Carcinoid of the uterine cervix: a case report with light and electron microscopic studies

Low-grade Neuroendocrine Tumor of the Cervix: Report of 3 Cases of a Rare Neoplasm With Review of the Literature

Neuroendocrine neoplasms are uncommon in the cervix with almost all representing neuroendocrine carcinomas (NECs), either small cell or large cell type. Cervical low-grade neuroendocrine tumors (NETs) are extremely rare with few recent reports using contemporary modern diagnostic criteria. We report 3 cases of cervical NET in patients aged 32 to 57 yr and undertake a review of the literature. The first case was a pure grade 2 NET with pelvic lymph node metastasis (FIGO stage IIIC1). In the second case, a grade 1 NET was associated with high-grade squamous intraepithelial lesion, adenocarcinoma in situ and human papillomavirus (HPV)-associated adenocarcinoma and was FIGO stage IA1. The third patient underwent chemoradiotherapy following a biopsy diagnosis of a high-grade NEC which was radiologically FIGO stage IIIC1 and salvage hysterectomy revealed residual tumor with features of a grade 1 NET. In all cases, the NET was diffusely positive with at least 2 of the neuroendocrine markers chromogranin, synaptophysin, and CD56. The first tumor was p16 negative and the third exhibited block-type immunoreactivity. Molecular tests revealed high risk HPV types 18 and 51 in the third case but no HPV in the first case. p16 immunohistochemistry and HPV molecular testing was not available in the second case. The patients remain disease free with follow-up ranging from 2 to 8 yr. Since a combination of NET and NEC is extremely rare at all sites due to a different pathogenesis, we speculate that in the third case, the NET developed out of the NEC as a "maturation" phenomenon secondary to chemoradiotherapy.

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.

Large cell neuroendocrine cervical carcinoma: a report of two cases and review of the literature

BACKGROUND

Large cell neuroendocrine cervical carcinoma is a rare malignancy. These tumors appear to mimic the aggressive behavior of small cell neuroendocrine tumors. Metastasis and recurrent disease are common. Due to the low incidence of these tumors, optimal therapy has not been delineated.

CASES

Two patients presented with large cell neuroendocrine cervical carcinoma, stage IB1 and IIA, at our institution from 1997 to 1999. We describe the clinical course for these two patients and review the relevant literature for the management of large cell cervical carcinoma.

CONCLUSION

Unlike squamous cell carcinoma, early-stage large cell neuroendocrine tumors of the cervix are aggressive. Disease recurrences are frequent and distant metastasis is common. Multimodal therapy should be considered at the time of initial diagnosis.

Endocrine tumors of the cervix: morphologic assessment, expression of human papillomavirus, and evaluation for loss of heterozygosity on 1p,3p, 11q, and 17p

BACKGROUND

Cervical endocrine tumors are rare lesions, with a varied diagnostic nomenclature. A recent consensus meeting proposed a standardized terminology. This study evaluated: 1) applicability of histopathologic guidelines; 2) evidence of loss of heterozygosity (LOH) at selected sites; and 3) the presence of human papillomavirus (HPV) detected by nonisotopic in situ hybridization (ISH).

METHODS

Thirty-eight cases (patient age range, 19-88 years; mean, 48 years) were retrieved. Outcome data were available for 32 patients. Classification was based on architectural and cytologic features. Tissue was available from 15 cases for LOH analysis with D3S1234(3p14), D3S1289(3p21), THRB(3p24), TP53(17p13), D1S468(1p36), and INT-2(11q13). In ten cases, tissue was analyzed by nonisotopic ISH with HPV probes for types 6/11, 16/18, and 31/33.

RESULTS

Tumors were divided into four groups: small cell carcinoma (SCC) (n=25); large cell neuroendocrine carcinoma (LCNC) (n=5); SCC with focal LCNC differentiation (n=3), and carcinoid tumor (n=5). Tumors defined as exclusively or predominantly SCC had a particularly poor prognosis, with 20 patients dead of disease (<6 years after diagnosis) and 6 alive with disease (after <3 years of follow-up). LOH at various 3p loci (3p14, 3p21, and 3p24) was observed in eight cases. One patient demonstrated LOH on 17p(TP53). Eight of ten cases assessed by ISH showed nuclear staining using a combined HPV-16/18 probe.

CONCLUSIONS

Cervical endocrine tumors are highly aggressive and can be subdivided into definable categories. LOH at 3p loci is a frequent finding, as is nuclear staining with a combined HPV-16/18 probe. LOH at 17p(TP53 locus) appears to be relatively uncommon, suggesting that p53 mutations may not be developmentally significant.

Cervical carcinoma metastatic to the brain

Brain metastases from cervical cancer are uncommon and are usually considered incurable. Characterization of presentation and a consensus on standard effective treatment have not been published. We present a case in which long-term disease-free survival has been achieved by surgical resection of a solitary brain metastasis with postoperative whole brain radiation. The world literature is examined and discussed in relation to this experience.

Large cell neuroendocrine [corrected] carcinoma of the uterine cervix: a clinicopathologic study of 12 cases

Twelve cervical tumors showing morphologic evidence of neuroendocrine differentiation and lesional cells larger than those of typical small cell carcinoma are reported in women 21 to 62 (mean 34) years of age. The patients presented with an abnormal Papanicolaou smear or vaginal bleeding. Two tumors were stage Ia2, nine were stage Ib, and one was stage IIa. All patients were treated by radical hysterectomy, and most received adjuvant chemotherapy. Seven of 10 patients with > 1 year of follow-up died of tumor 6 to 24 months after hysterectomy. The tumors had insular, trabecular, glandular, and solid growth patterns and contained medium to large cells with moderate to abundant cytoplasm; eosinophilic cytoplasmic granules were present in nine cases. The tumors were mitotically active, and necrosis was present in 10 of them. Nine of 10 tumors were argyrophilic, and all 12 were immunoreactive for chromogranin. Individual cells containing somatostatin, serotonin, or glucagon were identified in four of eight cases. Adenocarcinoma in situ was present adjacent to the tumor in eight cases; invasive adenocarcinoma of non-neuroendocrine type was present in three of these tumors. Using diagnostic criteria established for pulmonary neuroendocrine tumors, the 12 tumors were classified as large cell neuroendocrine carcinomas. Cervical large cell neuroendocrine carcinomas are distinctive cervical carcinomas that are frequently misdiagnosed and have an unfavorable outcome, similar to that of small cell carcinoma.

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

BACKGROUND

Small cell carcinoma of the cervix is a rare and aggressive tumor. Most gynecologic oncology centers have little experience with this tumor, and only small series have been published.

METHODS

Twenty-six patients with small cell carcinoma of the uterine cervix were treated at the Norwegian Radium Hospital. Clinical data, immunohistochemical characteristics, and infection with human papillomavirus were studied.

RESULTS

Twelve tumors were of oat cell type and 14 of intermediate cell type. Twelve tumors were associated with other forms of carcinoma: squamous cell carcinoma (6 tumors), adenocarcinoma (5 tumors), and adenocarcinoma in situ (1 tumor). Neuroendocrine differentiation was expressed in 79% of the tumors. Human papillomavirus (HPV)-18 was detected in 40% of the tumors and HPV-16 in 28%. Fifteen patients had Stage I disease, 7 had Stage II, 2 had Stage III, and 3 had Stage IV. Fourteen patients with Stage I and II disease underwent radical hysterectomy with pelvic lymph node dissection. In four, the operation was preceded by intracavitary radiation treatment. The patients with Stage II, III, and IV disease were treated with a combination of intracavitary radium, external beam radiation therapy, and chemotherapy. The 5-year survival rate was 14%. Four patients are alive, one with recurrent disease 50 months after diagnosis. Three patients free of disease have been followed up 26, 54, and 101 months, respectively.

CONCLUSIONS

Small cell carcinoma of the cervix is an aggressive tumor with a propensity for rapid recurrence; it is associated with high mortality.

Carcinoid tumour of the uterine corpus

A carcinoid tumour occurred in the uterine fundus causing an enlargement (12-14 weeks size). The patient did not have the carcinoid syndrome, despite elevated urinary 5-hydroxyindole acetic acid levels. The tumour had a typical organoid pattern with argentaffin-positive cells. Whilst a metastasis from an occult primary lesion cannot be entirely excluded, it is felt that this is a primary tumour most likely arising from resident endocrine cells in the endometrium.

Neuroepithelial small cell carcinoma of the vagina

We studied two patients with primary vaginal small cell carcinomas. Their tumors show histologic and ultrastructural neuroepithelial elements similar to those reported in the literature in the cervix and the lung. The clinical behavior of the tumors was aggressive in both patients. Ultrastructural study of small cell genital tract neoplasms is indicated to help classify this disease. Adjunctive therapy may be required for neoplasms of neuroepithelial origin.

Carcinoid of the cervix: natural history and implications for therapy

Carcinoid tumors rarely occur in the cervix. We present a patient with FIGO stage IB disease who developed brain metastases 4 years after initial diagnosis and treatment. The clinical course of a collected series of patients with carcinoid of the cervix is reviewed. Even patients with low stage lesions frequently die of disseminated disease. Adjuvant chemotherapy may have a role in the treatment of such patients.

Argyrophilic and hormone immunoreactive cells in normal and hyperplastic pancreatic ducts and exocrine pancreatic carcinoma

Scattered argyrophil cells were present in normal, large, medium-sized and small pancreatic ducts (ductules). There was marked increase in argyrophil cells in ducts with hyperplastic epithelium. Argyrophil cells were also found in 67.7% of all exocrine pancreatic carcinomas. In a well differentiated group including cystadenocarcinoma, mucinous carcinoma and well differentiated ductal adenocarcinoma argyrophil cells were found in all cases examined. Using four antisera (against insulin, glucagon, somatostatin and gastrin), insulin, glucagon and somatostatin cells were identified in 2.65%, 0.001% and 1.2% of normal ducts, and 7.5%, 2.4% and 4.6% of ducts with hyperplastic epithelium respectively and were also greatly increased in numbers in the latter group. Immunoreactive cells were present in 66.7% of exocrine carcinomas. Cells reactive for insulin were found in 7/15 cases; glucagon in 6/15 cases; somatostatin in 5/15 cases and gastrin in 2/15 cases. Eight cases contained two or more than two types of immunoreactive cells. The presence of argyrophil and hormone immunoreactive cells in pancreatic ducts and carcinomas is indicative of the close developmental relationship between endocrine and exocrine parts of the pancreas. The inter-relationship of response in the different cell types following stimulus suggests that injury to a common precursor may be involved.

Neuroendocrine features in poorly differentiated and undifferentiated carcinomas of the cervix

Neuroendocrine or argyrophil cell carcinoma of the cervix has recently been accepted as a distinct clinical-pathological entity. The histologic pattern of these carcinomas is usually poorly differentiated or undifferentiated. Twenty patients with a histologic diagnosis of small cell carcinoma, undifferentiated carcinoma, poorly differentiated adenocarcinoma, or poorly differentiated, adenosquamous carcinoma of the cervix were evaluated for neuroendocrine features. The results of studies to detect neurosecretory granules were positive in seven of the 20 cases. Not only small cell carcinomas, but also tumors classified as undifferentiated carcinoma and poorly differentiated, adenosquamous carcinoma contained cytoplasmic granules consistent with neuroendocrine carcinoma of the cervix. The prognosis for survival appears poorer for patients having tumors with neurosecretory granules after controlling for stage and histologic grade of the neoplasm.

Minute carcinoid tumor of the uterine cervix associated with microinvasive adenocarcinoma, with reference to its histogenesis

A rare case of carcinoid tumor of the uterine cervix associated with adenocarcinoma was reported. The carcinoid tumor was composed of round to polygonal cells showing solid or trabecular proliferation. Most of these cells and a small number of isolated cells wedged in neoplastic glands were positive with either Grimelius or Fontana-Masson stains, and also positive for serotonin by immunostain (PAP method). Positively stained cells were thus considered to have the same histochemical nature as enterochromaffin cell. The carcinoid tumor was minute, about 2 X 2 mm and the adenocarcinoma was a microinvasive one. In some parts, smooth transition between both tumor components was observed. From these findings, it is suggested that both the carcinoid tumor and the adenocarcinoma in the present case were derived from a primitive precursor cell of common mesodermal origin.

Mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina

A mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina in a 32-year-old woman is reported. Special stains showed the argentaffin and argyrophil reactions of the small cell population of this tumor. The small cells also contained serotonin as demonstrated by immunocytochemistry. Electron microscopy revealed characteristic cytoplasmic neurosecretory granules. The large cells were columnar and contained mucin droplets similar to those in Goblet cells in the intestines. The observations suggest that the tumor was mixed intestinal adenocarcinoma-argentaffin carcinoma (malignant carcinoid), which probably arose in aberrant intestinal epithelial cells in the vagina. The patient died with metastases of pure argentaffin carcinoma in 1 year.

Endocrine carcinoma intermediate cell type of the uterine cervix

Nine cases of endocrine carcinoma, intermediate-cell type of the uterine cervix, were found in a study of 404 cases listed in the files of the University of Texas M. D. Anderson Hospital and Tumor Institute at Houston as adenocarcinoma of the cervix. Based on light microscopic patterns, these cases were divided into pure endocrine carcinoma (six cases), and endocrine carcinoma mixed with adenocarcinoma (three cases). All tumors were 3 cm or larger in at least one dimension. On light microscopic examination, the predominant pattern was trabecular; however, insular, glandular, and spindle patterns were also identified. Argyrophilic granules were demonstrated in all cases by Grimelius stain, and Fontana-Masson (argentaffin) stain was negative. Electron microscopic examination of three cases showed membrane-bound, dense-core granules of the neurosecretory type. Although no endocrine symptoms were found, immunoperoxidase studies demonstrated 5-hydroxytryptamine in seven cases, substance P in three, vasointestinal polypeptide in two, pancreatic polypeptide in one, and somatostatin in one. Clinical behavior of these tumors was extremely aggressive. Although five cases were Stage IB at presentation, two Stage IIB, one Stage IIIB, and one Stage IV, 87.5% of these patients died of their neoplasms within 3 years. This study emphasizes the importance of correctly diagnosing endocrine carcinoma, intermediate-cell type in the uterine cervix, because of the poor prognosis of this tumor when compared with adenocarcinoma of the cervix.

Production of immunoreactive-polypeptide hormones in cervical carcinoma

The levels of immunoreactive-polypeptide hormones were measured in tissue extracts of eight uterine cervical cancers by specific radioimmunoassays. In one case with argyrophil granules, high levels of somatostatin, pancreatic polypeptide, calcitonin, and vasoactive intestinal polypeptide (VIP) were found, ranging from 160 to 880 ng/g tissue. A second argyrophil cancer contained 310 ng/g tissue of somatostatin, and a third contained 1100 ng/g tissue of adrenocorticotropic hormone (ACTH) and 380 ng/g of beta-melanocyte-stimulating hormone (beta-MSH). In addition, of the five nonargyrophil cancers tested, four contained calcitonin, three had VIP, two had either somatostatin or glucagon, and one contained ACTH and beta-MSH; the measured levels of these hormones ranged from 1.4 to 2.3 ng/g tissue. Gel filtration on a Sephadex G-75 column showed that the immunoreactive-polypeptide hormones in the first case were chromatographically similar to the authentic or prehormones. These results indicate that ectopic production of multiple immunoreactive-polypeptide hormones is common not only in argyrophil cell carcinoma, but also in nonargyrophil cell carcinoma of the cervix.

Carcinoid tumor of the uterine cervix. A light and electron microscopic study

A case of carcinoid tumor of the uterine cervix is reported. The patient was a 76-year-old Japanese woman with a complaint of vaginal bleeding. She was clinically diagnosed as stage IVb carcinoma of the uterine cervix. Light microscopically, the tumor was characterized by formation of solid cell nests and, in limited areas, glandular structures. The tumor cells in solid cells nests showed positive argyrophil reaction but were negative for argentaffin reaction. At the ultrastructural level, the cytoplasm of the tumor cells contain numerous neurosecretory granules, microfilaments and well-developed Golgi complexes. On the bases of histochemical and electron microscopic features of tumor cells, the tumor was diagnosed as carcinoid tumor of the uterine cervix.

Carcinoid tumors of the eye and orbit: a clinicopathologic study of 15 cases, with histochemical and electron microscopic observations

This clinicopathologic study includes 15 cases of carcinoid tumors of the eye and orbit. The patients ranged in age from 14 to 86 years (median, 53). No prediction for either gender was found. Seven tumors involved the orbit, seven the choroid, and one the iris. The primary site of origin of the carcinoid tumor was known in 12 cases: seven in the bronchus, one in the trachea, and four in the ileum. In three cases an orbital tumor was present but no other known primary neoplasm was clinically apparent. The postoperative follow-up period ranged from 0 to 4 years. The urinary levels of 5-hydroxyindoleacetic acid (5-HIAA) were elevated in four of ten patients tested, each of whom had a known primary tumor and two of whom had clinical evidence of the carcinoid syndrome. Four main histologic patterns were recognized: pattern A (solid lobules or masses), pattern B (trabecular or cord-like), pattern C (tubular or rosette-like) and pattern D (mixed). The apparently primary carcinoid tumors and the orbital or ocular metastases were closely related by their histologic patterns, histochemical staining characteristics, and ultrastructural features.

Non-endocrine carcinoid tumour of the uterine cervix: aspects of diagnosis and treatment. Case report

A case of primary well-differentiated carcinoid tumour of the uterine cervix in a Chinese woman of 62 years without endocrine symptoms is reported and its clinico-pathological features, ultrastructure and response to radiotherapy discussed. To our knowledge, it is the first of such cases seen in Hong Kong. Clinically, it presented as a polypoid lesion. The initial diagnosis was squamous carcinoma of cervix stage Ib and the patient was treated with radiotherapy. The tumour disappeared after application of first intracavitary irradiation of 4500 mg h. After completion of 9000 mg h, Wertheim hysterectomy followed and no residual tumour was found. Retrospective staining of the pre-irradiation cervical tumour by Grimelius method was positive for argyrophil granules and electron microscopic study demonstrated neurosecretory granules in the cytoplasm and established the diagnosis.

Cervical carcinoid ("argyrophil cell" carcinoma) associated with an endocervical adenocarcinoma: a light and ultrastructural study

On microscopic examination of a cervical carcinoid removed from a 29-year-old woman, foci of endocervical adenocarcinoma in situ (AIS) and severe squamous dysplasia were present immediately adjacent to the invasive carcinoid tumor. Cells of the carcinoid tumor contained abundant intracytoplasmic argyrophilic granules and numerous neurosecretory granules (NSG) on ultrastructural study. Neoplastic cells of the endocervical AIS were devoid of argyrophilic granules and contained no NSGs. The present neoplastic process appeared similar to cases of a "mixed" type neoplasm composed of a carcinoid tumor and an adenocarcinoma, which have been reported from several areas of the body but only once previously from the cervix. The possible mechanisms accounting for such an unusual neoplastic process are discussed.