscopically negative margin.

METHODS

Patients who underwent curative-intent resection for pancreatic neuroendocrine tumors between 2000 and 2016 were identified at 8 hepatobiliary centers. Overall and recurrence-free survival were analyzed relative to surgical margin status using univariable and multivariable analyses.

RESULTS

Among 1,020 patients, 866 (84.9%) had an R0 (>1 mm margin) resection, whereas 154 (15.1%) had an R1 (≤1 mm margin) resection. R1 resection was associated with a worse recurrence-free survival (10-year recurrence-free survival, R1 47.3% vs R0 62.8%, hazard ratio 1.8, 95% confidence interval 1.2-2.7, P = .002); residual tumor at either the transection margin (R1t) or the mobilization margin (R1m) was associated with increased recurrence versus R0 (R1t versus R0: hazard ratio 1.8, 95% confidence interval 1.0-3.0, P = .033; R1m versus R0: hazard ratio 1.3, 95% confidence interval 1.0-1.7, P = .060). In contrast, margin status was not associated with overall survival (10-year overall survival, R1 71.1% vs R0 71.8%, P = .392). Intraoperatively, 539 (53.6%) patients had frozen section evaluation of the surgical margin; 49 (9.1%) patients had a positive margin on frozen section analysis; 38 of the 49 patients (77.6%) had reresection, and a final R0 (secondary R0) margin was achieved in 30 patients (78.9%). Extending resection to achieve an R0 status remained associated with worse overall survival (hazard ratio 3.1, 95% confidence interval 1.6-6.2, P = .001) and recurrence-free survival (hazard ratio 2.6, 95% confidence interval 1.4-5.0, P = .004) compared with primary R0 resection. On multivariable analyses, tumor-specific factors, such as cellular differentiation, perineural invasion, Ki-67 index, and major vascular invasion, rather than surgical margin, were associated with long-term outcomes.

CONCLUSION

Margin status was not associated with long-term survival. The reresection of an initially positive surgical margin to achieve a negative margin did not improve the outcome of patients with pancreatic neuroendocrine tumors. Parenchymal-sparing pancreatic procedures for pancreatic neuroendocrine tumors may be appropriate when feasible.

A case report of neuroendocrine tumor (G3) at lower rectum with liver metastasis

RATIONALE

Rectal neuroendocrine tumor is a rare disease that is difficult to diagnose by clinical and imageological examinations. The treatment of rectal neuroendocrine tumors is still controversial.

PATIENT CONCERNS

A 50-year-old woman complained of abdominal pain beneath the xiphoid process for 1 day. Physical checkup revealed tenderness at the right upper abdomen. A fecal occult blood test was positive. MRI showed an occupation lesion in the right lobe of the liver. Colonoscopy examination showed a lesion at the lower rectum with an ulcerated surface that was tough in texture. No abnormality was found in the tumor markers.

DIAGNOSIS

Rectal neuroendocrine tumor (G3) with liver metastasis.

INTERVENTIONS

Neoadjuvant chemotherapy followed by laparoscopic surgery was given.

OUTCOMES

The patient followed up regularly in the outpatient department for 13 months after surgery, and no sign of recurrence was found.

LESSONS

Neoadjuvant chemotherapy followed by laparoscopic surgery is a new idea for the treatment of rectal neuroendocrine carcinoma with distant metastasis, which offers favorable conditions for saving the anus during the surgery to enhance the patient's quality of life.