Neuroendocrine Tumors of the Colon and Rectum: Prognostic Relevance and Comparative Performance of Current Staging Systems

Background

With increasing interest in neuroendocrine tumors (NETs), three staging systems for NETs of the colon and rectum have been published. Their prognostic relevance has not been examined and compared in an independent clinical database.

Methods

From the National Cancer Database (NCDB), 5457 patients diagnosed with colorectal neuroendocrine tumor (CRNETs) between 1998 and 2002 were staged according to the staging systems from (1) European Neuroendocrine Tumor Society (ENETS, 2006; n = 1537); (2) American Joint Committee on Cancer (AJCC, 2009; n = 1140); and (3) location-specific staging systems from the Surveillance Epidemiology and End Results (SEER, 2008; n = 942). Stage-stratified overall survival (OS) and Cox-specific concordance indices were calculated for each system. Independent prognostic factors were identified by multivariate analysis.

Results

Five-year OS for stage I, II, III, and IV CRNETs as defined by the ENETS staging system were 90.8, 77.3, 53.1, and 14.8 %, respectively. For well-differentiated CRNETs, the 5-year OS for stage I, II, III, and IV as defined by the AJCC staging system were superior: 90.6, 83.9, 64.8, and 24.9 %, respectively. Both staging systems had a concordance index of 0.72. After specifying location in the colon versus rectum, all three systems demonstrated acceptable performance. Histologic grade was a significant independent predictor of OS not currently incorporated in the staging systems.

Conclusions

The three staging systems showed comparable prognostic stratification of CRNETs, while the AJCC and ENETS systems are the most parsimonious. The current analysis supports the use of the AJCC for well-differentiated disease and ENETS systems for all CRNETs until there is further evidence for modification.     

PLACENTAL CALCIUM PUMP: CLINICAL-BASED EVIDENCE

Placenta can be considered as a pump of calcium necessary for the normal development of the fetus. We believe that the location of this pump is in the placental basement membrane. The calcification of this membrane has been described only in cases of in utero fetal death. In this study we describe for the first time a case of placental calcification in a living fetus. The fetus of a normal 21-year-old pregnant woman showed heart abnormalities but the genetic analysis showed a normal male karyotype. The histology of the placenta demonstrated multiple intravillous linear and granular calcific incrustations The hemtoxylin/eosin stain of the sections revealed basement membrane calcific incrustations and intravillous calcium deposits. We postulate that the fetal circulation in the villi was impaired and the calcium that reached the villi from the mother was deposited at this level.     

Infusing Diversity and Equity Into Clinical Teaching: Training the Trainers

Clinical instructors in health care disciplines are charged with engaging students in experiential learning wherein respect and cultural sensitivity is applied. This article reports on the results of 3 diversity workshops conducted for clinical preceptors and field instructors from various disciplines. The workshops were developed in response to students’ growing concerns that their academic learning experiences were negatively affected by dissatisfying management of differences between students, faculty, and preceptors with respect to ethno‐racial group membership, socioeconomic level, and degree of privilege and power. The workshops included a didactic session that presented basic principles of social and health equity followed by small‐group reflection about various ethical and moral dilemmas that were presented in clinical education scenarios. Examples of discrimination on a variety of levels were addressed in these workshops, including race, ethnicity, immigration status, sexual orientation, religion, body size and appearance, ability, age, socioeconomic class, religious faith, and gender. The group exercises and discussion from these sessions provided valuable insight and approaches to difficult but common areas of discomfiture encountered in the clinical teaching setting. This article presents the findings from participants of these diversity workshops in order to encourage the application of equity principles into clinical teaching in midwifery and other health care education contexts.