Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website https://www.gastrores.org

Case Report

Volume 13, Number 6, December 2020, pages 269-278

Clinicopathologic and Molecular Features of Mixed Neuroendocrine Non-Neuroendocrine Neoplasms of the Gallbladder

Figure 1. Magnetic resonance cholangiopancreatographic image showing a distended gallbladder (red arrow) with debris and stones (about 1 cm) and two irregular septate nodules in the inferior fundus (about 1.5 cm) that enhanced after gadolinium administration.

Figure 3. Representative photomicrographs of the MiNEN. (a) Infiltrating squamous cell carcinoma (*) and neuroendocrine carcinoma (†) adjacent to each other (× 20). (b) Squamous component with keratinization (× 100). (c) Neuroendocrine component with necrosis (× 200). (d) Adenocarcinoma component with gland formation (× 20). H&E stain. MiNEN: mixed neuroendocrine non-endocrine neoplasm; H&E: hematoxylin and eosin.

Figure 4. Immunohistochemical staining showing: (a) p63-positive squamous component and negative neuroendocrine component (× 40); (b) synaptophysin-positive neuroendocrine component and negative squamous cell component (× 40); (c) CK7-positive adenocarcinoma component (× 20).

**Table 1.** Two- and Three-Component Mixed Neuroendocrine and Non-Neuroendocrine Tumors of the Gallbladder
No.	Gender/age (years)	Clinical presentation	Stones	Tumor location/size (cm)	Components	Liver invasion	Metastasis	Treatment	Follow-up (months)	Reference
5-FU: 5- fluorouracil; A: absent; Carb: carboplatin; Chem: chemotherapy; Chol: cholecystectomy; Cis: cisplatin; DF: disease free; EHBD: extrahepatic bile duct; EHX: extended hepatectomy; Epir: epirubicin; Eto: etoposide; F: female; Lant: lanreotide; Gem: gemcitabine; LCNEC: large cell neuroendocrine carcinoma; Leuc: leucovorin; LN: lymph nodes; Lnd: lymph node dissection; M: male; NA: not available; NEC: neuroendocrine carcinoma; Oct: octreotide; Oxa: oxaliplatin; P: present; PAC: papillary adenocarcinoma; Phx: partial hepatectomy; Rad: radiotherapy; RHT: right hepatic trisegmentectomy; RUQ: right upper quadrant; SARC: sarcomatoid differentiation; SCC: squamous cell carcinoma; SCNEC: small cell neuroendocrine carcinoma; Som: somatostatin/somatostatin analogue; WDAC: well-differentiated adenocarcinoma.
Two-component gallbladder mixed neuroendocrine non-neuroendocrine neoplasms
1	M/50	Symptomatic cholelithiasis	A	NA/< 1	LCNEC, AC	A	A	Chol	DF (12)	[1]
2	F/48	Abdominal pain	A	Fundus/3.5	LCNEC, AC	P	A	Chol, Ehx	NA	[5]
3	F/68	Jaundice	P	Fundus/3.1	LCNEC, AC	P	LN	Chol, Ehx	DF (12)	[8]
4	F/55	Back pain, fever	P	Body/4.9	LCNEC, SCNEC, AC	A	A	Chol	DF (20)	[15]
5	M/85	Anorexia, weight loss	P	Fundus/1.5	LCNEC, AC	A	Liver	Chol, Chem (Carb, Eto), Lant	Died (21)	[16]
6	F/55	Abdominal pain	P	Gallbladder bed/14	SCNEC, AC	P	Pancreas, omentum	Chol, Oct	DF (7)	[17]
7	M/59	Abdominal pain	NA	Body/4	LCNEC, AC	P	LN	Chol	NA	[18]
8	M/45	Abdominal pain, jaundice	P	Fundus/5.7	LCNEC, AC	P	NA	Chol	NA	[19]
9	M/56	Exophthalmos	P	Entire gallbladder/9	LCNEC, AC	P	Multiple organs, LN	Chem, Rad	Died (36)	[20]
10	F/54	Postprandial epigastric pain	A	Fundus and body/NA	LCNEC, AC	A	LN	Cho, EHBD resection	DF (24)	[21]
11	F/63	Abdominal pain	P	Body/2	LCNEC, AC	A	A	Chol, Phx, Lnd	DF (12)	[22]
12	F/62	Asymptomatic	A	Fundus/2	NEC, AC	A	A	Chol, Phx, Lnd	NA	[23]
13	F/55	Postprandial RUQ pain	P	Fundus/3.5	LCNEC, AC	A	A	Chol, Revision	NA	[24]
14	F/62	Abdominal and RUQ pain	A	Fundus/5.3	LCNEC, AC	A	A	Chol, Phx, Lnd, Rad, Chem (Cis, Eto)	Died (2)	[25]
15	F/42	RUQ pain	A	Gallbladder fossa/7.4	SCNEC, AC	P	A	Chol, Phx, Lnd, Chem (Cis: 75 mg/m²; Eto: 120 mg/m²), Som	Died (21)	[26]
16	F/70	Cholecystolithiasis	P	NA/3.5	SCNEC, WDAC	P (NEC)	LN (NEC)	NA	NA	[27]
17	F/70	NA	NA	NA/4.5	LCNEC, PAC	A	NA	NA	NA	[27]
18	F/70	Cholecystolithiasis	P	NA/4.5	NEC G2, WDAC	A	Duodenum invasion (NET)	NA	NA	[27]
19	F/60	Cholecystolithiasis	P	NA/1.5	SCNEC, PAC	A	LN (NEC & AC)	NA	NA	[27]
20	F/50	NA	NA	NA/15	LCNEC, WDAC	P	LN(NEC)	NA	NA	[27]
21	M/58	Epigastric pain	NA	NA/15	SCNEC, WDAC	P	Liver (portal vein)	RHT	Died (4) recurrence	[28]
22	F/56	RUQ pain and weight loss	NA	NA	SCNEC, AC	P	Liver (Recurrence)	Chol, EHX, Chem (Carb, Eto), Som	Alive (24), good response to Chem	[29]
Three-component gallbladder mixed neuroendocrine non-neuroendocrine neoplasms
23	F/62	RUQ pain, anorexia, jaundice	A	NA/6.5	AC, SCC, SCNEC	P	Liver	Palliative Chol	Died (5) (septicemia)	[7]
24	F/70	Epigastric pain	NA	Fundus/3.6	AC, SCC, NEC	A	LN, liver	Chol, Phx	Died (32)	[9]
25	F/81	Abdominal pain, weight loss, jaundice	P	Neck/5	AC, SCC, LCNEC	P	Bone	Palliative Chol	NA	[10]
26	F/80	Asymptomatic	A	Fundus/8.2	AC, SCC, NEC G2 SARC	A	A	Chol, Lnd	Alive (8)	[11]
27	F/81	Asymptomatic	P	Fundus/4	AC, SCC, LCNEC, SARC	A	LN	Chol, Phx	Alive (48)	[12]
28	M/52	Epigastric pain, fever	NA	NA	AC (40%), SCC (50%), LCNEC (10%)	A	A	Chol, Chem (Gem, Oxa)	NA	[13]
29	F/54	Epigastric pain	P	Fundus/4.3	AC (10%), SCC (80%), LCNEC (10%)	A	Liver, LN	Chol, Phx, Chem (Cis, Gem, Epir), Rad	Died (13)	[14]
30	F/62	RUQ pain	P	Fundus/5	AC (10%), SCC (60%), NEC (30%)	A	Umbilicus	Chol, Phx, Chem (5-FU, Leuc, Oxa)	Alive (14)	Present patient

Table 1. Two- and Three-Component Mixed Neuroendocrine and Non-Neuroendocrine Tumors of the Gallbladder

No.

Gender/age (years)

Clinical presentation

Stones

Tumor location/size (cm)

Components

Liver invasion

Metastasis

Treatment

Follow-up (months)

Reference

5-FU: 5- fluorouracil; A: absent; Carb: carboplatin; Chem: chemotherapy; Chol: cholecystectomy; Cis: cisplatin; DF: disease free; EHBD: extrahepatic bile duct; EHX: extended hepatectomy; Epir: epirubicin; Eto: etoposide; F: female; Lant: lanreotide; Gem: gemcitabine; LCNEC: large cell neuroendocrine carcinoma; Leuc: leucovorin; LN: lymph nodes; Lnd: lymph node dissection; M: male; NA: not available; NEC: neuroendocrine carcinoma; Oct: octreotide; Oxa: oxaliplatin; P: present; PAC: papillary adenocarcinoma; Phx: partial hepatectomy; Rad: radiotherapy; RHT: right hepatic trisegmentectomy; RUQ: right upper quadrant; SARC: sarcomatoid differentiation; SCC: squamous cell carcinoma; SCNEC: small cell neuroendocrine carcinoma; Som: somatostatin/somatostatin analogue; WDAC: well-differentiated adenocarcinoma.

Two-component gallbladder mixed neuroendocrine non-neuroendocrine neoplasms

M/50

Symptomatic cholelithiasis

NA/< 1

LCNEC, AC

Chol

DF (12)

[1]

F/48

Abdominal pain

Fundus/3.5

LCNEC, AC

Chol, Ehx

[5]

F/68

Jaundice

Fundus/3.1

LCNEC, AC

Chol, Ehx

DF (12)

[8]

F/55

Back pain, fever

Body/4.9

LCNEC, SCNEC, AC

Chol

DF (20)

[15]

M/85

Anorexia, weight loss

Fundus/1.5

LCNEC, AC

Liver

Chol, Chem (Carb, Eto), Lant

Died (21)

[16]

F/55

Abdominal pain

Gallbladder bed/14

SCNEC, AC

Pancreas, omentum

Chol, Oct

DF (7)

[17]

M/59

Abdominal pain

Body/4

LCNEC, AC

Chol

[18]

M/45

Abdominal pain, jaundice

Fundus/5.7

LCNEC, AC

Chol

[19]

M/56

Exophthalmos

Entire gallbladder/9

LCNEC, AC

Multiple organs, LN

Chem, Rad

Died (36)

[20]

F/54

Postprandial epigastric pain

Fundus and body/NA

LCNEC, AC

Cho, EHBD resection

DF (24)

[21]

F/63

Abdominal pain

Body/2

LCNEC, AC

Chol, Phx, Lnd

DF (12)

[22]

F/62

Asymptomatic

Fundus/2

NEC, AC

Chol, Phx, Lnd

[23]

F/55

Postprandial RUQ pain

Fundus/3.5

LCNEC, AC

Chol, Revision

[24]

F/62

Abdominal and RUQ pain

Fundus/5.3

LCNEC, AC

Chol, Phx, Lnd, Rad, Chem (Cis, Eto)

Died (2)

[25]

F/42

RUQ pain

Gallbladder fossa/7.4

SCNEC, AC

Chol, Phx, Lnd, Chem (Cis: 75 mg/m²; Eto: 120 mg/m²), Som

Died (21)

[26]

F/70

Cholecystolithiasis

NA/3.5

SCNEC, WDAC

P (NEC)

LN (NEC)

[27]

F/70

NA/4.5

LCNEC, PAC

[27]

F/70

Cholecystolithiasis

NA/4.5

NEC G2, WDAC

Duodenum invasion (NET)

[27]

F/60

Cholecystolithiasis

NA/1.5

SCNEC, PAC

LN (NEC & AC)

[27]

F/50

NA/15

LCNEC, WDAC

LN(NEC)

[27]

M/58

Epigastric pain

NA/15

SCNEC, WDAC

Liver (portal vein)

RHT

Died (4) recurrence

[28]

F/56

RUQ pain and weight loss

SCNEC, AC

Liver (Recurrence)

Chol, EHX, Chem (Carb, Eto), Som

Alive (24), good response to Chem

[29]

Three-component gallbladder mixed neuroendocrine non-neuroendocrine neoplasms

F/62

RUQ pain, anorexia, jaundice

NA/6.5

AC, SCC, SCNEC

Liver

Palliative Chol

Died (5) (septicemia)

[7]

F/70

Epigastric pain

Fundus/3.6

AC, SCC, NEC

LN, liver

Chol, Phx

Died (32)

[9]

F/81

Abdominal pain, weight loss, jaundice

Neck/5

AC, SCC, LCNEC

Bone

Palliative Chol

[10]

F/80

Asymptomatic

Fundus/8.2

AC, SCC, NEC G2 SARC

Chol, Lnd

Alive (8)

[11]

F/81

Asymptomatic

Fundus/4

AC, SCC, LCNEC, SARC

Chol, Phx

Alive (48)

[12]

M/52

Epigastric pain, fever

AC (40%), SCC (50%), LCNEC (10%)

Chol, Chem (Gem, Oxa)

[13]

F/54

Epigastric pain

Fundus/4.3

AC (10%), SCC (80%), LCNEC (10%)

Liver, LN

Chol, Phx, Chem (Cis, Gem, Epir), Rad

Died (13)

[14]

F/62

RUQ pain

Fundus/5

AC (10%), SCC (60%), NEC (30%)

Umbilicus

Chol, Phx, Chem (5-FU, Leuc, Oxa)

Alive (14)

Present patient

**Table 2.** Molecular Changes in Different Components of MiNENs of the Gastrointestinal Tract
MiNEN location	Molecular markers	Tumor composition	Testing modality	Comment	Reference
*Mutational profiles are from: COSMIC database (http://cancer.sanger.ac.uk/cosmic). LOH: loss of heterozygosity; MiNEN: mixed neuroendocrine non-endocrine neoplasm; PCR: polymerase chain reaction; PDNEC: poorly differentiated neuroendocrine carcinoma; SCNEC: small cell neuroendocrine carcinoma.
Gallbladder	17p13 loh/tp53	92%	77%	PCR (LOH)	There is a substantial overlap between the mutational profiles of gallbladder SCNEC and adenocarcinomas	[4]
	9p21 LOH INK4A	50%	44%
	18q21 LOH/DPC4/DCC	31%	43%
	K-Ras	0-17%	17%
Stomach	p53	73% (common mutational status in 11/15 cases)	Microdissection and direct sequencing	MiNEN components share the cell of origin	[32]
Colon	Cyclin D1	100%	19%	Immunohistochemistry	MiNENs evolve from a single epithelial precursor after an exocrine to neuroendocrine cell-type sequence	[33]
	p53	53%	74%
	β-catenin	9%	70%
	CDKN2A/B	9.8%*	6%	Genomic profiling	PDNEC mutational profiles are more specific for their primary locations, and similar to that of adenocarcinomas of the same site	[34]
	APC	49.3%*	47%
Pancreas	CDKN2A/B	28.3%*	27%			[35]
	APC	2.5%*	3%

Table 2. Molecular Changes in Different Components of MiNENs of the Gastrointestinal Tract

MiNEN location

Molecular markers

Tumor composition

Testing modality

Comment

Reference

Adenocarcinoma

Neuroendocrine

*Mutational profiles are from: COSMIC database (http://cancer.sanger.ac.uk/cosmic). LOH: loss of heterozygosity; MiNEN: mixed neuroendocrine non-endocrine neoplasm; PCR: polymerase chain reaction; PDNEC: poorly differentiated neuroendocrine carcinoma; SCNEC: small cell neuroendocrine carcinoma.

Gallbladder

17p13 loh/tp53

92%

77%

PCR (LOH)

There is a substantial overlap between the mutational profiles of gallbladder SCNEC and adenocarcinomas

[4]

9p21 LOH INK4A

50%

44%

18q21 LOH/DPC4/DCC

31%

43%

K-Ras

0-17%

17%

Stomach

p53

73% (common mutational status in 11/15 cases)

Microdissection and direct sequencing

MiNEN components share the cell of origin

[32]

Colon

Cyclin D1

100%

19%

Immunohistochemistry

MiNENs evolve from a single epithelial precursor after an exocrine to neuroendocrine cell-type sequence

[33]

p53

53%

74%

β-catenin

70%

CDKN2A/B

9.8%*

Genomic profiling

PDNEC mutational profiles are more specific for their primary locations, and similar to that of adenocarcinomas of the same site

[34]

APC

49.3%*

47%

Pancreas

CDKN2A/B

28.3%*

27%

[35]

APC

2.5%*