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  • Research article
  • Open Access
  • Open Peer Review

A modified M-stage classification based on the metastatic patterns of pancreatic neuroendocrine neoplasms: a population-based study

Contributed equally
BMC Endocrine Disorders201818:73

https://doi.org/10.1186/s12902-018-0301-z

  • Received: 18 January 2018
  • Accepted: 3 October 2018
  • Published:
Open Peer Review reports

Abstract

Background

The present study aims to improve the M-stage classification of pancreatic neuroendocrine neoplasms (pNENs).

Methods

Two thousand six hundred sixty six pNENs were extracted from the Surveillance, Epidemiology, and End Results database to explore the metastatic patterns of pNENs. Metastatic patterns were categorized as single, two, or multiple (three or more) distant organ metastasis. The mean overall survival and hazard rate of different metastatic patterns were calculated by Kaplan-Meier and Cox proportional hazards models, respectively. The discriminatory capability of the modified M-stage classification was evaluated by Harrell’s concordance index.

Results

The overall survival time significantly decreased with an increasing number of metastatic organs. In addition, pNENs with only liver metastasis had better prognosis when compared to other metastatic patterns. Thus, we modified the M-stage classification (mM-stage) as follows: mM0-stage, tumor without metastasis; mM1-stage, tumor only metastasized to liver; mM2-stage, tumor metastasized to other single distant organ (lung, bone, or brain) or two distant organs; mM3-stage, tumor metastasized to three or more distant organs. Harrell’s concordance index showed that the modified M-stage classification had superior discriminatory capability than both the American Joint Committee on Cancer (AJCC) and the European Neuroendocrine Tumor Society (ENETS) M-stage classifications.

Conclusions

The modified M-stage classification is superior to both AJCC and ENETS M-stage classifications in the prognosis of pNENs. In the future, individualized treatment and follow-up programs should be explored for patients with distinct metastatic patterns.

Keywords

  • Metastasis
  • Survival
  • Prognosis
  • Pancreas
  • Cancer

Background

Pancreatic neuroendocrine neoplasms (pNENs) are relatively rare tumors. However, a recent population study showed that the incidence of pNENs increased more than 4-fold from 1973 to 2012 [1]. Moreover, pNENs are considered the most serious neuroendocrine neoplasms (NENs), due to the patients have a shorter median overall survival times (3.6 years) when compared to those with tumors located in lung (5.5 years), rectum (24.6 years), and appendix (more than 30.0 years) [1].

Cancer staging classification systems are used to codify the extent of cancer. They allow clinicians to quantify prognosis and plan treatment for individual patients. Two widely used tumor staging classification systems, which are proposed by the American Joint Committee on Cancer (AJCC) and the European Neuroendocrine Tumor Society (ENETS), describe M0-stage as having no distant metastasis and M1-stage as having at least one distant metastasis [2, 3]. However, several studies demonstrated that pNENs with liver metastasis have better prognosis than other metastatic patterns [46].

Therefore, we utilized the Surveillance, Epidemiology, and End Result (SEER) database to explore the prognosis of different metastatic patterns of pNENs and propose a modified M-stage classification. This modified M-stage classification proves to be superior to both AJCC and ENETS M-stage classifications in prognosis.

Methods

Study cohort

As published previously [3], we utilized the topography codes (C25.0 to C25.9) and histology codes (8150, 8151, 8152, 8153, 8154, 8155, 8156, 8157, 8240, 8241, 8242, 8243, 8244, 8245, 8246, and 8249) of the International Classification of Diseases for Oncology (third edition) to identify pNENs.

Outcomes and variables

The primary outcome was overall survival. Demographic data included age, sex, and race; tumor characteristics included tumor size, primary site, differentiation, 7th AJCC T-stage, and N-stage; treatment information included surgery and radiotherapy. Single organ metastasis was defined as the tumor spreading from pancreas to another single distant organ [7]. Similarly, two organ metastases were defined as the tumor spreading from pancreas to two distant organs. Tumors spreading from pancreas to three or more distant organs were defined as multiple metastases.

Inclusion and exclusion criteria

Patients microscopically diagnosed as pNENs were included in the present study. We excluded cases with unclear or incomplete information about metastasis. In addition, we also excluded cases without information about survival time.

Statistical analyses

To compare the constituent ratio of variables among patients, we broke the continuous variables (age, tumor size) into binary variables. Survival time was plotted using the Kaplan-Meier estimator and Cox proportional hazards model. The results were presented as mean and hazard ratio, respectively, each with a 95% confidence interval (CI). Harrell’s concordance index was used to evaluate the discriminatory capability of the modified M stage classification. An index value of greater than 0.70 suggests the classification has an acceptable discriminatory capability [8]. Differences with P ≤ 0.05 divided by the number of meaningful comparisons, Bonferroni correction, were considered to be significant. Differences with P ≤ 0.1 divided by the number of meaningful comparisons, were considered to indicate a tendency. All statistical analyses were performed using SPSS 19.0 (IBM, New York, USA) or R (version 3.5.0).

Results

Patient characteristics

In total, 2666 patients (mean age 60.9 years ±13.6 years; 55.7% male, 78.8% white) were included in the present study (Fig. 1). Many patients (55.4%) underwent surgery, and some (4.7%) were treated with radiation. The constituent ratios of tumor size, location, differentiation, T-stage, and N-stage were significantly (P < 0.05) different between patients with and without metastasis (Table 1).
Fig. 1
Fig. 1

Flow chart of patient selection

Table 1

Clinicopathological Characters

 

Without Metastasis

Metastasis

P

N = 1679

N = 987

 

Age (years)

0.221b

  ≤ 60

793 (47.2%)

442 (44.8%)

 

  > 60

886 (52.8%)

545 (55.2%)

 

Sex

0.338a

 Male

924 (55.0%)

562 (56.9%)

 

 Female

755 (45.0%)

425 (43.1%)

 

Race

0.011a

 White

1314 (78.3%)

787 (79.7%)

 

 Black

191 (11.4%)

130 (13.2%)

 

 Other

174 (10.3%)

70 (7.1%)

 

Size (cm)

<  0.001b

  ≤ 2

670 (39.9%)

68 (6.9%)

 

  > 2

934 (55.6%)

699 (70.8%)

 

 Unclear

75 (4.5%)

220 (22.3%)

 

Primary Site

<  0.001b

 Head

502 (29.9%)

258 (26.2%)

 

 Body

295 (17.6%)

106 (10.7%)

 

 Tail

542 (32.3%)

314 (31.8%)

 

 Other

340 (20.2%)

309 (31.3%)

 

Differentiation

<  0.001b

 Well

1043 (62.1%)

189 (19.1%)

 

 Moderately

221 (13.2%)

86 (8.7%)

 

 Poorly

64 (3.8%)

95 (9.6%)

 

 Undifferentiated

17 (1.0%)

28 (2.8%)

 

 Unclear

334 (19.9%)

589 (59.7%)

 

T-sage

<  0.001b

 T1

602 (35.9%)

37 (3.7%)

 

 T2

538 (32.0%)

276 (28.0%)

 

 T3

389 (23.2%)

271 (27.5%)

 

 T4

67 (4.0%)

102 (10.3%)

 

 Tx

83 (4.9%)

301 (30.5%)

 

N-stage

<  0.001b

 N0

1247 (74.3%)

463 (46.9%)

 

 N1

401 (23.9%)

338 (34.3%)

 

 Nx

31 (1.8%)

186 (18.8%)

 

Surgery

<  0.001b

 Yes

1313 (78.2%)

164 (16.6%)

 

 No

339 (20.2%)

813 (82.4%)

 

 Unclear

27 (1.6%)

10 (1.0%)

 

Radiation

<  0.001b

 Yes

52 (3.1%)

74 (7.5%)

 

 No

1609 (95.8%)

905 (91.7%)

 

 Unclear

18 (1.1%)

8 (0.8%)

 

aChi-square test; bKruskal-Wallis test

Metastatic patterns and survival

At the time of diagnosis, 1679 (62.98%) patients showed no metastasis. As shown in Fig. 2a, single organ metastases comprised 850 (31.88%) patients, including 817 liver (30.64%), 22 lung (0.83%), nine bone (0.34%), and two brain (0.07%) cases. One hundred and twelve patients (4.20%) showed two-organ metastases, including 52 liver plus bone (1.95%), 53 liver plus lung (1.99%), four bone plus lung (0.15%), two liver plus brain (0.08%), and one bone plus brain (0.04%) cases. Twenty-five patients (0.94%) presented multiple organ metastases, including 19 cases of liver plus lung plus bone (0.71%), three cases of liver plus lung plus brain (0.11%), and three cases of liver plus lung plus brain plus bone (0.11%).
Fig. 2
Fig. 2

a Metastatic patterns of pNENs. b Survival time of patients different metastatic patterns. c Survival time of patients with single distant organ metastasis. d Kaplan-Meier curve of overall survival of patients with modified M-stage classification. e Survival time of patients with modified M-stage classification. * Significant difference: P < 0.008; T Tendentious difference: P < 0.017

To assess survival time of different metastatic patterns, we compared the survival time of patients without metastasis to those with single distant organ metastasis, two-organ metastases, and multiple organ metastases. As the number of metastatic organs increased, survival time was significantly (P < 0.001) reduced (Fig. 2b). In addition, patients with only liver metastasis had a longer survival time than did other single-organ metastases (Fig. 2c), whereas patients with bone, lung or two-organ metastasis had similar mean survival time (bone, 18.32 months ± 5.27 months; lung, 17.77 months ± 3.54 months, two organs metastases, 15.79 months ± 1.70 months).

Modified M-stage classification and discriminatory capability

Thus, based on the observed metastatic patterns and survival times, we modified the M-stage classification (mM-stage) as shown in Table 2. Tumor without metastasis was defined as mM0-stage. Tumor spread from pancreas only to liver was defined as mM1-stage. Tumor spreading from pancreas to other single distant organ or to two distant organs was defined as mM2-stage. Tumor spreading to three or more distant organs was defined as mM3-stage.
Table 2

Definition of M-stage classifications

AJCC and ENTES M-stage classifications

Modified M-stage classifications

M0-stage, no distant metastasis

M1-stage, distant metastasis

mM0-stage, no distant metastasis

mM1-stage, only liver metastasis

mM2-stage, other single distant organ or two organs metastases

mM3-stage, three or more organs metastases

AJCC American Joint Committee on Cancer; ENETS European Neuroendocrine Tumor Society

To evaluate survival time among mM-stage classifications, survival curves were plotted using the Kaplan-Meier estimator and then compared with the log-rank test. We observed that all survival curves were well separated (Fig. 2d). Patients with advanced mM stages (mM1, mM2, mM3) had significantly (P < 0.001) shorter survival times than patients with mM0-stage (Fig. 2e). Moreover, the modified M-stage classification was an independent prognostic factor for pNENs, after adjusting for other clinical and pathological characteristics (Table 3).
Table 3

Independent Prognostic Factors

 

Univariate

Multivariate

HR and 95% CI

P-value

HR and 95% CI

P-value

Age (years)

  ≤ 60

Reference

Reference

  > 60

1.875 (1.595–2.204)

< 0.001

1.744 (1.479–2.055)

< 0.001

Sex

 Male

Reference

Reference

 Female

0.808 (0.691–0.945)

0.008

0.850 (0.726–0.996)

0.044

Race

 White

Reference

Reference

 Black

1.345 (1.082–1.670)

0.007

1.247 (0.998–1.558)

0.052

 Other

0.715 (0.527–0.970)

0.031

0.767 (0.565–1.043)

0.090

Size (cm)

  ≤ 2

Reference

Reference

  > 2

2.889 (2.241–3.724)

< 0.001

1.322 (1.009–1.731)

0.043

 Unclear

6.799(5.110–9.047)

< 0.001

1.547(1.129–2.119)

0.007

Primary Site

a

 Head

Reference

 

 Body

0.684(0.530–0.884)

0.004

  

 Tail

0.682(0.556–0.836)

< 0.001

  

 Other

1.128(0.929–1.368)

0.223

  

Differentiation

 Well

Reference

Reference

 Moderately

1.557 (1.095–2.215)

0.014

1.049 (0.735–1.498)

0.791

 Poorly

7.414 (5.608–9.803)

< 0.001

3.349 (2.498–4.489)

< 0.001

 Undifferentiated

9.494 (6.113–14.743)

< 0.001

3.166 (2.000–5.011)

< 0.001

 Unclear

5.136 (4.179–6.311)

< 0.001

1.626 (1.290–2.048)

< 0.001

T-stage

a

 T1

Reference

 

 T2

3.434(2.474–4.766)

< 0.001

  

 T3

3.353(2.399–4.688)

< 0.001

  

 T4

7.082(4.867–10.306)

< 0.001

  

 Tx

9.288(6.696–12.882)

< 0.001

  

N-stage

 N0

Reference

Reference

 N1

1.679 (1.415–1.993)

< 0.001

1.304 (1.092–1.557)

0.003

 Nx

3.732 (3.019–4.613)

< 0.001

1.452 (1.152–1.829)

0.002

Surgery

 Yes

Reference

Reference

 No

8.556 (6.941–10.548)

< 0.001

3.901 (3.013–5.050)

< 0.001

 Unclear

1.991 (0.812–4.883)

0.133

1.487 (0.601–3.680)

0.391

Radiation

a

 Yes

Reference

 

 No

1.984(1.511–2.603)

< 0.001

  

 Unclear

0.939(0.420–2.098)

0.878

  

mM-stage

 mM0-stage

Reference

Reference

 mM1-stage

4.520 (3.789–5.393)

< 0.001

1.643 (1.339–2.016)

< 0.001

 mM2-stage

8.199(6.380–10.537)

< 0.001

2.249(1.704–2.968)

< 0.001

 mM3-stage

16.356 (10.266–26.059)

< 0.001

5.034 (3.110–8.150)

< 0.001

avariables excluded by multivariate forward stepwise cox regression

To explore discriminatory capability of the modified M-stage classification, Harrell’s concordance index was calculated. The mM-stage classification had a better discriminatory capability (Harrell’s concordance index, 0.712; 95% CI, 0.692–0.732) than AJCC M-stage and ENETS M-stage (Harrell’s concordance index, 0.697; 95% CI, 0.678–0.717).

Discussion

In agreement with previous studies [911], the present study also demonstrated that nearly one quarter of patients (37.02%, 987/2666) presenting metastasis at the time of pNEN diagnosis. In addition, liver metastasis was the majority metastatic pattern, followed by lung, bone and brain metastasis. The hematogenous mode of metastasis might contribute to the metastatic pattern, which we have observed in the present study. Unsually, carcinoma cells seed in the liver via the portal venous system. Then, these cells would spread to lung via the inferior vena cava and pulmonary arteries. Finally, the carcinoma cells from lung metastases would seed in other organs via arterial blood [12].

The present study found that with an increasing number of metastatic organs, there was a significant decrease in survival time. In addition, pNENs with liver metastasis had longer overall survival than other single-organ metastatic patterns. However, AJCC and ENETS classify both pNENs with liver metastasis and pNENs with the other metastasitic patterns as M1-stage. Our modified M-stage classification distinguishes that tumor spreading from pancreas only to liver should be separated from the other metastatic patterns, and that it is necessary to design individualized treatment and follow-up programs for patients with lung, bone, or brain metastasis.

Usually, pancreatic resection is not performed when the pancreatic malignant tumor has spread to other organs [13]. However, considering the indolent behavior of pNENs and the high frequency of liver metastasis, several clinicians suggested surgical management could give rise to benefit to pNENs with liver metastasis [4, 14]. Birnbaum et al. pancreatic resection could slow down tumor growth and reduce hormone production [14], possibly resulting in considerable benefit for patients with liver metastasis [4].

Consistent with previous studies, the tumor size, primary site, differentiation, AJCC T-stage and AJCC N-stage were identified as predictors of distant organ metastasis (Additional file 1: Table S1). Unfortunately, SEER database did not record Ki-67 status and graded the primary tumor only on the basis of morphological description (ICD-O-3) in the pathology report. Thus, we failed to evaluate the predictive role of Ki-67 status and WHO 2010 grading classification (NET G1, NET G2, NET G3 and NEC) in distant organ metastasis.

It seems the primary tumor site is a particularly useful predictor because it is available before any operation occurs. Hao et al. reported that compared to tumors located in the head and neck of the pancreas, tumors in the body and tail showed a decreased risk of liver metastasis in pancreatic adenocarcinoma [15]. In contrast, the present study showed that pNENs located in the pancreatic tail are actually 1.728 times more likely (P < 0.001) to develop metastasis, as compared to tumors located in the pancreatic head. This may be due to the fact that patients with pNENs, especially non-functioning pNENs, in the tail of the pancreas are less likely to experience obstructive signs and hormonal symptoms until tumors spread to the peritoneum, spleen, and distant organs [16, 17]. Thus, at the time of diagnosis, distant organ metastases exist in most of these patients.

Some limitations of the present study should be noted. First, the SEER database only provides information on pNEN metastasis to liver, lung, bone, and brain. The frequency of pNEN metastasis might be underestimated. Second, Hlatky et al. noted that multiple metastatic lesions may be related to a short survival time [18]. However, the SEER database did not collect data on the number of metastatic lesions in each distant organ.

Conclusions

In conclusion, this is the first population-based study to investigate the metastatic patterns and predictors in advanced pNENs. We found significant differences in survival time across different metastatic patterns. Thus, the modified M-stage classification show a better discriminatory capability than the AJCC and ENETS M-stage classifications. In the future, clinicians should determine individualized treatment and follow-up programs for pNENs with different metastatic patterns.

Notes

Abbreviations

AJCC: 

American Joint Committee on Cancer

ENETS: 

European Neuroendocrine Tumor Society

OS: 

Overall survival

pNENs: 

Pancreatic neuroendocrine neoplasms

SD: 

Standard deviation

SEER: 

Surveillance, Epidemiology, and End Result

Declarations

Acknowledgments

We thank the Surveillance, Epidemiology, and End Results (SEER) program providing the original data. We also thank Prof. Wenli Zhang and Prof. Houli Zhang gave us critical comments during the revision of the manuscript.

Funding

This work was supported by the National Natural Science Foundation of China [grant number 81473504, 81200989]; China Scholarship Council [grant number 201608080195]. The funders had no any role in the manuscript.

Availability of data and materials

The datasets generated and analyzed during the current study are available in the SEER database (https://seer.cancer.gov/).

Authors’ contributions

XZ identified the pNENs from SEER database, designed the study and wrote the manuscript; XZ, JS, MM, PL, LL, YS analyzed and interpreted the data; YW is responsible for the statistical analyses; PG and LM contributed to conception, design and funding. All authors have been involved in revising and proofreading of the manuscript. All authors listed have approved the manuscript.

Ethics approval and consent to participate

The original data of our study were provided by SEER database (research data agreement to Xianbin Zhang) and the study protocol was approved by the Ethics Committee of the First Affiliated Hospital of Dalian Medical University (approval number: YJ-KY-FB-2017-05).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
The First Affiliated Hospital of Dalian Medical University, Zhongshan 222, Dalian, 116011, China
(2)
Institute for Experimental Surgery, Rostock University Medical Center, Schillingallee 69a, 18057 Rostock, Germany
(3)
Department of Epidemiology, Dalian Medical University, Lvshun West 9, Dalian, 116044, China
(4)
Department of Evidence-based Medicine and Statistics, the First Affiliated Hospital of Dalian Medical University, Zhongshan 222, Dalian, 116011, China
(5)
Department of General Surgery, the Shenzhen University General Hospital and Shenzhen University School of Medicine, Xueyuan 1098, Shenzhen, 518055, China
(6)
Department of Epidemiology, Dalian Medical University, Zhongshan Road 222, Dalian, 116011, China

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Copyright

© The Author(s). 2018

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