Endocrine tumors of the uterine cervix: incidence, demographics, and survival with comparison to squamous cell carcinoma

State of the art of cervical cancer treatment in rare histologies

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.

Small-cell neuroendocrine carcinoma of the female genital tract: A comprehensive overview

Small-cell neuroendocrine carcinomas (SCNECs) of the female genital tract are rare and aggressive tumors that are characterized by a high rate of recurrence and poor prognosis. They can arise from various sites within the female genital tract, including the cervix, endometrium, ovary, fallopian tube, vagina, and vulva. They are composed of cells with neuroendocrine features, such as the ability to produce and secrete hormones and peptides, and a high mitotic rate. Immunohistochemical staining for neuroendocrine markers, such as chromogranin A, synaptophysin, and CD56, can aid in the diagnosis of these tumors. This article provides an overview of the epidemiology, etiology, and risk factors associated with these tumors, as well as their clinical presentation, cellular characteristics, diagnosis, and finally the current treatment options for SCNECs, including surgery, chemotherapy, and radiation therapy, alone or in combination.

Competing risk nomogram and risk classification system for evaluating overall and cancer-specific survival in neuroendocrine carcinoma of the cervix: a population-based retrospective study

OBJECTIVE

Neuroendocrine carcinoma of the cervix (NECC) is a rare malignancy with poor clinical prognosis due to limited therapeutic options. This study aimed to establish a risk-stratification score and nomogram models to predict prognosis in NECC patients.

METHODS

Data on individuals diagnosed with NECC between 2000 and 2019 were retrieved from the Surveillance Epidemiology and End Results (SEER) database and then randomly classified into training and validation cohorts (7:3). Univariate and multivariate Cox regression analyses evaluated independent indicators of prognosis. Least absolute shrinkage and selection operator (LASSO) regression analysis further assisted in confirming candidate variables. Based on these factors, cancer-specific survival (CSS) and overall survival (OS) nomograms that predict survival over 1, 3, and 5 years were constructed. The receiver operating characteristic (ROC) curve, the concordance index (C-index), and the calibration curve estimated the precision and discriminability of the competing risk nomogram for both cohorts. Finally, we assessed the clinical value of the nomograms using decision curve analysis (DCA).

RESULTS

Data from 2348 patients were obtained from the SEER database. Age, tumor stage, T stage, N stage, chemotherapy, radiotherapy, and surgery predicted OS. Additionally, histological type was another standalone indicator of CSS prognosis. For predicting CSS, the C-index was 0.751 (95% CI 0.731 ~ 0.770) and 0.740 (95% CI 0.710 ~ 0.770) for the training and validation cohorts, respectively. Furthermore, the C-index in OS prediction was 0.757 (95% CI 0.738 ~ 0.776) and 0.747 (95% CI 0.718 ~ 0.776) for both cohorts. The proposed model had an excellent discriminative ability. Good accuracy and discriminability were also demonstrated using the AUC and calibration curves. Additionally, DCA demonstrated the high clinical potential of the nomograms for CSS and OS prediction. We constructed a corresponding risk classification system using nomogram scores. For the whole cohort, the median CSS times for the low-, moderate-, and high-risk groups were 59.3, 19.5, and 7.4 months, respectively.

CONCLUSION

New competing risk nomograms and a risk classification system were successfully developed to predict the 1-, 3-, and 5-year CSS and OS of NECC patients. The models are internally accurate and reliable and may guide clinicians toward better clinical decisions and the development of personalized treatment plans.

Advancements in the Understanding of Small-Cell Neuroendocrine Cervical Cancer: Where We Stand and What Lies Ahead

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.

Integrated mutational landscape analysis of poorly differentiated high-grade neuroendocrine carcinoma of the uterine cervix

High-grade neuroendocrine cervical cancers (NETc) are exceedingly rare, highly aggressive tumors. We analyzed 64 NETc tumor samples by whole-exome sequencing (WES). Human papillomavirus DNA was detected in 65.6% (42/64) of the tumors. Recurrent mutations were identified in PIK3CA, KMT2D/MLL2, K-RAS, ARID1A, NOTCH2, and RPL10. The top mutated genes included RB1, ARID1A, PTEN, KMT2D/MLL2, and WDFY3, a gene not yet implicated in NETc. Somatic CNV analysis identified two copy number gains (3q27.1 and 19q13.12) and five copy number losses (1p36.21/5q31.3/6p22.2/9q21.11/11p15.5). Also, gene fusions affecting the ACLY-CRHR1 and PVT1-MYC genes were identified in one of the eight samples subjected to RNA sequencing. To resolve evolutionary history, multiregion WES in NETc admixed with adenocarcinoma cells was performed (i.e., mixed-NETc). Phylogenetic analysis of mixed-NETc demonstrated that adenocarcinoma and neuroendocrine elements derive from a common precursor with mutations typical of adenocarcinomas. Over one-third (22/64) of NETc demonstrated a mutator phenotype of C > T at CpG consistent with deficiencies in MBD4, a member of the base excision repair (BER) pathway. Mutations in the PI3K/AMPK pathways were identified in 49/64 samples. We used two patient-derived-xenografts (PDX) (i.e., NET19 and NET21) to evaluate the activity of pan-HER (afatinib), PIK3CA (copanlisib), and ATR (elimusertib) inhibitors, alone and in combination. PDXs harboring alterations in the ERBB2/PI3K/AKT/mTOR/ATR pathway were sensitive to afatinib, copanlisib, and elimusertib (P < 0.001 vs. controls). However, combinations of copanlisib/afatinib and copanlisib/elimusertib were significantly more effective in controlling NETc tumor growth. These findings define the genetic landscape of NETc and suggest that a large subset of these highly lethal malignancies might benefit from existing targeted therapies.

Diagnostic Challenges and Long-term Outcomes of Neuroendocrine Carcinoma of the Cervix: A Case Series

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.

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

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

Extrapulmonary Neuroendocrine Carcinomas: Current Management and Future Perspectives

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.

Application of preoperative fluorodeoxyglucose-PET/CT parameters for predicting prognosis of high-grade neuroendocrine cervical cancer

OBJECTIVE

High-grade neuroendocrine cervical cancer (HGNECC) is a rare and aggressive cervical cancer subtype. In this study, we aimed to evaluate the prognostic value of fluorodeoxyglucose-PET/computed tomography (CT) parameters for HGNECC.

MATERIALS AND METHODS

This single-center retrospective study included 29 patients with HGNECC who underwent fluorodeoxyglucose-PET/CT scan followed by surgery between 2006 and 2016.

RESULTS

The median follow-up period was 40 (range, 4-184) months. After surgery, the resection margins were tumor-negative in 28 patients (96.6%), 8 (27.6%) patients had parametrial tumor invasion, and 7 patients (24.1%) tested positive for lymph node metastasis. The tumor recurred in 20 patients (69%) and 18 patients (62.1%) died during the observation period. In the univariate analyses, age and total lesion glycolysis (TLG) were associated with worse disease-free survival (DFS) (age, hazard ratio 1.056, 95% CI 1.014-1.100, P  = 0.009; TLG2.5, hazard ratio 1.003, 95% CI 1-1.006, P  = 0.033; and TLG3.0, hazard ratio 1.003, 95% CI 1-1.006, P  = 0.034). In the multivariate analyses, older age and higher TLG3.0 were identified as independent poor prognostic factors for DFS (age, hazard ratio 1.058, 95% CI 1.014-1.104, P  = 0.009; TLG3.0, hazard ratio 1.004, 95% CI 1-1.007, P  = 0.033), while resection margin involvement was identified as an independent factor to predict poor overall survival (hazard ratio 20.717, 95% CI 1.289-332.964, P  = 0.032).

CONCLUSION

Among the preoperative fluorodeoxyglucose-PET/CT parameters, TLG3.0 may be useful for predicting DFS in patients with HGNECC.

Neuroendocrine carcinoma of the cervix: About a rare case and literature review

INTRODUCTION

Neuroendocrine carcinomas of the uterine cervix are rare carcinomas, accounting for only 0.9-1.5 % of cervical tumors. Given their rarity and the absence of randomized trials, the diagnostic and therapeutic management of these tumors is complicated and is essentially modeled on that of pulmonary neuroendocrine tumors.

PRESENTATION OF CASE

We report a new case of large-cell neuroendocrine carcinoma of the uterine cervix, and review the various aspects of this rare entity.

DISCUSSION

Neuroendocrine carcinoma is a rare and aggressive malignant tumor, It differs from squamous cell carcinoma in its higher recurrence rate and delayed diagnosis. On the other hand, association with human papillomavirus (HPV) 16 and 18 is a common risk factor for both carcinomas.

CONCLUSION

To improve the survival of patients with large-cell neuroendocrine carcinomas of the uterine cervix, it is imperative to conduct multicenter clinical trials aimed at defining an effective, standardized treatment.

Cervical neuroendocrine carcinoma in the third trimester: a rare case report and literature review

BACKGROUND

The incidence of cervical neuroendocrine carcinoma (CNECC) during pregnancy is extremely rare. Insufficient awareness of gynecological tumor screening, as well as atypical and insidious initial clinical symptoms, may result in diagnostic delays and misdiagnosis. There is no standardized treatment for cervical cancer in pregnancy. Herein, we present a case of cervical neuroendocrine carcinoma diagnosed in the third trimester of pregnancy.

CASE PRESENTATION

A 26-year-old female at 30 1/7 weeks of gestation presented with lower back and sacroiliac joint pain, abdominal distension, and lower limb dyskinesia. A pelvic examination revealed a large fungating gray mass that encompassed the entire cervix, with cervical contact bleeding testing positive. Imaging studies showed a significant cervical mass, diffuse liver changes, and metastasis to multiple sites. Biopsy results revealed poorly differentiated cervical carcinoma exhibiting high-grade neuroendocrine features, consistent with a diagnosis of large cell neuroendocrine carcinoma. The patient was diagnosed with stage IVB CNECC with HPV18 (+), and due to the gestational age of the fetus and her deteriorating condition, she underwent cesarean section delivery after receiving fetal lung maturation therapy. Following surgery, eight cycles of neoadjuvant chemotherapy were applied. Unfortunately, she succumbed to multiple tumor metastases six months post-treatment. Despite this tragic outcome, the infant was discharged in a healthy condition.

CONCLUSIONS

CNECC during pregnancy, particularly the large-cell type, is an ultra-rare condition with poor prognosis. This case highlights the importance of individualized treatment approach and the need for better screening, early detection, and treatment. Given the rarity of the disease, further research is warranted to determine the prognostic factors and develop effective treatment strategies for this ultra-rare and aggressive malignancy.

The prognosis of patients with small cell carcinoma of the cervix: a retrospective study of the SEER database and a Chinese multicentre registry

BACKGROUND

Small cell carcinoma of the cervix is a rare but poor prognosis pathological type of cervical cancer, for which advice in clinical guidelines is unspecific. We therefore aimed to investigate the factors and treatment methods that affect the prognosis of patients with small cell carcinoma of the cervix.

METHODS

In this retrospective study, we collected data from the Surveillance, Epidemiology, and End Results (SEER) 18 registries cohort and a Chinese multi-institutional registry. The SEER cohort included females diagnosed with small cell carcinoma of the cervix between Jan 1, 2000, and Dec 31, 2018, whereas the Chinese cohort included women diagnosed between Jun 1, 2006, and April 30, 2022. In both cohorts, eligibility was limited to female patients older than 20 years with a confirmed diagnosis of small cell carcinoma of the cervix. Participants who were lost to follow-up or those for whom small cell carcinoma of the cervix was not the primary malignant tumour were excluded from the multi-institutional registry, and those with an unknown surgery status (in addition to those for whom small cell carcinoma of the cervix was not the primary malignant tumour) were excluded from the SEER data. The primary outcome of this study was overall survival (length of time from the date of first diagnosis until the date of death from any cause, or the last follow-up). Kaplan-Meier analysis, propensity score matching, and Cox-regression analyses were used to assess treatment outcomes and risk factors.

FINDINGS

1288 participants were included in the study; 610 in the SEER cohort and 678 in the Chinese cohort. Both univariable and multivariable Cox regression analysis (SEER hazard ratio [HR] 0·65 [95% CI 0·48-0·88], p=0·0058; China HR 0·53 [0·37-0·76], p=0·0005) showed that surgery was associated with a better prognosis. In subgroup analyses, surgery remained a protective factor for patients with locally advanced disease in both cohorts (SEER HR 0·61 [95% CI 0·39-0·94], p=0·024; China HR 0·59 [0·37-0·95]; p=0·029). Furthermore, the protective effect of surgery was observed among patients with locally advanced disease after propensity score matching in the SEER cohort (HR 0·52 [95% CI 0·32-0·84]; p=0·0077). In the China registry, surgery was associated with better outcomes in patients with stage IB3-IIA2 cancer (HR 0·17 [95% CI 0·05-0·50]; p=0·0015).

INTERPRETATION

This study provides evidence that surgery improves outcomes of patients with small cell carcinoma of the cervix. Although guidelines recommend non-surgical methods as first-line treatment, patients with locally advanced disease or stage IB3-IIA2 cancer might benefit from surgery.

FUNDING

The National Key R&D Program of China and the National Natural Science Foundation of China.

Impacts of ovarian preservation on the prognosis of neuroendocrine cervical carcinoma: a retrospective analysis based on machine learning

BACKGROUND

Neuroendocrine cervical carcinoma (NECC) is a rare but aggressive malignancy with younger patients compared to other common histology types. This study aimed to evaluate the impacts of ovarian preservation (OP) on the prognosis of NECC through machine learning.

METHODS

Between 2013 and 2021, 116 NECC patients with a median age of 46 years received OP or bilateral salpingo-oophorectomy (BSO) and were enrolled in a retrospective analysis with a median follow-up of 41 months. The prognosis was estimated using Kaplan-Meier analysis. Random forest, LASSO, stepwise, and optimum subset prognostic models were constructed in training cohort (randomly selected 70 patients) and tested in 46 patients through receiver operator curves. Risk factors for ovarian metastasis were identified through univariate and multivariate regression analyses. All data processing was carried out in R 4.2.0 software.

RESULTS

Among 116 patients, 30 (25.9%) received OP and showed no significantly different OS compared with BSO group (p = 0.072) and got better DFS (p = 0.038). After construction of machine learning models, the safety of OP was validated in lower prognostic risk group (p > 0.05). In patients ≤ 46 years, no impacts of OP were shown for DFS (p = 0.58) or OS (p = 0.67), and OP had no impact on DFS in different relapse risk population (p > 0.05). In BSO group, regression analyses showed that later stage, para-aortic LNM, and parametrial involvement were associated with ovarian metastasis (p < 0.05).

CONCLUSIONS

Preserving ovaries had no significant impact on prognosis in patients with NECC. OP should be considered cautiously in patients with ovarian metastasis risk factors.

Liquid-based cytology and immunocytochemistry in the evaluation of a vault lesion in a postmenopausal woman

Cytological features of small cell neuroendocrine carcinoma of the cervix in a liquid-based preparation from a vault lesion.

Detection of HPV RNA in Extracellular Vesicles from Neuroendocrine Cervical Cancer Cells

Background: Neuroendocrine carcinoma of the cervix (NECC) is an aggressive and rare type of cervical cancer. The five-year overall survival is low at 30% and there is no standardized therapy based on controlled trials for this type of tumour. Most are locally advanced or metastasized at the time of the diagnosis. Extracellular vesicles (EVs) could be a carrier of viral DNA/RNA, given their vital role in cellular communication. The content of EV derived from NECC cells has not been investigated due to the lack of cell line, and it is not known whether they contain human papillomaviruses (HPV) DNA/RNA or not. Methods: The presence of viral E7 DNA/RNA in EVs purified from a culture of a recently established NECC cell line, GUMC-395, was evaluated by using droplet digital polymerase chain reaction (ddPCR). These EVs were characterized using nanoparticle tracking analysis (NTA) for size distribution, transmission electron microscopy (TEM) for morphology, Western blot for CD63, and bioanalyser for RNA quantity and quality. Results: HPV16 viral-RNA, but not DNA, was detected in EVs from GUMC-395 using ddPCR. NTA identified EVs with a mean diameter of 105.0 nm, TEM confirmed normal morphological shape and size, and Western blot analysis confirmed the presence of EV-associated proteins CD63. The EVs were found to be enriched with small RNAs using a bioanalyser. Conclusions: HPV16 RNA is found in EVs from a neuroendocrine cervical cancer and could be involved in the pathogenesis of the disease and used as a diagnostic biomarker.

Impact of adjuvant chemotherapy on the overall survival of patients with resectable bulky small cell neuroendocrine cervical cancer: a JSGO-JSOG joint study

OBJECTIVE

The aim of this study was to review the clinicopathological characteristics of small cell neuroendocrine cervical cancer (SCNEC) and to identify the optimal treatment.

METHODS

The Japanese Society of Gynecologic Oncology conducted a retrospective cohort study of SCNECs enrolled in the Gynecological Tumor Registry of the Japan Society of Obstetrics and Gynecology between 2004 and 2015. All cases were modified and unified by International Federation of Gynecology and Obstetrics 2008 (Union for International Cancer Control 7th edition).

RESULTS

There were 822 registered patients diagnosed with SCNEC from 2004 to 2015 which comprised 1.1% (822/73,698) of all uterine cervical cancer cases. Rates of lymph-node and distant metastasis were significantly higher in T1b2 (38.9% and 13.7%, respectively) than T1b1 (14.2% and 4.4%, respectively) (p<0.01). In IB2 and T1bN1M0 SCNEC, the 5-year survival rate with surgery followed by chemotherapy was significantly higher than that with surgery followed by radiation therapy/concurrent chemoradiation therapy (p<0.01).

CONCLUSION

SNCEC tumors >4 cm in size had greater rates of lymph-node and distant metastasis when compared with tumors ≤4 cm. Adjuvant chemotherapy, rather than radiotherapy, may improve prognosis after surgery in T1bN1M0 SCNEC.

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

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

Prevalence, Associated Factors, and Survival Outcomes of Small-Cell Neuroendocrine Carcinoma of the Gynecologic Tract: A Large Population-Based Analysis

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.

Ubiquitin C-terminal hydrolase L1 promotes lymph node metastasis in small cell neuroendocrine carcinomas of the cervix

Objective

To screen for specific differentially expressed genes in small cell neuroendocrine carcinoma of the cervix (SCNEC) and to further explore their roles and mechanisms in tumor progression.

Methods

Differentially expressed genes in SCNEC compared with squamous cell carcinoma (SCC) and adenocarcinoma (AC) were screened by microarray and immunohistochemical analyses. The biological functions of the identified genes were examined in a SCNEC cell line using RNA interference and over-expression plasmid-transfection technologies. Co-expression network analysis and immunoprecipitation technology were used to explore the potential mechanisms.

Results

Compared with SCC and AC, UCHL1 (encoding ubiquitin C-terminal hydrolase L1) was identified as a specific differentially expressed gene in SCNEC, which was positively related to lymph node metastasis (LNM). Migration and invasion of SCNEC tumor cells were induced by UCHL1 over-expression and suppressed by UCHL1 down-regulation, as shown by scratch and transwell invasion assays. Co-expression network analysis suggested that Prospero homeobox protein 1 (PROX1) might interact with UCHL1, and in vivo immunoprecipitation and western blots verified that levels of ubiquitinated PROX1 were significantly decreased following UCHL1 overexpression.

Conclusion

UCHL1 is a potential biomarker of LNM in SCNEC. UCHL1 might promote SCNEC cell migration and invasion by reducing PROX1 ubiquitination.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 2 with Recommendations on Psycho-oncology, Rehabilitation, Follow-up, Recurrence, Palliative Therapy and Healthcare Facilities

Aim This is an update of the interdisciplinary S3-guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL), published in March 2021. The work on the updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).

Method The process used to update the 2014 S3-guideline was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or – if evidence was lacking – on the consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which would take account of more recently published literature and the recent appraisal of new evidence.

Recommendations The short version of this guideline consists of recommendations and statements on palliative therapy and follow-up of patients with cervical cancer. The most important aspects included in this updated guideline are the new FIGO classification published in 2018, the radical open surgery approach used to treat cervical cancer up to FIGO stage IB1, and the use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Data from small cell neuroendocrine carcinoma of the cervix: FIGO 2018 staging is more accurate than FIGO 2009

OBJECTIVE

To compare the prognostic value of International Federation of Gynecology and Obstetrics (FIGO) 2009 and 2018 staging systems in surgical patients with small cell neuroendocrine carcinoma of the cervix (SCNEC).

METHODS

We re-staged 64 surgical IB-IIA (FIGO 2009) SCNEC patients according to the FIGO 2018 system and refined stage IIIC of FIGO 2018 based on tumor local invasion. The prognostic factors were analyzed, and the advantages of FIGO 2018 were compared with 2009.

RESULTS

The 5-year overall survival rate (OS) was 78.5% for stage I and 22.2% for stage II (FIGO 2009). In FIGO 2018, there was no difference between stage I and II, and the 5-year OS was 74.1%, 60.2%, and 0% for stage I/II, IIIC1, and IIIC2. After combining stage IIIC with the local invasion stage (T1 was limited to the cervix and vagina; T2 involved the parametrium; T3 involved the pelvic or abdominal cavity), the 5-year OS for stage IIICT1, IIICT2, and IIICT3 was 83.3%, 30.0%, and 0%, respectively.

CONCLUSIONS

For stage II SCNEC patients, FIGO 2009 underestimated the prognosis, while FIGO 2018 was more accurate. For stage IIIC, FIGO 2018 might be more individualized and accurate after combining stage IIIC with tumor local invasion.

Distant organ metastasis patterns and prognosis of neuroendocrine cervical carcinoma: a population-based retrospective study

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.

Prognostic Value of FDG PET/CT in Patients With Neuroendocrine Carcinoma of the Uterine Cervix

PURPOSE

We evaluated the prognostic value of metabolic parameters measured on pretreatment FDG PET/CT in patients with cervical neuroendocrine carcinomas (NECs).

METHODS

A total of 22 patients with cervical NECs who underwent pretreatment FDG PET/CT were retrospectively reviewed. The SUVmax, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the primary lesion were measured. The associations between prognostic factors and progression-free survival (PFS) and overall survival (OS) were investigated using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox proportional hazards model.

RESULTS

Of the 22 patients, 12 developed disease progression, and 5 died during the follow-up period. Univariate analyses revealed that MTV, TLG, and the International Federation of Gynecology and Obstetrics stage were significantly associated with PFS (all P < 0.05), whereas SUVmax did not show a significant correlation with PFS. Kaplan-Meier survival curves revealed that patients with MTV >31.9 cm3 (log-rank, P < 0.001), TLG >154.3 (log-rank, P < 0.001), and higher International Federation of Gynecology and Obstetrics stage (log-rank, P = 0.026) had significantly shorter PFS. In the multivariate analyses, MTV (P = 0.017; hazard ratio [HR], 7.298; 95% confidence interval [CI], 1.427-37.316) and TLG (P = 0.003; HR, 15.175; 95% CI, 2.470-93.244) were independent prognostic factors, whereas for OS, the univariate analysis revealed that only TLG >154.3 showed statistical significance (P = 0.043; HR, 9.821; 95% CI, 1.080-89.290).

CONCLUSIONS

Metabolic tumor volume and TLG on FDG PET/CT were the significant prognostic factors of PFS in patients with cervical NECs. Patients with high MTV and TLG had worse clinical outcomes. In addition, TLG may also be a predictor of OS.

A real-world, population-based study of the trends for incidence and prognosis in high-grade neuroendocrine tumor of cervix

To explore the incidence and prognosis trends for high-grade cervical neuroendocrine tumor (HGCNET) and construct a nomogram to predict prognosis for HGCNET. Annual age-adjusted incidence of HGCNET from 1975 to 2015 was retrieved from the Surveillance, Epidemiology, and End Results program, the linear regression, poisson regression and annual percentage changes were used to assess the incidence trend. Also, trends for relative survival (RS) and overall survival (OS) in HGCNET patients from 1975 to 2015 were evaluated. From 1988 to 1975, 514 HGCNET patients were selected and divided into two cohorts with a ratio of 7:3. Nomogram to predict OS for these patients was constructed and validated. The incidence trend for HGCNET was unchanged in the past four decades (P = 0.734), but the proportion of HGCNET in diagnosed cervical cancer slightly increased from 0.9% in 1975 to 1.9% in 2015 (P < 0.001). The 5-year RS and OS for HGCNET in the study periods decreased steadily (RS: P = 0.009; OS: P = 0.008). Nomogram incorporating age, T stage, lymph-node positive, distant metastasis and surgery was constructed. The C-index of the nomogram was 0.716 (0.680-0.752), which was higher than the FIGO staging system. The incidence of HGCNET remained unchanged in the past four decades but the proportion of HGCNET has slightly increased. Besides, a steadily decreasing survival for HGCNET was observed in the study periods. A nomogram was constructed to better predict prognosis for HGCNET.

The importance of choosing the right strategy to treat small cell carcinoma of the cervix: a comparative analysis of treatments

Background

Standard treatments for small cell carcinoma of the cervix (SCCC) have not been established. In this study, we aimed to estimate the optimal treatment strategy for SCCC.

Methods

This was a multicenter retrospective study. Medical records of patients with pathologically proven SCCC treated between 2003 and 2016 were retrospectively analyzed. Overall survival (OS) was plotted using the Kaplan-Meier method. Log-rank tests and Cox regression analysis were used to assess the differences in survival according to stage, treatment strategy, and chemotherapy regimen.

Results

Data of 78 patients were collected, and after excluding patients without immunohistopathological staining, 65 patients were evaluated. The median age of the included patients was 47 (range: 24–83) years. The numbers of patients with International Federation of Gynecology and Obstetrics (FIGO) 2018 stages I-IIA, IIB-IVA, IVB were 23 (35%), 34 (52%), and 8 (12%), respectively. Of 53 patients who had undergone chemotherapy, 35 and 18 received SCCC and non-SCCC regimens as their first-line chemotherapy regimen, respectively. The 5-year OS for all patients was 49%, while for patients with FIGO stages I-IIA, IIB-IVA, IVB, it was 60, 50, and 0%, respectively. The 5-year OS rates for patients who underwent treatment with SCCC versus non-SCCC regimens were 59 and 13% (p < 0.01), respectively. This trend was pronounced in locally advanced stages. Multivariate analysis showed that FIGO IVB at initial diagnosis was a significant prognostic factor in all patients. Among the 53 patients who received chemotherapy, the SCCC regimen was associated with significantly better 5-year OS in both the uni- and multivariate analyses.

Conclusion

Our results suggest that the application of an SCCC regimen such as EP or IP as first-line chemotherapy for patients with locally advanced SCCC may play a key role in OS. These findings need to be validated in future nationwide, prospective clinical studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08772-x.

Case Report: Circulating Tumor DNA Fraction Analysis Using Ultra-Low-Pass Whole-Genome Sequencing Correlates Response to Chemoradiation and Recurrence in Stage IV Small-Cell Carcinoma of the Cervix - A Longitudinal Study

Neuroendocrine carcinoma of the cervix is a rare and aggressive form of cervical cancer that presents with frequent metastasis at diagnosis and high recurrence rates. Primary treatment is multimodal, which often includes chemotherapy with or without radiation therapy. There are no data available to guide treatment for recurrence, and second-line therapies are extrapolated from small-cell lung carcinoma data. Close monitoring of these patients for recurrence is paramount. Evaluation of circulating tumor DNA (ctDNA) in the peripheral blood is an attractive approach due to its non-invasive nature. Ultra-low-pass whole-genome sequencing (ULP-WGS) can assess tumor burden and response to therapy and predict recurrence; however, data are lacking regarding the role of ULP-WGS in small-cell carcinoma of the cervix. This study demonstrates a patient whose response to chemotherapy and cancer recurrence was accurately monitored by ctDNA analysis using ULP-WGS and confirmed with radiologic imaging findings.

Cytomorphological features of cervical small cell neuroendocrine carcinoma in SurePath™ liquid-based cervical samples

Small cell neuroendocrine carcinoma (SCNEC) of the cervix is a rare, highly aggressive tumour with poor prognosis and high propensity for distant metastases. The cytological features of SCNEC have rarely been described in cervical samples, and to the best of our knowledge, there are no previous reports using SurePath™ liquid-based cytology. In the present report we present the cytomorphological features of histopathologically confirmed cases of cervical SCNEC in SurePath preparations. On cytological examination, all three cases demonstrated variable numbers of tumour cells, ranging from a few dispersed cells and tiny micro-biopsies to large aggregates of small tumour cells with a high nucleus-to-cytoplasmic ratio, stippled chromatin, inconspicuous nucleoli, and scant cytoplasm. Immunocytochemistry for CD56 on the cervical preparation confirmed the diagnosis in one case. The presence of small tumour cells with characteristic stippled/salt-and-pepper type nuclear chromatin were the most consistent cytological features in these cases. Knowledge of these characteristic cytological features can help in suggesting a diagnosis of SCNEC in cervical samples which can then be confirmed by immunocytochemistry.

Neuroendocrine carcinoma of the uterine cervix: 15-year experience from a tertiary care centre in Southern India

Aim:

To analyse the presentation, treatment strategies and outcomes of neuroendocrine carcinoma of cervix treated with multi-modality approach at our institute.

Materials and methods:

The data of patients diagnosed to have cervical cancer between October 2004 and November 2018 were retrieved, and 14 patients of neuroendocrine carcinoma cervix who received treatment in our institution were identified. The patients were analysed based on demographic characteristics, disease stage, pathological characteristics, treatment and follow-up. The median overall survival and disease-free survival were calculated.

Results:

Median follow-up period was 8 months (range 1–52 months). Six patients died within 4 months of completion of treatment due to disease progression. Median overall survival was 12 months and median disease-free interval was 5·5 months. Four of the patients who underwent combined modality treatment consisting of neoadjuvant chemotherapy, concurrent chemoradiation therapy and brachytherapy are still on regular follow-up and are disease-free.

Conclusion:

Neuroendocrine carcinoma of the cervix is a rare but aggressive histological subtype. Combined modality approach with judicious use of systemic chemotherapy along with surgery and radiation therapy is essential for optimal outcomes.

Pitfalls and challenges in managing neuroendocrine carcinoma of gynecological origin: A case series and brief review

Due to gynecologic tract (gNET) rarity, gynecologists may not have a strong index of suspicion for which to diagnose these tumors ultimately causing misdiagnoses and potential mismanagement. Gynecologists should be wary of diagnostic pitfalls.

The puzzle of gynecologic neuroendocrine carcinomas: State of the art and future directions

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.

Expanding Our Impact in Cervical Cancer Treatment: Novel Immunotherapies, Radiation Innovations, and Consideration of Rare Histologies

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.

Trends and predictors of survival for small cell carcinoma of the cervix uteri: A SEER population study

OBJECTIVE

Small cell carcinoma of the cervix uteri (SCCC) is an uncommon cancer associated with unsatisfactory survival outcomes. We aimed to investigate the incidence and prognostic factors of survival in SCCC patients using the Surveillance, Epidemiology, and End Results database.

METHODS

Eligible patients with histopathologic diagnoses of SCCC were identified between 2004 and 2015. Overall survival (OS) and cause-specific survival (CSS) for the included patients were calculated using the Kaplan-Meier method. Univariate and multivariate analyses of clinical factors were performed using Cox proportional hazard regression models.

RESULTS

We identified 272 SCCC patients based on predefined criteria. The average incidence of SCCC was 1.01 % per year between 2004 and 2015. The median OS and CSS were 17.0 and 19.0 months, respectively, accompanying with 5-year OS rate was 26.3 % and 5-year CSS rate was 30.1 %. In the multivariate analysis, advanced age (age ≥ 65 years old), late FIGO stage, surgery at the primary site, radiotherapy (RT) and chemotherapy (CT) were strong prognostic factors for OS. The corresponding variables for CSS were: advanced age, late FIGO stage, RT and CT. In the subgroup analysis for nonsurgical management of SCCC, the combination of RT and CT provided the best survival outcomes when compared with other therapeutic modalities. Again, advanced age was interrelated to worse survival outcomes for both OS and CSS.

CONCLUSIONS

SCCC is an infrequent disease with aggressive nature, which lead to poor survival outcomes. In addition to other known parameters, advanced age is a strong predictive factor for OS and CSS. The combination of RT and CT was the best therapeutic strategy for patients who received nonsurgical management.

Evaluation of PARP and PDL-1 as potential therapeutic targets for women with high-grade neuroendocrine carcinomas of the cervix

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.

Comparative genomics of high grade neuroendocrine carcinoma of the cervix

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.

Updates and management algorithm for neuroendocrine tumors of the uterine cervix

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.

Postoperative adjuvant radiation improves local control in surgically treated FIGO stage I-II small cell carcinoma of the cervix

Objective

To determine the prognostic effect of adjuvant radiation and clinicopathological variables in surgically treated patients with small cell carcinoma of the cervix (SCCC).

Methods

Clinical data of SCCC patients with International Federation of Gynaecology and Obstetrics (FIGO) stage I-II underwent radical surgery from May 2000 to August 2014 at Sun Yat-sen Memorial Hospital were retrospectively reviewed. Forty-three patients with SCCC were included to this study. Chi-square test or Fisher’s exact test, Student’s t test or Mann–Whitney U test, Kaplan–Meier method and multivariate analysis of Cox proportional hazards regression were used for statistical analysis. P < 0.05 was considered to be statistically significant.

Results

Among 43 patients (median age, 49 years old) recruited, 25(58.1%) had stage I, 18(41.9%) had stage II disease. The 5-year overall survival (OS) rate was 39.54%, and the 5-year disease free survival (DFS) was 27.91%. Distant metastasis was the main cause of treatment failure (71.9%). Patients with adjuvant chemoradiation displayed lower rate of local recurrence than those with adjuvant chemotherapy (10.7% vs 60.0%, P < 0.0001). Multivariable analysis identified lymph node metastasis as a significant prognostic factor for both DFS and OS (P = 0.001, 0.004 respectively). Age was also an independent predictor of OS (P = 0.004). Adjuvant radiation appeared to significantly improve DFS (HR = 0.383, 95% CI, 0.185–0.791), but not OS.

Conclusions

Adjuvant radiotherapy could improve the local control and prolong DFS in surgically treated SCCC. However, a large prospective clinical trial is needed to confirm this.

A multi-center retrospective study of neuroendocrine tumors of the uterine cervix: Prognosis according to the new 2018 staging system, comparing outcomes for different chemotherapeutic regimens and histopathological subtypes

OBJECTIVE

To analyze the clinical behavior of neuroendocrine tumors (NETs) of the uterine cervix, we conducted a multicenter, retrospective study of 193 patients.

METHODS

We evaluated the prognosis of NETs according to the new International Federation of Gynecology and Obstetrics (FIGO) staging system, compared the clinical response to different chemotherapy regimens, and compared different histological subtypes of NETS.

RESULTS

Diagnoses of the subjects were atypical carcinoid tumor (ACT, n = 37), small cell neuroendocrine carcinoma (SCNEC, n = 126), large cell neuroendocrine carcinoma (LCNEC, n = 22), and NET, not elsewhere classified (n = 8), according to central pathological review. According to FIGO 2018, 69, 17, 74, and 33 patients were at stage I, II, III, or IV, respectively. Five-year survival was 64.5%, 50.1%, 30.2%, and 3.4% for patients at stage I, II, III and IV. About 40% of patients with stage IIIC1 survived >5 years. On multivariate analyses, locally-advanced disease, para-aortic node metastasis, distant metastasis, and <4 cycles of chemotherapy were associated with poor survival. Histological subtype and pelvic node metastasis had no prognostic significance. Response rates to etoposide-platinum (EP) or irinotecan-platinum (CPT-P) regimens were 43.8% (28/64), but only 12.9% to a taxane-platinum (TC) regimen (4/31). The response rate for ACT was 8.7% (2/23), significantly less than the 36.6% for high-grade neuroendocrine carcinomas (HGNEC: both SCNEC and LCNEC, 41/111).

CONCLUSIONS

Locally-advanced, extra-pelvic disease and insufficient chemotherapy were independent prognostic factors for cervical NET. HGNEC showed good responses to EP or CPT-P but not TC. Chemotherapy was less effective for ACT, which had a prognosis identical to HGNEC.

Small cell carcinoma of the uterine cervix during pregnancy

Small cell carcinoma of the uterine cervix is a rare histological entity that has a poor prognosis. We report the case of a patient with small cell carcinoma of the uterine cervix who underwent a radical hysterectomy during pregnancy. A 33-year-old Japanese woman with genital bleeding was referred at 15 weeks' gestation. A speculum exam revealed a 5.4-cm-dia. mass in the cervix, and a cervical biopsy revealed small cell carcinoma of the uterine cervix. Imaging studies demonstrated a tumor confined to the cervix, swelling of intra-pelvic lymph nodes, and no distant spread of the tumor. She was diagnosed as having small cell carcinoma of the uterine cervix, stage IB2, and underwent a radical hysterectomy with pelvic lymphadenectomy. She refused any adjuvant therapies, had a systemic relapse 4 months after surgery, and died of the disease 5 months after surgery. Early-stage small cell carcinoma of the uterine cervix should be treated with a definitive therapy soon after diagnosis whether the patient is pregnant or not. Saving the mother's life should be the top priority.

Clinical comparison between neuroendocrine and endometrioid type carcinoma of the uterine corpus

OBJECTIVE

To compare the clinicopathologic features and survival outcomes of neuroendocrine tumor of the uterine corpus (NET-U) to endometrioid type endometrial carcinoma (EC).

METHODS

From 1993 to 2012, the Surveillance, Epidemiology and End Results cancer registry was queried for women diagnosed with EC or NET-U. Data regarding stage, grade, presence of extra-uterine disease, lymph node metastasis, receipt of adjuvant radiation, surgical intervention and overall survival (OS) was extracted. Chi-square tests, t-tests and Kaplan Meir curves were used for statistical analysis.

RESULTS

A total of 98,363 patients were identified: 98,245 with EC and 118 with NET-U. The mean age at diagnosis for EC was 61.7 years and 64.8 years for NET-U (p=0.01). NET-U cases were more likely to be poorly differentiated (97.0% vs. 15.6%; p≤0.01) and have nodal metastasis (56.4% vs. 11.1%; p≤0.01) when compared to EC. Presence of extrapelvic disease at the time of diagnosis was observed more frequently in NET-U compared to EC, 49.1% vs. 4.8%, respectively (odds ratio=18; 95% confidence interval=13.1-27.2; p≤0.01). Significant improvement in OS was observed in NET-U patient who received radiation (OS: 7.7 vs. 3.3 years; p≤0.01) or underwent surgical management (5.6 vs. 0.9 years; p≤0.01). The OS for EC was 14.4 vs. 4.6 years for NET-U (p≤0.01).

CONCLUSION

NET-U represents an aggressive form of uterine malignancy. When compared to EC, patients with NET-U present at more advanced stage, have more frequent extra-uterine disease and lower OS.

Brachytherapy and survival in small cell cancer of the cervix and uterus

PURPOSE

Small cell cancer involving the cervix and uterus is considered the same rare disease, but management is controversial and disparate. Patterns of care and outcomes in the United States are unclear.

METHODS AND MATERIALS

Clinical data from patients with small cell cancer of the cervix and uterus were abstracted from the National Cancer Database from 2004 to 2014. Patients with missing clinical stage, incomplete followup, or receiving treatment >90 days from diagnosis were excluded.

RESULTS

There were 621 cervical and 95 uterine patients with cancer treated from 2004 to 2014. Compared to patients with a cervix primary site, patients with a uterine primary site were older (median age 64 years vs. 47 years), more likely to present with distant metastatic disease (47% vs. 33%), less likely to receive any pelvic radiation (31% vs. 64%), less likely to receive brachytherapy (3% vs. 27%), more likely to have at least a total hysterectomy (58% vs. 28%), and less likely to receive chemotherapy (74% vs. 88%), all p < 0.05. Brachytherapy was associated with improved overall survival (OS) for patients with locally advanced cervical small cell carcinoma (II-IVA, p = 0.03), but only 38% of patients with Stage II-IVA disease received brachytherapy. For the uterine site, hysterectomy (p = 0.001) and external irradiation (p = 0.03) were associated with improved OS in unadjusted Kaplan-Meier analysis, but only chemotherapy and stage were significantly associated with higher OS in multivariable analysis.

CONCLUSIONS

Brachytherapy may improve OS for Stage II-IVA small cell cancer of the cervix but appears underutilized. Brachytherapy was not commonly delivered for uterine primaries.

Large cell neuroendocrine carcinoma of the uterine cervix

We report a case of large cell neuroendocrine carcinoma of the uterine cervix. A 33-year-old woman presented with a 4-month history of irregular vaginal bleeding and suspicious cervix. Transvaginal ultrasound showed a 3×3.8 cm cervical mass with a marked increase in the blood flow. MRI pelvis showed an exophytic tumour with left external iliac lymph node metastasis. Immunohistochemistry of the tumour cells showed strong positivity for the neuroendocrine markers synaptophysin and a very high Ki67 proliferation index. A diagnosis of high-grade large cell neuroendocrine carcinoma of the uterine cervix was made with FIGO stage IIA2. She was treated with chemotherapy and palliative radiotherapy but died 21 months after presenting. Neuroendocrine tumour of the uterine cervix is an extremely aggressive cancer with the late presentation-the need for a more rigorous treatment protocol as well as potential screening methods could improve outcomes for these patients.

The clinicopathological features and treatment modalities associated with survival of neuroendocrine cervical carcinoma in a Chinese population

Background

Neuroendocrine cervical carcinoma (NECC) is a rare but aggressive form of cervical cancer representing less than 3% of all cervical cancer cases. The objective of this study is to evaluate the effects of the clinicopathologic features and treatment modalities on the survival of patients with NECC.

Methods

In all, 89 stage I-IV patients with NECC that were diagnosed and treated between 2006 and 2014 at the Zhejiang Cancer Hospital were retrospectively recruited in this study. The Kaplan-Meier method, Cox regression analysis models and the log-rank test were used for the statistical analyses.

Results

NECC patients with advanced FIGO stage, tumor size > 4 cm, lymph node metastasis (LNM) and lymph-vascular space invasion (LVSI) were more likely to have significantly worse survival. Neither neo-adjuvant chemotherapy (NACT) nor radiotherapy (RT) was associated with improved overall survival. In the stratified analysis of stage I-IIA patients, those with advanced FIGO stage (P = 0.018), LNM (P = 0.008) and LVSI (P = 0.024) were associated with significantly worse survival. Patients without LNM who did not receive RT had significantly better survival rates than those who received RT (HR = 3.363, 95%CI = 1.245–10.619; P = 0.018). Moreover, for stage I-IIA patients with tumor size > 4 cm, NACT was not associated with a significantly better survival rate compared with no NACT (P = 0.600). None of the clinicopathologic features or treatment modalities was an independent prognostic factor in the multivariate analysis.

Conclusions

In conclusion, advanced FIGO stage, tumor size > 4 cm, LNM and LVSI were associated with poor survival. For stage I-IIA patients, RT should be carefully used in patients who are negative for LNM, and NACT may not be the optimal treatment for patients with tumor size > 4 cm.

Imaging and staging of neuroendocrine cervical cancer

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.

A clinical analysis of small-cell neuroendocrine carcinoma of the gynecologic tract: report of 20 cases

OBJECTIVE

The aim of this retrospective observational study was to analyze the clinical and pathological characteristics of small-cell neuroendocrine carcinoma of the gynecologic tract (SCNCGT).

METHODS

Twenty patients with SCNCGT were enrolled and their clinic-pathological features were analyzed. All patients were treated at the Beijing Obstetrics and Gynecology Hospital, Capital Medical University, China, and were followed up until December 31, 2017.

RESULTS

(1) Patient characteristics: The incidence of SCNCGT was 0.3% (20/6578) of gynecologic cancer in our hospital from January 1, 2007, to December 31, 2017. The average age of the patients was 42.0 ± 11.8 (23-63 years). Out of 20 patients enrolled, seven (35.0%) had lymph node metastasis. Out of 17 patients treated with complete surgery, 14 (82.4%) had lymph-vascular space invasion. (2) Treatment: Eleven out of the 14 patients with small-cell neuroendocrine carcinoma of the cervix (SCNCC) were treated with radical surgery; all the 11 patients received chemotherapy and radiotherapy postoperatively. The remaining three patients received comprehensive chemotherapy and/or radiotherapy instead of radical surgery. The six patients who had one or the other type of SCNCGT (involving the ovary, endometrium, or vagina) were all treated with comprehensive surgery. (3) Prognosis: The follow-up time for the study ranged from 8 to 87 months. Three (15.0%) of the 20 patients were diagnosed with distant metastasis at the beginning of the study. Eight (40.0%) patients died as of December 31, 2017, while the other 12 patients were in follow-up. The average survival time was 43.6 months (16-77 months).

CONCLUSION

SCNCGT is a highly malignant tumor characterized by rare morbidity, a propensity for metastasis, and poor prognosis. Comprehensive treatment may be a good approach to prolong survival in some patients.

Coexisting squamous cell carcinoma and high-grade neuroendocrine carcinoma, small cell type: a rare collision in cervix

Collision tumours of the uterine cervix are extremely uncommon with exact incidence not known. Unlike squamous cell carcinoma (SCC) and adenocarcinoma that are known to coexist, small cell neuroendocrine carcinoma (SCNEC) is rarely documented with other histological types in the cervix. We report such rare case of a collision tumour in cervix displaying dual histological component of SCNEC and SCC in a 36-year-old woman. The case is being presented because of its rarity and represents a unique and hitherto seldom-reported combination of two malignant tumours with distinct and often contrasting epidemiology, histology and prognosis coexisting in the same patient.