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

Small Cell Cervical Carcinoma in Pregnancy: Therapeutic Options for an Aggressive Cancer Diagnosis

Neuroendocrine small cell cervical carcinoma is an aggressive cancer which accounts for approximately 1 to 3% of all cervical neoplasms. Therapy must be altered in pregnancy to optimize maternal-fetal outcomes. A 39-year-old woman presented for a routine prenatal visit and was noted to have a grossly abnormal cervix. Cervical biopsies confirmed small cell carcinoma. At 19 weeks' gestation, chemotherapy was initiated. The patient delivered at 34 weeks' gestation to initiate radiation therapy. Six months later, she was diagnosed with metastatic disease and died from cancer complications. In pregnancy, treatment modalities for small cell cervical carcinoma are based on the patient's gestational age at diagnosis. While aggressive early treatment is preferred, platinum-based chemotherapy can be initiated in the second trimester and radiation therapy delayed until delivery. Small cell cervical carcinoma complicating pregnancy requires aggressive treatment. Chemotherapy in the second trimester with planned delayed radiation therapy, may optimize fetal outcomes.

PD-L1, Mismatch Repair Protein, and NTRK Immunohistochemical Expression in Cervical Small Cell Neuroendocrine Carcinoma

Background

Cervical small cell neuroendocrine carcinoma (SCNC) is a rare and aggressive disease that lacks a standard treatment strategy or effective methods of targeted therapy. PD-L1 inhibitors for DNA mismatch repair system-deficient (dMMR) tumors and neurotrophin receptor tyrosine kinase (NTRK) inhibitors offer potential pan-cancer treatments.

Methods

Immunohistochemistry was employed as the main detection method, and any NTRK positive cases, identified by immunohistochemistry, were further submitted for evaluation by fluorescence in situ hybridization (FISH) and real-time polymerase chain reaction (RT-PCR) methods.

Results

Forty-six patients were enrolled. Positive PD-L1 expression was seen in 22 of the 43 patients (51.16%) with an average combined positive score of 6.82. PD-L1-positive patients were more likely to have a higher proliferation rate in the tumor, and they experienced less recurrence and death (p = 0.048 and 0.033, respectively) compared with the patients with negative PD-L1 expression. However, in the multivariate analysis, none of the clinical parameters was associated with the expression of PD-L1. There was no association between PD-L1 expression and disease recurrence or overall survival in the Kaplan-Meier analysis. All cases were found to be MMR-stable and lacked NTRK gene fusion. However, pan-Trk expressed in 14 (32.56%) of the 43 tested cases, but FISH and RT-PCR failed to confirm any positive fusion signals in IHC-positive cases.

Conclusions

PD-L1 may be an effective therapeutic target for cervical SCNC. Cervical SCNC is a MMR-stable tumor and lacks NTRK gene fusion. IHC isn’t a reliable method in the detection of NTRK gene fusion in cervical SCNC.

Histology-specific FGFR2 alterations and FGFR2-TACC2 fusion in mixed adenoid cystic and neuroendocrine small cell carcinoma of the uterine cervix

Neuroendocrine small cell carcinoma of the uterine cervix portends a dismal prognosis with limited treatment options. Rarely, tumors of mixed-lineage appear in gynecologic malignancies. Here, we report a 77-year-old woman who presented with complete uterine prolapse and 4-month history of vaginal bleeding. Histopathologic evaluation revealed a mixed adenoid cystic carcinoma and neuroendocrine small cell carcinoma of the uterine cervix. The tumor was PD-L1 and HPV 35 positive. The patient was treated with up-front surgery and adjuvant radiation. Independent, histology-specific alterations in FGFR2 and a FGFR2-TACC2 fusion were identified. Progression of disease occurred within 6 months for which she received chemotherapy and immunotherapy. However, the patient expired within a year. We comprehensively review how screening for and targeting of FGFR alterations in recurrent and metastatic cervical cancer might serve as a touchstone for future treatment regimens.

Prognostic factors and outcomes of early-stage small cell neuroendocrine carcinoma of the cervix: 37 cases from a single center

Background

The objective of this study is to investigate small cell neuroendocrine carcinoma of the cervix (SCCC), using a retrospective clinicopathological characteristic and treatment approach.

Method

We retrospectively analyzed cases of early-stage SCCC, identified between 2006 and 2016, in women who received radical surgery and adjuvant chemotherapy with or without radiotherapy. Kaplan–Meier and one-way ANOVA analyses were performed.

Result

A total of 37 cases of SCCC are presented in this study, of which 21 had stage IB1 SCCC, 12 had stage IB2, 3 had stage IIA1, and 1 had stage IIA2. All patients were treated with radical surgery and adjuvant chemotherapy, specifically, 26 with radical surgery followed by adjuvant chemotherapy plus radiation and 11 with neoadjuvant chemotherapy (NACT) followed by radical surgery. After a median follow-up time of 27 months (range, 8–115 months), the 2-year and 5-year disease-free survival rate for all patients was 51.9% and 34.1%, respectively, and the overall survival rate was 60.3% and 38.6%, respectively. Univariate analysis showed that International Federation of Gynecology and Obstetrics (FIGO) stage and tumor size may be a predictor of a poor prognosis. NACT and adjuvant radiation did not improve survival over adjuvant chemotherapy alone but should not be a significant independent prognostic factor for survival.

Conclusion

Even in patients with early-stage SCCC, the prognosis is poor, although FIGO stage and tumor size may act as surrogate factors prognostic of survival.

Metastatic Small Cell Carcinoma of the Breast from Cancer of the Uterine Cervix: A Case Report

We report here on a case of 51-year-old woman with metastatic small cell carcinoma of the breast that came from her cancer of the uterine cervix. She underwent radical hysterectomy with bilateral salpingo-oophorectomy due to small cell carcinoma of the uterine cervix, and adjuvant radiotherapy was administered to the pelvis. Breast metastasis with a palpable mass then occurred 3 months after the primary surgery. Simple mastectomy and adjuvant chemotherapy were performed. She initially showed a good response to the therapy, yet she ultimately died of multiple metastases with a fulminating disease course. This is an extremely rare case, and only 1 similar case has been reported earlier, so we report on this case along with a review of the relevant literature.

Brain Metastases in Patients with Gynecologic Cancers: A Single Institution Experience and Review of the Literature

Objective:

Brain Metastasis (BM) from primary gynecologic cancers is a rare entity. The advances and successes in the treatment of primary gynecologic malignancies, have led to prolonged survival and, a higher incidence of BM. This study aims to report the experience at our institution in managing these patients, and provide possible data points that may be essential to note as prognostic factors, and see if our findings are consistent with the literature in this subject. We also aim to provide a brief literature review of patients with gynecologic cancers and BM.

Methods:

This is a small single institution retrospective study of 23 patients with a gynecologic malignancy and BM, identified between the years 2007–2015. Data were collected on variables including patient demographics, disease and treatment.

Results:

The median overall survival from the primary diagnosis was 28 months. Median time from diagnosis of BM to death was 9 months.

Conclusion:

The outcomes in our study are similar to what is stated in the current literature with regard to BM from gynecologic malignancies. Our literature search also revealed that the molecular analysis and treatment of the primary tumor remain important to prevent BMs. The tendency of tumors to metastasize varies for one tumor type to another for the same type of tumor. The tendency to develop BM may not only depend on risk factors such as stage, grade, and histology, but also on the genetic profile of the primary tumor. The study suggests that multimodal treatment of BM has better outcomes in managing BM from gynecologic cancers.

A Rare Case of Metastasis of Small Cell Carcinoma of Cervix to Breast

Extrapulmonary small cell carcinomas (SCCs) are rare and often have an aggressive natural course. A 42-year-old female presented to the hospital with vaginal bleeding and lower abdominal pain. She was eventually diagnosed with SCC of cervix by biopsy. She was treated with chemoradiation. However, on follow-up positron emission tomography (PET) scan, fluorodeoxyglucose (FDG) uptake was noted in bilateral breasts. Biopsy of these lesions was consistent with metastatic SCC. Breast is a very unusual site for metastasis of cervical SCC and only four cases have been reported in the medical literature to date. Our case highlights the importance of considering metastatic disease when evaluating breast mass in patients with history of SCC of cervix.

Small cell carcinoma of the uterine cervix in pregnancy: A case report and review of the literature

The occurrence of cervical cancer during pregnancy is extremely rare, particularly small cell carcinoma. Small cell cervical carcinoma (SCCC) is a neuroendocrine tumor with a poor prognosis. This study presents the case of an 18-year-old female with stage IB2 SCCC complicated by pregnancy, who was treated with chemotherapy and radiotherapy. The patient was diagnosed shortly after giving birth, and is the youngest female case to be reported in the world. The patient was treated with cisplatin and etoposide chemotherapy and radiotherapy. Complete remission was achieved following neoadjuvant chemotherapy and radiotherapy, and the patient remains in clinical remission eight months following treatment. Cytological screening, colposcopy and if necessary, biopsy, and selective conization at 14-20 weeks should be considered in the patient evaluation.

A multicenter study of the importance of systemic chemotherapy for patients with small-cell neuroendocrine carcinoma of the uterine cervix

AIMS

We investigated the prognosis of patients with small-cell neuroendocrine carcinoma of the uterine cervix (SCNEC) in relation to treatment modalities.

METHODS

We retrospectively reviewed the medical records and pathological reports of 102 patients who were histologically diagnosed with SCNEC at 5 different institutes. Time to progression (TTP) and overall survival (OS) were analyzed for each treatment modality.

RESULTS

Of the patients with early-stage [International Federation of Obstetrics and Gynecology (FIGO) stage IB2 or below] SCNEC, 57.8 and 79.3% underwent radical hysterectomy followed by adjuvant therapy. In advanced-stage SCNEC, concurrent chemoradiation therapy was given to 51.4% of the patients. The overall recurrence rate was 51.6%. In early- and advanced-stage SCNEC, the TTP was not different (22.3 vs. 13.3 months, p = 0.104), but the OS was different (40.7 vs. 21.4 months, p = 0.029). Parametrial involvement and lymph vascular space invasion were found to be associated with an unfavorable prognosis. Interestingly, survival was the most unfavorable in patients with early-stage SCNEC who had never received chemotherapy. FIGO stage and use of chemotherapy were identified as independent prognostic factors in SCNEC patients.

CONCLUSIONS

SCNEC requires systemic chemotherapy as part of the initial treatment, along with surgery or radiation, even in patients with early-stage disease.

[Small cell neuroendocrine carcinoma of the uterine cervix: Report of six cases and a review of the literature]

Neuroendocrine carcinoma is a rare and aggressive malignant tumour, mainly developing at the expense of the respiratory and of the digestive tract. Gynecological neuroendocrine tumours are rare and small cell neuroendocrine tumours of the uterine cervix represent 2% of cervical cancer. Given their rarity and the lack of randomized trials, the diagnostic and therapeutic management of these tumors is difficult and essentially based on that of pulmonary neuroendocrine tumours. Like the latter, and despite multimodality regimens, the prognosis of these tumours remains poor. Through this series, we report our experience in the management of these particular tumours while comparing our data with those of the literature.

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.

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

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

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

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

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Neuroendocrine small cell carcinoma of the uterine cervix

Neuroendocrine small cell carcinoma of the uterine cervix (SCC) is a rare disease that mixes clinical and biological characteristics of both cervical neoplasms and neuroendocrine small cell cancer. The prognosis is poor and the optimal treatment has not yet been clarified. Multimodality treatment, with surgery and concurrent chemoradiation has recently been shown to improve local control and survival rates.

Incidence, mortality, and prognostic factors of small cell carcinoma of the cervix

OBJECTIVE

To compare the incidence, mortality, and presentation of small cell carcinoma of the cervix with other histologies.

METHODS

From 1977 to 2003, 290 women with small cell carcinoma of the cervix uteri were identified from the Surveillance, Epidemiology, and End Results database. Also, 27,527 patients with squamous cell carcinoma of the cervix and 5,231 patients with adenocarcinoma of the cervix were identified for comparison. The annual incidence was calculated and examined for trend. Patient and disease characteristics were compared among histologies. Univariable analyses were conducted using the log-rank test. Multivariable analysis was performed using Cox regression.

RESULTS

The mean annual incidence for small cell carcinoma was 0.06 per 100,000 women, compared with 6.6 and 1.2 for squamous cell carcinoma and adenocarcinoma, respectively. There were significant differences at presentation between small cell carcinoma compared with squamous cell carcinoma and adenocarcinoma for race, treatment, International Federation of Gynecology and Obstetrics stage, and lymph node involvement (P<.05). A trend for improved survival was identified for adenocarcinoma (P=.036) and squamous cell carcinoma (P<.001) but not for small cell carcinoma (P=.672). Five-year survival for small cell carcinoma (35.7%) was worse compared with squamous cell carcinoma (60.5%, hazard ratio 0.55; 95% confidence interval (CI) 0.43-0.69) and adenocarcinoma (69.7%, hazard ratio 0.48; 95% CI 0.37-0.61). On multivariable analysis, age, stage, and race were prognostic for survival in women with small cell carcinoma (P<.05).

CONCLUSION

Small cell carcinoma is a rare histology of cervical cancer associated with a worse prognosis and a predilection for nodal and distant metastasis. The decrease in survival was marked in early-stage and node-negative patients. Because of the high rates of nodal involvement even with early-stage disease, multimodality treatment with radiotherapy and chemotherapy should be considered.

LEVEL OF EVIDENCE

II.

Prognostic factors in extrapulmonary small cell carcinomas. A large retrospective study

BACKGROUND

Extrapulmonary small cell carcinoma (EPSCC) is a heterogeneous group of cancers. The clinicopathological features of EPSCC remain poorly defined.

PATIENTS AND METHODS

Patients with the clinicopathological features of EPSCC, treated at three major medical centers in Taiwan, were included. Histologic and clinical diagnoses, smoking history, staging, clinical course and treatment outcome were reviewed and analyzed.

RESULTS

A total of 90 patients, treated between 1995 and 2005, were eligible for analysis. Forty-nine patients had limited disease and 41 extensive disease. Ten, 18, 17 and 45 patients received no treatment, local treatment, chemotherapy alone or combined modality treatment, respectively; the median survival for these four groups was 1.1, 13.8, 6.7 and 24.9 months. The origin of cancer was head and neck in 17, gastrointestinal in 27, genitourinary in 10, gynecologic in 27 and unknown in 9 patients; the median survival time was 34.2, 6.4, 9.1, 23.7 and 9.2 months, respectively. Ten out of 90 patients were long-term survivors, and 9 of them had tumors of head-and-neck and gynecologic origin. There was no statistically significant difference in survival between smokers and non-smokers. Factors associated with survival in univariate analysis included age < or =60, female gender, limited disease, head-and-neck and gynecologic origin, as well as combined modality treatment. However, in multivariate analysis, only female gender, limited disease and combined modality treatment were independent predictors of survival.

CONCLUSIONS

Female gender, limited disease and combined modality treatment are favorable prognostic factors for patients with EPSCC. Prolonged survival is more likely in patients with tumors of head-and-neck and gynecologic origin.

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.

Neuroendocrine carcinoma of the uterine cervix: A clinicopathologic retrospective study of 31 cases with prognostic implications

The present study describes 31 clinical cases of neuroendocrine cervical carcinoma (NECC) treated at Mackay Memorial Hospital between January 1, 1991 and October 31, 2003. There are two cases of atypical carcinoid tumor (ACT), four cases of large-cell neuroendocrine carcinoma (LCNEC), and 25 cases of small-cell neuroendocrine carcinoma (SCNEC). Overall survival did not differ significantly in relation to surgery, tumor histology, age, FIGO stages, chemotherapeutic regimens or lymph node involvement. The specimens available did not permit HPV (human papillomavirus)-DNA analysis in 5 cases (5/31, 9.7%). The HPV viral infection was absent in 8 cases (8/31, 26%); 17 cases of HPV-18 (17/31); and 1 case of HPV-16 (1/31). The prognosis between mixed and pure type histologic patterns is not significant. The mean survival time for all patients was 32.3 months. The 2-year and 5-year survival rates were 54.8% and 31.5% for all patients. The results of this study reaffirm the biologically aggressive nature of this rare malignancy, its low survival rate, and its very unpredictable prognostic factors. Effective treatments of neuroendocrine cervical tumor still remain inconclusive. Further efforts are still required to identify prognostic factors for this uncommon disease.

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 carcinoma of the uterus and the vagina: experience with ten patients

BACKGROUND

Small cell carcinomas (small-CCs) of the uterine cervix are rare and highly malignant neoplasms. Patients tend to develop distant metastasis early and thus are potential candidates for systemic therapy. We reviewed the experience with small-CCs of the uterus and vagina at two Austrian University hospitals.

MATERIAL AND METHODS

Ten patients (median age, 50 years; range, 18-92) with small-CC of the cervix (n=7), uterine corpus (n=2), and the vagina (n=1) were treated at the two centers between 1988 and 1998. Eight patients underwent radical surgery, 7 of whom also received chemotherapy. Two additional patients underwent primary radiotherapy.

RESULTS

All Pap smears were suspicious for cervical malignancy. The median survival was 12 months (range, 6-86) and overall 5-year survival was 10%. Five of 8 surgically treated patients had lymph node involvement (62%). Of the 7 patients with small-CC of the cervix only one, who had FIGO stage IIB disease and positive pelvic nodes, survived long-term (86 months) with no evidence of disease. She had received six courses of dose-intensive platinum chemotherapy after radical surgery. All three patients with small-CC of the uterine corpus or vagina developed recurrence within the first year after diagnosis. Of the 7 patients who received chemotherapy, 5 developed progressive or recurrent disease in the paraaortic region (n=2), peritoneum (n=1), liver (n=1), or pelvis (n=1).

CONCLUSION

These results confirm the particularly unfavorable prognosis of patients with small-CC of the genital tract. The optimal treatment for these patients most probably including concurrent chemo-radiotherapy remains to be defined.

MRI of Small Cell Carcinoma of the Uterine Cervix with Pathologic Correlation

OBJECTIVE

The purpose of this study was to evaluate the MRI features of small cell carcinoma of the uterine cervix and to correlate those features with pathologic findings.

CONCLUSION

Small cell carcinoma of the uterine cervix can be characterized by frequent parametrial invasion and extensive lymphadenopathy, although the tumor morphology seems to be nonspecific on MRI.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

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 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.

Predictors of outcome in small cell carcinoma of the cervix--a case series

OBJECTIVE

The objective of this study was to determine whether clinicopathologic findings or the immunohistochemical presence of molecular markers are predictive of clinical outcome in patients with small cell carcinoma of the cervix (SCCC).

METHODS

A retrospective review of cases of carcinoma of the cervix was conducted to identify SCCC. From 1978 to 1999, 16 patients were identified at our institution with the diagnosis of SCCC. Microscopic sections of paraffin-embedded tissue specimens were evaluated for confirmation of diagnosis. Specimens were immunohistochemically stained with antibodies to three neuroendocrine markers: neuron-specific enolase, chromagranin (CGR), and synaptophysin. Specimens were also stained for protein expression of p53, erbB2, proliferating cell nuclear antigen, and c-myc. The relationship between molecular markers and clinical outcome was determined.

RESULTS

All 16 cases met the histologic criteria for SCCC. Fourteen of 16 tumors (88%) stained positive for neuroendocrine differentiation. Eleven of 16 patients (69%) died from disease with a median survival of 19 months; there were 3 long-term survivors (greater than 5 years). CGR was positive in 8 (50%) specimens and was found to be highly predictive of death (P = 0.001). Complete loss of p53 protein was seen in 8 patients, 7 of whom died with a median survival of 20 months.

CONCLUSION

Immunohistochemistry can be helpful in confirming difficult cases of SCCC. Further studies are necessary to define molecular markers that may be predictive of outcome in patients with SCCC.

Coexistence of metastatic neuroendocrine carcinoma of the uterine cervix with human immunodeficiency virus infection

Women now constitute 28% of new cases of human immunodeficiency virus (HIV) infection. Cervical cancer in HIV-infected women has a high recurrence and death rate, as well as decreased intervals to recurrence and death. Neuroendocrine carcinomas of the cervix are characterized by a high frequency of early nodal and distant metastases. We present the first report of a neuroendocrine carcinoma of the cervix in an HIV-positive patient. A 28 year old with a 9-year history of HIV succumbed to metastatic neuroendocrine carcinoma of the cervix 5 months after diagnosis. Given the aggressive nature of the cell type, an extended metastatic workup should be considered prior to surgery. The immune suppression present in HIV-positive patients with neuroendocrine cervical carcinoma may make such a workup particularly crucial, such that surgery is offered only to those who can be expected to benefit.

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.

Multimodality therapy in early-stage neuroendocrine carcinoma of the uterine cervix

OBJECTIVE

Patients with early-stage neuroendocrine cervical carcinoma (NECC) have a high mortality rate despite aggressive therapy. The rarity of this tumor precludes initiation of a randomized, prospective trial. We reviewed our experience in early stage disease and performed a meta-analysis of the literature to identify prognostic factors and determine optimal multimodality therapy.

METHODS

Eleven women with International Federation of Gynecology and Obstetrics (FIGO) early stage (IB--IIA) NECC were treated with surgery and chemotherapy at our institutions between 1978 and 1998. Administration of radiation therapy was recorded, but not required for inclusion in this study. A gynecologic pathologist reviewed all histopathologic sections. Medical records were retrospectively reviewed and clinical data obtained. Twenty-three early-stage NECC patients who were similarly treated during the study interval were identified by a Medline search of the English literature and included in the analysis. The Kaplan--Meier method and log-rank test were used for survival analysis.

RESULTS

The overall 2-year survival rate for the 34 patients was 38%. The median age was 37 years (range, 20--75 years). Median cervical tumor diameter was 3.2 cm (range 0.5--11.0 cm). Lymphovascular space invasion was present in 21 (78%) of 27 patients (7 unknown). Fifteen (52%) of twenty-nine had lymph node metastases (5 unknown). Fifteen patients received postoperative platinum/etoposide (PE), seven received vincristine/adriamycin/cyclophosphamide (VAC), two received alternating cycles of VAC and PE, and ten received other chemotherapy regimens. Twenty women were treated with radiation therapy. The presence of lymph node metastases was a poor prognostic factor (P < 0.001). PE and VAC chemotherapy was associated with increased survival (P < 0.01).

CONCLUSION

NECC is a highly lethal variant of cervical cancer. The presence of lymph node metastases is the most important prognostic variable. Postoperative VAC or PE appears most likely to improve chances for survival.

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

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

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

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

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.

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.

Neoadjuvant chemotherapy with mitomycin C, etoposide, and cisplatin for adenocarcinoma of the cervix

Between May 1990 and February 1995, 16 patients with adenocarcinoma or adenosquamous carcinoma of the uterine cervix were prescribed neoadjuvant chemotherapy consisting of cisplatin (50 mg/m2) on day 1, mitomycin C (10 mg/m2) on day 1, and etoposide (100 mg/m2) on days 1, 3, and 5 (MEP). In 2 patients stage was IB1, 5 were in stage IB2, 1 was in stage IIA, 5 were in stage IIB, 2 were in stage IIIB, and one was in stage IVB. A median of three courses of chemotherapy was given (range two to five). Of the 16 patients, 3 had a complete response and 5 had a partial response (response rate, 50%). Following termination of this chemotherapy, 12 patients with stage I or stage II carcinoma underwent radical hysterectomy. Three were given adjuvant radiotherapy because of positive pelvic nodes. One stage IIB patient, 1 stage IIIB patient and 1 stage IVB patient underwent standard radiotherapy and 1 stage IIIB patient underwent chemotherapy with another regimen because MEP therapy was without effect. Histopathological examinations revealed that changes as a result of the chemotherapy correlated well with clinical responses. Moderate or marked pathological changes occurred in 3 with a clinically complete response. The mean survival period of responders was 47.5 months while that of nonresponders was 28.3 months. Side effects of chemotherapy with MEP were within acceptable limits. The dose-limiting toxicity was myelosuppression and for only 1 patient the dose was reduced because of thrombocytopenia. Our preliminary study indicates that this chemotherapy regimen is effective for subjects with adenocarcinoma of the cervix. A prospective cooperative group trial on this regimen is ongoing.

Efficacy of radical hysterectomy as treatment for patients with small cell carcinoma of the cervix

BACKGROUND

This study was performed to identify pathologic and clinical features that best predict disease free survival of patients with early stage small cell carcinoma of the cervix treated by radical hysterectomy.

METHODS

Three hundreds and seventy patients with cervical carcinoma were analyzed retrospectively to define those variable that best predict disease free survival (DFS). Variables included age, weight, race, marital status, economic status, tumor size, depth of invasion (DI), lymph-vascular space involvement (LVSI), cell type, tumor grade, lymph node metastasis (LNM), and total number of lymph nodes removed. Patients with lymph node metastasis, parametrial involvement, and positive or close surgical margins were offered postoperative radiation.

RESULTS

Twelve patients were found to have small cell carcinoma (3.2%). One patient had microinvasive carcinoma of the cervix (MIC) as defined by the Society of Gynecologic Oncologists with a depth of invasion of 3 mm or less and no lymph-vascular space invasion, and has been reported previously. A detailed analysis of the other patients with nonsmall cell carcinoma is presented separately. Five patients achieved a DFS of at least 5 years, whereas 7 patients died with disease. Excluding the patient with MIC, the 5-year DFS rate was 36.4%.

CONCLUSIONS

Relative to other cell types, small cell carcinomas of the cervix is an aggressive neoplasm with a higher rate of LVSI and LNM despite smaller DI and tumor size. These data suggest that multimodality therapy, combining radical surgery and radiation with cytotoxic chemotherapy, may provide these patients with the best chance for cure.

Small cell carcinoma of the cervix of neuroendocrine origin causing obstructed labour

Small cell carcinoma of the cervix complicating pregnancy is rare, only 4 cases having been reported. This is the first case in which the tumour is reported as causing obstructed labour.

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.