Practical hints for the diagnosis of mixed neuroendocrine-non-neuroendocrine neoplasms of the digestive system

In this editorial, a comment on the article by Díaz-López et al published in the recent issue of the 2024 is provided. We focus on the practical implications critical for providing a correct and complete diagnosis of mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) in the gastrointestinal system. The diagnosis of MiNEN begins with the recognition of neuroendocrine features in one component of a biphasic tumor. The non-neuroendocrine counterpart can be virtually represented by any neoplastic type, even though the most frequent histologies are glandular and squamous. However, qualification of the neuroendocrine component requires histological and immunohistochemical confirmation. Neuroendocrine tumors are characterized by a peculiar architectural organization and bland nuclei with granular "salt and pepper" chromatin. Although neuroendocrine carcinomas have multiple and variable presentations, they typically show a solid or organoid architecture. The histological aspect needs to be confirmed by immunohistochemistry, and a diagnosis is confirmed whenever the expression of keratin and neuroendocrine markers is observed. Once both histopathological and immunohistochemical features of neuroendocrine neoplasms are identified, it is important to consider the three major pitfalls of MiNEN diagnostics: (1) Entrapment of neuroendocrine non-neoplastic cells within the tumor mass; (2) Differential diagnosis with amphicrine neoplasms; and (3) Differential diagnosis of tumors that partially express neuroendocrine markers. According to the current guidelines for diagnosing digestive MiNEN, each component must represent at least 30% of the entire neoplastic mass. Although the high-grade histopathological subtype frequently determines disease prognosis, both components can significantly affect prognosis. Thus, if one of the components, either neuroendocrine or non-neuroendocrine, does not fulfill the volumetric criteria, the guidelines still encourage reporting it. These strict criteria are essential for correctly recognizing and characterizing digestive MiNENs. This task is essential because it has prognostic relevance and substantial potential value for guiding further studies in this field. In the future, systematic analyses should be performed to validate or reconsider the current 30% cutoff value.