Neuroendocrine tumor

WHO The World Health Organization (WHO) classification scheme places neuroendocrine tumors into three main categories, which emphasize the tumor grade rather than the anatomical origin: Placing a given tumor into one of these categories depends on well-defined histological features: size, lymphovascular invasion, mitotic count, Ki-67 labelling index, invasion of adjacent organs, presence of metastases and whether they produce hormones. Neuroendocrine carcinomas are poorly differentiated high-grade neuroendocrine neoplasms and a designation of tumor grade is therefore redundant. NETs include certain tumors of the gastrointestinal tract and of the pancreatic islet cells, or excluded. representing only a small proportion of the tumors or cancers in most of these tissues: • Pituitary gland: Neuroendocrine tumor of the anterior pituitary • Thyroid gland: Neuroendocrine thyroid tumors, particularly medullary carcinoma • Parathyroid tumors • Thymus and mediastinal carcinoid tumors • Pulmonary neuroendocrine tumors • bronchus • Extrapulmonary small cell carcinomas (ESCC or EPSCC) • Gastroenteropancreatic neuroendocrine tumors (GEP-NET) • Foregut GEP-NET (foregut tumors can conceptually encompasses not only NETs of the stomach and proximal duodenum, but also the pancreas, and even thymus, lung and bronchus) • Pancreatic endocrine tumors (if considered separately from foregut GEP-NET) • Midgut GEP-NET (from distal half of 2nd part of the duodenum to the proximal two-thirds of the transverse colon) • appendix, including well differentiated NETs (benign); well differentiated NETs (uncertain malignant potential); well differentiated neuroendocrine carcinoma (with low malignant potential); mixed exocrine-neuroendocrine carcinoma (goblet cell carcinoma, also called adenocarcinoid and mucous adenocarcinoid) • Hindgut GEP-NET • Liver and gallbladder • Adrenal tumors, particularly adrenomedullary tumors • Pheochromocytoma • Peripheral nervous system tumors, such as: • Schwannoma • paraganglioma • neuroblastoma • Breast • Genitourinary tract • urinary tract carcinoid tumor and neuroendocrine carcinoma • ovary • neuroendocrine tumor of the cervix • Prostate tumor with neuroendocrine differentiation • testes • Merkel cell carcinoma of skin (trabecular cancer) • Inherited conditions: • multiple endocrine neoplasia type 1 (MEN1) • multiple endocrine neoplasia type 2 (MEN2) • von Hippel-Lindau (VHL) disease • tuberous sclerosis • Carney complex Grading Neuroendocrine lesions are graded histologically according to markers of cellular proliferation, rather than cellular polymorphism. The following grading scheme is currently recommended for all gastroenteropancreatic neuroendocrine neoplasms by the World Health Organization: If mitotic count and Ki-67 are discordant, the figure which gives the highest grade is used. G1 and G2 neuroendocrine neoplasms are called neuroendocrine tumors (NETs) – formerly called carcinoid tumours. G3 neoplasms are called neuroendocrine carcinomas (NECs). It has been proposed that the current G3 category be further separated into histologically well-differentiated and poorly-differentiated neoplasms to better reflect prognosis. Staging Currently there is no one staging system for all neuroendocrine neoplasms. Well-differentiated lesions generally have their own staging system based on anatomical location, whereas poorly differentiated and mixed lesions are staged as carcinomas of that location. For example, gastric NEC and mixed adenoneuroendocrine cancers are staged as primary carcinoma of the stomach. TNM staging of gastroenteropancreatic Grade 1 and Grade 2 neuroendocrine tumors are as follows: ==Signs and symptoms==

Gastroenteropancreatic Conceptually, there are two main types of NET within the gastroenteropancreatic neuroendocrine tumors (GEP-NET) category: those that arise from the gastrointestinal (GI) system and those that arise from the pancreas. In usage, the term "carcinoid" has often been applied to both, although sometimes it is restrictively applied to NETs of GI origin (as herein), or alternatively to those tumors which secrete functional hormones or polypeptides associated with clinical symptoms, as discussed. Carcinoid tumors Carcinoids most commonly affect the small bowel, particularly the ileum, and are the most common malignancy of the appendix. Many carcinoids are asymptomatic and are discovered only upon surgery for unrelated causes. These coincidental carcinoids are common; one study found that one person in ten has them. Many tumors do not cause symptoms even when they have metastasized. or less of carcinoids, primarily some midgut carcinoids, secrete excessive levels of a range of hormones, most notably serotonin (5-HT) or substance P, causing a constellation of symptoms called carcinoid syndrome: • flushing • diarrhea • asthma or wheezing • congestive heart failure (CHF) • abdominal cramping • peripheral edema • heart palpitations A carcinoid crisis with profound flushing, bronchospasm, tachycardia, and widely and rapidly fluctuating blood pressure Occasionally, haemorrhage or the effects of tumor bulk are the presenting symptoms. Bowel obstruction can occur, sometimes due to fibrosing effects of NET secretory products or "pancreatic endocrine tumors". Familial syndromes Most pancreatic NETs are sporadic. However, neuroendocrine tumors can be seen in several inherited familial syndromes, including: • multiple endocrine neoplasia type 1 (MEN1) • multiple endocrine neoplasia type 2 (MEN2) • von Hippel-Lindau (VHL) disease • neurofibromatosis type 1 • tuberous sclerosis • Carney complex Given these associations, recommendations in NET include family history evaluation, evaluation for second tumors, and in selected circumstances testing for germline mutations such as for MEN1. ==Pathophysiology==

NETs are believed to arise from various neuroendocrine cells whose normal function is to serve at the neuroendocrine interface. Neuroendocrine cells are present not only in endocrine glands throughout the body that produce hormones, but are found in all body tissues. ==Diagnosis==

Markers Symptoms from secreted hormones may prompt measurement of the corresponding hormones in the blood or their associated urinary products, for initial diagnosis or to assess the interval change in the tumor. Secretory activity of the tumor cells is sometimes dissimilar to the tissue immunoreactivity to particular hormones. • urine 5-hydroxyindoleacetic acid (5-HIAA) • neuron-specific enolase (NSE, gamma-gamma dimer) • synaptophysin (P38) Newer markers include N-terminally truncated variant of Hsp70 is present in NETs but absent in normal pancreatic islets. High levels of CDX2, a homeobox gene product essential for intestinal development and differentiation, are seen in intestinal NETs. Neuroendocrine secretory protein-55, a member of the chromogranin family, is seen in pancreatic endocrine tumors but not intestinal NETs. Advances in nuclear medicine imaging, also known as molecular imaging, have improved diagnostic and treatment paradigms in patients with neuroendocrine tumors. This is because of its ability to not only identify sites of disease but also characterize them. Neuroendocrine tumours express somatostatin receptors providing a unique target for imaging. Octreotide is a synthetic modification of somatostatin with a longer half-life. OctreoScan, also called somatostatin receptor scintigraphy (SRS or SSRS), utilizes intravenously administered octreotide that is chemically bound to a radioactive substance, often indium-111, to detect larger lesions with tumor cells that are avid for octreotide. Somatostatin receptor imaging can now be performed with positron emission tomography (PET) which offers higher resolution, three-dimensional and more rapid imaging. Gallium-68 receptor PET-CT is much more accurate than an Octreotide scan. Thus, octreotide scanning for NET tumors is being increasingly replaced by gallium-68 DOTATOC scan. Imaging with fluorine-18 fluorodeoxyglucose (FDG) PET may be valuable to image some neuroendocrine tumors. This scan is performed by injected radioactive sugar intravenously. Tumors that grow more quickly use more sugar. Using this scan, the aggressiveness of the tumor can be assessed. However, neuroendocrine tumors are often slow growing and indolent, and these do not show well on FDG-PET. Functional imaging with gallium-labelled somatostatin analog and 18F-FDG PET tracers ensures better staging and prognostication of neuroendocrine neoplasms. The combination of somatostatin receptor and FDG PET imaging is able to quantify somatostatin receptor cell surface (SSTR) expression and glycolytic metabolism, respectively. Histopathology , as seen here on H&E stain and Pap stain. neuroendocrine tumor at bottom third of image, showing the typical intramural (within the wall) location, and overlying intact epithelium. H&E stain. Features in common Neuroendocrine tumors, despite differing embryological origin, have common phenotypic characteristics. NETs show tissue immunoreactivity for markers of neuroendocrine differentiation (pan-neuroendocrine tissue markers) and may secrete various peptides and hormones. There is a lengthy list of potential markers in neuroendocrine tumors; several reviews provide assistance in understanding these markers. Widely used neuroendocrine tissue markers are various chromogranins, synaptophysin and PGP9.5. Neuron-specific enolase (NSE) is less specific. NETs are often small, yellow or tan masses, often located in the submucosa or more deeply intramurally, and they can be very firm due to an accompanying intense desmoplastic reaction. The overlying mucosa may be either intact or ulcerated. Some GEP-NETs invade deeply to involve the mesentery. Histologically, NETs are an example of "small blue cell tumors," showing uniform cells which have a round to oval stippled nucleus and scant, pink granular cytoplasm. The cells may align variously in islands, glands or sheets. High power examination shows bland cytopathology. Electron microscopy can identify secretory granules. There is usually minimal pleomorphism but less commonly there can be anaplasia, mitotic activity, and necrosis. Some neuroendocrine tumor cells possess especially strong hormone receptors, such as somatostatin receptors and uptake hormones strongly. This avidity can assist in diagnosis and may make some tumors vulnerable to hormone targeted therapies. Argentaffin and hormone secretion NETs from a particular anatomical origin often show similar behavior as a group, such as the foregut (which conceptually includes pancreas, and even thymus, airway and lung NETs), midgut and hindgut; individual tumors within these sites can differ from these group benchmarks: • Foregut NETs are argentaffin negative. Despite low serotonin content, they often secrete 5-hydroxytryptophan (5-HTP), histamine, and several polypeptide hormones. There may be associated atypical carcinoid syndrome, acromegaly, Cushing disease, other endocrine disorders, telangiectasia, or hypertrophy of the skin in the face and upper neck.  These tumors can metastasize to bone. • Midgut NETs are argentaffin positive, can produce high levels of serotonin 5-hydroxytryptamine (5-HT), kinins, prostaglandins, substance P (SP), and other vasoactive peptides, and sometimes produce corticotropic hormone (previously adrenocorticotropic hormone [ACTH]). Bone metastasis is uncommon. • Hindgut NETs are argentaffin negative and rarely secrete 5-HT, 5-HTP, or any other vasoactive peptides. Bone metastases are not uncommon. ==Treatment==

Several tumor characteristics guide appropriate treatment of a neuroendocrine tumor, including its location, invasiveness, hormone secretion, and metastasis. Treatments may be aimed at curing the disease or at relieving symptoms (palliation). Treatments can be broadly divided into surgery to remove the tumor or its metastases, systemic therapies which travel throughout the bloodstream to treat the tumor, and locoregional therapies, which target the tumor or its metastases in a specific region e.g. targeted liver therapies to treat liver metastases Treatments have improved over the past several decades, and outcomes are improving. NCCN, NANETS, and ENETS. The NCI has guidelines for several categories of NET: islet cell tumors of the pancreas, gastrointestinal carcinoids, Merkel cell tumors and pheochromocytoma/paraganglioma. However, effective predictive biomarkers are yet to be discovered. Similarly, recent advances in understanding neuroendocrine tumor's molecular and genomic alterations still have to find their ways into a definitive management strategy. Surgery Surgery is typically the treatment of choice for neuroendocrine tumors that can be completely removed, . Even if the tumor has advanced and metastasized to the point where curative surgery is not possible, surgery often has a role for palliation of symptoms and possibly increased lifespan. Systemic Therapies Somatostatin analogs Somatostatin analogs help relieve hormonal symptoms by blocking hormone release from secretory tumors A consensus review has reported on the use of somatostatin analogs for GEP-NETs. These medications may also anatomically stabilize or shrink tumors, and increase progression-free survival. ==== Chemotherapy ==== Chemotherapy treatments work by killing or stopping the growth of fast growing cells, including cancer cells. Different chemotherapy drugs can be used depending on the type of NET being treated. Examples of chemotherapy treatments used for neuroendocrine tumors include Carboplatin, Cisplatin, Fluorouracil, and Irinotecan showing 10 to 20% response rates that are typically less than 6 months. Combining chemotherapy medications has not usually been of significant improvement The peptide receptor may be bound to lutetium-177, yttrium-90, indium-111 and other isotopes including alpha emitters. This is a highly targeted and effective therapy with minimal side effects in tumors with high levels of somatostatin cell surface expression, because the radiation is absorbed at the sites of the tumor, or excreted in the urine. The radioactively labelled hormones enter the tumor cells which, together with nearby cells, are damaged by the attached radiation. PRRT was initially used for low grade NETs. It is also very useful in more aggressive NETs such as Grade 2 and 3 NETs provided they demonstrate high uptake on SSTR imaging to suggest benefit. Locoregional Therapies ==== External beam radiation therapy ==== External beam radiation therapy can be used to treat neuroendocrine tumors. This treatment involves using a machine to deliver a beam of radiation targeted to the region of the tumor or metastases in order to kill the tumor cells. Treatments typically take place on scheduled days over several weeks. ==== Hepatic artery embolization ==== Hepatic artery treatments are performed by placing a small catheter into a blood vessel, guiding it into the hepatic artery, then delivering treatments directly into the hepatic artery (or arteries) to target the tumor or metastases in the liver. Neuroendocrine metastases to the liver can be treated by hepatic artery treatments based on the observation that tumor cells get nearly all their nutrients from the hepatic artery, while the normal cells of the liver get about 70–80 percent of their nutrients and 50% their oxygen supply from the portal vein, and thus can survive with the hepatic artery effectively blocked. • Transarterial embolization (TAE) occludes blood flow to the tumors by injecting small particles (embospheres) into the artery which lodge in downstream capillaries. • Transarterial chemoembolization (TACE) combines transarterial embolization with chemotherapy delivery: embospheres bound with chemotherapy agents are injected into the hepatic artery and lodge in downstream capillaries. • Transarterial radioembolization (TACE), also called selective internal radiation therapy (SIRT) delivers radioactive microsphere therapy (RMT) by injection into the hepatic artery, lodging (as with TAE and TACE) in downstream capillaries. In contrast to hormone-delivered radiotherapy, the lesions need not overexpress peptide receptors. The mechanical targeting delivers the radiation from the yttrium-labeled microspheres selectively to the tumors without unduly affecting the normal liver. This type of treatment is FDA approved for liver metastases secondary to colorectal carcinoma and is under investigation for treatment of other liver malignancies, including neuroendocrine malignancies. and supported by the crowdfunding campaign iCancer was used in a Phase 1 trial against NET in 2016. Further efforts towards more personalized therapies in neuroendocrine tumors are undertaken i.a. combining drug screening platforms and patient-derived ex vivo cell cultures that mimic relevant aspects of the original tumors. ==Epidemiology==

Although estimates vary, the annual incidence of clinically significant neuroendocrine tumors is approximately 2.5–5 per 100,000; two thirds are carcinoid tumors and one third are other NETs. The prevalence has been estimated as 35 per 100,000, As diagnostic imaging increases in sensitivity, such as endoscopic ultrasonography, very small, clinically insignificant NETs may be coincidentally discovered; being unrelated to symptoms, such neoplasms may not require surgical excision. ==History==

Small intestinal neuroendocrine tumors were first distinguished from other tumors in 1907. They were named carcinoid tumors because their slow growth was considered to be "cancer-like" rather than truly cancerous. neuroendocrine cells sometimes produce various types of hormones and amines, and the differences between these schema have often been confusing. Nonetheless, these systems all distinguish between well-differentiated (low and intermediate-grade) and poorly differentiated (high-grade) NETs. Cellular proliferative rate is of considerable significance in this prognostic assessment. == References ==