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Nora Sahnane Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Daniela Furlan Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Matilde Monti Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Chiara Romualdi Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Alessandro Vanoli Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Emanuela Vicari Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Enrico Solcia Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Carlo Capella Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Fausto Sessa Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Stefano La Rosa Section of Anatomic Pathology, CRIBI Biotechnology Center, Department of Molecular Medicine, Department of Pathology, Department of Surgical and Morphological Sciences, University of Insubria, Via O. Rossi, 9, 21100 Varese, Italy

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Gastroenteropancreatic (GEP) neuroendocrine carcinomas (NECs) and mixed adenoneuroendocrine carcinomas (MANECs) are heterogeneous neoplasms characterized by poor outcome. Microsatellite instability (MSI) has recently been found in colorectal NECs showing a better prognosis than expected. However, the frequency of MSI in a large series of GEP-NEC/MANECs is still unknown. In this work, we investigated the incidence of MSI in GEP-NEC/MANECs and characterized their clinicopathologic and molecular features. MSI analysis and immunohistochemistry for mismatch repair proteins (MLH1, MSH2, MSH6 and PMS2) were performed in 89 GEP-NEC/MANECs (six esophageal, 77 gastrointestinal, three pancreatic, and three of the gallbladder). Methylation of 34 genes was studied by methylation-specific multiplex ligation probe amplification. Mutation analysis of BRAF and KRAS was assessed by PCR-pyrosequencing analysis. MSI was observed in 11 NEC/MANECs (12.4%): seven intestinal and four gastric. All but two MSI-cases showed MLH1 methylation and loss of MLH1 protein. The remaining two MSI-cancers showed lack of MSH2 or PMS2 immunohistochemical expression. MSI-NEC/MANECs showed higher methylation levels than microsatellite stable NEC/MANECs (40.6% vs 20.2% methylated genes respectively, P<0.001). BRAF mutation was detected in six out of 88 cases (7%) and KRAS mutation was identified in 15 cases (17%). BRAF mutation was associated with MSI (P<0.0008), while KRAS status did not correlate with any clinicopathologic or molecular feature. Vascular invasion (P=0.0003) and MSI (P=0.0084) were identified as the only independent prognostic factors in multivariate analysis. We conclude that MSI identifies a subset of gastric and intestinal NEC/MANECs with distinct biology and better prognosis. MSI-NEC/MANECs resemble MSI-gastrointestinal adenocarcinomas for frequency, molecular profile and pathogenetic mechanisms.

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