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1. Chan JK, Loizzi V, Burger RA, Rutgers J, Monk BJ: Prognostic factors in neuroendocrine small cell cervical carcinoma: a multivariate analysis. Cancer; 2003 Feb 1;97(3):568-74
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Prognostic factors in neuroendocrine small cell cervical carcinoma: a multivariate analysis.
  • BACKGROUND: The purpose of this study was to evaluate the clinical and pathologic factors associated with survival in patients with neuroendocrine (NE) cervical carcinoma.
  • METHODS: All patients with NE cervical carcinoma diagnosed between 1979-2001 were identified from tumor registry databases at two hospitals.
  • The impact of clinical and pathologic risk factors on the survival of patients with small cell NE carcinoma of the cervix was evaluated using Kaplan-Meier life table analyses and log-rank tests.
  • RESULTS: Thirty-four patients (median age, 42 years) were diagnosed with neuroendocrine cervical carcinoma, which included 21 with International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, 6 with FIGO Stage II disease, 5 with FIGO Stage III disease, and 2 with FIGO Stage IV disease.
  • Fourteen women received adjuvant therapy with pelvic radiation and/or cisplatin-based chemotherapy.
  • Ten women received primary radiotherapy with (n = 5) or without (n = 4) chemotherapy and the remaining patient refused therapy.
  • CONCLUSIONS: Smoking and advanced stage are reported to be poor prognostic factors for survival in patients with NE small cell carcinoma of the cervix.
  • The role of primary or postoperative radiation with or without chemotherapy is unclear and yields uniformly poor results, particularly in patients with advanced lesions.
  • [MeSH-major] Carcinoma, Small Cell / mortality. Uterine Cervical Neoplasms / mortality

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  • [Copyright] Copyright 2003 American Cancer Society.DOI 10.1002/cncr.11086
  • (PMID = 12548598.001).
  • [ISSN] 0008-543X
  • [Journal-full-title] Cancer
  • [ISO-abbreviation] Cancer
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] United States
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2. Chen J, Macdonald OK, Gaffney DK: Incidence, mortality, and prognostic factors of small cell carcinoma of the cervix. Obstet Gynecol; 2008 Jun;111(6):1394-402
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Incidence, mortality, and prognostic factors of small cell carcinoma of the cervix.
  • OBJECTIVE: To compare the incidence, mortality, and presentation of small cell carcinoma of the cervix with other histologies.
  • METHODS: From 1977 to 2003, 290 women with small cell carcinoma of the cervix uteri were identified from the Surveillance, Epidemiology, and End Results database.
  • Also, 27,527 patients with squamous cell carcinoma of the cervix and 5,231 patients with adenocarcinoma of the cervix were identified for comparison.
  • RESULTS: The mean annual incidence for small cell carcinoma was 0.06 per 100,000 women, compared with 6.6 and 1.2 for squamous cell carcinoma and adenocarcinoma, respectively.
  • There were significant differences at presentation between small cell carcinoma compared with squamous cell carcinoma and adenocarcinoma for race, treatment, International Federation of Gynecology and Obstetrics stage, and lymph node involvement (P<.05).
  • A trend for improved survival was identified for adenocarcinoma (P=.036) and squamous cell carcinoma (P<.001) but not for small cell carcinoma (P=.672).
  • Five-year survival for small cell carcinoma (35.7%) was worse compared with squamous cell carcinoma (60.5%, hazard ratio 0.55; 95% confidence interval (CI) 0.43-0.69) and adenocarcinoma (69.7%, hazard ratio 0.48; 95% CI 0.37-0.61).
  • On multivariable analysis, age, stage, and race were prognostic for survival in women with small cell carcinoma (P<.05).
  • CONCLUSION: Small cell carcinoma is a rare histology of cervical cancer associated with a worse prognosis and a predilection for nodal and distant metastasis.
  • Because of the high rates of nodal involvement even with early-stage disease, multimodality treatment with radiotherapy and chemotherapy should be considered.
  • [MeSH-major] Carcinoma, Small Cell / epidemiology. Uterine Cervical Neoplasms / epidemiology
  • [MeSH-minor] Adenocarcinoma / epidemiology. Adenocarcinoma / mortality. Aged. Carcinoma, Squamous Cell / epidemiology. Carcinoma, Squamous Cell / mortality. Female. Humans. Middle Aged. Prognosis. Proportional Hazards Models. Survival Rate

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  • (PMID = 18515524.001).
  • [ISSN] 0029-7844
  • [Journal-full-title] Obstetrics and gynecology
  • [ISO-abbreviation] Obstet Gynecol
  • [Language] eng
  • [Publication-type] Comparative Study; Journal Article
  • [Publication-country] United States
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3. Saga Y, Suzuki M, Tamura N, Ohwada M, Sato I: Establishment and characterization of a new cell line (SKS) from neuroendocrine small cell carcinoma of the uterine cervix and its chemosensitivity. Oncology; 2001;60(4):367-72
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  • [Title] Establishment and characterization of a new cell line (SKS) from neuroendocrine small cell carcinoma of the uterine cervix and its chemosensitivity.
  • A new cell line (SKS) established from ascites of a patient with neuroendocrine small cell carcinoma of the uterine cervix had a good tumorigenicity and caused marked peritoneal dissemination, and was also highly sensitive to gemcitabine in an in vitro chemosensitivity test.
  • SKS cells were small round cells with a high nuclear/cytoplasmic (N/C) ratio and grew into colony-like aggregates, forming spherical aggregates of floating cells.
  • The population doubling time was 44 h.
  • On examination of the ultrastructure, membrane-bound dense-core neurosecretory-type granules were observed in the cytoplasm.
  • Neuron-specific enolase (NSE) was immunocytochemically positive in the cytoplasm, and 9.3 ng/ml of NSE was detected in the cell culture supernatant.
  • SKS exhibited good tumorigenicity, and the tumor doubling time was 11 days.
  • SKS cells are useful as a model of neuroendocrine small cell carcinoma of the cervix, and chemotherapy using gemcitabine may possibly be effective in this malignancy.
  • [MeSH-major] Antineoplastic Agents / therapeutic use. Carcinoma, Small Cell / pathology. Tumor Cells, Cultured / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Animals. Cell Division / drug effects. DNA, Neoplasm / metabolism. Female. Humans. Immunoenzyme Techniques. Karyotyping. Mice. Mice, Inbred BALB C. Mice, Nude. Mutation. Papillomaviridae. Phenotype. Phosphopyruvate Hydratase / blood. Tumor Virus Infections


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4. Korcum AF, Aksu G, Bozcuk H, Pestereli E, Simsek T: Small cell carcinoma of the cervix: a case report. Arch Gynecol Obstet; 2008 Apr;277(4):367-70
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Small cell carcinoma of the cervix: a case report.
  • Small cell carcinoma of the uterine cervix accounts for 1-3% of all cervix cancers.
  • It is an aggressive disease with a poor prognosis.
  • To date, no effective treatment protocol has been determined.
  • Surgery, radiotherapy, and chemotherapy have been used either alone or in combination.
  • Recent data suggests that survival in patients with early staged small cell carcinoma of the cervix is better with surgery combined with chemo-radiotherapy.
  • Here, we presented two patients with stage IB1 small cell carcinoma of the uterine cervix.
  • For both patients, definitive surgery was performed with pelvic and para-aortic lymphadenectomy.
  • Subsequently, they were treated with pelvic external radiotherapy and high-dose-rate intracavitary brachytherapy with concurrent cisplatin based chemotherapy.
  • [MeSH-major] Carcinoma, Small Cell / therapy. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Antineoplastic Agents, Phytogenic / therapeutic use. Brachytherapy. Cervix Uteri / pathology. Cisplatin / administration & dosage. Combined Modality Therapy. Female. Humans. Pregnancy

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  • (PMID = 17828547.001).
  • [ISSN] 0932-0067
  • [Journal-full-title] Archives of gynecology and obstetrics
  • [ISO-abbreviation] Arch. Gynecol. Obstet.
  • [Language] eng
  • [Publication-type] Case Reports; Journal Article; Research Support, Non-U.S. Gov't
  • [Publication-country] Germany
  • [Chemical-registry-number] 0 / Antineoplastic Agents, Phytogenic; Q20Q21Q62J / Cisplatin
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5. Liu J, Li Y, Li S, Wang D, Hu T, Meng Y, Ma D, Cai H, Wang Z, Xiong C, Zhang H: Clinicopathological features and prognosis of small cell carcinoma of the cervix. J Huazhong Univ Sci Technolog Med Sci; 2010 Oct;30(5):626-30
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  • [Title] Clinicopathological features and prognosis of small cell carcinoma of the cervix.
  • Small cell carcinoma of cervix (SCCC) is a rare disease with highly aggressive behaviour and is pathologically hard to diagnose.
  • In this study, the clinicopathological features, diagnosis, treatment and prognosis of the condition were examined.
  • Pathological examination revealed that the stroma was diffusely infiltrated with small monomorphous cells ranging from round to oval shape.
  • One case was accompanied with squamous cell cancer.
  • On the basis of their stages of condition, one subject with stage III b underwent chemotherapy, and one with stage Ib2 received extensive hysterectomy plus pelvic lymphadenectomy, while the other 5 cases were treated by extensive hysterectomy and pelvic lymphadenectomy in combination with pre- and/or post-operative adjuvant chemotherapy and radiotherapy.
  • Early-stage patients should be treated by extensive hysterectomy and pelvic lymphadenectomy in combination with pre- and/or post-operative adjuvant chemotherapy and radiotherapy.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Carcinoma, Small Cell / therapy. Uterine Cervical Neoplasms / pathology. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Chemotherapy, Adjuvant. Combined Modality Therapy. Female. Humans. Hysterectomy / methods. Middle Aged. Neoplasm Staging. Prognosis. Radiotherapy. Retrospective Studies

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  • (PMID = 21063846.001).
  • [ISSN] 1672-0733
  • [Journal-full-title] Journal of Huazhong University of Science and Technology. Medical sciences = Hua zhong ke ji da xue xue bao. Yi xue Ying De wen ban = Huazhong keji daxue xuebao. Yixue Yingdewen ban
  • [ISO-abbreviation] J. Huazhong Univ. Sci. Technol. Med. Sci.
  • [Language] eng
  • [Publication-type] Journal Article; Research Support, Non-U.S. Gov't
  • [Publication-country] China
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6. Albores-Saavedra J, Latif S, Carrick KS, Alvarado-Cabrero I, Fowler MR: CD56 reactivity in small cell carcinoma of the uterine cervix. Int J Gynecol Pathol; 2005 Apr;24(2):113-7
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] CD56 reactivity in small cell carcinoma of the uterine cervix.
  • Small cell carcinoma (SCC) of the uterine cervix, like its pulmonary counterpart, is a rare but distinctive neoplasm that should be separated from nonendocrine carcinomas because of its highly aggressive clinical course and response to chemotherapy and irradiation.
  • CD56 (neural cell adhesion molecule) has recently been shown to be the best marker for the diagnosis of pulmonary SCC.
  • In this study, we assessed the sensitivity and specificity of CD56 in the diagnosis of SCC of the uterine cervix compared with those of chromogranin and synaptophysin.
  • Twenty-two (88%) of 25 SCCs of the uterine cervix labeled with CD56 in a predominantly membranous and diffuse pattern, whereas 16 of 25 (64%) stained with synaptophysin in a predominantly diffuse pattern and 8 of 25 (32%) showed predominantly focal immunoreactivity for chromogranin.
  • In contrast, 3 of 21 (14%) moderately to poorly differentiated squamous cell carcinomas and 1 of 16 (6%) moderately differentiated adenocarcinomas showed focal immunoreactivity for CD56.
  • Although not specific, CD56 seems to be the most sensitive marker for the diagnosis of SCC of the uterine cervix.
  • Moreover, its diffuse reactivity reduces the possibility of obtaining negative results in small biopsy samples.
  • [MeSH-major] Antigens, CD56 / metabolism. Biomarkers, Tumor / analysis. Carcinoma, Small Cell / diagnosis. Uterine Neoplasms / diagnosis
  • [MeSH-minor] Cervix Uteri / pathology. Chromogranin A. Chromogranins / metabolism. Diagnosis, Differential. Female. Humans. Immunohistochemistry. Sensitivity and Specificity. Synaptophysin / metabolism

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  • (PMID = 15782066.001).
  • [ISSN] 0277-1691
  • [Journal-full-title] International journal of gynecological pathology : official journal of the International Society of Gynecological Pathologists
  • [ISO-abbreviation] Int. J. Gynecol. Pathol.
  • [Language] eng
  • [Publication-type] Comparative Study; Journal Article
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Antigens, CD56; 0 / Biomarkers, Tumor; 0 / Chromogranin A; 0 / Chromogranins; 0 / Synaptophysin
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7. Yu A, Zhang P, Lou H: Clinicophathologic characteristics and treatment of small cell carcinoma of uterine cervix. Zhonghua Zhong Liu Za Zhi; 2002 Jul;24(4):400-3
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Clinicophathologic characteristics and treatment of small cell carcinoma of uterine cervix.
  • OBJECTIVE: To study the clinicopathologic characteristics, prognostic factors, response to chemotherapy, chemotherapy-caused disease-free interval and overall survival of small cell carcinoma of uterine cervix (SCCUC).
  • All 12 samples were assessed through immunohistochemical methods including epithelial cell markers and neuroendocrine cell markers, showing positive results in all.
  • Five of these 9 patients had received neoadjuvant chemotherapy (NCH) once or twice before operation, three patients received adjuvant chemotherapy (ACH) once to six times after operation.
  • Three patients with advanced lesions received concurrent chemotherapy twice to four times.
  • The success rate of surgery in the NCH group was 100%, 60% of whom showed chemotherapy response pathologically.
  • CONCLUSION: Poor prognosis of small cell carcinoma of uterine cervix, even the early lesions, is due to its high incidence of pelvic lymph metastasis.
  • The risk factor of this lesion is high sensitivity to chemotherapy, but chemotherapeutic long-term survival should be studied further with more allotted material.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Female. Humans. Middle Aged. Neoplasm Staging. Treatment Outcome

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  • (PMID = 12408776.001).
  • [ISSN] 0253-3766
  • [Journal-full-title] Zhonghua zhong liu za zhi [Chinese journal of oncology]
  • [ISO-abbreviation] Zhonghua Zhong Liu Za Zhi
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] China
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8. Deng GH, Zhang X, Wu LY: [Clinicopathological analysis of nine cases of small cell carcinoma of the uterine cervix]. Zhonghua Zhong Liu Za Zhi; 2010 Mar;32(3):199-202
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  • [Title] [Clinicopathological analysis of nine cases of small cell carcinoma of the uterine cervix].
  • OBJECTIVE: To investigate the clinicopathologic characteristics, therapy and prognostic factors of small cell carcinoma of the uterine cervix (SCCC).
  • METHODS: Nine patients with SCCC underwent radical hysterectomy at the Cancer Hospital of CAMS between 2000 to 2009.
  • All tumors were composed of small-sized cells with scant cytoplasm, darkly stained round to oval nuclei, finely dispersed chromatin and absence of nucleoli.
  • All patients received postoperative chemotherapy, with or without radiotherapy.
  • Correct diagnosis of SCCC depends on the combination of light microscopic and immunohistochemical analysis.
  • It is necessary to use multimodality treatment for SCCC, especially the chemotherapy.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Hysterectomy. Nuclear Proteins / metabolism. Transcription Factors / metabolism. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Antigens, CD56 / metabolism. Antineoplastic Combined Chemotherapy Protocols / therapeutic use. Chromogranin A / metabolism. Cisplatin / therapeutic use. Combined Modality Therapy. Cyclin-Dependent Kinase Inhibitor p16 / metabolism. Female. Follow-Up Studies. Humans. Lymph Node Excision. Middle Aged. Neoplasm Staging. Phosphopyruvate Hydratase / metabolism. Radiotherapy, High-Energy. Survival Rate. Synaptophysin / metabolism. Taxoids / therapeutic use

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  • (PMID = 20450588.001).
  • [ISSN] 0253-3766
  • [Journal-full-title] Zhonghua zhong liu za zhi [Chinese journal of oncology]
  • [ISO-abbreviation] Zhonghua Zhong Liu Za Zhi
  • [Language] chi
  • [Publication-type] English Abstract; Journal Article; Review
  • [Publication-country] China
  • [Chemical-registry-number] 0 / Antigens, CD56; 0 / Chromogranin A; 0 / Cyclin-Dependent Kinase Inhibitor p16; 0 / Nuclear Proteins; 0 / Synaptophysin; 0 / Taxoids; 0 / Transcription Factors; 0 / thyroid nuclear factor 1; EC 4.2.1.11 / Phosphopyruvate Hydratase; Q20Q21Q62J / Cisplatin; TP protocol
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9. Collinet P, Lanvin D, Declerck D, Chevalier-Place A, Leblanc E, Querleu D: Neuroendocrine tumors of the uterine cervix. Clinicopathologic study of five patients. Eur J Obstet Gynecol Reprod Biol; 2000 Jul;91(1):51-7
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  • [Title] Neuroendocrine tumors of the uterine cervix. Clinicopathologic study of five patients.
  • Four main clinicopathologic features of neuroendocrine tumors (NETs) of the cervix may be stressed: primary diagnosis at an advanced stage, early nodal metastasis even for low disease, early failure of appropriate local treatment (surgery and/or radiation therapy) and aggressive clinical treatment.
  • Five patients with NET of the uterine cervix (small cell carcinoma type) are reported (one stage I, two stages II, one stage III and one stage IV).
  • One patient was treated by surgery combined with radiation therapy, one by surgery combined with chemotherapy and one by surgery with radiation therapy and chemotherapy.
  • Two patients received radiation therapy alone.
  • Three early stage patients are alive with no evidence of disease 8, 26 and 41 months after diagnosis.
  • The two patients with advanced stage died of disease, 3 and 12 months respectively, after diagnosis.
  • Combination chemotherapy (cisplatin and etoposide) is warranted in disseminated NETs.
  • Neoadjuvant or adjuvant chemotherapy should be combined with radiation therapy and surgery even in early stages.
  • [MeSH-major] Neuroendocrine Tumors / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Aged. Aged, 80 and over. Antineoplastic Combined Chemotherapy Protocols / therapeutic use. Carcinoma, Small Cell / pathology. Carcinoma, Small Cell / therapy. Combined Modality Therapy. Female. Humans. Hysterectomy / methods. Middle Aged

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  • (PMID = 10817879.001).
  • [ISSN] 0301-2115
  • [Journal-full-title] European journal of obstetrics, gynecology, and reproductive biology
  • [ISO-abbreviation] Eur. J. Obstet. Gynecol. Reprod. Biol.
  • [Language] eng
  • [Publication-type] Case Reports; Journal Article
  • [Publication-country] IRELAND
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10. Hoskins PJ, Swenerton KD, Pike JA, Lim P, Aquino-Parsons C, Wong F, Lee N: Small-cell carcinoma of the cervix: fourteen years of experience at a single institution using a combined-modality regimen of involved-field irradiation and platinum-based combination chemotherapy. J Clin Oncol; 2003 Sep 15;21(18):3495-501
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  • [Title] Small-cell carcinoma of the cervix: fourteen years of experience at a single institution using a combined-modality regimen of involved-field irradiation and platinum-based combination chemotherapy.
  • PURPOSE: To determine the efficacy and toxicity of a combined-modality regimen of irradiation with platinum-based combination chemotherapy in small-cell carcinoma of the cervix (SCCC).
  • PATIENTS AND METHODS: Thirty-four patients with SCCC were seen and treated at the British Columbia Cancer Agency between May 1988 and November 2002.
  • Both protocols used cisplatin, etoposide, and involved-field irradiation (essentially pelvis plus or minus para-aortics) with concurrent chemotherapy.
  • CONCLUSION: SCCC can be successfully treated in approximately 55% of patients with a combination of irradiation and platinum-based chemotherapy.
  • [MeSH-major] Antineoplastic Combined Chemotherapy Protocols / therapeutic use. Carcinoma, Small Cell / therapy. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Aged. Carboplatin / administration & dosage. Carboplatin / adverse effects. Cisplatin / administration & dosage. Cisplatin / adverse effects. Combined Modality Therapy. Disease-Free Survival. Etoposide / administration & dosage. Etoposide / adverse effects. Female. Humans. Middle Aged. Paclitaxel / administration & dosage. Paclitaxel / adverse effects. Radiotherapy Dosage. Survival Rate

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  • (PMID = 12972526.001).
  • [ISSN] 0732-183X
  • [Journal-full-title] Journal of clinical oncology : official journal of the American Society of Clinical Oncology
  • [ISO-abbreviation] J. Clin. Oncol.
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] United States
  • [Chemical-registry-number] 6PLQ3CP4P3 / Etoposide; BG3F62OND5 / Carboplatin; P88XT4IS4D / Paclitaxel; Q20Q21Q62J / Cisplatin
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11. Ohwada M, Suzuki M, Hironaka M, Irie T, Sato I: Neuroendocrine small cell carcinoma of the uterine cervix showing polypoid growth and complicated by pregnancy. Gynecol Oncol; 2001 Apr;81(1):117-9
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  • [Title] Neuroendocrine small cell carcinoma of the uterine cervix showing polypoid growth and complicated by pregnancy.
  • BACKGROUND: Neuroendocrine small cell carcinoma of the uterine cervix is an aggressive disease, and it rarely is complicated by pregnancy.
  • CASE: A polypoid tumor was found in the uterine cervix in a 27-year-old Japanese woman at 27 weeks of gestation.
  • The polyp was excised and diagnosed as neuroendocrine small cell carcinoma by histological examination, including Grimelius, neuron-specific enolase, and chromogranin staining.
  • After surgery, four cycles of combination chemotherapy with cisplatin and etoposide were administered, and the patient is disease-free as of 13 months after surgery.
  • [MeSH-major] Carcinoma, Neuroendocrine / pathology. Carcinoma, Small Cell / pathology. Pregnancy Complications, Neoplastic / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Cell Division / physiology. Female. Humans. Polyps / drug therapy. Polyps / pathology. Polyps / surgery. Pregnancy

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  • [Copyright] Copyright 2001 Academic Press.
  • (PMID = 11277662.001).
  • [ISSN] 0090-8258
  • [Journal-full-title] Gynecologic oncology
  • [ISO-abbreviation] Gynecol. Oncol.
  • [Language] eng
  • [Publication-type] Case Reports; Journal Article; Review
  • [Publication-country] United States
  • [Number-of-references] 15
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12. Delaloge S, Pautier P, Kerbrat P, Castaigne D, Haie-Meder C, Duvillard P, Guivarch C, Goupil A, Borel C, Lhommé C: Neuroendocrine small cell carcinoma of the uterine cervix: what disease? What treatment? Report of ten cases and a review of the literature. Clin Oncol (R Coll Radiol); 2000;12(6):357-62
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  • [Title] Neuroendocrine small cell carcinoma of the uterine cervix: what disease? What treatment? Report of ten cases and a review of the literature.
  • Neuroendocrine small cell carcinoma of the uterine cervix (NESCCC) is an entity with very aggressive behaviour.
  • The optimal initial therapeutic approach to this rare disease has not yet been clearly defined.
  • One patient had metastatic disease at presentation; three developed metastases during initial treatment.
  • Eight patients underwent surgery and eight received radiation therapy.
  • Six patients received pre- or postoperative cisplatinumvepeside (PE) combination chemotherapy, either alone or concurrently with radiation therapy.
  • PE alone as primary chemotherapy led to disease stabilization in the two patients so treated; concurrent PE and radiation therapy resulted in a pathological complete response in one patient.
  • Eight patients relapsed within 16 months and died of their disease within 29 months from the initial diagnosis.
  • Our series confirms the previously described very poor prognosis of NESCCC, despite initial aggressive multidisciplinary treatment.
  • It may be that the introduction of chemotherapy, especially combined primary chemoradiotherapy, might allow patients to do a little better, although at the moment there is no good evidence one way or the other.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Antineoplastic Combined Chemotherapy Protocols / therapeutic use. Chemotherapy, Adjuvant. Combined Modality Therapy. Female. Humans. Middle Aged. Prognosis. Radiotherapy, Adjuvant


13. Conner MG, Richter H, Moran CA, Hameed A, Albores-Saavedra J: Small cell carcinoma of the cervix: a clinicopathologic and immunohistochemical study of 23 cases. Ann Diagn Pathol; 2002 Dec;6(6):345-8
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  • [Title] Small cell carcinoma of the cervix: a clinicopathologic and immunohistochemical study of 23 cases.
  • Twenty-three patients with primary small cell carcinoma of the uterine cervix are presented.
  • Nuclear molding, single cell necrosis, and high mitotic activity were found in all tumors.
  • There was a minor component of large cell neuroendocrine carcinoma in three cases, while foci of adenocarcinoma were identified in two cases.
  • Ten small cell carcinomas were immunoreactive for chromogranin, 13 for synaptophysin, and 10 expressed p53 protein.
  • Treatment modalities included hysterectomy alone or combined with chemotherapy and/or radiation therapy.
  • A few patients received chemotherapy and/or radiation alone.
  • Small cell carcinoma of the cervix is a highly aggressive neoplasm.
  • However, early diagnosis and combined therapeutic modalities may lead to longer survival in some patients.
  • Although the use of immunohistochemistry may be helpful in the diagnosis, small cell carcinoma still remains a morphologic diagnosis.
  • [MeSH-major] Carcinoma, Small Cell / metabolism. Carcinoma, Small Cell / pathology. Uterine Cervical Neoplasms / metabolism. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adenocarcinoma / pathology. Adult. Biomarkers. Chromogranins / metabolism. Female. Follow-Up Studies. Humans. Immunohistochemistry. Keratins / metabolism. Middle Aged. Synaptophysin / metabolism. Treatment Outcome. Tumor Suppressor Protein p53 / metabolism

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  • [Copyright] Copyright 2002, Elsevier Science (USA). All rights reserved.
  • (PMID = 12478483.001).
  • [ISSN] 1092-9134
  • [Journal-full-title] Annals of diagnostic pathology
  • [ISO-abbreviation] Ann Diagn Pathol
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Biomarkers; 0 / CAM 5.2 antigen; 0 / Chromogranins; 0 / Synaptophysin; 0 / Tumor Suppressor Protein p53; 68238-35-7 / Keratins
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14. Ota T, Kitano T, Miyai K, Ogishima D, Yoshida M, Miyake K, Kinoshita K: Small cell carcinoma of the uterine cervix metastasizing to the bone marrow: a case report. J Obstet Gynaecol Res; 2008 Aug;34(4 Pt 2):692-5
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  • [Title] Small cell carcinoma of the uterine cervix metastasizing to the bone marrow: a case report.
  • We report a case of small cell carcinoma (SmCC) of the uterine cervix that metastasized to the bone marrow.
  • A 60-year-old woman with stage IIB SmCC of the cervix was treated with three courses of neoadjuvant chemotherapy followed by radical hysterectomy.
  • Because of the presence of a large residual tumor, the patient underwent postoperative adjuvant chemotherapy.
  • Two months after the last course of chemotherapy, severe pancytopenia developed, and erythroblastic cells were found in the peripheral blood.
  • The patient died of the disease 8 months after the initial diagnosis.
  • This case suggests that SmCC of the cervix can metastasize to bone marrow, that such metastasis can occur in isolation and lead to severe pancytopenia, influencing the clinical course of the disease.
  • [MeSH-major] Bone Marrow Neoplasms / secondary. Carcinoma, Small Cell / secondary. Cervix Uteri / pathology. Uterine Cervical Neoplasms / pathology


15. Cheng M, Wu LY, Bai P, Zhang R, Zheng S: [Clinicopathologic characteristics of eight patients with small cell carcinoma of the cervix]. Zhonghua Fu Chan Ke Za Zhi; 2008 Mar;43(3):189-92
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

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  • [Title] [Clinicopathologic characteristics of eight patients with small cell carcinoma of the cervix].
  • OBJECTIVE: To investigate the clinicopathologic characteristics, therapy and prognostic factors of small cell carcinoma of the cervix.
  • Histopathologic findings showed the small tumor cells had scant cytoplasm, round nuclei, absence of nucleoli, and finely dispersed chromatin.
  • Three patients with stage I b disease and 1 patient with stage III b disease underwent radical hysterectomy and postoperative chemotherapy, with or without radiotherapy, and the survival period was 64, 22, 14 and 6 months respectively.
  • Two patients with stage II b disease and 2 with stage III b disease underwent chemotherapy and radiotherapy, and the survival period was 25, 9, 10 and 5 months respectively.
  • CONCLUSIONS: Immunohistochemical analysis using several kinds of neuroendocrine markers is helpful in establishing the correct diagnosis in addition to focusing on characteristic histopathological features.
  • It is necessary to use comprehensive treatment including surgery, chemotherapy and radiotherapy for patients with small cell carcinoma of the cervix.
  • Chemotherapy may play an important role in the treatment.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Antineoplastic Agents / therapeutic use. Biomarkers, Tumor. Chemotherapy, Adjuvant. Combined Modality Therapy. Female. Humans. Hysterectomy. Immunohistochemistry. Lymph Node Excision. Microscopy. Middle Aged. Neoplasm Staging. Prognosis. Retrospective Studies. Survival Rate. Young Adult

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  • (PMID = 18788567.001).
  • [ISSN] 0529-567X
  • [Journal-full-title] Zhonghua fu chan ke za zhi
  • [ISO-abbreviation] Zhonghua Fu Chan Ke Za Zhi
  • [Language] chi
  • [Publication-type] English Abstract; Journal Article
  • [Publication-country] China
  • [Chemical-registry-number] 0 / Antineoplastic Agents; 0 / Biomarkers, Tumor
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16. Alphandery C, Dagrada G, Frattini M, Perrone F, Pilotti S: Neuroendocrine small cell carcinoma of the cervix associated with endocervical adenocarcinoma: a case report. Acta Cytol; 2007 Jul-Aug;51(4):589-93
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  • [Title] Neuroendocrine small cell carcinoma of the cervix associated with endocervical adenocarcinoma: a case report.
  • BACKGROUND: Small-cell carcinoma (SCC) of the cervix is an uncommon member of the neuroendocrine group of cervical carcinomas that is frequently intermixed with a non-SCC component in the form of an adenocarcinoma (ADC) or squamous carcinoma.
  • CASE: Colposcopy revealed a cervical mass in a 41-year-old woman and a Pap smear the presence of some tumor cells from SCC, which was confirmed by subsequent biopsy.
  • The patient received 3 cycles of chemotherapy and then underwent major surgery.
  • The cervical samples showed areas of endocervical ADC adjacent to and intermixed with the SCC.
  • On subsequent molecular investigation to assess clonality by microsatellite analysis, the presence of HR-HPV DNA18 on real-time polymerase chain reaction, p16(INK4a) fluorescence in situ hybridization status and the corresponding immunohistochemical expression supported the hypothesis that the two components of the tumor shared the same cell origin.
  • CONCLUSION: SCC of the cervix is a rare but distinct HR-HPV-18-related cervical carcinoma often intermixed with a clonally related non-small cell component consisting of an ADC or squamous carcinoma.
  • The presence of SCC tumor cells in a cervical smear should prompt a search for malignant glandular or squamous tumor cells.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Neuroendocrine Tumors / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Antigens, CD56 / metabolism. Biopsy. Cervix Uteri / pathology. Chromogranin A / metabolism. Chromosomes, Human, Pair 17 / genetics. Chromosomes, Human, Pair 18 / genetics. Cyclin-Dependent Kinase Inhibitor p16 / metabolism. Female. Humans. In Situ Hybridization, Fluorescence. Microsatellite Repeats / genetics. Papanicolaou Test. Synaptophysin / metabolism. Vaginal Smears

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  • (PMID = 17718130.001).
  • [ISSN] 0001-5547
  • [Journal-full-title] Acta cytologica
  • [ISO-abbreviation] Acta Cytol.
  • [Language] eng
  • [Publication-type] Case Reports; Journal Article; Research Support, Non-U.S. Gov't
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Antigens, CD56; 0 / Chromogranin A; 0 / Cyclin-Dependent Kinase Inhibitor p16; 0 / Synaptophysin
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17. Trinh XB, Bogers JJ, Van Marck EA, Tjalma WA: Treatment policy of neuroendocrine small cell cancer of the cervix. Eur J Gynaecol Oncol; 2004;25(1):40-4
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Treatment policy of neuroendocrine small cell cancer of the cervix.
  • Small cell cancers of the cervix are very rare and aggressive tumours.
  • There are no clinical trials, due to their rarity, that would suggest optimal treatment.
  • The present report describes a patient with a neuroendocrine small cell cancer of the cervix Stage IB2 with a positive lymph node.
  • The treatment consisted of radical hysterectomy and node dissection, adjuvant chemotherapy, chemoradiation and brachytherapy.
  • Since 1996, there has been a classification for neuroendocrine tumours (NETs) of the cervix in four categories (large cell, small cell, typical carcinoid and atypical carcinoid).
  • The aggressive behaviour of neuroendocrine small cell cancer is demonstrated by the high percentage of early lymphatic node and vessel invasion (68 and 90%).
  • Multimodal therapy for these tumours appears to give good response but often implies severe side-effects.
  • [MeSH-major] Carcinoma, Neuroendocrine / diagnosis. Carcinoma, Neuroendocrine / therapy. Uterine Cervical Neoplasms / diagnosis. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Combined Modality Therapy. Decision Trees. Diagnosis, Differential. Female. Humans. Lymphatic Metastasis. Neoplasm Staging


18. Viswanathan AN, Deavers MT, Jhingran A, Ramirez PT, Levenback C, Eifel PJ: Small cell neuroendocrine carcinoma of the cervix: outcome and patterns of recurrence. Gynecol Oncol; 2004 Apr;93(1):27-33
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Small cell neuroendocrine carcinoma of the cervix: outcome and patterns of recurrence.
  • OBJECTIVES: To analyze the sites of relapse and overall survival in women with neuroendocrine marker-positive small cell carcinoma of the cervix.
  • METHODS: The records of all women who had their initial treatment for cervical cancer at The University of Texas M.D.
  • Anderson Cancer Center between 1980 and 2000 were reviewed.
  • Fifty-one patients had stages I-III cancers that were originally described as "small cell" or "neuroendocrine."
  • Histological material was available for reexamination in 45 cases; of these, 21 were found to have small cell neuroendocrine carcinoma (SCNEC) as indicated by positive staining for chromogranin, synaptophysin, or CD56.
  • Local treatment consisted of a radical hysterectomy in six patients and radiation therapy in 15.
  • Thirteen patients received chemotherapy as part of their initial treatment.
  • The median time to first relapse from the initiation of treatment was 8.4 months (range, 3.6-28 months).
  • Most patients developed hematogenous distant metastases before their death.
  • Only 2 of 15 patients who were treated with radiation therapy had a recurrence within the radiation fields.
  • However, five patients had a recurrence above the radiation fields in the paraaortic lymph nodes, and two patients had a recurrence distal to the pelvic fields in the vagina.
  • However, two patients developed brain metastases concurrently with lung metastases.
  • CONCLUSIONS: Patients with small cell neuroendocrine cervical cancer have a poor prognosis.
  • [MeSH-major] Carcinoma, Neuroendocrine / pathology. Carcinoma, Neuroendocrine / therapy. Neoplasm Recurrence, Local / pathology. Uterine Cervical Neoplasms / pathology. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Aged. Combined Modality Therapy. Female. Humans. Middle Aged. Neoplasm Staging. Retrospective Studies. Survival Rate. Treatment Outcome

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  • (PMID = 15047210.001).
  • [ISSN] 0090-8258
  • [Journal-full-title] Gynecologic oncology
  • [ISO-abbreviation] Gynecol. Oncol.
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] United States
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19. Niwa K, Nonaka-Shibata M, Satoh E, Hirose Y: Cervical large cell neuroendocrine carcinoma with cytologic presentation: a case report. Acta Cytol; 2010 Sep-Oct;54(5 Suppl):977-80
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

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  • [Title] Cervical large cell neuroendocrine carcinoma with cytologic presentation: a case report.
  • BACKGROUND: Large cell neuroendocrine carcinoma (LCNEC) is a rare and aggressive cervical neoplasm.
  • The cervical smears showed cells dispersed as single cells or arranged as loosely cohesive sheets or glandlike aggregate and the nuclear size was almost 3-5 times larger than that of small lymphocytes.
  • The patient underwent a radical hysterectomy and then received radiation and systemic chemotherapy.
  • CONCLUSION: Cytologic and colposcopic findings for LCNEC of the uterine cervix are reported.
  • Early diagnosis of the tumor is important.
  • [MeSH-major] Carcinoma, Large Cell / pathology. Carcinoma, Neuroendocrine / pathology. Cervix Uteri / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Cell Nucleus / pathology. Colposcopy. Fatal Outcome. Female. Humans

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  • (PMID = 21053581.001).
  • [ISSN] 0001-5547
  • [Journal-full-title] Acta cytologica
  • [ISO-abbreviation] Acta Cytol.
  • [Language] eng
  • [Publication-type] Case Reports; Journal Article
  • [Publication-country] United States
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20. Cohen JG, Kapp DS, Shin JY, Urban R, Sherman AE, Chen LM, Osann K, Chan JK: Small cell carcinoma of the cervix: treatment and survival outcomes of 188 patients. Am J Obstet Gynecol; 2010 Oct;203(4):347.e1-6
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Small cell carcinoma of the cervix: treatment and survival outcomes of 188 patients.
  • OBJECTIVE: To determine the clinicopathologic factors associated with survival in neuroendocrine small cell cervical cancer patients.
  • A total of 55.3% underwent surgery, 16.0% had chemoradiation, 12.8% radiation, and 3.2% chemotherapy alone.
  • Adjuvant chemotherapy or chemoradiation was associated with improved survival in patients with stages IIB-IVA disease compared with those who did not receive chemotherapy (17.8% vs 6.0%; P = .04).
  • On multivariable analysis, early-stage disease and use of chemotherapy or chemoradiation were independent prognostic factors for improved survival.
  • CONCLUSION: Use of adjuvant chemotherapy or chemoradiation was associated with higher survival in small cell cervical cancer patients.
  • [MeSH-major] Carcinoma, Small Cell / mortality. Carcinoma, Small Cell / therapy. Uterine Cervical Neoplasms / mortality. Uterine Cervical Neoplasms / therapy
  • [MeSH-minor] Adult. Aged. Aged, 80 and over. Antineoplastic Agents / therapeutic use. Chemotherapy, Adjuvant. Cisplatin / therapeutic use. Etoposide / therapeutic use. Female. Humans. Hysterectomy. Kaplan-Meier Estimate. Lymph Node Excision. Lymphatic Metastasis. Middle Aged. Multivariate Analysis. Neoplasm Recurrence, Local. Radiotherapy, Adjuvant. Registries

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  • [Copyright] Copyright ¬© 2010 Mosby, Inc. All rights reserved.
  • (PMID = 20579961.001).
  • [ISSN] 1097-6868
  • [Journal-full-title] American journal of obstetrics and gynecology
  • [ISO-abbreviation] Am. J. Obstet. Gynecol.
  • [Language] eng
  • [Publication-type] Journal Article; Review
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Antineoplastic Agents; 6PLQ3CP4P3 / Etoposide; Q20Q21Q62J / Cisplatin
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21. Huang CY, Chen YL, Chu TC, Cheng WF, Hsieh CY, Lin MC: Prognostic factors in women with early stage small cell carcinoma of the uterine cervix. Oncol Res; 2009;18(5-6):279-86
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Prognostic factors in women with early stage small cell carcinoma of the uterine cervix.
  • Small cell carcinoma of the uterine cervix (SCCUC) is an uncommon, aggressive disease accounting for less than 5% of all cervical cancers.
  • Due to its rarity, definitive treatment strategies have not been developed.
  • Our aim was to analyze the clinical factors, treatment modalities, sites of relapse, and overall survival of women with early stage SCCUC and thus determine prognostic factors.
  • The clinical records of 18 women diagnosed with stage IB1 to IIA SCCUC were reviewed, and patient characteristics and treatment modalities were analyzed to determine the prognostic factors for disease-free survival (DFS) and overall survival (OS).
  • Radical hysterectomy followed by adjuvant chemotherapy resulted in higher 2-year survival rates compared to radical hysterectomy followed by adjuvant radiotherapy (62.5% vs. 16.7%); however, the difference was not statistically significant due to the small sample size.
  • Further larger scale analysis is warranted to determine whether adjuvant chemotherapy may facilitate a better prognosis than adjuvant radiotherapy.
  • [MeSH-major] Carcinoma, Small Cell / pathology. Uterine Cervical Neoplasms / pathology
  • [MeSH-minor] Adult. Aged. Aged, 80 and over. Chemotherapy, Adjuvant. Combined Modality Therapy. Female. Humans. Lymphatic Metastasis. Middle Aged. Prognosis. Radiotherapy, Adjuvant. Survival Rate. Treatment Outcome

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  • (PMID = 20225765.001).
  • [ISSN] 0965-0407
  • [Journal-full-title] Oncology research
  • [ISO-abbreviation] Oncol. Res.
  • [Language] eng
  • [Publication-type] Journal Article
  • [Publication-country] United States
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22. Yang YJ, Trapkin LK, Demoski RK, Bellerdine J, Powers CN: The small blue cell dilemma associated with tamoxifen therapy. Arch Pathol Lab Med; 2001 Aug;125(8):1047-50
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  • [Title] The small blue cell dilemma associated with tamoxifen therapy.
  • CONTEXT: Several endometrial diseases, such as endometrial hyperplasia, endometrial carcinoma, and endometrial polyps, have been reported to be associated with tamoxifen administration.
  • We recently observed a high incidence of distinctive small blue cells in Papanicolaou tests of women who had received tamoxifen treatment for breast carcinoma.
  • OBJECTIVES: To define the characteristics of these small blue cells, to identify the patient population in which they are found, and to determine the clinical significance and possible etiology of these findings.
  • DESIGN: A total of 154 Papanicolaou tests from 60 patients with a clinical history of tamoxifen therapy were reviewed retrospectively.
  • RESULTS: Small blue cells were found in 40% of Papanicolaou tests from patients who received tamoxifen therapy.
  • Patients with small blue cells in their Papanicolaou tests were an average of 9 years older at the time tamoxifen therapy was initiated than those without.
  • CONCLUSIONS: We conclude that these distinctive small blue cells are found more frequently in older patients and most probably represent proliferative reserve cells of cervical/vaginal epithelium resulting from the estrogenic agonist effect of tamoxifen.
  • [MeSH-major] Cervix Uteri / pathology. Papanicolaou Test. Tamoxifen / adverse effects. Vagina / pathology. Vaginal Smears
  • [MeSH-minor] Adult. Aged. Aged, 80 and over. Atrophy. Breast Neoplasms / drug therapy. Endometrial Neoplasms / chemically induced. Endometrium / pathology. Epithelium / pathology. Female. Humans. Hysterectomy. Menstrual Cycle. Middle Aged


23. Nijhuis ER, van der Zee AG, in 't Hout BA, Boomgaard JJ, de Hullu JA, Pras E, Hollema H, Aalders JG, Nijman HW, Willemse PH, Mourits MJ: Gynecologic examination and cervical biopsies after (chemo) radiation for cervical cancer to identify patients eligible for salvage surgery. Int J Radiat Oncol Biol Phys; 2006 Nov 1;66(3):699-705
International Agency for Research on Cancer - Screening Group. diagnostics - Histopathology and cytopathology of the uterine cervix - digital atlas .

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  • [Title] Gynecologic examination and cervical biopsies after (chemo) radiation for cervical cancer to identify patients eligible for salvage surgery.
  • PURPOSE: The aim of this study was to evaluate efficacy of gynecologic examination under general anesthesia with cervical biopsies after (chemo) radiation for cervical cancer to identify patients with residual disease who may benefit from salvage surgery.
  • METHODS AND MATERIALS: In a retrospective cohort study data of all cervical cancer patients with the International Federation of Gynecology and Obstetrics (FIGO) Stage IB1 to IVA treated with (chemo) radiation between 1994 and 2001 were analyzed.
  • Patients underwent gynecologic examination under anesthesia 8 to 10 weeks after completion of treatment.
  • Cervical biopsy samples were taken from patients judged to be operable.
  • In case of residual cancer, salvage surgery was performed.
  • RESULTS: Between 1994 and 2001, 169 consecutive cervical cancer patients received primary (chemo) radiation, of whom 4 were lost to follow-up.
  • CONCLUSIONS: Gynecologic examination under anesthesia 8 to 10 weeks after (chemo) radiation with cervical biopsies allows identification of those cervical cancer patients who have residual local disease, of whom a small but significant proportion may be salvaged by surgery.
  • [MeSH-major] Cervix Uteri / pathology. Salvage Therapy. Uterine Cervical Neoplasms
  • [MeSH-minor] Adenocarcinoma / drug therapy. Adenocarcinoma / pathology. Adenocarcinoma / radiotherapy. Adenocarcinoma / surgery. Adult. Aged. Anesthesia, General. Biopsy. Carcinoma, Adenosquamous / drug therapy. Carcinoma, Adenosquamous / pathology. Carcinoma, Adenosquamous / radiotherapy. Carcinoma, Adenosquamous / surgery. Carcinoma, Squamous Cell / drug therapy. Carcinoma, Squamous Cell / pathology. Carcinoma, Squamous Cell / radiotherapy. Carcinoma, Squamous Cell / surgery. Combined Modality Therapy / methods. Female. Follow-Up Studies. Humans. Middle Aged. Neoplasm, Residual. Retrospective Studies. Survival Analysis

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  • (PMID = 16904839.001).
  • [ISSN] 0360-3016
  • [Journal-full-title] International journal of radiation oncology, biology, physics
  • [ISO-abbreviation] Int. J. Radiat. Oncol. Biol. Phys.
  • [Language] eng
  • [Publication-type] Evaluation Studies; Journal Article
  • [Publication-country] United States
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