the incidence has been estimated to be 2.5 - 5 per 100000 people per year with a prevalence of 35 per 100000 ( 1 ) .
neuroendocrine cervical carcinoma is a rare subtype of cervical cancer with a high proliferation rate and a marked propensity for regional lymph node metastases and distant metastases , which is similar to its counterpart in the lung and other anatomic locations .
growing evidence indicates that 2-[f ] fluoro-2-deoxy - d - glucose positron emission tomography / computed tomography ( f - fdg pet / ct ) scan is feasible for assessing the pre - treatment staging , detecting lymph node metastases , and evaluating the treatment response in squamous cervical carcinoma . to the best of our knowledge , there are no f - fdg pet / ct studies with cervical - vaginal neuroendocrine tumor . here
, we describe five cases of neuroendocrine cervical - vaginal carcinoma , and discuss the potential of the f - fdg pet / ct scans for the detection of this rare malignancy .
from september 2009 to august 2011 , five patients were diagnosed with neuroendocrine tumor in our hospital ( four subjects had a tumor in the uterine cervix and one subject had a tumor in the vagina ) .
the diagnosis of neuroendocrine carcinoma was made , according to the recently proposed classification of neuroendocrine tumors ( 2 ) .
all of the patients underwent f - fdg pet / ct scans for the initial staging procedure and three subjects received post - treatment f - fdg pet / ct scans for detecting possible tumor recurrences or distal metastases .
each of them was intravenously injected with 370 megabecquerel ( mbq ) of f - fdg and rested on a supine position in a quiet , dimly lit room .
imaging was performed with a pet / ct scanner ( discovery ste , general electric healthcare , milwaukee , wi , usa ) .
scanning began approximately 40 minutes after the injection of f - fdg . when patients were positioned in the scanner , a molded headrest and a head - restraining velcro band
we used four - phase f - fdg pet / ct imaging protocol to improve the lesion detectability in patients with pelvic carcinoma .
this protocol included the following : 1 ) saline infusion was given before the tracer injection .
whole - body f - fdg pet / ct scan was acquired , approximately 40 minutes after the intravenous injection of 370 mbq of f - fdg ; 2 ) post - void delayed abdominal and pelvic f - fdg pet / ct images were obtained , approximately 70 minutes after f - fdg injection ; 3 ) after voiding of the urinary bladder again , the patients were injected with 20 mg of furosemide intravenously .
focal supine abdominal and pelvic diuretic f - fdg pet / ct images were obtained , approximately 90 minutes after f - fdg injection ; 4 ) additional focal imaging of the abdomen and pelvis was performed , approximately 110 minutes after f - fdg injection , with the patients in the prone position .
the pet / ct examinations started with the acquisition of a topogram of ct that is used to define the axial examination range of the pet / ct study .
after the definition of the axial imaging range , a spiral non - contrast - enhanced low - radiation - dose ct scan ( 0.8-second rotation time , 120 kvp , variable ma with automa technique , 3.75-millimeter slice thickness and 1.75 : 1 pitch ) were acquired , first , for anatomical references and attenuation correction .
then , the pet emission images were acquired after ct scans at 2 minutes per field of view ( fov ) in the 3-dimensional acquisition mode with eleven - slice overlap at the borders of the fov .
the ct images were reconstructed onto a 512  512 matrix , and then converted to a 128  128 matrix , 511-kev - equivalent attenuation factors for the attenuation correction of the corresponding pet emission images .
then , the pet images were reconstructed to the same thickness of ct images , 3.27 millimeter transaxial slice thickness for further interpretation .
a semiquantitative parameter , standardized uptake value ( suv ) , was defined as the " tracer activity in the target region per unit mass , divided by the amount of injected radioactivity , per unit body mass " .
the maximum standardized uptake value ( suvmax ) was calculated from each region of interest with increased f - fdg radioactivity
. a 46-year - old female of gravida 3 and para 3 visited our emergency department with complaints of massive vaginal bleeding and abdominal fullness in july 2011 .
the pelvic examination revealed an exogenous mass lesion over the upper third of the vagina with malodorous discharge .
colposcopic biopsy of the cervical lesion revealed a poorly differentiated , large - cell neuroendocrine cervical carcinoma .
an f - fdg pet / ct scan was performed , subsequently , for the demonstration of possible metastases and shown in figure 1 .
the tumor was clinically staged as international federation of gynecology and obstetrics ( figo ) stage iva .
pelvic examination found an area of easy bleeding over the uterine cervix , without parametrial extension , 4 cm in its largest dimension ( figo stage ib2 ) .
a pre - treatment primary lesion was detected on the f - fdg pet / ct scan , as shown in figure 2 .
four months later , the progression of disease was evidenced by multiple lymph node and bone metastases .
she was admitted for salvage chemotherapy , and was given cisplatin ( 500 mg / m ) and 5-fu ( 1000 mg / m ) .
she expired 24 months after the initial diagnosis . a 66-year - old postmenopausal woman , with a diagnosis of stage iia large - cell neuroendocrine cervical carcinoma was treated with radical hysterectomy , concurrent chemotherapy and radiation .
ten months after she completed her treatment , general weakness and abnormal laboratory data were noted .
f - fdg pet / ct scan , as shown in figure 3 was arranged for detecting possible metastases , and it revealed multiple f - fdg - avid lesions in the mediastinum , liver , and abdominal lymphatic chain .
a 46-year - old woman was presented to our gynecology department with complaints of intermittent vaginal spotting and a malodorous vaginal discharge for 2 months .
pelvic examination , which was done under anesthesia on dec . 3 , 2010 , showed a bulky tumor of about 4.0 cm in diameter .
computed tomography scan revealed enlarged lymph nodes in the bilateral internal iliac and the left common iliac regions .
however , she developed oliguria and was found to have acute renal insufficiency related to obstructive nephropathy .
the f - fdg pet / ct scan of this patient is shown in figure 4 .
in addition to the primary tumor seen in the pelvis , the enlarged lymph nodes shown on a ct scan were hypermetabolic .
the patient is currently receiving palliative chemotherapy consisting of cisplatin ( 50 mg / m ) , doxirubicin ( 50 mg / m ) and etoposide ( 75 mg / m ) .
a 42-year - old female presented with a right vaginal septum of about 2.3  2.0  0.5 cm in size , around the middle to lower third of the vagina on the annual exam . according to her statement , she suffered from painful sensation during sexual intercourse and post - coital bleeding for nearly 2 years .
radical resection was done on december 7th , 2009 . the first f - fdg pet / ct scan is shown in figure 5 .
the treatment plan for this patient , which consisted of six courses of chemotherapy with concurrent radiation and four courses of brachytherapy , was completed on march 4th , 2010 . however ,
mildly elevated carcinoembryonic antigen , 19.13 ng / dl , was noted six months later .
she underwent a second f - fdg pet / ct scan , which showed an f - fdg - avid lesion in the right side of the uterine cervical region .
from september 2009 to august 2011 , five patients were diagnosed with neuroendocrine tumor in our hospital ( four subjects had a tumor in the uterine cervix and one subject had a tumor in the vagina ) .
the diagnosis of neuroendocrine carcinoma was made , according to the recently proposed classification of neuroendocrine tumors ( 2 ) .
all of the patients underwent f - fdg pet / ct scans for the initial staging procedure and three subjects received post - treatment f - fdg pet / ct scans for detecting possible tumor recurrences or distal metastases .
the patients were asked to fast for at least 4 hours before scanning . each of them was intravenously injected with 370 megabecquerel ( mbq ) of f - fdg and rested on a supine position in a quiet , dimly lit room .
imaging was performed with a pet / ct scanner ( discovery ste , general electric healthcare , milwaukee , wi , usa ) .
scanning began approximately 40 minutes after the injection of f - fdg . when patients were positioned in the scanner , a molded headrest and a head - restraining velcro band
we used four - phase f - fdg pet / ct imaging protocol to improve the lesion detectability in patients with pelvic carcinoma .
this protocol included the following : 1 ) saline infusion was given before the tracer injection .
whole - body f - fdg pet / ct scan was acquired , approximately 40 minutes after the intravenous injection of 370 mbq of f - fdg ; 2 ) post - void delayed abdominal and pelvic f - fdg pet / ct images were obtained , approximately 70 minutes after f - fdg injection ; 3 ) after voiding of the urinary bladder again , the patients were injected with 20 mg of furosemide intravenously .
focal supine abdominal and pelvic diuretic f - fdg pet / ct images were obtained , approximately 90 minutes after f - fdg injection ; 4 ) additional focal imaging of the abdomen and pelvis was performed , approximately 110 minutes after f - fdg injection , with the patients in the prone position .
the pet / ct examinations started with the acquisition of a topogram of ct that is used to define the axial examination range of the pet / ct study .
after the definition of the axial imaging range , a spiral non - contrast - enhanced low - radiation - dose ct scan ( 0.8-second rotation time , 120 kvp , variable ma with automa technique , 3.75-millimeter slice thickness and 1.75 : 1 pitch ) were acquired , first , for anatomical references and attenuation correction .
then , the pet emission images were acquired after ct scans at 2 minutes per field of view ( fov ) in the 3-dimensional acquisition mode with eleven - slice overlap at the borders of the fov .
the ct images were reconstructed onto a 512  512 matrix , and then converted to a 128  128 matrix , 511-kev - equivalent attenuation factors for the attenuation correction of the corresponding pet emission images .
then , the pet images were reconstructed to the same thickness of ct images , 3.27 millimeter transaxial slice thickness for further interpretation .
a semiquantitative parameter , standardized uptake value ( suv ) , was defined as the " tracer activity in the target region per unit mass , divided by the amount of injected radioactivity , per unit body mass " .
the maximum standardized uptake value ( suvmax ) was calculated from each region of interest with increased f - fdg radioactivity .
a 46-year - old female of gravida 3 and para 3 visited our emergency department with complaints of massive vaginal bleeding and abdominal fullness in july 2011 .
the pelvic examination revealed an exogenous mass lesion over the upper third of the vagina with malodorous discharge .
colposcopic biopsy of the cervical lesion revealed a poorly differentiated , large - cell neuroendocrine cervical carcinoma .
an f - fdg pet / ct scan was performed , subsequently , for the demonstration of possible metastases and shown in figure 1 .
the tumor was clinically staged as international federation of gynecology and obstetrics ( figo ) stage iva .
. pelvic examination found an area of easy bleeding over the uterine cervix , without parametrial extension , 4 cm in its largest dimension ( figo stage ib2 ) .
a pre - treatment primary lesion was detected on the f - fdg pet / ct scan , as shown in figure 2 .
four months later , the progression of disease was evidenced by multiple lymph node and bone metastases .
she was admitted for salvage chemotherapy , and was given cisplatin ( 500 mg / m ) and 5-fu ( 1000 mg / m ) .
she expired 24 months after the initial diagnosis . a 66-year - old postmenopausal woman , with a diagnosis of stage iia large - cell neuroendocrine cervical carcinoma was treated with radical hysterectomy , concurrent chemotherapy and radiation .
ten months after she completed her treatment , general weakness and abnormal laboratory data were noted .
f - fdg pet / ct scan , as shown in figure 3 was arranged for detecting possible metastases , and it revealed multiple f - fdg - avid lesions in the mediastinum , liver , and abdominal lymphatic chain .
a 46-year - old woman was presented to our gynecology department with complaints of intermittent vaginal spotting and a malodorous vaginal discharge for 2 months .
the pathological finding was small - cell neuroendocrine cervical carcinoma . computed tomography scan revealed enlarged lymph nodes in the bilateral internal iliac and the left common iliac regions .
however , she developed oliguria and was found to have acute renal insufficiency related to obstructive nephropathy .
the f - fdg pet / ct scan of this patient is shown in figure 4 .
in addition to the primary tumor seen in the pelvis , the enlarged lymph nodes shown on a ct scan were hypermetabolic .
the patient is currently receiving palliative chemotherapy consisting of cisplatin ( 50 mg / m ) , doxirubicin ( 50 mg / m ) and etoposide ( 75 mg / m ) .
a 42-year - old female presented with a right vaginal septum of about 2.3  2.0  0.5 cm in size , around the middle to lower third of the vagina on the annual exam . according to her statement , she suffered from painful sensation during sexual intercourse and post - coital bleeding for nearly 2 years .
radical resection was done on december 7th , 2009 . the first f - fdg pet / ct scan is shown in figure 5 .
the treatment plan for this patient , which consisted of six courses of chemotherapy with concurrent radiation and four courses of brachytherapy , was completed on march 4th , 2010 .
however , mildly elevated carcinoembryonic antigen , 19.13 ng / dl , was noted six months later .
she underwent a second f - fdg pet / ct scan , which showed an f - fdg - avid lesion in the right side of the uterine cervical region .
a 46-year - old female of gravida 3 and para 3 visited our emergency department with complaints of massive vaginal bleeding and abdominal fullness in july 2011 .
the pelvic examination revealed an exogenous mass lesion over the upper third of the vagina with malodorous discharge .
colposcopic biopsy of the cervical lesion revealed a poorly differentiated , large - cell neuroendocrine cervical carcinoma .
an f - fdg pet / ct scan was performed , subsequently , for the demonstration of possible metastases and shown in figure 1 .
the tumor was clinically staged as international federation of gynecology and obstetrics ( figo ) stage iva .
a 28-year - old female suffered from malodorous vaginal spotting for one month . pelvic examination found an area of easy bleeding over the uterine cervix , without parametrial extension , 4 cm in its largest dimension ( figo stage ib2 ) .
a pre - treatment primary lesion was detected on the f - fdg pet / ct scan , as shown in figure 2 .
four months later , the progression of disease was evidenced by multiple lymph node and bone metastases .
she was admitted for salvage chemotherapy , and was given cisplatin ( 500 mg / m ) and 5-fu ( 1000 mg / m ) .
a 66-year - old postmenopausal woman , with a diagnosis of stage iia large - cell neuroendocrine cervical carcinoma was treated with radical hysterectomy , concurrent chemotherapy and radiation .
ten months after she completed her treatment , general weakness and abnormal laboratory data were noted .
f - fdg pet / ct scan , as shown in figure 3 was arranged for detecting possible metastases , and it revealed multiple f - fdg - avid lesions in the mediastinum , liver , and abdominal lymphatic chain .
a 46-year - old woman was presented to our gynecology department with complaints of intermittent vaginal spotting and a malodorous vaginal discharge for 2 months
the pathological finding was small - cell neuroendocrine cervical carcinoma . computed tomography scan revealed enlarged lymph nodes in the bilateral internal iliac and the left common iliac regions .
however , she developed oliguria and was found to have acute renal insufficiency related to obstructive nephropathy .
the f - fdg pet / ct scan of this patient is shown in figure 4 .
in addition to the primary tumor seen in the pelvis , the enlarged lymph nodes shown on a ct scan were hypermetabolic .
the biopsy of this lesion showed metastastic neuroendocrine carcinoma . the patient is currently receiving palliative chemotherapy consisting of cisplatin ( 50 mg / m ) , doxirubicin ( 50 mg / m ) and etoposide ( 75 mg / m ) .
a 42-year - old female presented with a right vaginal septum of about 2.3  2.0  0.5 cm in size , around the middle to lower third of the vagina on the annual exam . according to her statement , she suffered from painful sensation during sexual intercourse and post - coital bleeding for nearly 2 years .
radical resection was done on december 7th , 2009 . the first f - fdg pet / ct scan is shown in figure 5 .
the treatment plan for this patient , which consisted of six courses of chemotherapy with concurrent radiation and four courses of brachytherapy , was completed on march 4th , 2010 .
however , mildly elevated carcinoembryonic antigen , 19.13 ng / dl , was noted six months later .
she underwent a second f - fdg pet / ct scan , which showed an f - fdg - avid lesion in the right side of the uterine cervical region .
the clinical characteristics , treatment modalities and outcome data of the five patients with neuroendocrine cervical - vaginal carcinoma are listed in table 1 .
five cases of cervical neuroendocrine carcinoma were retrospectively collected within two years ( from september 2009 to august 2011 ) at our hospital .
the mean age of these patients at initial diagnosis was 44.8 years ( range , 28 - 62 years ) .
the clinical staging distributions were figo stage ib2 ( 1/5 , 25% ) , stage iia ( 3/5 , 75% ) and stage iva ( 1/5 , 25% ) .
only one patient underwent radical hysterectomy ( 1/5 , case 3 ) , followed by postoperative concurrent chemotherapy and radiation therapy .
two patients ( 2/5 , cases 2 and 5 ) received concurrent chemotherapy and radiation therapy , one patient ( 1/5 , case 4 ) received palliative chemotherapy and one patient ( 1/5 , case 1 ) received palliative radiotherapy .
the f - fdg pet / ct scan was performed after radical hysterectomy in case 3 ; therefore , no primary lesion was detected .
5 ) , respectively . the mean suvmax of primary lesions was 5.89 in the early images , and 8.68 in delayed images .
distant metastases were presented in the pretreatment f - fdg pet / ct scan in case 1 and 4 . in case 1 , the highest suvmax ( 11.46 )
, the fdg - avid lesion with a highest suvmax ( 5.08 ) in the 3 phase was noted in the right iliac lymph nodes .
the restaging f - fdg pet / ct in case 2 and 3 revealed previous unknown distant metastatic disease .
the clinical characteristics , treatment modalities and outcome data of the five patients with neuroendocrine cervical - vaginal carcinoma are listed in table 1 .
five cases of cervical neuroendocrine carcinoma were retrospectively collected within two years ( from september 2009 to august 2011 ) at our hospital .
the mean age of these patients at initial diagnosis was 44.8 years ( range , 28 - 62 years ) .
the clinical staging distributions were figo stage ib2 ( 1/5 , 25% ) , stage iia ( 3/5 , 75% ) and stage iva ( 1/5 , 25% ) .
only one patient underwent radical hysterectomy ( 1/5 , case 3 ) , followed by postoperative concurrent chemotherapy and radiation therapy .
two patients ( 2/5 , cases 2 and 5 ) received concurrent chemotherapy and radiation therapy , one patient ( 1/5 , case 4 ) received palliative chemotherapy and one patient ( 1/5 , case 1 ) received palliative radiotherapy .
the f - fdg pet / ct scan was performed after radical hysterectomy in case 3 ; therefore , no primary lesion was detected .
5 ) , respectively . the mean suvmax of primary lesions was 5.89 in the early images , and 8.68 in delayed images .
distant metastases were presented in the pretreatment f - fdg pet / ct scan in case 1 and 4 . in case 1 , the highest suvmax ( 11.46 )
, the fdg - avid lesion with a highest suvmax ( 5.08 ) in the 3 phase was noted in the right iliac lymph nodes . the restaging f - fdg pet / ct in case 2 and 3 revealed previous unknown distant metastatic disease .
carcinoma of the uterine cervix is a common gynecologic malignancy with squamous cell histology , accounting for the majority of the cases .
most cases of the uterine cervical carcinoma can be detected at an early stage of the disease by a pap smear test .
early - stage squamous cell carcinoma of the uterine cervix has good prognosis and outcome . however , cervical - vaginal neuroendocrine tumors show evidence of distal metastases in the early stage disease ( 3 - 5 ) .
these tumors exhibit aggressive behavior , with early hematogenous and lymphatic metastases . in a recent analysis of the data from the surveillance epidemiology and end results program of the u.s .
national cancer institute , it was stated that the neuroendocrine tumors of the uterine cervix are extremely aggressive , and that the survival is poor regardless of the stage at diagnosis , when compared with squamous cell types ( 6 ) . a retrospective study , which enrolled 31 patients in northern taiwan , demonstrated that the 2-year and 5-year survival rates were 54.8% and 31.5% , respectively , for all types of cervical neuroendocrine tumor ( 7 ) .
this phenomenon , including poor prognosis and metastases in the early stages , was also observed in our patients .
the staging methods of the figo system depend on conventional procedures , including plain chest radiography , barium enema , intravenous urography , lymphangiography , cystoscopy , proctoscopy , and physical examination , under general anesthesia .
however , the figo system is inherently inaccurate in the advanced stage disease , and does not address nodal involvement .
therefore , the expected roles of preoperative imaging are evaluation of invasion to the adjacent organs and assessment of the nodal involvement and distant metastases .
some recent studies reported that primary uterine cervical cancers have an avid uptake of f - fdg with the suvmax , ranging from 4.0 to 33 ( 8 - 10 ) . in our study , the suvmax of the primary cervical - vaginal neuroendocrine tumor ranged between 2.2 and 9.6 .
apparently , we can not differentiate the primary cervical - vaginal neuroendocrine tumors from primary uterine cervical cancers empirically based on suvmax .
however , the metastatic patterns of these two types of tumors may have different appearances .
the carcinoma of the uterine cervix is believed to typically advance with local growth and lymphatic spread initially , and by blood - borne metastases in the late stages .
tumor emboli spread orderly to peri - cervical , obturator , presacralthe hypogastric , external iliac , para - aortic , and then supraclavicular lymph nodes ( 12 ) . in the late stages ,
hematogeneous dissemination could happen , and mostly commonly , to the lung , liver , and bone .
on the contrary , the dissemination of cervical - vaginal neuroendocrine tumor seems not develop in an orderly manner .
the neuroendocrine tumor can be associated with hematogeneous spread even when no evidence of lymphatic spreading of the tumor is noted . in our study , there are multiple bone metastases without lymph nodes involvement in case 1 . in case 4 , metastatic lesion in the left breast
there are few articles concerning mri findings in cervical - vaginal neuroendocrine tumor ( 13 , 14 ) .
. demonstrated preoperative mri findings in seven patients with small cell neuroendocrine cervical carcinoma . in their study , 71% of patients
had parametrial invasion and 86% of patients had lymphadenopathy even with small size of primary tumor .
to the best of our knowledge , no study has been made to compare the diagnostic accuracies of cervical - vaginal neuroendocrine tumor , between f - fdg pet scan and magnetic resonance ( mr ) images .
for the common types of squamous cervical cancer , a prospective study investigated the efficacy of f - fdg pet scan in comparison with mr images of patients , with newly diagnosed ( 35% ) or recurrent ( 65% ) cervical cancer ( 15 ) , which showed f - fdg pet scan with significant superiority to that of the mri - ct in identifying metastatic lesions , although , the diagnostic accuracy was similar for local tumors . the pretreatment f - fdg pet / ct scan , which can reveal abnormal f - fdg uptake , consistent with nodal disease , is a robust predictor of disease recurrence and may alter the therapeutic management ( 16 ) . the advantage of the whole body survey in an f - fdg pet / ct scan may be more important in the staging of cervical - vaginal neuroendocrine tumor , since hematogenous spread can occur early in this type of tumor .
therefore , we considered that f - fdg pet / ct scans may be more appropriated than the local mr images for detecting the possible distant metastases , despite no evidence of local lymph node involvement . in our study , two cases were restaged ( cases 1 and 4 , shown in table 1 ) after f - fdg pet / ct scan . in case 4 ,
however , several f - fdg - avid areas in the bilateral iliac , the retroperitoneal regions , and the left breast were demonstrated in the f - fdg pet / ct scan , which altered the therapeutic management .
the patient received palliative chemotherapy for systemic metastases , and is still alive ( as of november 2011 , 11 months after initial treatment ) .
multiple modalities , such as radical hysterectomy and node dissection , adjuvant chemotherapy , chemoradiation and brachytherapy for neuroendocine tumors , have recently been shown to improve local control and survival rates . however , the optimal treatment has not yet been completely clarified .
approximately 30% of uterine cervical cancers eventually relapse , after the initial treatment ( 17 ) .
the recurrence rate in cervical - vaginal neuroendocrine tumor is even higher ( 18 ) .
follow - up protocols , including physical examination , evaluation of the serum tumor markers , ultrasonography , ct and/or mri , have certain limitations .
f - fdg pet scan or f - fdg pet / ct scan is a valuable tool in the case of suspected recurrence of cervical cancer .
cumulative data on 431 patients showed that f - fdg pet scan had the mean sensitivity of 94.7% , the mean specificity of 83.7% ( 60 - 100% ) , and the mean diagnostic accuracy of 87.9% ( 70 - 97.2% ) for the detection of recurrences in the uterine cervical cancers ( 19 ) .
a retrospective study enrolled 40 patients , who were suspected of having cervical cancer recurrence ( 20 ) .
the f - fdg pet / ct scans in these patients ( squamous or adenosquamous type on histology examination ) provided higher sensitivity and accuracy rates than that of the conventional imaging ( p < 10 ) , with a sensitivity of 94% for pet / ct scan , compared to 42.5% for the conventional imaging .
three patients ( cases 2 , 3 , and 5 ) were suspected of having recurrence in our study , and they underwent a second f - fdg pet / ct scan . despite completion of the treatment ( both chemotherapy and radiotherapy ) , rapid recurrence and
lymph node metastases in the pelvis , para - aortic lymphatic chain and mediastinum were demonstrated in the second f - fdg pet / ct scan .
two patients died from the disease within two years ( 21 months and 24 months ) , despite the ongoing treatment .
stage and treatment in cervical - vaginal neuroendocrine tumor remain to be determined because of the rarity of this type of cancer . here , we described five cases of cervical - vaginal neuroendocrine tumor with early lymph node metastases and poor prognosis , despite multiple modalities of treatment planning .
f - fdg pet / ct scan is a useful tool in cervical - vaginal neuroendocrine tumor . in initial staging ,
the f - fdg pet / ct scan may assess the possible nodal involvement or early hematogenous spreading , which altered the figo stage .
we can also use the f - fdg pet / ct scan to detect local recurrence and to evaluate the treatment response after clinical manipulations .
the limitations of our study are small case numbers and short - term follow - up
stage and treatment in cervical - vaginal neuroendocrine tumor remain to be determined because of the rarity of this type of cancer . here , we described five cases of cervical - vaginal neuroendocrine tumor with early lymph node metastases and poor prognosis , despite multiple modalities of treatment planning .
f - fdg pet / ct scan is a useful tool in cervical - vaginal neuroendocrine tumor . in initial staging ,
the f - fdg pet / ct scan may assess the possible nodal involvement or early hematogenous spreading , which altered the figo stage .
we can also use the f - fdg pet / ct scan to detect local recurrence and to evaluate the treatment response after clinical manipulations .
the limitations of our study are small case numbers and short - term follow - up .
 objectiveneuroendocrine cervical carcinoma is a rare subtype of cervical cancer . 
 these tumors exhibit an aggressive behavior with early regional lymph node and distant metastases . 
 the purpose of our study was to describe five cases of neuroendocrine cervical - vaginal carcinoma and to discuss the potential of the 2-[18f ] fluoro-2-deoxy - d - glucose positron emission tomography / computed tomography ( 18f - fdg pet / ct ) scan for the detection of this rare malignancy.materials and methodsfive cases of cervical - vaginal neuroendocrine tumor were retrospectively collected , during a two year ( from september 2009 to august 2011 ) period in our hospital . 
 the clinical staging distributions were international federation of gynecology and obstetrics ( figo ) stage ib2 ( 1 of 5 ) , stage iia ( 3 of 5 ) and stage iva ( 1 of 5).resultstwo cases ( cases 1 and 4 ) were restaged after 18f - fdg pet / ct scan in the initial staging process . 
 post - treatment 18f - fdg pet / ct scans , in three patients , revealed positive findings for tumor recurrence or lymph node metastases . 
 two patients ( cases 2 and 3 ) died of tumor within two years.conclusion18f-fdg pet / ct scan is a useful tool in cervical - vaginal neuroendocrine tumor . in its initial staging , the 18f - fdg pet / ct scan may help assess the possible nodal involvement or early hematogeneous spreading . 
 we can also use the 18f - fdg pet / ct to detect local recurrence and to evaluate the treatment response after clinical manipulation . 
INTRODUCTION
MATERIALS AND METHODS
Subjects
None
Case Reports
Case 1
Case 2
Case 3
Case 4
Case 5
RESULTS
Clinical Features
Image Analysis
DISCUSSION
Conclusion