P0397 - A Rare Case of Colonic MiNEN: Coexisting Large Cell Neuroendocrine Carcinoma and Mucinous Adenocarcinoma

Rishika Trivedi, MD¹, Mahmoud Barbarawi, MD¹, Prince Shah-Riar, MD², Prateek Harne, MD³, Arturo Suplee, MD⁴, Asif Zamir, MD, FACG⁵
1DHR Health, McAllen, TX; 2DHR Health, Edinburg, Tx, McAllen, TX; 3Allegheny Center for Digestive Health, Pittsburgh, PA; 4University of Arizona, Tucson, AZ; 5DHR Health Gastroenterology, Edinburg, TX

Introduction:

Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) of the colon are exceedingly rare, accounting for less than 1% of colorectal tumors. Their dual histology, often combining adenocarcinoma and neuroendocrine carcinoma, presents diagnostic and therapeutic challenges. We present a unique case of colorectal MiNEN with mucinous adenocarcinoma and large cell neuroendocrine carcinoma components.

Case Description/

Methods: A 74-year-old woman with hypertension and hyperlipidemia was referred for evaluation of iron-deficiency anemia. She denied overt gastrointestinal bleeding but reported increased fatigue. Colonoscopy revealed two adjacent lesions in the distal transverse colon: a large circumferential mass approximately 60 cm from the anal verge and a smaller polypoid lesion 5 cm proximally. Biopsy of the larger lesion showed poorly differentiated large cell neuroendocrine carcinoma with a Ki-67 index >90%, prompting urgent oncologic referral. She underwent laparoscopic extended right hemicolectomy with intraoperative tattoo localization. Gross examination revealed a 6.3 × 4.5 cm tumor infiltrating through the colonic wall (Figure 1). Final pathology demonstrated a rare mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN), composed of well-differentiated mucinous adenocarcinoma and high-grade large cell neuroendocrine carcinoma. One of twelve lymph nodes was positive for metastatic mucinous carcinoma. Margins were negative; no lymphovascular or perineural invasion was noted. The tumor was staged as pT3N1a. Immunohistochemistry showed loss of MLH1 and PMS2 with intact MSH2/MSH6, confirming Mismatch Repair Deficiency (dMMR). Focal chromogranin and synaptophysin expression supported neuroendocrine differentiation.  She completed 12 cycles of adjuvant FOLFOX. Follow-up PET/CT scans at 6 and 12 months showed no recurrence.

Discussion: This case highlights the exceptional rarity of colorectal MiNEN with both mucinous adenocarcinoma and large cell neuroendocrine carcinoma components. The coexistence of dual aggressive histologies presents a unique therapeutic challenge and complicates standard management and surveillance algorithms. As long-term outcomes remain unclear, this case reinforces the importance of close multidisciplinary follow-up and contributes to the limited literature on these complex malignancies.


Figure: Figure 1: Representative colonoscopic images from index evaluation.
(a) A 2 cm flat polyp in the cecum, resected via hot snare polypectomy after submucosal lift.
(b) A large, circumferential, infiltrative lesion in the distal transverse colon approximately 60 cm from the anal verge; biopsy was taken, and the distal margin was tattooed with India ink.
(c) A second polypoid lesion located at 55 cm from the anal verge, adjacent to the primary mass; distal margin also tattooed.
(d) Repeat view of the cecal polyp post-lift and tattoo.

Disclosures:
Rishika Trivedi indicated no relevant financial relationships.
Mahmoud Barbarawi indicated no relevant financial relationships.
Prince Shah-Riar indicated no relevant financial relationships.
Prateek Harne indicated no relevant financial relationships.
Arturo Suplee indicated no relevant financial relationships.
Asif Zamir indicated no relevant financial relationships.

Rishika Trivedi, MD¹, Mahmoud Barbarawi, MD¹, Prince Shah-Riar, MD², Prateek Harne, MD³, Arturo Suplee, MD⁴, Asif Zamir, MD, FACG⁵. P0397 - A Rare Case of Colonic MiNEN: Coexisting Large Cell Neuroendocrine Carcinoma and Mucinous Adenocarcinoma, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.