Extrapulmonary small cell cancer: a Canadian province's experience

Merkel cell polyomavirus and extrapulmonary small cell carcinoma

The Merkel cell polyomavirus (MCV) is involved in the development of up to 100% of Merkel cell cancer (MCC) cases. Early studies have reported that the virus was infrequently detected in other small cell or neuroendocrine lung carcinomas, which share histological features with MCC. The present study investigated the presence of MCV in cases of extrapulmonary small cell carcinoma (ESCC), which also shares histological features with MCC. A total of 25 cases of ESCC that were diagnosed between 2004 and 2009 were identified at The Dartmouth Hitchcock Medical Center. Archived tissue was available for testing in 16 of these cases. A total of 11 tissue specimens of MCC were used as positive controls. DNA that was extracted from the archived tissue was subjected to five separate quantitative (q)PCR assays for the detection of four MCV genomic targets. MCV DNA was detected in 3/16 (19%) of the ESCCs and in all 11 MCCs. In the three MCV-positive ESCCs, the viral target was only detected by either one or two of the PCR assays. In 8/11 MCV-positive MCCs, the DNA tested positive by either three or all four assays and the remaining three MCCs tested positive by either one or two assays. The β-globin endogenous control was detected in all the samples that were tested. Although MCC and ESCC share numerous histological features, MCV is detected at a lower frequency in ESCC. The possible role for MCV in the etiology of ESCC remains uncertain and may account for the rare cases of ESCC with no other identifiable etiology. The failure of other assays to detect MCV may be due to sequence variability in the MCV genome.

Neuroendocrine small cell rectal cancer metastasizing to the liver: a unique treatment strategy, case report, and review of the literature

We describe the treatment of a 46-year-old Saudi man with advanced stage liver metastatic neuroendocrine rectal cancer. The patient presented with a large liver lesion and rectal bleeding. He was cachectic, with a firm tender mass 20 mm above the anal verge. Computed tomography (CT) showed a mass 9.5 × 13 cm in size in the right hemi-liver, abutting the middle hepatic vein. The patient refused treatment, and consulted another hospital. After 3 months, he presented with the same symptoms in addition to delirium. Colonoscopy showed an ulcerating anorectal mass, from which a biopsy was taken. Repeat CT showed an increase in the size of the liver lesion to 17 cm and no change in the pelvis. The final histopathology report identified anaplastic small cell carcinoma. The patient underwent extended right liver resection followed by abdominoperineal resection, then 13 cycles of chemotherapy and monthly somatostatin injections. At the most recent follow-up, the patient had been disease-free for 48 months. Surgical resection (R0) of the primary and secondary tumor, followed by platinum-based chemotherapy can result in good survival in cases of small cell carcinoma with large liver metastasis, irrespective of whether the primary or secondary tumor is resected first.

Management of small cell carcinoma of esophagus in China

PURPOSE

Small cell carcinoma of esophagus (SCEC) is characterized by high malignancy and early metastasis. Although the morbidity of SCEC is very low, few studies of patients with SCEC have been conducted in China, there are no sufficient studies of SCEC conducted and reported in the existing published works, and the choices of treatment remain controversial. In this work, we aim to study the clinical characteristics of SCEC, and explore the corresponding treatment and prognosis through retrospective analysis.

MATERIAL AND METHODS

The original articles were identified through the leading digital libraries in China in which the terms "esophagus or esophageal" and "small cell esophageal carcinoma" appeared from 2005 to 2009, 1,176 eligible cases were reviewed for clinical data. Analysis of survival was conducted using the Kaplan-Meier method, and differences were compared using the log-rank test.

RESULTS

One thousand one hundred seventy-six eligible cases were analyzed; the median age of patients was 57 years, with a male-to-female ratio of 2.4:1. The number of SCEC accounted for 1.26 % of esophageal cancer treated in the same period. Of the tumors, 89.7 % were located in mid- and lower thoracic esophagus. The average tumor length was 5.4 cm (0.5-17 cm). The median overall survival was 11.1 months for all patients. The 1-, 2-, 3-, and 5-year average overall survival rates of 469 patients was 51.1, 25.5, 13.2, 7.9 %, respectively. The median survival time for LD patients who received systemic treatment was 16.8 m, whereas for those who received local treatment (surgery), the median survival time was 10.1 m; the median survival time for ED patients who received systemic treatment was 7.4 m, compared with 5.8 m for those who received sole treatment (chemotherapy or radiotherapy).

CONCLUSIONS

SCEC is a tumor characterized by high malignancy and early metastasis. Although our retrospective analysis cannot provide definitive conclusions on the optimal treatment modality for SCEC, however, our results suggest that systemic treatment combined with surgical resection plays a major role in the therapy of SCEC, systemic therapy may be an effective approach for the treatment of SCEC, and randomized, prospective, multicenter studies are needed to identify optimal treatment modalities for SCEC.

Imaging features of extrapulmonary small cell carcinoma

Small cell carcinoma accounts for approximately 20% of lung cancers; however, it rarely occurs at other sites. Extrapulmonary small cell carcinoma (EPSCC) is notoriously aggressive with a strong propensity for both regional and distant spread. The majority of the literature on these uncommon tumours is from a clinicopathological viewpoint with a relative paucity of detail regarding the radiological findings. This review will focus on the imaging features of EPSCC in its predominant sites of origin: the gastrointestinal tract, genitourinary tract, head, neck, and breast. We will also discuss the role of positron-emission tomography (PET)/computed tomography (CT) in the staging of EPSCC.

Small cell prostate carcinoma: a case report and review of the literature

Small cell prostate cancer constitutes less than 1% of all prostate cancers and has a poor prognosis. A 60-year-old male patient presented with dysuria, pollakiuria, and nocturia of about 1-year duration.The total PSA level at admission was 47.50 ng/mL. The prostate needle biopsy result was reported as adenocarcinoma Gleason 5 + 3. The patient underwent transurethral prostate resection (TUR-P) and bilateral orchiectomy. The TUR-P pathology result was consistent with small cell neuroendocrine carcinoma. He was offered systemic chemotherapy but refused it. Examinations and tests at the third postoperative month showed diffuse liver metastasis and vertebral bone metastasis. He died at the 6 months after surgery.

A useful treatment for patients with advanced mixed-type small cell neuroendocrine carcinoma of the prostate: A case report

Treating extended prostatic small cell neuroendocrine carcinoma (PSCNC) is extremely difficult and no standard treatment has yet been established. We experienced a case of advanced mixed-type PSCNC in which the patient achieved long-term survival and local control following combined therapy. Locally advanced PSCNC causing lower urinary obstruction was detected during androgen-ablation therapy for stage D2 mixed adenocarcinoma PSCNC. The patient was treated with intra-arterial infusion chemotherapy using a reservoir system and external-beam radiotherapy (EBRT) to the whole pelvis and local tumor. After chemoradiotherapy, the patient’s lower urinary obstruction was reduced and did not return during the remaining 40 months of the patient’s life. The patient survived for 70 months following the start of the androgen-ablation therapy. The present study reports a useful treatment for advanced mixed-type PSCNC, androgen-ablation therapy and chemoradiotherapy. The present results also suggest that the prognostic factors for advanced mixed-type PSCNC are the sensitivity of the conventional adenocarcinoma to androgen-ablation therapy, degree of metastasis and extent of the small cell neuroendocrine carcinoma component.

Neuroendocrine carcinoma of the pancreas with soft tissue metastasis

Neuroendocrine carcinoma (NEC) of the pancreas is rare. We report the case of a 34-year-old man with pancreatic NEC with soft tissue metastasis. The patient presented with right upper abdominal discomfort. Computed tomography revealed a low-density heterogeneous mass in the tail and body of the pancreas that encroached on the greater curvature of the stomach and spleen. We performed exploratory laparotomy and total pancreatectomy with splenectomy and total gastrectomy. Histopathological analysis showed spindle-shaped cells with scanty cytoplasm and hyperchromatic nuclei, confirming a primary pancreatic NEC. One month after the surgery, the patient experienced leg swelling. Positron emission tomography-computed tomography revealed high uptake of fludeoxyglucose in the left leg, and the leg was amputated. Histopathological analysis confirmed metastasis of pancreatic NEC. The patient was followed up and received chemotherapy (etoposide and cisplatin). One month after amputation, the level of tumor marker neuron-specific enolase was 142.70 μg/L and computed tomography scan revealed an aggravated metastatic lesion. The patient suffered from unbearable pain and we treated him with odynolysis. Four months postoperatively, the patient died of respiratory failure.

Limited disease of extra-pulmonary small cell carcinoma. Impact of local treatment and nodal status, role of cranial irradiation

PURPOSE

As extra-pulmonary small cell carcinoma (EPSCC) is a rare entity of tumors, the available treatment recommendations are mainly based on retrospective analyses and deduction from treatment of small cell lung cancer. The aim of this study was to provide a detailed analysis concerning prognostic factors and treatment modalities.

PATIENTS AND METHODS

A total of 20 patients with limited disease (LD) of EPSCC treated at our institution from 1999–2009 were retrospectively analyzed. Data were gathered from chart review. Localization, lymph node involvement, as well as local and systemic treatment were documented and their impact on pattern of failure and survival times statistically evaluated.

RESULTS

With a median follow-up of 21 months, the estimated median overall- and disease-free survival were 59 and 25 months, respectively. Local control was excellent with 100% at 2 years. Nodal involvement was observed in 74% (n = 14/19) of evaluable patients. However, outcome was not altered by this parameter. Local treatment consisted of surgery in 10 cases, radiotherapy in 7 cases, and a combination of both in 3 cases. Only 3 patients (15%) developed hematogenous central nervous system metastases, while none of the patients received prophylactic cranial irradiation.

CONCLUSION

Nodal involvement did not worsen prognosis. Local control was excellent irrespective of local treatment modality and the leading cause of failure was distant metastasis. Therefore, systemic treatment should not be omitted. Prophylactic cranial irradiation might be dispensable but discussed for head and neck malignancies.

Feasibility and efficacy of combined cisplatin and irinotecan chemotherapy for poorly differentiated neuroendocrine carcinomas

OBJECTIVE

No standard treatment has been established for poorly differentiated neuroendocrine carcinoma; the usual recommended treatment is based on the strategy for small cell lung carcinoma. The aim of this study was to evaluate the response of poorly differentiated neuroendocrine carcinoma to the combination of irinotecan and cisplatin in one institution.

METHODS

We retrospectively reviewed 50 poorly differentiated neuroendocrine carcinoma patients treated from September 2005 to April 2011 in our institution. Patients were divided into two stages: limited disease or extensive disease. Forty-four patients received the combination chemotherapy of irinotecan and cisplatin, consisting of 4-week cycles of 60 mg/m(2) irinotecan on days 1, 8, 15 and 60 mg/m(2) cisplatin on day 1.

RESULTS AND CONCLUSION

Median age was 60 years. Median follow-up time was 11.4 months. Overall survival did not reach the median, and 1-year overall survival was 67%. The response rate was 50% (64% at first line), and progression-free survival was 4.8 months (7.3 months at first line). Grade 3-4 hematologic adverse events were seen in 29 patients (66%) and Grade 3-4 non-hematologic adverse events were seen in 20 patients (45%), but no patients died of adverse events. Multivariate analysis showed a statistically significant relationship with neuron-specific enolase elevation and poor overall survival (P= 0.016, hazard ratio 6.261, 95% confidence interval). The combination chemotherapy of irinotecan and cisplatin is moderately effective and feasible, and it should be considered as a treatment option for poorly differentiated neuroendocrine carcinoma.

Extrapulmonary small cell carcinoma: a clinicopathological study with identification of potential diagnostic mimics

AIMS

To evaluate the clinicopathological features of small cell carcinoma arising outside the lung.

METHODS AND RESULTS

Thirty-seven cases with a pathology diagnosis of extrapulmonary small cell carcinoma (EPSCC) were selected. The clinical notes were reviewed and tumour blocks were selected for a fresh haematoxylin and eosin (H&E) section and immunohistochemical stains. The most common tumour locations were cervix and bladder. Twenty-five cases (68%) were finally diagnosed as EPSCC, nine of which were found with coexisting non small cell carcinoma. Two cases (5%) were diagnosed as large cell neuroendocrine carcinoma (LCNEC) of the cervix. The remainder was classified as 10 poorly differentiated carcinomas (PDCs) (27%). Positive staining for thyroid transcription factor 1 (TTF-1) was noted in nine cases of EPSCC and in none of the cases of PDC (P = 0.034). Synaptophysin immunoreactivity was found in 20 cases of EPSCC and two cases of PDC with neuroendocrine differentiation (P = 0.002), as well as two cases of LCNEC. 34βE12 was positive in eight cases of SCC and two cases of PDC.

CONCLUSIONS

Based on this series, EPSCC may be overdiagnosed. Immunohistochemistry for TTF-1, used in combination with synaptophysin, may help to discriminate EPSCC from PDC.

Primary small cell carcinoma of the lesser omentum

Although pulmonary small cell carcinoma (SCC) is seen frequently, SCC that originates from the extrapulmonary organs is extremely rare. We herein report a case of a SCC located in the lesser omentum. A 61-year-old male was admitted to our department due to intermittent epigastralgia for 2 months. Ultrasonography (US) revealed an irregular hypoechoic mass measuring about 58 mm × 50 mm × 45 mm under the left lobe of the liver. Magnetic resonance imaging (MRI) was performed to verify the irregular mass with T1- and T2- weighted images between the left lobe of liver and the stomach. At laparotomy, the well-circumscribed neoplasm was found in the lesser omentum, and the fundus of the neoplasm was located in the root of left gastric artery. Intraoperative microscopic evaluation of frozen sections revealed malignancy of the lesser omentum. Resection of the neoplasm was performed, and the combined resection of the vagal nerve was also performed for the partial adhesion. Pyloroplasty was performed for avoiding delayed gastric emptying caused by combined resection of vagal nerve. The lymph nodes dissection at lesser curvature and right cardia was also performed with a negative result. Based on the histological findings, the final diagnosis of primary lesser omental SCC was confirmed. The pathologic staging showed locoregional disease.

Comparison of chemotherapeutic treatment outcomes of advanced extrapulmonary neuroendocrine carcinomas and advanced small-cell lung carcinoma

BACKGROUND

The chemotherapy for small-cell lung carcinoma (SCLC) has been adopted for advanced extrapulmonary neuroendocrine carcinomas (EP-NECs). The aim of this study was to clarify the efficacy of standard SCLC regimens when used to treat EP-NECs and to compare the outcome with that for SCLC.

METHODS

We reviewed the medical records of 136 patients (41 with EP-NEC and 95 with SCLC) who were treated using a platinum-containing regimen for advanced disease between January 2000 and October 2008 at our hospital.

RESULTS

The primary site of the EP-NEC was the gastrointestinal tract in 18 patients (GI tract group); the liver, biliary tract or pancreas in 16 patients (HBP group), and other sites in 7 patients ('others' group). The response rate in the SCLC patients was 77.8%, and the response rate in the EP-NEC patients was 30.8% (37.5% in the GI tract group, 12.5% in the HBP group, and 57.1% in the 'others' group). The median survival time for the SCLC patients was 13.6 months, while that for the EP-NEC patients was 9.2 months (14.9 months in the GI tract group, 7.8 months in the HBP group, and 8.9 months in the 'others' group). A multivariate analysis demonstrated that a poor performance status, liver involvement, and the treatment regimen were independent unfavorable prognostic factors.

CONCLUSION

The response rate and prognosis of the patients with advanced EP-NECs were worse than those of the patients with SCLC in this study. The Eastern Cooperative Oncology Group performance status, liver involvement, and treatment regimen had a larger impact on the prognosis than the primary tumor site, as demonstrated by multivariate analysis.

Small cell carcinoma of the kidney: a clinicopathologic study of 14 cases

Small cell carcinoma of the kidney is distinctively rare. We searched pathology files in 2 institutions and found 14 cases of renal small cell carcinoma. The patients' mean age at diagnosis was 59 years (range, 22-75 years); 8 were women, and 6 were men. Patients usually presented with hematuria (n = 6) and abdominal pain (n = 5). The mean tumor size was 7.1 cm (range, 3.5-14.0 cm). The small cell carcinoma was pure in 9 cases and mixed with high-grade urothelial carcinoma in 5 cases. None was associated with any type of renal cell carcinoma. Tumor necrosis was present in all cases, and lymphovascular invasion was identified in 6 cases. The tumor invaded the perinephric adipose tissue in 13 cases and was confined to the kidney in only 1 case. Lymph node metastases were identified in all patients who underwent lymph node dissection (5/5). On immunostains, the small cell carcinoma cells were positive for pancytokeratin (11/12), chromogranin (6/9), and synaptophysin (8/9). Follow-up data were available for 13 patients, and 11 died of small cell carcinoma at a mean of 15 months (range, 4-31 months) after diagnosis. Of the 2 surviving patients, 1 was alive at 5 months after diagnosis, and the other, whose disease was confined to the kidney, was alive with no evidence of disease at 137 months. In summary, renal small cell carcinoma is a highly aggressive disease that often presents at an advanced stage with widespread metastases. Patients usually have a poor clinical outcome despite multimodal therapy. The frequent coexistence of small cell carcinoma with urothelial carcinoma suggests that renal small cell carcinomas may evolve from a preexisting urothelial carcinoma.

Extrapulmonary small cell carcinoma: a pictorial review

OBJECTIVE

Extrapulmonary small cell carcinoma (EPSCC) is a rare, aggressive neoplasm arising from virtually any organ. Numerous oncologic studies have addressed prognostic indicators and survival rates in EPSCC, however relatively little has been published regarding the imaging features and metastatic patterns of these uncommon tumors. This article provides a pictorial review of EPSCC in multiple organs, emphasizing the imaging appearance at presentation and the radiologic patterns of recurrence/metastasis.

CONCLUSION

Although the appearance of EPSCC is often nonspecific, the typical presentation is large aggressive tumors that, similar to small cell carcinoma in the lung, often respond well to local therapy but tend to recur relentlessly at distant sites.

Extrapulmonary small cell carcinoma metastasis to the external auditory canal with facial nerve paralysis

OBJECTIVES

The aim of the study was to present a case of small cell carcinoma arising from the tonsil with metastasis to the external auditory canal (EAC) and associated facial nerve paralysis.

METHODS

This study includes a case report and review of the literature.

CONCLUSIONS

Extrapulmonary small cell carcinoma from the head and neck is rarely described and carries a poor prognosis. It often presents with widely metastatic disease. To our knowledge, this is the first case report describing extrapulmonary small cell carcinoma from the tonsil with metastatic disease to the EAC. Irregular lesions in the EAC must be considered suspicious for metastasis in a patient with a history of cancer.

Mixed exocrine and endocrine carcinoma in the stomach: a case report

We report a rare case of the coexistence of a gastric small cell neuroendocrine carcinoma with a gastric adenocarcinoma. A 62-year-old man presented with epigastric soreness for 1 month. Esophagogastroduodenoscopy revealed a Borrmann type I tumor at the lesser curvature of the lower body of the stomach. The patient underwent a distal gastrectomy with D2 lymph node dissection and the resected specimen exhibited a 3.5×3.5 cm sized, fungating lesion. Two separated, not intermingling, lesions with non-adenocarcinoma components encircled by well differentiated adenocarcinoma components were identified microscopically. The non-adenocarcinoma component showed neuroendocrine features, such as a solid and trabecular pattern, and the tumor cells showed a high nuclear grade with minimal cytoplasm, indistinct nucleoli, and positive response for synaptophysin, CD56. The final pathological diagnosis was a gastric mixed exocrine-endocrine carcinoma (MEEC) composed of an adenocarcinoma and small cell neuroendocrine carcinoma of the collision type.

Extrapulmonary small cell carcinoma: An indication for prophylactic cranial irradiation? A single center experience

BACKGROUND

Information about extrapulmonary small cell carcinoma (EPSCC) is limited and the role of prophylactic cranial irradiation (PCI) is unknown.

PATIENTS AND METHODS

Disease presentation and outcome of all EPSCC at our hospital between 1990 and 2009 were retrospectively analyzed.

RESULTS

Of 30 EPSCC, the male:female ratio was 58%:42%; 83% had a performance status of 0-2. Median age was 71 years (32-80). Seventeen (57%) had limited stage (LS), 13 (43%) extensive stage (ES). The location of the primary tumor was gastrointestinal (n = 8), unknown (6), gynecological (6), urogenital (5), and ear nose throat (5). Four (13%) developed brain metastases (2 ES, 2 LS). In ES, first line chemotherapy (CT) was given in 85%, mostly platinum-etoposide (64%). Response rate was 90%. In LS, CT and radiotherapy (RT) ± resection resulted in persistent remissions in 67% of patients. Median survival was 16 months (1-107 months), 18 months (1-107 months), and 9 months (0.4-25 months) for LS + ES, LS, and ES, respectively. Weight loss ≥5 % and ECOG performance status 3 + 4 were associated with poorer survival (p < 0.001 and p < 0.01, respectively).

CONCLUSION

The incidence of brain metastases was relatively low (13%). More studies are necessary, before routinely offering PCI to patients with EPSCC. Best survival outcomes in LS were achieved with multimodality treatment including CT and RT. Prognosis was poor in patients with ES.

Does surgery or radiation therapy impact survival for patients with extrapulmonary small cell cancers?

BACKGROUND AND OBJECTIVES

Extrapulmonary small cell carcinomas (EPSCC) are rare tumors where therapy remains poorly defined. We sought to determine the impact of surgical extirpation and radiation therapy for outcomes of EPSCC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with EPSCC which were further categorized by site and evaluated for survival by specific treatment strategy.

RESULTS

We identified 94,173 patients with small cell carcinoma of which 88,605 (94.1%) and 5,568 (5.9%) had pulmonary small cell carcinoma and EPSCC, respectively. EPSCC patients were subdivided by site with the following proportions: genitourinary (24.1%), gastrointestinal (22.1%), head and neck (7.1%), breast (4%), and miscellaneous (42.7%). Overall EPSSC and specifically gastrointestinal disease had significantly improved median, 5- and 10-year survival with surgery and/or radiation for all stages and sizes. For all EPSCCs multivariate analysis revealed age (>50), gender (female), stage (regional, distant), radiation, and surgery to be independent predictors of survival.

CONCLUSIONS

Although outcomes for EPSCC remains poor, both surgery and radiation is shown to significantly improve median, 5- and 10-year survival rates. EPSCC patients who are potential candidates for surgical resection or radiation therapy may benefit from these treatments.

Small cell carcinoma of the renal pelvis: a case report and review of the literature

Extrapulmonary small cell carcinoma occurs in nearly all organs except the central nervous system and the liver. We are presenting a case of renal small cell carcinoma (SCC) with two unique characters. A 75-year-old patient was evaluated for back pain with no other complaints. Magnetic Resonance (MR) imaging of the abdomen revealed homogeneous tumor in the left renal pelvis extending beyond the kidney. Metastatic workup was negative. A left nephroureterectomy was performed. Histopathology and immunohistochemistry revealed a small cell carcinoma of the renal pelvis. The patient declined adjuvant therapy and died 2 months after surgery due to unrelated causes. After comprehensive worldwide literature search, we found 13 cases of SCC of the renal pelvis, including the current case. The mean age was 61.6 years (37–83), with a M : F ratio of 1 : 1.8. The average duration of symptoms was 71.4 days (21–168). Gross hematuria was the most common symptom (69.2%) followed by pain (61.5%). Adjuvant chemotherapy was provided to 4 patients (30.7%), and neoadjuvant to 1 patient. The median survival of patients who did and did not receive chemotherapy was 5.5 months (3–8) and 6 months (2–31), respectively, P < .50. In conclusion, renal SCC (both parenchymal and pelvic SCC) is a rapidly fatal disease with a median survival of ≤8 months.

Complete remission in a patient with metastatic mixed adenocarcinoma/extrapulmonary small cell carcinoma of the prostate

Approximately 10% of all extra-pulmonary small cell carcinoma (EPSCC) arises in the prostate either as de novo mixed adenocarcinoma with small cell components or a pure small cell carcinoma. Extensive disease carries a median survival of about 10 months in retrospective studies. We present a case managed aggressively with concomitant hormonal and chemotherapy, now 36 months without evidence of disease. At a routine physical, a 55 year male was found to have a 5 cm left upper lobe lung mass, invading his 3rd rib. An FNA revealed an adenocarcinoma of unknown primary. His PSA was elevated to 8 ng/mL and a prostate biopsy revealed Gleason 9 adenocarcinoma with neuro-endocrine/SCC components. A bone scan revealed extensive bone metastasis. He was managed aggressively with concomitant cisplatin, etoposide and hormonal therapy and received 73 Gy of radiation to the prostate. PET scans demonstrated marked response to chemotherapy. PSA and chromogrannin levels down trended to normal limits. His most recent PET scan in July 2010 revealed no evidence of disease and is in remission. We present a unique case of metastatic mixed adenocarcinoma/SCC of the prostate, in which the patient survived more than 36 months with complete remission after initiation of aggressive hormonal and chemotherapy. Data on survival in this patient population is limited to case reports, and ordinarily carries a poor prognosis of less than 1 year. In patients with clinical and pathologic features of mixed disease, initiation of early multi-modal therapy is warranted. Additionally, it may be of prognostic significance to biopsy any metastatic lesion.

Large cell neuroendocrine carcinoma of the ampulla of vater with adenocarcinoma and squamous cell carcinoma components

A 73-year-old woman visited our hospital complaining of general fatigue and jaundice. Laboratory tests revealed an elevated total bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and γ-glutamyltransferase. Computed tomography and magnetic resonance imaging demonstrated a mass lesion at the ampulla of Vater with dilatation of the common bile duct and main pancreatic duct. Percutaneous transhepatic cholangiography revealed dilatation of the bile duct and a negative filling defect due to the tumor. Pancreatoduodenectomy was performed. The specimen included an ulcerated firm tumor of the papilla Vater. The surface of the ampulla consisted of well-differentiated papillary adenocarcinoma, whereas the deep layer, such as submucosal or muscular layer, contained large cell neuroendocrine carcinoma and squamous cell carcinoma. Immunohistochemistry revealed that the large cell neuroendocrine carcinoma component was positive for chromogranin A, synaptophysin and CD56. The patient died from multiple liver and bone metastases 13 months after surgery. This is a very rare case of a large cell neuroendocrine carcinoma accompanied by adenocarcinoma and squamous cell carcinoma components.

Impact of 18F-fluorodeoxyglucose positron emission tomography in the staging and treatment response assessment of extra-pulmonary small-cell cancer

The aim of this study was to retrospectively evaluate the value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in extrapulmonary small-cell cancer (EPSCC). Patients with EPSCC who underwent PET for staging or response assessment between 1996 and 2007 were identified from a database. Patient records were reviewed. PET-based, and conventional staging and restaging results were compared. The binary staging classification of limited disease (LD) versus extensive disease (ED) was used. Patients with LD had tumours that could be encompassed within a tolerable radiation therapy (RT) volume. Of 33 eligible patients, 12 had staging PET scans, 11 had restaging scans and 10 had both. All known gross disease sites were FDG-avid. PET and conventional stage groupings were concordant in 21 of 22 cases. One patient was appropriately upstaged from LD to ED by PET. PET detected additional disease sites, without causing upstaging in three further patients. Restaging PET scans identified previously unrecognised persistent or progressive disease in 4 of 21 cases. In four further cases, persistent FDG uptake after treatment was either false positive (n = 2) or of uncertain (n = 2) aetiology. PPV was 100% for staging and 82% for restaging. In 8 of 43 imaging episodes (19%), PET appropriately influenced management in five cases by changing treatment intent from radical to palliative, and in three cases by altering the RT volume. PET has incremental value compared to conventional imaging for staging EPSCC, and may also be useful for restaging after therapy. PET influenced patient management in 19% of 43 imaging episodes.

Primary cutaneous small-cell carcinoma: a case report

Most commonly arising in the gastrointestinal and genitourinary tracts, extrapulmonary small-cell carcinoma is quite rare. Although its prognosis is very poor, complete remission or even cure can be achieved by combination of different treatment modalities. We report here a 32-year-old woman with a cutaneous gluteal mass diagnosed as small-cell carcinoma of the skin. Combination chemotherapy containing cisplatin and etoposide was started. Radiotherapy was administered after two courses of chemotherapy. Following radiotherapy, additional 4 courses of chemotherapy were given. She has been in remission for three years with no evidence of tumor recurrence.

Small cell carcinoma originating from the cavernous sinus

BACKGROUND

We report a rare case of small cell carcinoma originating from the right cavernous sinus in a 55-year-old male. The patient had sudden onset of right abducens palsy following right oculomotor palsy.

METHODS

Post-contrast T1-weighted MRI revealed a mass lesion of 3-cm maximum size occupying the right cavernous sinus and extending to the right middle cranial fossa. After biopsy via the frontozygomatic approach, one radiosurgery treatment was followed by four cycles of chemotherapy (cisplatin together with VP-16 therapy), after which the lesion diminished dramatically in size.

RESULTS

Complete remission has currently been achieved. The patient recovered from the extraocular muscle paresis and returned to his previous work. Although it is considered possible that small cell carcinoma can occur wherever neuroendocrine cells exist, a lesion originating in the cranium is extremely rare. To the best of our knowledge, this is the first report of small cell carcinoma of intracranial origin.

The epidemiology and survival of extrapulmonary small cell carcinoma in South East England, 1970-2004

BACKGROUND

Extrapulmonary small cell carcinoma (EPSCC) is a rare cancer and few studies describe its epidemiology. Our objectives were to compare the incidence and survival of EPSCC in South East England with small cell carcinoma of the lung (SCLC), to determine the most common anatomical presenting sites for EPSCC and to compare survival in EPSCC by disease stage and site of diagnosis.

METHODS

We used data from the Thames Cancer Registry database for South East England between 1970 and 2004 to determine the incidence, most common anatomical sites, and survival by site, and stage of EPSCC. 1618 patients registered with EPSCC were identified. We calculated the age-standardised incidence rate for EPSCC using the European standard population and compared this to that for SCLC. We calculated survival using the Kaplan-Meier method for EPSCC and SCLC, and reported 3-year survival for different EPSCC anatomical sites and disease stages.

RESULTS

The incidence of EPSCC was much lower than for SCLC, similar in males and females, and stable throughout the study period, with incidence rates of 0.45 per 100,000 in males and 0.37 in females during 2000-2004. In general, patients with EPSCC had a better 3-year survival (19%) than SCLC (5%). The most common anatomical sites for EPSCC were oesophagus (18%), other gastrointestinal (15%), genitourinary (20%), head and neck (11%), and breast (10%). Breast EPSCC had the best 3-year survival (60%) and gastrointestinal EPSCC the worst (7%).

CONCLUSION

This study suggests that EPSCC has a stable incidence and confirms that it presents widely, but most commonly in the oesophagus and breast. Site and extent of disease influence survival, with breast EPSCC having the best prognosis. Further studies using standardised diagnosis, prospective case registers for uncommon diseases and European cancer registries are needed to understand this disease.

Extrapulmonary small cell carcinoma localized in lymph nodes: is it a different clinical entity?

BACKGROUND

Extrapulmonary small cell carcinomas (EPSCC) can clinically progress differently depending on the primary site of disease involvement. This review is focused on patients with small cell carcinoma (SmCC) exclusively localized in a lymph node or in multiple lymph nodes without any evidence of a primary tumor in any other organ.

METHODS

We searched the period 1980 to 2007 in the PubMed database and identified 11 publications in the English language presenting at least one case of SmCC. In total 28 individual patients were included in the present study. They were scrutinized in terms of epidemiology, clinical presentation, staging, pathology, etiology, treatment and prognosis.

RESULTS

Characteristics such as age, gender and smoking were similar to those seen in other EPSCCs. Median survival was not reached (42+, range, 9.1 to 100 months). The survival rate was found to be 79% at 3 years. Seventy-seven percent of the patients had limited stage disease. These patients completely responded to surgical therapy, chemotherapy, radiotherapy or to a combination of these treatments. Seventy-one percent of the patients with limited stage SmCC localized in lymph nodes were recurrence-free during the study periods.

DISCUSSION

Our review patient group with SmCC localized in lymph nodes exhibited an excellent clinical behavior and survival results when compared to other patients with pulmonary and non-pulmonary SmCCs. SmCCs localized in lymph nodes may be a separate clinical entity.

Clinical and therapeutic aspects of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinoma (EPSCC) is usually treated similarly to small cell lung cancer. Differences in aetiology, clinical course, frequency of brain metastases, and survival, however, warrant a differential therapeutic approach. In this review, we focus on the treatment of the most predominant sites of origin of EPSCC; the gastrointestinal tract, the genitourinary tract, the head and neck region, and small cell carcinoma of unknown primary. Furthermore we review the available data concerning the controversial issue of prophylactic cranial irradiation (PCI) after optimal treatment of EPSCC. We found in the literature a significant lower incidence of brain metastases in EPSCC as compared to pulmonary small cell carcinoma when PCI is omitted and therefore we do not recommend PCI. An exception is EPSCC originating from the head and neck region which is associated with a higher incidence of brain metastasis, justifying addition of PCI.

Extrapulmonary small cell carcinoma: involvement of the brain without evidence of extracranial malignancy by serial PET/CT scans

Background

Extrapulmonary small cell carcinoma (EPSCC) involving the brain is a rare manifestation of an uncommon tumor type.

Case presentation

We report a 59 year-old Caucasian female diagnosed with an EPSCC involving the left parietal lobe without detectable extracranial primary tumor followed by serial positron emission tomography/computed tomography (PET/CT) imaging. Histopathological examination at both initial presentation and recurrence revealed small cell carcinoma. Serial PET/CT scans of the entire body failed to reveal any extracranial [¹⁸F]2-fluoro-2-deoxy-D-glucose (FDG) avid lesions at either diagnosis or follow-up.

Conclusion

Chemotherapy may show a transient response in the treatment of EPSCC. Further studies are needed to help identify optimal treatment strategies. Combination PET/CT technology may be a useful tool to monitor EPSCC and assess for an occult primary malignancy.

Breast metastasis from small cell lung carcinoma

Breast metastases from extramammary neoplasms are very rare. We presented a 66 year-old female with metastasis of small cell lung carcinoma to the breast. She presented with consolidation over the left upper lobe of her lung undetermined after endobronchial or video-assisted thoracoscopic surgery (VATS) biopsy, and this was treated effectively after antibiotic therapy at initial stage. The left breast lumps were noted 4 months later, and she underwent a modified radical mastectomy under the impression of primary breast carcinoma. However, the subsequent chest imaging revealed re-growing mass over the left mediastinum and hilum, and cells with the same morphological and staining features were found from specimens of transbronchial brushing and biopsy. An accurate diagnosis to distinguish a primary breast carcinoma from metastatic one is very important because the therapeutic planning and the outcome between them are different.

Prognostic factors in extrapulmonary small cell carcinomas. A large retrospective study

BACKGROUND

Extrapulmonary small cell carcinoma (EPSCC) is a heterogeneous group of cancers. The clinicopathological features of EPSCC remain poorly defined.

PATIENTS AND METHODS

Patients with the clinicopathological features of EPSCC, treated at three major medical centers in Taiwan, were included. Histologic and clinical diagnoses, smoking history, staging, clinical course and treatment outcome were reviewed and analyzed.

RESULTS

A total of 90 patients, treated between 1995 and 2005, were eligible for analysis. Forty-nine patients had limited disease and 41 extensive disease. Ten, 18, 17 and 45 patients received no treatment, local treatment, chemotherapy alone or combined modality treatment, respectively; the median survival for these four groups was 1.1, 13.8, 6.7 and 24.9 months. The origin of cancer was head and neck in 17, gastrointestinal in 27, genitourinary in 10, gynecologic in 27 and unknown in 9 patients; the median survival time was 34.2, 6.4, 9.1, 23.7 and 9.2 months, respectively. Ten out of 90 patients were long-term survivors, and 9 of them had tumors of head-and-neck and gynecologic origin. There was no statistically significant difference in survival between smokers and non-smokers. Factors associated with survival in univariate analysis included age < or =60, female gender, limited disease, head-and-neck and gynecologic origin, as well as combined modality treatment. However, in multivariate analysis, only female gender, limited disease and combined modality treatment were independent predictors of survival.

CONCLUSIONS

Female gender, limited disease and combined modality treatment are favorable prognostic factors for patients with EPSCC. Prolonged survival is more likely in patients with tumors of head-and-neck and gynecologic origin.

Extrapulmonary small-cell carcinoma compared with small-cell lung carcinoma: a retrospective single-center study

BACKGROUND

The study was conducted with the aim of reviewing the clinical features, therapy, and natural course of patients with extrapulmonary small-cell carcinoma (EPSCC) and small-cell lung carcinoma (SCLC) to better define current concepts regarding EPSCCs.

METHODS

The medical records of patients with proven diagnosis of small-cell carcinoma (SmCC) between January 1999 and May 2006 were retrospectively reviewed. A total of 65 SmCC cases were included in the study (11 [17%] cases of EPSCC and 54 [83%] cases of SCLC).

RESULTS

Progression-free survival of all patients with EPSCC and patients with extensive EPSCC disease was 7 months (95% confidence interval [CI], 0.58-13.42) and 7 months (95% CI, 4.71-13.29), respectively. Overall survival of all patients with EPSCC and patients with extensive EPSSC disease was 32 months (95% CI, 18.74-45.26) and 28 months (95% CI, 12.24-43.76), respectively. Progression-free survival and overall survival for all patients with SCLC were 5 months (95% CI, 2.26-7.74) and 10 months (95% CI, 5.95-14.05), respectively. Progression-free survival and overall survival for patients with extensive disease were 3 months (95% CI, 4.71-13.29) and 5 months (95% CI, 3.33-6.67), respectively. Overall survival was significantly better in all patients with EPSCC and in patients with extensive EPSCC disease compared with all patients with SCLC and patients with extensive SCLC disease (P = .014, P = .004, respectively). Early death and brain metastasis were observed in a higher number of patients with SCLC compared with EPSCC; however, these results were not statistically significant (P = .33 and P = .076, respectively). Smoking history was significantly less in the EPSCC group (P < .0001).

CONCLUSIONS

EPSCC is usually treated similarly to SCLC. However, this study suggests some differences such as etiology, clinic course, survival, frequency of brain metastases, and early death between these entities. These possible differences may influence the choice of therapeutic approach.

Limited-Stage Extrapulmonary Small Cell Carcinoma: Outcomes After Modern Chemotherapy and Radiotherapy

BACKGROUND

The purpose of this study was to determine the clinical outcomes and patterns of failure of limited-stage extrapulmonary small cell carcinoma (EPSCC) treated with modern chemotherapy and radiation (RT).

METHODS

We retrospectively identified 18 patients with limited-stage EPSCC treated definitively with three-dimensional conformal RT or intensity modulated radiation therapy and chemotherapy. Patients were treated between November 1987 and May 2006. Primary sites of disease included head and neck (n = 7), genitourinary (n = 7), gynecologic (n = 3), and gastrointestinal (n = 1). Chemotherapy consisted of combined platinum and etoposide in 88% of patients. The median number of chemotherapy cycles was 4 (range 3-6), and the median RT dose was 62 Gy (range 32.4-85 Gy). No patient received prophylactic cranial radiation.

RESULTS

With a median follow-up for all patients of 14 months (range 4-42 months), the median overall survival was 17 months, and median disease-free survival was 6 months. Eleven percent (2 of 18) of patients had a locoregional failure, and 78% (14 of 18) had a distant failure. One of these patients had a brain failure. There were no significant differences between the overall survival for patients with gynecologic, head and neck, and genitourinary disease.

CONCLUSIONS

Despite modern chemotherapy and RT, patients with limited-stage EPSCC do poorly. Consistent with previous findings the majority of the first failures are distant. Brain failures in this series were uncommon despite no prophylactic cranial radiation. These findings support the need for further studies in an attempt to improve systemic therapies for this disease.