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Arango-Bravo EA, Galicia-Carmona T, Cetina-Pérez L, Flores-de la Torre CB, Enríquez-Aceves MI, García-Pacheco JA, Gómez-García EM. State of the art of cervical cancer treatment in rare histologies. Front Oncol 2024; 14:1386294. [PMID: 39007101 PMCID: PMC11239379 DOI: 10.3389/fonc.2024.1386294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/17/2024] [Indexed: 07/16/2024] Open
Abstract
The objective of this review is to summarize the current scientific evidence to formulate clinical recommendations regarding the classification, diagnostic approach, and treatment of rare histological subtypes of cervical cancer; neuroendocrine carcinoma, gastric-type mucinous adenocarcinoma, and glassy cell adenocarcinoma. These histological subtypes are generally characterized by their low frequency, aggressive biological behavior, certain chemoradioresistance, and consequently, high recurrence rates with a deleterious impact on survival. Molecular studies have identified several associated mutations in neuroendocrine carcinoma (PIK3CA, MYC, TP53, PTEN, ARID1A, KRAS, BRCA2) and gastric-type adenocarcinoma (KRAS, ARID1A, PTEN) that may serve as molecular targets. While adenocarcinomas are typically treated and classified based on squamous histology across early, locally advanced, and advanced stages, the treatment strategies for neuroendocrine carcinomas in early stages or locally advanced cases differ, particularly in the sequencing of administering chemotherapy, chemoradiotherapy, or surgery. The chemotherapy regimen is based on etoposide plus cisplatin (EP). Unlike squamous cell carcinomas, immune checkpoint inhibitors are yet to establish a standard role in the treatment of recurrent neuroendocrine carcinomas due to the absence of clinical trials. Regarding glassy cell adenocarcinomas and gastric-type adenocarcinoma, the potential use of immunotherapy in advanced stages/disease requires further evaluation through international collaborations, given the limited number of cases.
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Affiliation(s)
- Eder Alexandro Arango-Bravo
- Medical Oncology Department, National Institute of Cancerology (INCan), Mexico City, Mexico
- Clinical Investigation Department, National Institute of Cancerology (INCan), Mexico City, Mexico
| | - Tatiana Galicia-Carmona
- Medical Oncology Department, National Institute of Cancerology (INCan), Mexico City, Mexico
- Clinical Investigation Department, National Institute of Cancerology (INCan), Mexico City, Mexico
| | - Lucely Cetina-Pérez
- Medical Oncology Department, National Institute of Cancerology (INCan), Mexico City, Mexico
- Clinical Investigation Department, National Institute of Cancerology (INCan), Mexico City, Mexico
| | | | - María Isabel Enríquez-Aceves
- Oncology Department, Regional Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) Hospital León, León de los Aldama, Guanajuato, Mexico
| | - José Antonio García-Pacheco
- Sistema Nacional de Investigadores (SNI), National Council of Science and Technology (CONACYT), Mexico City, Mexico
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Wang Y, Qiu H, Lin R, Hong W, Lu J, Ling H, Sun X, Yang C. Advancements in the Understanding of Small-Cell Neuroendocrine Cervical Cancer: Where We Stand and What Lies Ahead. J Pers Med 2024; 14:462. [PMID: 38793044 PMCID: PMC11122604 DOI: 10.3390/jpm14050462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Small-cell neuroendocrine cervical carcinoma (SCNCC) is a rare yet aggressive gynecological malignancy associated with dismal clinical outcomes. Its rarity has led to a limited number of retrospective studies and an absence of prospective research, posing significant challenges for evidence-based treatment approaches. As a result, most gynecologic oncology centers have limited experience with this tumor, emphasizing the urgent need for a comprehensive review and summary. This article systematically reviews the pathogenesis, immunohistochemical and molecular characteristics, prognostic factors, and clinical management of gynecologic SCNCC. We specifically focused on reviewing the distinct genomic characteristics of SCNCC identified via next-generation sequencing technologies, including loss of heterozygosity (LOH), somatic mutations, structural variations (SVs), and microRNA alterations. The identification of these actionable genomic events offers promise for discovering new molecular targets for drug development and enhancing therapeutic outcomes. Additionally, we delve deeper into key clinical challenges, such as determining the optimal treatment modality between chemoradiation and surgery for International Federation of Gynecology and Obstetrics (FIGO) stage I phase patients within a precision stratification framework, as well as the role of targeted therapy within the homologous recombination (HR) pathway, immune checkpoint inhibitors (ICIs), and prophylactic cranial irradiation (PCI) in the management of SCNCC. Finally, we anticipate the utilization of multiple SCNCC models, including cancer tissue-originated spheroid (CTOS) lines and patient-derived xenografts (PDXs), to decipher driver events and develop individualized therapeutic strategies for clinical application.
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Affiliation(s)
- Yan Wang
- Life Sciences Institute, Zhejiang University, Hangzhou 310058, China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Hangzhou First People’s Hospital, Hangzhou 310006, China
- Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Hui Qiu
- Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Rongjie Lin
- Department of Radiotherapy, West China Xiamen Hospital of Sichuan University, Xiamen 361021, China
| | - Weiwei Hong
- Department of Medical Oncology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Jiahao Lu
- Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Huan Ling
- Department of Ultrasound in Gynecology and Obstetrics, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Xiaoge Sun
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 750306, China
| | - Chunxu Yang
- Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
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Lamiman K, Wilhelm AB, Eyzaguirre E, Richardson G. Diagnostic Challenges and Long-term Outcomes of Neuroendocrine Carcinoma of the Cervix: A Case Series. Int J Gynecol Pathol 2024; 43:149-157. [PMID: 37922936 PMCID: PMC10852037 DOI: 10.1097/pgp.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Neuroendocrine carcinomas (NECs) of the cervix are rare, aggressive malignancies that are challenging to diagnose and treat. They are high-grade lesions that often share features with poorly differentiated adenocarcinoma and squamous cell carcinoma. NECs are classified into large-cell or small-cell subtypes but can often have a mixed appearance or occur concurrently with a squamous or adenocarcinoma. Diagnosis is dependent on tissue sampling, histomorphology, and immunohistochemistry. Eight cases of NEC were retrieved from the Department of Pathology at our institution from 2008 to 2022. Tumor slides were reviewed and evaluated by 2 independent pathologists. Seven of 8 patients tested positive for neuroendocrine markers, including CD56, synaptophysin, and chromogranin. We discuss the diagnostic challenges, review the histopathology, and describe the treatment courses and clinical outcomes. This case series reveals that traditional markers, such as p16, p63, and p40, may be focally positive in NEC and should not be considered a confirmation of squamous cell carcinoma. Patient outcomes can be affected by delays in diagnosis, misdiagnosis, and inadequate treatment when NEC is not considered in the initial differential diagnosis.
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4
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Stumpo S, Formelli MG, Persano I, Parlagreco E, Lauricella E, Rodriquenz MG, Guerrera LP, Zurlo IV, Campana D, Brizzi MP, Cives M, La Salvia A, Lamberti G. Extrapulmonary Neuroendocrine Carcinomas: Current Management and Future Perspectives. J Clin Med 2023; 12:7715. [PMID: 38137784 PMCID: PMC10743506 DOI: 10.3390/jcm12247715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Neuroendocrine carcinomas (NECs) are poorly differentiated and highly aggressive epithelial neuroendocrine neoplasms. The most common primary site is the lung, but they may arise in every organ. Approximately 37% of extrapulmonary NECs (EP-NECs) occur in the gastroenteropancreatic (GEP) tract, followed by the genitourinary (GU) system and gynecological tract. As a result of their rarity, there is scant evidence to guide treatment recommendations, and a multidisciplinary approach is essential for the management of such patients. Platinum-based chemotherapy currently represents the standard of care for EP-NECs of any site, mirroring the management of small-cell lung cancer (SCLC), but further approaches are still under investigation. Indeed, ongoing trials evaluating targeted therapies, immune checkpoint inhibitors (ICIs), and radionuclide therapy could provide potentially breakthrough therapeutic options. Given the relative dearth of evidence-based literature on these orphan diseases, the aim of this review is to provide an overview of the pathology and current treatment options, as well as to shed light on the most pressing unmet needs in the field.
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Affiliation(s)
- Sara Stumpo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum–University of Bologna, Via Zamboni 33, 40126 Bologna, Italy; (S.S.); (M.G.F.); (D.C.); (G.L.)
| | - Maria Giovanna Formelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum–University of Bologna, Via Zamboni 33, 40126 Bologna, Italy; (S.S.); (M.G.F.); (D.C.); (G.L.)
| | - Irene Persano
- Medical Oncology, AO S. Croce e Carle, 12100 Cuneo, Italy; (I.P.); (E.P.)
| | - Elena Parlagreco
- Medical Oncology, AO S. Croce e Carle, 12100 Cuneo, Italy; (I.P.); (E.P.)
| | - Eleonora Lauricella
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy; (E.L.); (M.C.)
| | - Maria Grazia Rodriquenz
- Oncology Unit, Ospedale IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Luigi Pio Guerrera
- Division of Medical Oncology, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
- Sarcomas and Rare Tumors Unit, Istituto Nazionale Tumori, IRCCS-Fondazione “G. Pascale”, 80131 Naples, Italy
| | | | - Davide Campana
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum–University of Bologna, Via Zamboni 33, 40126 Bologna, Italy; (S.S.); (M.G.F.); (D.C.); (G.L.)
- Medical Oncology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via P. Albertoni 15, 40138 Bologna, Italy
| | - Maria Pia Brizzi
- Department of Oncology, A.O.U. San Luigi Gonzaga Hospital, 10043 Orbassano, Italy;
| | - Mauro Cives
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy; (E.L.); (M.C.)
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70121 Bari, Italy
| | - Anna La Salvia
- National Center for Drug Research and Evaluation, National Institute of Health (ISS), 00161 Rome, Italy
| | - Giuseppe Lamberti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum–University of Bologna, Via Zamboni 33, 40126 Bologna, Italy; (S.S.); (M.G.F.); (D.C.); (G.L.)
- Medical Oncology Unit, Vito Fazzi Hospital, 73100 Lecce, Italy;
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Kotaka S, Kondo E, Kawai Y, Okamoto K, Kishigami Y, Yamawaki T, Nagao K, Toru H, Suzuki S. Paclitaxel-carboplatin plus bevacizumab therapy for advanced neuroendocrine carcinoma of the uterine cervix: A retrospective case series. J Obstet Gynaecol Res 2023; 49:2868-2874. [PMID: 37658751 DOI: 10.1111/jog.15783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
AIM There is no conclusive data on the prognosis of patients who receive paclitaxel-carboplatin (TC) plus bevacizumab therapy for advanced neuroendocrine carcinoma (NEC) of the uterine cervix, a rare histological subtype of cervical cancer. Thus, the aim of this study was to determine the efficacy of TC chemotherapy plus bevacizumab and bevacizumab single maintenance therapy for advanced NEC of the cervix. METHODS This was a retrospective review of patients who received TC plus bevacizumab therapy for metastatic, recurrent, or persistent NEC of the cervix at seven institutions between 2015 and 2020. Relevant data were extracted from the patients' medical records and analyzed. RESULTS Seven patients, including six with small-cell NEC and one with large-cell NEC, were included for analysis. Three patients received bevacizumab single maintenance therapy following TC plus bevacizumab therapy, whereas four patients did not receive bevacizumab single maintenance therapy. The median overall survival and progression-free survival of the patients who received bevacizumab single maintenance therapy were longer than those of the patients who did not receive the therapy (34 months vs. 10.5 months and 19 months vs. 5 months, respectively). However, the patients who received bevacizumab single maintenance therapy had received cisplatin-based chemotherapy previously. CONCLUSIONS On the premise that cisplatin-based chemotherapy is administered as the first-line treatment for advanced NEC of the cervix, bevacizumab single maintenance therapy following TC plus bevacizumab may be considered the second- or third-line treatment. However, the risk of adverse events, such as intestinal perforation, should be discussed with patients.
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Affiliation(s)
- Saki Kotaka
- Department of Gynecologic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
- Department of Obstetrics and Gynecology, Kuwana City Medical Center, Kuwana, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Yosuke Kawai
- Department of Obstetrics and Gynecology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Kota Okamoto
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Yasuyuki Kishigami
- Department of Obstetrics and Gynecology, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Takaharu Yamawaki
- Department of Obstetrics and Gynecology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Kenji Nagao
- Department of Obstetrics and Gynecology, Yokkaichi Municipal Hospital, Yokkaichi, Mie, Japan
| | - Hirata Toru
- Department of Obstetrics and Gynecology, Kuwana City Medical Center, Kuwana, Mie, Japan
| | - Shiro Suzuki
- Department of Gynecologic Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
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Ren X, Wu W, Li Q, Li W, Wang G. Advances in Research, Diagnosis, and Treatment of Neuroendocrine Cervical Carcinoma: A Review. Oncol Rev 2023; 17:11764. [PMID: 38025893 PMCID: PMC10645581 DOI: 10.3389/or.2023.11764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) were classified separately in the 5th edition (2020) of the World Health Organization (WHO) classification of female genital malignancies. Cervical neuroendocrine carcinoma (NEC) is distinguished by its low incidence, high invasiveness, early local dissemination, and distant metastases. The purpose of this review is to outline the achievements in pathology, diagnostics, gene sequencing, and multi-modality treatment of cervical NEC.
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Affiliation(s)
| | - Wenjuan Wu
- Department of Gynecological Oncology, The Affiliated Women’s and Children’s Hospital of Chengdu Medical College, Chengdu, China
| | - Qiufan Li
- Chengdu Medical College, Chengdu, China
| | - Wen Li
- Chengdu Medical College, Chengdu, China
| | - Gang Wang
- Department of Gynecological Oncology, The Affiliated Women’s and Children’s Hospital of Chengdu Medical College, Chengdu, China
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Salvo G, Flores Legarreta A, Ramalingam P, Jhingran A, Bhosale P, Saab R, Gonzales NR, Chisholm GB, Frumovitz M. Clinicopathologic characteristics, oncologic outcomes, and prognostic factors in neuroendocrine cervical carcinoma: a Neuroendocrine Cervical Tumor Registry study. Int J Gynecol Cancer 2023; 33:1359-1369. [PMID: 37567596 DOI: 10.1136/ijgc-2023-004708] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE To evaluate clinicopathologic features and oncologic outcomes of patients with neuroendocrine cervical carcinoma in an institutional neuroendocrine cervical tumor registry. METHODS Retrospective study including patients with neuroendocrine cervical carcinomas diagnosed between 1986 and 2022. Patients were categorized into International Federation of Gynecology and Obstetrics 2018 stage groups: early-stage (IA1-IB2, IIA1); locally advanced (IB3, IIA2-IVA); and advanced (IVB). Clinicopathologic characteristics and oncologic outcomes were evaluated by stage. Survival was compared between patients diagnosed in 1986-2003 and those diagnosed in 2004-2016. Progression-free and overall survival were estimated using the Kaplan-Meier product-limit estimator. RESULTS A total of 453 patients was included, 133 (29%) with early-stage, 226 (50%) with locally advanced, and 94 (21%) with advanced disease. Median age was 38 years (range 21-93). Sixty-nine percent (306/453) had pure and 32% (146/453) had mixed histology. The node positivity rate (surgical or radiological detection) was 19% (21/108) for tumors ≤2 cm, 37% (39/105) for tumors >2 to ≤4 cm, and 61% (138/226) for tumors >4 cm (p<0.0001). After primary treatment, rates of complete response were 86% (115/133) for early-stage, 65% (147/226) for locally advanced, and 19% (18/94) for advanced disease (p<0.0001). The recurrence/progression rate was 43% for early-stage, 69% for locally advanced, and 80% for advanced disease (p<0.0001). Five-year progression-free and overall survival rates were 59% (95% CI 50% to 68%) and 71% (95% CI 62% to 80%), respectively, for early-stage, 28% (95% CI 22% to 35%) and 36% (95% CI 29% to 43%), respectively, for locally advanced, and 6% (95% CI 0% to 11%) and 12% (95% CI 5% to 19%), respectively, for advanced disease. For early-stage disease, the 5-year progression-free survival rate was 68% for tumors ≤2 cm and 43% for tumors >2 to ≤4 cm (p=0.0013). Receiving cisplatin/carboplatin plus etoposide (HR=0.33, 95% CI 0.17 to 0.63, p=0.0008) and receiving curative radiotherapy (HR=0.32, 95% CI 0.17 to 0.6, p=0.0004) were positive predictors of survival for patients with advanced disease. CONCLUSION Among patients with neuroendocrine cervical carcinomas, overall survival is favorable for patients with early-stage disease. However, most patients present with locally advanced disease, and overall survival remains poor in this subgroup. For patients with advanced disease, receiving cisplatin/carboplatin plus etoposide and curative radiation therapy is associated with improved overall survival.
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Affiliation(s)
- Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alejandra Flores Legarreta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Preetha Ramalingam
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Priya Bhosale
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiology, University of Texas MD Anderson Cancer Center Division of Cancer Medicine, Houston, Texas, USA
| | - Reem Saab
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naomi R Gonzales
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gary B Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Eads JR, Halfdanarson TR, Asmis T, Bellizzi AM, Bergsland EK, Dasari A, El-Haddad G, Frumovitz M, Meyer J, Mittra E, Myrehaug S, Nakakura E, Raj N, Soares HP, Untch B, Vijayvergia N, Chan JA. Expert Consensus Practice Recommendations of the North American Neuroendocrine Tumor Society for the management of high grade gastroenteropancreatic and gynecologic neuroendocrine neoplasms. Endocr Relat Cancer 2023; 30:e220206. [PMID: 37184955 PMCID: PMC10388681 DOI: 10.1530/erc-22-0206] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 05/16/2023]
Abstract
High-grade neuroendocrine neoplasms are a rare disease entity and account for approximately 10% of all neuroendocrine neoplasms. Because of their rarity, there is an overall lack of prospectively collected data available to advise practitioners as to how best to manage these patients. As a result, best practices are largely based on expert opinion. Recently, a distinction was made between well-differentiated high-grade (G3) neuroendocrine tumors and poorly differentiated neuroendocrine carcinomas, and with this, pathologic details, appropriate imaging practices and treatment have become more complex. In an effort to provide practitioners with the best guidance for the management of patients with high-grade neuroendocrine neoplasms of the gastrointestinal tract, pancreas, and gynecologic system, the North American Neuroendocrine Tumor Society convened a panel of experts to develop a set of recommendations and a treatment algorithm that may be used by practitioners for the care of these patients. Here, we provide consensus recommendations from the panel on pathology, imaging practices, management of localized disease, management of metastatic disease and surveillance and draw key distinctions as to the approach that should be utilized in patients with well-differentiated G3 neuroendocrine tumors vs poorly differentiated neuroendocrine carcinomas.
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Affiliation(s)
- Jennifer R Eads
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Pennsylvania, USA
| | | | - Tim Asmis
- Division of Medical Oncology, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew M Bellizzi
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emily K Bergsland
- Department of Medicine, University of California, San Francisco, California, USA
| | - Arvind Dasari
- Division of Gastrointestinal Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghassan El-Haddad
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael Frumovitz
- Division of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joshua Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Erik Mittra
- Division of Molecular Imaging and Therapy, Oregon Health & Science University, Portland, Oregon, USA
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eric Nakakura
- Department of Surgery, University of California, San Francisco, California, USA
| | - Nitya Raj
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Heloisa P Soares
- Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Salt Lake City, Utah, USA
| | - Brian Untch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Namrata Vijayvergia
- Department of Hematology and Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jennifer A Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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9
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Alhaj-Suliman SO, Naguib YW, Wafa EI, Saha S, Ebeid K, Meng X, Mohammed HH, Abuo-Rahma GEDA, Yang S, Salem AK. A ciprofloxacin derivative with four mechanisms of action overcomes paclitaxel resistance in p53-mutant and MDR1 gene-expressing type II human endometrial cancer. Biomaterials 2023; 296:122093. [PMID: 36965280 PMCID: PMC10092294 DOI: 10.1016/j.biomaterials.2023.122093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023]
Abstract
Dysfunction of the p53 gene and the presence of the MDR1 gene are associated with many malignant tumors including endometrial cancer and are responsible for cancer therapeutic resistance and poor survival. Thus, there is a critical need to devise novel combinatorial therapies with multiple mechanisms of action to overcome drug resistance. Here, we report a new ciprofloxacin derivative (CIP2b) tested either alone or in combination with taxanes against four human endometrial cancer cell lines. In vitro studies revealed that a combination of paclitaxel + CIP2b had synergistic cytotoxic effects against MDR1-expressing type-II human endometrial cancer cells with loss-of-function p53 (Hec50co LOFp53). Enhanced antitumor effects were confirmed by substantial increases in caspase-3 expression, cell population shifts toward the G2/M phase, and reduction of cdc2 phosphorylation. It was found that CIP2b targets multiple pathways including the inhibition of MDR1, topoisomerase I, and topoisomerase II, as well as enhancing the effects of paclitaxel (PTX) on microtubule assembly. In vivo treatment with the combination of PTX + CIP2b also led to significantly increased accumulation of PTX in tumors (compared to CIP2b alone) and reduction in tumor growth. Enhanced in vivo cytotoxic effects were confirmed by histological and immunohistochemical examination of the tumor tissues. Complete blood count and blood biochemistry data confirmed the absence of any apparent off-target toxicity. Thus, combination therapy involving PTX and CIP2b targeted multiple pathways and represents an approach that could result in improved tolerance and efficacy in patients with type-II endometrial cancer harboring the MDR1 gene and p53 mutations.
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Affiliation(s)
- Suhaila O Alhaj-Suliman
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States
| | - Youssef W Naguib
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States; Departments of Pharmaceutics and Medicinal Chemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Emad I Wafa
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States
| | - Sanjib Saha
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States
| | - Kareem Ebeid
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States; Departments of Pharmaceutics and Medicinal Chemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Xiangbing Meng
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, United States
| | - Hamada H Mohammed
- Departments of Pharmaceutics and Medicinal Chemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Gamal El-Din A Abuo-Rahma
- Departments of Pharmaceutics and Medicinal Chemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Shujie Yang
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, United States
| | - Aliasger K Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa, IA, 52242, United States.
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10
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Small Cell Carcinoma of the Vagina: First Systematic Review of Case Reports and Proposal of a Management Algorithm. J Low Genit Tract Dis 2023; 27:56-67. [PMID: 36282979 PMCID: PMC9770126 DOI: 10.1097/lgt.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Small cell carcinoma of the vagina (SmCCV) is an extremely rare disease. Evidence-based data and specific guidelines are lacking. We conducted the first systematic review of case reports to provide the most overall picture of SmCCV. MATERIALS AND METHODS Literature search in PubMed and Scopus was performed using the terms "small cell carcinoma" and "vagina." English-language case reports of primary SmCCV up to January 2022 were included. RESULTS Twenty-nine articles describing 44 cases met our inclusion criteria. We report a new case of our hospital. The global median overall survival (mOS) was 12.00 months (95% CI = 9.31-14.69). The mOS was not reached for stage I, and it was 12.00, 12.00, 9.00, and 8.00 months for stages II, III, IVA, and IVB, respectively (statistically significant differences between stage I and stages II, III, or IVA [log rank p = .003-.017]). Thirty-five cases received local treatments (77.8%). The mOS of patients treated with surgery ± complementary chemotherapy, radiotherapy ± complementary chemotherapy, chemoradiation ± complementary chemotherapy, and surgery + radiotherapy ± complementary chemotherapy were 11.00, 12.00, 17.00, and 29.00 months, respectively. The use of adjuvant or neoadjuvant chemotherapy (64.5%, mostly platinum + etoposide) showed longer mOS (77.00 vs 15.00 months). Four of 5 tested cases presented human papillomavirus infection, 3 of them presenting type 18. CONCLUSIONS Small cell carcinoma of the vagina shows dismal prognosis. Multimodal local management plus complementary chemotherapy seems to achieve better outcomes. Human papillomavirus could be related to the development of SmCCV. A diagnostic-therapeutic algorithm is proposed.
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Qiu H, Su N, Yan S, Li J. Real-world Efficacy Data on Anti-Angiogenic Drugs in Recurrent Small Cell Cervical Carcinoma: A Retrospective Study. Technol Cancer Res Treat 2023; 22:15330338231160393. [PMID: 36883253 PMCID: PMC9996736 DOI: 10.1177/15330338231160393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVE Small cell carcinoma of the cervix (SCCC) is rare but extremely aggressive and resistant to current therapies. We herein evaluate the efficacy of bevacizumab, apatinib, and anlotinib in recurrent/metastatic SCCC patients in a real-world setting. METHODS Recurrent/metastatic SCCC patients were recruited between January 2013 and July 2020. Baseline characteristics were extracted from medical records, and patients were divided into an anti-angiogenic group and non-anti-angiogenic group. The efficacy of treatments was determined using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Kaplan-Meier analysis was performed for survival analysis. RESULTS Sixteen patients received anti-angiogenic drugs after tumor recurrence/metastasis; of them, 10 cases received them as first-line treatment, 5 cases as second-line treatment, and 1 case as fourth-line treatment. Another 23 patients received traditional therapies, including surgery, chemotherapy, and radiotherapy. The use of anti-angiogenic drugs in first-line treatment significantly prolonged progression-free survival (PFS) compared to the controls, with a median PFS of 8 months (2-20 months) and 3 months (1-10 months), respectively (P = .025). This trend was also notable in patients who started anti-angiogenic treatment after the second-line recurrence/metastasis. However, there was no benefits for overall survival (OS) in either the 10 first-line cases or all 16 cases (P = .499 and .31, respectively). Both bevacizumab and small molecule drugs (apatinib and anlotinib) presented similar efficacy in SCCC patients. CONCLUSIONS At present, this is the largest cohort study that provides real-world data, showing that anti-angiogenic regimens could significantly prolong PFS in recurrent/metastatic SCCC. Aside from bevacizumab, the novel oral small molecule drugs provide more choices with similar efficacy. These findings warrant further validation in well-designed future studies.
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Affiliation(s)
- Haifeng Qiu
- Department of Gynecology, 191599The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ning Su
- Department of Gynecologic Oncology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Shuping Yan
- Department of Pathology, 191599The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Li
- Department of Oncology, 191599The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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12
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Frumovitz M, Chisholm GB, Jhingran A, Ramalingam P, Flores-Legarreta A, Bhosale P, Gonzales NR, Hillman RT, Salvo G. Combination therapy with topotecan, paclitaxel, and bevacizumab improves progression-free survival in patients with recurrent high-grade neuroendocrine cervical cancer: a Neuroendocrine Cervical Tumor Registry (NeCTuR) study. Am J Obstet Gynecol 2022; 228:445.e1-445.e8. [PMID: 36516952 DOI: 10.1016/j.ajog.2022.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/21/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recurrent high-grade neuroendocrine cervical cancer has a very poor prognosis and limited active treatment options. OBJECTIVE This study aimed to evaluate the efficacy of the 3-drug regimen of topotecan, paclitaxel, and bevacizumab in women with recurrent high-grade neuroendocrine cervical cancer. STUDY DESIGN This retrospective cohort study used data from the Neuroendocrine Cervical Tumor Registry (NeCTuR), which include data abstracted directly from medical records of women diagnosed with high-grade neuroendocrine carcinoma of the cervix from English- and Spanish-speaking countries. The study compared women with recurrent high-grade neuroendocrine cervical cancer who received the topotecan, paclitaxel, and bevacizumab regimen as first- or second-line therapy for recurrence and women with recurrent high-grade neuroendocrine cervical cancer who received chemotherapy but not the topotecan, paclitaxel, and bevacizumab regimen. Patients continued chemotherapy until disease progression or the development of unacceptable toxic effects. Progression-free survival from the start of therapy for recurrence to the next recurrence or death, overall survival from the first recurrence, and response rates were evaluated. RESULTS The study included 62 patients who received the topotecan, paclitaxel, and bevacizumab regimen as first- or second-line therapy for recurrence and 56 patients who received chemotherapy but not the topotecan, paclitaxel, and bevacizumab regimen for recurrence. The median progression-free survival rates were 8.7 months in the topotecan, paclitaxel, and bevacizumab regimen group and 3.7 months in the non-topotecan, paclitaxel, and bevacizumab regimen group, with a hazard ratio for disease progression of 0.27 (95% confidence interval, 0.17-0.48; P<.0001). In the topotecan, paclitaxel, and bevacizumab regimen group, 15% of patients had stable disease, 39% of patients had a partial response, and 18% of patients had a complete response. Compared with patients in the non-topotecan, paclitaxel, and bevacizumab regimen group, significantly more patients in the topotecan, paclitaxel, and bevacizumab regimen group remained on treatment at 6 months (31% vs 67%, respectively; P=.0004) and 1 year (9% vs 24%, respectively; P=.02). The median overall survival rates were 16.8 months in the topotecan, paclitaxel, and bevacizumab regimen group and 14.0 months in the non-topotecan, paclitaxel, and bevacizumab regimen group, with a hazard ratio for death of 0.87 (95% confidence interval, 0.55-1.37). CONCLUSION Combination therapy with topotecan, paclitaxel, and bevacizumab was an active regimen in women with recurrent high-grade neuroendocrine cervical cancer and improved progression-free survival while decreasing the hazard ratio for disease progression.
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Affiliation(s)
- Michael Frumovitz
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Gary B Chisholm
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anuja Jhingran
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Preetha Ramalingam
- Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alejandra Flores-Legarreta
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Priya Bhosale
- Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naomi R Gonzales
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R Tyler Hillman
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gloria Salvo
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Liu R, He X, Li Z. Positive clinical outcomes following therapy with programmed cell death protein 1/programmed cell death ligand 1 inhibitors in neuroendocrine carcinoma of the cervix. Front Pharmacol 2022; 13:1029598. [DOI: 10.3389/fphar.2022.1029598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/03/2022] [Indexed: 11/18/2022] Open
Abstract
Neuroendocrine carcinoma of the cervix (NECC) is a highly aggressive and rare gynecological malignancy with a poor prognosis. Despite aggressive local and systemic treatments, there are high rates of locoregional recurrence and distant metastases. Therefore, more potent treatments are required to manage NECC. In recent years, emerging immune checkpoint inhibitors, such as programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors, have been used in treating various solid tumors and provide a new direction for immune-targeted therapy for NECC. In this review, we summarize the biomarkers useful for the evaluation of the therapy with PD-1/PD-L1 inhibitors in patients with NECC and the clinical applications and prospects of monotherapy with PD-1/PD-L1 inhibitors and combinations with other therapies in patients with NECC. In some individual case reports, therapeutic strategies with PD-1/PD-L1 inhibitors showed good efficacy. Further studies are needed to confirm the possibility of using PD-1/PD-L1 inhibitors as a standard treatment strategy in NECC.
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14
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Salvo G, Frumovitz M, Ramalingam P, Bhosale P. Advanced stage (FIGO IVB) neuroendocrine cervical carcinoma. Int J Gynecol Cancer 2022; 32:1469-1474. [PMID: 36343974 PMCID: PMC9665879 DOI: 10.1136/ijgc-2022-003946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Gloria Salvo
- Department of Gynecologic oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Frumovitz
- Department of Gynecologic oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Preetha Ramalingam
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Priya Bhosale
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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One small step can lead to one giant leap. Gynecol Oncol Rep 2022; 42:101045. [PMID: 35936353 PMCID: PMC9350584 DOI: 10.1016/j.gore.2022.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Ipilimumab and nivolumab for recurrent neuroendocrine cervical carcinoma. Gynecol Oncol Rep 2022; 42:101039. [PMID: 35846558 PMCID: PMC9284394 DOI: 10.1016/j.gore.2022.101039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/17/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022] Open
Abstract
Neuroendocrine carcinoma of the cervix is a rare and aggressive HPV-mediated malignancy with a high recurrence rate. Combination ipilimumab and nivolumab has been shown to effect disease response in pulmonary neuroendocrine carcinoma. We present three patients with recurrent neuroendocrine cervical carcinoma who experienced response to ipilimumab/nivolumab.
Neuroendocrine carcinoma of the cervix is a rare subtype of cervical cancer with a poor prognosis. Primary treatment of this disease involves a combination of surgery, chemotherapy, and radiation. The majority of patients will experience disease recurrence, for which there exist no treatment guidelines. Because of histologic similarities, small cell lung cancer has often informed management of extrapulmonary neuroendocrine carcinomas. Immunotherapy regimens, including a combination of ipilimumab and nivolumab, have been shown to have activity in small cell lung cancer. In this report, we present the cases of 3 patients with recurrent neuroendocrine carcinoma of the cervix who experienced durable response to a combination of ipilimumab and nivolumab.
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17
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Pan B, Wan T, Jiang Y, Zheng X, Liu P, Xiang H, Zheng M. Impact of the initial site of metastases on post-recurrence survival for neuroendocrine cervical cancer. BMC Cancer 2022; 22:655. [PMID: 35698184 PMCID: PMC9195210 DOI: 10.1186/s12885-022-09737-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/01/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To summarize the risk factors and emphasize the prognostic importance of the site of recurrent neuroendocrine cervical cancer (NECC). Methods We enrolled 88 patients who developed recurrence after radical surgery for pathological stage I–IVa primary NECC between January 2003 and 30 December 2020 and classified these cases into 7 groups based on the initial recurrence. The risk factors for post-recurrence survival (PRS) were analyzed by Kaplan–Meier and Cox regression methods. Results Among 88 NECC patients, nearly all patients (95.50%) experienced progression within 3 years. The time to progression was significantly longer in patients with lung recurrence than in patients without lung recurrence (p = 0.008). After the first recurrence, the median follow-up was 11.1 months (range 2.37–65.50 months), and the 5-year PRS was only 20.6%. The depth of invasion in the primary surgery, number of recurrent sites, abdominal organ recurrence were correlated with PRS by univariate analysis. Multivariate analyses revealed that the number of recurrent sites (p = 0.025) and abdominal organ recurrence (p = 0.031) were independent prognostic factors. Notably, the combination of immune checkpoint inhibitors and chemotherapy, with or without surgery, showed a 43.8% objective response rate in recurrent NECC. Conclusion Patients with abdominal organ recurrence need more sophisticated therapy. The combination of immune therapy and chemotherapy might be an opportunity for recurrent NECC. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09737-4.
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Affiliation(s)
- Baoyue Pan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Ting Wan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Yinan Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Xiaojing Zheng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Pingping Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Huiling Xiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China
| | - Min Zheng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China. .,Department of Gynecology, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.
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18
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Pang L, Wang S. Prevalence, Associated Factors, and Survival Outcomes of Small-Cell Neuroendocrine Carcinoma of the Gynecologic Tract: A Large Population-Based Analysis. Front Med (Lausanne) 2022; 9:836910. [PMID: 35479939 PMCID: PMC9035633 DOI: 10.3389/fmed.2022.836910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
Small-cell carcinomas are highly malignant tumors with neuroendocrine function and which often occur in the lungs. Primary small-cell neuroendocrine carcinomas of the gynecologic tract are extremely rare. This study aimed to evaluate the prevalence of independent predictors related to the prognosis and overall survival of patients with small-cell neuroendocrine carcinomas of the gynecologic tract. Patients with gynecologic small-cell neuroendocrine carcinomas diagnosed between 1973 and 2015 were identified from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox risk regression analyses were performed to determine the independent predictors of overall survival. Overall survival was calculated using the Kaplan–Meier method, and the log-rank test was used for comparison. We included 5,15,393 eligible carcinomas in the present study; the prevalence of gynecologic small-cell neuroendocrine carcinomas was 0.121% (N = 622). Multivariate analysis indicated that advanced age, stage III and IV cancer, and no chemotherapy treatment may be predictors of poor small-cell neuroendocrine cervical carcinoma prognosis. Stage III and IV cancer and lack of surgery, radiotherapy, or chemotherapy were identified as potential predictors of poor prognosis in patients with ovarian small-cell neuroendocrine carcinoma. Kaplan–Meier analysis suggested that the median survival was 19, 11, and 12 months for cervical, ovarian, and endometrial small-cell neuroendocrine carcinomas, respectively. The 1-, 3-, and 5-year overall survival rates were as follows: 58.8, 31.4, and 26.1%, respectively, for small-cell neuroendocrine cervical carcinoma; 46.3, 23.5, and 22.0%, respectively, for ovarian small-cell neuroendocrine carcinoma; and 49.4, 29.4, and 25.9%, respectively, for endometrial small-cell neuroendocrine carcinoma. Our findings indicate that comprehensive and individualized treatment of small-cell neuroendocrine carcinomas of the gynecologic tract may prolong patient survival, although further studies are required.
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19
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Zhang Y, Huang Y, Luo S, Li L, Yang H, Wang Z, Peng Y, Huang M, An J, Yang X, Wang J, Li C, Wu L. Therapeutic strategy analysis of patients with advanced stage high‐grade neuroendocrine cervical cancer: A real‐world multicenter study. Int J Gynaecol Obstet 2022; 158:722-729. [PMID: 35124799 DOI: 10.1002/ijgo.14125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 12/12/2021] [Accepted: 12/20/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Yuanyuan Zhang
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing PR China
| | - Yi Huang
- Department Gynecologic Oncology, Hubei Province Cancer Center/Hubei Cancer Hospital, The affiliated Cancer Hospital of Tongji Medical Colleague of Huazhong University of Science and Technology Wuhan Hubei Province PR China
| | - Suiyu Luo
- Department of Gynecology and Obstetrics, Henan Provincial People’s Hospital/Zhengzhou University People’s Hospital, The Affiliated People’s Hospital of Henan University Zhengzhou Henan Province PR China
| | - Lin Li
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital Chongqing PR China
| | - Hongying Yang
- Department Gynecologic Oncology, Yunnan Province Cancer Center/Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University Kunming Yunnan Province PR China
| | - Ziyi Wang
- Department Gynecologic Oncology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University Changsha Hunan Province PR China
| | - Yongmei Peng
- Department Gynecologic Oncology, Yunnan Province Cancer Center/Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University Kunming Yunnan Province PR China
| | - Manni Huang
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing PR China
| | - Jusheng An
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing PR China
| | - Xi Yang
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing PR China
| | - Jing Wang
- Department Gynecologic Oncology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University Changsha Hunan Province PR China
| | - Chunmei Li
- Department of Gynecology and Obstetrics, Henan Provincial People’s Hospital/Zhengzhou University People’s Hospital, The Affiliated People’s Hospital of Henan University Zhengzhou Henan Province PR China
| | - Lingying Wu
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Beijing PR China
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20
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Jiang AG, Cai X. Construction and validation of the prognostic model for patients with neuroendocrine cervical carcinoma: a competing risk nomogram analysis. BMC Cancer 2022; 22:4. [PMID: 34980030 PMCID: PMC8722105 DOI: 10.1186/s12885-021-09104-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/07/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Neuroendocrine cervical carcinoma (NECC) is an uncommon malignancy of the female reproductive system. This study aimed to evaluate cancer-specific mortality and to construct prognostic nomograms for predicting the survival of patients with NECC. Methods we assembled the patients with NECC diagnosed between 2004 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Meanwhile, we identified other patients with NECC from the Wenling Maternal and Child Health Care Hospital between 2002 to 2017. Fine and Gray’s test and Kaplan–Meier methods were used to evaluate cancer-specific mortality and overall survival (OS) rates, respectively. Nomograms were constructed for predicting cancer-specific survival (CSS) and OS for patients with NECC. The developed nomograms were validated both internally and externally. Results a total of 894 patients with NECC were extracted from the SEER database, then classified into the training cohort (n = 628) and the internal validation cohort (n = 266). Besides, 106 patients from the Wenling Maternal and Child Health Care Hospital served as an external validation cohort. Nomograms for predicting CSS and OS were constructed on clinical predictors. The validation of nomograms was calculated by calibration curves and concordance indexes (C-indexes). Furthermore, the developed nomograms presented higher areas under the receiver operating characteristic (ROC) curves when compared to the FIGO staging system. Conclusions we established the first competing risk nomograms to predict the survival of patients with NECC. Such a model with high predictive accuracy could be a practical tool for clinicians. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-09104-9.
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Affiliation(s)
- Ai-Guo Jiang
- Department of Obstetrics and Gynecology, Wenling Maternal and Child Health Care Hospital, Wenling, Taizhou, 317500, Zhejiang province, China
| | - Xu Cai
- Department of Obstetrics and Gynecology, Wenling Maternal and Child Health Care Hospital, Wenling, Taizhou, 317500, Zhejiang province, China.
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Li Q, Yu J, Yi H, Lan Q. Distant organ metastasis patterns and prognosis of neuroendocrine cervical carcinoma: a population-based retrospective study. Front Endocrinol (Lausanne) 2022; 13:924414. [PMID: 36051393 PMCID: PMC9424674 DOI: 10.3389/fendo.2022.924414] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/29/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Neuroendocrine carcinoma of the cervix (NECC) is a rare pathological form of cervical cancer. The prognosis of NECC with distant organ metastases is unclear. In our study, the patterns and prognosis of distant organ metastasis of NECC were investigated. METHODS Data were obtained from the surveillance epidemiology and end results (SEER) database from 2000 to 2018. Cox regression, Kaplan-Meier and log-rank analyses were conducted. RESULTS NECC was prone to single and multi-site metastases. The median overall survival (OS) was greatly decreased in patients with distant metastasis (P < 0.0001). Other characteristics such as age ≥60 years, poorer grade, higher T stage, those without surgery, no radiotherapy, and no chemotherapy were predictors of poor prognosis. CONCLUSIONS Metastasis is an independent prognostic factor for patients with NECC. Surgery, radiotherapy, and chemotherapy give an overall survival advantage for patients with distant organ metastases.
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Affiliation(s)
- Qing Li
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, China
| | - Jie Yu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Oncology, Dongguan Tungwah Hospital, Dongguan, China
| | - Hanjie Yi
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, China
| | - Qiongyu Lan
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, China
- *Correspondence: Qiongyu Lan,
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22
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Complete Response to Combination Nivolumab and Ipilimumab in Recurrent Neuroendocrine Carcinoma of the Cervix. Obstet Gynecol 2021; 138:813-816. [PMID: 34619736 DOI: 10.1097/aog.0000000000004573] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Small cell neuroendocrine carcinoma of the cervix is a rare, aggressive tumor treated with a combination of surgery, chemotherapy, and radiation. Survival rates are poor, and innovative therapies are needed. CASE A 52-year-old woman was diagnosed with small cell neuroendocrine carcinoma of the cervix. Over a 10-year period, she was treated with six different systemic therapeutic regimens, underwent planned hysterectomy with bilateral salpingo-oophorectomy, and received radiation to the pelvis and brain. After a second recurrence of disease, she was treated with a combination of nivolumab and ipilimumab and experienced a complete and durable response. CONCLUSION The combination of nivolumab and ipilimumab may represent a promising new treatment option for recurrent small cell neuroendocrine carcinoma of the cervix.
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Mabuchi S, Waki K. The first case of recurrent small cell neuroendocrine carcinoma of the uterine cervix successfully treated with robotic-assisted super radical hysterectomy. Gynecol Oncol Rep 2021; 38:100882. [PMID: 34926763 PMCID: PMC8651782 DOI: 10.1016/j.gore.2021.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/07/2021] [Accepted: 10/10/2021] [Indexed: 12/02/2022] Open
Abstract
Recurrent cervical cancer occurring in a previously irradiated field is one of the most complicated challenges for gynecological oncologists. Super-radical hysterectomy is a standard procedure for laterally extended cervical tumors, particularly recurrent cervical cancer in a previously irradiated field. This potentially curative procedure is challenging to perform due to the technical complexities and lack of reproducibility. Thus, it is performed only by skilled surgeons, either via open or laparoscopic approaches wherein the entire paracervix at the pelvic wall and the hypogastric vessels are transected. In this report, we described the first case of recurrent small cell neuroendocrine carcinoma of the uterine cervix that was successfully treated with robot-assisted super-radical hysterectomy.
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Key Words
- CCRT, concurrent chemoradiotherapy
- CT, computed tomography
- Complete resection
- FDG, fluorodeoxyglucose
- H&E, hematoxylin and eosin
- LACC, laparoscopic approach to cervical cancer
- LEER, laterally extended endopelvic resection
- MIS, minimally invasive surgery
- MRI, magnetic resonance imaging
- PE, pelvic exenteration
- Persistent cervical cancer
- RH, radical hysterectomy
- Recurrent cervical cancer
- Robotic surgery
- SCNEC, small cell neuroendocrine carcinoma
- SRH, super-radical hysterectomy
- Super radical hysterectomy
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Affiliation(s)
- Seiji Mabuchi
- Department of Gynecology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka-shi, Osaka 541-8567, Japan
| | - Keita Waki
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Nara, Japan
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Zhang Z, Pan Y, Zhao Y, Ren M, Li Y, Lu G, Wu K, He S. Topotecan-loaded thermosensitive nanocargo for tumor therapy: In vitro and in vivo analyses. Int J Pharm 2021; 606:120871. [PMID: 34246742 DOI: 10.1016/j.ijpharm.2021.120871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 01/09/2023]
Abstract
This study demonstrates the development of topotecan (TCN) loaded thermosensitive nanocargos (TCN-TS-NC) for intramuscular (IM) administration with enhanced antitumor activity. In this regards, TCN loaded temperature dependent solid lipid nanoparticles (SLNs) were prepared with micro-emulsion method, which were then incorporated into temperature sensitive poloxamer solution to develop TCN-TS-NC. The particle size, entrapment efficiency (%EE), zeta potential and transmission electron microscopy (TEM) analysis of the TCN-TS-NC were performed. Moreover, the inject-ability, release pattern, apoptosis, cellular uptake, pharmacokinetics and antitumor studies of the TCN-TS-NC were attained and compared with TCN solution and TCN-Emulgel (poloxamer solution containing TCN). At room temperature, the TCN loaded SLNs were solid and poloxamer solution remains liquid, however, TCN loaded SLNs melted to liquid and Emulgel converted into gel from, at body temperature, resulting controlled release of the incorporated drug. The TCN-TS-NC showed enhanced cellular uptake and better apoptosis. Similarly, it reduces Cmax and sustained its level for a significantly longer time in rats, as compared to the TCN-Emulgel and TCN solution. Moreover, a significantly improved antitumor activity was observed in TCN-TS-NC treated tumor bearing athymic nude mice when compared with the control, TCN solution and TCN-Emulgel applied mice. Thus, the TCN-TS-NC system showed control release of the drug with no initial fast effect. Furthermore, it enhanced the antitumor activity of TCN with comparatively no toxicity. It is therefore concluded that TCN-TS-NC could be a potentially more suitable drug delivery system for the delivery of TCN.
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Affiliation(s)
- Zhiyong Zhang
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Yan Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Shaanxi, China
| | - Yan Zhao
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Mudan Ren
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Yarui Li
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Guifang Lu
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Shaanxi, China
| | - Shuixiang He
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China.
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25
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Winer I, Kim C, Gehrig P. Neuroendocrine tumors of the gynecologic tract update. Gynecol Oncol 2021; 162:210-219. [PMID: 34023130 DOI: 10.1016/j.ygyno.2021.04.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Affiliation(s)
- I Winer
- Division of Gynecologic Oncology, Department of Oncology, Wayne State University, Detroit, MI, USA.
| | - C Kim
- New York Cancer Blood Specialists, Patchogue, NY, USA; Division of Hematology/Oncology, Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - P Gehrig
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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26
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Bos L, Goulder A, Prescott L, Podoll M, Frumovitz M, Brown AJ. Isolated subcutaneous recurrence of high-grade neuroendocrine tumor of the cervix. Gynecol Oncol Rep 2021; 37:100780. [PMID: 34095421 PMCID: PMC8165541 DOI: 10.1016/j.gore.2021.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/21/2021] [Accepted: 04/29/2021] [Indexed: 11/17/2022] Open
Abstract
•This case reports an isolated subcutaneous recurrence of neuroendocrine carcinoma of the cervix.•Multiple recurrences of NECC were treated surgically without additional systemic therapy.•There is a need for further studies to evaluate optimal treatment regimens for NECC.
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Affiliation(s)
- Lia Bos
- Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 1161 21st Ave. South, R-1200 Medical Center North, Nashville, TN 37232, USA
- Corresponding author.
| | - Alison Goulder
- Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 1161 21st Ave. South, R-1200 Medical Center North, Nashville, TN 37232, USA
| | - Lauren Prescott
- Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 1161 21st Ave. South, R-1200 Medical Center North, Nashville, TN 37232, USA
| | - Mirna Podoll
- Vanderbilt University Medical Center, Department of Pathology, 1161 21st Ave. South, C-3322 Medical Center North, Nashville, TN 37232, USA
| | - Michael Frumovitz
- The University of Texas MD Anderson, Department of Gynecologic Oncology , Main Building, 1515 Holcombe St., Houston, TX 77030, USA
| | - Alaina J. Brown
- Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 1161 21st Ave. South, R-1200 Medical Center North, Nashville, TN 37232, USA
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27
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Stelwagen J, de Vries EGE, Walenkamp AME. Current Treatment Strategies and Future Directions for Extrapulmonary Neuroendocrine Carcinomas: A Review. JAMA Oncol 2021; 7:759-770. [PMID: 33630040 DOI: 10.1001/jamaoncol.2020.8072] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients with extrapulmonary neuroendocrine carcinomas (EPNECs) receive essentially the same treatment as those with small cell lung cancer (SCLC) despite differences in origin, clinical course, and survival. This SCLC-based approach is attributable to the rarity of EPNECs, which impedes the use of randomized clinical trials. However, neuroendocrine carcinomas are becoming more common because of the increasing use of systemic cancer therapy for adenocarcinomas. This treatment can transdifferentiate certain adenocarcinomas into neuroendocrine carcinomas. In addition, the treatment landscape for SCLC is slowly changing, potentially impacting the treatment paradigms for EPNECs. Observations New information on tumorigenesis of EPNECs from different origins, either as a primary malignant tumor or after neuroendocrine differentiation from adenocarcinomas, demonstrates their biological similarity. Activated molecular pathways that appear to underlie the development of EPNECs are potentially targetable, and some of these targets, such as poly(adenosine diphosphate-ribose) polymerase, Wee1, and Aurora A kinase, are currently under investigation. Immune checkpoint inhibitors (ICIs) already constituted a new treatment modality for patients with SCLC and produced some promising results in patients with EPNECs. Conclusions and Relevance Although only moderately effective, the introduction of ICIs signifies the first new option in systemic treatment of SCLC in decades. To prove the value of ICIs and other new drugs for patients with EPNECs, these patients should be included in clinical trials independent of the primary tumor site. Furthermore, to optimize clinical decision-making for patients with EPNECs, experts from the neuroendocrine tumor board should collaborate with members from tumor site-specific boards, which will require patient referral to a center with EPNEC expertise.
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Affiliation(s)
- Johannes Stelwagen
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Annemiek M E Walenkamp
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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28
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Caruso G, Sassu CM, Tomao F, Di Donato V, Perniola G, Fischetti M, Benedetti Panici P, Palaia I. The puzzle of gynecologic neuroendocrine carcinomas: State of the art and future directions. Crit Rev Oncol Hematol 2021; 162:103344. [PMID: 33933568 DOI: 10.1016/j.critrevonc.2021.103344] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 04/05/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022] Open
Abstract
Primary gynecologic neuroendocrine carcinomas (gNECs) are a heterogeneous spectrum of rare and highly aggressive neoplasms, accounting for about 2% of all gynecologic malignancies, which mostly resemble the small cell lung carcinoma (SCLC). Due to the lack of standardized treatment guidelines, their management poses a noteworthy clinical challenge. Currently, cumulative data retrieved from the management of SCLC and from retrospective studies supports a multimodality strategy, based on surgery, chemotherapy, and radiotherapy. Nevertheless, the prognosis remains poor and recurrences are extremely frequent. Hence, there is an urgent need for novel treatment options and promising molecular targets. Recently, there has been an increasing interest on the potential role of immune checkpoint inhibitors, especially in the recurrent setting. However, only scant evidence exists and there is still a long road ahead. A solid collaboration between gynecologists and oncologists worldwide is required to improve the treatment of these puzzling tumors.
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Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy.
| | - Carolina Maria Sassu
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
| | - Federica Tomao
- Department of Gynecologic Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
| | - Margherita Fischetti
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, University of Rome "Sapienza", Policlinico "Umberto I", Rome, Italy
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29
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Randall LM, Walker AJ, Jia AY, Miller DT, Zamarin D. Expanding Our Impact in Cervical Cancer Treatment: Novel Immunotherapies, Radiation Innovations, and Consideration of Rare Histologies. Am Soc Clin Oncol Educ Book 2021; 41:252-263. [PMID: 34010052 DOI: 10.1200/edbk_320411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cervical cancer is a socially and scientifically distinguishable disease. Its pathogenesis, sexual transmission of high-risk HPV to a metaplastic portion of the uterine cervix, makes cervical cancer preventable by safe and effective HPV vaccines commercially available since 2006. Despite this, cervical cancer remains the deadliest gynecologic cancer in the world. Regrettably, global incidence and mortality rates disproportionately affect populations where women are marginalized, where HIV infection is endemic, and where access to preventive vaccination and screening for preinvasive disease are limited. In the United States, cervical cancer incidence has gradually declined over the last 25 years, but mortality rates remain both constant and disparately higher among communities of color because of the adverse roles that racism and poverty play in outcome. Until these conditions improve and widespread prevention is possible, treatment innovations are warranted. The last standard-of-care treatment changes occurred in 1999 for locally advanced disease and in 2014 for metastatic and recurrent disease. The viral and immunologic nature of HPV-induced cervical cancer creates opportunities for both radiation and immunotherapy to improve outcomes. With the advent of T cell-directed therapy, immune checkpoint inhibition, and techniques to increase the therapeutic window of radiation treatment, an overdue wave of innovation is currently emerging in cervical cancer treatment. The purpose of this review is to describe the contemporary developmental therapeutic landscape for cervical cancer that applies to most tumors and to discuss notable rare histologic subtypes that will not be adequately addressed with these treatment innovations.
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Affiliation(s)
- Leslie M Randall
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA
| | - Amanda J Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Devin T Miller
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA
| | - Dmitriy Zamarin
- Department of Medicine, Gynecologic Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Medicine, Weill-Cornell Medical College, New York, NY
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30
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Reed N, Balega J, Barwick T, Buckley L, Burton K, Eminowicz G, Forrest J, Ganesan R, Harrand R, Holland C, Howe T, Ind T, Iyer R, Kaushik S, Music R, Sadozye A, Shanbhag S, Siddiqui N, Syed S, Percival N, Whitham NL, Nordin A, Fotopoulou C. British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2020; 256:433-465. [PMID: 33143928 DOI: 10.1016/j.ejogrb.2020.08.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 01/20/2023]
Abstract
Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.
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Affiliation(s)
- Nick Reed
- Beatson Oncology Centre, Glasgow, United Kingdom.
| | | | | | - Lynn Buckley
- Clinical Nurse Specialist, Hull University Teaching Hospitals NHS Trust, United Kingdom
| | | | | | | | | | | | | | | | - Thomas Ind
- Royal Marsden Hospital, London, United Kingdom
| | - Rema Iyer
- East Kent Hospitals University Foundation NHS Trust, United Kingdom
| | | | - Robert Music
- Jo's Cervical Cancer Trustt, London, United Kingdom
| | | | - Smruta Shanbhag
- University Hospitals Coventry and Warwickshire NHS Trust, United Kingdom
| | | | - Sheeba Syed
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Natasha Lauren Whitham
- Lancashire Teaching Hospitals (Royal Preston Hospital, Fulwood, Lancashire), United Kingdom
| | - Andy Nordin
- East Kent Gynaecological Oncology Centre, East Kent Hospitals University Foundation Nhs Trust, Queen Elizabeth The Queen Mother Hospital, Margate, United Kingdom
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31
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Frumovitz M, Westin SN, Salvo G, Zarifa A, Xu M, Yap TA, Rodon AJ, Karp DD, Abonofal A, Jazaeri AA, Naing A. Phase II study of pembrolizumab efficacy and safety in women with recurrent small cell neuroendocrine carcinoma of the lower genital tract. Gynecol Oncol 2020; 158:570-575. [PMID: 32534809 PMCID: PMC7486997 DOI: 10.1016/j.ygyno.2020.05.682] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/31/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of pembrolizumab in women with recurrent small cell neuroendocrine tumors of the lower genital tract. METHODS We conducted an open-label, investigator-initiated phase II basket trial of pembrolizumab 200 mg intravenously every 3 weeks in patients with rare tumors (ClinicalTrials.gov: NCT02721732). The trial had prespecified cohorts, including small cell malignancies of extrapulmonary origin. Eligibility criteria included disease progression during standard treatment in the 6 months before study enrollment. Patients were enrolled from February 2017 to February 2019. The primary endpoint was the proportion of patients alive without progression at 27 weeks. Response to pembrolizumab was evaluated every 9 weeks (3 cycles) with radiographic imaging. RESULTS Seven women with gynecologic extrapulmonary small cell carcinoma were enrolled, 6 with cervical and 1 with vulvar carcinoma. No patient was progression free at 27 weeks. At first radiologic assessment, 1 patient had stable disease, while 6 had progression. The single patient with stable disease at 6 weeks had disease progression at 14 weeks. The median progression-free interval was 2.1 months (range 0.8-3.3 months). Severe treatment-related adverse events (≥grade 3) were seen in 2 of 7 patients (29%); 1 patient had grade 3 asymptomatic elevation of serum alkaline phosphatase, and 1 had grade 3 asymptomatic elevation of serum alanine aminotransferase. CONCLUSIONS Pembrolizumab alone showed minimal activity in women with recurrent small cell neuroendocrine tumors of the lower genital tract. Treatment was well tolerated in the majority of study participants, and the rate of severe adverse events was low.
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Affiliation(s)
- Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Abdulrazzak Zarifa
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Mingxuan Xu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Ahnert J Rodon
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Abdulrahman Abonofal
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
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32
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Carroll MR, Ramalingam P, Salvo G, Fujimoto J, Solis Soto LM, Phoolcharoen N, Hillman RT, Cardnell R, Byers L, Frumovitz M. Evaluation of PARP and PDL-1 as potential therapeutic targets for women with high-grade neuroendocrine carcinomas of the cervix. Int J Gynecol Cancer 2020; 30:1303-1307. [PMID: 32727929 DOI: 10.1136/ijgc-2020-001649] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Women with recurrent high-grade neuroendocrine cervical cancer have few effective treatment options. The aim of this study was to identify potential therapeutic targets for women with this disease. METHODS Specimens from patients with high-grade neuroendocrine carcinomas of the cervix were identified from pathology files at MD Anderson Cancer Center. Immunohistochemical stains for PD-L1 (DAKO, clone 22-C3), mismatch repair proteins (MLH1, MSH2, MSH6, PMS2), somatostatin, and Poly (ADP-ribose) polymerase (PARP) were performed on sections from formalin-fixed paraffin-embedded tissue blocks. Nuclear PARP-1 staining was quantified using the H-score with a score of <40 considered low, 40-100 moderate, and ≥100 high. RESULTS Forty pathologic specimens from patients with high-grade neuroendocrine carcinomas of the cervix were examined (23 small cell, 5 large cell, 3 high-grade neuroendocrine, not otherwise specified, and 9 mixed). The mean age of the cohort was 43 years and the majority of patients (70%) were identified as white non-Hispanic. All 28 (100%) samples tested stained for mismatch repair proteins demonstrated intact expression, suggesting they were microsatellite stable tumors. Of the 31 samples tested for PD-L1 expression, only two (8%) of the 25 pure high-grade neuroendocrine carcinomas were positive whereas three (50%) of the six mixed carcinoma tumors tested positive. Of the 11 small cell specimens tested for PARP-1, 10 (91%) showed PARP expression with six (55%) demonstrating high expression and four (36%) showing moderate expression. Somatostatin staining was negative in 18 of 19 small cell cases (95%). CONCLUSIONS Pure high-grade neuroendocrine cervical carcinomas were microsatellite stable and overwhelmingly negative for PD-L1 expression. As the majority of tumors tested expressed PARP-1, inclusion of PARP inhibitors in future clinical trials may be considered.
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Affiliation(s)
| | | | - Gloria Salvo
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Junya Fujimoto
- Molecular and Translational Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Luisa Maren Solis Soto
- Molecular and Translational Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Cardnell
- Thoracic/Head & Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren Byers
- Thoracic/Head & Neck Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Frumovitz
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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33
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Hillman RT, Cardnell R, Fujimoto J, Lee WC, Zhang J, Byers LA, Ramalingam P, Leitao M, Swisher E, Futreal PA, Frumovitz M. Comparative genomics of high grade neuroendocrine carcinoma of the cervix. PLoS One 2020; 15:e0234505. [PMID: 32544169 PMCID: PMC7297329 DOI: 10.1371/journal.pone.0234505] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
In order to improve treatment selection for high grade neuroendocrine carcinomas of the cervix (NECC), we performed a comparative genomic analysis between this rare tumor type and other cervical cancer types, as well as extra-cervical neuroendocrine small cell carcinomas of the lung and bladder. We performed whole exome sequencing on fresh-frozen tissue from 15 NECCs and matched normal tissue. We then identified mutations and copy number variants using standard analysis pipelines. Published mutation tables from cervical cancers and extra-cervical small cell carcinomas were used for comparative analysis. Descriptive statistical methods were used and a two-sided threshold of P < .05 was used for significance. In the NECC cohort, we detected a median of 1.7 somatic mutations per megabase (range 1.0-20.9). PIK3CA p.E545K mutations were the most frequency observed oncogenic mutation (4/15 tumors, 27%). Activating MAPK pathway mutations in KRAS (p.G12D) and GNAS (p.R201C) co-occurred in two tumors (13%). In total we identified PI3-kinase or MAPK pathway activating mutations in 67% of NECC. When compared to NECC, lung and bladder small cell carcinomas exhibited a statistically significant higher rate of coding mutations (P < .001 for lung; P = .001 for bladder). Mutation of TP53 was uncommon in NECC (13%) and was more frequent in both lung (103 of 110 tumors [94%], P < .001) and bladder (18 of 19 tumors [95%], P < .001) small cell carcinoma. These comparative genomics data suggest that NECC may be genetically more similar to common cervical cancer subtypes than to extra-cervical small cell neuroendocrine carcinomas of the lung and bladder. These results may have implications for the selection of cytotoxic and targeted therapy regimens for this rare disease.
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Affiliation(s)
- R. Tyler Hillman
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Robert Cardnell
- Department of Thoracic/Head & Neck Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Junya Fujimoto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Won-Chul Lee
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
- Department of Thoracic/Head & Neck Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jianjun Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
- Department of Thoracic/Head & Neck Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Lauren A. Byers
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Preetha Ramalingam
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Mario Leitao
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Medical Center, New York, NY, United States of America
| | - Elizabeth Swisher
- Department of Gynecologic Oncology, University of Washington Medical Center, Seattle, WA, United States of America
| | - P. Andrew Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Michael Frumovitz
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
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Huang R, Gan Q, Cheng J. Prognostic Factors and Local Treatment Modalities of Small-Cell Carcinoma of the Cervix: An Analysis According to the International Federation of Gynecology and Obstetrics Stage. Cancer Manag Res 2020; 12:3445-3456. [PMID: 32523375 PMCID: PMC7236046 DOI: 10.2147/cmar.s247081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose Small-cell carcinoma of the cervix (SCCC) is a rare type of cervical cancer. This study aimed to investigate the clinicopathological characteristics and survival as well as the optimal local treatment modalities for SCCC. Patients and Methods We retrospectively evaluated the data of patients diagnosed with SCCC between 1988 and 2015 in our institution - those included in the Surveillance, Epidemiology, and End Results (SEER) database and those in the Periodical Database. Kaplan-Meier method and Cox regression proportional hazard methods were used to evaluate overall survival (OS). A nomogram that could predict OS was constructed based on the Cox proportional hazard model. Results In total, 695 patients were included in this study. The 5-year overall survival in FIGO stage I-IIA and IIB-IV patients was 45.7% and 14.4%, respectively (P <0.01). Univariate and multivariate analyses showed that lymph node status (P <0.01) and cancer-directed surgery (P <0.01) were independent prognostic factors for FIGO I-IIA stage patients, and age (P <0.05), tumor size (P <0.01), chemotherapy (P <0.01) and radiation (P <0.01) were independent prognostic factors for FIGO stage IIB-IV patients. Conclusion Better prognosis was associated with negative lymph node status, no lymphatic vasculature, surgery, and early-stage patients. Furthermore, our data showed that the prognosis and treatment pattern varied depending on the FIGO stage, and that optimal treatment modalities included radical surgery for early-stage SCCC and chemoradiotherapy for advanced-stage SCCC. It is helpful to assess the individual prognosis of SCCC patients and choose personalized treatment modalities.
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Affiliation(s)
- Ru Huang
- Department of Obstetrics and Gynecology, The Shanghai East Hospital, Shanghai 200120, People's Republic of China
| | - Qiyu Gan
- Department of Obstetrics and Gynecology, The Shanghai East Hospital, Shanghai 200120, People's Republic of China
| | - Jingxin Cheng
- Department of Obstetrics and Gynecology, The Shanghai East Hospital, Shanghai 200120, People's Republic of China
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Nakao Y, Tamauchi S, Yoshikawa N, Suzuki S, Kajiyama H, Kikkawa F. Complete Response of Recurrent Small Cell Carcinoma of the Uterine Cervix to Paclitaxel, Carboplatin, and Bevacizumab Combination Therapy. Case Rep Oncol 2020; 13:373-378. [PMID: 32355492 PMCID: PMC7184850 DOI: 10.1159/000506446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 11/19/2022] Open
Abstract
We report a case of recurrent small cell carcinoma of the uterine cervix that showed a complete response to paclitaxel, carboplatin, and bevacizumab (TC + Bev) combination therapy. Small cell carcinoma of the uterine cervix is extremely rare, with an incidence of only 1.3% in Japan, and a poor outcome. The patient was a 62-year-old woman with a chief complaint of irregular vaginal bleeding. Magnetic resonance imaging showed a 10-cm irregular mass from the uterine corpus's posterior wall to the cervix. Abdominal total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node sampling were performed for suspected uterine sarcoma. Histopathological findings revealed small cell carcinoma with lymph node metastasis. Although 6 cycles of etoposide + cisplatin were performed, para-aortic lymph node recurrence was found 3 months after chemotherapy. Subsequently, the patient received 8 cycles of TC + Bev, which eliminated the metastases. The patient is currently alive at 24 months.
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Affiliation(s)
- Yuri Nakao
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Tamauchi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhisa Yoshikawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Salvo G, Gonzalez Martin A, Gonzales NR, Frumovitz M. Updates and management algorithm for neuroendocrine tumors of the uterine cervix. Int J Gynecol Cancer 2020; 29:986-995. [PMID: 31263021 DOI: 10.1136/ijgc-2019-000504] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 11/03/2022] Open
Abstract
Neuroendocrine carcinomas of the cervix account for less than 2% of all invasive cervical cancers and are classified as low-grade (carcinoid, atypical carcinoid tumor) or high-grade (known as small- and large-cell) neuroendocrine carcinomas. There are increasing data showing that cervical neuroendocrine carcinomas may be associated with the human papillomavirus (HPV), especially HPV18, and most will stain positive for p16. Immunohistochemistry markers such as synaptophysin and CD56 are the most sensitive markers. Although there are no commonly associated mutations, PIK3CA, KRAS, and TP53 are the most frequently found mutations in neuroendocrine tumors. Neuroendocrine cervical carcinomas are exceedingly aggressive tumors with a high tendency for nodal involvement and distant metastases. Age, lymph node metastases, smoking, pure small-cell histology, and tumor size are independent prognostic factors. Overall, the 5-year survival rate is 36% and the median overall survival ranges between 22 and 25 months. Treatment options are often extrapolated from small-cell lung cancer and limited retrospective studies. The preferred treatment is a multimodal approach of surgery, chemoradiation, and systemic chemotherapy. The most common chemotherapy regimen used as initial therapy is a combination of cisplatin and etoposide. In the setting of recurrent disease, a combination of topotecan, paclitaxel, and bevacizumab has demonstrated favorable outcomes. Multicenter tumor registries, such as the Neuroendocrine Cervical Tumor Registry (NeCTuR), are an opportunity to evaluate patterns of disease treatment and oncologic outcomes.
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Affiliation(s)
- Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Naomi R Gonzales
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Rose PG, Sierk A. Treatment of neuroendocrine carcinoma of the cervix with a PARP inhibitor based on next generation sequencing. Gynecol Oncol Rep 2019; 30:100499. [PMID: 31649992 PMCID: PMC6804835 DOI: 10.1016/j.gore.2019.100499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 01/18/2023] Open
Abstract
This case reports the treatment of neuroendocrine carcinoma of the cervix with a PARPi based on NGS. NGS reports have demonstrated somatic mutations BRCA in neuroendocrine carcinoma of the cervix. The use of a PARPi in neuroendocrine carcinoma of the cervix has not been previously reported.
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Affiliation(s)
- Peter G Rose
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cleveland Clinic, United States of America
| | - Anne Sierk
- Department of Anatomic Pathology, Cleveland Clinic, United States of America
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Clinicopathologic features, incidence, and survival trends of gynecologic neuroendocrine tumors: a SEER database analysis. Am J Obstet Gynecol 2019; 221:53.e1-53.e6. [PMID: 30849352 DOI: 10.1016/j.ajog.2019.02.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/24/2019] [Accepted: 02/27/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary gynecologic neuroendocrine tumors are uncommon malignant neoplasms associated with poor prognosis. Clinically, these tumors present a significant challenge because of the lack of standardized management guidelines. OBJECTIVE The objective of this study is to evaluate the clinicopathologic features, incidence, and survival trends in gynecologic neuroendocrine tumors. MATERIALS AND METHODS The Surveillance, Epidemiology and End Results (SEER) cancer registry was queried for women diagnosed with primary gynecologic neuroendocrine tumors from 1987 to 2012. Data regarding stage, grade, presence of extrauterine disease, receipt of adjuvant radiation, surgical intervention, incidence, and overall survival were extracted. Patients were classified as having early-stage disease (International Federation of Gynecology and Obstetrics Stage I/II) or advanced-stage disease (Stage III/IV). Extrauterine disease was defined as either regional or distant metastasis. χ2 Tests, Pearson correlation, and Kaplan-Meier curves were used for statistical analysis. RESULTS In all, 559 cases of gynecologic neuroendocrine tumors were identified during the study period: 242 cervical, 160 ovarian, 118 uterine, and 39 vulvar/vaginal. The majority of patients in all subsets of gynecologic neuroendocrine tumors presented with poorly differentiated tumors, extrauterine disease spread, and advanced-stage disease. Poorly differentiated tumors represented 65.0% of cervical tumors, 45.3% of ovarian tumors, and 57.4% of uterine tumors. Extrauterine disease at the time of diagnosis was present in the case of 66.9% of cervical tumors, 83.5% of ovarian tumors, and 83.6% of uterine tumors. The overall incidence of gynecologic neuroendocrine tumors increased 4-fold during the study period, from 0.3 in 1987 to 1.30 per million in 2012. The study period was divided into two 13-year periods (1987-1999 and 2000-2012) for time trend mean survival analysis. We observed no significant change in overall survival across all gynecologic neuroendocrine tumor subtypes. The mean survival time of cervical neuroendocrine tumors was 74.3 vs 45.4 months (P = .31), ovarian neuroendocrine tumors 47.8 vs 41.2 months (P = .56), and uterine neuroendocrine tumors 42.9 vs 47.7 months (P = .44) for each time period, respectively. CONCLUSION Neuroendocrine tumors of the gynecologic tract are uncommon aggressive malignancies. These poorly differentiated tumors present at advanced stage, with a high incidence of extrauterine disease. Despite 25 years of advances in cancer therapy, we observed no improvement in overall survival.
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Elsherif S, Odisio EGLC, Faria S, Javadi S, Yedururi S, Frumovitz M, Ramalingam P, Bhosale P. Imaging and staging of neuroendocrine cervical cancer. Abdom Radiol (NY) 2018; 43:3468-3478. [PMID: 29974177 DOI: 10.1007/s00261-018-1667-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Neuroendocrine cervical cancer (NECC) is a rare and aggressive subtype of cervical cancer, accounting for less than 2% of cervical tumors. They are divided into low-grade and high-grade tumors. High-grade NECC is associated with human papillomavirus (HPV) 18 and to a smaller extent type 16. The most common molecular alterations in NECC include PIK3CA, KRAS, and TP53 mutations. Immunohistochemical staining for CD56, synaptophysin, and chromogranin is a helpful tool in the diagnosis. NECCs pose a significant clinical and therapeutic challenge because of their aggressive nature which is explained by their tendency towards early nodal and hematogenous spread. They have a median survival of 21-22 months, compared to 10 years in cervical squamous cell carcinomas. NECCs have a homogeneous high T2 signal intensity, homogeneous contrast enhancement and lower ADC values in MRI, compared to non-neuroendocrine tumors of the cervix. It is recommended to treat NECC with a multimodality therapeutic approach combining radical hysterectomy, systemic chemotherapy, and radiotherapy. The objective of this manuscript is to address the pathogenesis of NECC, elaborate the role of radiological imaging in the diagnosis and staging of NECCs, evaluate their prognosis, and summarize the suggested management plans for this lethal disease.
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Hodroj MH, Jardaly A, Abi Raad S, Zouein A, Rizk S. Andrographolide potentiates the antitumor effect of topotecan in acute myeloid leukemia cells through an intrinsic apoptotic pathway. Cancer Manag Res 2018; 10:1079-1088. [PMID: 29785137 PMCID: PMC5955015 DOI: 10.2147/cmar.s160924] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Topotecan (TP) is an anticancer drug acting as topoisomerase I inhibitor that is used in the treatment of many types of cancers including leukemia, but it has significant side effects. Andrographolide, a compound extracted from Andrographis paniculata, was recently proven to inhibit the growth of cancer cells and can induce apoptosis. The aim of this study is to investigate the possible synergism between TP and andrographolide in acute myeloid cells in vitro. Materials and methods U937 acute myeloid leukemic cells were cultured using Roswell Park Memorial Institute (RPMI) medium and then treated for 24 h with TP and andrographolide prepared through the dilution of dimethyl sulfoxide (DMSO) stocks with RPMI on the day of treatment. Cell proliferation was assessed using cell proliferation assay upon treatment with both compounds separately and in combination. Cell-cycle study and apoptosis detection were performed by staining the cells with propidium iodide (PI) stain and Annexin V/PI stain, respectively, followed by flow cytometry analysis. Western blotting was used to assess the expression of various proteins involved in apoptotic pathways. Results Both TP and andrographolide showed an antiproliferative effect in a dose-dependent manner when applied on U937 cells separately; however, pretreating the cells with andrographolide before applying TP exhibited a synergistic effect with lower inhibitory concentrations (half-maximal inhibitory concentration). Treating the cells with TP alone led to specific cell-cycle arrest at S phase that was more prominent upon pretreatment combination with andrographolide. Using Annexin V/PI staining to assess the proapoptotic effect following the pretreatment combination showed an increase in the number of apoptotic cells, which was supported by the Western blot results that manifested an upregulation of several proapoptotic proteins expression. Conclusion The pretreatment of U937 with andrographolide followed by low doses of TP showed an enhancement in inducing apoptosis when compared to the application of each compound separately.
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Affiliation(s)
| | - Achraf Jardaly
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon
| | - Sarah Abi Raad
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon
| | - Annalise Zouein
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon
| | - Sandra Rizk
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon
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Tempfer CB, Tischoff I, Dogan A, Hilal Z, Schultheis B, Kern P, Rezniczek GA. Neuroendocrine carcinoma of the cervix: a systematic review of the literature. BMC Cancer 2018; 18:530. [PMID: 29728073 PMCID: PMC5935948 DOI: 10.1186/s12885-018-4447-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 04/26/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Neuroendocrine carcinoma of the cervix (NECC) is a rare variant of cervical cancer. The prognosis of women with NECC is poor and there is no standardized therapy for this type of malignancy based on controlled trials. METHODS We performed a systematic literature search of the databases PubMed and Cochrane Central Register of Controlled Trials to identify clinical trials describing the management and outcome of women with NECC. RESULTS Three thousand five hundred thirty-eight cases of NECC in 112 studies were identified. The pooled proportion of NECC among women with cervical cancer was 2303/163470 (1.41%). Small cell NECC, large cell NECC, and other histological subtypes were identified in 80.4, 12.0, and 7.6% of cases, respectively. Early and late stage disease presentation were evenly distributed with 1463 (50.6%) and 1428 (49.4%) cases, respectively. Tumors expressed synaptophysin (424/538 cases; 79%), neuron-specific enolase (196/285 cases; 69%), chromogranin (323/486 cases; 66%), and CD56 (162/267; 61%). The most common primary treatment was radical surgery combined with chemotherapy either as neoadjuvant or adjuvant chemotherapy, described in 42/48 studies. Radiotherapy-based primary treatment schemes in the form of radiotherapy, radiochemotherapy, or radiotherapy with concomitant or followed by chemotherapy were also commonly used (15/48 studies). There is no standard chemotherapy regimen for NECC, but cisplatin/carboplatin and etoposide (EP) was the most commonly used treatment scheme (24/40 studies). Overall, the prognosis of women with NECC was poor with a mean recurrence-free survival of 16 months and a mean overall survival of 40 months. Immune checkpoint inhibitors and targeted agents were reported as being active in three case reports. CONCLUSION NECC is a rare variant of cervical cancer with a poor prognosis. Multimodality treatment with radical surgery and neoadjuvant/adjuvant chemotherapy with cisplatin and etoposide with or without radiotherapy is the mainstay of treatment for early stage disease while chemotherapy with cisplatin and etoposide or topotecan, paclitaxel, and bevacizumab is appropriate for women with locally advanced or recurrent NECC. Immune checkpoint inhibitors may be beneficial, but controlled evidence for their efficacy is lacking.
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Affiliation(s)
- Clemens B. Tempfer
- Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany
| | - Iris Tischoff
- Department of Pathology, Ruhr-Universität Bochum, Bochum, Germany
| | - Askin Dogan
- Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany
| | - Ziad Hilal
- Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany
| | - Beate Schultheis
- Department of Hematology and Oncology, Ruhr-Universität Bochum, Bochum, Germany
| | - Peter Kern
- Department of Obstetrics and Gynecology, St. Elisabeth Hospital, Bochum, Germany
| | - Günther A. Rezniczek
- Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany
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Influence of clinicopathological characteristics and comprehensive treatment models on the prognosis of small cell carcinoma of the cervix: A systematic review and meta-analysis. PLoS One 2018; 13:e0192784. [PMID: 29641578 PMCID: PMC5894955 DOI: 10.1371/journal.pone.0192784] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/21/2018] [Indexed: 01/11/2023] Open
Abstract
Small cell carcinoma of the cervix (SCCC) is a rare primary neuroendocrine cervical carcinoma with a high degree of invasiveness. SCCC is prone to early-stage lymph node and distant metastases and characterized by a poor prognosis. Currently, there is no standard treatment. This study aimed to evaluate the clinicopathological factors and treatment models that influence SCCC prognosis through a systematic review and meta-analysis, to improve the diagnosis and treatment of SCCC. A comprehensive search was performed in multiple medical literature databases to retrieve studies on the clinical prognosis of SCCC published in China and abroad as of March 1, 2017. Twenty cohort studies with 1904 patients were analyzed. Meta-analysis showed statistical significance for the following factors: FIGO staging (hazard ratio [HR] = 2.63, 95% confidence interval [CI]: 2.13–3.24; odds ratio [OR] = 3.72, 95% CI: 2.46–5.62), tumor size (HR = 1.64, 95% CI: 1.25–2.15), parametrial involvement (HR = 2.40, 95% CI: 1.43–4.05), resection margin (HR = 4.09, 95% CI: 2.27–7.39), lymph node metastasis (OR = 2.09, 95% CI: 1.18–3.71), depth of stromal invasion (HR = 1.99, 95% CI: 1.33–2.97), neoadjuvant chemotherapy (HR = 2.06, 95% CI: 1.14–3.73), and adjuvant chemotherapy (HR = 1.63, 95% CI: 1.26–2.12; OR = 1.48, 95% CI: 1.02–2.16). FIGO staging, tumor size, parametrial involvement, resection margin, depth of stromal invasion, and lymph node metastasis can be used as clinicopathological characteristics for the prediction of SCCC prognosis. Neoadjuvant chemotherapy tended to improve prognosis. Our findings suggest that neoadjuvant chemotherapy plus adjuvant chemotherapy may be the preferred strategy. However, adjuvant radiotherapy appeared to cause no significant improvement in prognosis. Therefore, the clinical application of radiotherapy and the relationship between radiotherapy and clinicopathological factors need to be re-examined. The results of this study should be validated and developed in formal, well-designed multicenter clinical trials.
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Kostamo K, Peart M, McKenzie N, Holloman C, Carlan SJ, Ge L, Maksem J. Novel Treatment of Small-Cell Neuroendocrine of the Vagina. Case Rep Oncol Med 2018; 2018:9157036. [PMID: 29535879 PMCID: PMC5817301 DOI: 10.1155/2018/9157036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/11/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Primary vaginal small-cell neuroendocrine carcinoma is an extremely rare and highly aggressive malignancy. Eighty-five percent of patients die within one year of diagnosis from metastatic disease despite multimodal therapy. Gene expression profiling of tumor tissue may be useful for treatment options for various malignancies. CASE A 34-year-old nulliparous woman was diagnosed with primary vaginal small-cell neuroendocrine carcinoma. Twenty weeks after the initial visit, she was diagnosed with recurrence and started on chemoradiation based on the results of gene expression profile of tumor tissue. She died 34 months after the initial visit and had a 14-month progression-free survival (PFS). CONCLUSION Gene expression profile of tumor tissue in the management of primary vaginal small-cell neuroendocrine carcinoma may be helpful in extending progression-free survival.
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Affiliation(s)
- Kathryn Kostamo
- Department of Obstetrics and Gynecology, Orlando Regional Healthcare, Orlando, FL, USA
| | - Mishka Peart
- Department of Obstetrics and Gynecology, Orlando Regional Healthcare, Orlando, FL, USA
| | - Nathalie McKenzie
- Gynecologic Oncology, Florida Hospital Medical Group, Maitland, FL, USA
| | - Conisha Holloman
- Department of Obstetrics and Gynecology, Orlando Regional Healthcare, Orlando, FL, USA
| | - S. J. Carlan
- Department of Obstetrics and Gynecology, Orlando Regional Healthcare, Orlando, FL, USA
| | - Li Ge
- Department of Pathology, Orlando Regional Healthcare, Orlando, FL, USA
| | - John Maksem
- Department of Pathology, Orlando Regional Healthcare, Orlando, FL, USA
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Andón FT, Digifico E, Maeda A, Erreni M, Mantovani A, Alonso MJ, Allavena P. Targeting tumor associated macrophages: The new challenge for nanomedicine. Semin Immunol 2017; 34:103-113. [PMID: 28941641 DOI: 10.1016/j.smim.2017.09.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 12/23/2022]
Abstract
The engineering of new nanomedicines with ability to target and kill or re-educate Tumor Associated Macrophages (TAMs) stands up as a promising strategy to induce the effective switching of the tumor-promoting immune suppressive microenvironment, characteristic of tumors rich in macrophages, to one that kills tumor cells, is anti-angiogenic and promotes adaptive immune responses. Alternatively, the loading of monocytes/macrophages in blood circulation with nanomedicines, may be used to profit from the high infiltration ability of myeloid cells and to allow the drug release in the bulk of the tumor. In addition, the development of TAM-targeted imaging nanostructures, can be used to study the macrophage content in solid tumors and, hence, for a better diagnosis and prognosis of cancer disease. The major challenges for the effective targeting of TAM with nanomedicines and their application in the clinic have already been identified. These challenges are associated to the undesirable clearance of nanomedicines by, the mononuclear phagocyte system (macrophages) in competing organs (liver, lung or spleen), upon their intravenous injection; and also to the difficult penetration of nanomedicines across solid tumors due to the abnormal vasculature and the excessive extracellular matrix present in stromal tumors. In this review we describe the recent nanotechnology-base strategies that have been developed to target macrophages in tumors.
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Affiliation(s)
- Fernando Torres Andón
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy; Center for Research in Molecular Medicine & Chronic Diseases (CIMUS), University of Santiago de Compostela, 15706 Campus Vida, Santiago de Compostela, Spain.
| | - Elisabeth Digifico
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy; Humanitas University, Via A. Manzoni 113, 20089 Rozzano, Milan, Italy
| | - Akihiro Maeda
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy
| | - Marco Erreni
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy
| | - Alberto Mantovani
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy; Humanitas University, Via A. Manzoni 113, 20089 Rozzano, Milan, Italy
| | - María José Alonso
- Center for Research in Molecular Medicine & Chronic Diseases (CIMUS), University of Santiago de Compostela, 15706 Campus Vida, Santiago de Compostela, Spain; Pharmacy & Pharmaceutical Technology Department, School of Pharmacy, University of Santiago de Compostela, 15705 Campus Vida, Santiago de Compostela, Spain; Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Paola Allavena
- Istituto Clinico Humanitas, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Via A. Manzoni 113, 20089 Rozzano, Milan, Italy
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