Mixed adenoneuroendocrine carcinoma 江世偉醫師/ 陳周誠醫師/陳周斌主任 台中榮民總醫院 外科部大腸直腸外科 March .19th , 2017

Case presentation Name : 詹 x x Sex: female Age : 48 y/o Body length : 150 cm. Body weight : 54 kg. Chief complain : right upper abdominal pain

Present illness This 54 y/o female patient had right upper abdominal pain, and visited local hospital . Acute cholecystitis was told, then she received laparoscopic cholecystectomy there. But abdominal fullness and pain progressed. After CT scan survey, reoperation was suggested , and then she came to our hospital for second opinion.

Physical examination Clinical lab data Severe abdominal distention WBC = 8670 Hb = 13.6 Platelet = 402 k Physical examination Severe abdominal distention Tenderness at RUQ No fever, nausea (+)

CT scan image Wall thickening at hepatic flexure colon with lumen obstruction, make proximal A-colon and small bowel dilatation. 2. No ascites seen, no significant peritoneal seeding

Operation : right hemicolectomy Tumor location : hepatic flexure colon Size : 1.5 cm x 1.5 cm May, 30 th, 2016

Pathology

於LPF中，可見到tumor cells invasion 於mucosa, submucosa, and muscular layer 8

將顯微鏡轉成HPF， 9

首先我們先在HPF下染CDX2, 呈現STRONG POSITIVE，表示TUMOR CELL 有ADENOCARCINOMA的表現 10

同一個位置，我們染上SYNAPTOPHYSIN，原來CDX2 POSITIVE的 Glandular cells已消失，其他地方則顯現出neuroendocine的component 11

另外的位置，染上Chromogranin A，也顯示POSITIVE FINDINGS，表示 TUMOR含有neuroendocine的component 12

Pathology Mixed adenoneuroendocrine carcinoma , poorly differentiated Mesocolic soft tissue involvement LN ( 0/50 ) T3N0M0

WHO Classification 2010 Neuroendocrine Neoplasms(NENs) of the Gastroenteropancreatic (GEP) System Carcinoid：類癌 神經內分泌腫瘤：在胃腸胰（GEP）系統NENS Bosman FT, et al. WHO Classification of Tumours of the Digestive System. Lyon, France: IARC Press; 2010. 14

WHO Classification 2010: Neuroendocrine Neoplasms of the Digestive System Working principles ”Neuroendocrine” defines the peptide hormone-producing tumors and share neural-endocrine markers ”Neuroendocrine neoplasm” includes well-and poorly differentiated tumors Premise: All neuroendocrine neoplasms have a malignant potential This premise has an influence on the incidence data because NENs that were regarded as benign and not considered in the incidence data (eg, SEERS data) now have to be included Main criteria determining the malignant potential Tumor histopathology Well differentiated Poorly differentiated Proliferative activity : G1, G2, G3 Site, size, infiltration/invasion, metastasis (TNM) Esophagus, stomach, duodenum, ileum, appendix, colorectum, pancreas 根據WHO 2010的分類原則，前所有的neuroendocrine neoplasm預設為都 有惡性潛在性 該分類根據以下判定其惡性度︰ 1.Tumor histopathology 組織病理學：分化良好，分化不良 2. Proliferative activity 增生活性 3. 腫瘤位置、大小、侵犯、轉移(TNM) Bosman FT, et al. WHO Classification of Tumours of the Digestive System. Lyon, France: IARC Press; 2010. 15

Historical Nomenclature of GI-NETs Based on Embryonic Origin Foregut: the stomach, first portion of the duodenum, pancreas, bronchus, lung, and thymus –Higher incidence of MEN1gene mutations and deletions in chromosome 11 –Produce peptides such as gastrin, glucagon, insulin –Argentaffin negative Midgut: Second portion of the duodenum, jejunum, ileum, appendix, and ascending colon –Higher incidence of deletions in chromosome 18 –Produce hormones such as serotonin and bradykinin –Argentaffin positive Hindgut: Transverse colon, descending colon, and rectum –Tend to be asymptomatic Embryonic nomenclature should be replaced by organ of origin NETs已經由胚胎起源為前腸，中腸，後腸或腫瘤歷來分類。 前腸：胃的.NET，十二指腸胰腺第一部分，支氣管，肺和胸腺 在11號染色體基因MEN1突變和缺失的發病率較高 生產生物胺，如胃泌素，胰高血糖素，胰島素 中腸：十二指腸，空腸，迴腸，盲腸，和上行結腸的第二部分 在18號染色體缺失的發病率較高 生產生物胺如血清素和緩激肽 嗜銀陽性 後腸：橫結腸，降結腸和直腸 往往無症狀 而有益的胚胎分類帶來了混亂非專家的醫療服務提供者。 最新的建議是由原屬機關查明NET，並進一步完善以任何附帶綜合徵的描述，如果存在的話 。 根據原發腫瘤位點，存活時間而有所不同 NETs have been historically classified by embryonic origin as foregut, midgut, or hindgut tumours.1- 3 Foregut: NET of the stomach, first portion of the duodenum pancreas, bronchus, lung and thymus Higher incidence of MEN1 gene mutations and deletions in chromosome 11 Produce bioamines such as gastrin, glucagon, insulin Midgut: second portion of the duodenum, jejunum, ileum, appendix, and ascending colon Higher incidence of deletions in chromosome 18 Produce bioamines such as serotonin and bradykinin Argentaffin positive Hindgut: transverse colon, descending colon, and rectum Tend to be asymptomatic The embryonic classification while helpful has led to confusion among the nonexpert healthcare providers. The latest recommendation is to identify the NET by the organ of origin, and further refining the description by any accompanying syndrome, if present. 4 Survival times differ according site of the primary tumour5 1. Modlin IM, Öberg K, Chung DC, et al. Lancet Oncol. 2008;9:61-72. 2. Modlin IM, Kidd M, Latich I, et al. Gastroenterology. 2005;128:1717-1751. NCCN. In: Practice Guidelines in Oncology. V.1. 2008. February 2008. 4. Klimstra DS, Modlin IM, Adsay NV, et al. Am J Surg Pathol. 2010;34:300-313. 5. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063-3072. 16

NETs of Pancreas, Ileum/Jejunum, and Colon showed the highest malignancy (Austria) Colon NET 普遍惡性度較高 根據奧地利一年期前瞻性的試驗，在收案的285個病人中，胃、直腸、盲 腸的NET大多屬良性；而小腸、胰臟及結腸的NET則大多為惡性 Whereas NETs in the stomach (67.7%), rectum (65%) and appendix (62.7%) were mainly classified as benign, those in the small intestine (86.4%), pancreas (75.8%) and colon (70.0%) were predominantly malignant Niederle MB, et al. Endocr Relat Cancer. 2010;17:909-918. 17

40 % Digestive NET below jejunum Topographic Distribution of 35,825 NETs - US 1973-2004 40 % Digestive NET below jejunum NET分佈的位置以foregut, midgut和hindgut區分，近六成的NET發生 在消化系統。 Foregut包括胃、胰、氣管、肺和胸腺，分泌gastrin，glucagon ，insulin Midgut包括十二指腸第二部分、空腸、迴腸、盲腸和升結腸 ，分泌serotonin(血清素)或bradykinin Hindgut包括transverse colon，降結腸和直腸，通常無症狀 上述的部位區分其實仍然混淆，所以NET現在主要是以原發器官和 伴隨的症狀來辨別。 NET have been historically classified by embryonic origin as foregut, midgut, or hindgut tumours. Foregut NET of the stomach, first portion of the duodenum (pancreas, bronchus, lung and thymus) Higher incidence of MEN1 gene mutations and deletions in chromosome 11 Produce bioamines such as gastrin, glucagon, insulin Midgut Second portion of the duodenum, jejunum, ileum, appendix, and ascending colon Higher incidence of deletions in chromosome 18 Produce bioamines such as serotonin and bradykinin Argentaffin positive Hindgut Transverse colon, descending colon, and rectum Tend to be asymptomatic The embryonic classification has led to confusion and has been replaced. NET are now identified by their organ of origin and refined by description of any accompanying syndrome.  Reference: 1. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063–3072. Yao JC, et al. J Clin Oncol. 2008:26:3063-3072.. 18

NETs Are the Second Most Prevalent Type of GI Malignancy 雖然GEP NET的發生率不高，但因診斷後病人可存活一段較長時間 ，所以盛行率相對很高，為腸胃道腫瘤中僅次於大腸直腸癌的第二 位，高於胰臟癌二倍以上。 It is important to remember that even though the incidence of GEP NET is low, because these patients can live for a long time after diagnosis, the prevalence is quite high in that it is the second most prevalent GI malignancy (colorectal cancer is the most prevalent). Prevalence of GEP NET are more than two times greater than pancreatic cancer (carcinoma). Reference: 1. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063–3072. 1. National Cancer Institute. US SEER Cancer Statistics Review, 1975-2004. http://seer.cancer.gov/csr/1975_2004. 2. Modlin IM, et al. Cancer. 2003;97:934-959. 19

The Overall Incidence of NETs Is Increasing Rapidly Compared With All Malignant Neoplasms The incidence and prevalence of NETs has increased by approximately 5-fold over the past 30 years, which may be partially due to improved diagnosis US SEER 1974-2004資料顯示，NET的發生率上升速度顯著高於所有 癌症的速度，由1973年每十萬人有1.09人，上升至2004年的5.25人。 這樣大幅的增加部分可能是由於對症狀的認識和早期發現，若以迴 歸分析推估，2013年的發生率可能會接近8人/十萬人。 A total of 35,825 NET were identified in the SEER registries (includes only malignant NET) from 1973 to 2004. Incidence of NET was expressed as cases per 100,000 per year and age- adjusted to the 2000 US standard population. The data set used contained a total of 4.9 million neoplasms in 4.5 million patients diagnosed from 1973 to 2004. There was a significant increase in reported annual age-adjusted incidence from 1.09 per 100,000 in 1973 to 5.25 per 100,000 in 2004. This striking increase in incidence may be partly due to the increase in symptom recognition and earlier detection. Using regression analysis to extrapolate, it is estimated that the incidence in 2013 could be nearly 8 per 100,000. Reference: 1. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063–3072. Source: US SEER database. Adapted with permission from Yao JC, et al. J Clin Oncol. 2008:26:3063-3072. 20

However... NETs Are Often Diagnosed Late Estimated time to diagnosis: 5 to 7 yr Death Diarrhea * Vague abdominal symptoms Flushing * Metastases NET病人通常無症狀期可長達數年，造成診斷的困難。 由於hormone或peptide分泌引起的carcinoid syndrome如腹瀉或潮紅，通常是 在腫瘤已轉移後才會在臨床上發現。 一般而言，NET需要5-7年的時間才會確診。 Neuroendocrine tumours can remain asymptomatic for a long period of time. Vague abdominal symptoms may be associated with primary tumour growth. These are not usually identified until they have metastasized and spread. Symptoms from syndromes secondary to hormone/peptide secretion such as diarrhea and flushing seen with carcinoid syndrome often does not appear until metastatic spread. Reference: Vinik A, et al. Pancreas. 2009 Nov;38(8):876-89. Primary tumor growth 1 2 3 4 5 6 7 8 9 Time (yr) *Symptoms of carcinoid syndrome Vinik AI, Silva MP, Woltering EA, et al. Pancreas. 2009;38:876-889. 21

Therefore... NETs Are Often Advanced at the Time of Diagnosis 依據SEER資料庫，一半的NET病人在確診時的已局部或遠端轉移。 According to the SEER database, half of the patients with NET with known primary sites presented with either regional or distant metastasis. Reference: 1. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063–3072. Source: US SEER Database. Yao JC, et al. J Clin Oncol. 2008;26:3063-3072. 22

33-mo Median Survival of Patients with Metastatic NETs Tumors with well-and moderately differentiated histology1 5-yr survival rate in metastatic NETs is similar to that in other metastatic cancers –Poorly differentiated NET—4%1 –Well/moderately differentiated NET—35%1 –Lung—4%2 SEER registry的資料顯示，well and moderately differentiated NET中， 若以腫瘤侵犯程度來區分，localized、regional和distant NET個別的整 體存活率有顯著的差異，若病人是distant metastases NET，median survival只有33個月(低於3年)。 轉移性NET的5年存活率，只略高於轉移性攝護腺癌 There is a significant difference in survival for patient with well and moderately differentiated NET dependent on the disease spread: localized, regional or distant (includes only malignant NET) A localized NET was defined as an invasive neoplasm confined entirely to the organ of origin A regional NET was defined as a neoplasm that: Extended beyond the limits of the organ of origin directly into surrounding organs or tissue and/or Involved regional lymph nodes A distant NET was defined as a neoplasm that spread to parts of the body remote from the primary tumour Reference: 1. Yao JC, Hassan M, Phan A, et al. J Clin Oncol. 2008;26:3063–3072. Yao J, et al. J Clin Oncol. 2008;26:3063-3072; Jemal A, et al. CA Cancer J Clin.2010;60:277-300. 23

Diagnostic Standards for NETs Mandatory: Histopathology―well or poorly differentiated Expression of neuroendocrine markers synaptophysin and chromogranin A(CgA)－ Proliferative activity: G1–G3 Stage: pTNM (ENETs 2007 and UICC 2009)1 NET確診必須要有︰ 病理組織分化：well or poorly differentiated 病理組織染色有NET的表現︰Synaptophysin和CgA 組織增生活性G1-G3 分級︰pTNM Klöppel G, et al. Neuroendocrinology.2009;90:162-166. 24

Neuroendocrine Cell Chromogranin是一種分泌蛋白，儲存於神經內分泌細胞內的分泌小泡 (secretory vesicles)，跟peptides和amines一起分泌出來。 Chromogranin由腎上腺髓質的嗜鉻細胞、腸嗜鉻細胞(ECL)和內分泌 細胞分泌，在hormone的運送處理過程為不可或缺的角色。 因此Plasma CgA可提供與tumor burden和treatment response相關訊息 。 The chromogranin/secretogranin family of neuroendocrine secretory proteins consists of at least 3 unique water-soluble acidic glycoproteins (CgA, CgB, and CgC) that are stored in the secretory vesicles of neuroendocrine cells and are co-secreted with peptide hormones and amines. At the cellular level, the chromogranins (chromogranin family of peptides) are an integral part of the biological processes involved in hormone packaging and delivery prior to exocytosis. CgA can be measured in the serum or plasma or detected within the secretory vesicles by IHC as a general diagnostic biomarker for NET Plasma CgA levels provide information regarding tumour burden and response to treatment. Reference: Feldman SA, et al. Endocr Pathol. 2003;14(1):3-23. Feldman SA, et al. Endocr Pathol. 2003;14(1):3-23. 25

Biomarkers in NET CgA is the best available biomarker for diagnosis of NET CgA is elevated 80%–100% of the time in NET Elevated CgA may correlate with tumor progression Other biomarkers are available, but few have achieved widespread acceptance CgA是現有最適用於NET的biomarker 80-100%的NET病人其CgA會高於正常值 CgA上升與腫瘤惡化相關 其他biomarkers運用的廣泛度較低 ［鉻素A是NET的診斷最好的生物標誌物］ －高架鉻素A可能與腫瘤的進展相關 －鉻素A升高80％-100％的淨時間 ［NSE也在NET表示］ －不作為一般的鉻素A －低分化腫瘤常升高 ［其他生物標誌物是可用的，但很少有達到廣泛接受］ ［在NET的新生物標記都需要提供更好的診斷和預後信息］ Neuron-specific enolase 5-HIAA = 5-hydroxy-3-indoleacetic acid 5-HT = serotonin GHRH = gonadotropin hormone release hormone hCG = human chorionic gonadotropin ANP/BNP = atrial natriuretic peptide and brain/ventricular natriuretic peptide NSE = neuron-specific enolase PYY = peptide YY Vinik A, et al.Pancreas. 2009;38:876-889 26

Therapeutic modalities for neuroendocrine tumor 1. Surgery : cytoreduction and /or metastatectomy 2. Local ablation: RFA, embolization 3. Irradiation : radioactive therapy (DOTATOC, MIBG) radionuclides (yttrium 90Y) 4. Medical therapy : cytotoxic agent, Somatostatin analogs, anti-angiogenesis, mTOR inhibitor, IFN-a

Conclusion 1. Elevated incidence rate of NET maybe the cause of aggressive surgical approach and acknowledege of pathology 2. It would be better prognosis for resectable localized neuroendocrine tumor. 3. Adjust postoperative somatostatin analogs would be the suitable regimen

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