A Rare Case of Ectopic Adrenocorticotropic Hormone Syndrome in Small Cell Carcinoma of the Vagina: A Case Report

Small Cell Carcinoma of the Vagina: First Systematic Review of Case Reports and Proposal of a Management Algorithm

OBJECTIVES

Small cell carcinoma of the vagina (SmCCV) is an extremely rare disease. Evidence-based data and specific guidelines are lacking. We conducted the first systematic review of case reports to provide the most overall picture of SmCCV.

MATERIALS AND METHODS

Literature search in PubMed and Scopus was performed using the terms "small cell carcinoma" and "vagina." English-language case reports of primary SmCCV up to January 2022 were included.

RESULTS

Twenty-nine articles describing 44 cases met our inclusion criteria. We report a new case of our hospital. The global median overall survival (mOS) was 12.00 months (95% CI = 9.31-14.69). The mOS was not reached for stage I, and it was 12.00, 12.00, 9.00, and 8.00 months for stages II, III, IVA, and IVB, respectively (statistically significant differences between stage I and stages II, III, or IVA [log rank p = .003-.017]). Thirty-five cases received local treatments (77.8%). The mOS of patients treated with surgery ± complementary chemotherapy, radiotherapy ± complementary chemotherapy, chemoradiation ± complementary chemotherapy, and surgery + radiotherapy ± complementary chemotherapy were 11.00, 12.00, 17.00, and 29.00 months, respectively. The use of adjuvant or neoadjuvant chemotherapy (64.5%, mostly platinum + etoposide) showed longer mOS (77.00 vs 15.00 months). Four of 5 tested cases presented human papillomavirus infection, 3 of them presenting type 18.

CONCLUSIONS

Small cell carcinoma of the vagina shows dismal prognosis. Multimodal local management plus complementary chemotherapy seems to achieve better outcomes. Human papillomavirus could be related to the development of SmCCV. A diagnostic-therapeutic algorithm is proposed.

Neuroendocrine carcinoma of vagina with prolonged survival

We report the case of a woman in her 70s with a stage IVA small cell neuroendocrine carcinoma of the vagina. The patient started chemotherapy with cisplatin and etoposide followed by concurrent chemoradiotherapy and adjuvant chemotherapy. Pelvic MRI after completion of treatment did not show residual disease. Three years and 8 months after definitive treatment, the patient remains on regular follow-up without evidence of disease.

Small cell neuroendocrine carcinoma of vagina: Report of a unique case with literature review

Small cell carcinoma (SCC) of vagina is extremely rare. The association between this tumor and high-risk HPV infection is unclear. To our knowledge, HPV status has been reported in only 3 previous cases of SCC of vagina. Herein, we present a unique case of vaginal small cell carcinoma with discordant HPV testing results between vaginal and cervical samples. We also review and discuss findings from previously reported cases of small cell carcinoma of vagina.

Neuroendocrine Neoplasia of the Female Genital Tract

Neuroendocrine neoplasia is relatively uncommon in the female genital tract (FGT) and occurs at any site, most often the ovary and cervix. A unified dichotomous nomenclature, introduced by the World Health Organization Classification of Tumors in all fifth edition volumes, divides neuroendocrine neoplasms (NENs) into well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs). The term carcinoid tumor is retained in the ovary and represents the commonest FGT NEN. NEC is most common in the cervix and is usually admixed with another human papillomavirus-associated epithelial neoplasm. Despite shared neuroendocrine differentiation, NET and NEC show diverse etiology, morphology, and clinical behavior.

Primary poorly differentiated carcinoma of the vagina with focal neuroendocrine differentiation: a tumour with aggressive behaviour

Primary vaginal neuroendocrine tumours are extremely rare but aggressive. We report a case of primary poorly differentiated vaginal carcinoma with focal neuroendocrine differentiation. The clinical stage was cT3N1M0, FIGO stage III. The patient received six cycles of cisplatin-based concurrent chemoradiation therapy (CCRT) followed by six cycles of adjuvant chemotherapy (IEP protocol: ifosfomide, epirubicin and cisplatin). Pelvic MRI scans obtained after treatment completion revealed no residual tumour in the vagina. However, the patient experienced severe dyspnoea 2 months later. Chest X-ray revealed a reticulonodular interstitial pattern over bilateral lungs with suspicion of lymphangitic carcinomatosis. Further chest, abdominal and pelvic CT scans showed bilateral lung metastases with multiple mediastinal, left lower neck and left axilla, intra-abdominal and pelvic lymphadenopathies. For this rare tumour, cisplatin-based CCRT followed by IEP protocol adjuvant chemotherapy may have a limited treatment effect. Further studies are necessary to provide more information on clinical management.

Primary small cell carcinoma of the vagina: a rare instance of prolonged survival

Small cell carcinoma (SmCC) of the vagina is a rare and aggressive tumour. It comprises only 1% -2% of all gynaecological malignancies 85% of the patients with SmCC vagina die within a year of diagnosis. Here we report the case of a 65-year-old woman with stage III primary neuroendocrine carcinoma of vagina who was treated with chemoradiotherapy. The patient survived 1 year and 10 months after the initial presentation. SmCC of the vagina is very rare and despite being aggressive, the local disease can be controlled with a chemoradiation regimen.

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.

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.

A case of small cell carcinoma of the vagina

Primary small cell carcinoma of the vagina is quite rare, and a standard treatment has not been established yet. Herein, we report a case of an 81-year-old woman who was diagnosed with a vaginal tumor without continuity with the uterine cervix. Histopathological diagnosis indicated alveolar solid growth of nuclear chromatin-rich atypical cells with a high N/C ratio and a partially recognized rosette-like structure, suggesting a differentiated neuroendocrine system. Chromogranin A and synaptophysin were positive. Stage I vaginal small cell carcinoma localized to the vagina was diagnosed. The tumor disappeared by radiation monotherapy with external beam irradiation and endocavitary irradiation. The patient remains alive without any disease 1 year and 8 months after the treatment, suggesting the efficacy of radiotherapy in small cell carcinoma of the vagina.

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.

Glucocorticoid receptor haplotype is associated with a decreased risk of delirium in the elderly

Delirium is the most common mental disorder at older age in hospitals after acute admission. The pathogenesis of delirium is largely unknown. Hyperactivity of the hypothalamic-pituitary-adrenal axis, leading to increased cortisol levels, has been suggested to play a role in the development of delirium. The effects of cortisol, the most important glucocorticoid (GC) in humans, are mainly mediated by the GC receptor (GR). Several polymorphisms in the GR gene that alter the GC sensitivity are known. The aim of this study was to study the role of these GR polymorphisms in delirium in elderly patients. Patients aged 65 years and older admitted to the medical department or scheduled for hip surgery were included. Delirium was diagnosed using the Confusion Assessment Method. Five single nucleotide polymorphisms in the GC receptor gene were genotyped and haplotypes were constructed. Delirium was associated with impaired cognitive (P < 0.001) and functional function (P < 0.001), as well as with older age (P < 0.001). Homozygous carriers of haplotype 4, characterized by the presence of the BclI and TthIIII minor alleles, had a 92% decreased risk of developing delirium (P = 0.02), independent of age, cognitive, and functional state. Homozygous carriage of the BclI-TthIIII haplotype of the GR gene is related to a reduced risk of developing delirium. This suggests that altered GC signaling may be involved in the pathogenesis and development of delirium in the elderly.