Supplementary Material for: A Comparative Study On The Progression Of Neuroendocrine Carcinomas and Mixed Neuroendocrine-Non-Neuroendocrine Neoplasms

Introduction:The prognostic differences between neuroendocrine carcinoma (NEC) and mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) remain unclear. Methods:This study aims to compare the prognostic outcomes of NEC and MiNEN by analyzing the clinicopathological features of these diseases and exploring factors affecting progression after radical surgery. Additionally, we employed whole-exome sequencing to investigate the molecular mechanisms influencing the prognosis of both conditions. Results: Among the 252 patients followed, 163 underwent surgical treatment. The median time to tumor progression was 16 months (range: 9 to 56 months). Tumor pathology type (P=0.007), lymph node metastasis (P<0.0001), and distant metastasis (P<0.0001) were identified as independent factors affecting disease progression in NEC and MiNEN patients. MiNEN patients without lymph node or distant metastasis generally had a better prognosis. First-line chemotherapy regimens did not show a significant impact on disease progression (P=0.160, mPFS: 36 vs 13 vs 23 vs 15 months). However, the EP (etoposide plus cisplatin) regimen has shown good efficacy in gastric NENs (neuroendocrine neoplasms) (P=0.048, mPFS: 45 vs 12 vs 32 vs 16 months), especially in gastric MiNENs (P=0.022, mPFS: Undefined vs 11 vs 52 vs 37 months). Further investigation into the genetic mutation differences between NECs and MiNENs revealed that among previously sequenced data, rectal NECs commonly exhibited mutations in MUC16, SPTA1, ATM, PDGFB, NF1, FAT4, AR, APC, ANTXR2, and ADGRA2. In contrast, rectal MiNENs showed common mutations in NOTCH2, ZNRF3, CARD11, TP53, OBSCN, FPR1, APC, ANGPT2, ARID1A, and AR. Mutations in ANGPT2 and OBSCN were present in two rectal MiNEN cases, while NF1 and PDGFB mutations were found in two rectal NEC cases but not in MiNENs. The JAK-STAT signaling pathway appears to be specific to rectal NECs and may be involved in tumor progression. Conclusion: EP regimen remains the most effective chemotherapy option for neuroendocrine tumor patients. There were prognostic differences between NECs and MiNENs, as well as differences in genetic mutations and signaling pathways. This study provided new insights into the prognosis assessment and treatment strategies for NENs, particularly highlighting the importance of personalized treatments and the development of novel targeted therapies.引言：神经内分泌癌（Neuroendocrine carcinoma, NEC）与混合性神经内分泌-非神经内分泌肿瘤（Mixed neuroendocrine-non-neuroendocrine neoplasm, MiNEN）的预后差异目前尚未明确。方法：本研究旨在通过分析两类疾病的临床病理特征，并探讨根治性手术后影响疾病进展的相关因素，对比神经内分泌癌与混合性神经内分泌-非神经内分泌肿瘤的预后结局。此外，本研究采用全外显子测序技术，探究影响两类疾病预后的分子机制。结果：本研究纳入252例随访患者，其中163例接受手术治疗。肿瘤进展中位时间为16个月（范围：9~56个月）。肿瘤病理类型（P=0.007）、淋巴结转移（P<0.0001）及远处转移（P<0.0001）被确定为影响神经内分泌癌与混合性神经内分泌-非神经内分泌肿瘤患者疾病进展的独立危险因素。无淋巴结转移及远处转移的混合性神经内分泌-非神经内分泌肿瘤患者通常预后更佳。一线化疗方案对疾病进展无显著影响（P=0.160，中位无进展生存期[median progression-free survival, mPFS]：36 vs 13 vs 23 vs 15个月）。然而，EP方案（依托泊苷联合顺铂）在胃神经内分泌肿瘤（Neuroendocrine neoplasms, NENs）中显示出良好疗效（P=0.048，mPFS：45 vs 12 vs 32 vs 16个月），尤其在胃混合性神经内分泌-非神经内分泌肿瘤患者中效果更显著（P=0.022，mPFS：未明确 vs 11 vs 52 vs 37个月）。针对神经内分泌癌与混合性神经内分泌-非神经内分泌肿瘤的基因突变差异的进一步分析显示，在已测序数据中，直肠神经内分泌癌常见MUC16、SPTA1、ATM、PDGFB、NF1、FAT4、AR、APC、ANTXR2及ADGRA2基因突变。与之相比，直肠混合性神经内分泌-非神经内分泌肿瘤常见NOTCH2、ZNRF3、CARD11、TP53、OBSCN、FPR1、APC、ANGPT2、ARID1A及AR基因突变。ANGPT2与OBSCN基因突变在2例直肠混合性神经内分泌-非神经内分泌肿瘤病例中检出，而NF1与PDGFB基因突变在2例直肠神经内分泌癌病例中检出，但未在混合性神经内分泌-非神经内分泌肿瘤病例中发现。JAK-STAT信号通路似乎为直肠神经内分泌癌所特有，可能参与肿瘤进展过程。结论：EP方案仍是神经内分泌肿瘤患者最为有效的化疗选择。神经内分泌癌与混合性神经内分泌-非神经内分泌肿瘤存在预后差异，同时二者的基因突变特征及信号通路亦存在不同。本研究为神经内分泌肿瘤的预后评估与治疗策略提供了新的思路，尤其强调了个体化治疗及新型靶向治疗药物研发的重要性。