Small cell carcinoma of the cervix. A clinicopathologic study of 26 patients

Small cell carcinoma of the cervix: treatment and survival outcomes of 188 patients

OBJECTIVE

To determine the clinicopathologic factors associated with survival in neuroendocrine small cell cervical cancer patients.

STUDY DESIGN

Patients were identified from a review of literature with an additional 52 patients from four hospitals. Kaplan-Meier and Cox regression methods were used for analyses.

RESULTS

Of 188 patients, 135 had stages I-IIA, 45 stages IIB-IVA, and 8 stage IVB disease. A total of 55.3% underwent surgery, 16.0% had chemoradiation, 12.8% radiation, and 3.2% chemotherapy alone. The 5-year disease-specific survival in stage I-IIA, IIB-IVA, and IVB disease was 36.8%, 9.8%, and 0%, respectively (P < .001). Adjuvant chemotherapy or chemoradiation was associated with improved survival in patients with stages IIB-IVA disease compared with those who did not receive chemotherapy (17.8% vs 6.0%; P = .04). On multivariable analysis, early-stage disease and use of chemotherapy or chemoradiation were independent prognostic factors for improved survival.

CONCLUSION

Use of adjuvant chemotherapy or chemoradiation was associated with higher survival in small cell cervical cancer patients.

Neuroendocrine small cell carcinoma of the uterine cervix

Neuroendocrine small cell carcinoma of the uterine cervix (SCC) is a rare disease that mixes clinical and biological characteristics of both cervical neoplasms and neuroendocrine small cell cancer. The prognosis is poor and the optimal treatment has not yet been clarified. Multimodality treatment, with surgery and concurrent chemoradiation has recently been shown to improve local control and survival rates.

Small cell neuroendocrine carcinoma of the cervix: Analysis of outcome, recurrence pattern and the impact of platinum-based combination chemotherapy

OBJECTIVES

To analyze progression-free (PFS) and overall survival (OS) in patients with small cell neuroendocrine carcinoma of the cervix (SCNEC), and to determine whether platinum-based combination chemotherapy is beneficial for this population.

METHODS

We performed a retrospective analysis of all patients with SCNEC who were treated at our institution between 1/1990 and 2/2007. Patients were excluded if pathologic diagnosis was not confirmed at our institution. Standard statistical methods were utilized.

RESULTS

Seventeen patients met inclusion criteria. The estimated 3-year PFS and OS rates for the entire group were 22% and 30%, respectively. Median time to progression was 9.1 months. Extent of disease was the only significant prognostic factor. Median OS for patients with early stage disease (IA1-IB2) was 31.2 months and 6.4 months for patients with advanced stage disease (IIB-IV, P=0.034). In the early-stage disease group, the 3-year distant recurrence-free survival rate was 83% for patients who received chemotherapy and 0% for patients who did not receive chemotherapy as part of their initial treatment (P=0.025). The estimated 3-year OS rate was 83% for patients who received and 20% for patients who did not receive chemotherapy as part of their initial treatment (P=0.36).

CONCLUSION

Given the rarity of SCNEC this retrospective analysis is limited by a small number of patients. However, the natural history of this rare disease is akin to small cell lung cancer and the prognosis is poor due to the tumor's propensity for distant spread. The treatment should conform to the treatment of small cell lung cancer.

A case of uterine cervical adenocarcinoma associated with small cell carcinoma

Extrapulmonary small cell carcinomas are often associated with carcinomas of other cell types. Although a hypothesis that extrapulmonary small cell carcinomas arise from a multipotential stem cell could explain this mixed feature, recent molecular evidence supports another possibility that the small cell component may arise as a late-stage phenomenon in the progression of more organ-typical carcinomas. Here, we report a case of uterine cervical adenocarcinoma containing 30% of small cell carcinoma. Adenocarcinoma was located in the endometrial side of the tumor that was adjacent to the normal cervical region, while small cell carcinoma was located in the periphery of the tumor. The transition from adenocarcinoma to small cell carcinoma was observed in the boundary area. These findings suggest that cervical small cell carcinoma can be differentiated from pre-existing adenocarcinoma and offer further support to the hypothesis that the small cell component arises as a late-stage phenomenon in the progression of more organ-typical carcinomas.

Small cell carcinomas and large cell neuroendocrine carcinomas of the endometrium and cervix: polypoid tumors and those arising in polyps may have a favorable prognosis

We report 5 polypoid high-grade neuroendocrine carcinomas of the uterus, 2 small cell carcinomas of the endometrium, and 3 large cell neuroendocrine carcinomas, 2 from the cervix and 1 from the endometrium. The 2 small cell carcinomas of the endometrium arose from and were confined to endometrial polyps, one of which also showed foci of endometrioid adenocarcinoma. The myometrium was free of tumor, despite extensive sampling. The 3 large cell neuroendocrine carcinomas, 2 from the cervix and 1 from the endometrium, were polypoid but did not originate in polyps. Two of these tumors infiltrated myometrium, and one did not. The age of the 5 patients ranged from 25 to 66 years (mean age, 43 years). Four patients presented with vaginal bleeding. One pregnant woman had the largest polypoid tumor discovered during a routine gynecologic examination. Tumor sizes ranged from 2.7 to 10 cm. All 5 patients were treated by radical hysterectomy and 4 received adjuvant chemotherapy. Only 2 patient had pelvic lymph node metastasis. All patients are alive and disease-free from 9 months to 7 years after treatment (mean survival, 47 months). All 5 tumors labeled with chromogranin and synaptophysin and 4 with CD56. Two small cell carcinomas and 2 large cell neuroendocrine carcinomas accumulated p53 protein. Two small cell carcinomas and 2 large cell neuroendocrine carcinomas expressed p16. Our findings suggest that stage of disease and a polypoid gross feature are the best predictors for outcome in small cell carcinomas and large cell neuroendocrine carcinomas of the uterus.

Incidence, mortality, and prognostic factors of small cell carcinoma of the cervix

OBJECTIVE

To compare the incidence, mortality, and presentation of small cell carcinoma of the cervix with other histologies.

METHODS

From 1977 to 2003, 290 women with small cell carcinoma of the cervix uteri were identified from the Surveillance, Epidemiology, and End Results database. Also, 27,527 patients with squamous cell carcinoma of the cervix and 5,231 patients with adenocarcinoma of the cervix were identified for comparison. The annual incidence was calculated and examined for trend. Patient and disease characteristics were compared among histologies. Univariable analyses were conducted using the log-rank test. Multivariable analysis was performed using Cox regression.

RESULTS

The mean annual incidence for small cell carcinoma was 0.06 per 100,000 women, compared with 6.6 and 1.2 for squamous cell carcinoma and adenocarcinoma, respectively. There were significant differences at presentation between small cell carcinoma compared with squamous cell carcinoma and adenocarcinoma for race, treatment, International Federation of Gynecology and Obstetrics stage, and lymph node involvement (P<.05). A trend for improved survival was identified for adenocarcinoma (P=.036) and squamous cell carcinoma (P<.001) but not for small cell carcinoma (P=.672). Five-year survival for small cell carcinoma (35.7%) was worse compared with squamous cell carcinoma (60.5%, hazard ratio 0.55; 95% confidence interval (CI) 0.43-0.69) and adenocarcinoma (69.7%, hazard ratio 0.48; 95% CI 0.37-0.61). On multivariable analysis, age, stage, and race were prognostic for survival in women with small cell carcinoma (P<.05).

CONCLUSION

Small cell carcinoma is a rare histology of cervical cancer associated with a worse prognosis and a predilection for nodal and distant metastasis. The decrease in survival was marked in early-stage and node-negative patients. Because of the high rates of nodal involvement even with early-stage disease, multimodality treatment with radiotherapy and chemotherapy should be considered.

LEVEL OF EVIDENCE

II.

Small cell cervical cancer: an unusual finding at cholecystectomy

BACKGROUND

Small cell carcinoma of the cervix is a rare cancer, comprising less than 3% of all cervical neoplasms. It uniformly has a poor prognosis, and has a high mortality even with early stage disease. It can metastasise rapidly and metastatic sites include lung, liver, brain, bone, pancreas and lymph nodes.

CASE

Here, we report the case of a 60-year-old woman with no symptoms of cervical pathology who developed post-renal failure following a laparoscopic cholecystectomy. The cause was bilateral ureteric obstruction from metastatic small cell cervical cancer and metastases were subsequently found on her gallbladder specimen.

CONCLUSION

This is an unusual presentation of small cell cervical cancer and demonstrates the aggressive nature of this disease.

Combined large cell neuroendocrine and endometrioid carcinoma of the endometrium

We present the surgical and pathological findings and follow-up of 5 women diagnosed with combined endometrioid and high-grade neuroendocrine carcinoma of large cell type (LCNEC) arising in the endometrium. The mean age of the women was 75 years (range, 50-88 years). Of the 5 tumors, 4 formed polypoid endometrial masses associated with extensive lymphovascular involvement of the myometrium by neoplastic cells. A single endometrial tumor was formed by LCNEC alone, and 4 tumors were composite with varying proportions formed by endometrioid (4/5) and small cell neuroendocrine carcinoma (1/5). In all 5 LCNEC tumor components, an insular growth pattern was noted, whereas a diffuse (solid) pattern was found in 4 tumors, a trabecular in 2, and rosettes/pseudorosettes in another 2. In all 5 tumors, the LCNEC tumor components were labeled with neuron-specific enolase (NSE). Four tumors were reactive for chromogranin A, CAM 5.2, and p53. Three tumors were labeled for AE1/AE3, CD56 (NCAM), p16, and cytokeratin 7. Synaptophysin was reactive in 2 tumors, and CD117 was found in only a single tumor. Of the 3 endometrioid tumor components examined, all were reactive for NSE. Two tumors were reactive for p16 and p53, 1 for CD56, but none for synaptophysin orchromogranin A. We conclude that LCNEC of the endometrium is a distinct clinicopathological entity with a poor prognosis irrespective of stage. The gross and histomorphological features are often suggestive, but confirmation requires immunoperoxidases, including NSE, synaptophysin, chromogranin A, p16, and p53. Combined endometrioid and high-grade LCNEC possess more characteristics of a type II than a type I endometrial carcinoma.

Small cell carcinoma of the cervix: a case report

Small cell carcinoma of the uterine cervix accounts for 1-3% of all cervix cancers. It is an aggressive disease with a poor prognosis. To date, no effective treatment protocol has been determined. Surgery, radiotherapy, and chemotherapy have been used either alone or in combination. Recent data suggests that survival in patients with early staged small cell carcinoma of the cervix is better with surgery combined with chemo-radiotherapy. Here, we presented two patients with stage IB1 small cell carcinoma of the uterine cervix. For both patients, definitive surgery was performed with pelvic and para-aortic lymphadenectomy. Subsequently, they were treated with pelvic external radiotherapy and high-dose-rate intracavitary brachytherapy with concurrent cisplatin based chemotherapy. They were alive with no evidence of disease at 91 and 65 months, respectively.

The pathology of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinomas (EPSCCs) are uncommon malignant neoplasms with a reported incidence of 0.1% to 0.4% in the United States. Since their first description in 1930, they have been seen in nearly every organ system. Like their more common pulmonary counterparts, EPSCCs are thought to arise from a multipotential stem cell. However, there is recent molecular evidence that small cell elements may arise as a late-stage phenomenon in the genetic progression of more organ-typical carcinomas. The morphologic, immunohistochemical, and ultrastructural features are similar to those described in pulmonary small cell carcinomas (PSCCs). The differential diagnosis of EPSCC includes PSCC, other neuroendocrine tumors, small round blue cell tumors, metastatic melanoma, lymphoma, and poorly differentiated non-small cell carcinomas. Molecular alterations reported to occur in EPSCCs include abnormalities described in PSCC and changes found in carcinomas more typically encountered in the organ from which they arise. In this article we discuss the pathology of EPSCC with a review of theories of histogenesis, sites of occurrence, diagnostic features, differential diagnosis, molecular alterations, and clinical behavior.

Mixed small cell carcinomas of the uterine cervix: prognostic impact of focal neuroendocrine differentiation but not of Ki-67 labeling index

Small cell neuroendocrine carcinomas sometimes represent a non-small cell component. Because of infection with the high-risk human papillomavirus of small cell carcinomas (SmCCs), several host cell regulatory proteins are altered, thus causing altered proliferative activity. Knowledge regarding the prognostic impact of focal neuroendocrine differentiation in mixed SmCCs and the value of proliferative activity in these tumors is very limited. Small cell carcinomas were selected for immunohistochemical staining with neuroendocrine markers and Ki-67. In cases with mixed tumors, the percentage of the SmCC component was calculated and correlated with survival. Of 677 tumors, 9 (1.3%) were classified as SmCCs after Grimelius staining (8/9 positive tumors) and immunohistochemical reaction against neuron-specific enolase, chromogranin A, synaptophysin (7/9 positive tumors), and CD56 (8/9 positive tumors); all specimens were positive for at least 2 of these. CD99 staining was completely negative. Two thirds of the SmCCs showed non-small cell differentiation. Four patients died of the tumor after a median time of 36.7 months (range, 15-56 months). Even an SmCC component of 17% was associated with a fatal course. Small cell carcinoma represented a significantly lower proliferation (Ki-67 labeling index) than did the non-small cell component in the same tumor (12.8% vs 70.8%; P < .001). Even a small SmCC component in mixed carcinomas of the uterine cervix was associated with adverse outcome. Proliferative activity, determined by Ki-67 labeling index, is of no prognostic value.

p16, p14, p53, and Cyclin D1 Expression and HPV Analysis in Small Cell Carcinomas of the Uterine Cervix

Small cell carcinomas (SmCCs) of the uterine cervix are rare tumors. The knowledge regarding protein expression of several checkpoint candidates of cell cycle regulation is limited. Surgically treated SmCCs were selected from our files for immunohistochemical staining (neuroendocrine markers, p53, p16, p14, and cyclin D1). Polymerase chain reaction analysis, using general primers, was performed for human papillomavirus analysis. Nine of 677 tumors (1.3%) were classified as SmCCs after Grimelius staining (8/9 tumors positive) and immunohistochemical reaction against neurone-specific enolase, chromogranin A, synaptophysin (7/9 positive tumors), and CD 56 (8/9 positive tumors). All specimens were positive for at least two of the above. Two SmCCs were p53 positive and one case was p14 positive. Cyclin D1 staining was completely negative. All cases showed strong nuclear and/or cytoplasmic p16-immunostaining. Seven tumors represented human papillomavirus positivity for high-risk types. Four patients died of the tumor after a median time of 36.7 months (range, 15-56 months), representing a 5-year survival rate of 56%. The results suggest that p16 is up-regulated or accumulated in the SmCCs of the uterine cervix, probably caused by infection with human papillomavirus. p14 inactivation is of high prevalence in SmCCs and detection rate of p53 is similar to other histologic types of cervical carcinomas.

Neuroendocrine features in poorly differentiated endometrioid adenocarcinomas of the endometrium

This study aimed to clarify neuroendocrine features (NEF) in poorly differentiated (G3) endometrioid adenocarcinoma of the endometrium and to evaluate its prognostic significance. Forty cases with G3 carcinoma were investigated for NEF immunohistochemically. The histopathologic specimens were immunostained with chromogranin A, synaptophysin, and leu-7, using the labeled streptavidin-biotin method. The staining pattern was classified into diffuse, partial, or focal. The NEF was compared with clinicopathologic variables, including patients' survival. Chromogranin A was positive diffusely in 1 patient (2.5%), partially in 8 (20%), and focally in 13 (32.5%). Synaptophysin was positive diffusely in one (2.5%), partially in three (7.5%), and focally in nine (22.5%). Leu-7 was focally positive in 10 (25%) patients. The overall positive rate of the three neuroendocrine markers was 62.5%. A patient with diffusely positive staining for both chromogranin A and synaptophysin was diagnosed with neuroendocrine carcinoma. One or more neuroendocrine markers were positive in 25 cases (62.5%). Positive NEF was correlated with clinicopathologic parameters such as stage and myometrial invasion. The survival of the patients with positive NEF, especially with positive leu-7, was significantly lower than that without NEF. NEF was detected immunohistochemically in approximately 63% of the G3 carcinomas, and these patients had a poor prognosis.

Large-cell neuroendocrine carcinoma of the cervix associated with cervical-type invasive adenocarcinoma: a report of case and discussion of histogenesis

A case of cervical large-cell neuroendocrine carcinoma with mucinous-type cervical adenocarcinoma component adjacent to it is presented, and its histopathogenesis and clinical course are discussed under the light of the literature.

Expression of HER-2/neu, epidermal growth factor receptor, vascular endothelial growth factor, cyclooxygenase-2, estrogen receptor, and progesterone receptor in small cell and large cell neuroendocrine carcinoma of the uterine cervix: a clinicopathologic and prognostic study

We studied the immunohistochemical expression of HER-2/neu, epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), cyclooxygenase-2 (COX-2), estrogen receptor (ER), and progesterone receptor (PR) in uterine cervical small cell and large cell neuroendocrine carcinomas (SCNECs and LCNECs) from 24 patients seen at The University of Texas M.D. Anderson Cancer Center. The objectives were to determine their expression and prognostic role in survival. Twenty-three cases (95.8%) expressed VEGF. The tumors expressing EGFR, HER-2/neu, and COX-2 were modest in numbers: eight (33.3%), 10 (41.7%), and seven (29.2%), respectively. Only one tumor (4.2%) expressed ER, and only two tumors (8.3%) expressed PR. No significant differences in the expression of these factors were found between SCNECs and LCNECs or between stage I and stage II-III tumors. The median overall survival was 21.1 months (95% confidence interval [CI], 17.2-25.0 months). Only HER-2/neu expression was significantly associated with survival. Patients with negative HER-2/neu expression tumors had significantly shorter survival than those whose tumors were positive, 14.2 months (95% CI, 10.6-17.7 months) versus 33.1 months (95% CI, 0-76.92 months) (P = 0.03). There was a trend toward worse survival in patients with EGFR expression, but this finding was not significant. The combination of negative HER-2/neu expression and positive EGFR expression had the worst impact on survival.

Neuroendokrine Karzinome der Cervix uteri

Neuroendocrine carcinomas of the cervix are rare. They cover a wide age range occurring in young adult women and very old women. Two types are distinguished: small cell carcinoma (oat cell) and large cell neuroendocrine carcinoma. They either occur in pure form or in combination with adenocarcinoma or squamous cell carcinoma. By immunohistochemistry, the expression of at least one neuroendocrine marker (chromogranin, synaptophysin, NSE) is a constant finding. PRb protein can not be detected, whereas the expression of p53 varies. Typically, there is an association with a high risk HPV infection. HPV 18 is found more often than HPV 16. The prognosis is still poor with early metastases to regional lymph nodes and distant sites such as lung, liver, bone, and brain.

Small-cell carcinoma of the uterine cervix: a clinicopathologic study of 11 cases

We report the clinical profiles and immunohistochemical features of small-cell carcinoma of the uterine cervix. Eleven cases that we have encountered at the Department of Gynecology, Kitasato University Hospital, between 1971 and 2003 are presented. Of 1370 invasive carcinomas of the uterine cervix, the incidence of small-cell carcinoma was 0.8%. Patient ages ranged between 32 and 65 years, with a mean age of 46.3 years. The clinical stages at diagnosis were Ib in four patients, IIb in three, IIIb in three, and IVb in one. All patients presented with abnormal vaginal bleeding. Two patients who are alive with no evidence of disease for 12 years and 3 years 6 months, while eight patients died of primary carcinoma between 4 and 25 months after treatment. Histopathologic findings showed solid nests with marked peripheral palisading pattern and rosette formation. Small tumor cells with scant cytoplasm demonstrated a very high nuclear/cytoplasm ratio and indistinct cell borders. The nuclei were round to oval and demonstrated increased but fine granular chromatin. Nucleoli were indistinct in all cases. Immunohistochemical findings were positive in 81.8% each for neuron-specific enolase and protein gene product 9.5, 72.7% for synaptophysin, 63.6% for chromogranin A, and 54.5% for neural cell adhesion molecule. All specimens were positive for at least one of the above. In conclusion, small-cell carcinoma of the uterine cervix revealed poor prognosis. Making an accurate diagnosis of small-cell carcinoma before performing treatment is of great significance but often difficult. Immunohistochemical analysis using several kinds of neuroendocrine markers is helpful in establishing the correct diagnosis in addition to focusing on characteristic histo- and cytopathologic features.

Small Cell Neuroendocrine Carcinomas of the Uterine Cervix: A Histological, Immunohistochemical, and Molecular Genetic Study

Small cell carcinomas of the uterine cervix are rare tumors with an aggressive behavior. Although these tumors can exhibit neuroendocrine differentiation, the criteria for neuroendocrine differentiation are subjective and not well defined. In this study, the authors tentatively defined small cell neuroendocrine carcinoma (SCNEC) as a tumor composed of small cells with at least two of the following: argyrophilic cytoplasm, chromogranin A immunoreactivity, and synaptophysin immunoreactivity. We found 10 cases fulfilling these requirements. Five of the 10 tumors were composed mainly of small ("oat") cells and 5 of mainly larger "intermediate" cells. The majority of both subtypes showed an insular pattern. Three of the 10 SCNECs were pure, whereas the other seven were mixed with adenocarcinoma and/or squamous cell carcinoma or cervical intraepithelial neoplasia. In addition to the definitional markers noted earlier, the tumors were immunoreactive for serotonin (6 cases), somatostatin, gastrin, glucagon, and pancreatic polypeptide. No tumors were immunoreactive for cytokeratin 20. Human papillomavirus (HPV)-18 was detected in all of the pure tumors and both the SCNEC and adenocarcinomatous components in four of the mixed tumors. No other types of HPV were detected. The tumors showed a relatively low frequency of loss of heterozygosity for representative tumor suppressor gene sites; p53 mutations were found in only one case.

Detection of Human Papillomavirus DNA and Expression of p16, Rb, and p53 Proteins in Small Cell Carcinomas of the Uterine Cervix

Human papillomavirus (HPV) has been implicated as an etiologic agent for the development of primary small cell carcinoma of the uterine cervix, a rare but highly aggressive malignancy. It has been shown that the HPV E6 and E7 oncoproteins are able to inactivate the tumor suppressor functions of p53 and Rb. In squamous cell carcinoma and adenocarcinoma of the cervix, HPV infection is also associated with overexpression of p16, a cyclin-dependent kinase inhibitor. In this study, 22 cases of primary small cell carcinoma of the uterine cervix were subjected to broad-spectrum HPV DNA amplification and typing, and immunohistochemically examined for the expression of p16, Rb, and p53 proteins. The results show that HPV DNA was detected in every case (100%), with 18 cases (82%) harboring type 18. The tumor cells exhibited strong nuclear staining for p16 in 20 cases (91%). This was associated with a complete loss of Rb nuclear staining in tumor cells in 16 cases (73%). The p53 protein was essentially undetectable in all cases. In contrast, HPV DNA was not detected in 9 colorectal and 8 urinary bladder small cell carcinomas included in this study for comparison. While similar p16 and Rb expression patterns were observed in these HPV-negative tumors, a different expression pattern for p53 was noted where strong nuclear staining was seen in 8 cases (47%; P = 0.0004 compared with cervical tumors). These observations indicate that different mechanisms are involved in the pathogenesis of small cell carcinomas of the uterine cervix and support the notion that nuclear p16 overexpression serves as an indication of Rb defunctioning in tumor cells, which may or may not result from high-risk HPV infection.

Small-cell carcinoma of the uterus and the vagina: experience with ten patients

BACKGROUND

Small cell carcinomas (small-CCs) of the uterine cervix are rare and highly malignant neoplasms. Patients tend to develop distant metastasis early and thus are potential candidates for systemic therapy. We reviewed the experience with small-CCs of the uterus and vagina at two Austrian University hospitals.

MATERIAL AND METHODS

Ten patients (median age, 50 years; range, 18-92) with small-CC of the cervix (n=7), uterine corpus (n=2), and the vagina (n=1) were treated at the two centers between 1988 and 1998. Eight patients underwent radical surgery, 7 of whom also received chemotherapy. Two additional patients underwent primary radiotherapy.

RESULTS

All Pap smears were suspicious for cervical malignancy. The median survival was 12 months (range, 6-86) and overall 5-year survival was 10%. Five of 8 surgically treated patients had lymph node involvement (62%). Of the 7 patients with small-CC of the cervix only one, who had FIGO stage IIB disease and positive pelvic nodes, survived long-term (86 months) with no evidence of disease. She had received six courses of dose-intensive platinum chemotherapy after radical surgery. All three patients with small-CC of the uterine corpus or vagina developed recurrence within the first year after diagnosis. Of the 7 patients who received chemotherapy, 5 developed progressive or recurrent disease in the paraaortic region (n=2), peritoneum (n=1), liver (n=1), or pelvis (n=1).

CONCLUSION

These results confirm the particularly unfavorable prognosis of patients with small-CC of the genital tract. The optimal treatment for these patients most probably including concurrent chemo-radiotherapy remains to be defined.

Overexpression of c-kit protein is an infrequent event in small cell carcinomas of the uterine cervix

Primary small cell carcinomas of the uterine cervix are uncommon but highly aggressive malignancies. The recent observations that c-kit proto-oncogene, a tyrosine kinase, is overexpressed in small cell lung cancers and that advanced c-kit-expressing gastrointestinal stromal tumors were successfully treated with a selective tyrosine kinase inhibitor STI-571 (Gleevec, imatinib mesylate) prompted us to investigate c-kit protein expression in cervical small cell carcinomas. Using a polyclonal antibody against c-kit protein (CD117), our immunohistochemical studies demonstrated a cytoplasmic staining in six of 22 cases (27%) of cervical small cell carcinoma. However, in five of these c-kit-positive cases, the immunoreactivity was focal and/or weak. Only one case (5%) exhibited a strong and diffuse staining pattern comparable to that seen in gastrointestinal stromal tumors. This was in contrast to small cell lung cancers where a positive staining for c-kit was observed in nine of 14 cases (64%) included in the study for comparison. Among them, five (36%) exhibited a strong and diffuse staining pattern. These results indicate that overexpression of c-kit protein is an infrequent event in small cell carcinomas of the uterine cervix. In comparison with small cell lung cancers, the findings presented in this report may reflect the difference in etiopathogenetic mechanisms underlying these two types of small cell carcinomas.

MRI of Small Cell Carcinoma of the Uterine Cervix with Pathologic Correlation

OBJECTIVE

The purpose of this study was to evaluate the MRI features of small cell carcinoma of the uterine cervix and to correlate those features with pathologic findings.

CONCLUSION

Small cell carcinoma of the uterine cervix can be characterized by frequent parametrial invasion and extensive lymphadenopathy, although the tumor morphology seems to be nonspecific on MRI.

Small cell neuroendocrine carcinoma of the cervix: outcome and patterns of recurrence

OBJECTIVES

To analyze the sites of relapse and overall survival in women with neuroendocrine marker-positive small cell carcinoma of the cervix.

METHODS

The records of all women who had their initial treatment for cervical cancer at The University of Texas M.D. Anderson Cancer Center between 1980 and 2000 were reviewed. Fifty-one patients had stages I-III cancers that were originally described as "small cell" or "neuroendocrine." Histological material was available for reexamination in 45 cases; of these, 21 were found to have small cell neuroendocrine carcinoma (SCNEC) as indicated by positive staining for chromogranin, synaptophysin, or CD56. Local treatment consisted of a radical hysterectomy in six patients and radiation therapy in 15. Thirteen patients received chemotherapy as part of their initial treatment. The median follow-up for surviving patients was 83 months (range, 25-209 months).

RESULTS

Fourteen (66%) of the 21 patients had a relapse. The median time to first relapse from the initiation of treatment was 8.4 months (range, 3.6-28 months). Most patients developed hematogenous distant metastases before their death. Only 2 of 15 patients who were treated with radiation therapy had a recurrence within the radiation fields. However, five patients had a recurrence above the radiation fields in the paraaortic lymph nodes, and two patients had a recurrence distal to the pelvic fields in the vagina. No patient had brain metastases as the sole site of first recurrence. However, two patients developed brain metastases concurrently with lung metastases. The overall survival rate was 29% at 5 years; none of the patients who had disease more extensive than stage IB1 or clinical evidence of lymph node metastases survived their disease.

CONCLUSIONS

Patients with small cell neuroendocrine cervical cancer have a poor prognosis. Their course is frequently characterized by the development of widespread hematogenous metastases; locoregional recurrence outside irradiated fields is also frequent. Brain metastases were seen only in patients who also had lung metastases, suggesting that prophylactic cranial irradiation would be of little benefit.

Primary neuroendocrine carcinoma of the fallopian tube: a case report

Neuroendocrine carcinomas arise from Kulchitsky cells and are frequently seen in gastrointestinal tract and lungs. But they are unusual in gynecology practice. The Fallopian tube is one of the rarest locations for the development of a female genital malignancy. The most common histologic subtype is adenocarcinoma in malignancies of fallopian tubes, but rarely other histologic subtypes have been reported. Here we present a primary neuroendocrine carcinoma of the fallopian tube. To the best of the our knowledge, it was not reported previously.

P16 overexpression and human papillomavirus infection in small cell carcinoma of the uterine cervix

Carcinogenesis of cervical cancer has been investigated, and p16(INK4a) overexpression in squamous cell carcinoma of the cervix has been reported as a result of infection by human papillomavirus (HPV) (eg, HPV 16), and the consequence of the retinoblastoma (Rb) protein inactivation by HPV E7 protein. However, to our knowledge, there have been no studies on the relation between p16(INK4a) overexpression associated with HPV and small cell carcinoma of the cervix, which behaves more aggressively clinically than squamous cell carcinoma. The purpose of this study was to determine whether p16(INK4a) is overexpressed in small cell carcinoma, and if p16(INK4a) is overexpressed, the types of HPV that are related to this cancer. We reviewed 10 cases of small cell carcinoma and examined them for p16(INK4a) overexpression by immunohistochemistry. We also performed HPV typing with polymerase chain reaction (PCR)-sequencing analysis and in situ hybridization and found that p16(INK4a) was overexpressed in every case. PCR-sequencing analyses revealed that all cases were HPV-positive and that 9 cases were positive for HPV 18. Five of the 9 cases positive for HPV 18 were also positive by in situ hybridization and yielded a punctate signal, considered to represent the integrated form. In conclusion, p16(INK4a) was overexpressed and HPV 18 was frequently detected in an integrated form in small cell carcinoma. Therefore, inactivation of Rb protein by HPV 18 E7 protein may be associated with carcinogenesis of small cell carcinoma the same as inactivation of Rb protein by HPV 16 E7 protein is associated with carcinogenesis of squamous cell carcinoma.

Small-cell carcinoma of the cervix: fourteen years of experience at a single institution using a combined-modality regimen of involved-field irradiation and platinum-based combination chemotherapy

PURPOSE

To determine the efficacy and toxicity of a combined-modality regimen of irradiation with platinum-based combination chemotherapy in small-cell carcinoma of the cervix (SCCC).

PATIENTS AND METHODS

Thirty-four patients with SCCC were seen and treated at the British Columbia Cancer Agency between May 1988 and November 2002. Two protocols were used, SMCC (May 1988 to December 1995) and SMCC2 (January 1996 to November 2002). Both protocols used cisplatin, etoposide, and involved-field irradiation (essentially pelvis plus or minus para-aortics) with concurrent chemotherapy. In addition, SMCC2 included carboplatin and paclitaxel, and the para-aortics were irradiated routinely.

RESULTS

Thirty-one patients received either SMCC (n = 17) or SMCC2 (n = 14), and three patients did not (disease too extensive, n = 1; patient refusal, n = 1; and alternative regimen, n = 1). For the 31 patients treated on one of the protocols, the 3-year overall and failure-free survival (FFS) rates were 60% and 57%, respectively. The results were equivalent for SMCC and SMCC2. Radiologic stage was the only independent predictor for FFS (80% at 3 years for stage I and II patients v 38% at 3 years for stage III and IV patients). Distant failure (28%) was the most common cause of failure, with local failure occurring in 13% of patients. The switch to SMCC2 did not improve efficacy but did lessen the toxicity.

CONCLUSION

SCCC can be successfully treated in approximately 55% of patients with a combination of irradiation and platinum-based chemotherapy. Disease extent predicts for chance of curability.

Pathology of Cervical Cancer

Squamous cell carcinoma is the most common malignant cervical tumor, but the incidence of adenocarcinomas has been rising during the past few decades. This article discusses the epidemiology and pathogenesis of the squamous cell carcinoma, its clinical and histologic features, including microinvasive carcinoma, its histologic grade, and variant tumors. The prognostic impact of these features and the differential diagnosis are also covered. The second portion of this article is devoted to the glandular tumors of the cervix, including adenocarcinoma in situ and invasive adenocarcinoma and its variants. The differential diagnosis of these tumors with tumor like glandular lesions is given special attention. Finally, less common malignant cervical tumors are covered, with an emphasis being placed on their significance.

Reproducibility of classification in non-squamous cell carcinomas of the uterine cervix

OBJECTIVE

Reproducibility of histopathologic classification systems is of major importance for their utility in daily practice and in research. The reproducibility of histologic classification of non-squamous carcinomas (non-SCC) of the uterine cervix was evaluated, using population-based material from two 5-year periods in Norway.

METHODS

Histologic slides from 388 tumors were reviewed by three experienced pathologists and analyzed for inter- and intraobserver agreement on histological subtypes and grade.

RESULTS

Kappa values of inter- and intraobserver agreement were moderate to substantial for all major adenocarcinoma subgroups (endocervical, endometrioid, clear cell, or serous carcinoma), and fair to poor for mixed carcinomas and adenocarcinomas not otherwise specified (NOS). Interobserver agreement on villoglandular and adenosquamous carcinomas was poor, and the distinction of adenocarcinoma in situ from well-differentiated carcinoma proved difficult. Reproducibility of the high-risk subgroups of small cell and undifferentiated carcinomas was acceptable from a statistical point of view (kappa values >0.50). However, the authors agreed upon the diagnosis of small cell carcinomas and undifferentiated carcinomas only in 2/3 of these high-risk diagnoses. Patients with high-risk diagnoses showed significantly lower overall survival than patients with non-high-risk diagnoses (P < 0.001). This inferior survival was independent of whether the reviewers had agreed on the high-risk diagnosis or not.

CONCLUSION

Clinicians should be aware of the potential inconsistencies of histopathologic diagnoses. No histopathological classification system will ever be perfectly reproducible. Future histopathologic classification of the uterine cervix should emphasize the distinction between groups of particularly low or high prognostic risks.

Large cell neuroendocrine carcinoma of the uterine cervix: a clinicopathological study of six cases

Six cases of cervical large cell neuroendocrine carcinomas (LCNEC) were found among 972 patients (0.6%) with invasive cervical carcinoma. The patients, who were from 27 to 51 (mean 38) years of age, presented with vaginal bleeding or an abnormal Papanicolaou smear. Five tumors were stage Ib and one was IIa. All patients underwent radical hysterectomy and received adjuvant chemotherapy and pelvic radiotherapy. Four patients died of tumor 6 to 19 months (mean 14 months) postoperatively. On histologic examination, the tumor cells were arranged in an organoid growth pattern and were larger than those of typical small cell carcinoma. Glandular differentiation was present in one case. Mitotic figures ranged from 15 to 45 (mean 29) per 10 high-power fields. Prominent vascular invasion and necrosis was seen in all of the tumors. Each tumor was immunoreactive for chromogranin A and/or synaptophysin. The results of this study confirm the aggressive nature of cervical LCNECs. The recognition of LCNECs is necessary to establish the most effective treatment for these aggressive tumors.

Endocrine tumors of the uterine cervix: incidence, demographics, and survival with comparison to squamous cell carcinoma

OBJECTIVE

The aim was to describe the epidemiology of endocrine tumors of the cervix in comparison with invasive squamous cell carcinomas using population-based data reported to the Surveillance, Epidemiology and End-Results (SEER) program.

METHODS

Retrospective analysis of actively followed cases reported to SEER from 1973 to 1998. Incidence, demographic characteristics, and survival were compared for endocrine and squamous tumors.

RESULTS

There were 239 cases of endocrine tumors and 18,458 cases of invasive squamous cell carcinoma of the cervix included in the study. Mean age at diagnosis was 49 years for endocrine tumors versus 52 years for squamous cell carcinoma (P < 0.01). Endocrine tumors were more likely to present at a later FIGO stage (P < 0.01), and to have lymph node involvement at diagnosis (57 vs 18%, P < 0.01) compared to squamous cell carcinoma. Observed median survival for women with endocrine tumors was 22 months versus 10 years for women with squamous cell carcinoma. Age and FIGO stage-adjusted hazards of death were 1.84 times greater for endocrine tumors than for squamous cell carcinoma (95% CI 1.52-2.23). At all stages of disease, survival was worse for women with endocrine tumors compared to women with squamous cell carcinomas.

CONCLUSIONS

Endocrine tumors of the cervix are extremely aggressive and survival is poor regardless of stage at diagnosis.

Expression of cadherins, p53, and BCL2 in small cell carcinomas of the cervix: potential tumor suppressor role for N-cadherin

Cadherins are tissue-specific cell adhesion molecules that function as tumor suppressors. Analysis of cadherin expression is useful for differentiation of tumor histogenesis, and because they serve as markers of tumor behavior and prognosis. Since the pattern of cadherin expression is not well characterized for small cell carcinoma of the cervix, we examined cases of these tumors for expression of cadherins, and two other oncoproteins p53 and BCL2. Four cases of small cell neuroendocrine carcinomas were identified from the Gynecologic Oncology Service with diagnoses confirmed by immunohistochemistry for neuroendocrine markers. Archival paraffin blocks were studied by heat-enhanced immunohistochemistry using commercially available antibodies specific for E-cadherin, P-cadherin, and N-cadherin, p53, and BCL2. Sections were examined for specific membrane staining of cadherins, nuclear staining of p53, and cytoplasmic staining of BCL2. E-cadherin was expressed in three of four cases, P-cadherin in one of four, and N-cadherin in none of four cases. P53 was expressed in one of four cases and BCL2 in one of four cases. The four cases showed three different patterns of immunohistochemical staining for the five oncoproteins. Specifically, two cases expressed E-cadherin only; one case lacked all three cadherins, was negative for BCL2, and was only positive for p53; and one case expressed E- and P-cadherin and BCL2. Prior studies of other neuroendocrine and small cell tumors of other organs showed E-cadherin expressed in 98% (42 /43), N-cadherin in 65% (28/43), and P-cadherin in 40% (17/43) of cases. Additionally, one case of vaginal small cell carcinoma showed expression of all three cadherins. The only significant difference between cervical primaries and other primary sites is that N-cadherin was not detected in our four cases vs. 65% expression in other sites (P < 0.001). We conclude that cadherin and oncoprotein profiles in small cell carcinoma of the cervix are different in the four cases analyzed. Additional cases need to be studied to determine the specificity and frequency of these oncoprotein profiles for small cell carcinoma of the cervix. These may possibly represent different oncogenic pathways in development of small cell cancer of the cervix. Also, our results suggest that N-cadherin may be a tumor suppressor gene in these tumors.

Prognostic factors in neuroendocrine small cell cervical carcinoma: a multivariate analysis

BACKGROUND

The purpose of this study was to evaluate the clinical and pathologic factors associated with survival in patients with neuroendocrine (NE) cervical carcinoma.

METHODS

All patients with NE cervical carcinoma diagnosed between 1979-2001 were identified from tumor registry databases at two hospitals. Data were collected from hospital charts, office records, and tumor registry files. The impact of clinical and pathologic risk factors on the survival of patients with small cell NE carcinoma of the cervix was evaluated using Kaplan-Meier life table analyses and log-rank tests. The independent prognostic factors found to be predictive of survival in univariate analysis were evaluated using Cox regression. All tests were two-tailed with P values < 0.05 considered significant.

RESULTS

Thirty-four patients (median age, 42 years) were diagnosed with neuroendocrine cervical carcinoma, which included 21 with International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, 6 with FIGO Stage II disease, 5 with FIGO Stage III disease, and 2 with FIGO Stage IV disease. Seventeen patients underwent a radical and 6 patients underwent a simple hysterectomy. Fourteen women received adjuvant therapy with pelvic radiation and/or cisplatin-based chemotherapy. Ten women received primary radiotherapy with (n = 5) or without (n = 4) chemotherapy and the remaining patient refused therapy. Women with early-stage (Stage I-IIA) disease had median survival rates of 31 months compared with 10 months in the advanced-stage (Stage IIB-IVB) group (P = 0.002). In univariate analysis, advanced stage (P = 0.002), tumor size >2 cm (P = 0.02), margin involvement (P = 0.016), pure versus a mixed histologic pattern (P = 0.04), margin status (P = 0.016), and smoking (P = 0.04) were considered poor prognostic factors. In multivariate analysis, smoking for early-stage patients and stage of disease in the overall population remained as independent prognostic factors of survival.

CONCLUSIONS

Smoking and advanced stage are reported to be poor prognostic factors for survival in patients with NE small cell carcinoma of the cervix. Only those with early lesions amenable to extirpation are cured. The role of primary or postoperative radiation with or without chemotherapy is unclear and yields uniformly poor results, particularly in patients with advanced lesions. Clinical trials are needed.

Operable Stages IB and II cervical carcinomas: a retrospective study comparing preoperative uterovaginal brachytherapy and postoperative radiotherapy

PURPOSE

To evaluate our data concerning prognostic factors and treatment toxicity in a series of operable cervical carcinomas.

METHODS AND MATERIALS

Between May 1972 and January 1994, 414 patients with cervical carcinoma, staged according to the 1995 FIGO staging system (286 Stage IB1, 38 Stage IB2, 56 Stage IIA, and 34 Stage IIB with 1/3 proximal parametrial involvement), underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection (N+: n = 68). Group I included 168 patients who received postoperative radiation therapy (RT): 64 patients had low-dose-rate vaginal brachytherapy with a median total dose (MTD) of 50 Gy; 93 patients had external beam pelvic RT (EBPRT) with an MTD of 45 Gy over 5 weeks, followed by low-dose-rate vaginal brachytherapy (MTD: 20 Gy); and 11 patients had EBPRT alone (MTD: 50 Gy over 6 weeks). Group II included 246 patients treated with preoperative low-dose-rate uterovaginal brachytherapy (MTD: 65 Gy); 32 of these 246 patients also received postoperative EBPRT (MTD: 45 Gy over 5 weeks) delivered to the parametria and pelvic nodes. Mean follow-up from the beginning of treatment was 106 months.

RESULTS

First events included isolated locoregional recurrences (35 patients), isolated distant metastases (27 patients), and locoregional recurrences with synchronous metastases (13 patients). The 10-year disease-free survival (DFS) rate was 88% for Stage IB1, 44% for Stage IB2, 65% for Stage IIA, and 48% for Stage IIB. Multivariate analysis showed that independent factors influencing the probability of DFS were as follows: cervical site (exocervical or endocervical vs. both endo- and exocervical, relative risk [RR]: 1.77, p = 0.047), vascular space invasion (no vs. yes, RR: 1.95, p = 0.041), age (>51 years vs. <or=51 years, RR: 1.90, p = 0.013), 1995 FIGO staging system (IB1 vs. IIA, RR: 2.95, p = 0.004; IB1 vs. IB2, RR: 3.49, p = 0.0009; and IB1 vs. IIB, RR: 4.54, p = 0.00002), and histologic pelvic lymph node involvement (N- vs. N+, RR: 2.94, p = 0.00009). The sequence of adjuvant RT did not influence the probability of DFS (Group I vs. Group II, p = 0.10). In Group II, after univariate analysis, DFS was significantly influenced by histologic residual cervical tumor in the hysterectomy specimen (yes vs. no: 71% vs. 93%, respectively, p < 10(-6)) and by the size of the residual tumor (<or=1 cm vs. >1 cm: 83% vs. 41%, respectively, p = 0.001). The overall postoperative complication rate was 10% in Group I and 9% in Group II (p = 0.7). The rate of postoperative ureteral complications requiring surgical intervention was lower in Group I than in Group II (0.6% vs. 2.3%, respectively, p = 0.03). The overall 10-year rate for Grade 3 and 4 late radiation complications was 10.4%. Postoperative EBPRT significantly increased the 10-year rate for Grade 3 and 4 late radiation complications (yes vs. no: 22% vs. 7%, respectively, p = 0.0002).

CONCLUSION

The prognosis for patients with cervical carcinoma was not influenced by the sequence of adjuvant RT (preoperative uterovaginal brachytherapy vs. postoperative RT) for Stages IB, IIA, and IIB with 1/3 proximal parametrial involvement. However, postoperative EBPRT increased the risk of late radiation complications.

Neuroendocrine marker expression in cervical carcinomas of non-small cell type

Small-cell carcinomas of the uterine cervix are highly aggressive tumors. Up to 100% of these tumors express at least one neuroendocrine marker such as neuron-specific enolase (NSE), chromogranin A (CgA), and synaptophysin (SYN). In other tumor types such as non-small-cell carcinomas of the lung, colon, and prostate, the presence of these markers has been associated with a better prognosis in some studies, a worsened prognosis in others, or has had no prognostic effect in still other studies. However, little is known about their expression and prognostic significance in the common "non-small-cell" carcinomas of the uterine cervix. The primary tumors of 54 previously untreated patients with histologically confirmed non-small-cell carcinoma of the cervix uteri (squamous carcinoma, adenosquamous carcinoma, and adenocarcinoma) were analyzed by immunohistochemistry for expression of NSE, CgA, and SYN. The expression status was correlated to pathological characteristics and outcome. In addition, the expression of these markers was investigated in cervical carcinoma cell lines. None of the 54 tumors expressed NSE or CgA, although SYN was positive in five tumors (9%) of which four were squamous and one was adenocarcinoma. These five patients relapsed within the first 6 months of follow-up and four have died. Among eight cancer cell lines only one was positive for CgA and another one for SYN. We conclude that the neuroendocrine marker SYN is expressed in a small subset of non-small-cell carcinomas of the cervix and its expression seems to correlate with a poor outcome.

Transitional cell metaplasia of the uterine cervix is related to human papillomavirus: molecular analysis in seven patients with cytohistologic correlation

BACKGROUND

Transitional cell metaplasia of the uterine cervix is an under-recognized entity in cervical pathology. The underlying etiology and biologic significance remains uncertain. The thin-layer cytology findings and association with human papillomavirus (HPV) have not been studied thoroughly.

METHODS

The authors retrospectively reviewed the clinical findings, thin-layer cytology and histologic features of pure transitional cell metaplasia of the uterine cervix occurring in seven perimenopausal or postmenopausal Chinese women at Pamela Youde Nethersole Eastern Hospital, Hong Kong, during the period from January, 1998 to April, 2001. Molecular techniques for HPV screening and genotyping using polymerase chain reaction and restriction fragment length polymorphism analysis were employed in the thin-layer cytology specimens and paraffin block material.

RESULTS

In all seven patients, transitional cell metaplasia represented an incidental histologic finding. It occurred in the ectocervix, transformation zone, endocervix, or vagina. Histologically, it resembled urothelium of the urinary bladder and was comprised of multilayers of mitotically inactive, immature epithelial cells with vertically aligned oval nuclei, fine chromatin, indistinct nucleoli, and conspicuous longitudinal nuclear grooves. The superficial cells were oriented more horizontally and contained pale-staining cytoplasm similar to umbrella cells. Features consistent with transitional cell metaplasia were identified in two of seven preoperative thin-layer preparations. Cytologically, the affected parabasal cells recapitulated the features that were seen in histologic sections. In addition to the bland nuclear morphology and longitudinal nuclear grooves, the cell borders appeared distinct, and the appearance of a perinuclear cytoplasmic halo was common. Sometimes, the metaplastic cells assumed a spindle shape and appeared as cohesive, streaming cell clusters. Molecular study successfully demonstrated the presence of HPV in all seven patients, mostly in the liquid-based cytology samples. In general, the viral DNA load was relatively low; and, for samples in which HPV genotyping was feasible, HPV type 58 was the prevalent genotype.

CONCLUSIONS

The current study demonstrates that transitional cell metaplasia of the uterine cervix is related to HPV. It also carries a distinctive cytologic appearance in thin-layer preparations. Based on the limited follow-up data from a small number of reported patients, transitional cell metaplasia seems to run an indolent clinical course. However, its peculiar association with HPV and its possible correlation, both morphologic and histogenetic, with cervical intraepithelial neoplasia need further investigation.

[Operable stage IB and II cancer of the uterine neck: retrospective comparison between preoperative utero-vaginal curietherapy and initial surgery followed by radiotherapy]

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable stages IB and II cervical carcinomas.

PATIENTS AND METHODS

Between May 1972 and January 1994, 414 patients (pts) with cervical carcinoma staged according to the 1995 FIGO staging system underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection. Lateral ovarian transposition to preserve ovarian function was performed on 12 pts. The methods of radiation therapy (RT) were not randomised and depended on the usual practices of the surgical teams. Group I: 168 pts received postoperative RT (64 pts received vaginal brachytherapy alone [mean total dose (MD): 50 Gy], 93 pts had external beam pelvis RT (EBPRT) [MD: 45 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 20 Gy], and 11 pts had EBPRT alone [MD: 50 Gy over 6 weeks]. Group II: 246 pts received preoperative utero-vaginal brachytherapy [MD: 65 Gy], and 32 of theses 246 pts also received postoperative EBPRT [MD: 45 Gy over 5 weeks] delivered to the parametric and the pelvic lymph nodes with a midline pelvic shield. The mean follow-up was 106 months.

RESULTS

The 10-year disease-free survival (DFS) rate was 80%. From 75 recurrences, 35 were isolated locoregional. Multivariate analysis showed that independent factors decreasing the probability of DFS were: both exo and endocervical tumour site (p = 0.047), lymph-vascular space invasion (p = 0.041), age < or = 51 yr (p = 0.013), 1995 FIGO staging system (stage IB1 vs stage IIA, p = 0.004, stage IB1 vs stage IB2, p = 0.0009, and stage IB1 vs stage IIB with 1/3 proximal parametrical infiltration, p = 0.00002), and histological pelvic involved lymph nodes (p = 0.00009). Methods of adjuvant RT did not influence the probability of DFS (group I vs group II, p = 0.10). The postoperative complication rate was 10.2% in group I and 8.9% in group II (p = 0.7) but the postoperative urethral complication rate necessitating surgical intervention with reimplantation was lower in group I than in group II (0.6% vs 2.3%, respectively, p = 0.03). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 10.4%. EPRT significantly increased the 10-year rate for grade 3 and 4 late radiation complications (yes vs no: 22% vs 7%, respectively, p = 0.0002).

CONCLUSION

In our series, the methods of adjuvant RT (primary surgery vs preoperative uterovaginal brachytherapy) do not seem to influence the prognosis of the stage IB, IIA, and IIB (with 1/3 proximal parametrical involvement only) cervical carcinomas. The postoperative EPRT applied according to histopathological risk factors after surgical treatment increases the risk of late radiation complications.

Allelic losses at 3p and 11p are detected in both epithelial and stromal components of cervical small-cell neuroendocrine carcinoma

Microdissected epithelial and stromal cells from 15 cervical small-cell carcinoma patients and 9 healthy control subjects were assessed for loss of heterozygosity with polymorphic DNA markers at chromosomes 3p and 11p. Among malignant lesions assessed with 7 markers at 3p, 21 allelic losses were detected from 193 informative samples. Of losses, 20 were in epithelial and 1 was in normal-appearing stromal cells. Among losses in epithelial cells, 16 were from 44 samples informative for 3 markers within 3p21.2-p14.2 (0.36 loss/sample), whereas only 4 were from 54 samples informative for 4 markers outside the region (0.09 loss/sample), suggesting a "hot spot" of genetic alterations within 3p21.2-p14.2. Among malignant lesions assessed with 2 markers within 11p14-p12, 15 losses were seen in 52 informative samples. Of losses, 10 were in epithelial and 5 were in normal-appearing stromal cells. Of 10 epithelial samples showing losses within 11p14-p12, 8 also displayed losses within 3p21.2-p14.2, suggesting a concurrent involvement of these loci in tumor development or progression. The five losses in stromal cells were in four cases that showed no loss in epithelial cells with same markers, suggesting that stromal cells might play initiative roles in tumor development.

Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix

BACKGROUND

The incidence of adenocarcinoma of the uterine cervix is increasing. For better prognostic information, the authors studied all nonsquamous cell carcinomas (non-SCCs) in the Norwegian population over a total of 15 years.

METHODS

All non-SCCs from three 5-year periods (1966-1970, 1976-1980, and 1986-1990) were reviewed and classified according to the World Health Organization classification system, and histopathologic and clinical parameters were registered. Tissue blocks were available from all patients.

RESULTS

Of 505 patients, 417 had tumors classified as adenocarcinoma, and 88 had tumors classified as other non-SCC. The mean ages were 53 years and 52 years for patients with adenocarcinoma and non-SCC, respectively. Sixty-two percent of the staged patients had clinical Stage I disease according to the classification system of the International Federation of Gynecology and Obstetrics (FIGO). In univariate analyses, histology, architectural and nuclear grade, extension to the vagina or corpus uteri, tumor length (> 20 mm) or tumor volume (> 3000 mm(3)), infiltration depth (in thirds of the cervical wall), thickness of the remaining wall (< 3 mm), vascular invasion, lymph node metastases, treatment, and patient age were significant variables in patients with FIGO Stage I disease. Variables with no significance in patients with Stage I disease were number of mitoses, state of resection margins, infiltration to ectocervix, tumor thickness, lymphoid reaction, earlier or concomitant cervical intraepithelial neoplasia, stump carcinoma, DNA ploidy or DNA index, or time period. Multivariate analyses of patients with FIGO Stage I disease identified small cell carcinoma, corpus infiltration, vascular invasion, and positive lymph nodes as independent prognostic factors.

CONCLUSIONS

Small cell carcinoma was the only histologic subgroup of independent importance for prognosis in patients with non-SCC of the uterine cervix. No significant difference between major subtypes of adenocarcinoma favored a simplified classification. Extension to the corpus in patients with early-stage disease was of independent significance and should be acknowledged in planning treatment.

Correlation of human papillomavirus 16 and 18 with cervical neoplasia in histological typing and clinical stage in Taiwan: an in-situ polymerase chain reaction approach

BACKGROUND AND OBJECTIVES

In situ polymerase chain reaction (ISPCR) promises to considerably enhance our ability to detect a few copies of target nucleic acid sequences in fixed tissues and cells. The aim of this study was to investigate cervical carcinoma to determine the human papillomavirus (HPV) types on paraffin-embedded tissue sections by ISPCR and standard in situ hybridization. The results will correlate the morphological characteristics of lesions with viral typing results.

METHODS

This study examined prevalence of HPV 16 and 18 DNA in biopsies from 85 cervical cancer patients by ISPCR, employing HPV 16, 18 consensus primers. There are 45 patients with squamous cell carcinomas, 13 with adenocarcinoma, 2 with adenosquamous carcinomas, 3 with small cell carcinomas, and 22 carcinoma in situ. The relation between the types of HPV detected, tumor type, and clinical stage were analyzed.

RESULTS

Fifty-two of 85 biopsies were HPV 16- or 18-positive, HPV 16 being the most prevalent type. Squamous cell carcinoma had a high prevalence of HPV 16 and adenocarcinoma had a high prevalence of HPV 18. HPV 18 was the predominant type among high clinical stage (III-IV) cases while HPV 16 and mixed HPV 16 with HPV18 were significantly correlated with low clinical stage (0-I-II).

CONCLUSION

Our results indicate that certain malignant cervical tumor phenotypes and stages correlate with specific HPV type, and that ISPCR is a sensitive and fast method to detect HPV in these patients.