Carcinoid of the uterine cervix: additional observations on a new tumor entity

Neuroendocrine carcinoma of cervix and review literature

INTRODUCTION

Neuroendocrine carcinoma of the cervix (NECC) is a rare variant of cervical cancer with poor prognosis and high mortality. Recurrence is seen with multi-organ metastasis including liver.

CASE PRESENTATION

A 65 year old female presented with vaginal bleeding for the past one year. Cervical cancer screening and biopsy demonstrated poorly differentiated squamous carcinoma. Immunohistochemistry showed positive expression of chromogranin, synaptophysin, pancytokeratin, TTP1, and CEA and negative expression of p40 and estrogen receptors. An adenocarcinoma with neuroendocrine tumor was suggested. Hysterectomy with bilateral salpingo-oophrectomy was performed. This was followed by carboplatin and etoposide therapy to have clinical remission for a year. Then recurrence was observed to start same drugs again resulting in to partial improvement. It was followed by radiotherapy. The patient succumbed to death approximately after three months.

CONCLUSION

A metastatic lesion in liver may be a case of Neuroendocrine tumor of cervix, a rare condition that can be easily missed on histopathological examination. More studies are required to establish a standard therapeutic protocol.

Development of an improved diagnostic nomogram for preoperative prediction of small cell neuroendocrine cancer of the cervix

OBJECTIVES

Accurate preoperative diagnosis of small cell neuroendocrine cancer of the cervix (SCNECC) is crucial for establishing the best treatment plan. This study aimed to develop an improved, non-invasive method for the preoperative diagnosis of SCNECC by integrating clinical, MR morphological, and apparent diffusion coefficient (ADC) information.

METHODS

A total of 105 pathologically confirmed cervical cancer patients (35 SCNECC, 70 non-SCNECC) from multiple centres with complete clinical and MR records were included. Whole lesion histogram analysis of the ADC was performed. Multivariate logistic regression analysis was used to develop diagnostic models based on clinical, morphological, and histogram data. The predictive performance in terms of discrimination, calibration, and clinical usefulness of the different models was assessed. A nomogram for preoperatively discriminating SCNECC was developed from the combined model.

RESULTS

In preoperative SCNECC diagnosis, the combined model, which had a diagnostic AUC (area under the curve) of 0.937 (95% CI: 0.887-0.987), outperformed the clinical-morphological model, which had an AUC of 0.869 (CI: 0.788-0.949), and the histogram model, which had an AUC of 0.872 (CI: 0.792-0.951). The calibration curve and decision curve analyses suggest that the combined model achieved good fitting and clinical utility.

CONCLUSIONS

Non-invasive preoperative diagnosis of SCNECC can be achieved with high accuracy by integrating clinical, MR morphological, and ADC histogram features. The nomogram derived from the combined model can provide an easy-to-use clinical preoperative diagnostic tool for SCNECC.

ADVANCES IN KNOWLEDGE

It is clear that the therapeutic strategies for SCNECC are different from those for other pathological types of cervical cancer according to V 1.2021 of the NCCN clinical practice guidelines in oncology for cervical cancer. This research developed an improved, non-invasive method for the preoperative diagnosis of SCNECC by integrating clinical, MR morphological, and apparent diffusion coefficient (ADC) information.

"Neuroendocrine Tumor Grade 3 (NET G3)" of the Uterine Cervix: A Report of 2 Cases

In the fifth edition of the World Health Organization classification of female genital tumors, neuroendocrine neoplasms are subcategorized as neuroendocrine tumors (NETs) of grade 1 (G1) and G2, and neuroendocrine carcinoma. NET G3 is not included, as it is for classification of pancreas tumors. Herein, we report 2 cases of "NET G3" of the uterine cervix with long-term follow-up. The patients are 40- and 36-yr-old women who presented with polypoid masses on the uterine cervix. Microscopic examination of hysterectomy specimens revealed tumor features similar to those of pancreatic NET G3 and intestinal type mucinous carcinoma cells invading the cervical stroma. In both cases, the NET component was positive for synaptophysin and chromogranin A, and negative for TTF-1. Mitotic counts were <1/2 mm 2 and 5/2 mm 2 , and the Ki-67 labeling indexes were 57% and 39%, respectively. Pathologic stage classifications (AJCC, version 9) were pT1b1, pN0, and cM0 (FIGO stage IB1), and both patients received adjuvant therapy. One patient had lung and pancreas metastases 4 to 8 yr after initial surgery, which were surgically removed. Both patients remain alive without evidence of recurrent disease 6 and 16 yr after initial surgery. The indolent clinical courses of these cases appear to indicate that cervical "NET G3" is biologically closer to NET than neuroendocrine carcinoma; thus, including uterine cervical "NET G3" in the classification may be justified. However, the optimal management for this tumor type remains undetermined.

Importance of tumor subtypes in cancer imaging

Cancer therapy has evolved from being broadly directed towards tumor types, to highly specific treatment protocols that target individual molecular subtypes of tumors. With the ever-increasing data on imaging characteristics of tumor subtypes and advancements in imaging techniques, it is now often possible for radiologists to differentiate tumor subtypes on imaging. Armed with this knowledge, radiologists may be able to provide specific information that can obviate the need for invasive methods to identify tumor subtypes. Different tumor subtypes also differ in their patterns of metastatic spread. Awareness of these differences can direct radiologists to relevant anatomical sites to screen for early metastases that may otherwise be difficult to detect during cursory inspection. Likewise, this knowledge will help radiologists to interpret indeterminate findings in a more specific manner.

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Tumor subtypes can be identified based on their different imaging characteristics.

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Awareness of tumor subtype can help radiologists chose the appropriate modality for additional imaging workup.

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Awareness of differences in metastatic pattern between tumor subtypes can be helpful to identify early metastases.

Emerging Therapeutic Concepts and Latest Diagnostic Advancements Regarding Neuroendocrine Tumors of the Gynecologic Tract

Neuroendocrine neoplasms (NENs) are particularly rare in all sites of the gynecological tract and include a variety of neoplasms with variable prognosis, dependent on histologic subtype and site of origin. Following the expert consensus proposal of the International Agency for Research on Cancer (IARC), the approach in the latest World Health Organization (WHO) Classification System of the Female Genital Tumours is to use the same terminology for NENs at all body sites. The main concept of this novel classification framework is to align it to all other body sites and make a clear distinction between well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs). The previous WHO Classification System of the Female Genital Tumours featured more or less the same principle, but used the terms ‘low-grade neuroendocrine tumor’ and ‘high-grade neuroendocrine carcinoma’. Regardless of the terminology used, each of these two main categories include two distinct morphological subtypes: NETs are represented by typical and atypical carcinoid and NEC are represented by small cell neuroendocrine carcinoma (SCNEC) and large cell neuroendocrine carcinoma (LCNEC). High-grade NECs, especially small cell neuroendocrine carcinoma tends to be more frequent in the uterine cervix, followed by the endometrium, while low-grade NETs usually occur in the ovary. NENs of the vulva, vagina and fallopian tube are exceptionally rare, with scattered case reports in the scientific literature.

Case Report: Circulating Tumor DNA Fraction Analysis Using Ultra-Low-Pass Whole-Genome Sequencing Correlates Response to Chemoradiation and Recurrence in Stage IV Small-Cell Carcinoma of the Cervix - A Longitudinal Study

Neuroendocrine carcinoma of the cervix is a rare and aggressive form of cervical cancer that presents with frequent metastasis at diagnosis and high recurrence rates. Primary treatment is multimodal, which often includes chemotherapy with or without radiation therapy. There are no data available to guide treatment for recurrence, and second-line therapies are extrapolated from small-cell lung carcinoma data. Close monitoring of these patients for recurrence is paramount. Evaluation of circulating tumor DNA (ctDNA) in the peripheral blood is an attractive approach due to its non-invasive nature. Ultra-low-pass whole-genome sequencing (ULP-WGS) can assess tumor burden and response to therapy and predict recurrence; however, data are lacking regarding the role of ULP-WGS in small-cell carcinoma of the cervix. This study demonstrates a patient whose response to chemotherapy and cancer recurrence was accurately monitored by ctDNA analysis using ULP-WGS and confirmed with radiologic imaging findings.

Cervical Neuroendocrine Carcinoma: A Rare Case Report

Neuroendocrine carcinoma is a rare tumor in the uterine cervix with a dismal prognosis. Clinically, it is difficult to differentiate from other cervical malignancies. Clinical presentation varies from vaginal bleeding, discharge per vaginum and cervical mass. For better clinical outcomes, it is vital to diagnose promptly and accurately. We report a 35-year-old female presented with whitish discharge per vaginum and lower abdominal pain for six months. Per speculum reveals an irregular, firm mass measuring 4x3 cm involving both the cervical lips, which turned out to a small cell neuroendocrine carcinoma.

PD-L1, PARP1, and MMRs as potential therapeutic biomarkers for neuroendocrine cervical cancer

Objective

Neuroendocrine cervical cancer (NECC) is a rare cervical cancer with high aggressivity that causes poor prognosis even in the early stage. Given other neuroendocrine carcinomas and other types of cervical cancer have been proved to have expression of programmed cell death protein 1 ligand 1(PD‐L1) and poly ADP‐ribose polymerase‐1(PARP1), we would measure and analyze these proteins in this invasive cancer. The purpose of this study is to investigate the application value of PD‐1/PD‐L1 and PARP1 inhibitors in NECC.

Methods

The NECC cases in our center with formalin‐fixed paraffin‐embedded tissue blocks were collected, and immunohistochemical (IHC) staining of PD‐L1, PARP1, Mismatch repair proteins (MMRs), and P53 was performed. Chi‐square test was used to analyze associations between various protein expressions. We analyzed the efficacy of immunotherapy in a recent patient with secondary recurrence after two courses of chemotherapy.

Results

After rigorous screening, 20 cases were finally included. Three cases did not undergo surgical treatment because of their advanced stage. Twelve (60%) developed distant metastases or relapsed within five years, and most of them within two years. The positive rate of PD‐L1 and PARP1 were 70% and 75% respectively. Among all the cases, microsatellite instability (MSI) was seen in six cases (30%) and abnormal p53 expression was in 15 patients (75%). PD‐L1 was associated with PARP1 expression in the MSI subgroup. The patient treated with chemotherapy + VEGF inhibitor (VEGFi) + programmed cell death protein 1(PD‐1) inhibitor had an excellent improvement in clinical symptoms, tumor markers, and mass size.

Conclusion

The IHC results of PD‐L1, PARP1, and MMRs suggested that NECC was the target of immunotargeted therapy. Our case confirmed that immune checkpoint therapy was effective in patients with PD‐L1 positive and MMRs loss. Considering the clinical practicability, more cases should be collected, and effective biomarkers still need to be further searched.

Prognostic Factors and Impact of Minimally Invasive Surgery in Early-stage Neuroendocrine Carcinoma of the Cervix

STUDY OBJECTIVE

To investigate the prognostic factors and impact of minimally invasive surgery (MIS) in surgically treated early-stage high-grade (HG) neuroendocrine cervical carcinoma (NECC).

DESIGN

Retrospective cohort study.

SETTING

Asan Medical Center, Seoul, Korea.

PATIENTS

Patients with International Federation of Obstetrics and Gynecology (2009) stages IB1 to IIA HG NECC.

INTERVENTIONS

All patients underwent radical hysterectomy (RH) with a laparotomy or an MIS approach.

MEASUREMENTS AND MAIN RESULTS

Between 1993 and 2017, 47 patients with International Federation of Obstetrics and Gynecology stages IB1 to IIA1 HG NECC were initially treated with RH. Clinicopathologic variables of patients were retrospectively reviewed from electronic medical records. The median follow-up period was 28.2 months (interquartile range, 17.1-42). Stage IB1 disease was the most common (70.2%). Twenty-nine patients (61.7%) underwent RH by MIS. The overall survival (OS) and disease-free survival (DFS) rates were 63.8% and 38.3%, respectively. Lymph node metastasis and resection margin involvement were significant risk factors for DFS (hazard ratio [HR], 2.227; 95% confidence interval [CI], 1.018-4.871; p =.045 and HR, 6.494; 95% CI, 1.415-29.809; p =.016, respectively) and OS (HR, 3.236; 95% CI, 1.188-8.815; p =.022 and HR, 12.710; 95% CI, 1.128-143.152; p =.040, respectively). The Kaplan-Meier survival curves revealed no significant differences in OS and DFS between the laparotomy and MIS groups (50% vs 72.4% log-rank p =.196, 38.9% vs 37.9% p =.975).

CONCLUSION

Lymph node metastasis and resection margin involvement were poor prognostic factors of survival outcomes in initially surgically treated early-stage HG NECC. No difference was observed in the survival outcomes between the MIS and laparotomy approaches.

Small cell carcinoma of cervix: A population-based study evaluating standardized provincial treatment protocols

Objectives

To describe the patient characteristics, patterns of treatment, and outcome of patients with small cell carcinoma of Cervix (SmCC) treated with radical radiotherapy from a provincial cancer registry database.

Methods

Overall 25 patients with SmCC were treated with radical radiotherapy (with or without chemotherapy) from January 1, 1994 to December 31, 2013. Nineteen patients had pure SmCC while 6 had additional neuroendocrine component. Patients were treated with combined chemo-radiotherapy using multi-agent chemotherapy with pelvic or combined pelvic and para-aortic radiotherapy. All patients received brachytherapy. Use of prophylactic cranial irradiation was dependent on physician discretion. Survival was estimated using Kaplan-Meier method and compared using log-rank test.

Results

We report a median overall survival of 53.8 months for our cohort. After a median follow-up of 54 months for surviving patients, the overall survival (OS) and progression free survival (PFS) at 5-years were 48% and 46.4% respectively. Patients with stage I-IIA disease had superior 5-year PFS (67.3% vs. 11.1%; p = .004) and 5-year OS (62.5% vs. 22.2%; p = .006). Patients with node-negative disease had a trend towards better 5-year PFS (55.7% vs. 19%; p = .07) and OS (61.1% vs. 14.3% at 5-years; p = .06) Distant metastasis was the predominant site of disease progression (n = 12; 48%).

Conclusion

Distant metastasis is the predominant pattern of failure for patients with SmCC treated with radical chemo-radiotherapy. With modern chemo-radiotherapy protocols we can expect a 5 year survival of around 50%. Early stage and node-negative status appear to be favorable prognostic factors with survival rates at 5-year over 60%.

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Multi-agent chemotherapy with radiotherapy results in 50% overall survival at 5-years in small cell carcinoma of cervix

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Distant metastasis remains the predominant site of disease progression

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Stage and node-involvement bears significant association with survival

Contribution of Human papillomavirus in neuroendocrine tumors from a series of 10,575 invasive cervical cancer cases

Aims

Neuroendocrine tumors (NET) of the cervix are rare tumors with a very aggressive course. The human papillomavirus (HPV) has been linked to its etiology. The objective of this study is to describe HPV prevalence and genotype distribution of NET.

Methods and Results

Forty-nine tumors with histological neuroendocrine features were identified among 10,575 invasive cervical cancer (ICC) cases from an international study. HPV DNA detection was done using SPF10/DEIA /LiPA₂₅ system. Immunohistochemical (IHC) staining for neuroendocrine markers (chromogranin A, synaptophysin, CD56) and for p16^INK4a as a surrogate for HPV transforming infection was performed. In 13 samples with negative IHC for all 3 neuroendocrine markers studied, it was possible to conduct electron microscopy (EM).

NET represented 0.5% of the total ICC series and HPV was detected in 42 out of 49 samples (85.7%, 95%CI:72.8%,94.1%). HPV16 was the predominant type (54.8%), followed by HPV18 (40.5%). p16^INK4a overexpression was observed in 38/44 cases (86.4%). Neuroendocrine IHC markers could be demonstrated in 24/37 (64.9%) cases. EM identified neuroendocrine granules in 8 samples with negative IHC markers.

Conclusions

Our data confirms the association of cervical NET with HPV and p16^INK4a overexpression. Specifically, HPV16 and 18 accounted together for over 95% of the HPV positive cases. Current HPV vaccines could largely prevent these aggressive tumors.

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Neuroendocrine tumors of the cervix are rare tumors with aggressive course.

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We identified HPV DNA in 85.7% of neuroendocrine tumors analyzed.

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HPV16 and 18 accounted together for over 95% of the HPV DNA positive cases.

Cervical Carcinomas With Neuroendocrine Differentiation: A Report of 28 Cases With Immunohistochemical Analysis and Molecular Genetic Evidence of Common Clonal Origin With Coexisting Squamous and Adenocarcinomas

Cervical neuroendocrine carcinomas are rare, aggressive tumors and their immunohistochemical features and clonal relationship to coexisting tumors are incompletely described. Twenty-eight cases were identified (17 small cell, 9 large cell, and 2 mixed), 10 of which had an invasive squamous or adenocarcinoma component. Staining for synaptophysin, chromogranin A, TTF1, c-kit, CD44, and p16 was performed. Analyses for loss of heterozygosity (LOH) at 5 polymorphic microsatellite markers (D3S1300, D9S171, D11S914, D13S319, and TP53) and X-chromosome inactivation were performed. Of 17 cases with available blocks, 13 (76%) were synaptophysin+, 8 (47%) were chromogranin A+, 8 (47%) were TTF1+, 7 (41%) were c-kit+, and 6 (35%) were CD44+. Strong patchy or strong diffuse p16 staining was seen in all cases. LOH and X-chromosome inactivation analysis were performed for 17 cases, 8 of which had a coexisting squamous or adenocarcinoma component. Five of the 8 (63%) cases with 2 components showed allelic loss in both components. All 5 of these cases demonstrated identical LOH between the neuroendocrine and squamous or adenocarcinoma components. Nonrandom X-chromosome inactivation was seen in the neuroendocrine and other components in 4 of the 8 cases. In all 4 cases the pattern of inactivation was identical between the 2 components. Cervical neuroendocrine carcinomas have features similar to other extrapulmonary neuroendocrine carcinomas, including expression of TTF1, c-kit, and CD44. Consistent staining for p16 is also seen. Concordant genetic alterations support common clonal origin for neuroendocrine carcinomas with a coexisting squamous or adenocarcinoma component.

Cytological features of adenocarcinoma admixed with small cell neuroendocrine carcinoma of the uterine cervix

Adenocarcinoma admixed with neuroendocrine carcinoma of the uterine cervix is a rare malignancy with a poor prognosis, and few reports have described the cytological features of this carcinoma. To characterize the cytological features of this malignancy in cervical smears, we report a case of a 52-year-old Japanese woman with cervical adenocarcinoma admixed with small cell neuroendocrine carcinoma (SCNEC). Cytologically, there were two types of cells with different sizes. The smaller cells formed clusters, which showed a partially Indian file pattern, a high nuclear/cytoplasmic ratio, and hyperchromatic nuclei. In contrast, the larger cells showed cytological features of adenocarcinoma, indicating a glandular-like pattern. Histological examination of biopsy specimens revealed that the tumors were composed of almost equal areas of SCNEC and adenocarcinoma. Neuroendocrine differentiation was confirmed by immunohistochemistry for synaptophysin and CD56. Thus, when adenocarcinoma cells are detected in smears, attempts to search for SCNEC cells should be made by combined cytological and histological analyses in order to reach an accurate diagnosis of the carcinoma in the uterine cervix.

Enhanced efficacy of adjuvant chemotherapy and radiotherapy in selected cases of surgically resected neuroendocrine carcinoma of the uterine cervix: A retrospective cohort study

The aim of the present study is to identify the prognostic factors of overall survival and examine the effects of adjuvant chemotherapy and radiotherapy on the overall survival in neuroendocrine carcinoma of the uterine cervix (NECUC) patients.Forty-eight surgically treated patients were retrospectively recruited and clinicopathologic characteristics and treatments were reviewed. Kaplan-Meier product-limit method and Cox proportional-hazards regression were utilized for univariate and multivariate analyses.The median follow-up time was 20.6 months and the median overall survival was 30.7 months. The estimated 2-year and 5-year overall survival rates were 57.5% and 31.3%, respectively. Forty patients had ≤ stage IIA disease and 8 had >IIA disease. Univariate analysis identified the clinical stage ≤ IIA (P = 0.042), tumor size ≤ 4 cm (P = 0.005), negative lymph nodes metastasis (P < 0.001), depth of stromal invasion ≤ 1/2 (P = 0.001), negative parametrial involvement (P = 0.004), and weak staining of synaptophysin (P = 0.037), and chromogranin (P = 0.011) as the prognostic factors for an improved overall survival, while chemotherapy and radiotherapy were not prognostic factors in the whole cohort. However, surgery combined with chemotherapy and radiotherapy produced a survival advantage over surgery alone in patients with large tumors (P = 0.006). The combination of surgery and chemotherapy (with or without radiotherapy) did not show any significant difference in overall survival for small tumors (P = 0.816), compared with no chemotherapy (with or without radiotherapy). In addition, radiotherapy for tumors with squamous cell carcinoma or adenocarcinoma components achieved a better survival (P = 0.01), and there was a tendency of an unfavorable survival for radiotherapy in homogeneous carcinoma (P = 0.099). Tumor size was an independent prognostic factor in the multivariate analysis (HR: 12.724, 95% CI: 1.697-95.423, P = 0.013).In conclusion, clinicopathologic features significantly influence a NECUC patient's outcome. Tumor size and tumor histology can influence the effect of adjuvant chemotherapy and radiotherapy on overall survival. We recommend that platinum-based adjuvant chemotherapy should be used in all cases, while radiotherapy should be reserved for the selected NECUC patients whose tumors have mixed histology.

Resident Neuroendocrine Cells in the Normal Ectoendocervical Epithelium

Among the major difficulties in determining the histogenesis of small-cell neuroendocrine carcinomas of the cervix is the issue of identifying the cell from which the neoplasm arises. In this study we performed an immunohistochemical analysis of the neuroendocrine cells in the normal ectoendocervical epithelium by using a microwave heating technique. In ectocervical epithelium, positivity for chromogranin and/or neuron-specific enolase was detected in 18% of the cases, whereas 46% of the endocervical mucosae demonstrated immunoreactive cells for these antibodies. Isolated endocervical neuroendocrine cells showed immunoreactivity for antigastrin (1 case), anti-VIP (3 cases), and antisynaptophysin (14 cases) antibodies. A comparative analysis of 4 diagnosed cases of small-cell carcinoma of the cervix demonstrated immunoreactivity for neuron-specific enolase and chromogranin, respectively, in 3 cases and for synaptophysin in 1 case. Thus, small-cell carcinoma of the cervix likely originates from cells with neuroendocrine differentiation localized mainly in the endocervical glands. These findings offer an explanation for the paraneoplastic syndromes described in some cases of small-cell carcinoma of the cervix.

Large cell neuroendocrine cervical tumor treated by radical surgery and adjuvant chemotherapy: A case report and literature review

Neuroendocrine carcinomas of the uterine cervix are rare, but extremely aggressive, gynecological malignancies that are associated with an overall poor prognosis. The present study reports the case of a 41-year-old patient diagnosed with large cell neuroendocrine cervical tumor. A radical total hysterectomy with bilateral adnexectomy, pelvic and lymph node dissection was performed. The post-operative course was uneventful, and the patient was discharged on post-operative day 8.

Natural history and outcome of neuroendocrine carcinoma of the cervix

OBJECTIVE

Neuroendocrine carcinomas of the cervix (NECC) are rare and thought to be aggressive. We performed a population-based analysis to examine the natural history, treatment patterns and outcomes of women with NECC compared to squamous cell carcinoma (SCCC) and adenocarcinoma (AC) of the cervix.

METHODS

The National Cancer Database (NCDB) was utilized to identify women with NECC, SCCC, and AC treated from 1998 to 2011. Clinical, demographic, and treatment characteristics were compared between the groups. The association between tumor histology and survival was examined using Kaplan-Meier analyses and multivariable Cox proportional hazards regression models.

RESULTS

We identified 127,332 patients, including 1,896 (1.5%) with NECC and 101,240 (79.5%) with SCCC and 24,196 (19.0%) with AC. Patients with NECC were younger, more often white, commercially insured, and diagnosed with metastatic disease at presentation compared to women with SCCC. Patients with early-stage NECC were more likely to receive adjuvant chemotherapy and radiation after surgery (P<0.05 for both). In multivariable models stratified by stage and adjusted for clinical and demographic characteristics, the risk of death was higher for patients with NECC compared to SCCC for all stages of disease: stages IB-IIA (HR=2.96; 95% CI, 2.48-3.52), stages IIB-IVA (HR=1.70; 95% CI, 1.45-1.99) and stage IVB (HR=1.14; 95% CI, 0.91-1.43).

CONCLUSION

NECC are aggressive tumors associated with an increased risk of death. Survival is inferior for NECC compared to squamous cell tumors for women with both early and advanced stage disease.

Neuroendocrine Tumors of the Female Reproductive Tract: A Literature Review

Neuroendocrine tumors of the female reproductive tract are a heterogeneous group of neoplasms that display various histologic findings and biologic behaviors. In this review, the classification and clinicopathologic characteristics of neuroendocrine tumors of the female reproductive tract are described. Differential diagnoses are discussed, especially for non-neuroendocrine tumors showing high-grade nuclei with neuroendocrine differentiation. This review also discusses recent advances in our pathogenetic understanding of these disorders.

Challenges in the diagnosis and management of cervical neuroendocrine carcinoma

Neuroendocrine carcinoma represents about 1% all cervical cancers accounting for 100-200 diagnoses annually in the USA. Although it is uncommon, it is an aggressive histologic subtype of this otherwise favorable disease. To date, there are no prospective studies or randomized trials specific to this disease to guide standard of care management. Published literature consists of small case series mostly describing single-institution experiences. The Society of Gynecologic Oncology and Gynecologic Cancer InterGroup have issued consensus guidelines about the treatment of this disease based on the existing retrospective literature and expert opinion. Ongoing research is focused on further clarifying the best treatment regimen and defining molecular alterations of these tumors that can be exploited by novel treatment mechanisms. The objective of this manuscript is to describe this entity, review the literature, summarize current treatment recommendations, and propose possible research efforts for women with neuroendocrine cervical cancer.

Prognostic risk factors for small cell carcinoma of the cervix and impact of platinum-based neoadjuvant chemotherapy

OBJECTIVE

To evaluate prognostic risk factors and the effects of platinum-based neoadjuvant chemotherapy (NACT) among patients with small cell carcinoma of the cervix (SCCC).

METHODS

In a retrospective multicenter study, data were analyzed from patients with SCCC diagnosed between July 2001 and October 2009 at one of three hospitals in China. Prognostic risk factors were identified by the Cox proportional hazards model.

RESULTS

Follow-up information was available for 22 patients, including 18 cases of early (FIGO stage IA-IIA) and four cases of advanced (stage IIB-IV) SCCC. The 3-year disease-free survival (DFS) rate was 62% for patients with early stage disease and 0% for those at a late stage (P=0.003). The 3-year overall survival (OS) rate was 68% and 0%, respectively (P=0.001). The 3-year OS rate was 73% for patients with no lymphovascular space invasion and 0% for those with lymphovascular space invasion (P=0.031). Advanced FIGO stage was the only independent risk factor for 3-year DFS (P=0.017) and 3-year OS (P=0.006). Patients who received NACT plus radical surgery had a lower rate of distant recurrence than did patients who received radical surgery as the primary treatment (0/8 vs 5/9; P=0.029).

CONCLUSION

Advanced disease was an independent risk factor for SCCC prognosis. Platinum-based NACT seemed to prevent distant recurrence.

Neuroendocrine carcinoma of the cervix presenting as intractable hyponatremic seizures due to paraneoplastic SIADH-a rare case report and brief review of the literature

Herein is presented an interesting case of small-cell neuroendocrine carcinoma of the cervix which initially manifests as seizures due to hyponatremia caused by paraneoplastic syndrome of inappropriate anti diuretic hormone (SIADH). Awareness of a paraneoplastic syndrome at presentation can lead to early diagnosis and early initiation of treatment. The management is also unique in that it combines treating the paraneoplastic aspects as well as targeting the tumour itself. Multimodality treatment gives the best outcome in this aggressive tumour.

Analysis of the impact of platinum-based combination chemotherapy in small cell cervical carcinoma: a multicenter retrospective study in Chinese patients

BACKGROUND

Small cell cervical carcinoma (SCCC) is a rare, aggressive tumor with a poor prognosis. However, information in relation to its treatment is scarce due to the limited numbers of patients. The aim of this study was to establish whether platinum-based combination chemotherapy may by beneficial in this patient population.

METHODS

We carried out a multicenter, retrospective study comprising of 72 Chinese patients with SCCC. The patients were treated between 1995 and 2010 at Sun Yat-sen Memorial Hospital or the Cancer Center of Sun Yat-Sen University, and at the First Affiliated Hospital of Shantou University Medical College, China.

RESULTS

Of the 72 patients, 46/72 (63.9%) had Federation of Gynecology and Obstetrics (FIGO) stage Ia-Ib2 and 26/72 (36.1%) had stage IIa-IV disease. Surgery was performed in 63/72 (87.5%) patients, 61/72 (84.7%) patients received chemoradiotherapy and 35/72 (48.6%) received radiotherapy. The 3-year overall survival (OS) and disease-free survival (DFS) rates were as follows: Ia (100%, 100%); Ib1 (62%, 57%); Ib2 (53%, 48%); IIa (36%, 23%); IIb (29%, 21%); IIIb (50%, 50%); and IV (0%, 0%), respectively. The estimated 3-year OS and DFS rates in patients who received platinum-based combination chemotherapy (etoposide + cisplatin [EP], or paclitaxel + cisplatin [TP]) as part of their adjuvant treatment were 64.8% and 63.0%, respectively, compared to 25.2% and 22.0% in those who did not (P = 0.0003; P = 0.0003). Univariate analysis showed that platinum-based combination chemotherapy was associated with improved survival compared to other chemotherapy techniques or no chemotherapy (OS: HR = 0.227; 95% CI, 0.099-0.524; P = 0.001; DFS: HR = 0.210; 95% CI, 0.087-0.506; P = 0.001). Multivariate analysis identified FIGO stage, lymphatic metastasis and platinum-based combination chemotherapy as independent prognostic factors for improved survival in patients with SCCC.

CONCLUSIONS

Platinum-based combination chemotherapy (with EP or TP) can improve the 3-year survival outcomes in patients with SCCC. Therefore, it should be considered an important component in a future standardized treatment strategy for SCCC.

Neuroendocrine tumors of the gynecologic tract: select topics

Tumors of the diffuse neuroendocrine cell system (DNES) may arise in any component of the gynecologic tract, including the vulva, vagina, cervix, endometrium, and ovary. Overall such tumors in the gynecologic tract are rare, constituting only 2% of gynecologic cancers, comprising a spectrum of tumors of variable biologic potential. Due to the rarity of such tumors, pathologists experience may be limited and these may present diagnostic challenges. Currently the nomenclature employed is still that of the pulmonary classification systems, carcinoid, atypical carcinoid, small and large cell neuroendocrine carcinoma that broadly correlates to low/grade 1, intermediate/grade 2, and high grade/grade 3 of the WHO gastroenteropancreatic neuroendocrine tumors classification. Furthermore in keeping with the lung, proliferative rate is assessed based on mitotic index rather than Ki-67 staining. In this review we cover select neuroendocrine tumors of the gynecologic tract.

Atypical carcinoid of the uterine cervix with aggressive clinical behavior: A case report

•We herein report a case of a 44-year-old Japanese woman diagnosed with stage IB1 atypical carcinoid of the uterine cervix.•After radical hysterectomy, she developed recurrence with aggressive clinical behavior, resistance to CPT-11 + cisplatin and paclitaxel + CBDCA chemotherapy.

Management of neuroendocrine small cell carcinoma of cervix-a single centre retrospective study

Purpose: To determine disease-free and overall survival of neuroendocrine small cell cancer of cervix treated at the Northern Ireland Cancer centre between 1999 and 2010.

Materials and methods: A retrospective review of all patients diagnosed and treated with neuroendocrine small cell cancer of cervix in Northern Ireland. Details of treatment modality including chemotherapy, radiotherapy and surgery were recorded.

Results: Fifteen patients diagnosed with neuroendocrine small cell carcinoma (NSCC) of cervix were identified between 1999 and 2010, twelve with disease localised to the pelvis and three with metastatic disease. Three-year overall survival for all patients was 65% and disease-free survival was 45% for all patients. In patients with pelvic confined disease 3-year overall survival was 79% and disease-free survival was 57%. Median disease-free and overall survival was 30 and 39.6 months respectively. These survival rates compare very favourably to those reported in the literature. Stage of disease at diagnosis was the main determinant of survival.

Conclusion: Local control and survival can be achieved in NSCC of patients with a combination of irradiation and platinum-based chemotherapy. Stage of disease determines outcomes.

The management of small-cell carcinomas of the gynecologic tract

PURPOSE OF REVIEW

Small-cell carcinomas of the gynecologic tract are aggressive malignancies that can be misdiagnosed or inappropriately managed. This review provides a summary of current literature that will help the clinician to correctly diagnose and treat patients with small-cell carcinomas of the cervix, ovary, uterus, vagina, and vulva.

RECENT FINDINGS

Small-cell carcinomas of gynecologic sites are rare and carry a poor prognosis. Stage is an important prognostic factor in small-cell carcinoma of the cervix, uterus, and ovary. Early stage disease has varied treatment approaches based on the site of malignancy, but systemic chemotherapy with or without radiation plays a role in the adjuvant setting to mitigate the risk of recurrence. Advanced stage patients require treatment with chemotherapy and possibly radiation, usually in a manner analogous to small-cell lung cancer. The preferred chemotherapy regimen contains a platinum agent and etoposide. For small-cell ovarian carcinomas, it is important to differentiate those of the hypercalcemic type from those of the pulmonary type. The small-cell carcinomas of the vagina and vulva need to be distinguished from Merkel cell cancers.

SUMMARY

The majority of small-cell tumors of the gynecologic tract will require systemic chemotherapy with a platinum agent and etoposide, both in the setting of early and advanced stage disease. Prospective trials with new chemotherapy or targeted agents are needed to improve the treatment of this aggressive cancer.

Primary pulmonary carcinoid tumor with metastasis to endometrial polyp

INTRODUCTION

A carcinoid tumor occurring in the endometrium has been documented in the literature, but there is no report in regard to carcinoid tumor metastasis to endometrium.

PRESENTATION OF CASE

We report a case of a malignant carcinoid metastasis to an endometrial polyp. Patient underwent hysteroscopy, and polypectomy. The pathology demonstrated an endometrial polyp containing a 4 mm x 5 mm nodule of metastatic carcinoid tumor, consistent with metastasis from patient's known pulmonary carcinoid. The tumor was morphologically similar to the tumors of the right lung, with similar immune-profile.

DISCUSSION

This patient presented with a suspicious pelvic ultrasound. Due to her age, the first priority was to exclude uterine cancer. The endometrial polyp, which was found, had a small focus of metastatic carcinoid tumor. To the best of our knowledge, this finding has not been previously recorded in the literature. Our patient also had a history of metastatic carcinoid tumor to breast. This finding is also very uncommon.

CONCLUSION

This is the first case in the literature described a malignant carcinoid metastasis to an endometrial polyp.

Neuroendocrine tumors of the gynecologic tract: A Society of Gynecologic Oncology (SGO) clinical document

OBJECTIVE

Neuroendocrine tumors of the gynecologic tract are rare, and pose a significant clinical challenge because of the tumor heterogeneity and lack of standardized guidelines for treatment. This manuscript summarizes the available literature concerning these tumors in an effort to provide the clinician a framework from which to guide patient management.

METHODS

MEDLINE was searched for all research articles published in English between January 1, 1966 and March 1, 2011 in which the studied population included women diagnosed with neuroendocrine tumors of the gynecologic tract. Although preference was given to prospective studies, studies were not limited by design or by numbers of subjects given the limited availability of reports.

RESULTS

Most, but not all, neuroendocrine tumors of the gynecologic tract have an aggressive clinical course and those of the cervix histologically and clinically share similarities with small cell lung cancer. Cumulative data supports a multi-modality therapeutic strategy. A proposed management algorithm for neuroendocrine carcinomas of the cervix is outlined. For less frequent disease sites including the adnexa, uterus, vagina and vulva, as well as well differentiated carcinoid tumors, surgical resection is appropriate in selected cases. Etoposide/platinum based chemotherapy is used for neuroendocrine carcinomas but not for well differentiated carcinoid tumors. Well differentiated carcinoid and atypical carcinoid tumors should be managed similar to gastroenteropancreatic NETs (GEP-NETs).

CONCLUSIONS

Most neuroendocrine tumors of the gynecologic tract require a multi-modality therapeutic approach, determined by extent of disease and primary organ of involvement. Pathologic diagnosis is critical to guide therapy.

Pap smear screening for small cell carcinoma of the uterine cervix: a case series and review of the literature

Objective

Small cell carcinoma of the uterine cervix (SMCC) is extremely rare, and an aggressive disease that proliferates rapidly. It was often reported that the diagnostic accuracy of cytologic smears in diagnosing SMCC was low. This is a report of the Severance Hospital experience with the patients suffering from SMCC.

Methods

Twenty-seven patients with small cell carcinoma of the uterine cervix were diagnosed and treated at the Severance Hospital from November 1991 to January 2010. The data were analyzed retrospectively, based on the available charts and pathology reports. Various fields, such as chief complaints and symptoms present at first clinic visit, age, International Federation of Obstetrics and Gynecology (FIGO) clinical stage, treatment modality, the 5-year overall survival rate, and recurrence rate were investigated.

Results

Among the 27 patients diagnosed with small cell carcinoma of the uterine cervix, 18 of them (66.7%) presented with symptoms, including vaginal bleeding, at the first clinic visit, and the remaining 9 patients (33.3%) showed abnormal Pap smear screening in the process of their routine health check-up. The median age of the patients was 54 years (range, 24 to 77 years). FIGO stage IIB was the most common stage (11 of 27 patients). The 5-year overall survival rate of 21 patients, who could be followed up, was 57.2%. Six patients showed recurrence after remission, and the mean disease free interval of them was 9.2 months (range, 6 to 11 months). Abnormal Pap smear screening results of 9 patients was investigated, and the diagnostic accuracy of the cytologic findings was 22.2%.

Conclusion

Our study was consistent with the concept that Pap smear screening might not be helpful in early diagnosis of SMCC considering its low diagnostic accuracy. Further large-scale multicenter prospective studies are definitely needed in order to produce abundant information about optimal therapy and diagnosis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Large cell neuroendocrine carcinoma of the uterine cervix with cytogenetic analysis by comparative genomic hybridization: a case study

Large cell neuroendocrine carcinoma (LCNEC) of the uterine cervix is a newly introduced category of the revised World Health Organization classification. We reported a case of cervical LCNEC with cytogenetic analysis by comparative genomic hybridization (CGH). The cervical tumor showed moderately increased mitotic activity (8-14 mitotic figures per 10 high-power fields) and focal necrosis, which made it problematic to differentiate from atypical carcinoid. CGH analysis failed to detect chromosome 11q loss that has been reported to be characteristic of pulmonary atypical carcinoids. Furthermore, chromosome 3q amplification, which has been detected frequently in pulmonary small cell carcinomas and LCNECs but not in pulmonary typical and atypical carcinoids, was the most remarkable chromosomal aberration. Although CGH reports are extremely rare in neuroendocrine tumors of the uterine cervix, specific chromosomal aberrations may be useful in their distinction.

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

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

CD56 Reactivity in Small Cell Carcinoma of the Uterine Cervix

Small cell carcinoma (SCC) of the uterine cervix, like its pulmonary counterpart, is a rare but distinctive neoplasm that should be separated from nonendocrine carcinomas because of its highly aggressive clinical course and response to chemotherapy and irradiation. CD56 (neural cell adhesion molecule) has recently been shown to be the best marker for the diagnosis of pulmonary SCC. In this study, we assessed the sensitivity and specificity of CD56 in the diagnosis of SCC of the uterine cervix compared with those of chromogranin and synaptophysin. Twenty-two (88%) of 25 SCCs of the uterine cervix labeled with CD56 in a predominantly membranous and diffuse pattern, whereas 16 of 25 (64%) stained with synaptophysin in a predominantly diffuse pattern and 8 of 25 (32%) showed predominantly focal immunoreactivity for chromogranin. In contrast, 3 of 21 (14%) moderately to poorly differentiated squamous cell carcinomas and 1 of 16 (6%) moderately differentiated adenocarcinomas showed focal immunoreactivity for CD56. Although not specific, CD56 seems to be the most sensitive marker for the diagnosis of SCC of the uterine cervix. Moreover, its diffuse reactivity reduces the possibility of obtaining negative results in small biopsy samples.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

MR imaging of the uterine cervix: imaging-pathologic correlation

Magnetic resonance (MR) imaging is useful not only for preoperative staging of gynecologic malignancies but also for prediction of the histopathologic features of a variety of intrapelvic tumors. Familiarity with the specific imaging findings that have been reported for the uterine cervix is a goal of radiologists. The typical MR imaging findings of uterine cervical lesions correspond to the histopathologic features. These lesions can be categorized as epithelial neoplasms, nonepithelial neoplasms, and nonneoplastic diseases. Cervical carcinoma accounts for most cases of malignant lesions and is staged by using the classification system established by the International Federation of Gynecology and Obstetrics. MR imaging allows differentiation between endophytic and exophytic growth and between normal and abnormal findings after hysterectomy and irradiation. Other epithelial neoplasms of the uterine cervix include adenoma malignum, which is a special type of cervical adenocarcinoma, as well as carcinoid tumor and malignant melanoma. Nonepithelial neoplasms of the uterine cervix include malignant lymphoma and leiomyoma. Nonneoplastic diseases of the uterine cervix include cervical pregnancy, cervicitis, nabothian cysts, polyps, and endometriosis.

Neuroendocrine small cell carcinoma of the uterine cervix: what disease? What treatment? Report of ten cases and a review of the literature

Neuroendocrine small cell carcinoma of the uterine cervix (NESCCC) is an entity with very aggressive behaviour. The optimal initial therapeutic approach to this rare disease has not yet been clearly defined. We reviewed our experience of this disease over the past 10 years with regard to chemosensitivity. Since 1988, ten patients (mean age 33 years; range 24-47) have been diagnosed with NESCCC and treated in our institutions. Disease stage at presentation was IA (one), IB (five, two with lymph node involvement), IIB (one), IIIB (one), and IV (two). One patient had metastatic disease at presentation; three developed metastases during initial treatment. Eight patients underwent surgery and eight received radiation therapy. Six patients received pre- or postoperative cisplatinumvepeside (PE) combination chemotherapy, either alone or concurrently with radiation therapy. PE alone as primary chemotherapy led to disease stabilization in the two patients so treated; concurrent PE and radiation therapy resulted in a pathological complete response in one patient. Eight patients relapsed within 16 months and died of their disease within 29 months from the initial diagnosis. Two patients are alive with no evidence of disease at 13 and 53 months. Our series confirms the previously described very poor prognosis of NESCCC, despite initial aggressive multidisciplinary treatment. It may be that the introduction of chemotherapy, especially combined primary chemoradiotherapy, might allow patients to do a little better, although at the moment there is no good evidence one way or the other.

Neuroendocrine tumors of the uterine cervix. Clinicopathologic study of five patients

Four main clinicopathologic features of neuroendocrine tumors (NETs) of the cervix may be stressed: primary diagnosis at an advanced stage, early nodal metastasis even for low disease, early failure of appropriate local treatment (surgery and/or radiation therapy) and aggressive clinical treatment. Five patients with NET of the uterine cervix (small cell carcinoma type) are reported (one stage I, two stages II, one stage III and one stage IV). One patient was treated by surgery combined with radiation therapy, one by surgery combined with chemotherapy and one by surgery with radiation therapy and chemotherapy. Two patients received radiation therapy alone. Three early stage patients are alive with no evidence of disease 8, 26 and 41 months after diagnosis. The two patients with advanced stage died of disease, 3 and 12 months respectively, after diagnosis. Combination chemotherapy (cisplatin and etoposide) is warranted in disseminated NETs. Neoadjuvant or adjuvant chemotherapy should be combined with radiation therapy and surgery even in early stages.

Exfoliative cytology of primary poorly differentiated (small-cell) neuroendocrine carcinoma of the uterine cervix in ThinPrep material: a case report

Poorly differentiated neuroendocrine (small-cell) carcinoma of cervical origin is a rare neoplasm that frequently metastasizes. Although the cytologic features have been described for conventional cervical smears, we know of no reports of its appearance in ThinPrep (TP) material. Therefore, we present a TP case of primary, small-cell carcinoma arising in a 46-yr-old female, confirmed by histologic and immunohistochemical analysis. Similar to conventional smears, the neoplastic cells occurred either individually or in small clusters. The cells were relatively monomorphic, with stippled chromatin and minimal amounts of cytoplasm. Unlike conventional smears, nuclear molding was not prominent (although overlap was observed), and nuclear smearing was not identified. The features are compared to TP cases of squamous-cell carcinoma, small-cell type, and endometrioid adenocarcinoma, which are close mimics of small-cell carcinoma. We conclude that correct diagnosis of small-cell carcinoma in TP is difficult, requiring a high degree of suspicion and immunohistochemical confirmation.