TREATMENT OF GYNECOLOGIC NEUROENDOCRINE TUMORS

July 7, 2011 — For neuroendocrine tumors of the gynecologic tract, the Society of Gynecologic Oncology (SGO) recommends, in most cases, a multimodality therapeutic approach determined by extent of disease and primary organ of involvement.
On behalf of the SGO, Ginger J. Gardner, MD, from the Department of Surgery at the Memorial Sloan-Kettering Cancer Center, New York City, and colleagues published the clinical document in the July 2011 issue of Gynecologic Oncology.
"Neuroendocrine tumors primary to the gynecologic tract are still considered to be uncommon, with limited prospective data from which to guide decisions," the researchers write. The goal of the manuscript, they state, "is to provide a comprehensive review on gynecologic neuroendocrine tumors, and a platform from which to evaluate the available treatment options for these challenging cases."
Dr. Gardner and colleagues searched for all research articles published in English between January 1, 1966, and March 1, 2011, in which participants included women diagnosed with neuroendocrine tumors of the gynecologic tract. Specifically, they searched all publications with the keywords "cervix," "ovary," "uterus," and "vagina" combined and then searched for the keyword "neuroendocrine, small cell, carcinoid." Prospective studies were given preference, but there were no limitations in the design or study size because of the small number of studies available.
Neuroendocrine tumors of the gynecologic tract were classified as either poorly differentiated or well differentiated. Most have an aggressive clinical course, and tumors of the cervix share histologic and clinical similarities with small-cell lung cancer.
The data support a multimodality therapeutic strategy for most tumor types. A proposed management algorithm for neuroendocrine carcinomas of the cervix is as follows: tumors are separated on the basis of early stage (I - IIA) or late stage (IIB - IV). Early-stage tumors are further separated into size 4 cm or smaller or larger than 4 cm.
Early-stage tumors 4 cm or smaller should be treated with radial hysterectomy with lymphadenectomy, followed by chemotherapy with etoposide/cisplatin with or without radiation therapy. Early-stage tumors larger than 4 cm should be treated with neoadjuvant chemotherapy or chemoradiation (Hoskin's protocol). Late-stage tumors should also be treated with chemoradiation.
"Recognizing the lack of prospective randomized control trials, it is important to realize that individualized treatment of these challenging cases is appropriate," the authors note.
Surgical resection is considered appropriate in selected less-frequent disease sites, including the adnexa, uterus, vagina, and vulva, as well as well-differentiated carcinoid tumors. Etoposide/platinum-based chemotherapy is used for neuroendocrine carcinomas, but not for well-differentiated carcinoid tumors, the authors note. They also suggest that well-differentiated carcinoid and atypical carcinoid tumors should be managed similar to gastroenteropancreatic neuroendocrine tumors.
Agents currently in clinical trials for neuroendocrine tumors of the gynecologic tract include vascular endothelial growth factor and mammalian target of rapamycin inhibitors.
This study was not commercially supported. The authors have disclosed no relevant financial relationships.
Gynecol Oncol. 2011;122:190-198. Abstract