AJR 2004; 182:1255-1258
© American Roentgen Ray Society
MRI of Small Cell Carcinoma of the Uterine Cervix with Pathologic Correlation
Dong Hyun Yang1,
Jeong Kon Kim1,
Kyoung Won Kim1,
Sang-Jin Bae2,
Kie Hwan Kim3 and
Kyoung-Sik Cho1
1 Department of Radiology, Asan Medical Center, University of Ulsan, College of
Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, South Korea.
2 Department of Radiology, Inje University, Sanggyepaik Hospital, 761-1
Sanggye-7 dong, Nowon-gu, Seoul 139-707, South Korea.
3 Department of Radiology, Korea Cancer Center Hospital, 215-4 Gongreung-dong,
Nowon-gu, Seoul 139-706, South Korea.
Received September 22, 2003;
accepted after revision November 6, 2003.
Address correspondence to J. K. Kim
(rialto{at}amc.seoul.kr).
Abstract
OBJECTIVE. The purpose of this study was to evaluate the MRI
features of small cell carcinoma of the uterine cervix and to correlate those
features with pathologic findings.
CONCLUSION. Small cell carcinoma of the uterine cervix can be
characterized by frequent parametrial invasion and extensive lymphadenopathy,
although the tumor morphology seems to be nonspecific on MRI.
Introduction
Small cell carcinoma is a rare primary neoplasm of the uterine cervix,
accounting for 0.5–6% of all uterine cervical cancers
[1–3].
Small cell carcinoma of the uterine cervix is an aggressive tumor with early
spread to the entire body, thereby leading to a fatal clinical course and
minimal chance of survival
[1–4].
Because of the distinct natural history of small cell carcinoma of the uterine
cervix and because patients with this condition are considered to have a
systemic disease, the treatment strategies for this disease are different from
those of other carcinomas [4,
5].
Papanicolaou's smear, a popular screening method for uterine cervix cancer,
is not sensitive for the diagnosis of small cell carcinoma of the uterine
cervix. Accordingly, some patients may be inadequately treated because they
are initially considered to have non–small cell carcinoma on the basis
of Papanicolaou's smear result alone
[4–6].
Therefore, the suggestion of small cell carcinoma on imaging studies is
important for adequate patient treatment.
MRI has been proposed as the gold standard for the imaging evaluation of
uterine cervical cancer. To our knowledge, no report of small cell carcinoma
of the uterine cervix exists in the radiology literature. The purpose of this
study was to evaluate the MRI features of small cell carcinoma of the uterine
cervix and to correlate those features with the pathologic findings.
Materials and Methods
Patient Population
A computerized search at our institution of the medical records, radiology
reports, and pathology reports from October 1998 through September 2002
revealed seven patients (mean age ± standard deviation [SD], 50
± 8 years; age range, 42–65 years) with pathologically proven
small cell carcinoma of the uterine cervix. The diagnosis of primary small
cell carcinoma of the uterine cervix was made when patients had small cell
carcinoma in the uterine cervix but had no primary tumor in the other organs
and no previous history of small cell carcinoma in the lung.
MRI
MRI was performed in all patients using a Signa 1.5-T scanner (General
Electric Medical Systems). T1-weighted spin-echo images using a body coil (TR
range/TE range, 400–600/8–11; section thickness, 7–8 mm;
intersection gap, 1 mm; field of view, 32 cm; number of acquisitions, 2;
matrix, 256 x 256) were obtained from the renal hila to the femoral
neck. Transverse and sagittal T2-weighted fast spinecho images using a body
coil (4,000–5,000/90–110; echo-train length, 8; section thickness,
5–6 mm; intersection gap, 1 mm; field of view, 32 cm; number of
acquisitions, 3; matrix, 512 x 512) were obtained from the aortic
bifurcation to the femoral neck. Finally, transverse, sagittal, and coronal
T2-weighted fast spin-echo images using an endovaginal coil
(3,500–4,500/100–120; echo-train length, 8; section thickness, 4
mm; intersection gap, 1 mm; field of view; 15 cm; number of acquisitions, 3;
matrix, 512 x 512) were obtained. At our institution, an MRI examination
of patients with uterine cervix cancer does not include contrast-enhanced
imaging. Therefore, contrast-enhanced MR images were not available for this
study.
MR Image Analysis
MR images were retrospectively evaluated in consensus by three radiologists
who were unaware of the patient information. MR images were reviewed for the
following characteristics: morphologic characteristics, including the greatest
diameter of the tumor, tumor margin (smooth or irregular), tumor shape (round,
ovoid, or lobular), signal intensity of tumor compared with that of skeletal
muscle on both T1- and T2-weighted images, and internal appearance
(homogeneous or heterogeneous); the presence or absence of tumor invasion into
the parametrium, vagina, and adjacent organs by referring to the criteria in
the previous report [7]; and
the presence or absence of lymphadenopathy. Lymphadenopathy was considered to
be present when the short diameter of the lymph node was greater than 1 cm and
the location of lymphadenopathy was determined as parametrial, internal iliac,
external iliac, obturator, common iliac, and paraaortic areas. We encountered
a number of areas in which lymphadenopathy was noted; lymphadenopathy was
considered to be present when a lymph node was greater than 1 cm in the
minimal diameter or when three or more lymph nodes were conglomerated.
In patients who had undergone radical hysterectomy and lymphadenectomy, we
correlated MRI features and pathologic findings with regard to tumor
morphology, the presence or absence of vaginal or parametrial invasion, and
the extent of lymph node metastasis.
Results
MRI Findings
The mean ± SD of the greatest tumor diameter was 4.1 ± 2.2 cm
(range, 1.5–8.6 cm). The greatest diameter was greater than 4 cm in two
patients (29%) and 4 cm or less in five patients (71%). Five (71%) of seven
tumors showed irregular margins and the remaining two tumors (29%) had smooth
margins. Four patients (57%) had round or oval tumors, and the other three
(43%) had lobulated tumors. In both patients with a greatest tumor diameter of
more than 4 cm, the tumors had irregular margins and a lobular shape. All
tumors showed low signal intensity on T1-weighted images and high signal
intensity on T2-weighted images. The internal tumor appearance was homogeneous
in all patients.
Vaginal invasion was noted in three (43%) of seven patients: in both
patients (100%) having a greatest tumor diameter of more than 4 cm
(Fig. 1A), but in only one
patient (20%) with a greatest tumor diameter of 4 cm or less
(Fig. 2A).
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Fig. 1A. —49-year-old woman with small cell carcinoma of uterine
cervix. Sagittal T2-weighted image shows mass (arrowheads) in uterine
cervix that invades upper vagina and extends upward along posterior surface of
uterus.
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Fig. 2A. —43-year-old woman with small cell carcinoma of uterine
cervix. Sagittal T2-weighted image obtained using endovaginal coil shows mass
(arrowheads) in uterine cervix and invading upper vagina
(arrows). B = bladder, C = endovaginal coil, U = uterus.
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Parametrial invasion was noted in five (71%) of seven patients. Both
patients (100%) with a greatest tumor diameter larger than 4 cm had
parametrial invasion (Figs. 1B
and 1C), and three (60%) of
five patients with a greatest tumor diameter of 4 cm or less had parametrial
invasion (Figs. 2B and
2C). One patient with a
greatest tumor diameter of 1.5 cm had no vaginal or parametrial invasion.
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Fig. 1B. —49-year-old woman with small cell carcinoma of uterine
cervix. Transverse T2-weighted (TR/TE, 4,000/90) (B) and T1-weighted
(500/11) (C) images using body coil at similar level to A show
lobulated mass (arrowheads) involving uterine cervix. Mass has
homogeneous low signal intensity on A and homogeneous high signal
intensity on B. Note several lymph nodes, exceeding 1 cm in short
diameter, in parametrial (single arrows) and right obturator
(double arrows) areas.
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Fig. 1C. —49-year-old woman with small cell carcinoma of uterine
cervix. Transverse T2-weighted (TR/TE, 4,000/90) (B) and T1-weighted
(500/11) (C) images using body coil at similar level to A show
lobulated mass (arrowheads) involving uterine cervix. Mass has
homogeneous low signal intensity on A and homogeneous high signal
intensity on B. Note several lymph nodes, exceeding 1 cm in short
diameter, in parametrial (single arrows) and right obturator
(double arrows) areas.
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Fig. 2B. —43-year-old woman with small cell carcinoma of uterine
cervix. Transverse T2-weighted image (TR/TE, 4,000/90) obtained using body
coil show mass (arrowheads) involving uterine cervix. Mass has
homogeneous high signal intensity and invades left parametrium
(arrows).
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Fig. 2C. —43-year-old woman with small cell carcinoma of uterine
cervix. Transverse T2-weighted image (4,000/100) obtained using endovaginal
coil at same level as B shows mass (arrowheads) in uterine
cervix. Mass invades left parametrium (arrows). R = rectum.
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We found no patient with tumor invading adjacent organs.
Six (86%) of seven patients showed lymphadenopathy on MRI
(Fig. 1D), and only one patient
(14%), whose greatest tumor diameter was 1.5 cm, had no lymphadenopathy.
Therefore, lymphadenopathy was noted in four patients (80%) with tumors of 4
cm or less in the greatest diameter and in both patients (100%) with tumors
greater than 4 cm. The number of lymphadenopathy foci was one in two patients
(29%), three in two (29%), and nine in two (29%). Both patients with tumors
greater than 4 cm had paraaortic lymphadenopathy.
Pathologic Correlation
Three patients underwent radical hysterectomy and lymphadenectomy. All of
the remaining four patients underwent punch biopsy. On microscopic
examination, all tumors consisted of small irregular nests of neoplastic cells
that had hyperchromatic nuclei and scanty cytoplasm
(Fig. 1E).
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Fig. 1E. —49-year-old woman with small cell carcinoma of uterine
cervix. Photomicrograph shows features of small cell carcinoma of uterine
cervix. Tumor consists of small irregular nests of neoplastic cells that have
hyperchromatic nucleus and scanty cytoplasm. (H and E, x100)
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In the three patients who underwent radical hysterectomy, all tumors were
homogeneous, solid, soft masses without internal hemorrhage or necrosis on
gross examination. Microscopic examination revealed parametrial invasion in
two patients and vaginal invasion in one patient, as noted on MR images. In
the remaining one patient who had a greatest tumor diameter of 1.5 cm on MRI,
tumors did not invade the vagina or parametrium as shown on MRI. Lymph node
metastasis was noted in two patients (67%), corresponding to MRI findings.
However, in the two patients with lymph node metastases, more metastatic lymph
nodes were seen on microscopic examination than on the MR images: one patient
with three foci of metastatic lymphadenopathy on MRI had seven foci on
microscopic examination, and one patient with one focus of metastatic
lymphadenopathy on MRI had four foci on microscopic examination.
Discussion
Small cell carcinoma consists of heterologous tumor cells because some
cells are of epithelial origin and others are of neuroendocrine origin.
Microscopic findings of small cell carcinoma show a predominance of uniformly
small cells with poorly defined cytoplasmic outlines and a high
nuclear–cytoplasmic ratio
[5]. The tumor cells usually
show neuroendocrine differentiation
[2,
3,
6,
7].
In previous reports, small cell carcinoma of the uterine cervix has been
found to have aggressive biologic behavior leading to a rapid and fatal
clinical course
[1–3,
7]. The incidence of lymph node
involvement and systemic metastasis is much higher in small cell carcinoma
than in non–small cell carcinoma
[1,
8]. Although most local
squamous cell carcinomas or adenocarcinomas can be successfully treated with
radical hysterectomy alone, more complex adjuvant and neoadjuvant treatment is
required for small cell carcinoma
[4,
5]. In recent reports,
multiagent chemotherapy and pelvic radiotherapy before surgery produced a
better outcome than local treatment alone
[1,
9–13].
Also, improved clinical responses to adjuvant chemotherapy after surgery were
reported [12]. Small cell
carcinoma of the uterine cervix should be considered and approached as a
systemic disease.
In establishing a treatment plan for patients with small cell carcinoma of
the uterine cervix, accurate diagnosis is important. However, the major
dilemma is that early accurate diagnosis is limited on routine screening
examination because Papanicolaou's smear has very low
accuracy—14%—for diagnosing small cell carcinoma, according to one
study [2], and even
conventional microscopic examination is not highly sensitive
[2–4].
Therefore, some patients have a potential risk of skipping adjuvant or
neoadjuvant treatment and being treated simply with local treatment alone.
In our study, MR signal intensity of small cell carcinoma of the uterine
cervix seems to be nonspecific because the tumor signal intensity was low on
T1-weighted images and high on T2-weighted images. Although a tendency was
seen toward homogeneous internal appearance and irregular margins, we believe
that these findings are not helpful in differentiating small cell carcinoma
from other carcinomas. However, compared with other carcinomas of the uterine
cervix, small cell carcinoma seems to be frequently accompanied by extensive
lymphadenopathy and parametrial invasion. In our results, 71% of patients had
parametrial invasion and 86% of patients had lymphadenopathy. Even tumors of 4
cm or smaller had considerable incidence of parametrial invasion (60%) and
lymphadenopathy (80%). These results correlate well with the aggressive
behavior of small cell carcinoma.
In treating patients with small cell carcinoma of the uterine cervix, to
avoid ineffective and unnecessary surgery in those with distant metastases,
the whole body should be fully evaluated because the incidence of metastasis
in small cell carcinoma is much greater than that of other carcinomas
[1–3].
The presumption of small cell carcinoma on MRI is important to determine the
range of preoperative evaluation.
In conclusion, small cell carcinoma of the uterine cervix is characterized
by frequent parametrial invasion and extensive lymphadenopathy, although the
tumor morphology seems to be nonspecific on MRI.
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Abstract
Introduction
