Cushing's syndrome with small cell carcinoma of the uterine cervix

Small cell neuroendocrine tumour of the cervix in pregnancy: the importance of multidisciplinary management

A woman in her mid-20s presented with bleeding at 18 weeks gestation from a cervical 'polyp'. Histopathology demonstrated a rare small cell neuroendocrine of the cervix. There were only 18 cases of neuroendocrine tumours of the cervix in and around pregnancy in the literature, so the evidence base for treatment was scarce. She was treated with neoadjuvant chemotherapy, using a regimen used for small cell neuroendocrine tumours of the lung, to allow for fetal lung maturity. Disease initially responded, then progressed and she was delivered at 32 weeks by caesarean radical hysterectomy. Adjuvant treatment included further chemotherapy and radical pelvic radiotherapy. The woman and her child are doing well over 6 years after treatment, although the woman has significant side effects of both radical surgery and radiotherapy. This case emphasises the need for excellent communication between multidisciplinary professionals, patients and their families and using external colleagues to help with rare clinical problems.

Small Cell Neuroendocrine Carcinoma of the Cervix in Pregnancy: A Case Report and Review

Small cell neuroendocrine carcinoma of the cervix is a rare subtype of cervical cancer. Here we report a case in which a 27-year-old female patient presented at 34-week gestation with abnormal vaginal bleeding, underwent normal labor, and gave birth to a healthy neonate. Her pregnancy was complicated with a cervical tumor which turned out to be small cell neuroendocrine cervical carcinoma. We reviewed and discussed the features, diagnosis, and prognosis of small cell neuroendocrine carcinoma of the cervix.

Hormone producing gynecological tumors: pathologic entities and clinical significance

INTRODUCTION

Due to their derivation from the cell types involved in gynecologic hormonal networks, many gynecologic tumors may produce hormones. In a normal physiological setting, these hormones are essential for regulating the biology and function of gynecological organs, the ovary and uterus in particular. Overproduction of hormones by the tumor may lead to abnormal clinical manifestations of the patients and spillage of excess hormonal products into the blood. Abnormal elevation of serum hormones may be considered as biomarkers that are important to pathologists and clinicians in making precise tumor diagnoses and likely useful in monitoring the tumor burden/recurrence to guide patient treatment options. This review will discuss gynecologic neoplasms that produce hormonal biomarkers and assess their relevance to pathological diagnosis, evaluation for therapeutic response and monitoring disease progression.

AREAS COVERED

Studies involving hormonal production by a gynecologic tumor were candidates for inclusion in this review.

EXPERT COMMENTARY

Serum hormonal biomarkers have clinical utility both in the diagnosis of gynecologic neoplasms and clinical monitoring of treatment efficacy and recurrence.

Neuroendrocrine tumors of the uterine cervix: A therapeutic challenge for gynecologic oncologists

Neuroendocrine tumors (NETs) are aggressive diseases developing from neuroendocrine cells that most frequently involve the gastro-entero-pancreatic tract and the lung, but more rarely are found in almost all body tissues. Limited biological and clinical data are currently available for NETs in uncommon sites, such as female genital tract. NETs represent 0.9% to 1.5% of the tumors of the uterine cervix. They are more likely to have lymph-vascular space invasion and lymph node involvement, and to develop local and distant relapses when compared with the mostly common cervical squamous cell carcinomas or adenocarcinomas. Positive immunostaining for synaptophysin, chromogranin, CD56, and neuron-specific enolase is often detected in cervical NETs . The most recent editions of the World Health Organization Classification of Gynecologic Tract tumors grouped cervical carcinoid tumor and atypical carcinoid tumor into low-grade NETs and cervical small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma into high-grade NETs. High-risk HPV DNA is detected in almost all cervical high-grade NETs. No treatment guidelines, based on prospective, well-designed clinical trials, are currently available due to the rarity of these tumors. Many authors have reported different multimodality approaches, mainly derived from NETs of the lung. These usually consist in radical hysterectomy followed by adjuvant chemotherapy or concurrent chemoradiation for early stage disease, definitive concurrent chemoradiation sometimes preceded by neoadjuvant chemotherapy and followed by adjuvant chemotherapy for locally advanced disease, and palliative chemotherapy for metastatic disease. In this systematic review, we address the histologic classification of cervical NETs, analyze their pathogenesis and overall prognosis, and evaluate the different treatment modalities described in the literature, in order to offer a possible algorithm that may help the clinicians in diagnosing and treating patients with these uncommon and aggressive malignancies.

Resident Neuroendocrine Cells in the Normal Ectoendocervical Epithelium

Among the major difficulties in determining the histogenesis of small-cell neuroendocrine carcinomas of the cervix is the issue of identifying the cell from which the neoplasm arises. In this study we performed an immunohistochemical analysis of the neuroendocrine cells in the normal ectoendocervical epithelium by using a microwave heating technique. In ectocervical epithelium, positivity for chromogranin and/or neuron-specific enolase was detected in 18% of the cases, whereas 46% of the endocervical mucosae demonstrated immunoreactive cells for these antibodies. Isolated endocervical neuroendocrine cells showed immunoreactivity for antigastrin (1 case), anti-VIP (3 cases), and antisynaptophysin (14 cases) antibodies. A comparative analysis of 4 diagnosed cases of small-cell carcinoma of the cervix demonstrated immunoreactivity for neuron-specific enolase and chromogranin, respectively, in 3 cases and for synaptophysin in 1 case. Thus, small-cell carcinoma of the cervix likely originates from cells with neuroendocrine differentiation localized mainly in the endocervical glands. These findings offer an explanation for the paraneoplastic syndromes described in some cases of small-cell carcinoma of the cervix.

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

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Utility of [(18)F] fluoro-2-deoxy-D: -glucose positron emission tomography in the localization of ectopic ACTH-secreting tumors

Ectopically ACTH producing tumors may be difficult to localize by conventional radiology and functional imaging may be helpful. Case 1: 31-year-old man was diagnosed with ectopic ACTH-dependent Cushing's syndrome (ECS). Thorax CT revealed a 1.3 cm nodular opacity in upper left lobe, suggestive of residual lesion. [(18)F] fluoro-2-deoxy-D: -glucose ([(18)F] FDG) positron emission tomography ([(18)F] FDG PET) scan revealed mild glycolytic metabolic activity. Pathological examination confirmed an ACTH-positive carcinoid tumor. Case 2: 53-year-old woman presented with very rapid onset ECS. Pituitary MRI was normal. Thorax CT revealed no tumoral lesion. Abdominal and pelvic MRI showed images suggestive of hepatic and iliac, femoral and lumbar secondary implants. [(18)F] FDG PET scan revealed intense uptake in uterus, especially cervix, suggesting this to be the primary tumor site. These cases illustrate the role of [(18)F] FDG PET in the investigation of an ECS where conventional imaging studies were not elucidative in the search for a responsible tumor.

The pathology of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinomas (EPSCCs) are uncommon malignant neoplasms with a reported incidence of 0.1% to 0.4% in the United States. Since their first description in 1930, they have been seen in nearly every organ system. Like their more common pulmonary counterparts, EPSCCs are thought to arise from a multipotential stem cell. However, there is recent molecular evidence that small cell elements may arise as a late-stage phenomenon in the genetic progression of more organ-typical carcinomas. The morphologic, immunohistochemical, and ultrastructural features are similar to those described in pulmonary small cell carcinomas (PSCCs). The differential diagnosis of EPSCC includes PSCC, other neuroendocrine tumors, small round blue cell tumors, metastatic melanoma, lymphoma, and poorly differentiated non-small cell carcinomas. Molecular alterations reported to occur in EPSCCs include abnormalities described in PSCC and changes found in carcinomas more typically encountered in the organ from which they arise. In this article we discuss the pathology of EPSCC with a review of theories of histogenesis, sites of occurrence, diagnostic features, differential diagnosis, molecular alterations, and clinical behavior.

CD56 Reactivity in Small Cell Carcinoma of the Uterine Cervix

Small cell carcinoma (SCC) of the uterine cervix, like its pulmonary counterpart, is a rare but distinctive neoplasm that should be separated from nonendocrine carcinomas because of its highly aggressive clinical course and response to chemotherapy and irradiation. CD56 (neural cell adhesion molecule) has recently been shown to be the best marker for the diagnosis of pulmonary SCC. In this study, we assessed the sensitivity and specificity of CD56 in the diagnosis of SCC of the uterine cervix compared with those of chromogranin and synaptophysin. Twenty-two (88%) of 25 SCCs of the uterine cervix labeled with CD56 in a predominantly membranous and diffuse pattern, whereas 16 of 25 (64%) stained with synaptophysin in a predominantly diffuse pattern and 8 of 25 (32%) showed predominantly focal immunoreactivity for chromogranin. In contrast, 3 of 21 (14%) moderately to poorly differentiated squamous cell carcinomas and 1 of 16 (6%) moderately differentiated adenocarcinomas showed focal immunoreactivity for CD56. Although not specific, CD56 seems to be the most sensitive marker for the diagnosis of SCC of the uterine cervix. Moreover, its diffuse reactivity reduces the possibility of obtaining negative results in small biopsy samples.

Small Cell Neuroendocrine Carcinomas of the Uterine Cervix: A Histological, Immunohistochemical, and Molecular Genetic Study

Small cell carcinomas of the uterine cervix are rare tumors with an aggressive behavior. Although these tumors can exhibit neuroendocrine differentiation, the criteria for neuroendocrine differentiation are subjective and not well defined. In this study, the authors tentatively defined small cell neuroendocrine carcinoma (SCNEC) as a tumor composed of small cells with at least two of the following: argyrophilic cytoplasm, chromogranin A immunoreactivity, and synaptophysin immunoreactivity. We found 10 cases fulfilling these requirements. Five of the 10 tumors were composed mainly of small ("oat") cells and 5 of mainly larger "intermediate" cells. The majority of both subtypes showed an insular pattern. Three of the 10 SCNECs were pure, whereas the other seven were mixed with adenocarcinoma and/or squamous cell carcinoma or cervical intraepithelial neoplasia. In addition to the definitional markers noted earlier, the tumors were immunoreactive for serotonin (6 cases), somatostatin, gastrin, glucagon, and pancreatic polypeptide. No tumors were immunoreactive for cytokeratin 20. Human papillomavirus (HPV)-18 was detected in all of the pure tumors and both the SCNEC and adenocarcinomatous components in four of the mixed tumors. No other types of HPV were detected. The tumors showed a relatively low frequency of loss of heterozygosity for representative tumor suppressor gene sites; p53 mutations were found in only one case.

Ectopic pro-opiomelanocortin syndrome

Ectopic POMC syndrome remains one of the most challenging differential diagnoses in endocrinology. Recent progress in the understanding of the tissue specific regulation of POMC gene expression and new insights into the processing of the POMC peptide in nonpituitary tissues has helped elucidate some of the molecular events leading to ectopic expression and secretion of POMC peptides. Corticotropin and other POMC-derived peptides have diverse effects on adrenal steroidogenesis, growth, and extra-adrenal tissues. Differences in POMC gene regulation in the corticotrope versus ectopic POMC-producing tumors provides a scientific framework for the clinical distinction between eutopic and ectopic Cushing's syndrome. In an attempt to revisit recent basic and clinical advances in the diagnosis of ectopic POMC syndrome the authors undertook an extensive literature review of 530 cases in 197 published papers and provided a molecular biologic, demographic and diagnostic update. According to this review, the four most common causes of ectopic POMC syndrome are the small cell carcinoma of the lung (27%), bronchial carcinoids (21%), islet cell tumor of the pancreas (16%), and thymic carcinoids (10%). Although the clinical features of patients with ectopic POMC syndrome are similar to those with Cushing's disease, subgroup analysis reveals a broad spectrum of severity and progression of signs and symptoms of hypercortisolism. The endocrine workup of a patient with suspected ectopic POMC syndrome includes the establishment of pathologic hypercortisolism, diagnosis of corticotropin dependency, and the differential diagnosis of corticotropin-dependent Cushing's syndrome. The use of a variety of baseline endocrine values, dynamic endocrine testing, and invasive procedures leads to the correct diagnosis in the majority of patients with ectopic POMC syndrome. Diagnostic imaging, including conventional radiological techniques and somatostatin receptor scintigraphy, aids in the correct localization and eventual treatment of ectopic POMC production.

Metastatic cervical carcinoma with ectopic calcitonin production presenting as a thyroid mass

OBJECTIVE

To describe a case of cervical carcinoma metastatic to the thyroid in association with ectopic production of calcitonin.

METHODS

We present the medical history, clinical findings, and laboratory results in a 38-year-old woman with a neck mass, and we discuss the frequency of metastatic involvement of the thyroid.

RESULTS

A 38-year-old woman was referred for evaluation of an enlarging neck mass. She had undergone radical hysterectomy and irradiation for invasive cervical carcinoma 1 year earlier. Laboratory investigation showed only mild anemia, high plasma bicarbonate concentration, increased alkaline phosphatase, and mild hypoalbuminemia. Computed tomography of the abdomen and pelvis disclosed multiple lesions in the liver. Fine-needle aspiration biopsy of the thyroid mass revealed a poorly differentiated carcinoma, which stained negative for thyroglobulin but positive for several neuroendocrine tumor markers. Measurement of serum calcitonin showed a dramatically increased level (5,000 pg/mL). The same histologic and immunochemical profile was found in a liver biopsy specimen and in the original cervical tumor. Metastatic neuroendocrine cervical carcinoma was diagnosed, and the patient died 6 months later despite four cycles of chemotherapy.

CONCLUSION

To the best of our knowledge, this is the first case report of a neuroendocrine cervical carcinoma manifesting as a palpable thyroid mass, associated with ectopic production of calcitonin.

Neuroendocrine small cell carcinoma of the uterine cervix showing polypoid growth and complicated by pregnancy

BACKGROUND

Neuroendocrine small cell carcinoma of the uterine cervix is an aggressive disease, and it rarely is complicated by pregnancy.

CASE

A polypoid tumor was found in the uterine cervix in a 27-year-old Japanese woman at 27 weeks of gestation. No polyp had been detected at 14 weeks of gestation. The polyp was excised and diagnosed as neuroendocrine small cell carcinoma by histological examination, including Grimelius, neuron-specific enolase, and chromogranin staining. A healthy infant was born by cesarean section at 29 weeks of gestation: this was followed by radical hysterectomy with pelvic lymphadenectomy. After surgery, four cycles of combination chemotherapy with cisplatin and etoposide were administered, and the patient is disease-free as of 13 months after surgery.

CONCLUSION

When a polypoid lesion is found, especially when it demonstrates rapid growth, it may be necessary to excise and histologically examine the polyp even during pregnancy.

Carcinoid syndrome caused by an atypical carcinoid of the uterine cervix

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

Endocrine tumors of the cervix: morphologic assessment, expression of human papillomavirus, and evaluation for loss of heterozygosity on 1p,3p, 11q, and 17p

BACKGROUND

Cervical endocrine tumors are rare lesions, with a varied diagnostic nomenclature. A recent consensus meeting proposed a standardized terminology. This study evaluated: 1) applicability of histopathologic guidelines; 2) evidence of loss of heterozygosity (LOH) at selected sites; and 3) the presence of human papillomavirus (HPV) detected by nonisotopic in situ hybridization (ISH).

METHODS

Thirty-eight cases (patient age range, 19-88 years; mean, 48 years) were retrieved. Outcome data were available for 32 patients. Classification was based on architectural and cytologic features. Tissue was available from 15 cases for LOH analysis with D3S1234(3p14), D3S1289(3p21), THRB(3p24), TP53(17p13), D1S468(1p36), and INT-2(11q13). In ten cases, tissue was analyzed by nonisotopic ISH with HPV probes for types 6/11, 16/18, and 31/33.

RESULTS

Tumors were divided into four groups: small cell carcinoma (SCC) (n=25); large cell neuroendocrine carcinoma (LCNC) (n=5); SCC with focal LCNC differentiation (n=3), and carcinoid tumor (n=5). Tumors defined as exclusively or predominantly SCC had a particularly poor prognosis, with 20 patients dead of disease (<6 years after diagnosis) and 6 alive with disease (after <3 years of follow-up). LOH at various 3p loci (3p14, 3p21, and 3p24) was observed in eight cases. One patient demonstrated LOH on 17p(TP53). Eight of ten cases assessed by ISH showed nuclear staining using a combined HPV-16/18 probe.

CONCLUSIONS

Cervical endocrine tumors are highly aggressive and can be subdivided into definable categories. LOH at 3p loci is a frequent finding, as is nuclear staining with a combined HPV-16/18 probe. LOH at 17p(TP53 locus) appears to be relatively uncommon, suggesting that p53 mutations may not be developmentally significant.

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

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

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

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

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

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

Production of immunoreactive atrial natriuretic polypeptide in neuroendocrine tumors

BACKGROUND

Peptide hormone synthesis in neuroendocrine tumors is a well-recognized phenomenon. However, production in neuroendocrine tumors of atrial natriuretic polypeptide (ANP), a newly discovered peptide hormone from the heart, has not been studied extensively.

METHODS

The presence of immunoreactive human ANP (IR-hANP) in neuroendocrine tumors was determined using a specific human ANP radioimmunoassay. Neuroendocrine tumors examined included 9 small cell carcinomas of the uterus, 28 small cell carcinomas of the lung, 20 carcinoid tumors, 54 pancreatic endocrine tumors, 17 neuroblastic tumors, 14 pheochromocytomas, and 14 medullary carcinomas of the thyroid. Twenty atrial tissues also were examined as the control. Molecular size of IR-hANP in the extracts of atrial and tumor tissues was determined by gel chromatography.

RESULTS

IR-hANP was detected in the extracts of small cell carcinoma of the uterus, small cell carcinoma of the lung, and carcinoid tumor, with concentrations ranging from 3.1 to 210 ng/g wet weight tissue. No IR-hANP was detected in the extracts of pancreatic endocrine tumor, neuroblastic tumor, pheochromocytoma, and medullary carcinoma of the thyroid. The frequency of production of IR-hANP in neuroendocrine tumors was highest in small cell carcinoma of the uterus (44%), followed by small cell carcinoma of the lung (18%) and carcinoid tumor (15%). IR-hANP present in the extracts of small cell carcinomas of the uterus had molecular size heterogeneity, with three fragments in addition to alpha-, beta- and gamma-human ANP.

CONCLUSIONS

These results indicate that IR-hANP is produced by neuroendocrine tumors and that the molecular size of IR-hANP in tumor tissues is different from that in atrial tissues.

Small cell carcinoma of the cervix. A clinicopathologic study of 26 patients

BACKGROUND

Small cell carcinoma of the cervix is a rare and aggressive tumor. Most gynecologic oncology centers have little experience with this tumor, and only small series have been published.

METHODS

Twenty-six patients with small cell carcinoma of the uterine cervix were treated at the Norwegian Radium Hospital. Clinical data, immunohistochemical characteristics, and infection with human papillomavirus were studied.

RESULTS

Twelve tumors were of oat cell type and 14 of intermediate cell type. Twelve tumors were associated with other forms of carcinoma: squamous cell carcinoma (6 tumors), adenocarcinoma (5 tumors), and adenocarcinoma in situ (1 tumor). Neuroendocrine differentiation was expressed in 79% of the tumors. Human papillomavirus (HPV)-18 was detected in 40% of the tumors and HPV-16 in 28%. Fifteen patients had Stage I disease, 7 had Stage II, 2 had Stage III, and 3 had Stage IV. Fourteen patients with Stage I and II disease underwent radical hysterectomy with pelvic lymph node dissection. In four, the operation was preceded by intracavitary radiation treatment. The patients with Stage II, III, and IV disease were treated with a combination of intracavitary radium, external beam radiation therapy, and chemotherapy. The 5-year survival rate was 14%. Four patients are alive, one with recurrent disease 50 months after diagnosis. Three patients free of disease have been followed up 26, 54, and 101 months, respectively.

CONCLUSIONS

Small cell carcinoma of the cervix is an aggressive tumor with a propensity for rapid recurrence; it is associated with high mortality.

Reproduction and the APUD system

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

Neuroendocrine carcinoma of the uterus

Neuroendocrine carcinomas of the cervix and endometrium were reviewed. They have been variously designated as carcinoid, argyrophil cell carcinoma, apudoma, small cell carcinoma, oat cell carcinoma, endocrine carcinoma, and neuroendocrine carcinoma, the last-mentioned term being preferred in this chapter. Adenocarcinomas with neuroendocrine cells are occasionally encountered in the cervix and endometrium. It is generally questioned whether they should be included in the spectrum of neuroendocrine carcinomas, although differential diagnosis between some such tumors of the gastrointestinal tract and neuroendocrine carcinoma is reported to be difficult. Since the majority of neuroendocrine carcinomas of the cervix are highly aggressive, it is important to establish the neuroendocrine nature in the cervical carcinomas. In addition to the characteristic histologic features and argyrophil stainability, immunohistochemical demonstration of several neuroendocrine markers may be helpful in diagnosing neuroendocrine carcinoma of the cervix. Ultrastructural demonstration of neurosecretory granules is almost decisive in establishing the tumor's neuroendocrine nature, but it is not applicable in all cases. Neuroendocrine carcinomas of the cervix have been treated by surgery, radiation therapy, and chemotherapy, but optimal treatment methods have not yet been established because of the rarity of the tumor. Finally, we have described a typical neuroendocrine carcinoma of the cervix and reported some data regarding its experimental study.

Extrapulmonary and pulmonary small-cell carcinoma: tumor biology, therapy, and outcome

Extrapulmonary small-cell cancer is a distinct clinicopathological entity from small-cell anaplastic carcinoma of the lung. Approximately 1,000 cases have been projected annually in the United States, which represents an overall incidence of between 0.1% and 0.4% of all cancer. Not surprisingly then, little information is available regarding the treatment of this disease, which presents a challenge to the clinician when it is regionally confined. The majority of patients with extrapulmonary small-cell neoplasms have only been treated with local modalities of therapy, surgery, radiation, or a combination of both. Prolonged survival is not infrequent, which is in contrast to the experience for small-cell lung cancer and surprising given our current systemic approach to patients with this disease. This report will summarize the similarities and differences in biology, natural history, and clinical characteristics of patients with extrapulmonary small-cell cancer and small-cell anaplastic carcinoma of the lung. The histogenesis of small-cell cancer is briefly reviewed. A general therapeutic approach to patients with small-cell lung cancer is reported. Lastly, recommendations for therapy of patients with regionally confined extrapulmonary small-cell cancer by primary site are outlined.

A case of cervical carcinoma of the uterus presenting with hyperosmolar non-ketotic coma as a manifestation of ectopic adrenocorticotropic hormone syndrome

A case of advanced cervical carcinoma of the uterus with ectopic adrenocorticotrophic hormone (ACTH) syndrome is described. The patient was seen for general malaise 21 months after surgical treatment of the primary lesion whose histology was undifferentiated small cell carcinoma of the uterine cervix. She had extensive metastases in the liver and the abdominal wall. In addition to the typical clinical manifestations of Cushing's syndrome such as moon face, central obesity and acne vulgaris, hyperglycemia was so severe that she was in a hyperosmolar non-ketotic coma. Endocrinological examinations revealed elevated plasma ACTH and cortisol, and urinary excretion of 17-hydroxycorticosteroids and 17-ketosteroids, which were not suppressed by high-dose dexamethasone administration. Based on these clinical and laboratory findings, a diagnosis of ectopic ACTH syndrome was made. Among the results of other endocrinological examinations conducted to find the etiological cause of the hyperglycemic coma, which seemed to be unusual for ectopic ACTH syndrome, the plasma somatostatin level was abnormally high. Metastatic tumors in the liver obtained at the time of autopsy contained large amounts of both ACTH and somatostatin, and gel filtration studies revealed that the peptides produced by the tumor had the molecular sizes of the biologically active forms of the respective peptides. These observations suggest possible involvement of the somatostatin in deteriorating glucose intolerance to develop hyperglycemic hyperosmolar non-ketotic coma as a drastic disturbance of metabolism.

An immunohistochemical study of small-cell and poorly differentiated carcinomas of the cervix using neuroendocrine markers

Small-cell and poorly differentiated carcinomas of the cervix were studied immunohistochemically for several neuroendocrine and epithelial markers. Neuroendocrine markers were frequently expressed in small-cell carcinomas with argyrophilia; of the seven such tumors, four were immunoreactive with anti-chromogranin, seven with antineuroendocrine, five with anti-Leu 7, and seven with anti-neuron-specific enolase. Only neuron-specific enolase, however, was expressed in two of the three small-cell carcinomas without argyrophilia. On the other hand, one of the epithelial markers, epithelial membrane antigen, was strongly positive in all three small-cell carcinomas without argyrophilia and all seven poorly differentiated carcinomas, while it was expressed only weakly and focally in all small-cell carcinomas with argyrophilia except in one case. In conclusion, it is suggested that the immunohistochemical demonstration of several neuroendocrine markers may be helpful in diagnosing neuroendocrine carcinoma of the cervix as a supplement to conventional light microscopy, silver staining, and electron microscopy.

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

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

Small cell carcinoma of the uterine cervix

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

Mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina

A mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina in a 32-year-old woman is reported. Special stains showed the argentaffin and argyrophil reactions of the small cell population of this tumor. The small cells also contained serotonin as demonstrated by immunocytochemistry. Electron microscopy revealed characteristic cytoplasmic neurosecretory granules. The large cells were columnar and contained mucin droplets similar to those in Goblet cells in the intestines. The observations suggest that the tumor was mixed intestinal adenocarcinoma-argentaffin carcinoma (malignant carcinoid), which probably arose in aberrant intestinal epithelial cells in the vagina. The patient died with metastases of pure argentaffin carcinoma in 1 year.

Intestinal metaplasia with argentaffin cells in the uterine cervix

Three cases showing focal intestinal metaplasia of the endocervical glands are presented. The intestinal-type epithelium contained absorptive cells, goblet cells and argentaffin cells, and resembled that found in intestinal types of mucinous ovarian tumours. Two of the cases were associated with squamous cell carcinoma-in-situ (CIN III), and both of these also showed borderline glandular malignancy.

Endocrine cells in the female genital tract

Endocrine cells are normal inhabitants of the para-urethral, Bartholin's and endocervical glands and of mesonephric rests. All these cells were characterized as serotonin-storing cells. In the para-urethral and Bartholin's glands, serotonin-containing cells were most often found in the transitional epithelium of excretory ducts. Endocrine cells participated in some pathological conditions. Abundant argentaffin cells were observed among the terminal ductules in chronic bartholinitis and serotonin-storing cells were identified in a peculiar ectocervical epithelium. Numerous serotonin-storing cells were detected in a well-differentiated adenocarcinoma of cervix occurring in a patient with the Peutz-Jeghers syndrome. Argyrophilic cells were present in cases of endometrial carcinomas; a striking feature was the demonstration of gut peptide hormones in an unusual type of endometrial adenocarcinoma. Finally, serotonin-storing cells were a constituent of Brenner tumours. It is suggested that a similar endocrine pattern may be shared by tissues originating from both Müllerian ducts and the urogenital sinus.

Insular carcinoid of ovary associated with malignant mucinous tumors

Ovarian carcinoids are frequently encountered in association with mucinous cysts and occasionally with mucinous cystadenomas. From a series of more than 200 ovarian carcinoids, this report describes 2 cases of insular carcinoid, 1 of which arose in a cystadenoma of borderline malignancy and the other in a mucinous adenocarcinoma. Histogenesis, histologic patterns, and natural history of carcinoid are discussed.

Production of immunoreactive-polypeptide hormones in cervical carcinoma

The levels of immunoreactive-polypeptide hormones were measured in tissue extracts of eight uterine cervical cancers by specific radioimmunoassays. In one case with argyrophil granules, high levels of somatostatin, pancreatic polypeptide, calcitonin, and vasoactive intestinal polypeptide (VIP) were found, ranging from 160 to 880 ng/g tissue. A second argyrophil cancer contained 310 ng/g tissue of somatostatin, and a third contained 1100 ng/g tissue of adrenocorticotropic hormone (ACTH) and 380 ng/g of beta-melanocyte-stimulating hormone (beta-MSH). In addition, of the five nonargyrophil cancers tested, four contained calcitonin, three had VIP, two had either somatostatin or glucagon, and one contained ACTH and beta-MSH; the measured levels of these hormones ranged from 1.4 to 2.3 ng/g tissue. Gel filtration on a Sephadex G-75 column showed that the immunoreactive-polypeptide hormones in the first case were chromatographically similar to the authentic or prehormones. These results indicate that ectopic production of multiple immunoreactive-polypeptide hormones is common not only in argyrophil cell carcinoma, but also in nonargyrophil cell carcinoma of the cervix.