Pulmonary carcinomas with a sarcomatoid element: an immunocytochemical and ultrastructural analysis

Spindle cell variant of pulmonary adenocarcinoma

A 45-year-old male developed a transverse lesion of the spinal cord two years after resection of a pulmonary adenocarcinoma. Laminectomy revealed a spindle cell tumor, immunohistochemically considered as leiomyosarcoma. Autopsy disclosed a spindle cell variant of an adenocarcinoma of the lung. The present report demonstrates that spindle cell formations can be found not only in squamous cell carcinomas but also in adenocarcinomas of the lung, and that metastases may be composed of this spindle cell component only.

A case of adenocarcinoma of the lung with a spindle cell component

We report a 60-year-old man, who was admitted to the hospital with complaints of cough and sputum. His chest x-ray showed an abnormal mass in the right upper lobe. After admission he noticed the painful gingival tumor. Right upper lobectomy and resection of the gingival tumor were performed. Their histological features showed that the tumor consisted of a papillary and tubular adenocarcinoma mixed with a component of spindle cells. Immunohistochemical study demonstrated a positive reaction in the epithelial component for keratin and epithelial membrane antigen, and not only these epithelial markers but also vimentin were expressed in some spindle tumor cells. Electron microscopic study confirmed the biphasic pattern, showing gland formation and undifferentiated cells. We diagnose this case as adenocarcinoma of the lung with a spindle cell component and the gingival tumor was metastatic. Autopsy showed that metastatic lesions were found in the left adrenal gland and in the left kidney. The tumor cells in the left adrenal gland were composed of spindle cells and the tumor in the left kidney showed gland formation. Immunohistochemical and electron microscopic findings of surgical and autopsy specimen suggest that this tumor is of epithelial origin, and the spindle cells are derived from immature mesenchymal cell transformation of epithelial cells.

Lung carcinoma with spindle cell components: sixteen cases examined by immunohistochemistry

Sixteen cases of lung carcinoma with spindle cell components were studied by conventional histochemistry and immunohistochemistry. The epithelial components were squamous cell carcinoma in six cases, adenocarcinoma in four, adenosquamous carcinoma in five, and large cell carcinoma in one. In every case sarcomatous areas were distinctly observed and, in general, neoplastic spindle cells proliferated in close proximity to the epithelial elements. Some of the histochemical procedures suggested mesenchymal features in the stroma of the exophytic portions of three cases, but heterogeneous elements, such as bone or striated muscle, were not observed. By immunohistochemical examination the epithelial elements showed positive reactions for keratin, epithelial membrane antigen, and/or carcinoembryonic antigen to a varying degree according to the histologic types. The spindle cell elements revealed a positive immunoreaction for keratin in all but one case. Epithelial membrane antigen was demonstrated in sarcomatous areas of only five cases and carcinoembryonic antigen was not expressed at all. In contrast, vimentin was distinctly demonstrated in sarcomatous areas of five cases, although other mesenchymal markers, such as desmin, actin, and myosin, were negative. These findings indicate that the spindle cell components in these 16 cases may represent mesenchymal features with partial or complete loss of epithelial features.

True pulmonary carcinosarcoma (squamous cell carcinoma and chondrosarcoma). A case report

True pulmonary carcinosarcoma (squamous cell carcinoma and chondrosarcoma) originating in the right lower lobe in a 62-year-old Japanese male is reported. The tumor, measuring 5.5 x 3.5 x 3.5 cm, was markedly necrotic and its apex protruded into the bronchial lumen. Light microscopy showed that the tumor was composed of squamous cell carcinoma with sarcomatous spindle or polygonal cell proliferation and true chondrosarcoma. Immunohistochemically, the cytoplasm of numerous cells of the squamous cell carcinoma component was stained with anti-cytokeratin (PKK 1) and the cytoplasmic membrane with anti-epithelial membrane antigen (EMA). Although sarcomatous regions were stained with anti-vimentin (vimentin) and no tumor cells were reactive for EMA, a few tumor cells were positive for PKK 1. The cytoplasm of numerous chondrosarcoma cells was positively stained for vimentin and S-100 protein. Based on these findings, we concluded that the present tumor was a true carcinosarcoma composed of squamous cell carcinoma with sarcomatous regions and true chondrosarcoma.

A major solid undifferentiated carcinoma pattern correlates with tumour progression in locally advanced prostatic carcinoma

Solid undifferentiated carcinoma was the major microscopic pattern in 24 prostatic carcinomas, 12 of which were clinically recurrent. Tumour cells were uniform, with moderately hyperchromatic nuclei and indistinct cytoplasm, and were arranged in solid or focally irregular aggregates. In areas, the tumour cells were large with vesicular nuclei, nucleoli and more abundant cytoplasm. In previous specimens, solid undifferentiated carcinoma was absent or was a minor pattern. Twenty of 23 cases showed prostate specific antigen and prostatic acid phosphatase immunoreactivity, and nine of 17 cases contained scattered argyrophilic or chromogranin-immunoreactive cells. On proliferating cell nuclear antigen immunostaining of 12 specimens, the mean tumour proliferative fraction in solid undifferentiated carcinoma (range: 10.5-18%) was greater than in areas of grade 3 prostatic carcinoma (range: 3-6%). In all 22 stage C and D cases, there was a close correlation with clinical evidence of tumour progression, and the overall 2-year survival rate was only 16.7%. It is concluded that a major solid undifferentiated pattern correlates with increased biological aggressiveness and a poor prognosis in locally advanced prostatic carcinoma.

'Pleural' and pulmonary carcinosarcomas

The histological distinction between carcinosarcoma and mesothelioma has received little attention. The object of this study was to describe the histology and immunohistochemistry of two carcinosarcomas presenting as pleural tumours. These were compared with 12 carcinosarcomas from sites within the lung, and with the established features of mesothelioma. Histologically and immunohistochemically, these 'pleural' carcinosarcomas are similar to conventional pulmonary carcinosarcomas but accurate recognition is hindered by their gross appearance and biphasic histology which closely mimic mesothelioma. They may exhibit features such as neutral mucin, expression of carcinoembryonic antigen, squamous differentiation, and neuroendocrine differentiation which, when present, are evidence against mesothelioma. These tumours are rare and have passed unnoticed until now.

A case of pulmonary adenocarcinoma with sarcomatous elements initially manifested as a submucosal tumor of the stomach

A case of pulmonary adenocarcinoma, which was initially manifested as a gastric submucosal tumor, is presented. Endoscopy showed a submucosal tumor in the fundic region in a 79-year-old Japanese woman. Initial biopsy specimens of the stomach revealed atypical spindle cell proliferation, suggesting primary leiomyosarcoma of the stomach. However, biopsy specimens obtained one year later were diagnosed as malignant lymphoma or malignant histiocytosis of the stomach. Autopsy revealed a large necrotic lesion in the right S8 region with metastases in multiple organs. Microscopy demonstrated well to moderately differentiated adenocarcinoma containing spindle or pleomorphic sarcomatous elements. Metastatic nodules including the gastric tumors all showed sarcomatous elements with no epithelial component. Immunohistochemistry showed positive reactions for keratin, epithelial membrane antigen, and carcinoembryonic antigen in areas of carcinoma, whereas most of the sarcomatous elements revealed no positivity for any of the antibodies used, except for focal keratin and EMA positivity in the primary site. This is a rare case of pulmonary adenocarcinoma with sarcomatous elements discovered as a gastric tumor at initial diagnosis, resulting from metastasis of the sarcomatous element in the submucosa.

Peripheral biphasic adenocarcinoma of the lung: light microscopic and immunohistochemical findings

We report two cases of peripheral biphasic adenocarcinoma primary in the lung. To our knowledge, peripheral adenocarcinoma of the lung with a spindle-cell component has not been described previously. Diffuse positive cytokeratin and negative vimentin immunostaining of the spindle-cell components support an epithelial differentiation of the malignant spindle cells. Although study of additional cases is needed, our initial findings suggest that immunohistochemical staining pattern may help distinguish these neoplasms from other biphasic neoplasms primary or secondary to the lung, such as carcinosarcoma or malignant mesothelioma.

Sarcomatoid carcinoma of the lung. Immunohistochemical and ultrastructural studies of 14 cases

The authors retrospectively reviewed data regarding 14 patients with sarcomatoid carcinomas of the lung seen and treated at M.D. Anderson Cancer Center from 1955 to 1986. The following were the histologic criteria for inclusion in the study: (1) the concurrent presence of malignant epithelial and sarcomatoid spindle cell components, and (2) positive immunoreactivity for antikeratin antibody or ultrastructural demonstration of epithelial differentiation in sarcomatoid tumors in which the epithelial component was inconspicuous. For the sarcomatoid components, the most frequent pattern was malignant fibrous histiocytoma, which was present in ten tumors. An unclassified sarcomatoid pattern was found in two cases and a fibrosarcomatous pattern in two remaining cases. Clinically, the median patient age was 59 years; 12 patients were male and 2 were female; 13 were smokers and 1 used snuff. Three patients had Stage I, ten had Stage III, and one had Stage IV disease. One patient with Stage I, seven with Stage III, and one with Stage IV disease died of their carcinomas 2 to 26 months after diagnosis (median survival time 12 months). All patients who had lymph node metastases at presentation died of disease. The authors concluded the following: (1) patients with sarcomatoid carcinoma of the lung usually presented at an advanced stage; (2) lymph node metastasis, as with a usual carcinoma of the lung, is an important prognostic factor; and (3) for all lung tumors with a sarcomatoid pattern, especially a malignant fibrous histiocytoma pattern, extensive samples should be obtained and immunoperoxidase or ultrastructural studies done to identify epithelial differentiation.

Immunoreactive Prostatic Specific Antigen in Male Periurethral Glands

Prostatic specific antigen (PSA) is considered an antigen unique to benign and malignant prostatic tissue. Recent evidence in the literature has raised serious doubts about the specificity of this antigen. In this study twenty male urethral specimens were evaluated for PSA and prostatic acid phosphatase (PAP) from patients without evidence of prostatic cancer. Eight of these 20 urethral specimens exhibited strong immunostaining for both PSA and PAP, localized in the periurethral glands. Five of the 17 urethral biopsies were positive for both antigens, while all three of the whole mount autopsy specimens stained positive for PSA and PAP. Within the autopsy series, there was heterogenous staining of the periurethral glands within the same specimen. This evidence disproves the fact that PSA and PAP are organ specific as previously described. More than likely any tissue of cloacal origin has potential for staining positive for prostatic specific antigen and prostatic acid phosphatase.

Carcinosarcoma of the lung with hypertrophic pulmonary osteoarthropathy

Carcinosarcoma of the lung is a rare malignancy. Endobronchial and parenchymal variants are classically described. Clinicopathological features are often related to anatomical location, as is the case for most lung neoplasms. This case report details the surgical management of a carcinosarcoma in a patient seen with pulmonary osteoarthropathy.

Unusual primary lung neoplasms: spindle cell and undifferentiated lung carcinomas expressing only vimentin

Two unusual primary carcinomas of the lung are described. One occurred in a 31-year-old man and was composed of large, undifferentiated, ovoid to polygonal cells. The other occurred in a 72-year-old man, was composed of spindle-shaped cells, and was initially diagnosed as a localized fibrous mesothelioma. The neoplastic cells of these tumors expressed only vimentin intermediate filaments and showed no other immunohistochemical features of epithelial neoplasms, although they exhibited a metastatic pattern characteristic of lung carcinomas. These two malignant neoplasms further expand the spectrum of unusual lung neoplasms, and suggest that there are pulmonary carcinomas that contain only vimentin intermediate filaments.

An immunohistological comparison of primary lung carcinosarcoma and sarcoma

We wished to assess the antigenic expression of primary lung tumors diagnosed as either carcinosarcoma or sarcoma in order to determine whether this information would be useful in distinguishing the two. We therefore immunohistochemically analyzed six pulmonary carcinosarcomas and five primary lung sarcomas for the presence of carcinoembryonic antigen (CEA), S100 protein, cytokeratin and vimentin using commercially available monoclonal and polyclonal antibodies on formalin fixed tissues. Six of six carcinosarcomas stained positively for cytokeratin while none of the sarcomas stained. In three carcinosarcomas both the carcinomatous and sarcomatous areas were positive while in three only the carcinomatous areas were positive. CEA staining was present in five carcinosarcomas and absent in all the sarcomas. CEA positivity was strong and not confined to those tumors with obvious gland formation. Staining for S100 protein was positive in two carcinosarcomas but only in those areas showing chondroid differentiation. Immunohistochemical staining for vimentin using two different monoclonal antibodies gave inconsistent results. We conclude that in differentiating between a carcinosarcoma and a sarcoma of the lung, immunohistochemical staining for both cytokeratin and CEA are useful with cytokeratin marginally preferable. The data indicate that carcinosarcoma of the lung, like that of the upper aerodigestive tract, expresses antigens suggesting both epithelial and mesenchymal differentiation.

The role of tumor markers in the early detection of cancer

Tumor markers include a broad range of substances expressed at different levels and in different biochemical forms. Bence-Jones protein, carcino-embryonic antigen and alpha-fetoprotein are recognized as some of the earlier utilized markers. Recent technologic advances have led to the development of a variety of serum tumor markers, tumor markers in body fluids, tissue tumor markers, and genetic tumor markers, such as protooncogenes.