Neuroendocrine carcinoma of the cervix

Overview

Neuroendocrine carcinoma of the cervix is best defined separately:

Neuroendocrine: Of, relating to, or involving the interaction between the nervous system and the hormones of the endocrine glands.

Carcinoma: An invasive malignant tumor derived from epithelial tissue that tends to metastasize to other areas of the body.

Contents

Neuroendocrine carcinoma affects many different parts of the body.

In the cervix, it is a rare, but very aggressive form of cervical cancer. In its early stages, neuroendocrine carcinoma is asymptomatic (not showing or producing indications of a disease or other medical condition)

Symptoms

In more advanced stages, symptoms of Neuroendocrine carcinoma of the cervix are: abnormal vaginal bleeding, increased vaginal discharge, and pelvic pain, painful urination, pain during sex, tiredness, leg swelling, and backache. When left untreated, metastasis or even death may occur.

Causes

Cervical cancer is vastly more common in developing nations than it is in developed nations, and it is fairly rare in the United States. In the U.S. in 2007, 12,280 women in the United States were diagnosed with cervical cancer and 4,021 women in the United States died from cervical cancer. This puts cervical cancer as the 12th most common cancer that women develop, and the 14th most common cause of cancer death for women in the U.S. However, cervical cancer is the 2nd most common cause of cancer death in developing nations, with about 370,000 new cases annually having a 50% mortality rate. Decades ago, cervical cancer was the number one cause of cancer deaths in women in the U.S. There has been a 75% decrease in incidence and mortality from cervical cancer in developed nations over the past 50 years. Most of this decrease is attributed to the effective institution of cervical cancer screening programs in the wealthier nations.

Although there are several known risk factors for getting cervical cancer, no one knows exactly why one woman gets it and another doesn't. One of the most important risk factors for cervical cancer is infection with a virus called HPV (human papilloma virus). HPV is a sexually transmitted disease that is incredibly common in the population; most college-aged men and women have been exposed to HPV. HPV is the virus that causes genital warts, but having genital warts doesn't necessarily mean you are going to get cervical cancer. There are different subtypes, or strains, of HPV. Only certain subtypes are likely to cause cervical cancer, and the subtypes that cause warts are unlikely to cause a cancer. Often, infection with HPV causes no symptoms at all, until a woman develops a pre-cancerous lesion of the cervix. It should be stressed that only a very small percentage of women who have HPV will develop cervical cancer; so simply having HPV doesn't mean that you will get sick. However, almost all cervical cancers have evidence of HPV virus in them, so infection is a major risk factor for developing it.

Because infection with a sexually transmitted disease is a risk factor for cervical cancer, any risk factors for developing sexually transmitted diseases are also risk factors for developing cervical cancer. Women who have had multiple male sexual partners, began having sexual intercourse at an early age, or have had male sexual partners who are considered high risk (meaning that they have had many sexual partners and/or began having sexual intercourse at an early age) are at a higher risk for developing cervical cancer. Also, contracting any other sexually transmitted diseases (like herpes, gonorrhea, syphilis, or Chlamydia) increases a woman's risk. HIV infection is another risk factor for cervical cancer, but it may be so for a slightly different reason. It seems that any condition that weakens your immune system also increases your risk for developing cervical cancer. Conditions that weaken your immune system include HIV, having had an organ transplantation, and Hodgkin's disease. Another important risk factor for developing cervical cancer is smoking. Smokers are at least twice as likely as non-smokers to develop cervix tumors. Smoking may also increase the importance of the other risk factors for cancer. Finally, being in a low socioeconomic group seems to increase the likelihood for developing and dying from cervical cancer. This may be because of increased smoking rates, or perhaps because there are more barriers to getting annual screening exams. Cervical cancer is one of the few cancers that affects young women (in their twenties and even their teens), so no one who is sexually active is really too young to begin screening. Additionally, the risk for cervical cancer doesn't ever decline, so no one is too old to continue screening. Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get cervical cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease.

Prevention

Fortunately, there are several actions that women can take to decrease the risk of dying from cervix cancer. The first of these is undergoing regular Pap testing. Pap tests will be discussed further in the next section, but the reason that women have had such a drastic drop in cervical cancer cases and deaths in this country has been because of the Pap test and annual screening.

Recently, two vaccines, called Gardasil and Ceravix have been developed. These vaccines have been demonstrated to be effective in preventing infection with some strains of HPV, when given before a person is exposed to HPV. For this reason, is the vaccines are recommended and approved for girls and young women ages 9 – 26 years. Vaccination can also be given to boys, ages 9-26, to prevent genital warts and further spread of HPV in women and men. HPV is also a cause of penile and anal cancers and head & neck cancers.

For further prevention, women should try to reduce risk factors as much as possible. Don't start smoking, and if you are already a smoker, it is time to quit. Smoking has been shown to decrease the immune system’s ability to clear an HPV infection. Women can limit their numbers of sexual partners, and delay the onset of sexual activity to reduce risk, as more partners increases the likelihood of infection. Unfortunately, condoms do not protect you from developing HPV, so even though they can protect you from other sexually transmitted diseases and HIV, they cannot help lower your risk for being infected with HPV.

Many people are interested in preventing cervical cancer with vitamins or diets. Studies looking at beta-carotene and folic acid for preventing cervical cancer have shown no benefit. Some people think that anti-oxidants (like vitamin A and vitamin E) may play a role in cervical cancer prevention, but there is currently no convincing data that would suggest so. Further studies need to be performed before any nutritional recommendations can be made regarding cervix cancer prevention.

Diagnosis

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Prognosis

The 'prognosis' of Neuroendocrine carcinoma of the cervix usually refers to the likely outcome of Neuroendocrine carcinoma of the cervix. The prognosis of Neuroendocrine carcinoma of the cervix may include the duration of Neuroendocrine carcinoma of the cervix, chances of complications of Neuroendocrine carcinoma of the cervix, probable outcomes, prospects for recovery, recovery period for Neuroendocrine carcinoma of the cervix, survival rates, death rates, and other outcome possibilities in the overall prognosis of Neuroendocrine carcinoma of the cervix. Naturally, such forecast issues are by their nature unpredictable.

Treatment

The list of treatments mentioned in various sources for Neuroendocrine carcinoma of the cervix includes the following list. Always seek professional medical advice about any treatment or change in treatment plans. * Chemotherapy, radiation therapy, surgery

Pre-cancerous lesions

Women who have pre-cancerous lesions demonstrated on biopsy after colposcopy have a few different options how to proceed. A woman may decide on a specific option depending on whether or not she plans to have children in the future, her current health status and life expectancy, and her concerns about the future and the possibility of having a cancer come back. You should talk to your doctor about you fears, concerns and preferences. Sometimes, women with low grade lesions may choose to not have any further treatment, especially if the biopsy removed the entire lesion. If you decide to do this, you will need frequent pelvic exams and Pap tests. There are several; different ways to remove pre-cancerous lesions without removing the entire uterus (and thus preserving a woman's ability to have a baby in the future). Women can have cryosurgery (freezing off the abnormal lesion), a LEEP (the same type of electrosurgical procedure used for biopsies), a conization (the thicker type of biopsy that gets tissue under the surface), or have the cells removed with a laser. Your doctor can discuss the benefits and drawbacks of each of these modalities. Women who do not have any plans to have children in the future and are particularly worried about their chances of getting an invasive cancer may elect to have a hysterectomy (a surgery that removes your uterus and cervix). This procedure is much more invasive than any of the previous treatment modalities, but can provide peace of mind to women finished with childbearing.

Surgery

Surgery is generally only employed in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible, but it usually isn't used unless all of the cancer can be removed at the time of surgery. Cancers that have a high chance of already being in the lymph nodes are not treated with surgery (lymph nodes are small, pea-sized pieces of tissue that filter and clean lymph, a liquid waste product). There are a few different types of surgeries that can be performed. The earliest stage IA tumors can sometimes be treated with only a hysterectomy (removal of the uterus and cervix). Bigger stage IA, stage IB, and occasionally stage IIA tumors can be treated with more extensive hysterectomies coupled with lymphadenectomies (procedures that remove lymph nodes in the pelvis). Depending on the amount of disease, your surgeon may have to remove tissues around the uterus, as well as part of the vagina and the fallopian tubes. One of the benefits of surgery in young women is that sometimes their ovaries can be left, so that they do not go through menopause at an early age. Higher stage disease is usually treated with radiation and chemotherapy, but sometimes surgery is employed if cervical cancer comes back after it has already been treated. A pelvic exenteration is reserved for recurrent cervical cancers. A pelvic exenteration is a major surgery in which the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon are removed. This surgery is not commonly employed, but is occasionally used for recurrent cancers.

Radiotherapy

Radiation therapy has proven very effective in treating cervical cancer. Radiation therapy uses high energy x-rays to kill cancer cells. Radiation therapy is another option besides surgery for early stage cervical cancer; and when advanced stage cervical cancer needs to be treated, it is usually done with radiation therapy. Surgery and radiation have been shown to be equivalent treatments for early stage cervical cancers, and radiation helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation has the benefit of being able to treat all of the disease in the radiation field; thus lymph nodes can be treated as well as the primary tumor in the course of the same treatment.

Radiation therapy for cervical cancer either comes from an external source (outside of the patient, known as external beam radiation) or an internal source (inside the patient, known as brachytherapy). External beam radiation therapy requires patients to come in 5 days a week for up 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. With all cervical cancers above stage IB, the standard approach with radiotherapy is to use external beam radiation coupled with internal brachytherapy. Brachytherapy (also called intracavitary irradiation) allows your radiation oncologist to "boost" the radiation dose to the tumor site. This provides an added impact to the tumor, while sparing your normal tissues. This is done by inserting a hollow, metal tube with two egg shaped cartridges into your vagina. Then a small radioactive source is placed in the tube and cartridges. A computer has calculated how long the source needs to be there, but usually for what is called low dose rate (LDR) brachytherapy, you will need to have the source in for a few days. This procedure is done in the hospital, because for those few days you have to remain in bed. Another type of brachytherapy, called high dose rate (HDR) brachytherapy, uses more powerful sources that only stay in for a few minutes. Although this option usually sounds more appealing to patients, there is debate as to which type is more effective and some institutions favor one over the other. Talk to your radiation oncologist about your options and your doctor’s opinions as to HDR versus LDR for cervical cancer treatment.

Another use of radiation is for palliation - meaning that patients with very advanced cases of cervical cancer are treated with the intent of easing their pain or symptoms, rather than trying to cure their disease.

Sometimes, women with early stage are treated with surgery, but after the results of the surgery, it becomes clear that they will need radiation as well. In any setting, radiation is often combined with chemotherapy, and, depending on your case, your doctor will decide on the best possible treatment arrangement for your lifestyle and wishes.

Chemotherapy

Despite the fact that tumors are removed by surgery or treated with radiation, there is always a risk of recurrence because there may be microscopic cancer cells left in the body. In order to decrease a patient's risk of a recurrence, she may be offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Practically all patients who are in good medical condition and receiving radiation for stage IIA or higher cervical cancer will be offered chemotherapy in addition to their radiation. It may even be offered for earlier stage cases depending individual aspects of the patient and her disease. There have been many studies that demonstrate the usefulness of adding chemotherapy to radiation in terms of decreasing mortality from cervical cancer.

There are many different chemotherapy drugs, and they are often given in combinations for a series of months. Depending on the type of chemotherapy regimen you receive, you may get medication every week or few weeks; and you usually have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein. The most commonly employed regimens use a drug called Cisplatin, but other drugs like 5-FU, Hydroxyurea, Ifosfamide, and Paclitaxel may also be employed. There are advantages and disadvantages to each of the different regimens that your gynecologic oncologist or medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.

Resources

Once a patient has been treated for cervix cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will have to go for checkups. Your doctor will tell you when he or she wants follow-up visits, Pap tests, and/ or scans depending on your case. Your doctor will also do pelvic exams regularly during your office visits. It is very important that you let your doctor know about any symptoms you are experiencing and that you keep all of your follow-up appointments.