[Positron emission tomography in the management of cervix cancer patients]

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.

[Neuroendocrine carcinoma of the cervix: a case report and review of the literature]

Small cell neuroendocrine carcinomas of the gynecologic tract are unusual, accounting for only 2% of the cervical cancers. Given the rarity of these tumors and the absence of randomized trials, their diagnosis and treatment programmes are difficult and are essentially based on those of neuroendocrine tumors of the lung. As in the case of the neuroendocrine tumors of the lung and despite multimodal treatment they are associated with a poor prognosis. We here report a new case of small cell neuroendocrine carcinoma of the cervix and, throught a literature review, we highlight the various aspects of this rare entity.

Para-aortic workup in locally advanced cervical cancer: heterogeneity is still the rule. Results from a retrospective multicenter study

PURPOSE

We retrospectively studied the different strategies of para-aortic (PA) staging of patients with PA involvement in locally advanced cervical cancer as conducted in eight centers in France and their impact upon survival and management.

METHODS

All patients enrolled in this multicenter study presented with cervical cancer with PA involvement. The diagnosis of PA spread was based on imaging assessment of the PA area and/or pathological examination of harvested PA lymph nodes when staging lymphadenectomy was performed. Imaging modalities comprised positron emission tomography (PET), magnetic resonance imaging and/or computed tomography. Survival outcomes were evaluated retrospectively.

RESULTS

One hundred and fifteen women were retrospectively studied. Radiological staging was conducted in 101 (87.8 %) patients. PET was performed in 66 patients (57.4 %). Its FN rate was 22.7 % (15/66) and its sensitivity 77.3 %. Para-aortic lymphadenectomy was conducted in a large proportion of patients (67.8 %). Its indications were not restricted to negative radiological workup. The lymphadenectomy rate was significantly higher in patients with earlier stages (p = 0.02) and lower tumor volume (p = 0.01). Treatment consisted of chemoradiation therapy with extended-field radiotherapy in all patients, followed by intracavitary brachytherapy in 94 cases (81.7 %) and completion surgery in 69 cases (60 %). Patients without para-aortic metastasis on radiological examination were more likely to receive all treatment modalities (p = 0.04).

CONCLUSION

Despite established recommendations, our results point out the tremendous heterogeneity regarding para-aortic assessment. These differences in management are perhaps related to a recommended therapeutic strategy that does not appear to improve the poor prognosis associated with PA involvement.

[Advanced cervical cancer: Evolutionary and prognostic. Moroccan experience]

INTRODUCTION

Standard treatment of locally advanced cervical carcinoma is actually represented by concomitant chemoradiotherapy followed by brachytherapy. However, in spite of good local control rates after treatment, local and regional relapses still a major cause of failure treatment. The occurrence of progressions and relapses depends on prognostic factors of disease evolution. Their treatment is often palliative.

METHODS

The aim of this study is to report the evolution of our retrospective series after radiotherapy with or without concomitant chemotherapy, and to discuss progressions and relapses factors for the stages IIIB and IVA of cervical carcinoma.

RESULTS

Progressions occurred in 15 patients (13.7%) with an average of three months. Recurrences occurred in 15 patients (13.7%) with an average of 19.6 months. The overall treatment failure rate was 27.5%. Seventy-six of treated patients were in good locoregional control with a median follow of 64 months (61-76). The overall survival at five years was 41.3%.

CONCLUSION

Relapses of cervical cancer have a poor prognosis and long-term survival remains very poor. The suitable treatment of the primary disease, respecting essentially therapeutic times, is the only guarantee of a good prognosis, as well as screening at early stages, involving less poor prognostic factors.

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

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

[((18)F)-fluorodeoxyglucose PET/CT in cervix cancer: lymph node assessment and prognostic/predictive value of primary tumour analysis]

PURPOSE

In cervix carcinoma: (a) to evaluate the ability of ((18)F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the lymph node detection; (b) to investigate the prognostic and predictive value of the primary cervical PET parameters.

PATIENTS AND METHODS

Ninety patients treated for cervix carcinoma and evaluated initially by MRI and FGD PET were included. The performances of FDG-PET for lymph node detection (relatively to the lymph node dissection) have been described (sensitivity, specificity, positive predictive value and negative predictive value). PET tumour parameters analyzed were: maximum standard uptake value (SUVmax), the volume and the maximum diameter. The prognostic and predictive values of these parameters were investigated. The tumour response was evaluated on surgical specimens.

RESULTS

PET detected the cervical tumour with a sensitivity of 97% (mean values: SUVmax=15.8, volume=27 mm(3), maximum diameter=47). For the detection of the lymph nodes, the values of sensibility, specificity, positive predictive value and negative predictive value were: 86, 56, 69 and 78% in the pelvic, and 90, 67, 50 and 95% for the para-aortic area, respectively. The SUVmax was correlated with histologic response (P=0.04). The frequency of partial histological response was significantly higher for tumour SUVmax>10.9 (P=0.017). The maximum PET diameter and pathologic response had an impact on disease-free survival and overall survival in multivariate analysis (P<0.05).

CONCLUSION

PET has high sensitivity in detecting pelvic and para-aortic lymph nodes. Some primary cervical tumour PET parameters are useful as prognostic and predictive factors.