Carcinoid tumor within a squamous cell carcinoma of the cervix

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.

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.

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

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

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.

Small-cell neuroendocrine carcinoma of the uterine cervix associated with micro-invasive squamous cell carcinoma and adenocarcinoma in situ

A case of small-cell neuroendocrine carcinoma of the uterine cervix associated with squamous cell carcinoma and adenocarcinoma in situ is reported. The tumor consisted mainly of uniform small cells with a population of intermediate cells that resembled carcinoid tumor cells. Foci of micro-invasive squamous cell carcinoma and adenocarcinoma in situ were recognized separately, adjacent to the main tumor. Both Grimelius stain and immunostaining of serotonin were positive for small-cell and intermediate-cell carcinoma. Neurosecretory granules were demonstrated by electron microscopy. Microacini with positive mucin staining and microvilli-like structures suggested glandular or exocrine differentiation of the tumor. Three distinctive types of differentiation, neuroendocrine, exocrine and squamous characteristics, were expressed in the tumor.

Neuroendocrine differentiation in cervical carcinoma

AIMS

To examine neuroendocrine differentiation, as shown by chromogranin A (CGA) expression, in cervical carcinomas.

METHODS

Sixty seven cervical carcinomas were studied and were classified as adenocarcinomas, adenosquamous carcinomas or squamous cell carcinomas based on the assessment of haematoxylin and eosin staining and stains for mucin. Where features of glandular differentiation were identified, sections were also stained for evidence of intestinal type mucin. CGA immunostaining was done and the results were graded on a three point scale: 0, + (1-5% of cells positive) and ++ (> 5% of cells positive). These findings were then analysed with respect to lymph node status, tumour differentiation and clinical outcome.

RESULTS

There were 32 adenocarcinomas, 18 adenosquamous carcinomas and 17 squamous cell carcinomas. Positive staining was seen in 14 (20.9%) cases, of which four were strongly positive. All but one case were either adenocarcinomas or adenosquamous carcinomas. There was a trend for CGA positivity to be related to intestinal differentiation but this failed to reach statistical significance. No correlation could be demonstrated between CGA staining and lymph node status, tumour differentiation and clinical outcome.

CONCLUSIONS

Neuroendocrine differentiation is common in cervical carcinomas where there is evidence of glandular differentiation. Whilst the numbers in this study are relatively small, the presence of neuroendocrine cells in otherwise typical carcinomas does not seem to have any association with clinical behaviour.

Neuroendocrine carcinoma of the uterus

Neuroendocrine carcinomas of the cervix and endometrium were reviewed. They have been variously designated as carcinoid, argyrophil cell carcinoma, apudoma, small cell carcinoma, oat cell carcinoma, endocrine carcinoma, and neuroendocrine carcinoma, the last-mentioned term being preferred in this chapter. Adenocarcinomas with neuroendocrine cells are occasionally encountered in the cervix and endometrium. It is generally questioned whether they should be included in the spectrum of neuroendocrine carcinomas, although differential diagnosis between some such tumors of the gastrointestinal tract and neuroendocrine carcinoma is reported to be difficult. Since the majority of neuroendocrine carcinomas of the cervix are highly aggressive, it is important to establish the neuroendocrine nature in the cervical carcinomas. In addition to the characteristic histologic features and argyrophil stainability, immunohistochemical demonstration of several neuroendocrine markers may be helpful in diagnosing neuroendocrine carcinoma of the cervix. Ultrastructural demonstration of neurosecretory granules is almost decisive in establishing the tumor's neuroendocrine nature, but it is not applicable in all cases. Neuroendocrine carcinomas of the cervix have been treated by surgery, radiation therapy, and chemotherapy, but optimal treatment methods have not yet been established because of the rarity of the tumor. Finally, we have described a typical neuroendocrine carcinoma of the cervix and reported some data regarding its experimental study.

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.

An immunohistochemical study of small-cell and poorly differentiated carcinomas of the cervix using neuroendocrine markers

Small-cell and poorly differentiated carcinomas of the cervix were studied immunohistochemically for several neuroendocrine and epithelial markers. Neuroendocrine markers were frequently expressed in small-cell carcinomas with argyrophilia; of the seven such tumors, four were immunoreactive with anti-chromogranin, seven with antineuroendocrine, five with anti-Leu 7, and seven with anti-neuron-specific enolase. Only neuron-specific enolase, however, was expressed in two of the three small-cell carcinomas without argyrophilia. On the other hand, one of the epithelial markers, epithelial membrane antigen, was strongly positive in all three small-cell carcinomas without argyrophilia and all seven poorly differentiated carcinomas, while it was expressed only weakly and focally in all small-cell carcinomas with argyrophilia except in one case. In conclusion, it is suggested that the immunohistochemical demonstration of several neuroendocrine markers may be helpful in diagnosing neuroendocrine carcinoma of the cervix as a supplement to conventional light microscopy, silver staining, and electron microscopy.

Synchronous adenocarcinoma and carcinoid of the uterine cervix: immunohistochemical study of a case and review of literature

Mixed neoplasms, adenocarcinoma and carcinoid, have been reported to occur in several areas of the body, including gastrointestinal tract, breast, prostate, lung, skin, and kidney. Mixed tumors of the uterine cervix are very rare. Their histogenesis, immunohistochemical profile, and prognosis are not well established. Here, we report a case of a 49-year-old female with infiltrating adenocarcinoma of the cervix within which was found a separate nodule of small cell endocrine carcinoma.

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.

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.

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.

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.