Prognostic factors and treatment of neuroendocrine tumors of the uterine cervix based on the FIGO 2018 staging system: a single-institution study of 172 patients

Prognostic model for survival in patients with neuroendocrine carcinomas of the cervix: SEER database analysis and a single-center retrospective study

OBJECTIVE

Neuroendocrine carcinoma of the cervix (NECC) is extremely rare in clinical practice. This study aimed to methodologically analyze the clinicopathological factors associated with NECC patients and to develop a validated survival prediction model.

METHODS

A total of 535 patients diagnosed with NECC between 2004 and 2016 were identified from the Surveillance, Epidemiology and End Results (SEER) database, while 122 patients diagnosed with NECC at Yunnan Cancer Hospital (YCH) from 2006 to 2019 were also recruited. Patients from the SEER database were divided into a training cohort (n = 376) and a validation cohort (n = 159) in a 7:3 ratio for the construction and internal validation of the nomogram. External validation was performed in a cohort at YCH. The Kaplan-Meier method was used for survival analysis, the Log-rank method test was used for univariate analysis of prognostic influences, and the Cox regression model was used for multivariate analysis.

RESULTS

The 3-year and 5-year overall survival (OS) rates for patients with NECC in SEER were 43.6% and 39.7%, respectively. In the training cohort, multivariate analysis showed independent prognostic factors for NECC patients including race, tumor size, distant metastasis, stage, and chemotherapy (p<0.05). For extended application in other cohorts, a nomogram including four factors without race was subsequently created. The consistency index (C-index) of the nomogram predicting survival was 0.736, which was well-validated in the validation cohorts (0.746 for the internal validation cohort and 0.765 for the external validation cohort). In both the training and validation cohorts, the 3-year survival rates predicted by the nomogram were comparable to the actual ones. We then succeeded in dividing patients with NECC into high- and low-risk groups concerning OS using the nomogram we developed. Besides, univariate analysis showed that chemotherapy ≥4 cycles may improve the OS of patients at YCH with NECC.

CONCLUSION

We successfully constructed a nomogram that precisely predicts the OS for patients with NECC based on the SEER database and a large single-center retrospective cohort. The visualized and practical model can distinguish high-risk patients for recurrence and death who may benefit from clinical trials of boost therapy effectively. We also found that patients who received more than 4 cycles of chemotherapy acquired survival benefits than those who received less than 4 cycles.

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.

PD-L1 expression and prognosis in definitive radiotherapy patients with neuroendocrine cervical carcinoma

Background

Neuroendocrine carcinoma of the cervix (NECC) is more prone to lymphatic infiltration, lymph node involvement, local recurrence, and distant metastasis. Using concurrent chemoradiotherapy (CCRT) with or without adjuvant chemotherapy as the standard treatment for locally advanced NECCs and CCRT for patients with early lesions confined to the cervix. However, the prognosis of NECC patients treated with definitive radiotherapy (RT) is unknown. Immune checkpoint inhibitors are a promising therapeutic strategy for locally advanced cervical cancer. Some reports suggest that the expression of PD-L1 in solid tumors correlates with prognosis.

Aim

This study investigates prognostic factors for survival in patients with neuroendocrine cervical carcinoma (NECC) treated with definitive RT and the relationship between PD-L1 expression and prognosis in these patients.

Methods

This retrospective study included 66 patients with histologically confirmed NECC who received RT with or without chemotherapy. From January 2015 to December 2020, patients received routine extended-field irradiation (EFI), and PD-L1 expression was assessed by immunohistochemistry. The most commonly used chemotherapy agents were etoposide-platinum and paclitaxel-platinum.

Results

PD-L1 expression was positive in 17 of 45 (37.8%) patients. There were 52 cases of pure NECC and 14 cases of mixed carcinoma. Sixty stage IB-III patients received definitive RT. The 3- and 5-year progression-free survival (PFS) was 39.8% and 34.1%, and 3- and 5-year overall survival (OS) was 48.0% and 40.2%, respectively. There was no significant difference in 3 and 5-year PFS and 3 and 5-year OS between patients with pure and mixed carcinoma. Positive PD-L1 expression was associated with higher 3-year PFS in patients with mixed histology. Univariate analysis showed that lymph node metastasis (LNM) and the International Federation of Gynecology and Obstetrics stages predicted 3- and 5-year PFS in patients who received definitive RT. The median OS in patients receiving less than four cycles and at least four cycles of chemotherapy (CT) was 26.0 and 44.0 months, respectively (P = 0.038); moreover, 3- and 5-year PFS was 34.1% and 25.7% in the former and 46.4% and 40.4% in the latter. There were no significant differences in OS and PFS between pelvic irradiation and prophylactic EFI in patients treated with definitive RT. There were no significant differences in para-aortic failure rate after concurrent chemoradiotherapy between patients who underwent pelvic irradiation or prophylactic EFI (P = 0.147).

Conclusion

In patients with mixed NECC, positive PD-L1 expression is correlated with higher 3-year PFS. Chemoradiotherapy was effective for NECCs. The LNM and stage predicted PFS. Four or more cycles of chemotherapy improve prognosis. Prophylactic EFI did not significantly improve PFS and OS.

Relevance for Patients

This study is relevant to patients as it confirms that chemoradiotherapy is effective for both early and locally advanced NECC and that four or more cycles of chemotherapy improved prognosis. The regimen should be carefully evaluated to ensure that patients receive the most effective radiation therapy for the prophylactic of para-aortic LNM. Potential risk factors for the recurrence of radical radiotherapy should be fully understood to minimize these risks. This study observed that PD-L1 expression positive in patients with mixed NECC types is correlated with higher 3-year PFS.

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.

Prognostic value of apparent diffusion coefficient in neuroendocrine carcinomas of the uterine cervix

Objectives

This research was designed to examine the associations between the apparent diffusion coefficient (ADC) values and clinicopathological parameters, and to explore the prognostic value of ADC values in predicting the International Federation of Gynecology and Obstetrics (FIGO) stage and outcome of patients suffering from neuroendocrine carcinomas of the uterine cervix (NECCs).

Methods

This retrospective study included 83 patients with NECCs, who had undergone pre-treatment magnetic resonance imaging (MRI) between November 2002 and June 2019. The median follow-up period was 50.7 months. Regions of interest (ROIs) were drawn manually by two radiologists. ADC values in the lesions were calculated using the Functool software. These values were compared between different clinicopathological parameters groups. The Kaplan–Meier approach was adopted to forecast survival rates. Prognostic factors were decided by the Cox regression method.

Results

In the cohort of 83 patients, nine, 42, 23, and nine patients were in stage I, II, III, and IV, respectively. ADCmean, ADCmax, and ADCmin were greatly lower in stage IIB–IVB than in stage I–IIA tumours, as well as in tumours measuring ≥ 4 cm than in those < 4 cm. ADCmean, FIGO stage, and age at dianosis were independent prognostic variables for the 5-year overall survival (OS). ADCmin, FIGO stage, age at diagnosis and para-aortic lymph node metastasis were independent prognostic variables for the 5-year progression-free survival (PFS) in multivariate analysis. For surgically treated patients (n = 45), ADCmax was an independent prognostic parameter for both 5-year OS and 5-year PFS.

Conclusions

ADCmean, ADCmin, and ADCmax are independent prognostic factors for NECCs. ADC analysis could be useful in predicting the survival outcomes in patients with NECCs.

Exploring a Better Adjuvant Treatment for Surgically Treated High-Grade Neuroendocrine Carcinoma of the Cervix

OBJECTIVES

The objective of this study was to explore a better adjuvant treatment for patients with high-grade (HG) neuroendocrine cervical carcinomas (NECC) who had undergone surgery as a primary treatment.

DESIGN

A retrospective cohort study, which involved women diagnosed as HG-NECC, was conducted in the Obstetrics and Gynecology Hospital of Fudan University. All patients had undergone radical surgery and pelvic lymphadenectomy with a laparotomy or a minimally invasive surgery. An analysis was made of the prognosis of HG-NECC.

METHODS

Overall survival (OS) and progression-free survival (PFS) curves were drawn using the Kaplan-Meier method to be compared via log-rank tests. A Cox proportional hazards model was used to estimate the independent prognostic factors.

RESULTS

A number of 110 patients diagnosed as HG-NECC at the pathological stage IA2 to IIIC2 according to the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system were initially treated with a primary surgery between 2008 and 2020. The eligible patients had the median age of 42.5 years (range: 22-76), with the median follow-up period of 39.6 months (range: 1.0-156.6). The 5-year OS of the patients at pathological stage I, II, and III accounted for 84.9%, 85.7%, and 60.9%, respectively. The Kaplan-Meier survival curves revealed no significant differences in OS and PFS between postoperative chemoradiotherapy and chemotherapy alone (OS: p = 0.77; PFS: p = 0.41). Etoposide plus platinum therapy did not improve OS when compared with platinum plus paclitaxel therapy after surgery (p = 0.71). The univariable analysis showed that chemotherapy with cycles ≥4 presented a better prognosis than with cycles <4 (OS: p = 0.01; HR = 6.71; PFS: p = 0.02; HR = 5.18). The multivariate analysis indicated that the cycles of chemotherapy (p = 0.02; HR 0.29) were a prognostic factor for PFS.

LIMITATIONS

A retrospective design and the absence of partial follow-up data are limitations of the study.

CONCLUSIONS

In initially surgically treated HG-NECC, postoperative chemotherapy alone showed no inferiority when compared with chemoradiotherapy for HG-NECC, and 4+ cycles of chemotherapy tended to produce a better prognosis than 4-ones.

Positive clinical outcomes following therapy with programmed cell death protein 1/programmed cell death ligand 1 inhibitors in neuroendocrine carcinoma of the cervix

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.

Neuroendocrine Neoplasms of the Gynecologic Tract

Simple Summary

Neuroendocrine refers to the cells that synthesize and secrete messenger chemicals such as neuropeptides and amines. Neuroendocrine neoplasms (NENs) are aggressive tumors arising from neuroendocrine cells, with an annual incidence of 6.98/100,000 and a prevalence of 170,000 in the United States. Primary gynecologic NENs constitute ≤2% of female reproductive tumors. NENs of the gynecologic tract are associated with high recurrence rates and dismal prognosis, making their treatment challenging. This article focuses on the updated staging classifications, clinicopathological characteristics, imaging, and management of NENs of the gynecological tract.

Abstract

Gynecological tract neuroendocrine neoplasms (NEN) are rare, aggressive tumors from endocrine cells derived from the neuroectoderm, neural crest, and endoderm. The primary gynecologic NENs constitute 2% of gynecologic malignancies, and the cervix is the most common site of NEN in the gynecologic tract. The updated WHO classification of gynecologic NEN is based on the Ki-67 index, mitotic index, and tumor characteristics such as necrosis, and brings more uniformity in the terminology of NENs like other disease sites. Imaging plays a crucial role in the staging, triaging, restaging, and surveillance of NENs. The expression of the somatostatin receptors on the surface of neuroendocrine cells forms the basis of increasing evaluation with functional imaging modalities using traditional and new tracers, including ⁶⁸Ga-DOTA-Somatostatin Analog-PET/CT. Management of NENs involves a multidisciplinary approach. New targeted therapies could improve the paradigm of care for these rare malignancies. This article focuses on the updated staging classifications, clinicopathological characteristics, imaging, and management of gynecologic NENs of the cervix, ovary, endometrium, vagina, and vulva, emphasizing the relatively common cervical neuroendocrine carcinomas among these entities.