Clinical features of ovarian large-cell neuroendocrine carcinoma: Four case reports and review of the literature

Role of radiotherapy in the management of rare gynaecological cancers

There are a large number of gynaecological cancers with rare histologies, for which the available data are limited and usually retrospective. Because of their rarity and poor prognosis, the management of these cancers must be centralized in expert centres, for both histological diagnosis and treatment. With the exception of sarcomas, most endometrial or cervical cancers with rare histologies respond to the same radiation treatment modalities than cancers with more common histologies, although there are some specificities regarding treatments such as neuroendocrine carcinomas (chemotherapy with platinum and etoposide, major role of surgery). For localized or locally advanced ovarian cancer, external beam radiotherapy has a role in the management of hypercalcaemic small cell carcinoma of the ovary. This article summarizes the current role of external beam radiotherapy and brachytherapy in the management of cancers of the uterine cervix, uterine corpus and ovaries, with rare or very rare histologies, and with localized or locally advanced stages.

Large-cell neuroendocrine carcinoma of the gynecologic tract: Prevalence, survival outcomes, and associated factors

BACKGROUND

We aimed to assess the clinical behavior of gynecologic large-cell neuroendocrine carcinoma (LCNEC) via a retrospective analysis of data from 469 patients.

METHODS

Patients diagnosed with gynecologic LCNEC from 1988 to 2015 were identified using the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox hazard regression analyses were performed to assess independent predictors of overall survival (OS) and cancer-specific survival (CSS). OS and CSS were also evaluated using the Kaplan-Meier method, and the effects of different treatment regimens on prognosis were compared according to disease stage.

RESULTS

Cervical, ovarian, and endometrial LCNEC were observed in 169, 219, and 79 patients, respectively. The 5-year OS rates for patients with cervical, ovarian, and endometrial LCNEC were 35.98%, 17.84%, and 23.21%, respectively, and the median duration of overall survival was 26, 11, and 11 months in each group. The 5-year CSS rates for the three groups were 45.23%, 19.23%, and 31.39%, respectively, and the median duration of CSS was 41, 12, and 11 months in each group. Multivariate analysis revealed that American Joint Committee on Cancer stage, lymph node metastasis, and chemotherapy were independent prognostic factors for OS and CSS in patients with cervical LCNEC. Lymph node metastasis, surgery, and chemotherapy were independent prognostic factors for OS and CSS in the ovarian group and for OS in the endometrial group. Lymph node metastasis and surgery were also independent prognostic factors for CSS in the endometrial group.

CONCLUSION

Surgery alone may help to improve overall survival and CSS in patients with early-stage cervical LCNEC. In contrast, surgery+chemotherapy and surgery+radiotherapy may help to improve survival in those with early-stage ovarian and endometrial LCNEC, respectively. Regardless of subtype, comprehensive treatment involving surgery, CTX, and RT should be considered to improve prognosis in patients with advanced-stage gynecologic LCNEC.

An Ovarian Large-Cell Neuroendocrine Carcinoma Accompanied by Clear Cell Carcinoma with Specific High Level of AFP: Case Report and Review of the Literature

Large cell neuroendocrine carcinoma (LCNEC) is a rare histological subtype of ovarian cancer. A few cases have been reported in the literature with extreme invasiveness and a poor prognosis. However, there still have not been accepted criteria for diagnosis and treatment of LCNEC. Here we report an unmarried 37 year-old woman who was diagnosed with LCNEC associated with clear cell carcinoma and the tumor index was manifested with a specific increase of AFP. The case received six courses of etoposide and carboplatin chemotherapy as an adjuvant therapy after primary curative surgery. However, she relapsed within 6 months after surgery and metastasized rapidly to distant organs despite combined chemotherapy of paclitaxel, cisplatin, and bevacizumab, and died 18 months after primary surgery. This is the first reported case of LCNEC manifested with a specific increase of AFP and characteristically metastasized to the spine as recurrence. Reviewing our case as well as previously reported cases, LCNEC present with aggressive malignancy and vulnerable to distant metastasis through a hematogenous approach, we conjectured that adding Bevacizumab in primary chemotherapy may be beneficial to extend disease-free survival. But so far there is no recommendation of this regimen for treatment of LCNEC in current guidelines. Further research is needed to confirm this view so as to find the best treatment of LCNEC and improve the prognosis of these patients.

Differences in Characteristics and Outcomes Between Large-Cell Neuroendocrine Carcinoma of the Ovary and High-Grade Serous Ovarian Cancer: A Retrospective Observational Cohort Study

Background

Owing to its extremely low incidence and the paucity of relevant reports, there is currently no recognized first-line treatment strategy for ovarian large-cell neuroendocrine carcinoma, and there are no statistics related to prognosis derived from large samples. This study aimed to investigate the characteristics, outcomes, and independent predictors of survival for ovarian large-cell neuroendocrine carcinoma and compare them with those of high-grade serous ovarian cancer.

Methods

The Surveillance, Epidemiology, and End Results database was used to identify women diagnosed with ovarian large-cell neuroendocrine carcinoma or high-grade serous ovarian cancer from 1988 to 2015. Clinical, demographic, and treatment characteristics were compared between the groups. Propensity-score matching, Cox risk regression analysis, and Kaplan-Meier survival curves were used to analyze the data.

Results

In total, 23,917 women, including 23,698 (99.1%) diagnosed with high-grade serous ovarian cancer and 219 (0.9%) diagnosed with ovarian large-cell neuroendocrine carcinoma, were identified. Age >77 years, diagnosis before 2003-2010, and advanced-stage disease were more common in patients with ovarian large-cell neuroendocrine carcinoma than in those with high-grade serous ovarian cancer. Women with ovarian large-cell neuroendocrine carcinoma were less likely to receive adjuvant chemotherapy (54.8% vs. 81.9%) but more likely to receive radiotherapy (3.2% vs. 1.5%; both P<0.001) than women with high-grade serous ovarian cancer. Stage, chemotherapy, and tumor size were independent predictors of overall survival, and the risk of death was greater in the advanced stage than in the early stage (P=0.047). Chemotherapy and tumor size were also independent predictors of cancer-specific survival. Overall and cancer-specific survival rates were significantly low for ovarian large-cell neuroendocrine carcinoma than for more malignant high-grade serous ovarian cancer.

Conclusions

Compared to patients with high-grade serous ovarian cancer, those with ovarian large-cell neuroendocrine carcinoma presented more often with advanced-stage disease and had decreased overall and cancer-specific survival rates.

Primary pure large cell neuroendocrine carcinoma of the ovary: histopathologic and immunohistochemical analysis with review of the literature

BACKGROUND

Primary ovarian large cell neuroendocrine carcinoma (POLNEC) is an extremely rare and highly aggressive malignancy. Establishing a definite diagnosis requires histopathologic examination with immunohistochemical demonstration of neuroendocrine differentiation in the tumor cells. The histopathology may overlap with a variety of other ovarian malignancies; however, rendering an accurate diagnosis is essential, owing to the therapeutic and prognostic implications.

CASE

A 62-year-old, post-menopausal woman presented with complaints of abdominal fullness and dull-aching abdominal pain for the last three months. A pelvic ultrasound revealed the presence of a complex adnexal mass. Serum levels of tumor markers, CA125, carcinoembryonic antigen, alpha-fetoprotein, and beta-human chorionic gonadotropin, were within normal limits. Pelvic magnetic resonance imaging showed a heterogeneous lobulated right adnexal mass measuring 6.7×5.8×5.6 cm, which was T2-hyperintense and T1-hypointense. A provisional diagnosis of ovarian carcinoma was made, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.

RESULTS

Histopathology showed an organoid and nesting pattern with a focal perivascular arrangement of the tumor cells with large, moderately pleomorphic, round to oval nuclei, granular chromatin, conspicuous nucleoli, and a moderate amount of pale-eosinophilic cytoplasm. Brisk mitosis and lymphovascular space involvement were noted. On immunohistochemistry, the tumor cells showed positivity for chromogranin, synaptophysin, and neuron-specific enolase and were negative for PAX8, WT1, vimentin, and epithelial membrane antigen. p53 showed wild-type, and SMARCB1/INI-1 showed retained nuclear expression. Based on the histopathologic and immunohistochemical features, a final diagnosis of POLNEC was rendered. The patient received 4 cycles of adjuvant chemotherapy and is disease-free, 28 months post-treatment.

CONCLUSIONS

The present report highlights the characteristic histopathologic and immunohistochemical features of POLCNEC to distinguish it from other clinicopathologic mimics and present a comprehensive review of the published literature of all such cases.

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.

INSM1 Is Less Sensitive But More Specific Than Synaptophysin in Gynecologic High-grade Neuroendocrine Carcinomas: An Immunohistochemical Study of 75 Cases With Specificity Test and Literature Review

Insulinoma-associated protein 1 (INSM1) has emerged as a promising diagnostic marker for high-grade neuroendocrine carcinomas (HGNECs); however, it is controversial whether INSM1 is more sensitive than conventional markers chromogranin, synaptophysin, and CD56. Here, we investigated immunohistochemical expression of INSM1 in 75 gynecologic HGNECs using full tissue sections (30 small-cell carcinomas [SmCCs], 34 large-cell neuroendocrine carcinomas [LCNECs], and 11 mixed SmCC and LCNEC), with specificity analysis in 422 gynecologic non-neuroendocrine tumors (410 in tissue microarrays and 12 full sections) and comparison with conventional neuroendocrine markers for their sensitivity and specificity. Positive INSM1 staining was seen in 69 (92%) HGNECs, whereas chromogranin, synaptophysin, and CD56 staining was seen in 61 (81%), 72 (96%), and 44 (69%) tumors, respectively (INSM1 vs. chromogranin, P=0.09; INSM1 vs. synaptophysin, P=0.4942; and INSM1 vs. CD56, P<0.001). The mean percentage of INSM1-positive tumor cells was 54% (median: 60%, range: 0% to 100%), similar to chromogranin (58%, P=0.2903) and higher than CD56 (30%, P=0.00001) but significantly lower than synaptophysin (89%, P<0.00001). INSM1 showed no staining difference among SmCCs, LCNECs, and mixed SmCC-LCNECs. Among the 422 non-neuroendocrine tumors, positive staining was seen in 5% tumors for INSM1, 18% for chromogranin, 19% for synaptophysin, and 25% for CD56. Our study indicates that INSM1 is a highly specific marker (95% specificity) for gynecologic HGNECs with high sensitivity (92%), but it is less sensitive than synaptophysin (96% sensitivity). INSM1 is more specific than chromogranin, synaptophysin, and CD56 for gynecologic HGNECs. Our literature review reveals that INSM1 has consistently (the same antibody clone A8 used for all reported studies) shown higher or similar sensitivity to chromogranin (for all 3 chromogranin antibody clones LK2H10, DAK-A3, DAKO polyclonal); however, whether INSM1 is more or less sensitive than synaptophysin or CD56 for HGNECs is highly dependent on the antibody clones used for synaptophysin (clones MRQ-40 and SNP88 showing higher sensitivity than clones 27G12 and DAK-SYNAP) or CD56 (clones CD564, MRQ-42, and MRQ-54 showing higher sensitivity than clones 123C3D5, 1B6, and Leu243).

Primary pure large cell neuroendocrine carcinoma of the ovary: A rare case report and review of literature

INTRODUCTION

Ovarian large cell neuroendocrine carcinoma (LCNEC), or ovarian non-small cell neuroendocrine carcinoma, which is a newly described tumour in the classification of primary ovarian neoplasms by the World Health Organization, is a rare entity that is frequently associated with a surface epithelial and germ cell neoplasm component. Few cases have been reported in the literature, and only 18 primary pure ovarian LCNEC cases have been reported so far, including our 1 case. Ovarian LCNEC is a highly aggressive tumor with a poor prognosis even at an early stage.

PATIENT CONCERNS

We report a case of a 55-year-old postmenopausal woman who complained of abdominal pain. CT examination revealed a mass in the right adnexial region and CA125 level was elevated.

DIAGNOSIS

She underwent a exploratory laparotomy, and diagnosed as LCNEC histopathologically.

INTERVENTIONS

Cytoreductive surgery was administered to the patient, and had accepted 5 cycles of chemotherapy consisting of paclitaxel and cisplatin.

OUTCOMES

Follow-up for 12 months showed no clinical or radiological evidence of disease recurrence.

CONCLUSION

This case is 1 of the ovarian LCNEC which is a rare and extremely malignant tumor. Diagnosis requires histopathology and immunohistochemistry. The treatment includes primary cytoreductive surgery followed by chemotherapy.

Gynecologic large cell neuroendocrine carcinoma: A review

Large cell neuroendocrine carcinomas (LCNEC) are rare, aggressive high-grade neuroendocrine neoplasms within the neuroendocrine cell lineage spectrum. This manuscript provides a detailed review of published literature on LCNEC of gynecological origin. We performed a PubMed search for material available on gynecologic LCNEC. We analyzed 104 unique cases of gynecologic LCNECs, of which 45 were cervical primary, 45 were ovarian, 13 were uterine, and 1 was vaginal. A total of 45 cases of cervical LCNEC were identified with a median age of 36 years. Median overall survival was 16 months. We identified 45 ovarian LCNEC cases in the published literature with a median age of 54 years. Median overall survival was 8 months. 13 LCNEC cases of uterine origin were identified; 12 out of 13 were of endometrial origin and the median age was 71 years. The majority of patients presented with Stage III/IV disease (stages I-IV were 31%, 8%, 38%, and 23%, respectively). Gynecologic LCNEC is an aggressive malignancy. Our current understanding of the disease biology is very limited. Efforts are required to better understand the genomic and molecular characterizations of gynecological LCNEC. These efforts will elucidate the underlying oncogenic pathways and driver mutations as potential targets.

Role of diagnostic laparoscopy in patients with large cell neuroendocrine carcinoma of the ovary with cancerous peritonitis: case report and review of the literature

Background

Large cell neuroendocrine carcinoma is a very rare ovarian neoplasm that has a poor clinical outcome even in the early stage, and there is as yet no established treatment. Diagnostic laparoscopy has been used to determine the possibility of primary optimal cytoreductive surgery or neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer. However, the role of diagnostic laparoscopy is still unclear in large cell neuroendocrine carcinoma due to its rarity.

Case presentation

A 31-year-old woman with abdominal distention was referred to our hospital. She was strongly suspected of having advanced ovarian cancer because of a huge pelvic mass, massive ascites, and their appearance on medical imaging. However, cytological examinations from ascitic fluid by abdominal paracentesis did not show any malignant cells. She underwent diagnostic laparoscopy to evaluate the possibility of primary optimal cytoreductive surgery, and only tissue sampling was performed for pathological diagnosis because of the countless disseminated lesions of various sizes in the intraperitoneal organs. The patient had no postoperative complications, leading to the early start of postoperative chemotherapy.

Conclusions

To date, there have been no systematic reviews that focused on determining the treatment strategy using laparoscopy. Diagnostic laparoscopy can be helpful to determine the optimal treatment, including primary debulking surgery, neoadjuvant chemotherapy, or best supportive care, assisting in decision-making particularly for patients with advanced large cell neuroendocrine carcinoma with carcinomatous peritonitis.

Small-cell carcinoma-associated ovarian mucinous carcinoma: A case report and literature review

Neuroendocrine neoplasm-associated ovarian mucinous carcinoma occurs extremely rarely. Here, we report an ovarian composite tumor consisting of small-cell carcinoma and mucinous carcinoma in a 51-year-old woman presented with abdominal distention. Ultrasonography revealed the presence of a complex irregular cystic solid mass. Microscopic findings showed pulmonary-type small-cell carcinoma-associated, intestinal-type ovarian mucinous carcinoma-with positive results for several neuroendocrine markers (chromogranin, CD56) and the thyroid transcription factor-1. The patient underwent total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and six cycles of adjuvant chemotherapy but died eight months after the surgery due to disease progression. Few reports are available in China on this clinicopathological feature in this composite tumor type. The timely identification of ovarian small-cell carcinoma among other ovarian tumors is critically important to the accurate and prompt determination of the therapy due to its high invasiveness and metastatic potential.

Pathological features, clinical presentations and prognostic factors of ovarian large cell neuroendocrine carcinoma: a case report and review of published literature

Background

There is no consensus on the optimal chemotherapy regimen and the prognostic factors for ovarian large cell neuroendocrine carcinoma (LCNEC), a rare type of tumor. The objective of the present study is to present the case of a recent encounter of pure ovarian LCNEC and perform a brief review to summarize the clinicopathological features and prognostic factors of 57 cases of LCNEC patients that have been previously reported.

Method: case presentation

Eligible studies were searched for online and 57 cases with clear follow-up data were found to have been reported. We present the 58th case, which is of a 70-year-old woman with stage IIIc primary pure LCNEC of the ovary. The initial symptom of this patient was abdominal distension (more than 2 months). A recent ultrasound test showed a solid-cystic mass occupying the pelvic and abdominal cavity. She received two courses of cisplatin-etoposide chemotherapy as an adjuvant therapy. No signs of nonclinical or radiological evidence of disease recurrence was found at follow-up examinations during the first 3 months after operation. A retrospective review of these 58 cases was conducted and survival curves were estimated. Using the Kaplan-Meier method.

Conclusion

The patients included were aged between 18 and 80 years. A Kaplan-Meier survival curve revealed that the median overall survival was 10.000 months, while 26 (44.83%) patients died within 12 months. We compared the overall mean survival time of all patients with that of stage I patients (42.418 vs 42.047 months), which suggests that ovarian LCNEC has a very poor prognosis even at stage I. Mean survival was longer for patients who had undergone postoperative chemotherapy than for those without postoperative chemotherapy (48.082 vs 9.778 months). A small series, such as this, does not provide adequate data to establish a firm correlation between the postoperative chemotherapy and prognosis (p = 0.176). In our review of 58 cases with ovarian LCNEC, prognosis was unfavorable in most cases. Given the rarity of LCNEC, it is highly recommended that a global medical database of ovarian LCNEC and a standard system of diagnosis and treatment is established.

Prognostic impact of neuroendocrine differentiation in high-grade serous ovarian carcinoma

Neuroendocrine differentiation in high-grade serous ovarian carcinomas has only rarely been described. However, in our consultancy experience, we have been pointed at a case of neuroendocrine relapse in a patient with high-grade serous ovarian carcinoma where retrospectively, a minor neuroendocrine component in the primary tumor could be detected. Hypothesizing that immunohistochemical evidence of neuroendocrine differentiation might be more frequent in ovarian carcinoma than suspected by morphology, we immunophenotyped the tissue microarrays (TMAs) of a cohort of 178 high-grade serous carcinomas for chromogranin and synaptophysin expression. Synaptophysin expression was found in 12 (6.7 %) out of 172 patients, and chromogranin A expression was seen in 36 (20.7 %) out of 174 patients. Kaplan-Meier analysis revealed that carcinomas with synaptophysin expression of >20 % of positive cells (n = 4) had a significantly shorter survival time than those with 0-20 % of positive cells (p < 0.0001). Synaptophysin expression remained a significant prognostic factor in multivariate analysis (HR = 10.82, 95 % confidence interval 3.10-37.71, p < 0.0001), independently of age, FIGO stage, and residual tumor after surgery. A trend toward shorter survival was seen in patients with tumors that expressed chromogranin, irrespective of the amount of positive cells (p = 0.173). A neuroendocrine differentiation is important to keep in mind when a neuroendocrine tumor of unknown primary is detected in regional or temporal connection with an ovarian carcinoma. A minor neuroendocrine component in ovarian high-grade serous carcinomas might imply a dismal prognosis.

Large Cell Neuroendocrine Carcinoma of the Ovary and Its Skin Metastases: A Case Report and Review of the Literature

Large cell neuroendocrine carcinoma in the gynaecological organs affects the uterine cervix and ovary. Large cell neuroendocrine carcinoma of the ovary is extremely rare, and prognosis is quite poor even when diagnosed at an early stage. These tumours respond poorly to standard chemotherapy regimens. The clinical observation of skin metastasis in patients with epithelial ovarian cancer is relatively uncommon, occurring in only 3.5% of patients. These lesions are observed mostly in skin of the abdominal wall adjacent to the primary ovarian tumours. Metastatic skin lesions on extremities are much more rare; it is reported that only 12% of epithelial ovarian carcinoma skin metastases occur on the limbs. Skin metastasis due to large cell neuroendocrine carcinoma of the ovary has not been previously reported. We report the case of a large cell neuroendocrine tumour of the ovary with skin metastases on extremities appearing two months after surgery in a 68-year old woman.

Pure large cell neuroendocrine carcinoma of ovary: a rare clinical entity and review of literature

Large cell neuroendocrine carcinoma (LCNEC) of the ovary is a rare tumor and is now included in the World Health Organization tumor classification. Its prognosis is generally very poor even when the diagnosis is made at an early stage. We report a case of pure large cell neuroendocrine tumour of ovary, appearing 9 months following laparoscopic type I hysterectomy, bilateral pelvic lymph node dissection with ovarian preservation of anatomically normal looking ovaries performed for a cervical biopsy diagnosis of cervical intraepithelial neoplasia grade III with foci of invasion. The rarity lies in the rapid onset (9 months) of a large tumor following conservation of an anatomically normal ovaries. Surgical debulking and five cycles of chemotherapy (Etoposide and Cisplatin) were administered to the woman. She is on followup with no clinical or radiological evidence of disease recurrence for 6 months.