Neuroendocrine carcinoma of the cervix: implications for staging and therapy

[Neuroendocrine tumors of the cervix: case study and literature review]

Neuroendocrine tumors of the cervix are rare accounting for only 0.9-1.5% of these tumors. The non-specificity of the clinical signs and the absence of a screening test delay diagnosis. Immunohistochemical and histological studies play a crucial role to confirm the diagnosis. Today, therapeutic management is difficult and prognosis is unfavorable. We report a case of neuroendocrine tumor of the cervix and we will outline the peculiarities of this rare disease.

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.

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.

A retrospective clinicopathological analysis of small-cell carcinoma of the uterine cervix

Cervical cancer encompasses several histological types, including neuroendocrine tumors (NETs). Small-cell carcinoma of the uterine cervix (SCCC) is the most common and aggressive subtype of cervical NET. The objective of this case report was to investigate SCCC using a retrospective clinicopathological approach. Four cases of large (≥4 cm) SCCCs are presented in this case study. The patients were diagnosed with SCCC through a sequential hierarchy of physical examinations, laboratory reports, radiological reports, immunohistochemical and pathological tests. The diagnosis for each case was made at various stages (Ib1, Ib2, IIa2 and IIb, according to the FIGO staging system, 2000) and each of the patients received different multimodality therapeutic regimens. All the patients underwent radical hysterectomy and pelvic lymphadenectomy, followed by adjuvant chemotherapy. Neoadjuvant chemotherapy was administered prior to surgery in two of the patients. The clinical and pathological analyses were assessed using a retrospective measure, maintaining timely follow-ups. SCCC is a rare but serious gynecological malignancy. This condition has a poor prognosis due to its high aggressiveness, high rate of metastases and mortality. Furthermore, the rarity of this disease represents a hindrance to adequate research and development of novel, efficient therapeutic regimens.

Chromogranin A (CgA) as poor prognostic factor in patients with small cell carcinoma of the cervix: results of a retrospective study of 293 patients

BACKGROUND

Small cell carcinoma of the cervix (SCCC) is a very rare tumor. Due to its rarity and the long time period, there is a paucity of information pertaining to prognostic factors associated with survival. The objective of this study was to determine whether clinicopathologic finings or immunohistochemical presence of molecular markers predictive of clinical outcome in patients with SCCC.

METHODOLOGY AND FINDINGS

We retrospectively reviewed a total of 293 patients with SCCC (47 patients from Cancer Center of Sun Yat-sen University in china, 71 patients from case report of china journal, 175 patients from case report in PubMed database). Of those 293 patients with SCCC, the median survival time is 23 months. The 3-year overall survival rates (OS) and 3-year disease-free survival rates (DFS) for all patients were 34.5% and 31.1%, respectively. Univariate and multivariate analysis showed that FIGO stage (IIb-IV VS I-IIa, Hazard Ratio (HR) = 3.08, 95% confidence interval (CI) of ratio = [2.05, 4.63], P<0.001), tumor mass size (≥ 4 cm VS <4 cm, HR = 2.37, 95% CI = [1.28, 4.36], P = 0.006) and chromogranin A (CgA) (Positive VS Negative, HR = 1.81, 95% CI = [1.12, 2.91], P = 0.015) were predictive of poor prognosis. CgA stained positive was found to be highly predictive of death in early-stage (FIGO I-IIa) patient specifically.

CONCLUSIONS

Patients with SCCC have poor prognosis. FIGO stage, tumor mass size and CgA stained positive may act as a surrogate for factors prognostic of survival. CgA may serve as a useful marker in prognostic evaluation for early-stage patients with SCCC.

Downregulation of six microRNAs is associated with advanced stage, lymph node metastasis and poor prognosis in small cell carcinoma of the cervix

BACKGROUND

Small cell carcinoma of the cervix (SCCC) is very rare, and due to the long time period required to recruit sufficient numbers of patients, there is a paucity of information regarding the prognostic factors associated with survival. MicroRNAs (miRNAs) have been used as cancer-related biomarkers in a variety of tumor types, and the objective of this study was to determine whether microRNA expression profiles can predict clinical outcome in SCCC.

METHODOLOGY/PRINCIPAL FINDINGS

Forty-four patients with SCCC who underwent radical hysterectomy between January 2000 and October 2009 were enrolled. Using the GeneCopoeia All-in-One™ Customized Human qPCR Primer Array, the expression profiles of 30 miRNAs associated with tumor metastasis was obtained from the formalin-fixed paraffin embedded samples of all 44 patients. Seven miRNAs, has-let-7c, has-miR-10b, has-miR-100, has-miR-125b, has-miR-143, has-miR-145 and has-miR-199a-5p were significantly down-regulated in advanced stage SCCC patients (FIGO IB2-IV) compared to early stage SCCC patients (FIGOIB1). Among, downregulation of six miRNAs, has-let-7c, has-miR-100, has-miR-125b, has-miR-143, has-miR-145 and has-miR-199a-5p were significantly associated with lymph node metastasis and reduced survival in SCCC. Kaplan-Meier survival analyses revealed that SCCC patients with low expression of has-miR-100 (P = 0.019) and has-miR-125b (P = 0.020) projected a significant tendency towards poorer prognosis.

CONCLUSIONS/SIGNIFICANCE

This study demonstrates that downregulation of 7 miRNA associated with advanced stage, 6 miRNAs with metastasis and 2 with poor prognosis in SCCC. Functional analysis of these miRNAs may enhance our understanding of SCCC, as altered expression of specific miRNAs may regulate the metastatic pathway and provide novel targets for therapy.

Prognostic factors and treatment comparison in early-stage small cell carcinoma of the uterine cervix

Small cell carcinoma of the uterine cervix (SCCUC) is rare and its biologic behavior is aggressive. To analyze prognostic factors and determine optimal therapy in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IIA SCCUC, we retrospectively reviewed 96 patients (14 patients treated in our center and 82 patients identified by a search on PubMed) treated with radical surgery (SU), surgery plus adjuvant chemotherapy (SU+Chemo), or surgery plus adjuvant chemotherapy and radiotherapy (SU+Chemo+RT) between 1990 and 2010. Of the 96 patients, 11 patients were treated with SU, 33 with SU+Chemo, and 52 with SU+Chemo+RT. The 5-year survival rate for the 96 patients was 45%. A total of 6% (2/32) of patients had local recurrence, 75% (24/32) had distant metastases, and 19% (6/32) had both. The 5-year survival rate in stage IB1 and IB2-IIA disease was 58 and 34%, respectively (P=0.049). For patients with and without lymph node metastases (LNM), survival was 33 and 60%, respectively (P=0.045). Patients with inner 1/3 stromal invasion had a better survival than those with deep stromal invasion (DSI) (100 vs. 34%, P=0.003). Survival was not significantly different in patients treated with the above three modalities, albeit treatment selection was related to LNM (P=0.000) and DSI (P=0.027). Thus, FIGO stage, LNM and DSI are significant predictors of survival. Adjuvant therapy after SU has not improved survival compared with surgery alone. Thus, newer multimodality therapy should be evaluated.

Small cell carcinoma of the cervix: treatment and survival outcomes of 188 patients

OBJECTIVE

To determine the clinicopathologic factors associated with survival in neuroendocrine small cell cervical cancer patients.

STUDY DESIGN

Patients were identified from a review of literature with an additional 52 patients from four hospitals. Kaplan-Meier and Cox regression methods were used for analyses.

RESULTS

Of 188 patients, 135 had stages I-IIA, 45 stages IIB-IVA, and 8 stage IVB disease. A total of 55.3% underwent surgery, 16.0% had chemoradiation, 12.8% radiation, and 3.2% chemotherapy alone. The 5-year disease-specific survival in stage I-IIA, IIB-IVA, and IVB disease was 36.8%, 9.8%, and 0%, respectively (P < .001). Adjuvant chemotherapy or chemoradiation was associated with improved survival in patients with stages IIB-IVA disease compared with those who did not receive chemotherapy (17.8% vs 6.0%; P = .04). On multivariable analysis, early-stage disease and use of chemotherapy or chemoradiation were independent prognostic factors for improved survival.

CONCLUSION

Use of adjuvant chemotherapy or chemoradiation was associated with higher survival in small cell cervical cancer patients.

Small cell carcinoma of the cervix: a case report

Small cell carcinoma of the uterine cervix accounts for 1-3% of all cervix cancers. It is an aggressive disease with a poor prognosis. To date, no effective treatment protocol has been determined. Surgery, radiotherapy, and chemotherapy have been used either alone or in combination. Recent data suggests that survival in patients with early staged small cell carcinoma of the cervix is better with surgery combined with chemo-radiotherapy. Here, we presented two patients with stage IB1 small cell carcinoma of the uterine cervix. For both patients, definitive surgery was performed with pelvic and para-aortic lymphadenectomy. Subsequently, they were treated with pelvic external radiotherapy and high-dose-rate intracavitary brachytherapy with concurrent cisplatin based chemotherapy. They were alive with no evidence of disease at 91 and 65 months, respectively.

High-Grade Neuroendocrine Carcinoma of the Cervix

Neuroendocrine tumor of the uterine cervix is a rare and aggressive malignancy. Despite controversial, multimodal treatment methods, prognosis and treatment outcomes are worst in advanced stages. We report an early-stage case treated with the multimodal approach. The nomenclature proposed for this tumor type in 1997 by the College of American Pathologists still has some points of discussion. As in our case some of the tumors cannot be defined exactly into small or large cell types, and this causes confusion at least for nomenclature purposes. A 'mixed' type for this tumor may be appropriate.

Small cell undifferentiated (neuroendocrine) carcinoma of the uterine cervix

BACKGROUND

Small cell undifferentiated (neuroendocrine) carcinoma of the cervix is a rare and agressive tumor. Most medical centers have little experience with this tumor. The purposes of our study were to evaluate our experience and compare our findings with those reported in current literature.

STUDY DESIGN

Fifteen patients with small cell undifferentiated carcinoma of the cervix were treated between 1977 and 1997. Clinical data including age, pregnancy history, tumor stage, recurrence, type of therapy, presenting symptoms, location of metastasis, and survival were studied.

RESULTS

The ages of patients ranged from 20 to 83 years, with a mean of 47 years. Two patients were nulliparous, 2 primiparous, and 11 multiparous. Five patients (33%) were stage I, three (20%) stage II, one (7%) stage III, and six (40%) stage IV at diagnosis. Five patients (33%) progressed without response to treatment, and seven (47%) experienced a recurrence of their cancer, on average after 15 months. Treatments included surgery, radiation, chemotherapy, or a combination of them. Extrapelvic metastases developed in five patients with stage I or stage II disease. Three patients (20%) developed brain metastasis. Tumor lysis syndrome was encountered in one patient. Thirteen patients died of their disease, one remained alive 80 months after diagnosis, and one was lost to followup.

CONCLUSIONS

Our experience with this rare and aggressive tumor raises the question of increased incidence of central nervous system metastases with small cell undifferentiated carcinoma. Present therapy has not significantly improved outcomes. Tumor lysis syndrome is a possible risk when treating these patients.

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.

Prognostic factors in neuroendocrine small cell cervical carcinoma: a multivariate analysis

BACKGROUND

The purpose of this study was to evaluate the clinical and pathologic factors associated with survival in patients with neuroendocrine (NE) cervical carcinoma.

METHODS

All patients with NE cervical carcinoma diagnosed between 1979-2001 were identified from tumor registry databases at two hospitals. Data were collected from hospital charts, office records, and tumor registry files. The impact of clinical and pathologic risk factors on the survival of patients with small cell NE carcinoma of the cervix was evaluated using Kaplan-Meier life table analyses and log-rank tests. The independent prognostic factors found to be predictive of survival in univariate analysis were evaluated using Cox regression. All tests were two-tailed with P values < 0.05 considered significant.

RESULTS

Thirty-four patients (median age, 42 years) were diagnosed with neuroendocrine cervical carcinoma, which included 21 with International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, 6 with FIGO Stage II disease, 5 with FIGO Stage III disease, and 2 with FIGO Stage IV disease. Seventeen patients underwent a radical and 6 patients underwent a simple hysterectomy. Fourteen women received adjuvant therapy with pelvic radiation and/or cisplatin-based chemotherapy. Ten women received primary radiotherapy with (n = 5) or without (n = 4) chemotherapy and the remaining patient refused therapy. Women with early-stage (Stage I-IIA) disease had median survival rates of 31 months compared with 10 months in the advanced-stage (Stage IIB-IVB) group (P = 0.002). In univariate analysis, advanced stage (P = 0.002), tumor size >2 cm (P = 0.02), margin involvement (P = 0.016), pure versus a mixed histologic pattern (P = 0.04), margin status (P = 0.016), and smoking (P = 0.04) were considered poor prognostic factors. In multivariate analysis, smoking for early-stage patients and stage of disease in the overall population remained as independent prognostic factors of survival.

CONCLUSIONS

Smoking and advanced stage are reported to be poor prognostic factors for survival in patients with NE small cell carcinoma of the cervix. Only those with early lesions amenable to extirpation are cured. The role of primary or postoperative radiation with or without chemotherapy is unclear and yields uniformly poor results, particularly in patients with advanced lesions. Clinical trials are needed.

Neuroendocrine cervical carcinoma: a diagnostic and therapeutic challenge

OBJECTIVE

The aim of this study was to analyze diagnostic criteria, response to chemotherapy, rate and site of relapse, and overall survival (OS) in neuroendocrine cervical carcinoma.

METHODS

Twenty patients were included. Stage was Ia(2) in 1 case, Ib(1) in 4, Ib(2) in 4, II in 5, IIIb in 2, IVa in 2, and IVb in 2. Patients with stage Ib(2) or greater received neoadjuvant chemotherapy (NCH). Eighteen patients were operated on. Immunohistochemistry was performed on the surgical specimens. Statistical analysis included the Kaplan-Meier method and the chi(2) and log-rank tests.

RESULTS

The response to NCH was <50% in 2/13 cases (15.3%), >50% in 9/13 (69.4%), and complete in 2/13 (15.3%). Cytokeratin was positive in 17/18 cases, neuron-specific enolase in 15/18, chromogranin in 9/18, and synaptophysin in 8/18. Tumor was pure in 12 cases. Two cases had simultaneous ovarian carcinoma. Positive nodes were observed in 9/20 pts (45%). Tumors <4 cm had no recurrences. Pure tumors >4 cm had distant relapses (6/11). Mixed tumors >4 cm had 2/6 pelvic and 3/6 lung metastases. OS was 39%. When the initial tumor volume was <4 cm OS was 76%, and it was 18% for tumors >4 cm (P < 0.05). OS was 58% when the residual tumor after NCH was <2 cm and 21% when it was >2 cm (P < 0.05). When the tumor was pure OS was 54% and 19% when it was mixed (P < 0.05). OS was 72% among pts with negative nodes and 11% for those with positive nodes (P < 0.01).

CONCLUSIONS

(1) Stage IV was frequent (20%); (2) Response to NCH was high; (3) The pattern of relapse differs for mixed tumors; (4) For tumors <4 cm outcome is similar to that of squamous carcinoma.

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.

Granulocyte colony-stimulating factor-producing small-cell carcinoma of the uterine cervix: report of a case

A case of granulocyte colony-stimulating factor (G-CSF)-producing small-cell carcinoma of the uterine cervix is described. In a 70-yr-old woman, clusters of small cells with hyperchromatic nuclei at a high nuclear/cytoplasmic ratio were detected cytologically in the cervix. These clusters were diagnosed as a small-cell neuroendocrine carcinoma by the concomitant use of Grimelius staining and immunohistochemical staining, in addition to electron microscopic observation. This patient showed a significant increase in peripheral leukocytes, despite the absence of infectious signs. Immunohistochemical findings, together with a high blood G-CSF level, suggested the production of G-CSF from the tumor. Consistent with the knowledge that both small-cell carcinoma and G-CSF-producing tumors have a poor prognoses, the patient had no or partial response to therapies performed, and died from the cancer 11 mo after it was diagnosed. This case strongly indicates the need for early diagnosis of this type of tumor, based on cytological features.

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.

Carcinoid syndrome caused by an atypical carcinoid of the uterine cervix

Neuroendocrine tumors of the cervix are rare and are often under- or misdiagnosed. Because these tumors are very aggressive, early diagnosis and subsequent treatment are warranted. We describe a 46-yr-old woman with carcinoid syndrome caused by an atypical carcinoid of the uterine cervix. At age 44, she had dysplasia on Pap smear and underwent total abdominal hysterectomy with the diagnosis of adenocarcinoma. Fourteen months postoperatively, she developed the carcinoid syndrome and was found to have numerous liver metastases. Histological and immunohistochemical investigations of biopsy specimens from the patient's liver lesions and original cervical lesion ("adenocarcinoma") suggested that this woman had a primary atypical carcinoid of the uterine cervix with metastases to the liver. Treatment with octreotide and alkylating agents decreased the episodes of flushing and diarrhea within 8 weeks. If an adenocarcinoma of the uterine cervix is diagnosed, atypical carcinoid should be in the differential diagnosis. Symptoms of the carcinoid syndrome should be pursued and, if present, a urinary 5-hydroxyindolacetic acid level should be obtained. Timely diagnosis of a neuroendocrine tumor of the cervix may improve survival.

Small cell carcinoma of the cervix complicated by pregnancy

We report the results of treatment in a 26-year old patient with stage IB2 small cell carcinoma of the cervix complicated by pregnancy. A pathological complete remission was achieved following sandwich chemotherapy and radiotherapy. The patient remains in clinical remission 14 months after presentation.

Small cell neuroendocrine carcinoma of the cervix with involvement of multiple pelvic nodes--A successfully treated case by multimodal approach

Small cell neuroendocrine carcinoma of the cervix is very rare and is usually associated with dismal prognosis if treated by conventional surgery and radiotherapy even in early stage disease. This tumor is characterized by early lymphatic and hematogenous spread. Only one successfully treated case of small cell neuroendocrine carcinoma of the cervix with dissemination to the pelvic nodes had been reported before in the literature. We are reporting a case of small cell neuroendocrine carcinoma of the cervix with multiple pelvic nodal metastases including the common iliac nodes, which had been successfully treated with a multimodal approach including radical hysterectomy, pelvic/para-aortic lymphadenectomy, and postoperative chemotherapy using cisplatin-etoposide combinations and pelvic irradiation.

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.

Neuroendocrine small cell uterine cervix cancer in pregnancy: long-term survival following combined therapy

A 22-year-old woman carrying twin gestations at 30 weeks presented with preterm labor and a prolapsing cervical mass. Following Cesarean section birth, she was treated with multiagent chemotherapy followed by pelvic radiotherapy for a Stage IIA small cell cancer of the uterine cervix. She is without evidence of disease 5.5 years after diagnosis and is the first reported long-term survivor of a small cell cervical carcinoma diagnosed during pregnancy.

Prognostic factors in surgically treated small cell cervical carcinoma followed by adjuvant chemotherapy

BACKGROUND

Small cell carcinoma of the uterine cervix is an uncommon tumor associated with high mortality even among patients with early stage disease. The role of adjuvant chemotherapy after surgery has been suggested by regimens used for small cell lung carcinoma. During the years 1980-1997, 19 cases in which various adjuvant chemotherapies were given after hysterectomy were reported in the literature published in English.

METHODS

Adjuvant chemotherapy was administered consecutively to 23 patients with Stage Ib-II small cell cervical carcinoma who had been primarily treated with radical hysterectomy and had adequate bone marrow, renal, and hepatic functions. A combination of vincristine, doxorubicin, and cyclophosphamide alternating with cisplatin and etoposide (VAC/PE) was administered to 14 patients during the years 1988-1996 according to a prospective study protocol. A combination of cisplatin, vinblastine, and bleomycin (PVB) was administered to 8 patients, and another regimen was administered to 1 patient during the years 1984-1988. Prognostic factors were evaluated by analyzing both the data on these 23 patients and the pooled data on the cases retrieved from the literature and our own files.

RESULTS

Ten of the 14 patients who received VAC/PE had no evidence of disease during a median follow-up of 41 months, whereas 3 of the 9 who received PVB or another regimen survived. Of the 10 patients who died of their disease, all died of distant metastasis within 10 months after recurrence. Meta-analysis of the pooled data showed that 68% of patients who received regimens containing VAC or PE survived, whereas 33% of patients who received regimens not containing VAC/PE survived (P = 0.0078, log rank test). Seventy percent of patients with no lymph node metastasis at hysterectomy and 35% with lymph node metastasis survived (P = 0.05). All patients who died of disease had extrapelvic metastasis.

CONCLUSIONS

Chemotherapies containing VAC or PE are favorable regimens for patients with early stage small cell cervical carcinoma after radical hysterectomy.

Establishment and characterization of 12 uterine cervical-carcinoma cell lines: common sequence variation in the E7 gene of HPV-16-positive cell lines

A total of 12 carcinoma cell lines of the human uterine cervix were established from 5 keratinizing and 5 nonkeratinizing squamous-cell carcinomas, and 2 small-cell carcinomas. Of these, 10 lines grew as adherent cells and 2 as floating aggregates. All lines showed (i) similarity in morphology to the primary tumor from which they were derived; (ii) high viability with relatively long doubling times (48-96 hr); (iii) absence of Mycoplasma and other bacteria, apart from one Mycoplasma-contaminated line; (iv) genetic heterogeneity by DNA-fingerprinting analysis; (v) absence of p53 mutation from exon 4 through 9; and (vi) the presence of HPV DNA sequence. Among the lines, 7 were infected by HPV-16, 3 by HPV-18, 1 by HPV-31, and 1 by HPV-33; the 2 cell lines derived from small-cell carcinomas contained HPV-18. Interestingly, 6 of the 7 cell lines containing HPV-16-type DNA harbored the same alteration of E7 at nucleotide position 647 (amino acid 29, AAT --> AGT, Asn --> Ser), whereas the 3 HPV-18-positive lines did not; 3 cell lines proved to have intact E1/E2 of HPV, suggesting the presence of episomally replicating HPV DNA as well as the integrated form, whereas the other 9 lines were shown to have integrated HPV. Taken together, these cell lines would be very useful for studying the biology of uterine cervical carcinoma.

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.

Small cell carcinoma of the cervix

Small cell carcinoma of the cervix represents an uncommon variant of cervical cancer with a particularly poor prognosis. Traditionally, the diagnosis was established from routine histopathological sections, but there has been a trend to refer to this tumour as neuroendocrine carcinoma, with a requirement to demonstrate cytoplasmic granules. Five patients are described, who share the clinical features of young age of onset, early metastasis in the presence of apparently low stage disease, early failure of appropriate local treatment, and extreme chemosensitivity (features that are quite distinct from those seen in squamous cell cancer of the cervix). Light microscopy suggested a diagnosis of small cell cancer in all five tumours, but not all showed evidence of neuroendocrine differentiation. It is proposed that the present criteria for the diagnosis of cervical small cell carcinoma are too strict. The diagnosis should rely on the light microscopy of haemotoxylin and eosin sections and the distinctive clinical behaviour. The absence of neuroendocrine differentiation should not exclude the diagnosis, it does not appear to influence the clinical behaviour. The appropriate management of small cell carcinoma of the cervix is systemic, with chemotherapy as the first line of treatment. Surgery and radiotherapy may improve control of local disease but are unlikely significantly to influence the overall prognosis.

Effect of dibutyryl cyclic AMP on morphologic features and marker production of human cervical argyrophil small-cell carcinoma cell line

The effect of dibutyryl cyclic AMP (dB-cAMP) on the morphologic features and marker production of a human cervical argyrophil small-cell carcinoma (ASCC) cell line was examined. Following 1-5 days' exposure to 5 mM dB-cAMP, morphologic differentiation as defined by the expression of cytoplasmic processes (stellate cells) was observed. The number of stellate cells depended on the dose of dB-cAMP and incubation time. Shortly after removal of dB-cAMP from the culture medium, the treated cells returned to their original spherical shape. dB-cAMP caused a reduction in the growth rate of cells which recovered after removal of the agent. The morphological changes appeared not to be the result of growth inhibition by dB-cAMP, because the cells maintained in a serum-free medium did not show any change in shape. Electron microscopic study revealed the development of intracytoplasmic microtubules, microfilaments, and an increase in the number of neurosecretory granules in the treated cells. The levels of neuron-specific enolase, serotonin and gastrin in treated cells were significantly higher than those in untreated controls. These findings indicate that a reversible differentiation of cultured ASCC cells into neuroendocrine cells occurs in a growth medium containing dB-cAMP.

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.

Reproduction and the APUD system

Substantial evidence for involvement of the APUD system in the normal reproductive tract is limited to the prostate gland and uterine cervix. Most supportive data simply documents the presence of neuro-endocrine cells in these tissues. A biological product(s) or role(s) remains to be discovered, but appears likely in the prostate. Tumors possessing cells with APUD characteristics have been described in many reproductive tissues including the prostate, cervix, endometrium, ovary, and testes. These tumors are generally aggressive in behavior, and optimum therapy needs to be determined.

Treatment of small cell carcinoma of the cervix with cisplatin, doxorubicin, and etoposide

Between July 1986 and February 1991, 10 patients with small cell carcinoma of the cervix were prospectively treated with combination chemotherapy using cisplatin (50 mg/m2) and doxorubicin (50 mg/m2) on Day 1 and etoposide (75 mg/m2) on Days 1-3. All patients underwent an extensive pretreatment metastatic survey and had histologic confirmation of small cell carcinoma prior to entry in the study. Seven patients had stage Ib, 1 stage IIa, and 2 stage IIb. Nine patients received chemotherapy at primary presentation and 1 was treated for recurrent disease. In 6 cases, chemotherapy was given and then followed by radiation therapy. Three patients received chemotherapy following radical hysterectomy and 1 was treated for persistent disease after radiation therapy. Patients received a median of four courses of chemotherapy (range 2-6). Neutropenia was the dose-limiting toxicity with 9 of 10 patients requiring a dose reduction. There was no instance of neutropenic sepsis or other major toxicity. Seven patients had measurable disease at the start of therapy. Three of these patients had a complete clinical response, 1 had a partial response, 2 had stable disease, and 1 had progressive disease (response rate = 57%). The median survival was 28 months. At the time of this report, 4 of 6 patients with stage Ib cancers given primary treatment on this regimen remained free of disease (with 28 months the median follow-up). Our pilot study indicates that this chemotherapy regimen has activity in small cell carcinoma of the cervix and should be further evaluated as an adjuvant to surgery or radiation in patients with early stage disease.

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.

Human papillomaviruses and small cell carcinoma of the uterine cervix

The in vitro DNA amplification technique of polymerase chain reaction was used to evaluate the possible presence of human papillomavirus (HPV) in small cell carcinoma of the uterine cervix. None of the 12 cases examined contain detectable amounts of either HPV type 16, 18, 31, or 33 DNA. On the other hand, HPV types 16 and 18 DNA were found in 14 (93.3%) and 9 (60.0%) of 25 invasive cervical squamous carcinoma tissues. The results seem to suggest that these types of HPV are not present or are present in extremely small quantities in cervical small cell carcinoma. Such an absence of HPV DNA makes it unlikely that these types of HPV play any etiological role in the pathogenesis of cervical small cell carcinoma.

Adjuvant therapy for neuroendocrine small cell carcinoma of the cervix: review of the literature

Neuroendocrine cell carcinoma of the cervix is a virulent tumor associated with an extremely poor prognosis. Even in clinical Stage I disease, there may be subclinical hematogenous and lymphatic metastases with frequent recurrences. Adjuvant postoperative external pelvic radiotherapy has been reported to offer some degree of local control; however, most patients succumb to distant disease. Following radical abdominal hysterectomy and pelvic lymphadenectomy, with confirmation of the neuroendocrine tumor by electron microscopy and immunohistochemical staining, two patients were given adjuvant systemic chemotherapy with concurrent pelvic radiotherapy, employing regimens with documented activity against small cell carcinoma of the lung of neuroendocrine origin. Despite severe myelotoxicity and persistent neuropathy, both patients are alive without clinical evidence of disease at 28+ and 47+ months.

Stage I small cell carcinoma of the vulva treated with vulvectomy, lymphadenectomy, and adjuvant chemotherapy

Neuroendocrine small cell carcinoma is a lethal, but rare, tumor that arises most frequently in the lung. Small cell cancer also rarely may occur in the female genital tract, usually in the cervix. This article concerns the fourth reported case of neuroendocrine small cell carcinoma of the vulva. Previously, small cell carcinoma of the vulva has been treated with regional therapy including surgery and radiation. Survival has been poor, however, due to the propensity of these tumors to metastasize early in the course of the disease. Recently, the median survival of patients with small cell carcinoma of the lung has been improved with the use of chemotherapy. The authors review the literature on the treatment of small cell carcinoma of the vulva and report on a patient who was treated successfully with vulvectomy and inguinal lymphadenectomy followed by adjuvant chemotherapy.

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.

Carcinoma of the uterine cervix with variegated histological patterns and calcitonin production

This is a report of a calcitonin-producing cervical cancer with variegated histological patterns. The levels of calcitonin correlated with the clinical course. Multiple lung metastases were completely controlled by cisplatin/Adriamycin/cyclophasphamide combination chemotherapy, although only for a short period. Microscopically, the tumor showed dominant small cell carcinoma; however, it did show differentiation into large cell nonkeratinizing carcinoma, keratinizing carcinoma, adenocarcinoma, and possibly carcinoid. Ultrastructural study revealed a few dense core secretory granules. Multiple immunohistochemical studies were performed. It is presumed that the tumor originated from the totipotent, immature precursor cells in the cervix and differentiated into endocrine carcinoma, squamous cell cancer, and adenocarcinoma.

Small cell carcinoma of the uterine cervix

From 1962 to 1985, 2201 patients with invasive cervical cancer were staged, evaluated, and treated at the University of Kentucky Medical Center. After a thorough evaluation, 25 cases (1.1%) fulfilled the histologic criteria for small cell cancer defined by Reagan and coworkers. These patients were computer-matched for age, disease stage, and lesion size to 25 patients with large cell nonkeratinizing cancer and 25 patients with keratinizing squamous cell cancer. Morphometric analyses of nuclear size and maximum nuclear diameter were performed on all cases without knowledge of cell type. Small cell cancers were characterized by a nuclear area of 160 mu 2 or less and a maximum nuclear diameter of 16.2 mu, which was significantly lower than that for large cell tumors. Thirty-three percent of the small cell carcinomas stained positively for the neuroendocrine markers (neuron-specific enolase [NSE] and chromogranin [CGR]), whereas the remainder contained only epithelial markers such as cytokeratin (CYK) and epithelial membrane antigen (EMA). Small cell cancers were associated with a high frequency of lymph-vascular space invasion and a diminished lymphoplasmacytic response. Patients with small cell cancer had a significantly higher recurrence rate, particularly to extrapelvic sites, than the matched patients with large cell cancers, and their survival was lower. Clinical trials to determine the efficacy of adjuvant chemotherapy in the treatment of small cell cervical cancer are needed.

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.

Neuroendocrine (Merkel cell) carcinoma of the vulva: a case report and review of the literature

The clinical and pathologic features of a vulvar neuroendocrine (Merkel cell) neoplasm are presented. Cytologic studies of material obtained from needle aspiration suggested that the tumor was a small cell neoplasm possibly of neuroendocrine derivation. The light-microscopic findings of sheets of small, uniform cells were consistent with a diagnosis of neuroendocrine tumor. The electron-microscopic characteristics, including the presence of neurosecretory granules, confirmed the diagnosis of a neuroendocrine (Merkel cell) carcinoma. Regional lymph node metastases were present at the time of initial surgery, and both local and distant metastases developed 8 months later. A comprehensive pretreatment metastatic evaluation is recommended. The role of chemotherapy for primary therapy is considered.

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.