Oat cell carcinomas of the oesophagus: a clinico-pathological study of 23 cases

Extrapulmonary and pulmonary small-cell carcinoma: tumor biology, therapy, and outcome

Extrapulmonary small-cell cancer is a distinct clinicopathological entity from small-cell anaplastic carcinoma of the lung. Approximately 1,000 cases have been projected annually in the United States, which represents an overall incidence of between 0.1% and 0.4% of all cancer. Not surprisingly then, little information is available regarding the treatment of this disease, which presents a challenge to the clinician when it is regionally confined. The majority of patients with extrapulmonary small-cell neoplasms have only been treated with local modalities of therapy, surgery, radiation, or a combination of both. Prolonged survival is not infrequent, which is in contrast to the experience for small-cell lung cancer and surprising given our current systemic approach to patients with this disease. This report will summarize the similarities and differences in biology, natural history, and clinical characteristics of patients with extrapulmonary small-cell cancer and small-cell anaplastic carcinoma of the lung. The histogenesis of small-cell cancer is briefly reviewed. A general therapeutic approach to patients with small-cell lung cancer is reported. Lastly, recommendations for therapy of patients with regionally confined extrapulmonary small-cell cancer by primary site are outlined.

Primary small cell carcinoma of the esophagus: case presentation and review of the literature

A case of primary small cell carcinoma of the esophagus is presented. The clinical, radiologic, and pathologic findings of our case and 72 other cases were reviewed. The most common presenting symptoms were weight loss and dysphagia. Eighty percent were larger than 4 cm at presentation and 97% were in the mid to distal esophagus. The esophageal tumors were identical histologically to small cell carcinoma of the lung. Esophageal luminal widening on esophagram has been found to be more common in nonsquamous cell carcinomas. While rare, small cell carcinoma should be considered in the differential diagnosis of primary esophageal tumors, particularly in the presence of these findings.

Small cell carcinoma of the gallbladder combined with adenocarcinoma

A rare case of small cell carcinoma (SCC) of the gallbladder combined with adenocarcinoma is reported. The patient was a 70-year-old Japanese man, who died of the disease shortly after the onset of symptoms. Autopsy disclosed a small tumor (1.0 cm in longest diameter) in the fundus of the gallbladder, with widespread metastasis. Histochemically, the tumor cells showed negative reactions for argyrophilic and argentaffin stainings, a weak immunohistochemical reaction only for neuron-specific enolase, and negative reactions for all of the other neurosecretory markers used, including neurofilament, chromogranin, somatostatin, gastrin and leu-7. However, electron microscopic examination revealed a few typical neurosecretory granules (NSG) in the cytoplasm of some tumor cells. We suggest that: 1. The presence of NSG in the cytoplasm of tumor cells is the most reliable diagnostic criterion for SCC. 2. SCC, at least the combined type, arises from a multipotential stem cell.

Basaloid-squamous carcinoma of the upper aerodigestive tract and so-called adenoid cystic carcinoma of the oesophagus: the same tumour type?

Basaloid-squamous carcinoma of the larynx, pharynx and base of tongue and the so-called adenoid cystic carcinoma of the oesophagus are rare but distinctive tumours associated with a grave prognosis. They occur most commonly in elderly males and present at an advanced stage. Our study of four such laryngeal tumours and five such oesophageal tumours shows that they are histologically and immunohistochemically identical, providing support for the idea that they are the same tumour type. They show a biphasic pattern in which basaloid tumour is intimately associated with a neoplastic squamous component which can be invasive or in situ. The basaloid component is in the form of invasive lobules with frequent comedo-necrosis and hyalinization. The constituent cells possess pale pleomorphic nuclei with frequent mitoses. Immunoreactivity for cytokeratin in the basaloid component is remarkable for its absence or weak and focal nature. Review of the literature shows that only a few cases of 'adenoid cystic carcinoma' of the oesophagus are bona fide examples of adenoid cystic carcinoma as it occurs in the salivary glands, while the others are identical to basaloid-squamous carcinoma of the upper aerodigestive tract. Their distinction is important because genuine adenoid cystic carcinoma is much less aggressive than basaloid-squamous carcinoma.

Primary undifferentiated small cell carcinoma of the esophagus: clinicopathological and flow cytometric evaluation of eight cases

We present a clinicopathological and flow cytometric evaluation of eight primary small cell carcinomas of the esophagus representing 1.5% of all esophageal malignancies diagnosed during a 22-year period (1965-1987) in the Tampere University Central Hospital. The mean age of the patients (four male and four female) was 67 years (range 55-75 years). Five cases had distant metastases at the time of diagnosis. Three patients were treated by esophageal resection, one by laser vaporisation, and four by chemotherapy. The median survival time was 4 months (range 9 days to 8 months). A complete local response to chemotherapy in serial esophagogramms was detected in one patient. All four patients given chemotherapy survived longer than those treated with esophageal resection only. Four (67%) of the six carcinomas analyzed by DNA flow cytometry contained DNA-aneuploid stemlines. The median S-phase fraction of these small cell carcinomas was high (16.3%), reflecting rapid cell proliferation rate, which may be related to their responsiveness to chemotherapy.

Small cell carcinoma of the urinary tract

Small cell carcinomas of the urinary tract are rare, but lethal. We report 3 cases of primary small cell carcinoma of the kidney, urinary bladder and prostate with light microscopic, immunohistochemical and electron microscopic findings. One patient with small cell carcinoma of the prostate died of disseminated disease 2 years after diagnosis and another patient with small cell carcinoma of the urinary bladder was free of tumour after 6 months. A partial remission was induced in the third patient with distant metastases of small cell carcinoma of the kidney by using chemotherapy protocols similar to the drug regimens for small cell carcinomas of the lung; the patient survived for 5 months. Immunohistochemical studies revealed the absence of argyrophilic immunostaining of tumour cells in all 3 cases, positive staining for keratin in 2 and staining for neuron-specific enolase in all 3. In the third patient, reactivity for prostate-specific antigen was negative. Dense-core, membrane-bound granules were identified in the cytoplasm of 2 patients. The paraneoplastic syndrome was not found, indicating that in considering the occurrence of ectopic hormones, specific cytoplasmic granules of origin need not be implicated. Recognition of this distinct entity requires full consideration of morphological, immunohistological, ultrastructural and biological features. In order to define the origin of this tumour more clearly and to evaluate the effectiveness of chemotherapy, larger series of patients are needed.

Small cell carcinoma of the pancreas and biliary tract

Four cases of anaplastic carcinoma of the pancreas or biliary tract were studied clinicopathologically and immunohistochemically. All four cases were intermediate cell type and contained a minimum amount of microscopic foci of differentiated glandular adenocarcinoma. Argyrophilic tumor cells were not seen in any of the four tumors. Immunohistochemically, no tumor was positive for hormonal products, but all tumors were positive for epithelial markers. These findings suggest that the anaplastic carcinoma are not derived from argyrophilic cells, but rather from adenocarcinomas which have the potential for anaplastic metaplasia. The long-term survival of one patient emphasized the importance of chemotherapy in the treatment of small cell carcinoma of the pancreas and biliary tract.

Small-cell carcinoma of the esophagus. Treatment by endoscopy

A case of primary carcinoma of the esophagus is presented that consisted of poorly differentiated small-cell carcinoma. The patient underwent endoscopic treatment, first with an Nd:YAG laser and, finally, with bougienage and the insertion of a prosthesis in order to relieve dysphagia and improve the nutritional status and quality of life. Even though it is generally uncommon for laser therapy to be chosen as a primary mode of treatment, the results obtained should permit to overcome this lack of confidence in the choice of laser treatment for small-cell carcinoma of the esophagus.

Small cell carcinoma of the esophagus. Report of three cases and review of the literature

Small cell carcinoma has been described in the lung, stomach, pancreas, small intestine, larynx, hypopharynx, thymus, kidney, prostate, breast, cervix, skin, and esophagus. Our three cases and review of the literature confirm that the clinical presentation and eventual evolution of small cell carcinomas of the esophagus appear to be basically similar to those of the far more frequently occurring squamous and glandular carcinomas. However, certain differences in age and sex distribution of cases should be noted. Although squamous cell carcinomas occur three to four times more commonly in males, the male-to-female ratio in SCC in 1.6. Squamous cell carcinomas of the esophagus reach a peak in the fifth and sixth decades of life; SCC cases occur a decade later. All of our patients had history of heavy smoking more than 50 pack-years, a factor that has also been implicated in predisposition to squamous cell carcinoma of the esophagus. History of smoking to this extent was also mentioned in three other patients. There are also some differences in the location of the tumor. SCC rarely occurs in the upper third of the esophagus. The most common location of this tumor is the lower third where APUD cells are most abundant. On the other hand, a majority of squamous cell carcinomas of the esophagus are localized to the middle third, the upper and lower third being involved in equal proportions of the cases. Despite the above reported differences in clinical symptoms and course of these two tumors, their gross appearance is similar. Mean survival of both diseases also seems to be similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Small cell carcinoma of the oesophagus: report of three cases and review of published cases

Small cell carcinoma of the oesophagus is a rare tumour with a poor prognosis. This report presents evidence favouring chemotherapy as the primary treatment.

Primary small cell carcinoma of the esophagus

A primary small cell carcinoma of the esophagus in a 61-year-old woman was treated by transhiatal esophagectomy. The clinical data were correlated with data obtained from a review of the 129 cases reported in the world literature, thereby providing a clinical profile and suggested management strategy for this rare type of esophageal malignancy. Presenting symptoms of esophageal small cell carcinoma include dysphagia (75.3%), weight loss (38.4%), and chest pain (23.3%). Treatment regimens have included surgical intervention in 58%, radiotherapy in 10%, chemotherapy in 6%, or some combination of these in 26%. Overall survival is only 20.7 weeks after diagnosis. The fact that three fourths of affected patients had metastatic disease at the time of diagnosis leads us to recommend surgical intervention plus systemic chemotherapy in these patients.

Cerebellar cortical degeneration in association with small-cell carcinoma of the oesophagus

We report the association of paraneoplastic cerebellar cortical degeneration with small-cell oesophageal carcinoma in a 60-year-old woman and describe the histopathological findings. We believe this to be the first report of such an occurrence. The cytoplasmic antigen PGP 9.5, which is strongly expressed in cerebellar Purkinje cells, was identified immunohistologically in the primary tumour and immunoglobulin demonstrated on Purkinje cells. These findings support an immunological pathogenesis for this condition and suggest that it is mediated by antibodies directed against tumour antigen which cross-react with Purkinje cells.

Squamous carcinoma of the oesophagus: histological criteria and their prognostic significance

One hundred resected cases of squamous cell carcinomas of the oesophagus were reviewed and a series of histological criteria related to the survival time. Two histological features were important in the assessment of survival. Good prognostic factors were a marked lymphocytic response to the tumour and a lack of intravenous tumour infiltration. Presence of tumour in the middle third of the oesophagus, infiltration through the muscularis propria, severe tumour necrosis, glandular or small cell tumour differentiation, lymphatic invasion and lack of peritumoural fibrosis were all factors which tended to worsen prognosis. None of these factors reached statistical significance. The degree of squamous differentiation had no effect on survival.

Small cell carcinoma of the esophagus

Ten cases of small cell carcinoma of the esophagus were studied clinicopathologically and immunohistochemically. Seven of the ten were also examined by electron microscopy. Histologically, six were oat cell type, four the intermediate cell type, and multiple histologic sections revealed squamous and glandular differentiations in small or minute areas of seven and two tumors, respectively. In four of the six polypoid tumors, the epithelium covering the tumor showed a malignant conversion accompanied by a proliferation of small anaplastic cells. Another one showed a cribriform pattern in a small area of the tumor. Argyrophilic tumor cells were seen in six cases and tumor cells immunohistochemically positive for ACTH and calcitonin were seen in six, and three cases, respectively. Neurosecretory granules were evident in three of the seven cases examined by electron microscopy. These findings suggest that a small cell carcinoma of the esophagus differentiates toward a squamous, glandular, or neurosecretory lesion, thereby supporting the idea of a totipotential stem cell origin of this tumor. The prognosis of patients with this tumor was poor, in accord with the evidence of aggressive lymphatic and blood vessel permeation.

Anaplastic small cell (oat cell) carcinoma of the tonsils: report of two cases

Two cases of anaplastic small cell (oat cell) carcinoma of the tonsils are presented. In the first, cervical metastases preceded the manifestation of the primary tumour by 2 years. In case 2 the tonsillar carcinoma was accompanied by a bronchial tumour of the same histological type and by cervical and axillary metastases. Positive Grimelius stain, positive immunohistochemical staining for chromogranin A and neurone-specific enolase and the presence, in case 1, of membrane-bound granules indicate that these tumours display many similarities with neuroendocrine carcinomas even if they originate from pluripotential ductal cells of tonsillar minor salivary glands and not from Kulchitsky-like cells.

Small cell neuroendocrine carcinoma of the urinary bladder. An immunohistochemical and ultrastructural evaluation of 3 cases with a review of the literature

Small cell carcinoma with the histological appearance of pulmonary small cell carcinoma is a rare tumour in the urinary bladder. In previous case reports the neuroendocrine nature of small cell bladder carcinoma has been accepted, but on review the evidence for true neuroendocrine differentiation appears unsatisfactory. In this study the histological, immunohistochemical and ultrastructural characteristics of three cases of small cell carcinoma of the urinary bladder are described. Ultrastructurally, the cytoplasm of all three tumours contained neurosecretory-type granules and each of the tumours demonstrated positive immunoreaction for two or more neuroendocrine markers, from a panel including neuron-specific enolase, chromogranin A, Leu-7, bombesin and synaptophysin. Although the combination of ultrastructural and immunohistochemical examination obviously offers the strongest evidence in establishing neuroendocrine differentiation, it is argued that immunohistochemistry alone may also yield important information in demonstrating a neuroendocrine nature, provided that at least neuron-specific enolase and synaptophysin are included as markers. The clinical relevance of identifying neuroendocrine differentiation in small cell bladder carcinoma is suggested by the favourable response to combination chemotherapy in two of our cases.

Effective chemotherapy for small cell carcinoma of the esophagus

This article documents the use of chemotherapy in a case of small cell carcinoma of the esophagus with multiple liver and lymph node metastases. A multi-drug regimen was used and included cis-dichlorodiamine platinum (CDDP), VP-16, vincristine (VCR), adriamycin (ADM), and cyclophosphamide (CPA). After chemotherapy, the esophageal tumor disappeared, and liver masses reduced in number and degenerated. Nine months later, however, the patient died of brain metastases. It was concluded that radiotherapy should be given to the brain for the prophylaxis of tumor relapse.

Small cell carcinoma of the kidney. A clinicopathologic, immunohistochemical, and ultrastructural study

Three cases of primary small cell carcinoma of the kidney with light microscopic, immunohistochemical, and electron microscopic findings are reported. Two patients died of disseminated disease 8 months and 1 year, respectively, after the diagnosis and the third was free of tumor after 18 months. Immunohistochemical studies revealed keratin immunostaining of tumor cells in two cases and staining for neuron-specific enolase in the third. The third case also showed a few dense neurosecretory granules at the ultrastructural level. Although no strong conclusions regarding histogenesis can be drawn, this study indicates that small cell carcinoma of the kidney exists and does not necessarily exhibit a neuroendocrine differentiation. Small cell carcinoma of the kidney must be considered in the differential diagnosis of malignant renal tumor, especially in cases in which a large necrotic tumor is present. Based on the few cases presented in this study and on the one previously reported case, small cell carcinoma of the kidney appears to be an aggressive tumor.

Endocrine differentiation of extra-pulmonary small cell carcinoma demonstrated by immunohistochemistry using antibodies to PGP 9.5, neuron-specific enolase and the C-flanking peptide of human pro-bombesin

Several recent studies have confirmed the endocrine nature of small cell carcinoma of the lung. In extra-pulmonary sites, small cell 'undifferentiated' carcinomas have classical morphological features similar to their pulmonary counterpart. We therefore investigated, using immunocytochemistry, the possibility that the non-pulmonary neoplasms may also be endocrine in nature. Sections of 29 small cell carcinomas from oesophagus, stomach, larynx, colon and urinary bladder were immunostained using antisera to protein gene product 9.5 (PGP 9.5), neuron-specific enolase (NSE), cytokeratin, leucocyte common antigen and peptides including bombesin, the C-flanking peptide of human probombesin, adrenocorticotrophic hormone, neurotensin, calcitonin and pancreatic polypeptide. All the tumours showed immunoreactivity for at least one of the two general endocrine markers PGP 9.5 and NSE. Twenty-three of the 29 cases were immunoreactive for PGP 9.5, 27 for NSE. All were positive for cytokeratin and negative for leucocyte common antigen. Of the regulatory peptides, immunoreactivity was obtained with antisera to bombesin (one case), the C-flanking peptide of human pro-bombesin (14 cases), adrenocorticotrophic hormone (one case) and calcitonin (three cases). No PGP 9.5-, NSE- or peptide-like immunoreactivity was detected in 25 control tumours from similar sites, including lymphomas and poorly differentiated tumours. These results suggest that non-pulmonary small cell carcinoma has an endocrine character.

Malignant carcinoid of oesophagus

This paper presents a unique apudoma variant--a malignant carcinoid of mid and lower oesophagus in an elderly man. It was remarkable in the short duration of the clinical symptoms, its rather easy resectability despite its large size and the local perigastric lymph node metastases. On light microscopy, the neoplasm was composed entirely of atypical but uniform round cells lacking argentaffin and argyrophilic staining, arranged in a carcinoid pattern. On electron microscopy, they exhibited dense-core neurosecretory granules.

Ultrastructural and immunocytochemical definition of component neoplasms in an unusual gastro-oesophageal collision tumour

An unusual collision tumour (concrescence of two neighbouring independent neoplasms) is reported. One tumour was a small cell undifferentiated (oat cell) carcinoma of the lower oesophagus and the other was a gastro-oesophageal adenocarcinoma. There was little intermingling of the two patterns. The adenocarcinoma stained strongly positive for mucin and carcinoembryonic antigen (CEA), but the small cell carcinoma was negative for both and also argyrophil-negative; both were negative for neurone-specific enolase and common leukocyte antigen. Ultrastructural study showed extra-cellular glandular lumina lined by cells with apical microvilli and junctional complexes in the adenocarcinoma; primitive cells without tonofilaments or dense-core granules, and joined by rudimentary desmosomes were seen in the small cell carcinoma. Collision carcinomas may result from a carcinogenic stimulus affecting two neighbouring regions of mucosa or may simply be the chance apposition of two unrelated tumours.

Primary oat cell carcinoma of the oesophagus

Three cases of oat cell carcinoma of the oesophagus are presented and published reports reviewed. This is mainly a disease of older age with a 3:2 predominance of men. Of all published cases, 43 (47.3%) occurred in the middle third, 41 (45.1%) in the lower third, and four (4.4%) in the upper third. In one case it was multifocal and in two the location was not stated. Dysphagia was the most common symptom and was found in 82.5% of cases. Overall survival was 4.7 months. The longest survival in a patient treated by resection was 24 months and in a patient treated by chemotherapy 11 months. All but one of the patients had widely disseminated metastatic disease at death. It is concluded that surgery, possibly with adjuvant chemotherapy, holds out the best prospect for such patients.

Primary combined small cell carcinoma of the larynx

The clinical and pathologic findings of six cases of combined small cell carcinoma of the larynx are described. This tumor is a subtype of small cell carcinoma in which there is a definite component of oat cell carcinoma (or intermediate cell type carcinoma) together with squamous cell carcinoma or adenocarcinoma or both. The neoplasm seems to derive from a common cell with subsequent divergent differentiation into the Kulchitsky cells, squamous cells, and/or glandular cells. After histologic diagnosis, adequate evaluation for tumor staging is mandatory. Like pulmonary combined small cell carcinoma, this neoplasm may be best treated with systemic chemotherapy and radiotherapy. The prognosis is similar to that of other subtypes of small cell carcinoma of the larynx.

Extrapulmonary oat cell carcinoma

Primary extrapulmonary tumors with histologic features indistinguishable from bronchogenic oat cell carcinoma are appearing with increasing frequency in the literature. These tumors have been described in the esophagus, stomach, pancreas, larynx, hypopharynx, salivary glands, nasal cavity and paranasal sinuses, thymus, small and large bowel, uterine cervix, endometrium, breast, prostate, urinary bladder, and skin. It is now widely believed that oat cell carcinoma is a poorly differentiated counterpart of carcinoid tumor and that both originate from an endocrine cell system. In this article, the authors review all cases of extrapulmonary oat cell carcinomas, which they were able to find in the English literature, and report personally studied examples of these tumors, occurring in the esophagus, stomach and urinary bladder. A closely related, if not identical, tumor arising in the skin is also described. It is emphasized that a wider recognition of these tumors is likely to lead to their more frequent diagnosis and possible treatment.

Oat cell carcinoma of esophagus: a report of six British patients with a review of the literature

This paper presents 6 British patients with a diagnosis of oat cell carcinoma of the esophagus. Sixty-six patients have previously been reported in the literature, the majority (30) being British. Approximately two-thirds of these tumors have been reported as pure oat cell carcinoma of the esophagus. Four other histological patterns have been described: oat cell carcinoma with squamous carcinoma in situ; oat cell carcinoma with squamous carcinoma; oat cell carcinoma with adenocarcinoma; and oat cell carcinoma with carcinoid differentiation. A preponderance of males has also been noted, although this series shows a 2:1 female:male ratio. The tumor arises most commonly in the mid or lower esophagus. The cell of origin of these tumors in considered to be the Kulchitsky or APUD cell of neuroectodermal derivation. They may show neurosecretory granules on electron microscopy. Polypeptides have been identified within the tumor cells. One previous report describes a patient with primary oat cell carcinoma of the esophagus and hypercalcemia. A patient with the syndrome of inappropriate anti-diuretic hormone secretion is described in this paper. Survival is poor following radiotherapy, with a median survival of 3 months in this series. On reviewing the records of the Radiation Oncology Unit in Edinburgh, no patient with oat cell carcinoma of the esophagus was reported before 1972. This suggests that awareness of this tumor is increasing and, although rare, its incidence is greater than previously reported.