Extrapulmonary oat cell carcinoma

Syndrome of inappropriate antidiuretic hormone associated with chemotherapy-induced tumour lysis in small-cell lung cancer: case report and literature review

A patient with a small-cell lung cancer (SCLC) developed an asymptomatic hyponatremia, with all features of the syndrome of inappropriate antidiuretic hormone secretion (SIADH), two days after the start of his first cycle of chemotherapy with vindesine, ifosfamide and cisplatin. Progression of the tumour with an increase in paraneoplastic SIADH, or drug-induced causes of hyponatremia, could be ruled out by his further clinical course. The event was interpreted as a consequence of ADH release during the initial tumour cell lysis after effective chemotherapy. The occurrence of hyponatremia during the initial phase of chemotherapy for SCLC should be interpreted with caution. Although it is most commonly due to an increase in paraneoplastic ADH secretion reflecting ineffective therapy, it can also be due to release of ADH from malignant cells in the period of rapid tumour lysis, reflecting effective therapy. Based on this rare occurrence, a review of the aetiology, clinical findings, diagnosis, prognosis and treatment of SIADH in general is presented.

Thymic neuroendocrine carcinomas with combined features ranging from well-differentiated (carcinoid) to small cell carcinoma. A clinicopathologic and immunohistochemical study of 11 cases

We reviewed 11 cases of primary thymic neuroendocrine carcinomas with combined features ranging from well-differentiated to poorly differentiated neuroendocrine carcinoma. For 3 asymptomatic patients, tumors were discovered during routine examination. Presentation in the other patients was as follows: Cushing syndrome, 2 patients; chest pain, 3 patients; superior vena cava syndrome, 1 patient; and hypercalcemia and hypophosphatemia, 1 patient. No clinical data were available for the 11th patient. All tumors were located in the anterior mediastinum and treated by surgical excision. The lesions were large and well-circumscribed with areas of hemorrhage and necrosis. They were characterized by areas showing a proliferation of monotonous, round tumor cells adopting a prominent organoid pattern admixed with areas showing sheets of atypical cells with hyperchromatic nuclei, frequent mitoses, and extensive areas of hemorrhage and necrosis. Immunohistochemical studies performed in 6 cases showed strong CAM 5.2 low-molecular-weight cytokeratin positivity in all cases, chromogranin and synaptophysin positivity in 4, Leu-7 in 3, and focal positivity for p53 in 2. Follow-up information for 9 cases showed that all patients died of their tumors between 1 and 4 years after diagnosis. The present cases highlight the heterogeneity of neuroendocrine neoplasms and reinforce the notion that these tumors form part of a continuous spectrum of differentiation.

Primary neuroendocrine small cell carcinoma of the breast

A 60-year-old Turkish woman presented with a left breast mass, which was considered for neoadjuvant chemotherapy. By the end of the treatment cycles, the tumor had decreased in size, and the patient underwent modified radical mastectomy with axillary lymph node dissection. Pathologic examination of the tumor revealed a small cell carcinoma with neuroendocrine features confirmed by immunohistochemical stains. Multiple axillary lymph nodes were involved by metastatic small cell carcinoma carrying the same morphologic characteristics noted in the primary breast tumor. We hereby present this case as a primary neuroendocrine small cell carcinoma of the breast. This entity occurs very rarely in the breast, and fewer than a dozen cases have been reported in the literature. Extrapulmonary small cell carcinoma of the breast is reportedly a very aggressive tumor for which no consensus for treatment has yet been drawn.

Combined small and transitional cell carcinoma of the urinary bladder with CA19-9 production

It is well known that extrapulmonary small cell carcinoma, which exhibits morphological features similar to those observed in the lung, occurs in various organs. Clinically, most cases manifest aggressive biological behavior. A case of small cell carcinoma of the urinary bladder producing a high level of serum carbohydrate antigen (CA) 19-9, in which expression was confirmed in cancer cells of small as well as transitional cell carcinoma in the same tumor mass by immunostaining is reported. This paper documents combined small and transitional cell carcinoma of the urinary bladder with CA19-9 production, although it has already been reported that adenocarcinoma or transitional cell carcinoma in various organs frequently expresses CA19-9. Observations suggest that the histogenesis of some cases of combined small and transitional cell carcinoma in the urinary bladder may be the same, as both can produce CA19-9.

Basaloid squamous carcinoma of esophagus: a clinicopathological, immunohistochemical and electron microscopic study of sixteen cases

AIM: To further clarify the clinicopathological, immunohistochemical and electron microscopic features, and prognostic aspect of basaloid squamous carcinoma (BSC), a rare esophageal carcinoma.

METHODS: We reviewed 763 documented cases of esophageal malignancies (1977-1996) from our hospital, and discovered 16 (2.1%) cases of BSC. The clinicopathological features of these cases were evaluated. Immunohistochemistry (S-P method), histochemical stains, and electron microscopy were used to further characterize the neoplasm.

RESULTS: The tumors were classified into stages I (n = 1), IIA (n = 6), IIB (n = 2), III (n = 5), and IV (n = 2) according to the criteria of the UICC TNM classification system of malignant tumors (1987). Most neoplasms were located in the mid third of the esophagus. Grossly, they had a similar appearance of conventional esophageal carcinoma, but showed a typical cytoarchitectural pattern of BSC histologically. The most important histologic feature of this tumor is carcinoma with a basaloid pattern, intimately associated with squamous cell carcinoma, dysplasia, or focal squamous differentiation. The basaloid cells were round to oval in shape with scant cytoplasm, arranged mainly in the form of solid, smooth-contoured lobules with peripheral palisading. A panel of immunostains were used for the basaloid component of the tumor with the following results: CK (Pan) 14/16 (+); EMA 16/16 (+); Vimentin 4/16 (+); S-100 protein 7/16 (+). CEA and smooth muscle actin were negative. Electron microscopy (EM) revealed that the basaloid cells were poorly differentiated, with a few desmosomes and fibrils, and numerous free and polyribosome. Of the 11 patients with adequate follow-up 8 died within 2 years, with an average survival time of 16.2 months. No stage II, III or IV cases survived beyond 5 years. The one-year survival rate was 60% and two-year 20%.

CONCLUSION: The BSC of esophagus is a distinct clinicopathological entity with poor prognosis. The cellular differentiation and biologic behavior of esophageal BSC were assumed to occupy a station intermediate between that of conventional squamous cell carcinoma and small undifferentiated cell carcinoma.

Gastric small-cell carcinoma in Japan: a case report and review of the literature

The authors encountered a patient with primary gastric small-cell carcinoma (primary gastric SCC). Histologic examination revealed combined carcinoma containing non-small-cell elements such as adenocarcinoma and squamous cell differentiation. On preoperative biopsy, only well-differentiated adenocarcinoma was collected. Since gastric SCC was first reported in 1976, this type of carcinoma has been detected in 54 patients in Japan. Concerning these cases, the authors reviewed the light and/or electron microscopic findings of neuroendocrine granules, positive reaction for neuron-specific enolase staining, and the histologic type of resected specimens. There were only three patients positive for neuron-specific enolase in which light and electron microscopy demonstrated neuroendocrine granules. However, 50 patients (approximately 93%) overall satisfied at least one of these findings. Concerning the histologic characteristics of the resected specimens, multidirectional differentiation was more markedly observed compared with that in SCC of the lung. Adenocarcinomatous and/or squamous differentiation was observed in more than half the cases, and preoperative biopsy suggested carcinoma other than SCC or undifferentiated carcinoma in several cases.

Fine-needle aspiration biopsy of metastatic small cell carcinoma from extrapulmonary sites

Like a pulmonary counterpart, extrapulmonary small cell carcinoma (SCC) is an aggressive tumor with a high rate of metastasis. Forty-nine fine-needle aspiration biopsies (FNABs) (36 patients) of various primary sites other than the lung diagnosed as metastatic SCC (including Merkel cell carcinoma) were reviewed. FNABs were derived from lymph nodes (20), liver (7), bone (2), breast (1), pancreas (1), and skin/soft tissue (18). Primary tumor sites included the prostate (14), skin (11; Merkel cell carcinoma), cervix (5), urinary bladder (3), urethra (1), ovary (1), and parotid (1). Aspirates revealed predominantly dispersed single tumor cells with occasional clustering. Tumor cells were small with scant cytoplasm, fine powdery chromatin, and inconspicuous nucleoli. Nuclear molding, mitotic figures, and apoptotic bodies were frequently observed. In four cases, findings from the FNABs were used to render the initial diagnosis of SCC. FNAB is useful for determining whether metastases contain a SCC component, a finding that may alter clinical management. Cytologically, SCC from different primary sites cannot be differentiated, and its distinction requires clinical and radiographic correlation.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses

Small cell neuroendocrine carcinomas (SNECs) of the sinonasal tract are extremely uncommon tumors. We reviewed the clinicopathologic features of six cases of this neoplasm. There was no sex preponderance with three females and three males and a mean age at presentation of 51 years (range, 38 to 68). Two patients had disease limited to the nasal cavity, and in four the tumor involved the nasal cavity and maxillary or ethmoid sinuses. Involvement of the orbit was present in two patients. Surgery was the primary treatment. After a mean follow-up of 37 months, one patient died of local disease and liver metastases, four were alive with recurrent or metastatic disease, and one died of unrelated causes. The tumors were composed of sheets, nests, and trabeculae with extensive areas of necrosis and hemorrhage. The individual cells were small to intermediate in size and had scanty cytoplasm. The nuclei were oval or round and hyperchromatic with absent or inconspicuous nucleoli. Nuclear molding and crush artefact were present in five cases. All tumors had a high mitotic rate with frequent abnormal mitotic figures. All cases stained for Cam 5.2, neuron-specific enolase, and chromogranin. Five cases were positive for AE1:AE3, and four for synaptophysin. No case stained for S-100 protein, or neurofilaments. O-13 stained one case. No case contained EBV-RNA. SNECs of the nasal cavity and paranasal sinuses are aggressive tumors with pathological features similar to those of anaplastic small cell carcinomas of the lung. They exhibit morphological and immunophenotypic features different from olfactory neuroblastoma and should be distinguished from this tumor.

Primary small cell carcinoma of the esophagus: flow cytometric analysis and immunohistochemical staining for the p53 protein and proliferating cell nuclear antigen

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the clinical course and effects of histopathologic characteristics of specific tumors including DNA contents and immunohistochemical aspects in patients with small cell carcinoma of the esophagus.

METHODS

Medical records of 4 patients who presented with small cell carcinoma of the esophagus were retrospectively reviewed.

RESULTS

DNA aneuploidy was observed in 2 cases. Staining for the p53 product was positive in all cases. The average proliferating cell nuclear antigen (PCNA) labeling rate (LR) was 77.6% (64.0-90.8%). The estimated median survival was 42 days for all patients. Distant metastases were observed in 2 of the 4 patients.

CONCLUSIONS

Higher PCNA LR of small cell carcinoma may be an unfavorable characteristic of biological behavior. Patients with disseminated disease should have symptomatically palliative operation combined with chemotherapy.

Genitourinary small cell carcinoma: determination of clinical and therapeutic factors associated with survival

PURPOSE

We assessed the prognostic impact of genitourinary small cell carcinoma tumor and patient characteristics, and therapy.

MATERIALS AND METHODS

We retrospectively reviewed the records of 180 patients with genitourinary small cell carcinoma in which patient and tumor characteristics, therapy, followup duration and survival status had been documented. Patient age, sex, primary site, histological features, tumor size, stage, locoregional therapy, systemic chemotherapy and hormonal manipulations were analyzed for association with survival.

RESULTS

There were 106 cases of bladder, 60 prostatic, 8 renal and 6 ureteral small cell carcinoma. Median survival was 10.5 months overall, and 7 and 13 months for prostatic and bladder small cell carcinoma, respectively (p <0.0001 log rank analysis). In all cases metastatic disease at presentation (p <0.008, risk ratio 1.9) predicted poor survival on multivariate analysis. Radical surgery (p <0.0001, risk ratio 0.34) and cisplatin chemotherapy (p <0.0001, risk ratio 0.20) were the only factors that predicted improved survival on multivariate analysis. For prostatic small cell carcinoma primary surgical therapy (p <0.012, risk ratio 0.46) was the only parameter that predicted survival on univariate analysis. For bladder small cell carcinoma only cisplatin chemotherapy (p <0.0001, risk ratio 0.15) predicted survival on multivariate analysis.

CONCLUSIONS

Genitourinary small cell carcinoma has a poor prognosis, which is worse in prostatic than bladder disease. Patient and tumor characteristics were not determinants of survival when prostatic and bladder small cell carcinoma were analyzed individually. For prostatic disease only primary surgical therapy was associated with prolonged survival, while for bladder disease cisplatin chemotherapy was associated with a favorable prognosis. We recommend considering primary surgical therapy for prostatic and cisplatin based chemotherapy for bladder small cell carcinoma.

Oat Cell Carcinoma of the Tongue from an Unknown Primary

Oat cell carcinoma is rarely diagnosed in the head and neck and can be primary or secondary. Primary tumors arise from amine precursor uptake and decarboxylation cells which are found throughout the head and neck. Secondary deposits metastasize most commonly from the lungs.

We report a 64-year-old woman with a known pancreatic oat cell carcinoma who came to the ENT Department with dysphagia. On examination, a lesion was seen at the base of the tongue and was histologically an oat cell carcinoma. No treatment was administered and the patient died one month after discharge.

This report highlights the difficulty in determining the primary site when a rare tumor metastasizes to the head and neck and no autopsy findings are obtained. To our knowledge, oat cell carcinoma of the tongue has not been previously reported.

Small cell carcinoma of the larynx: imaging findings

Small cell carcinoma of the larynx is an uncommon epithelial tumor, which is the most aggressive subtype of neuroendocrine carcinomas. Because of its nonspecific clinical and radiological manifestations, the diagnosis of small cell carcinoma of the larynx is essentially based on the light microscopic examination aided by electron microscopy or immunohistochemical staining. We report a case of supraglottic small cell carcinoma accompanied by large bilateral cervical lymph node metastasis ocurring in a 70-year-old man. On CT scans, no area of low attenuation indicating necrosis was demonstrated within such large metastatic lymph nodes. We suggest that small cell carcinoma of the larynx should be included in the diagnostic considerations when a laryngeal mass is accompanied by large cervical lymph nodes without necrosis shown by CT.

Small cell carcinoma arising from the outer urethral orifice: a case report examined by histologic, ultrastructural and immunohistochemical methods

A case of small cell carcinoma arising in the outer urethral orifice is presented. The resected tumor showed a proliferation of small round or fusiform neoplastic cells in the submucosa. Tumor cells were arranged in sheets or a trabecular manner and possessed markedly hyperchromatic nuclei with a high N:C ratio, closely resembling small cell carcinoma of the lung. Characteristically, pagetoid intraepithelial spreading could be identified. However, there was no evidence of in situ transitional cell carcinoma and adeno- or squamous cell carcinoma components anywhere. Ultrastructurally, each tumor cell contained only a few membrane-bound cored granules measuring 60-100 nm, which were compatible with neurosecretory granules, and desmosome-like intercellular attachments, but lacked aggregated microfilaments. By immunohistochemical examination, tumor cells were positive for epithelial markers, such as cytokeratin and epithelial membrane antigen, and neuron specific enolase, but negative for any other neuro-endocrine markers. Extensive systemic examination failed to show the primary site to be other than the outer urethral orifice. These findings indicate that the current tumor is a small cell carcinoma with neuro-endocrine differentiation arising from the outer urethral orifice.

Small cell carcinoma of the vagina causing Cushing's syndrome by ectopic production and secretion of ACTH: a case report

BACKGROUND

Small cell carcinomas of pulmonary or extrapulmonary origin are neuroendocrine tumors classically associated with ectopic hormone production, particularly ACTH secretion resulting in Cushing's syndrome. However, ectopic Cushing's syndrome has not previously been reported in the setting of small cell carcinoma of the vagina.

METHODS

A primary vaginal tumor with hepatic metastases was evaluated with light microscopy. Serum cortisol and plasma ACTH levels were evaluated by radioimmunoassay and immunoradiometric assay, respectively, during a standard high-dose (8 mg) overnight dexamethasone suppression test.

RESULTS

Vaginal small cell carcinoma with hepatic metastases was demonstrated. Electrolyte abnormalities, elevated cortisol and ACTH levels, and failure to suppress ACTH secretion during high-dose dexamethasone administration confirmed the diagnosis of ectopic ACTH syndrome.

CONCLUSIONS

This case report establishes a clinical association between vaginal small cell carcinoma and ectopic Cushing's syndrome, confirming the neuroendocrine potential of this malignancy and features common to small cell neoplasms originating in other sites.

Small cell neuroendocrine carcinoma of the urinary bladder. A clinicopathologic study with emphasis on cytologic features

BACKGROUND

Primary small cell neuroendocrine carcinoma (SCNEC) of the urinary bladder is a rare but important entity. The authors have attempted to define the cytopathologic features of this tumor.

METHODS

Sixty-one urine specimens (16 with histologic correlation) from 23 patients were studied. Twenty patients were male and 3 were female with an age range of 43 to 86 years (mean age, 68.8 years). Twenty-one cases were pure SCNEC and 2 were high grade undifferentiated carcinoma with neuroendocrine features. There were no false-positive or false-negative urine cytology diagnoses, but several cases of SCNEC were originally diagnosed as high grade transitional cell carcinoma by cytology.

RESULTS

Cytologic features of SCNEC included hypercellularity with isolated single cells and clustered cells with naked hyperchromatic nuclei, finely granular nuclear chromatin, rare nucleoli, and a high mitotic karyorrhectic index. Nuclear molding was prominent. No glandular formation or nesting was noted. Half of the cases had a bloody, necrotic, or inflamed background. Histology, when available, was confirmatory in all cases.

CONCLUSIONS

Cytologic features of SCNEC are distinct and an accurate urinary cytologic diagnosis can be made. Differential diagnosis is limited and includes metastatic small cell carcinoma, high grade transitional cell carcinoma, and malignant lymphoma.

Two cases of small cell carcinoma of the prostate

We describe the clinical and pathological findings in two Japanese men with small cell carcinoma of the prostate; case 1 was 58 years old and case 2 was 24 years old. Case 1 was initially diagnosed as a poorly differentiated adenocarcinoma of the prostate, stage D2, with marked elevation of serum neuron-specific enolase (NSE), carcinoembryonic antigen (CEA), and CA 19-9 levels. The patient had undergone castration and systemic chemotherapy. After three courses of chemotherapy, tumour markers were normalized. However, 6 months later serum levels of tumour markers again rose, and biopsy of the prostate revealed a small cell carcinoma component in the adenocarcinoma of the prostate and benign prostate hypertrophy. The patient was again treated with systemic chemotherapy but died within 1 year after relapse. In case 2, the patient presented with initial symptoms of lumbago and dysuria, and an enlarged prostate was radiologically diagnosed. Shortly after admission he developed ileus, and an exploratory laparotomy revealed a large tumour arising from the prostate and invading the peritoneal cavity. This tumour was pathologically diagnosed as a small cell carcinoma. The patient died shortly thereafter without responding to chemotherapy. Immunohistological evaluation was done using a panel of antibodies against NSE, chromogranin A, CEA, CA 19-9, prostatic acid phosphatase (PAP), prostate-specific antigen (PSA), leukocyte common antigen (LCA), epithelial membrane antigen (EMA), adrenocorticotropic hormone (ACTH), calcitonin, serotonin, gastrin, vasoactive intestinal peptide (VIP), and glucagon. CEA was intensely positive in the tumour lesions from case 1, and NSE and ACTH were focally positive, and calcitonin, serotonin, CA 19-9, and PSA were weakly positive only in several cells in the tumour lesions from case 1. In the tumour lesion from case 2, NSE was intensely positive, and chromogranin A was weakly positive. These findings support the neuroendocrine nature of this neoplasm.

Cytology of small cell carcinoma of the urinary bladder

To characterize the cytologic spectrum of small cell carcinoma of the urinary bladder, a review of 42 urinary cytology specimens from 13 patients with histologically proven tumors was conducted. Patients ages ranged from 45 to 81 yr (mean 68.9). In four tumors, small cell carcinoma was the sole malignant cellular component: all 11 urinary specimens in these patients harbored cells with features of an undifferentiated small cell carcinoma. In the remaining nine tumors, small cell carcinoma appeared with transitional, squamous cell or adenocarcinoma, but in four, small cell carcinoma was the sole invasive component. Almost one third of urinary specimens in this group lacked a small cell component. Neuroendocrine differentiation was confirmed by immunopathology in eleven cases (neuron specific enolase positive in 11 of 12, synaptophysin in 2/11, chromogranin in 2/13, Leu 7 in 2/7), and by ultrastructural analysis in two. Small cell carcinoma is a cytologically recognizable variant of bladder cancer, but admixture with other malignant components may mask its appearance in urinary specimens.

Response of small cell carcinoma of pancreas to a small cell lung cancer regimen: a case report

Small cell carcinoma of the pancreas is a very rare malignancy with 18 cases reported in the literature, of which only 3 were treated with chemotherapy. A 52-year-old man was diagnosed with small cell carcinoma originating in the head of the pancreas and invading the duodenum. He was treated with a similar approach as for localized small cell lung cancer, with six cycles of combination chemotherapy and local radiotherapy, and went into complete remission. After 3 months, he developed liver metastases along with an enlarged left supraclavicular lymph node. He was treated with two cycles of CVA, but developed lung metastases and was treated with ifosfamide/mesna. However, his overall condition deteriorated and hospice care was instituted until the patient's demise. The patient survived 14 months following diagnosis, significantly longer than the 15 reported patients with small cell pancreatic carcinomas not treated with chemotherapy. Combination chemotherapy and radiation therapy as it is utilized for small cell lung cancer appear to be beneficial for small cell carcinoma of the pancreas.

Undifferentiated small-cell carcinoma of the urinary bladder: report of two cases with a primary urinary cytodiagnosis

Two undifferentiated small-cell carcinomas of the urinary bladder are reported. The patients, 68- and 55-yr-old men, respectively, presented with painless hematuria. In the first case, numerous small, lymphocyte-like cells with coarse chromatin, sometimes with small nucleoli, and high nuclear/cytoplasmatic ratios were found in cytologic urine specimens. A cytodiagnosis of undifferentiated small-cell cancer was made. In the second case, urine samples showed rare aggregates of small, undifferentiated cells in association with malignant urothelial cells. The cytodiagnosis of mixed tumor composed of undifferentiated small cell and transitional carcinoma was confirmed by histologic examination. The presence of focal reactivity with anti-chromogranin antibody and neurosecretory granules via electron microscopy supports a neuroendocrine differentiation for the small neoplastic cells. The patients died 13 and 8 mo after diagnosis, respectively.

Successful treatment of metastatic small cell carcinoma of the bladder with methotrexate, vinblastine, doxorubicin and cisplatin therapy

A man with metastatic small cell carcinoma of the bladder who was treated with methotrexate, vinblastine, doxorubicin and cisplatin therapy achieved complete remission with disease-free survival of more than 9 years. The nature of this unusual form of bladder carcinoma and the course of the disease in our case are discussed.

Extrapulmonary small cell cancer

Extrapulmonary small cell cancer is rare, but it occurs in a wide variety of sites, where it has a behaviour quite different from the tumours normally found at those sites. Prognosis is generally poor, but combined modality treatment with combination chemotherapy can often achieve useful palliation and, occasionally, long term remission and cure.

Neurologic complications of patients with small cell prostate carcinoma. Report of two cases

BACKGROUND

Primary small cell carcinoma arising in organs other than the lung were thought to be relatively rare. However, with the increasing technical sophistication of pathology departments, tumors with foci of small cell neuroendocrine components are being identified more frequently. The pattern of disease involvement and optimal treatment have yet to be defined.

METHODS

Two cases of primary small cell carcinoma of the prostate are described in which patients previously had unreported degrees of central nervous system disease.

RESULTS

Approximately 75 cases of small cell carcinoma of the prostate have been reported. Neurologic complications have been reported infrequently, although a variety of neurologic paraneoplastic sequelae have been noted. However, carcinomatous meningitis or development of intraductal tumors without concomitant vertebral bone disease has never been reported. These tumors respond poorly to hormonal therapy alone, and recent reports suggest optimal therapeutic strategies may involve combination hormone and chemotherapy.

CONCLUSION

Small cell carcinoma of the prostate must be recognized when it arises de novo or with components of adenocarcinoma because the prognoses and response to treatment differs from the more common adenocarcinomas of the prostate.

Extrapulmonary small cell carcinoma: a single-institution experience and review of the literature

BACKGROUND

Small cell carcinoma (SCC) is a distinct pathologic entity that may also occur in extrapulmonary sites. In this report the retrospective results of multimodal therapy of primitive extrapulmonary (E) SCC, in a single institution series, are presented.

METHODS

Twenty-four patients (pts) with ESCC were referred to the Centro di Riferimento Oncologico, Aviano, Italy, from 1986 to 1992. Clinico-therapeutic findings were evaluated in 20 pts. Their ages ranged from 20 to 87, with a median of 60.5 years. Primary tumor sites were urinary bladder (5 pts), prostate (4 pts), larynx (3 pts), kidney (2 pts), ovary, skin, oropharynx, trachea, uterine cervix, ethmoid, and stomach (1 pt each); lymph node metastases of unknown origin were observed in 3 pts. More than 50% of pts presented extensive disease.

RESULTS

Histologically, 16 cases were pure ESCCs and 8 cases were combined, 4 of them with adenocarcinoma, 2 with transitional cell carcinoma, and 2 with squamous cell carcinoma. Immunohistochemical studies, performed in 7 cases, demonstrated the epithelial nature of these tumors. The cisplatin-VP16 (PE) regimen was used in 13 pts, and 9 of them (69%) obtained objective responses after chemotherapy (CT) alone, with 3 complete remissions (CR) and 6 partial remissions (PR). Median CR and PR duration was 13+ and 24 months, respectively. Radiotherapy was performed in 7/13 pts after induction CT and before consolidation CT. The objective response rate was 100%, with 6 CR and 1 PR. No severe toxic side effects and no toxic deaths were reported. A patient treated with surgery alone for a urinary bladder tumor showed continuous long-term survival, while 1 of 2 pts treated with radiotherapy alone obtained PR.

CONCLUSIONS

The PE regimen has an activity similar to the one observed in pulmonary SCC.

A metastatic neuroendocrine anaplastic small cell tumor in a patient with multiple endocrine neoplasia type 1 syndrome. Assessment of disease status and response to doxorubicin, cyclophosphamide, etoposide chemotherapy through scintigraphic imaging with 111In-pentetreotide

Extrapulmonary small cell and small cell neuroendocrine tumors of unknown primary site are, in general, aggressive neoplasms with a short median survival. Like small cell lung cancer (SCLC), they often are responsive to chemotherapy and radiotherapy. Small cell lung cancer and well differentiated neuroendocrine carcinomas of the gastrointestinal tract and pancreas tend to express somatostatin receptors. These tumors may be localized in patients by scintigraphic imaging using radiolabeled somatostatin analogues. A patient with anaplastic neuroendocrine small cell tumor arising on a background of multiple endocrine neoplasia type 1 syndrome is reported. The patient had a known large pancreatic gastrinoma and previously treated parathyroid adenopathy. At presentation, there was small cell cancer throughout the liver and skeleton. Imaging with a radiolabeled somatostatin analogue, 111In-pentetreotide (Mallinckrodt Medical B. V., Petten, Holland), revealed all sites of disease detected by routine biochemical and radiologic methods. After six cycles of chemotherapy with doxorubicin, cyclophosphamide, and etoposide, there was almost complete clearance of the metastatic disease. 111In-pentetreotide scintigraphy revealed uptake consistent with small areas of residual disease in the liver, the abdomen (in mesenteric lymph nodes), and posterior thorax (in a rib). The primary gastrinoma present before the onset of the anaplastic small cell cancer showed no evidence of response to the treatment. The patient remained well for 1 year and then relapsed with brain, lung, liver, and skeletal metastases. Despite an initial response to salvage radiotherapy and chemotherapy with carboplatin and dacarbazine, the patient died 6 months later.

Small cell carcinoma of the lung metastatic to the wall of a radicular cyst

This case report details the unusual presentation of small cell carcinoma at the periapex of a maxillary left lateral incisor. The initial clinical presentation was that of a symptomatic, nonhealing, well-circumscribed radiolucency about the periapex of the tooth. The biopsy specimen submitted by the endodontist was diagnosed as small cell carcinoma. This report stresses the need for submission of all tissue removed from the oral cavity for histopathological examination.

Small cell carcinoma of the esophagus

BACKGROUND

Small cell carcinoma of the esophagus is regarded as having a poor prognosis with frequent systemic dissemination.

METHODS

A review of the records and histologic sections of 11 patients with primary small cell carcinoma of the esophagus seen in 11 years was undertaken. They were analyzed and compared with the more common squamous cell carcinomas and adenocarcinomas.

RESULTS

Small cell carcinoma of the esophagus constituted 1% of all esophageal tumors and was mainly located at the middle and lower thirds (90%) of the esophagus. Primary treatment consisted of tumor resection in five patients (46%), chemotherapy and radiotherapy in two (18%); surgical bypass in one (9%), radiotherapy after exploratory laparotomy in one (9%), intubation in one (9%), and no active intervention in one (9%). Two of the five resected tumors were Stage IIB disease, and three were Stage III disease. Five of the six patients in the non-resection group had distant metastases at presentation (45% of all patients). The median survival of patients who had chemotherapy (three of whom also had radiotherapy) was 16.7 months (range, 2.8-72 months) and was 2.2 months (range, 4 days to 9.1 months) for those with no chemotherapy. The overall median survival was 3.1 months for all patients. The prognosis was not significantly different from those with squamous cell carcinomas or adenocarcinomas.

CONCLUSIONS

Small cell carcinoma of the esophagus should be regarded as a systemic disease, and multimodality treatment, including chemotherapy, should be used. Surgery may be offered in selected patients to manage local disease as part of a chemotherapy-based treatment program.

Primary small cell carcinoma of the larynx

Small cell carcinoma is a rare tumor of the larynx. We present such a case in a 78-year-old female. The histopathological diagnosis at the time of laryngomicroscopic biopsy was squamous cell carcinoma, upon which basis we initially chose surgical treatment. The surgical specimen, however, revealed small cell carcinoma. Despite the administration of radiotherapy and chemotherapy, the patient died 9 months after initial presentation. We believe that this case illustrates the need for a sufficiently large biopsy specimen in order to arrive at the correct histopathological diagnosis when small cell carcinoma of the larynx is present, and that immunohistochemistry and electron microscopy should be performed to aid the diagnosis.

Small cell carcinoma of the urinary bladder. A clinicopathological study of six cases

OBJECTIVE

To study the clinical, histological, and immunohistochemical findings of small cell carcinoma (SCC) of the urinary bladder, and also to delineate its behaviour in comparison with transitional cell carcinomas of the bladder.

MATERIALS AND METHODS

A retrospective review of 552 patients with bladder cancer yielded six cases (1%) of small cell carcinoma which were histologically identical to pulmonary small cell anaplastic carcinoma. Clinical data and follow-up were collected. Aside from the conventional histological parameters, an immunohistochemical study with AE1-AE3 and Cam 5.2 keratins, epithelial membrane antigen, neuron-specific enolase, chromogranin, synaptophysin, ACTH, calcitonin, and prostatic specific antigen was performed.

RESULTS

The clinical presentation did not differ from conventional transitional cell carcinoma, haematuria being the most frequent complaint (four cases). All the cases presented as flat tumours. On light microscopy, there were oat cell (four cases), intermediate (one case) and mixed oat-cell/intermediate (one case) variants. Three cases were associated with transitional cell carcinoma. Dysplastic changes were observed in the adjacent urothelium in one case only. At the time of diagnosis, all tumours were deeply invasive (pT3). Three cases were Stage III and three Stage IV, with involvement of regional lymph nodes and metastases to the liver (two cases) and lung (one case). Immunohistochemically, epithelial markers were variably expressed as AE1-AE3 keratin (5/6), Cam 5.2 keratin (2/6) and epithelial membrane antigen (3/6). Neuron specific enolase was demonstrated in every case. Chromogranin, however, was expressed in only one case. Synaptophysin, ACTH, calcitonin, and prostatic specific antigen all gave negative results. All the patients died of the disease and the overall length of survival was very poor (range 5-25 months, mean 13.3).

CONCLUSION

Small cell carcinomas show the same histological patterns as their pulmonary counterpart. Immunohistochemistry reveals a wide spectrum of activity, enolase and keratins being the most constant. The present study confirms that the overall prognosis of this tumour is very poor.

Pathology of APUDomas

The pathology of APUDomas involves two main areas. The first is the biochemical aspects of these tumours and the use of biochemical tests to investigate a patient suspected of having an APUDoma, and the other is the histopathology of these tumours. This review is devoted to the histopathological considerations.

Merkel cell carcinoma

Merkel cell carcinoma is a malignant neuroendocrine tumor with features of epithelial differentiation. Biologically aggressive, it may be difficult to diagnose and, particularly in its late stages, even more difficult to treat effectively. This article addresses what is known and what is still controversial about the histogenesis, diagnosis, and management of Merkel cell carcinoma and the structure and function of the Merkel cell from which it is believed to be derived. The incidence, clinical presentation and diagnosis, ultrastructure, immunocytochemistry, treatment, and prognosis of this tumor will be discussed.

Ectopic ACTH syndrome associated with anorectal carcinoma. Report of a case and review of the literature

A 25-year-old black homosexual was noted to be hypertensive, hypokalemic, and to have a rectal mass. Histopathology of the biopsied lesion revealed a mixture of poorly differentiated squamous cell and undifferentiated small cell carcinoma. Abdominopelvic CT showed multiple liver metastases, minimal local tumor extension, and normal adrenal glands. Despite aggressive treatment, he remained hypertensive and hypokalemic. Endocrine work-up revealed: normal 24-hr VMA and catecholamines, normal serum aldosterone and renin levels, elevated urinary free cortisol (3360 micrograms/24 hr), elevated serum cortisol (60 micrograms/dl), and elevated serum ACTH (1697 pg/dl). Liver biopsy confirmed metastatic anorectal carcinoma, and immunohistochemical stains of the rectal biopsy were positive for ACTH and neuron-specific enolase. Although many types of neoplasms have been associated with ectopic ACTH production, small cell carcinoma of the lung is the most common. While there are many reports of colorectal and anorectal neuroendocrine small cell carcinomas, few of these tumors have been associated with clinical ectopic hormone production. This case represents the first report of the ectopic ACTH syndrome associated with anorectal carcinoma.

Bladder preservation and durable complete remission of small cell carcinoma of the bladder with systemic chemotherapy and adjuvant radiation therapy

BACKGROUND

Small cell (oat cell) carcinoma of the bladder is a rare entity characterized clinically by an aggressive behavior with a high incidence of systemic metastases. Radical cystectomy has been the therapeutic focal point for this disease, but systemic relapse is almost universal.

RESULTS

The authors report that combination chemotherapy with cisplatin, methotrexate, and vinblastine, followed by external beam irradiation to the bladder, gave a durable continuous complete remission (more than 4.5 years). In addition, this bladder-sparing approach has preserved normal bladder function and an excellent quality of life.

CONCLUSION

This experience shows that radical cystectomy may not be necessary for small cell carcinoma of the bladder and that early intervention with systemic chemotherapy offers greater potential for cure.

Primary small cell carcinoma of the esophagus with ectopic gastrin production. Report of a case and review of the literature

A case of primary small cell carcinoma of the esophagus in which extensive hormonal studies could be performed is reported. The tumor was considered as a neuroendocrine tumor because the tumor cells showed intracytoplasmic argyrophilia, neurosecretory granules, and positive stain for neuron-specific enolase with Grimelius stain, electron microscopy, and immunohistochemistry, respectively. Furthermore, the tumor was regarded as a gastrin-producing tumor because of positive stain for gastrin in the tumor cells. The present case is the first case of primary small cell carcinoma of the esophagus with ectopic gastric production.

Tissue reactivity of anti-Leu19

Monoclonal antibody anti-Leu19, is a marker of natural killer cells. Since reactivity between anti-Leu7, another natural killer cell marker, and small cell neuroendocrine carcinomas has been described, we evaluated the reactivity of anti-Leu19 in 92 neuroendocrine tumours. Frozen sections in each case were immunostained using the avidin-biotin-peroxidase complex method with monoclonal anti-Leu19. We found Leu19 expression in 93% of the cases. We also evaluated 149 other tumours, including adenocarcinomas, undifferentiated large cell carcinomas, lymphomas, melanomas and soft tissue tumours. We found Leu19 expression in 36% (by liberal interpretative criteria), or 29% (by conservative interpretative criteria) of these cases. Thus, while anti-Leu19 appears to be a sensitive marker for neuroendocrine tumours, a lack of specificity limits its practical application in diagnostic histopathology.

Small cell undifferentiated carcinoma of the pancreas. Report of a patient with tumor marker studies

BACKGROUND

Small cell undifferentiated carcinoma of the pancreas is a rare type of pancreatic neoplasm.

METHODS

The authors report the clinical and pathologic aspects of a patient with this malignant lesion and an extensive serologic and immunohistochemical survey of potential ectopically produced hormones or tumor markers.

RESULTS

Neuron-specific enolase (NSE) emerged as a tumor marker.

CONCLUSIONS

NSE could be valuable in the diagnosis and management of other patients with this rare disease.

Small cell neuroendocrine carcinoma of the vagina

A 65-year-old woman with a history of recurrent vaginal intraepithelial neoplasia was found to have small cell carcinoma (SCC). Exfoliative cytology was instrumental in the discovery of each episode of vaginal neoplasia. Thorough examination of the patient established the tumor as being primary to the vagina, and immunohistochemistry confirmed it to be a neuroendocrine SCC. Eleven patients with neuroendocrine SCC of the vagina have been reported previously. Morphologic characteristics and histogenesis are discussed within the context of the embryology and natural history of extrapulmonary-genital SCC. They have been classified in the amine precursor uptake and decarboxylation family of neoplasms. Originally, a neuroectodermal origin was proposed, but derivation now is thought to be from multipotential epithelial stem cells of the genital tract. Neuroendocrine SCC tends to be an aggressive neoplasm with a propensity for early spread. Long-term survival for patients with vaginal SCC has not been documented. Therapeutic decisions regarding SCC from this site have been based on information gained from the treatment of these tumors elsewhere. Combined modality therapy using initial surgery and adjuvant treatment, including systemic chemotherapy and local exposure to radiation, has produced an apparent complete response in our patient.

An immunohistochemical and ultrastructural study of case of small-cell neuroendocrine carcinoma in the ampullary region of the duodenum

One case of small-cell neuroendocrine carcinoma in the ampullary region of the duodenum is reported. The histological appearance of the tumor was identical to pulmonary small-cell carcinoma. Neuroendocrine differentiation was demonstrated immunohistochemically by positive immunoreaction for neuron specific enolase, Leu-7 and chromogranin, and ultrastructurally by the presence of scanty dense-core neurosecretory type granules. Small-cell neuroendocrine carcinoma in the ampulla of Vater is extremely rare. To our knowledge, this is the sixth reported case.

Oat cell carcinoma of urinary bladder

Oat cell carcinoma of the urinary bladder is extremely uncommon. There have been 52 reported cases in world literature to date. On light microscopic, histochemical, and ultrastructural grounds, these tumors are similar to oat cell carcinoma of the bronchus and other extrapulmonary oat cell carcinomas. Furthermore, they may be grouped together as a clinical entity characterized by an aggressive clinical course with early and extensive metastases, and partial remission with certain chemotherapeutic agents. We report a case of primary small cell carcinoma of the urinary bladder in a forty-two-year-old man and review previous reports with similar histology. The importance of establishing this diagnosis and the optimum forms of therapy are discussed.