Small-cell carcinoma of the endometrium. A clinicopathological study of sixteen cases

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.

Clinical characteristic and prognostic factors in high-grade endometrial neuroendocrine carcinoma

Aim

The aim of the present study was to summarize the clinical characteristics and analyze the independent prognostic factors in patients with high‐grade endometrial neuroendocrine carcinoma (ENC).

Methods

Patients diagnosed with ENC, endometrioid adenocarcinoma (EAC), endometrial clear‐cell carcinoma (ECC), endometrial serous carcinoma (ESC), endometrioid carcinoma with mucinous features (EMC) from 1987 to 2016 were screened from the National Cancer Institute database (surveillance, epidemiology, and end results [SEER]). Kaplan–Meier were used to assess survival. Univariate and multivariate Cox proportional hazards analysis were done to examine factors affecting survival.

Results

The median survival times of ENC were 11 months, shorter than that of EAC, ECC, ESC, and EMC (p < 0.01). There was no significant difference in ages, survival rate, and median survival time between large‐cell ENC (LCENC) and small‐cell ENC (SCENC), which were all belong to ENC. In a multivariable model, the hazard ratio (HR) of death for women with Federation International of Gynecology and Obstetrics (FIGO) stage I‐II of ENC was 0.37 compared to FIGO stage III‐IV (p < 0.01). The HR of patients who under the surgery was 0.39 compared to the patients who without surgery (p < 0.01), and the HR of patients who received chemotherapy was 0.51 compared to the patients who did not received chemotherapy (p < 0.01). Radiotherapy did not significantly reduce the mortality risk of patients.

Conclusion

ENC was a kind of devastating endometrial cancers with the poorest prognosis. Surgical treatment and chemotherapy were necessary for improving prognosis of ENC. Early diagnosis favored better prognosis. There was no prognostic difference between with and without radiotherapy.

Primary Neuroendocrine Tumors of the Endometrium: Management and Outcomes

Objective

To analyze clinical behavior of, optimal treatment regimens for, outcomes, and prognosis of 170 patients with neuroendocrine tumors (NETs) of the endometrium.

Methods

The Surveillance, Epidemiology, and End Results database was used to identify patients with endometrial NETs diagnosed between 2004 and 2015. Clinical features and treatment regimens were analyzed, and 5-year overall survival (OS) and cancer-specific survival (CSS) were compared among different stages and treatment regimens. Univariate and multivariate analyses were performed to identify independent prognostic factors associated with endometrial NETs. Finally, prognosis was compared between small- and large-cell neuroendocrine carcinoma (SCNEC and LCNEC, respectively) of the endometrium.

Results

There were 20, 8, 47, and 95 patients with stage I, II, III, and IV NET, respectively. The 5-year OS rates of patients in each stage were 59.86%, 42.86%, 32.75%, and 6.04%, respectively. The 5-year CSS survival rates were 59.86%, 50.0%, 38.33%, and 6.39%, respectively. In the multivariate analysis, American Joint Committee on Cancer (AJCC) stage and treatment were associated with poor OS, while AJCC stage, nodal metastasis, and treatment were associated with poor CSS. Neither pathological type nor distant metastasis was associated with prognosis. The rate of distant metastasis was significantly higher for LCNEC than for SCNEC, while 5-year OS and CSS rates were significantly lower.

Conclusion

Complete surgical treatment should be selected regardless of staging for patients with endometrial NETs. For early-stage disease, individualized postoperative treatment with single chemotherapy or radiotherapy may improve OS and CSS. For advanced-stage disease, comprehensive postoperative adjuvant therapy may improve OS and CSS.

Pathological processes and pretreatment cytologic diagnosis of neuroendocrine carcinoma of the endometrium: addendum report of the Kansai Clinical Oncology Group/Intergroup study in Japan

A previous retrospective study of a neuroendocrine carcinoma of the endometrium including 42 cases employed a central pathologic review to ensure the reliability of the findings. However, the pathological processes were not described in detail. In this study, we further analyzed these processes and the results of pretreatment endometrial cytology of neuroendocrine carcinoma. Of the 65 patients from 18 institutions registered in the study, 42 (64.6%) were diagnosed with neuroendocrine carcinoma of the endometrium based on the central pathological review. Thirteen of the 23 excluded cases conflicted from their original diagnoses: 5 (38.5%) were diagnosed with endometrioid adenocarcinoma, 5 (38.5%) with undifferentiated carcinoma, and 3 (23.1%) with carcinosarcoma. Immunohistochemical staining led to a change in diagnosis for 8 (61.5%) of the 13 cases. Pretreatment endometrial cytology was examined in 38 (90.5%) cases; 34 (89.5%) of these 38 cases were found, or suspected, to be positive. To ensure the selection of appropriate therapy and keeping patients correctly informed, it is important to distinguish neuroendocrine carcinoma from other similar histologic types. Endometrial cytology may help in the early detection of this disease.

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.

Primary mixed large cell neuroendocrine and high grade serous carcinoma of the endometrium

Endometrial large-cell neuroendocrine carcinoma admixed with a high-grade serous (HGS) adenocarcinoma is extremely rare with only one reported case in the literature. We present the second reported case in a 47-year-old woman who presented with abdominal pain, distension and loss of weight. On examination she had a fixed pelvic mass and vascular left vaginal mass. Imaging confirmed a 13 cm solid cystic rectouterine pelvic mass, omental disease and retroperitoneal lymphadenopathy. She underwent a modified posterior exenteration, partial posterior vaginectomy, omentectomy and Hartmanns procedure with suboptimal debulking. Histopathology revealed a stage 4B mixed carcinoma with large cell neuroendocrine (70%) and HGS carcinoma (30%). Eight cycles of adjuvant cisplatin and paclitaxel were given with a complete radiological and biochemical response after 7 months. Unfortunately, she developed widespread recurrence at 9 month and was offered second line chemotherapy.

Neuroendocrine carcinoma of the endometrium: A very rare gynecologic malignancy

OBJECTIVE

To investigate the clinicopathologic characteristics, prognostic factors, outcome, and treatment of the neuroendocrine carcinoma (NEC) of the endometrium.

MATERIALS AND METHODS

We retrospectively reviewed the clinicopathologic and survival data of 10 patients who underwent surgery for NEC. The patients were collected between 1999 and 2017 from four referral centers in Turkey.

RESULTS

The median age of patients was 67 years (range: 34-75 years). The NEC of endometrium consist of 9 cases with small cell carcinoma (SC) NEC (two with mixed histotypes), and one with a large cell (LC) NEC. According to FIGO 2009 criteria, 70 % (7/10) of patients had advanced stage (III and IV) disease. All patients except one underwent surgical staging, eight patients received platinum-based chemotherapy (CTX) and of 6 those were additionally treated with radiotherapy (RT). Four patients died of disease ranging from 2 to 10 months and six were alive 12-72 months with no evidence of disease. In addition, 4 SC NEC cases raised in polypoid features had no evidence of disease from 24 to 72 months.

DISCUSSION

NEC of the endometrium is a rare disease with poor prognosis, which frequently diagnosed in advanced stages. The main treatment modality was the administration of platinum-based CTX as an adjuvant to surgery or surgery and RT. Our result suggests that the polypoid feature of the tumor might be one of the best predictors for the prognosis of SC NEC.

Clinicopathologic features, treatment, prognosis and prognostic factors of neuroendocrine carcinoma of the endometrium: a retrospective analysis of 42 cases from the Kansai Clinical Oncology Group/Intergroup study in Japan

Objective

We conducted a retrospective, multi-institutional, collaborative study to accumulate cases of neuroendocrine carcinoma of the endometrium, to clarify its clinicopathologic features, treatment, prognosis and prognostic factors to collate findings to establish future individualized treatment regimens. To our knowledge, this is the largest case study and the first study to statistically analyze the prognosis of this disease.

Methods

At medical institutions participating in the Kansai Clinical Oncology Group/Intergroup, cases diagnosed at a central pathologic review as neuroendocrine carcinoma of the endometrium between 1995 and 2014 were enrolled. We retrospectively analyzed the clinicopathologic features, treatment, prognosis and prognostic factors of this disease.

Results

A total of 65 cases were registered from 18 medical institutions in Japan. Of these, 42 (64.6%) cases were diagnosed as neuroendocrine carcinoma of the endometrium based on the central pathological review and thus included in the study. Advanced International Federation of Gynecology and Obstetrics stages (stage III and IV) and pure type small cell neuroendocrine carcinoma cases had a significantly worse prognosis. Upon multivariate analysis, only histologic subtypes and surgery were significant prognostic factors. Pure type cases had a significantly worse prognosis compared to mixed type cases and complete surgery cases had a significantly better prognosis compared to cases with no or incomplete surgery.

Conclusion

Our findings suggest that complete surgery improves the prognosis of neuroendocrine carcinoma of the endometrium. Even among cases with advanced disease stages, if complete surgery is expected to be achieved, clinicians should consider curative surgery to improve the prognosis of neuroendocrine carcinoma of the endometrium.

Long-term survival in a stage IV small cell carcinoma of the endometrium

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Small cell carcinoma of the endometrium is a rare malignancy with poor survival.

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A patient was diagnosed with stage IV small cell carcinoma of the endometrium.

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She was treated with surgery, chemotherapy (cisplatin/etoposide) and radiotherapy.

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She remains disease free 5 years after completion of her treatments.

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.

Rare Case of Neuroendocrine Small Cell Carcinoma of the Endometrium with Paraneoplastic Membranous Glomerulonephritis

Small cell carcinomas are well-recognized tumors known to occur predominantly in the lung. These neoplasms are occasionally associated with a variety of paraneoplastic syndromes. Four cases of paraneoplastic glomerulopathy associated with small cell lung carcinoma have been reported. However, there have been no reports in the literature indicating an association between endometrial small cell carcinoma and paraneoplastic glomerulopathy. We report a case of neuroendocrine small cell carcinoma of the endometrium associated with membranous glomerulonephritis (MGN), which appeared to be a component of an unusual paraneoplastic syndrome. A 33-year-old multiparous woman presented with abnormal vaginal bleeding and abdominal bloating. Endometrial biopsy revealed neuroendocrine small-cell carcinoma of the endometrium. On the eighth day of hospitalization the patient suddenly developed renal failure. Renal biopsy revealed MGN, probably due to tumor-antigen-related immune complex deposition. Small cell carcinoma of the endometrium may be associated with paraneoplastic MGN. Medical staff should take into account the possibility of a preexisting glomerular injury when managing a patient with small cell carcinoma of the endometrium.

Pathology of Neuroendocrine Tumours of the Female Genital Tract

Neuroendocrine tumours are uncommon or rare at all sites in the female genital tract. The 2014 World Health Organisation (WHO) Classification of neuroendocrine tumours of the endometrium, cervix, vagina and vulva has been updated with adoption of the terms low-grade neuroendocrine tumour and high-grade neuroendocrine carcinoma. In the endometrium and cervix, high-grade neoplasms are much more prevalent than low-grade and are more common in the cervix than the corpus. In the ovary, low-grade tumours are more common than high-grade carcinomas and the term carcinoid tumour is still used in WHO 2014. The term ovarian small-cell carcinoma of pulmonary type is included in WHO 2014 for a tumour which in other organs is termed high small-cell neuroendocrine carcinoma. Neuroendocrine tumours at various sites within the female genital tract often occur in association with other neoplasms and more uncommonly in pure form.

Small cell cancers of the female genital tract: Molecular and clinical aspects

OBJECTIVE

Extra-pulmonary small cell carcinomas of the gynecologic tract (EPSCC-GTs) are a rare group of aggressive malignancies associated with poor prognoses and limited treatment options. Here, we review the clinical and molecular aspects of EPSCC-GTs and discuss how understanding their molecular features can assist in their diagnosis and the identification of novel effective treatments.

METHODS

We searched PubMed and Scopus for articles using the following keywords: "small cell carcinoma" in combination with "neuroendocrine", "ovary", "vagina", "fallopian tube", "vulva", "endometrium", "uterus", "cervix", or "gynecologic". Articles were limited to those published in English from January 1984 to October 2017.

RESULTS

EPSCC-GTs account for 2% of all gynecologic malignancies. The molecular features of EPSCC-GTs are largely understudied and unknown, with the exception of small cell carcinoma (SCC) of the ovary, hypercalcemic type (SCCOHT) and SCC of the cervix (SCCC). In nearly all cases, SCCOHT displays mutation in a single gene, SMARCA4, a member of the SWI/SNF chromatin remodeling complex. The loss of expression of the SWI/SNF protein SMARCA2 is another feature of SCCOHT. Dual negative staining for SMARCA2 and SMARCA4 is specific for SCCOHT and is generally used by gynecologic pathologists for the accurate diagnosis of this malignancy. Mutational analysis of SCCC has shown alterations in PIK3CA, KRAS and TP53, of which the last is the most common, although other actionable mutations have been identified. The molecular features of other EPSCC-GTs are largely unknown.

CONCLUSIONS

Due to their rarity, the majority of EPSCC-GTs are understudied and poorly understood. As demonstrated in the case of SCCOHT, unraveling the mutational profiles of these tumors can lead to improved diagnosis and the identification of novel therapeutic targets.

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.

[New features in the 2014 WHO classification of uterine neoplasms]

The 2014 World Health Organization (WHO) classification of uterine tumors revealed simplification of the classification by fusion of several entities and the introduction of novel entities. Among the multitude of alterations, the following are named: a simplified classification for precursor lesions of endometrial carcinoma now distinguishes between hyperplasia without atypia and atypical hyperplasia, the latter also known as endometrioid intraepithelial neoplasia (EIN). For endometrial carcinoma a differentiation is made between type 1 (endometrioid carcinoma with variants and mucinous carcinoma) and type 2 (serous and clear cell carcinoma). Besides a papillary architecture serous carcinomas may show solid and glandular features and TP53 immunohistochemistry with an "all or null pattern" assists in the diagnosis of serous carcinoma with ambiguous features. Neuroendocrine neoplasms are categorized in a similar way to the gastrointestinal tract into well differentiated neuroendocrine tumors and poorly differentiated neuroendocrine carcinomas (small cell and large cell types). Leiomyosarcomas of the uterus are typically high grade and characterized by marked nuclear atypia and lively mitotic activity. Low grade stromal neoplasms frequently show gene fusions, such as JAZF1/SUZ12. High grade endometrial stromal sarcoma is newly defined by cyclin D1 overexpression and the presence of the fusion gene YWHAE/FAM22 and must be distinguished from undifferentiated uterine sarcoma. Carcinosarcomas (malignant mixed Mullerian tumors MMMT) show biological and molecular similarities to high-grade carcinomas.

Molecular Pathology: Predictive, Prognostic, and Diagnostic Markers in Uterine Tumors

This article focuses on the diagnostic, prognostic, and predictive molecular biomarkers in uterine malignancies, in the context of morphologic diagnoses. The histologic classification of endometrial carcinomas is reviewed first, followed by the description and molecular classification of endometrial epithelial malignancies in the context of histologic classification. Taken together, the molecular and histologic classifications help clinicians to approach troublesome areas encountered in clinical practice and evaluate the utility of molecular alterations in the diagnosis and subclassification of endometrial carcinomas. Putative prognostic markers are reviewed. The use of molecular alterations and surrogate immunohistochemistry as prognostic and predictive markers is also discussed.

Pathology of Endometrial Carcinoma

On a clinicopathological and molecular level, two distinctive types of endometrial carcinoma, type I and type II, can be distinguished. Endometrioid carcinoma, the typical type I carcinoma, seems to develop through an estrogen-driven "adenoma carcinoma" pathway from atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN). It is associated with elevated serum estrogen and high body mass index and expresses estrogen and progesterone receptors. They are mostly low grade and show a favorable prognosis. A subset progresses into high-grade carcinoma which is accompanied by loss of receptor expression and accumulation of TP53 mutations and behaves poorly. Other frequently altered genes in type I carcinomas are K-Ras, PTEN, and ß-catenin. Another frequent feature of type I carcinomas is microsatellite instability mainly caused by methylation of the MLH1 promoter. In contrast, the typical type II carcinoma, serous carcinoma, is not estrogen related since it usually occurs in a small uterus with atrophic endometrium. It is often associated with a flat putative precursor lesion called serous endometrial intraepithelial carcinoma (SEIC). The molecular pathogenesis of serous carcinoma seems to be driven by TP53 mutations, which are present in SEIC. Other molecular changes in serous carcinoma detectable by immunohistochemistry involve cyclin E and p16. Since many of the aforementioned molecular changes can be demonstrated by immunohistochemistry, they are useful ancillary diagnostic tools and may further contribute to a future molecular classification of endometrial carcinoma as recently suggested based on The Cancer Genome Atlas (TCGA) data.

Neuroendocrine Carcinoma of the Endometrium: A Clinicopathologic Study of 25 Cases

Neuroendocrine carcinoma (NECa) of the endometrium is an uncommon tumor. In this study, we present the clinicopathologic features of 25 such cases. The patients ranged in age from 37 to 87 years (median, 57 y) and most commonly presented with vaginal bleeding. The tumors were either pure NECa (10) or mixed with other histotypes (15), most commonly endometrioid carcinoma. The NECas were large cell type (15), small cell type (4), or a mixture of both (6). NECa was underrecognized in 89% of referral/consultation cases. All tumors were positive for ≥1 neuroendocrine marker (chromogranin, synaptophysin, CD56). Additional immunohistochemical (IHC) studies were obtained in 18 cases, with positive results as follows: keratin cocktail (17), diffuse p16 (6), PAX-8 (6), CD117 (6), and TTF-1 (1). Mismatch-repair protein expression by IHC was abnormal in 8 of 18 cases (6 MLH1/PMS2 loss; 1 MSH2/MSH6 loss; 1 MSH6 loss). According to FIGO staging, cases were distributed as follows: I (6), II (2), III (10), and IV (7). All patients underwent surgical treatment, and 20 patients received adjuvant therapy. Twelve patients died of disease (mean survival 12.3 mo). Eleven patients were alive 5 to 134 months after diagnosis, including 7 who achieved a 5-year survival (3 stage I; 4 stage III). In summary, most of our endometrial NECas were large cell type, mixed with other histotypes, and underrecognized. These tumors tend to be PAX-8 negative and may be associated with microsatellite instability. The recognition of NECa may have an impact on the treatment of the patients affected by this disease. Although NECa usually has an aggressive behavior, 28% of our patients survived at least 5 years.

Small cell neuroendocrine tumour of the endometrium and the importance of pathologic diagnosis

Small cell carcinoma of the endometrium is a very rare entity. They are very aggressive tumours, with a poor prognosis. They represent a clinical challenge because of a lack of a standardised treatment. We see here a case of a 67-year-old woman with a history of a lobular breast carcinoma, diagnosed in 2002. After presenting with postmenopausal vaginal bleeding in October 2014, she underwent a hysteroscopy-guided biopsy which revealed a metastasis of breast carcinoma. A hysterectomy and bilateral oophorectomy was performed because of uncontrolled uterine bleeding. The pathologic diagnosis was small cell carcinoma (SCC) of the endometrium. A surgical complete cytoreduction was achieved after the case being presented in a multidisciplinary tumour board. Pathologic results revealed metastasis from peritoneal implants of SCC on the endometrium, and metastasis in pelvic and para-aortic lymph nodes from serous carcinoma of the endometrium. A total of four cycles of adjuvant chemotherapy based on cisplatin (80mg/m² day one) and etoposide (100mg/m² day one, two, three) every 21 days was given. The patient experienced persistent disease and died 17 months after the diagnosis. SCC of the endometrium is a very rare and aggressive disease that requires an individualised multidisciplinary management.

CD10 expression in the neuroendocrine carcinoma component of endometrial mixed carcinoma: association with long survival

Backgound

Endometrial mixed carcinoma with the neuroendocrine carcinoma (NEC) component is rare and is believed to have a poor prognosis. CD10 expression is reported to be a favorable prognostic marker for some tumors such as B-lymphoblastic leukemia/lymphoma, but unfavorable for others. Here, we report the case of a 33-year-old woman diagnosed with endometrial mixed carcinoma with the NEC component expressing CD10 who showed a favorable outcome.

Case presentation

The patient presented with lumbago and brownish discharge from the genitals. Imaging modalities revealed a large exophytic mass in the uterine corpus, and a small one in the uterine cervix. Radical hysterectomy with bilateral salpingo-oophorectomy was performed. Microscopic examination of the endometrial and cervical masses revealed that the NEC component accounted for the maximum area in both masses. However, small areas in both lesions showed well differentiated endometrioid adenocarcinoma (WDEA) components, and histological transition between the two components was also observed. In addition to CD56 and synaptophysin expression, the NEC component was positive for CD10 but negative for estrogen receptor (ER), progesterone receptor (PgR), and carcinoembryonic antigen (CEA). In contrast, the WDEA component expressed both ER and PgR, but neither CD10 nor neuroendocrine markers were demonstrated. The CD10 and neuroendocrine markers clearly distinguished between the NEC and WDEA components. Furthermore, retained expression of phosphatase and tensin homolog (PTEN) and weak phosphorylated Akt expression were found, which were assumed to suppress the aggressive behavior of the tumor. The patient received postoperative chemotherapy and has survived without recurrence for 6 years after the operation.

Conclusion

This is the first case of endometrial mixed carcinoma with the NEC component expressing CD10 that showed a long survival.

Small cell neuroendocrine carcinoma of the endometrium with pulmonary metastasis: A clinicopathologic study of a case and a brief review of the literature

Neuroendocrine carcinomas (NEC) of the female genital tract are aggressive and rare tumors that usually involve the cervix and ovary, and are seen rarely in the endometrium in perimenopausal or postmenopausal women. We presented a case of a73 year-old postmenopausal woman with vaginal bleeding and abdominal pain. A subsequent computerized tomography (CT) scan of pelvis showed an enlarged uterus (20,0 × 12,0 cm) with para-aortic and pelvic lymph node metastases. She underwent surgical debulking and staging of an endometrial tumor with omental metastasis and positive lymph nodes. The pathological diagnosis was primary small cell carcinoma (SCC) combined with endometrioid carcinoma of uterine corpus. Her final FIGO stage was IVB. Three months after surgery CT-total body showed a metastasis to left lung of SCC. Because the small-cell component of endometrial tumor showed a strong positivity for TTF1 as pulmonary counterpart a differential diagnosis with a primary small cell carcinoma of the lung should be made. Identifying an appropriate therapeutic management for SCC of endometrium is challenging since these are extremely rare tumors. An optimal initial therapeutic approach to this rare disease, especially at an advanced stage, has not yet been clearly defined. However, in these a multidisciplinary therapy, including surgery, chemotherapy, and radiotherapy represent until this time the only therapeutic option.

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Neuroendocrine carcinomas (NEC) of endometrium are aggressive and rare tumors.

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As pulmonary counterpart may express Thyroid transcription factor-1 (TTF-1).

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To date, no effective treatment protocol has been established for this rare type of tumor.

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A multidisciplinary therapy represents until this time the only therapeutic option.

Neuroendocrine Tumors of the Female Reproductive Tract: A Literature Review

Neuroendocrine tumors of the female reproductive tract are a heterogeneous group of neoplasms that display various histologic findings and biologic behaviors. In this review, the classification and clinicopathologic characteristics of neuroendocrine tumors of the female reproductive tract are described. Differential diagnoses are discussed, especially for non-neuroendocrine tumors showing high-grade nuclei with neuroendocrine differentiation. This review also discusses recent advances in our pathogenetic understanding of these disorders.

Small cell neuroendocrine carcinoma of the endometrium: a clinicopathologic study of six cases

OBJECTIVES

Primary small cell carcinoma of the endometrium is a rare disease that can only be diagnosed at an advanced stage, and thus has a poor prognosis. In this study, the clinicopathologic characteristics of endometrial small cell carcinoma are described and the survival outcomes are discussed.

MATERIALS AND METHODS

The data from six patients from a single medical institution who were diagnosed with endometrial small cell carcinoma in the past 20 years were retrospectively reviewed.

RESULTS

The median age of the six patients was 60 years. Vaginal bleeding was the most common symptom. All six patients underwent complete staging surgery, including hysterectomy, bilateral salpingoophorectomy, and systematic lymphadenectomy. Three of the patients were diagnosed with early stage disease, [International Federation of Gynecology and Obstetrics (FIGO) stage I or II], and the other three were in an advanced stage (FIGO stage III). Pathologically, deep myometrial invasion was observed in five (83.3%) of the patients, and lymphovascular invasion in six. As adjuvant therapy, four (66.7%) patients received platinum-based chemotherapy and one (16.7%) underwent concurrent chemoradiotherapy. During the median follow-up period of 16.2 months, recurrence developed in four patients (66.7%). There were disseminated recurrences on the peritoneum and lymph nodes in two cases, and distant metastasis to the brain in the other two cases. The median time to recurrence was 7.5 months (range, 315 months). One patient died of disease.

CONCLUSION

Small cell carcinoma of the endometrium shows an aggressive clinical behavior, such as a disseminated disease and distant metastasis within a short time to recurrence. Initial active management with complete surgical resection and systemic chemotherapy might improve outcomes, although further large studies should be done to confirm this.

Neuroendocrine tumours of the female genital tract: a case-based imaging review with pathological correlation

Background

Both primary and secondary gynaecological neuroendocrine (NE) tumours are uncommon, and the literature is scarce concerning their imaging features.

Methods

This article reviews the epidemiological, clinical and imaging features with pathological correlation of gynaecological NE tumours.

Results

The clinical features of gynaecological NE tumours are non-specific and depend on the organ of origin and on the extension and aggressiveness of the disease. The imaging approach to these tumours is similar to that for other histological types and the Revised International Federation of Gynecology and Obstetrics (FIGO) Staging System also applies to NE tumours. Neuroendocrine tumours were recently divided into two groups: poorly differentiated neuroendocrine carcinomas (NECs) and well-differentiated neuroendocrine tumours (NETs). NECs include small cell carcinoma and large cell neuroendocrine carcinoma, while NETs account for typical and atypical carcinoids. Cervical small cell carcinoma and ovarian carcinoid are the most common gynaecological NE tumours. The former typically behaves aggressively; the latter usually behaves in a benign fashion and tends to be confined to the organ.

Conclusion

While dealing with ovarian carcinoids, extra-ovarian extension, bilaterality and multinodularity raise the suspicion of metastatic disease. NE tumours of the endometrium and other gynaecological locations are very rare.

Teaching Points

• Primary or secondary neurondocrine (NE) tumours of the female genital tract are rare.

• Cervical small cell carcinoma and ovarian carcinoids are the most common gynaecological NE tumours.

• Cervical small cell carcinomas usually behave aggressively.

• Ovarian carcinoids tend to behave in a benign fashion.

• The imaging approach to gynaecological NE tumours and other histological types is similar.

Small cell carcinoma of the gynecologic tract: a multifaceted spectrum of lesions

OBJECTIVE

Small cell carcinoma (SmCC) of the female genital tract constitutes a diagnostic and clinical challenge given its rarity and the lack of standardized therapeutic approaches. Here we review the morphological, clinical and molecular features of gynecologic SmCCs and discuss potential areas for future research.

METHODS

Data for this review article were identified by searches of PubMed, EMBASE and the Internet using the search terms "small cell carcinoma" or "neuroendocrine carcinoma" and "gynecologic", "uterine cervix", "cervix", "uterus", "endometrium", "ovary", "vagina", "fallopian tube" or "vulva", and research articles published in English between 1972 and February 2014 were included.

RESULTS

SmCCs arising from different organs within the gynecologic tract share the same histopathologic characteristics, which closely resemble those of small cell lung carcinoma. The expression of at least one immunohistochemical neuroendocrine marker is a common finding. The uterine cervix is the most frequent site of SmCC in the female genital tract. HPV infection seems to play a role in the development of cervical SmCC but not in cancers of other gynecologic sites. FIGO stage is an established prognostic factor, in particular in SCCs of the cervix. Irrespective of the site, SmCCs of the gynecologic tract display an aggressive clinical behavior with few reported long-term survivors. The therapeutic management includes surgery, radiotherapy and chemotherapy.

CONCLUSIONS

Despite the potential differences in etiology and risk factors, SmCCs from different sites of the gynecologic tract have similar morphologic appearances and clinical behavior. Recent genomic analyses of small cell carcinoma of the lung have revealed potential driver genomic alterations. We posit that the comprehensive genomic characterization of gynecologic SmCCs may lead to the identification of markers that result in an improvement of diagnostic reproducibility of SmCCs of the gynecologic tract, and of molecular aberrations that may be exploited therapeutically in subgroups of the disease.

Use of immunohistochemistry in the diagnosis of miscellaneous and metastatic tumors of the uterine corpus and cervix

Uncommon tumors in the uterus present diagnostic challenges. In some cases, the tumor subtype is usually seen outside the gynecologic tract and the possibility of a uterine primary is not considered. In other cases, histologic overlap with more common uterine tumors leads to potential misdiagnosis. Finally, metastatic carcinoma may involve the uterus and cervix. Rarely, symptoms related to the uterine metastasis may precede diagnosis of an extrauterine primary. Without the proper clinical context, the possibility of a missed diagnosis is increased. One must first be aware of these possibilities, but immunoperoxidase studies are often necessary to confirm the diagnosis. In this review, unusual and metastatic tumors involving the uterine corpus and cervix and immunoperoxidase studies used to diagnosis such tumors are discussed.

Neuroendocrine tumors of the gynecologic tract: select topics

Tumors of the diffuse neuroendocrine cell system (DNES) may arise in any component of the gynecologic tract, including the vulva, vagina, cervix, endometrium, and ovary. Overall such tumors in the gynecologic tract are rare, constituting only 2% of gynecologic cancers, comprising a spectrum of tumors of variable biologic potential. Due to the rarity of such tumors, pathologists experience may be limited and these may present diagnostic challenges. Currently the nomenclature employed is still that of the pulmonary classification systems, carcinoid, atypical carcinoid, small and large cell neuroendocrine carcinoma that broadly correlates to low/grade 1, intermediate/grade 2, and high grade/grade 3 of the WHO gastroenteropancreatic neuroendocrine tumors classification. Furthermore in keeping with the lung, proliferative rate is assessed based on mitotic index rather than Ki-67 staining. In this review we cover select neuroendocrine tumors of the gynecologic tract.

Small cell carcinoma of the endometrium: A report of three cases

Small cell carcinoma (SCC) is a tumour that occurs mostly in the lung, but may be found in any organ in the body. Since SCC of the endometrium is rare, clinical behaviour and management of the disease is not well-defined. The only known prognostic factor is the stage of the disease. Here, we reported three patients with SCC of the endometrium, their management and the follow-up period.

A case of MPO- and PR3-ANCA-negative pauci-immune renal-limited small-vessel vasculitis associated with endometrial neuroendocrine small cell carcinoma

A 69-year-old woman was admitted to our hospital for rapid increase in serum creatinine level with microscopic hematuria and nephrotic-range proteinuria. Three months prior to admission, she became aware of atypical genital bleeding, leading her gynecologist to suspect endometrial cancer. Light microscopy examination of renal biopsy revealed crescentic glomerulonephritis with peritubular capillaritis. Immunofluorescence microscopic examination did not detect any significant staining, and no electron-dense deposits were detected by electron microscopy. No autoantibodies, including anti-myeloperoxidase- or anti-proteinase3-anti-neutrophil cytoplasmic antibodies were detected. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and was found to have endometrial neuroendocrine small cell carcinoma (NSCC), stage 1B. In her clinical course, her serum creatinine level gradually improved without immunosuppression therapy. Endometrial NSCC is a rare endometrial malignancy. This is the first case report of vasculitis associated with NSCC originating from the uterus.

The management of small-cell carcinomas of the gynecologic tract

PURPOSE OF REVIEW

Small-cell carcinomas of the gynecologic tract are aggressive malignancies that can be misdiagnosed or inappropriately managed. This review provides a summary of current literature that will help the clinician to correctly diagnose and treat patients with small-cell carcinomas of the cervix, ovary, uterus, vagina, and vulva.

RECENT FINDINGS

Small-cell carcinomas of gynecologic sites are rare and carry a poor prognosis. Stage is an important prognostic factor in small-cell carcinoma of the cervix, uterus, and ovary. Early stage disease has varied treatment approaches based on the site of malignancy, but systemic chemotherapy with or without radiation plays a role in the adjuvant setting to mitigate the risk of recurrence. Advanced stage patients require treatment with chemotherapy and possibly radiation, usually in a manner analogous to small-cell lung cancer. The preferred chemotherapy regimen contains a platinum agent and etoposide. For small-cell ovarian carcinomas, it is important to differentiate those of the hypercalcemic type from those of the pulmonary type. The small-cell carcinomas of the vagina and vulva need to be distinguished from Merkel cell cancers.

SUMMARY

The majority of small-cell tumors of the gynecologic tract will require systemic chemotherapy with a platinum agent and etoposide, both in the setting of early and advanced stage disease. Prospective trials with new chemotherapy or targeted agents are needed to improve the treatment of this aggressive cancer.

Primary small cell neuroendocrine carcinoma of the endometrium

Background

Small cell neuroendocrine carcinoma is very rarely encountered within the endometrium.

Case Study

A patient underwent a hysterectomy and salpingo-oophorectomy for a suspicious gynecologic condition. Pathology revealed invasive small cell neuroendocrine carcinoma of the endometrium; the neoplasm exhibited positive immunoreactivity for synaptophysin, pancytokeratin and CD56 but was negative for CD3 and CD20. Prior to chemotherapy, a completion lymphadenectomy was indicated to determine the presence of nodal metastases.

Conclusion

The prognosis of small cell neuroendocrine carcinoma of the endometrium is unfavorable but prompt detection with surgery and adjuvant therapy may confer a better clinical outcome.

Endometrial carcinomas: a review emphasizing overlapping and distinctive morphological and immunohistochemical features

This review focuses on the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers in the differential diagnosis between the different subtypes of endometrial carcinomas, including: (1) endometrioid versus serous glandular carcinoma, (2) papillary endometrioid (not otherwise specified, villoglandular and nonvillous variants) versus serous carcinoma, (3) endometrioid carcinoma with spindle cells, hyalinization, and heterologous components versus malignant mixed müllerian tumor, (4) high-grade endometrioid versus serous carcinoma, (5) high-grade endometrioid carcinoma versus dedifferentiated or undifferentiated carcinoma, (6) endometrioid carcinoma with clear cells versus clear cell carcinoma, (7) clear cell versus serous carcinoma, (8) undifferentiated versus neuroendocrine carcinoma, (9) carcinoma of mixed cell types versus carcinoma with ambiguous features or variant morphology, (10) Lynch syndrome-related endometrial carcinomas, (11) high-grade or undifferentiated carcinoma versus nonepithelial uterine tumors. As carcinomas in the endometrium are not always primary, this review also discusses the differential diagnosis between endometrial carcinomas and other gynecological malignancies such as endocervical (glandular) and ovarian/peritoneal serous carcinoma, as well as with extra-gynecologic metastases (mainly breast and colon).

Neuroendocrine tumors of the gynecologic tract: A Society of Gynecologic Oncology (SGO) clinical document

OBJECTIVE

Neuroendocrine tumors of the gynecologic tract are rare, and pose a significant clinical challenge because of the tumor heterogeneity and lack of standardized guidelines for treatment. This manuscript summarizes the available literature concerning these tumors in an effort to provide the clinician a framework from which to guide patient management.

METHODS

MEDLINE was searched for all research articles published in English between January 1, 1966 and March 1, 2011 in which the studied population included women diagnosed with neuroendocrine tumors of the gynecologic tract. Although preference was given to prospective studies, studies were not limited by design or by numbers of subjects given the limited availability of reports.

RESULTS

Most, but not all, neuroendocrine tumors of the gynecologic tract have an aggressive clinical course and those of the cervix histologically and clinically share similarities with small cell lung cancer. Cumulative data supports a multi-modality therapeutic strategy. A proposed management algorithm for neuroendocrine carcinomas of the cervix is outlined. For less frequent disease sites including the adnexa, uterus, vagina and vulva, as well as well differentiated carcinoid tumors, surgical resection is appropriate in selected cases. Etoposide/platinum based chemotherapy is used for neuroendocrine carcinomas but not for well differentiated carcinoid tumors. Well differentiated carcinoid and atypical carcinoid tumors should be managed similar to gastroenteropancreatic NETs (GEP-NETs).

CONCLUSIONS

Most neuroendocrine tumors of the gynecologic tract require a multi-modality therapeutic approach, determined by extent of disease and primary organ of involvement. Pathologic diagnosis is critical to guide therapy.

Small cell carcinoma of the endometrium: a report of two cases

Primary small cell carcinoma of the endometrium is rare and has an extremely poor prognosis. This report describes two cases of small cell carcinoma of the endometrium diagnosed as stage III. Case 1 was diagnosed as stage IIIc. She underwent surgery and chemotherapy. For a locally recurrent tumor, she received radiotherapy. She has been well with no evidence of disease for 4 years. Case 2 was diagnosed as stage IIIa. She underwent surgery. The tumor recurred soon after the surgery, and she died 33 days after the surgery. In the literature, the median survival reported for patients with stage III and IV is only 5 months. Case 1 is the 4th case showing long-term survival with advanced-stage disease. The optimal treatment for this rare tumor has not been established. Considering its rarity and variability, it is difficult to establish an evidence-based therapeutic regimen.

Heterologous and rare homologous sarcomas of the uterine corpus: a clinicopathologic review

Pure sarcomas of the uterine corpus are uncommon, constituting less than 3% of all malignancies at this site, and most of them are leiomyosarcomas and endometrial stromal sarcomas. Rare histotypes of homologous sarcomas and heterologous sarcomas are occasionally encountered, and the absence of significant accumulated experience with these histotypes at this location may potentially raise diagnostic and patient management difficulties. In this article, the clinicopathologic attributes of all earlier reported sarcomas of the uterine corpus other than leiomyosarcomas and endometrial stromal sarcomas are summarized. Included are embryonal rhabdomyosarcoma, pleomorphic rhabdomyosarcoma, angiosarcoma, alveolar soft part sarcoma, malignant perivascular epithelioid cell tumors (PEComas), osteosarcoma, chondrosarcoma, liposarcomatous tumors, malignant extrarenal rhabdoid tumors, Ewing sarcoma/primitive neuroectodermal tumor, and other rare histotypes. Embryonal rhabdomyosarcoma (20%), Ewing sarcoma/primitive neuroectodermal tumor (17%), angiosarcoma (14%), and pleomorphic rhabdomyosarcoma (13%) appeared to be more common than the others, although there was no single overwhelmingly prevalent histotype in the group. A subset, including embryonal rhabdomyosarcoma, alveolar soft part sarcoma, and PEComas, peak in the premenopausal years, but most of the others were observed in postmenopausal women. Favorable outcomes have been reported for the patients diagnosed with alveolar soft part sarcoma, and the prognosis for their counterparts with PEComa remains a matter of debate. Multimodal therapeutic approaches to contemporary patients with embryonal rhabdomyosarcomas have resulted in significantly improved outcomes. Unfortunately, most of the other sarcomas have been associated with rapid tumor progression and unfavorable patient outcomes. The differential diagnosis for these sarcomas is often extensive and varies by histotype, but their accurate diagnosis fundamentally requires the careful exclusion of biphasic malignancies.

Large cell neuroendocrine carcinoma with sarcomatous changes of the endometrium: a case report with immunohistochemical studies and molecular genetic study of KIT and PDGFRA

The author herein reports a very rare case of large cell neuroendocrine carcinoma (LCNEC) with sarcomatous changes of the endometrium. A 40-year-old woman was admitted to our hospital because of abnormal uterine bleeding. Gynecologic examination and imaging modalities revealed a polypoid tumor of the uterine corpus. Uterine curettage biopsy revealed a sarcomatous undifferentiated carcinoma. Simple hysterectomy, salpingo-oophorectomy, extensive lymph node dissection, and omentectomy were performed. The patient was diagnosed as having FIGO stage Ib (T1N0M0) carcinoma, and adjuvant chemotherapy was performed. The patient is now alive 16 months after the operation. Pathologically, a polypoid tumor measuring 3x2x2 cm(3) was found in the uterine corpus. Histologically, the tumor consisted of relatively large-sized carcinoma cells without differentiation. The tumor cells have abundant cytoplasm and prominent nucleoli. It was composed of a spindle cell component (40%) and an epithelioid component (60%). A gradual transition between the two was recognized. Immunohistochemically, both elements showed the same immunophenotypes. The carcinoma cells were positive for cytokeratin, vimentin, CA125, CD34, estrogen receptor, progesterone receptor, p53 protein, Ki-67 antigen (80%), synaptophysin, CD56, KIT, and PDGFRA. They were negative for epithelial membrane antigen, CEA, desmin, S100 protein, melanosome, alpha-smooth muscle actin, chromogranin, and neuron-specific enolase. A molecular genetic analysis revealed no mutations of KIT (exons 9, 11, 13, and 17) and PDGFRA (exons 12 and 18) genes. The final diagnosis was LCNEC with sarcomatous changes.

Small-cell carcinoma of the endometrium presenting as Cushing's syndrome

Small-cell carcinoma (SCC) of neuroendocrine type is an uncommon tumor of the endometrium. No previous report has documented Cushing's syndrome due to ectopic ACTH production by SCC of the endometrium. We describe a 56-year-old Japanese woman with SCC of the endometrium and multiple lung metastases presenting as Cushing's syndrome. The patient was referred to our hospital because of general fatigue with facial and leg edema, and multiple nodular lesions in the bilateral lungs on chest X-ray examination. A physical examination revealed that the patient had moon face, buffalo hump, and truncal obesity. Endocrinological examinations confirmed ACTH-dependent Cushing's syndrome. Thoracic computed tomography imaging showed multiple nodular lesions in the bilateral lungs. Abdominal magnetic resonance imaging suggested a malignant tumor of the uterus. The patient received a lung tumor biopsy and surgical hysterectomy. The endometrial carcinoma was histologically a SCC admixed with endometrioid adenocarcinoma. The SCC of the endometrium showed immunoreactivity for pro-opiomelanocortin, ACTH, and vimentin, but not for thyroid transcription factor-1. The lung biopsy specimen had the same features. These findings indicated that the SCC originated from the endometrium, and the ectopic ACTH-producing tumor caused Cushing's syndrome. This study provides the evidence that SCC of endometrial origin was an ectopic ACTH-producing tumor causing Cushing's syndrome.

KIT-positive primary small cell carcinoma of the endometrium: a case report with immunohistochemical and molecular genetic analysis of KIT and PDGFRA genes

BACKGROUND

Primary small cell carcinoma of the endometrium is very rare, and there have been no reports on KIT and PDGFRA in endometrial small cell carcinoma.

CASE REPORT

An 87-year-old woman was admitted to our hospital because of genital bleeding. Endometrial cytology and biopsy revealed small cell carcinoma. Scrutiny of the body showed stage III endometrial carcinoma with metastases. An immunohistochemical study of the biopsy specimens revealed positive reactions for synaptophysin, CD56, KIT, and PDGFRA, and negative reactions for cytokeratins, neuron-specific enolase, and chromogranin. A molecular genetic analysis using PCR-direct sequencing identified no mutations of KIT (exons 9, 11, 13, and 17) and PDGFRA (exons 12 and 18) genes. The patient received chemotherapy and radiation, but showed a downhill course, and died of carcinomatosis 6 months after the initial presentation.

CONCLUSION

The present case is the first reported case of primary small cell carcinoma of the endometrium with an examination of KIT and PDGFRA expressions and KIT and PDFGRA gene mutations.

The significance of neuroendocrine expression in undifferentiated carcinoma of the endometrium

Carcinomas with neuroendocrine (NE) differentiation have been associated with poor outcome in different organs. The purpose of this study was to evaluate the presence and significance of NE expression in a series of 46 undifferentiated endometrial carcinomas diagnosed between 1988 and 2005. NE expression was studied by immunohistochemistry including synaptophysin, chromogranin, and/or CD56. The patients' age ranged from 30 to 84 years (mean 55). Staging information was available for 45 cases and according to the International Federation of Gynecology and Obstetrics system they were distributed as follows: stage I (9 cases), stage II (2 cases), stage III (9 cases), and stage IV (25 cases). NE expression was present in 19/46 (41%) cases; however, it was diffuse in only 9% of the tumors. The median survival for patients without NE expression was 7 months (95% confidence interval 4-10 mo) and for patients with NE expression was 12 months (95% confidence interval 6-27 mo). The survival curves do not differ significantly (P=0.49). NE expression is common in undifferentiated carcinoma of the endometrium, as it was found in 41% of our cases. In most cases, NE expression is only focally present (< or =10% of the cells). There is no difference in overall survival in patients with or without NE expression.

Small cell carcinomas and large cell neuroendocrine carcinomas of the endometrium and cervix: polypoid tumors and those arising in polyps may have a favorable prognosis

We report 5 polypoid high-grade neuroendocrine carcinomas of the uterus, 2 small cell carcinomas of the endometrium, and 3 large cell neuroendocrine carcinomas, 2 from the cervix and 1 from the endometrium. The 2 small cell carcinomas of the endometrium arose from and were confined to endometrial polyps, one of which also showed foci of endometrioid adenocarcinoma. The myometrium was free of tumor, despite extensive sampling. The 3 large cell neuroendocrine carcinomas, 2 from the cervix and 1 from the endometrium, were polypoid but did not originate in polyps. Two of these tumors infiltrated myometrium, and one did not. The age of the 5 patients ranged from 25 to 66 years (mean age, 43 years). Four patients presented with vaginal bleeding. One pregnant woman had the largest polypoid tumor discovered during a routine gynecologic examination. Tumor sizes ranged from 2.7 to 10 cm. All 5 patients were treated by radical hysterectomy and 4 received adjuvant chemotherapy. Only 2 patient had pelvic lymph node metastasis. All patients are alive and disease-free from 9 months to 7 years after treatment (mean survival, 47 months). All 5 tumors labeled with chromogranin and synaptophysin and 4 with CD56. Two small cell carcinomas and 2 large cell neuroendocrine carcinomas accumulated p53 protein. Two small cell carcinomas and 2 large cell neuroendocrine carcinomas expressed p16. Our findings suggest that stage of disease and a polypoid gross feature are the best predictors for outcome in small cell carcinomas and large cell neuroendocrine carcinomas of the uterus.

Pathology of uterine malignancies

This overview covers epithelial, stromal and mesenchymal malignancies of the body of the uterus, excluding the cervix. The distinction of type I and type II endometrial adenocarcinoma with the morphological variants of this tumour is discussed and some molecular aspects are explored. The concept of carcinosarcoma representing a metaplastic adenocarcinoma of the endometrium that behaves more like a carcinoma than a sarcoma is explained. Some types of mixed epithelial and stromal neoplasm are described and contrasted with carcinosarcoma. The concept of stromal sarcoma and high-grade uterine sarcoma is described and an outline of malignant smooth muscle tumours of the uterus includes a description of smooth muscle tumours of uncertain malignant potential and worrying benign smooth muscle lesions.

Combined large cell neuroendocrine and endometrioid carcinoma of the endometrium

We present the surgical and pathological findings and follow-up of 5 women diagnosed with combined endometrioid and high-grade neuroendocrine carcinoma of large cell type (LCNEC) arising in the endometrium. The mean age of the women was 75 years (range, 50-88 years). Of the 5 tumors, 4 formed polypoid endometrial masses associated with extensive lymphovascular involvement of the myometrium by neoplastic cells. A single endometrial tumor was formed by LCNEC alone, and 4 tumors were composite with varying proportions formed by endometrioid (4/5) and small cell neuroendocrine carcinoma (1/5). In all 5 LCNEC tumor components, an insular growth pattern was noted, whereas a diffuse (solid) pattern was found in 4 tumors, a trabecular in 2, and rosettes/pseudorosettes in another 2. In all 5 tumors, the LCNEC tumor components were labeled with neuron-specific enolase (NSE). Four tumors were reactive for chromogranin A, CAM 5.2, and p53. Three tumors were labeled for AE1/AE3, CD56 (NCAM), p16, and cytokeratin 7. Synaptophysin was reactive in 2 tumors, and CD117 was found in only a single tumor. Of the 3 endometrioid tumor components examined, all were reactive for NSE. Two tumors were reactive for p16 and p53, 1 for CD56, but none for synaptophysin orchromogranin A. We conclude that LCNEC of the endometrium is a distinct clinicopathological entity with a poor prognosis irrespective of stage. The gross and histomorphological features are often suggestive, but confirmation requires immunoperoxidases, including NSE, synaptophysin, chromogranin A, p16, and p53. Combined endometrioid and high-grade LCNEC possess more characteristics of a type II than a type I endometrial carcinoma.

Small cell neuroendocrine carcinoma of the endometrium and laparoscopic staging: a clinicopathologic study of a case and a brief review of the literature

Small cell neuroendocrine (NE) carcinoma is one of the most aggressive tumors that arise in the female genital tract. Small cell carcinoma of the endometrium (SCCE) is an extremely rare disease. Because of its rarity, the only clinical reports are limited to case studies, and therefore, clinical behavior and optimal treatment modalities are not well defined. To the best of our knowledge, we present the first case of SCCE staged by laparoscopic approach. A 54-year-old parous woman admitted with intermittent vaginal spotting. On physical examination, she had a 4- x 3-cm mass fungating out of the cervical os. Magnetic resonance imaging showed an endometrial mass of 25 x 30 x 50 mm in dimensions, invading less than 50% of the depth of the myometrium at the uterine fundus. Pathologic examination revealed undifferentiated malign NE tumor of endometrium of small cell type. The patient underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic pelvic and para-aortic lymphadenectomy. The disease was surgically staged as IB. Histologically, tumor cells were monotone, with scanty, ill-defined cytoplasm and hyperchromatic nuclei. Immunohistochemically, tumor showed positive immunoreactivity for P16, neuron-specific enolase, and synaptophysin. She underwent pelvic external radiation and brachytherapy postoperatively. Patient has no evidence of disease after 26 months of follow-up. Small cell NE carcinoma of the endometrium is an extremely rare and aggressive disease. With the availability of skilled endoscopic surgeons, laparoscopic management of women, even with SCCE in early stage, can be a feasible option.