Carcinosarcoma of the pancreas: a unique case with emphasis on metaplastic transformation and the presence of undifferentiated pleomorphic high-grade sarcoma

We report a rare case of pancreatic carcinosarcoma in a 48-year-old man. An abdominal ultrasound scan incidentally detected a large heterogeneous mass in the left upper quadrant. CT and MRI scans indicated a rapidly growing unilocular cystic mass in the pancreatic tail. Grossly, the resected pancreatic mass measured 7×5×5 cm and consisted of a unilocular cystic lesion that had several solid mural nodules. Microscopically, the cystic wall showed two carcinomatous components, mucinous cystadenocarcinoma and anaplastic carcinoma. The solid lesion predominantly consisted of pleomorphic spindle cells arranged in interlacing fascicles which had infiltrated the adjacent pancreatic parenchyma. In some areas of this sarcomatous component, anaplastic carcinoma cells intermingled with or transformed into spindle cells. Immunohistochemically, the carcinomatous components were strongly positive for epithelial markers, and transforming anaplastic carcinoma cells were immunoreactive for both epithelial markers and vimentin; in contrast, the sarcomatous component was strongly positive for only vimentin. Additionally, an identical mutation (G to A transition) at codon 12 of K-ras gene and concordant immunoreactivity for p53 protein were detected in the carcinomatous and sarcomatous components. These findings suggested that the pancreatic carcinosarcoma could be of monoclonal origin, and that the sarcomatous component might have arisen from metaplastic transformation of the carcinomatous component.

Expression and localization of E-cadherin and β-catenin in uterine carcinosarcoma

This study was designed to analyze the subcellular localization of E-cadherin and β-catenin both of which play a critical role in cell-cell adhesion in uterine carcinosarcoma (UCS). We performed an immunohistochemical reaction analysis of the subcellular localization of E-cadherin and β-catenin proteins in 46 cases of UCSs consisting of 28 UCSs with heterologous sarcoma and 18 UCSs with homologous sarcoma and compared their clinicopathological features. In most UCSs, membranous expression of E-cadherin and β-catenin was completely lost in sarcomatous components, but it was preserved in carcinomatous components. Nuclear β-catenin expression was observed significantly more frequently in sarcomatous components (31/46, 67.4%) than in carcinomatous components (22/46, 47.8%; P = 0.0025). In sarcomatous components, nuclear β-catenin expression was found significantly more frequently in heterologous sarcoma (23/28, 82.1%) than in homologous sarcoma (8/18, 44.4%; P = 0.0279). The stage was the only independent prognostic significant factor. These results suggest that reduced membranous expression of E-cadherin and β-catenin may contribute to the biphasic morphology of UCS. Furthermore, although the precise mechanism is unclear, nuclear β-catenin expression in sarcomatous components may also be associated with biphasic morphology and heterologous sarcomatous differentiation.

Carcinosarcomas (malignant mixed Müllerian tumor) of the uterus: advances in elucidation of biologic and clinical characteristics

Carcinosarcoma of the uterus (malignant mixed Müllerian tumor [MMMT]) is an uncommon, typically extremely aggressive neoplasm histologically composed of malignant epithelial and mesenchymal (stromal) elements. Although the literature contains some debate, most authors now agree that most MMMTs derive from sarcomatous differentiation in a high-grade carcinoma. This article reviews the clinical and histopathologic features of this interesting neoplasm, with particular emphasis on recent data supporting MMMTs as primarily epithelial malignant neoplasms with areas of mesenchymal/spindle cell differentiation.

Clinicopathological and immunohistochemical characteristics of esophageal carcinosarcoma

BACKGROUND

Esophageal carcinosarcoma is a very rare neoplasm and its clinicopathological characteristics and the prognostic factors that influence the clinical outcome of the patient remain a matter of controversy.

PATIENTS AND METHODS

Twenty patients with esophageal carcinosarcoma were referred to our institutions. Tissue blocks were reviewed and sections containing both carcinomatous and sarcomatous components were stained for epithelial and mesenchymal markers and a proliferating cell marker. The prognosis of the esophageal carcinosarcoma patients was compared with 142 cases of esophageal squamous cell carcinoma.

RESULTS

In the carcinomatous component, the expression of cytokeratin, epithelial membrane antigen, vimentin, smooth muscle actin, and S100 were detected in 20, 20, 1, 1, and 1 case, respectively, whereas in the sarcomatous component, expression of these were detected in 4, 2, 18, 15, and 3 cases, respectively. The Ki-67 labeling index of carcinomatous and sarcomatous components was 35.5% and 41.8%, respectively. The 5-year survival rate was not statistically different between squamous cell carcinoma and carcinosarcoma (p=0.219). However, for T1 cases only, carcinosarcoma patients had statistically poorer prognosis than did squamous cell carcinoma patients (p=0.008).

CONCLUSION

The sarcomatous component shows various histological and immunohistochemical forms. In comparison with squamous cell carcinoma patients, carcinosarcoma patients had poorer prognosis amongst the T1 cases. For the treatment of esophageal carcinosarcoma, it is important to monitor lymph nodes and be watchful for hematogenous metastasis, as in cases of esophageal squamous cell carcinoma.

Tissue microarray analysis of hormonal signaling pathways in uterine carcinosarcoma

OBJECTIVES

To evaluate the relationship of hormone (estrogen receptor alpha, estrogen receptor beta, progesterone receptor) and growth factor receptor (insulin-like growth factor receptor, human epidermal growth factor receptor 2) expression with disease progression in uterine carcinosarcoma.

STUDY DESIGN

Immunohistochemistry was performed on tissue arrays using standard methodology. Differences between groups were evaluated by the Wilcoxon rank-sum test. Interactions between tumor stage and receptor expression were determined by linear trend analysis.

RESULTS

Compared with normal endometrium, carcinosarcomas exhibited low estrogen receptor alpha and progesterone receptor expression (all P < .01), but overexpressed estrogen receptor beta (P = .02). Estrogen receptor beta expression increased in advanced stage disease (P = .02). Insulin-like growth factor receptor expression was lower in carcinosarcoma compared with normal endometrium (P = .01). Human epidermal growth factor receptor 2 expression was elevated and increased with disease progression (P < .01).

CONCLUSION

In uterine carcinosarcoma, estrogen receptor beta expression is elevated and increases with disease progression, whereas estrogen receptor alpha and progesterone receptor are suppressed. Human epidermal growth factor receptor 2 expression is increased, whereas insulin-like growth factor receptor is lower than in normal endometrium. These data support a potential role for estrogen receptor beta in disease progression via crosstalk with human epidermal growth factor receptor 2.

Effects of PDT with 5-aminolevulinic acid and chitosan on Walker carcinosarcoma

Porphyrins and new chitosan hydrogels based composites with porphyrins are used as active cytotoxic antitumor agents in photodynamic therapy (PDT).

AIM

The present study evaluates the effects of photodynamic therapy (PDT) with 5-aminolevulinic acid (5-ALA) and 5-ALA associated with chitosan (CS) using Walker carcinosarcoma in rats as experimental model.

METHODS

The animals were irradiated with red light ( lambda = 685 nm, D = 50 J/cm(2), 15 min) 3 h after i.p. administration of 5-ALA (250 mg/kg b.w.) or a mixture of 5-ALA (250 mg/kg b.w.) and CS (1.5 mg/kg b.w.). The animals were sacrificed at 1, 3, 6, 24 h and 14 days after the treatment. The effects of PDT were investigated by morphological studies, monitoring the 5-ALA induced protoporphyrin IX (Pp IX) level in tumor tissue and serum, MMP 2 and 9 (gelatinases) activity in tumor and malondialdehyde level (MDA), marker of the lipoperoxidation process, in tumor and serum.

RESULTS

Zymography revealed an increased activity of MMP 2 in tumors from animals treated with 5-ALA PDT. PDT with 5-ALA induced a higher lipid peroxidation in tumor tissue compared with 5-ALA-CS. CS associated to 5 ALA PDT enhanced the accumulation of PS in tumors inducing earlier necrotic changes. In the same time CS reduced MMP 2 activity.

CONCLUSION

Our results suggest that MMPs activation and oxygen reactive species are involved in PDT effects.

Fallopian tube malignant mixed müllerian tumor (carcinosarcoma): a case report with immunohistochemical profiling

We report a case of malignant mixed müllerian tumor (MMMT) (carcinosarcoma) of the right fallopian tube in a 69-year-old woman presenting with abdominal pain and an adnexal mass. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, received adjuvant chemotherapy and is without evidence of disease 12 months postoperatively. The tumor involved the fallopian tube and was composed of in situ and invasive high-grade serous and undifferentiated carcinoma, leiomyosarcoma, rhabdomyosarcoma and undifferentiated sarcoma. Immunohistochemically, the epithelial and mesenchymal cells expressed CD56, Leu-7 and p53. The epithelial elements expressed nuclear WT1 and calretinin while the mesenchymal cells showed negative nuclear and strong cytoplasmic staining. HBME was observed focally in carcinoma. The expression of mesothelial-associated antigens WT1, calretinin and HBME in MMMT likely reflects the common embryologic derivation of the mesothelium and urogenital ridge. Loss of nuclear WT1 expression in the mesenchymal component may be involved in MMMT tumorigenesis.

Pulmonary pleomorphic carcinoma producing hCG

An 80-year-old woman with a pleomorphic carcinoma (PC) producing hCG was admitted to Nippon Steel Hirohata Hospital because of an abnormal shadow on CT seen during a follow-up examination after surgery for breast cancer. A right upper lobectomy was performed due to rapid growth of the shadow 3 months later. Macroscopically the tumor was a 4.8 x 4.0 cm well-circumscribed grayish-white mass. On histology the tumor consisted mostly of intermingled spindle and polygonal cells, while evidence of poorly differentiated adenocarcinoma was seen in a few areas. A diagnosis of PC was made due to hCG expression in approximately 20% of the spindle and polygonal cells on immunohistology. Six months after the operation metastasis to the liver and adrenal gland was seen on CT. The patient died due to metastases 1 year after the operation, even though the patient had been at stage 1B at the time of the operation and appropriate chemotherapy had been given. PC patients with immunohistochemical hCG expression have elevated risk of local recurrence and metastasis.

Uterine Carcinosarcoma Associated With Hereditary Nonpolyposis Colorectal Cancer

BACKGROUND

Hereditary nonpolyposis colorectal cancer (HNPCC) was originally described as a genetic disorder predominantly involving colorectal cancer. Numerous neoplasms are known to be associated with this condition. Sarcomas have also been reported within families with HNPCC. The challenge is determining if these cancers are sporadic or hereditary.

CASE

We report on a 46-year-old woman with uterine carcinosarcoma and a family history suspicious for HNPCC. Genetic testing identified a germline MLH1 mutation. Immunohistochemistry testing of the carcinosarcoma revealed loss of MLH1 expression with preservation of MSH2 expression.

CONCLUSION

The loss of MLH1 protein expression suggests the germline mutation contributed to the development of the carcinosarcoma. Hereditary nonpolyposis colorectal cancer should be included in the differential diagnosis of persons with uterine carcinosarcoma when noted within a family history suspicious for HNPCC.

Immunohistochemical Detection of Progesterone and Cellular Proliferation in Canine Mammary Tumours

Immunohistochemical expression of progesterone and the cellular proliferation marker Ki-67 was assessed in formalin-fixed, paraffin wax-embedded samples from 43 canine mammary tumours. Benign tumours showed high surface membrane progesterone expression (mean 196.42+/-25.91 positively labelled cells per 500 tumour cells) and low cellular proliferation (52.14+/-16.73 positively labelled cells per 500 tumour cells), whilst malignant tumours had low progesterone expression (68.19+/-17.53 positively labelled cells per 500 tumour cells) and higher cellular proliferation (141.72+/-23.65 positively labelled cells per 500 tumour cells), the difference being statistically significant (P<0.005) in both cases. These findings suggest that the majority of progesterone receptors in canine mammary tumour tissue are not associated with bound progesterone. The progression towards malignancy in spontaneously arising canine mammary tumours therefore appears to be associated with a decrease in steroid hormone dependency. Progesterone expression was also noted in the cytoplasm of tumour cells where it may be associated with a cellular repair mechanism. This hypothesis is supported by the finding of significantly higher progesterone content in the cytoplasm of benign tumour cells.

[Sinonasal teratocarcinosarcoma: a clinical, radiologic and pathologic study of 5 cases]

OBJECTIVE

To study the clinical, radiologic and pathologic features, as well as differential diagnosis of teratocarcinosarcoma in nasal cavity and paranasal sinuses.

METHODS

Light microscopic examination and immunohistochemical study was performed in 5 cases of sinonasal teratocarcinosarcoma. The clinical, radiologic and pathologic features were analyzed and the literature was reviewed.

RESULTS

All 5 patients were males and their age ranged from 34 to 43 years (mean age = 39 years). The clinical presentation was nasal obstruction, epistaxis and headache. Physical examination often revealed a polypoid mass with contact bleeding. Computed tomography showed a homogeneous nasal mass with obturation of sinuses. Cystic changes, calcification or ossification was not observed. Histologically, the tumor showed a heterogeneous admixture of components from the 3 germ cell layers, exhibiting various degrees of maturation. Squamous epithelium, smooth muscle cells, chondro-osseous tissue, intestinal or respiratory type epithelium, "fetal-type" clear cells and immature neuroepithelium were commonly seen. Immunohistochemical study demonstrated that the epithelial component expressed cytokeratin and epithelial membrane antigen, while the mesenchymal component variably expressed vimentin, smooth muscle actin and S-100 protein. On the other hand, the neuroepithelial component expressed neuron-specific enolase, synaptophysin and chromogranin, and the primitive component expressed CD99. The initial biopsy diagnosis included capillary hemangioma, olfactory neuroblastoma, craniopharyngioma and malignant mixed tumor. Follow-up information was available in all patients. Two of which had local recurrence and 1 had cervical lymph node metastasis.

CONCLUSIONS

Sinonasal teratocarcinosarcoma is a rare and highly malignant tumor occurring in sinonasal tract. It manifests mainly in adult males and is characterized by a complex admixture of teratomatous and carcinosarcomatous components. "Fetal-type" clear cells, squamous epithelium and immature neuroepithelium represent important histologic characteristics useful in diagnosis.

Primary carcinosarcoma of the liver: clinicopathologic features of 5 cases and a review of the literature

Carcinosarcoma of the liver is very rare worldwide. The terminology and pathogenesis of hepatic carcinosarcoma remain controversial issues. In this article, we studied the clinicopathologic features of 5 cases of hepatic carcinosarcomas (matching the World Health Organization definition), analyzed the clinical data, histologic and immunohistochemical (IHC) results, and discussed the terminology, pathologic differential diagnoses, pathogenesis, and prognosis. The patients were 40 to 68 years old, and included 4 males and 1 female. All patients were Hepatitis B surface antigen positive with para-tumorous cirrhosis. The largest dimensions of the neoplasms ranged from 6.0 to 14.0 cm. Satellite nodules, portal vein tumor thrombi, direct invasion into local tissues (right diaphragm, right adrenal gland, and gastric wall) as well as metastatic foci in lungs and abdominal lymph nodes were identified. Pathologically, the neoplasms consisted of carcinomatous and sarcomatous components. The carcinomatous components were exclusively conventional hepatocellular carcinomas in all 5 cases, whereas the sarcomatous components exhibited complex features. Confirmed by IHC studies, the sarcomatous elements in different cases included rhabdomyosarcomas, malignant fibrous histiocytomas, fibrosarcoma, and poorly differentiated spindle cells without distinctive differentiation. Furthermore, the sarcomatous elements in these 5 neoplasms stained negative for all the epithelial markers we applied for IHC staining, which support the pathologic diagnosis of carcinosarcoma rather than sarcomatoid carcinoma. The presence of transitional zones between carcinomatous and sarcomatous components may support the transformation theory. Four patients with palliative hepatectomy died within 6 months, whereas 1 patient is still alive 21 months after radical resection. The poor prognosis of hepatic carcinosarcoma may be due to their highly invasive and metastatic features. Radical resection of early stage hepatic carcinosarcoma may contribute to a relatively optimistic prognosis.

Nasal teratocarcinosarcoma - a case report

A 79-year-old man noticed nasal obstruction and bleeding caused by a pedunculated tumor in the left nasal cavity. The tumor revealed a malignant neoplasm predominantly composed of immature neuroepithelial cells with rosettes and palisading patterns, rhabdomyoblastic cells with positivity for desmin and cross-striations, and immature mucin-producing glandular cells. Small amounts of mature chondroid tissue and neurofibrillary matrix were also present. Therefore, the tumor was diagnosed as nasal teratocarcinosarcoma.

Overexpression of Clostridium perfringens Enterotoxin Receptors Claudin-3 and Claudin-4 in Uterine Carcinosarcomas

PURPOSE

To evaluate the expression levels of claudin-3 and claudin-4, the low- and high-affinity receptors, respectively, for the cytotoxic Clostridium perfringens enterotoxin (CPE) in uterine carcinosarcomas and explore the potential for targeting these receptors in the treatment of this aggressive uterine tumor.

EXPERIMENTAL DESIGN

We analyzed claudin-3 and claudin-4 receptor expression at mRNA and protein levels in flash frozen and formalin-fixed, paraffin-embedded carcinosarcoma specimens. Recombinant CPE was used as a novel therapy against chemotherapy-resistant carcinosarcoma cell lines in vitro. The therapeutic effect of sublethal doses of CPE was studied in severe combined immunodeficient mouse xenografts harboring large s.c. carcinosarcomas.

RESULTS

All flash-frozen carcinosarcoma biopsies (12 of 12) and short-term carcinosarcoma cell lines evaluated overexpressed claudin-3 and claudin-4 by quantitative reverse transcription-PCR. Membranous immunoreactivity for claudin-4 protein expression was documented in 80% (20 of 25) of primary tumors and 100% (6 of 6) of the metastatic carcinosarcomas, whereas negligible staining was found in normal endometrial cells. Regardless of their resistance to chemotherapeutic agents, all short-term carcinosarcoma cell lines tested died within 1 h of exposure to 3.3 microg/mL of CPE in vitro. Intratumoral injections of well-tolerated doses of CPE in large s.c. carcinosarcoma xenografts led to large areas of tumor cell necrosis and tumor disappearance in all treated animals.

CONCLUSIONS

Claudin-3 and claudin-4 receptors are highly overexpressed in carcinosarcoma. These proteins may offer promising targets for the use of CPE as a novel type-specific therapy against this biologically aggressive variant of endometrial cancer.

Immunohistochemical study of DNA topoisomerase I, p53, and Ki-67 in uterine carcinosarcomas

Uterine carcinosarcomas (UCs) are highly aggressive neoplasms for which no effective adjuvant therapy has been established. The aim of this study was to test potential indicators of UC sensitivity to topoisomerase I (topo I)-targeted drugs. Laboratory studies have shown that the cellular response to topo I-targeted drugs is dependent on topo I expression, DNA replication rate, and activity of the apoptotic pathway. Therefore, this study investigated expression of topo I, a proliferation marker Ki-67, and the apoptosis initiator p53 in 20 cases of UC. Formalin-fixed paraffin-embedded tissue sections were immunostained with monoclonal antibodies against topo I, Ki-67, and p53. The hospital records of all 20 patients with UC were reviewed. Twelve (60%) of 20 cases showed increased expression of topo I. Staining for Ki-67 showed elevated expression in 15 (75%) of 20 cases. Fourteen cases (70%) showed positive staining for p53 in more than 20% of the tumor cells. However, analysis of the relationship between immunohistochemical results and clinical parameters revealed no correlations with topo I expression. There were no significant correlations between the expression of topo I and Ki-67 (P = .704), or topo I and p53 (P = .465). Significantly increased expression of topo I, Ki-67, and p53 in UC tumor cells suggests sensitivity to topo I-targeted drug treatment.

Uterine carcinosarcoma: Immunohistochemical studies on tissue microarrays with focus on potential therapeutic targets

OBJECTIVE

Carcinosarcoma of the uterus is a highly aggressive tumor containing both malignant epithelial and spindle (mesenchymal) components. Because of their rarity and poor clinical outcome, investigations into the expression of potential therapeutic targets are limited. The aim of this study was to determine the expression of therapeutic targets in both the epithelial and spindle (mesenchymal) components in 30 carcinosarcomas using tissue microarrays, for potential treatment strategy.

METHODS

We collected formalin-fixed, paraffin-embedded tissue blocks of carcinosarcoma of the uterine corpus resected from 30 patients who had undergone total abdominal hysterectomies at our institution between 1985 and 2005 (ages 38-83 years, mean 65.9 years). All hematoxylin-eosin stained sections from each tumor were reviewed to confirm the pathologic diagnosis. Two tissue cores from the paraffin-embedded tissue blocks were constructed into a tissue microarray. Sections were stained with monoclonal antibodies against HER-2, VEGF, c-KIT, COX-2, and EGFR. Unequivocal staining of at least 5% tumor cells was considered positive. HER-2 amplification was also examined by fluorescence in situ hybridization (FISH) in 2 cases.

RESULTS

In the epithelial component, expression of HER-2, VEGF, c-KIT, COX-2, and EGFR were detected in 2 (6%), 30 (100%), 0 (0%), 21 (70%), and 9 (30%) cases, respectively, whereas these expressions in the spindle (mesenchymal) component were detected in 0 (0%), 28 (93%), 0 (0%), 5 (16%), and 20 (67%) cases, respectively. By FISH, one of the two cases with HER-2 expression showed gene amplification (2.62).

CONCLUSIONS

VEGF is strongly expressed in both the epithelial and spindle (mesenchymal) components of uterine carcinosarcoma. This result warrants further study to evaluate the possible role of anti-angiogenic agents in cancer therapy for patients with uterine carcinosarcomas. The expression patterns of COX-2 and EGFR differed between the epithelial and spindle (mesenchymal) components. HER-2 and c-KIT are poor therapeutic targets for uterine carcinosarcomas.

Aggressive carcinosarcoma of the uterine cervix associated with high levels of granulocyte colony stimulating factor: Case report and laboratory correlates

BACKGROUND

Production of granulocyte colony stimulating factor (G-CSF) by solid tumors, including cervix cancers, is reported to be associated with an aggressive clinical course.

CASE

A 64-year-old female with a locally advanced carcinosarcoma of the cervix presents with a WBC count of 48,000 cells/microl with no infectious causes. Her WBCs returned to normal during primary radiotherapy and then increased again with recurrence. She expired of progressive disease 10 weeks after primary therapy. Serum and pleural fluid levels of G-CSF were 1500 and 6000 pg/ml, respectively. Cancer cells secreted G-CSF in culture and recombinant G-CSF increased cancer cell proliferation.

CONCLUSIONS

Like other sarcomas, carcinosarcomas can produce high levels of G-CSF and demonstrate an aggressive behavior that may be autocrine stimulation.