Gastric neuroendocrine neoplasms type 1: A systematic review and meta-analysis

Abstract

Background: To date, the histopathological parameters predicting the risk of lymph node (LN) metastases and local recurrence, associated mortality and appropriateness of endoscopic or surgical resection in patients with gastric neuroendocrine neoplasms type 1 (GNENs1) have not been fully elucidated.

Aim: To determine the rate of LN metastases and its impact in survival in patients with GNEN1 in relation to certain clinico-pathological parameters.

Methods: The PubMed, EMBASE, Cochrane Library, Web of Science and Scopus databases were searched through January 2019. The quality of the included studies and risk of bias were assessed using the Newcastle-Ottawa Scale (NOS) in accordance with the Cochrane guidelines. A random effects model and pooled odds ratios (OR) with 95%CI were applied for the quantitative meta-analysis.

Results: We screened 2933 articles. Thirteen studies with 769 unique patients with GNEN1 were included. Overall, the rate of metastasis to locoregional LNs was 3.3% (25/769). The rate of LN metastases with a cut-off size of 10 mm was 15.3% for lesions > 10 mm (vs 0.8% for lesions < 10 mm) with a random-effects OR of 10.5 (95%CI: 1.4 -80.8; heterogeneity: P = 0.126; I ² = 47.5%). Invasion of the muscularis propria was identified as a predictor for LN metastases (OR: 17.2; 95%CI: 1.8-161.1; heterogeneity: P = 0.165; I ² = 44.5%), whereas grade was not clearly associated with LN metastases (OR: 2; 95%CI: 0.3-11.6; heterogeneity: P = 0.304; I ² = 17.4%). With regard to GNEN1 local recurrence, scarce data were available. The 5-year disease-specific survival for patients with and without LN metastases was 100% in most available studies irrespective of the type of intervention. Surgical resection was linked to a lower risk of recurrence (OR: 0.3; 95%CI: 0.1-1.1; heterogeneity: P = 0.173; I ² = 31.9%). The reported complication rates of endoscopic and surgical intervention were 0.6 and 3.8%, respectively.

Conclusion: This meta-analysis confirms that tumor size ≥ 10 mm and invasion of the muscularis propria are linked to a higher risk of LN metastases in patients with GNEN1. Overall, the metastatic propensity of GNEN1 is low with favorable 5-year disease-specific survival rates reported; hence, no clear evidence of the prognostic value of LN positivity is available. Additionally, there is a lack of evidence supporting the prediction of local recurrence in GNEN1, even if surgery was more often a definitive treatment.

Keywords: Endoscopy; Gastric neuroendocrine neoplasms type 1; Invasion; Lymph node metastasis; Meta-analysis; Surgery; Tumor size.

Figure 1

PRISMA flow diagram of the quantitative meta-analysis.

Figure 2

Forest plot comparing the rate of lymph node metastases at a 10 mm size cut-off, i.e., in tumour size ≥ 10 mm vs tumour size < 10 mm. Meta-analysis of all studies carried out using a random-effects model; Odds ratios are shown with 95%CI.

Figure 3

Forest plot comparing the rate of lymph node metastases in patients with grade 1 vs grade 2 gastric neuroendocrine neoplasms type 1. Meta-analysis of all studies carried out using a random-effects model; Odds ratios are shown with 95%CI.

Figure 4

Forest plot comparing the rate of lymph node metastases in tumours with mucosal/submucosal invasion vs tumours with invasion of the muscularis propria. Meta-analysis of all studies carried out using a random-effects model; Odds ratios are shown with 95%CI.

Figure 5

Forest plot comparing the rate of local recurrence in patients with gastric neuroendocrine neoplasms type 1 undergoing endoscopic resection vs surgical resection. Meta-analysis of all studies carried out using a random-effects model; Odds ratios are shown with 95%CI.