1、Pap smear screening for small cell carcinoma of the uterine cervix: a case series and review of the literature,Innere Mongolei Forst General Hospital Tong Lijun 2014-03-10,INTRODUCTION,Small cell carcinoma of the uterine cervix (SMCC), which comprises about 2% to 5% of most cervical malignancies, te
2、nds to be progressive at an early stage, with metastasis to distant organs and lymph nodes, and is known to have a worse prognosis than squamous cell carcinoma or adenocarcinoma of the uterine cervix .,Due to the rarity of SMCC, previously reported studies were all conducted in a single institution
3、with a limited number of patients with prognostic factors, such as tumor size and International Federation of Obstetrics and Gynecology (FIGO) stage , which led to the conclusion that early detection of the disease is important.,The Pap test is a screening test initially introduced to clinical servi
4、ces by George N. Papanicolau in 1939. It has been proved that the test is effective to decreasing the frequency and recurrence rate of the invasive cervical cancer as well as the mortality rate due to the disease. The Pap test is also known to have contributed to prominently cordoning off the develo
5、pment of the invasive cervical cancer through detecting and treating the cervical intraepithelial neoplasia, the very prior stage of the disease .,However, in the case of SMCC, the earlier detection rate of SMCC was relatively low due to the rare prevalence of the disease, a growth pattern downward
6、into the epithelium while maintaining a normal epithelium, and the relative tumor location at a high endocervical portion . In these regards, it was often reported that, as a screening test, the Pap test for SMCC seemed to be destitute of its diagnostic values and effectiveness itself .The aim of th
7、is study is to review the Severance Hospital experience in the patients suffering from the SMCC with a review of the literature.,MATERIALS AND METHODS,Twenty-seven patients with small cell carcinoma of the uterine cervix were diagnosed and treated at the Severance Hospital from November 1991 to Janu
8、ary 2010. The clinical symptoms and chief complaints of the patients at their first clinic visit, age, FIGO clinical stage, and treatment modalities were investigated. The FIGO classification system was used for the determination of disease stages. The survival rate of patients was identified by mea
9、ns of correspondence and telephone.,Physical examination, including Pap smears, of patients was performed every 3 months after treatment. The abdominal and pelvic computed tomography and the magnetic resonance imaging were performed every 6 months, and the patients were carefully followed up. When r
10、ecurrence was suspected, bone scan and other imaging studies were performed, and biopsy was used to confirm the recurrence, if necessary. If recurrent disease was confirmed, radiation therapy and combination chemotherapy followed. The data were analyzed retrospectively based on the available charts
11、and obtained from pathology reports.,DISCUSSION,The rare prevalence of SMCC makes its diagnosis difficult and at the same time decreases the sensitivity of cytologic diagnosis. According to Kim et al. the diagnostic accuracy of cytologic smears in diagnosing SMCC is low (approximately 38.5%). In add
12、ition, Wang et al. reported that only 46% of the patients diagnosed with SMCC were diagnosed as having abnormal or malignant growths in cytologic smears, and Zhou et al. reported that only 14% were diagnosed with abnormal or malignant growths. There was no patient diagnosed with SMCC in the cytology
13、 smears in both studies. In this study, only two of the nine patients with abnormal Pap smear results were diagnosed with SMCC, resulting in 22.2% in terms of diagnostic accuracy with the cytologic findings.,It is known that SMCC shows a histological finding and prognosis that are similar to those o
14、f small cell carcinoma of the lung. SMCC shows rapid progression and early metastasis commonly occurring in the lymph nodes or other organs, leading to a 60-82% lymph lumen invasion and a 40-60% pelvic lymph node metastasis at the time of diagnosis . Sheets et al. reported that when surgical treatme
15、nt was conducted on patients with early-stage SMCC, nodal metastasis was found in approximately 57% of the patients. In addition, Sevin et al. reported that, unlike squamouscell carcinoma or adenocarcinoma of the uterine cervix, SMCC shows a shallow depth of invasion and a small tumor size, yet is a
16、n aggressive neoplasm that has a higher incidence of lymphovascular space involvement and lymph node metastasis.,The outcome of SMCC is associated with the disease stage. Chan et al. reported that, in the case of an early-stage disease, where the disease is limited within the radiation field, combin
17、ed-modality therapy showed approximately 30% treatment success. On the other hand, in the case of an advanced-stage disease, the prognosis was too bad to find survivors over two years. Due to the rare prevalence of this disease, the number of study specimens seen at a single institution was relative
18、ly small, and prognostic factors, such as the tumor size, LN involvement, and FIGO stage, were identified . In this study, FIGO stage IIB was the most common stage (11 of 27 patients), and the 5-year overall survival rate of 21 patients who could be followed up was reported to be 57.2%.,As the patho
19、physiology of SMCC is similar to that of small cell carcinoma of the lung (SCLC), SMCC treatment can also be deduced from the treatment of SCLC. It has been continually reported that, if an anticancer agent that is used for the treatment of general uterine cervical cancer is used, the survival rate
20、of SMCC patients will be 33%; however, if an anticancer agent that is used for the treatment of SCLC is used, the survival rate will be 68%, showing a statistically significant difference. This suggests that the anticancer agent used for the treatment of SCLC can be used for the postoperative adjuva
21、nt chemotherapy regimen of SMCC . In fact, other researchers reported that chemotherapy in combination with cisplatin and etoposide, and radiotherapy used for the treatment of SCLC, were applied to SMCC patients and successfully treated approximately 55% of the patients .,According to a large-scale
22、multicenter retrospective study that was conducted involving 68 stage IB-IIA patients who underwent surgery, neoadjuvant chemotherapy results in the downsizing of a bulky mass into an appropriate size for surgery, but had no benefit in the overall survival rate. In addition, adjuvant chemoradiation
23、therapy after surgery contributed less to the survival rate than adjuvant chemotherapy alone. Therefore, it was concluded that, for early-stage SMCC, primary radical surgery followed by adjuvant chemotherapy should be conducted as a preferable treatment modality .,Although this study suffered from l
24、imited case samples, it was consistent with the concept that Pap smear screening might not be helpful in early diagnosis of SMCC considering its low diagnostic accuracy. In the light of its low prevalence, a large-scale multicenter prospective study may be required to improve its diagnosis and treatment.,Thank You！,
