Analysis by comparative genomic hybridization of epithelial and spindle cell components in sarcomatoid carcinoma and carcinosarcoma: histogenetic aspects

Mechanoscopy: A Novel Device and Procedure for in vivo Detection of Chronic Colitis in Mice

BACKGROUND

Gut stiffening caused by fibrosis plays a critical role in the progression of inflammatory bowel disease (IBD) and colon cancer. Previous studies have characterized the biomechanical response of healthy and pathological gut, with most measurements obtained ex vivo.

METHODS

Here, we developed a device and accompanying procedure for in vivo quantification of gut stiffness, termed mechanoscopy. Mechanoscopy includes a flexible balloon catheter, pressure sensor, syringe pump, and control system. The control system activates the balloon catheter and performs automated measurements of the gut stress-strain biomechanical response.

RESULTS

A gut stiffness index (GSI) is identified based on the slope of the obtained stress-strain response. Using a colitis mouse model, we demonstrated that GSI positively correlates with the extent of gut fibrosis, the severity of mucosal damage, and the infiltration of immune cells. Furthermore, a critical strain value is suggested, and GSI efficiently detects pathological gut fibrotic stiffening when the strain exceeds this value.

CONCLUSIONS

Based on these results, we envision that mechanoscopy and GSI will facilitate the clinical diagnosis of IBD.

Sinonasal carcinosarcoma with cartilaginous and rhabdomyoblastic components: A previously undescribed entity

Carcinosarcomas are rare, aggressive tumors seldom found in the sinonasal region. They classically consist of sarcomatous spindle cell and carcinomatous squamous cell elements. A 61-year-old woman presented reporting right-sided nasal discharge and obstruction. Examination demonstrated a large right-sided nasal mass, from which a biopsy was taken. Computed tomography and magnetic resonance imaging revealed a mass arising from the maxillary antrum and extending into the nasal cavity, ethmoid air cells, and frontal sinus. Right total maxillectomy with resection of the nasal tumour component was performed. Histological analysis demonstrated a high-grade malignancy with features consistent with carcinosarcoma with cartilaginous and rhabdomyoblastic elements, a histologic pattern that has not previously been described at this site. Magnetic resonance imaging 5 weeks postoperatively showed sizeable recurrence. Adjuvant chemotherapy and radiotherapy were commenced to excellent effect. Carcinosarcomas, though very rare at sinonasal sites, should be considered if biopsy demonstrates undifferentiated high-grade neoplasm with cytokeratin expression. These tumors require aggressive multimodal therapy for optimal outcomes.

Histologic Variants of Urothelial Carcinoma: Morphology, Molecular Features and Clinical Implications

Bladder cancer is a heterogeneous disease including conventional urothelial carcinoma (UC) and its histologic variants, and non-urothelial carcinoma, including squamous and glandular neoplasms. Urothelial carcinoma accounts for the majority of bladder cancer cases, but morphologic variants are common and include nested, microcystic, micropapillary, lymphoepithelioma-like, plasmacytoid, sarcomatoid, giant cell, undifferentiated, clear cell and lipoid. Certain variants of UC tend to be associated with a poor prognosis and have diagnostic and potential treatment implications that make the identification of variant histology crucial to clinical decision making. While there is still uncertainty regarding the prognostic implications of many of these variants, identifying and reporting variant histology is important to develop our understanding of their biology. Unique molecular features accompany many of these morphologic variants and to better understand these tumors, we review the molecular and clinical implications of histologic variants of bladder cancer. Major efforts are underway to include variant histology and divergent differentiation of UC in clinical trials to develop evidence based approaches to treatment. The purpose of this article is to review the current literature on variant histology of urothelial cancer and to highlight molecular findings and the clinical relevance of these tumors.

Immunohistochemical evaluation of mismatch repair proteins and p53 expression in extrauterine carcinosarcoma/sarcomatoid carcinoma

Introduction

Carcinosarcoma (CS) is a tumor with components: epithelial (carcinomatous) and mesenchymal (sarcomatous), developing in the mechanism of epithelial-mesenchymal transition. It is known that the p53 defect is a frequent finding in a carcinosarcoma in different anatomical locations, additionally, in a subgroup of uterine CS MMR defect plays a role in the pathogenesis. The aim of this paper was to investigate the frequency of MMR and p53 aberrations in extrauterine CS.

Material and methods

Twenty eight extrauterine CS from the lung (n = 8), breast (n = 6), head and neck (n = 5), ovary (n = 3), urinary bladder (n = 3), adrenal gland (n = 1), skin (n = 1), and stomach (n = 1) were stained for hMLH1, PMS2, hMSH2, hMSH6 and p53. The pattern of expression was evaluated separately in carcinomatous and sarcomatous component.

Results

Immunostainings for hMLH1, PMS2, hMSH2 and hMSH6 were positive in all tumors. p53 defect was observed in 19 out of 28 samples (67.85%). In all cases except one (96.42%) there was a concordance between sarcomatoid and carcinomatous components.

Conclusions

MMR deficiency does not seem to play a role in the pathogenesis of extrauterine CS. p53 aberrant expression is frequent and almost always consistent in carcinomatous and sarcomatous component.

MLH1 promoter hypermethylation in uterine carcinosarcoma rarely coexists with TP53 mutation

Introduction

Carcinosarcoma (CS) is an infrequent neoplasm composed of a carcinomatous and a sarcomatous element. Its molecular pathogenesis is poorly understood. In this study, we investigated the disturbances in the immunohistochemical expression of p53 and mismatch repair (MMR) proteins, as well as their molecular background.

Material and methods

The study group consisted of 20 uterine CSs. We analysed their morphology and immunohistochemical expression of hMLH1, hPMS2, hMSH2, MSH6, and p53 as well as the presence of mutations in TP53 and promoter methylation of the hMLH1. Loss of hMLH1 and PMS2 was found in 3/20 tumours. All cases were positive for hMSH2 and hMSH6. The TP53 mutation was detected in 8/19 tumours (42.1%), whereas MLH1 promoter hypermethylation in 4/19 cases (21%), and one case with synchronous aberrations (5%). Agreement between the results of the genetic and immunohistochemical study was moderate for p53 (k = 0.615, p< 0.01) and strong for MLH1 (k = 0.826, p< 0.01).

Results and conclusions

We demonstrated MLH1 promoter hypermethylation in uterine CS, leading to loss of MLH1 immunostaining. Concomitant aberrations of p53 and hMLH1 are infrequent. It is likely that uterine CS may develop in two independent molecular pathways in association with either chromosomal or microsatellite instability.

Primary carcinosarcoma of the ureteropelvic junction associated with ureteral duplication: A case report

RATIONALE

Primary carcinosarcoma of the upper urinary tract is rare. Ureteral duplication is one of the most common urinary tract malformations. Additionally, the association between ureteral duplication and malignancy is unknown. To the best of our knowledge, no cases of malignant tumors diagnosed as carcinosarcoma with ureteral duplication have been reported. We herein report the case of a patient with carcinosarcoma of the ureteropelvic junction associated with incomplete ureteral duplication.

PATIENT CONCERNS

A 60-year-old Japanese woman presented with painless gross hematuria. She had a history of total hysterectomy and chemotherapy for endometrioid carcinoma 5 years before. She had no history of occupational chemical exposure.

DIAGNOSES

Radiographic imaging revealed right incomplete ureteral duplication, hydronephrosis, and a polypoid tumor in the ureteropelvic junction of the lower moiety of the right kidney. Urine cytology showed a small amount of degenerated atypical epithelial and nonepithelial cells. The transureteral biopsy specimen showed dysplastic urothelial cells and atypical myoid spindle cells. These findings were indefinite for malignancy.

INTERVENTIONS

The patient underwent right nephroureterectomy. Pathological examination of the resected tumor showed a biphasic neoplasm composed of carcinomatous and sarcomatous components. The sarcomatous component was immunohistochemically positive for vimentin, desmin, h-caldesmon, and α-SMA and negative for pancytokeratin (AE1/AE3), low molecular weight cytokeratin (CAM 5.2), EMA, E-cadherin, GATA3, uroplakin 2, and p63. Based on these findings, we diagnosed the tumor as carcinosarcoma.

OUTCOMES

The postoperative course was uneventful. No additional therapy was administered. The patient has remained alive without recurrence for 21 months since surgery.

LESSONS

Carcinosarcoma can arise from ureteral duplication. Although the majority of carcinosarcomas of the upper urinary tract are diagnosed at an advanced stage and have a poor prognosis, some can have a less aggressive course. Further studies are needed to determine the association between ureteral duplication and malignancy.

Spindle cell carcinoma of the esophagus: A multicenter analysis in comparison with typical squamous cell carcinoma

This study conducted a retrospective multicenter analysis to investigate the clinicopathological features, optimal therapeutic strategy, and prognosis of spindle cell carcinoma (SpCC) of the esophagus.A total of 71 patients with esophageal SpCC from 3 large cancer centers in China were systematically analyzed. All patients received curative resection, 13 patients received adjuvant radiotherapy and 15 patients received adjuvant combination chemotherapy. Additionally, a total of 1852 patients with typical esophageal SCC (SCC) were selected as controls in this study.SpCC mostly presented as a polypoid appearance (66.2%), and the surrounding mucosa showed high-grade hyperplasia or superficial SCC in 31 cases (43.7%). Two patients even had extensive carcinoma in situ that spread to the resection margins. Patients in the SpCC group were more likely to present with stage I lesions compared with those in the typical SCC group (33.8% vs 8.0%, P < 0.001). Although the percentage of T1/2 lesions was higher in the SpCC group than in the typical SCC group (67.6% vs 29.7%, P < 0.001), both groups had similar rates of locoregional lymphatic metastases (45.1% vs 48.4%, P = 0.578). The median survival time and 5-year overall survival of the SpCC group was 43 months and 44.8%, respectively, higher than 37.5 months and 38.3%, respectively, for the typical SCC group (P = 0.044). In univariate analysis, the macroscopical type and pathological T, N, and TNM stages had a statistically significant impact on the prognosis of SpCC after curative resection. However, only the TNM stage (hazard ratio, 2.708; 95% confidence interval, 1.786-4.105, P < 0.001) was identified as an independent prognostic factor in multivariate analysis. The 5-year OS of SpCC in stages I (79.8%) and II (39.7%) were significantly longer than that of stages III/IV (16.2%) (P < 0.001 and P = 0.012). As those SpCC cases that received chemoradiotherapy were in more advanced stages, their prognosis was still worse than SpCC patients who did not receive chemoradiotherapy even after such treatment (P = 0.042, 0.010, respectively).SpCC shows a highly aggressive tendency of lymphatic spread, although it does not tend to infiltrate deeply into the esophageal wall. Compared with typical SCC that also underwent esophagectomy with extended lymphadenectomy, SpCC may achieve a better survival rate. Further investigation is warranted to examine the effect of postoperative chemoradiotherapy on the prognosis of SpCC.

Spindle cell carcinoma of the conjunctiva: A rare entity

An 85-year-old male presented with painless bulging lesion over the cornea. Clinical history, diagnostic imaging studies, and histopathologic sections were evaluated. The patient clinically displayed an vascularized conjunctival lesion located at the superior bulbar conjunctiva with extension onto cornea covering 2/3 of his pupillary aperture superiorly. His visual acuity was counting fingers at 4 m. The patient underwent a total excision of the lesion including conjunctival and corneal parts. Histopathologic evaluation revealed spindle cell carcinoma which involves the whole conjunctival squamous epithelium with significant polarity loss, nuclear enlargement with hyperchromasia and pleomorphism, and mitotic activity. Diagnosis of spindle cell carcinoma is challenging because of overlapping histopathological features with other spindle cell tumors. The detailed pathologic examination is very important for the decision of proper treatment.

Carcinosarcoma of the upper urinary tract with an aggressive angiosarcoma component

Carcinosarcomas (CS) are biphasic tumors with malignant epithelial and mesenchymal elements. The sarcomatoid elements of CS can include chondrosarcoma, malignant fibrous histiocytoma, osteosarcoma, leiomyosarcoma, fibrosarcoma, or liposarcoma. CS of the upper urinary tract are extremely rare but are associated with a poor prognosis. We report a case of a 44-year-old man with a localized right renal pelvis mass treated with a right nephroureterectomy. The pathological examination showed a high-grade urothelial carcinoma of the renal pelvis, stage III (pT3aNxM0). A few days later, he developed lower back pain, hematuria, cough with hemoptoic sputum and progressive dyspnea. Radiological explorations showed multiple bilateral lung nodules and a retroperitoneal mass. A CT-guided biopsy of the retroperitoneal mass revealed a high-grade angiosarcoma. A review of the nephrectomy specimen showed a microscopic focus of angiosarcoma in the urothelial carcinoma. Therefore, the initial diagnosis was changed to CS of the renal pelvis with an angiosarcoma component. The patient developed progressive respiratory failure and died 8 weeks after surgery. An autopsy revealed a large retroperitoneal mass with metastatic nodules to the abdominal wall, diaphragm, small intestine, liver, spleen, and lung. All lesions were angiosarcoma, with no evidence of urothelial carcinoma. This is the first case reported of a patient with CS of the upper urinary tract with an angiosarcoma component with a very aggressive course that caused the immediate appearance of multiple angiosarcoma metastases. We also describe the clinical and molecular characteristics of CS, which will help to contribute to a better understanding of this type of tumor.

Spindle Cell Carcinoma of the Larynx: A Confusing Diagnosis for the Pathologist and Clinician

Laryngeal spindle cell carcinoma (SpCC) is an uncommon subtype of squamous cell carcinoma which represents 0.5% of all laryngeal squamous cell carcinomas. It is a biphasic tumor consisting of the combination of a malignant mesenchymal spindle cell component and a squamous cell component that includes dysplasia, carcinoma in situ, or invasive carcinoma. Although it has aggressive biological features, the probability of making a diagnosis in the early stages is high as it often leads to obstructive symptoms in the early period. Due to its low incidence, there is no clear consensus on prognostic factors and optimal treatment strategies yet. In this paper, a 60-year-old laryngeal SpCC case that was effectively treated with wide local excision followed by adjuvant radiotherapy was presented with the literature.

Primary Sarcomatoid Tumor of the Bladder: A Different Entity but the Same Approach?

Bladder cancer remains a frequent cancer worldwide, and most tumors are diagnosed at localized stages. Urothelial carcinoma (UC) accounts for 90% of bladder cancer cases. Sarcomatoid carcinoma (SaC) of the bladder is a rare variant (0.5% of total bladder cancers) characterized by 2 components based on histology; the epithelial and mesenchymal phenotypes, which can be easily differentiated by immunohistochemistry. SaC has similar epidemiologic features to UC but different behavior, aggressiveness, and prognosis. In this review, we summarize the main differences between UC bladder cancers and SaC subtypes. The therapeutic strategies used in SaC today do not differ much from those used for the urothelial variant. However, there is still no standard treatment--the result of a lack of clinical trials for the sarcomatoid variant. Further multicenter comparative studies are needed to devise a better treatment strategy for patients with this rare histologic tumor subtype.

Squamous cell carcinoma variants of the upper aerodigestive tract: a comprehensive review with a focus on genetic alterations

CONTEXT

Squamous cell carcinoma of the upper aerodigestive tract is a heterogenous entity. Although conventional squamous cell carcinomas are easily recognized, the morphologic variants of squamous cell carcinoma can present a diagnostic challenge. Familiarity with these variants is necessary because many are associated with unique risk factors and are characterized by specific molecular alterations (eg, nuclear protein in testis midline carcinomas). Perhaps the most important distinction is in identifying viral-related from nonviral-related carcinomas. The accurate diagnosis of these variants is necessary for prognostic and therapeutic reasons.

OBJECTIVES

To provide a clinicopathologic overview and summary of the molecular alterations of the common squamous cell carcinoma variants, including verrucous, spindle cell, acantholytic, adenosquamous, basaloid, and papillary squamous cell carcinoma, as well as nuclear protein in testis midline carcinoma, and to discuss the distinguishing features of human papillomavirus- and Epstein-Barr virus-related squamous cell carcinomas.

DATA SOURCES

Published peer-reviewed literature.

CONCLUSIONS

Familiarity with squamous cell carcinoma variants is essential for proper diagnosis and to guide appropriate clinical management. Further insight into the molecular alterations underlying those variants may lead to alterations in existing treatment approaches and to evolution of novel treatment modalities.

Clinicopathological and immunohistochemical analysis of spindle cell carcinoma of the larynx or hypopharynx: A report of three cases

Spindle cell carcinoma (SpCC) is a rare and unusual biphasic malignant tumor, which involves sarcomatoid proliferation of pleomorphic spindle cells and squamous cell carcinoma. There are various reports on the clinical and pathological findings of SpCC in the head and neck; however, this type of tumor remains uncommon in the larynx and hypopharynx. The histogenesis of SpCC has been the subject of debate for many decades. Although it is generally accepted that SpCC is a monoclonal epithelial neoplasm, and the spindle cell element is derived from squamous epithelium with divergent mesenchymal differentiation, this type of tumor poses a significant diagnostic challenge to pathologists and clinicians with regard to the therapeutic approach. In the present report, three cases of SpCC of the larynx or hypopharynx were investigated. The histological and immunohistochemistry findings are presented to provide further data on this rare type of tumor.

Spindle cell carcinoma of the larynx presenting as a vocal fold cyst

Spindle cell carcinoma (SPCC) is a rare, malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of the conventional SCC component and malignant spindle shape cells with sarcomatous appearance. We present two cases of SPCC of the true vocal fold that presented as a benign appearing subepithelial mass. We discuss the patient presentation, voice assessment, surgical treatment, and a review of the literature.

Spindle cell carcinoma of the nasal cavity

Spindle cell carcinoma (SpCC) is a unique variant of squamous cell carcinoma (SCC). SpCC confined to the nasal cavity is extremely rare, with only one case having been previously reported. We present a case report of nasal cavity SpCC and review the literature on this rare entity. A 29-year-old male presented with intermittent epistaxis from the left nasal cavity. On physical examination, the patient had an ulcerated mass in the left nasal vestibule and a biopsy showed a proliferation of spindle and epitheliod cells. The patient underwent wide local excision of the mass via a lateral alotomy approach and reconstruction with a composite conchal bowl skin and cartilage graft. Histologically, the mass had dyplastic squamous epithelium and spindle-shaped cells admixed with epitheliod cells. Immunohistochemistry was only positive for pancytokeratin AE1/AE3 and vimentin. Six months after surgery, the patient continues to have no evidence of disease. On literature review, only one previous case of SpCC confined to the nasal cavity was identified. We present a rare case of nasal cavity SpCC. No definite treatment protocol exists for this unique entity, but we believe that this tumor should primarily be treated with aggressive, wide local excision. Adjuvant radiation and/or chemotherapy have also been used anecdotally.

Primary adrenocortical sarcomatoid carcinoma: Report of a case

We report the case of a 72-year-old man with a right adrenocortical mass who had undergone complete tumour excision with the adrenal gland and around adipose tissue. Pathologic examination led to a final diagnosis of primary sarcomatoid carcinoma of the right adrenal gland. The patient was without recurrence at the one year follow-up. To our knowledge, this is the first case in China and the second reported case in English published studies.

Spindle cell carcinoma of the larynx with rhabdomyoblastic heterologous element: a rare form of divergent differentiation

Spindle cell (sarcomatoid) carcinoma of the larynx is a rare subtype of squamous cell carcinoma that shows a prominent spindle cell component with a mesenchymal phenotype. Heterologous elements may be seen in these spindled areas and usually consist of osteosarcomatous or chondrosarcomatous differentiation. We describe an unusual spindle cell carcinoma of the vocal cord in a 68-year-old male which demonstrated rhabdomyosarcomatous differentiation as confirmed by desmin and myogenin immunoreactivity. Thus rhabdomyosarcomatous differentiation adds to the phenotypic spectrum of spindle cell carcinomas of the larynx and should be considered before invoking a diagnosis of true rhabdomyosarcoma of the larynx.

Sarcomatoid carcinoma of the hand: a clinical case with an aggressive and uncommon presentation

Cutaneous sarcomatoid carcinoma is a high-grade malignancy. We describe a clinical case of an aggressive sarcomatoid carcinoma in an 87-year-old woman, who presented to the outpatients department with a haemorrhagic nodule on the dorsum of her right hand. By the time of excision 3 weeks later, the nodule had enlarged to 100 × 90 × 65 mm in size. On histological examination, a poorly differentiated carcinoma was seen, with both carcinomatous and sarcomatous elements, in keeping with a sarcomatoid carcinoma. The tumour was positive for cytokeratin, epithelial, smooth-muscle actin, and vimentin stains. Two months later, the patient presented with a recurrent growth on the excised scar along with numerous large right axillary lymph nodes. A right axillary dissection along with excision of the growth confirmed tumour recurrence with metastasis to lymph nodes. Soon after, the patient developed cerebral metastasis, which proved fatal. This case thus highlights the aggressive potential of sarcomatoid carcinoma.

Soft Tissue Pseudosarcomas

Soft tissue pathology is one of the most challenging areas of diagnostic pathology, not only because of the morphologic diversity of such lesions, but also because of their rarity and pathologists' subsequent lack of exposure to these tumors. Many lesions mimic malignant mesenchymal neoplasms, collectively referred to as "pseudosarcomas." The list of proliferations that can simulate a sarcoma is extensive and heterogeneous. This review addresses malignant, nonmesenchymal neoplasms; mesenchymal neoplasms that histologically mimic sarcomas but are benign; and benign reactive soft tissue lesions that are neither neoplastic nor malignant, but have worrisome clinical and/or morphologic features.

Sarcomatoid (spindle cell) carcinoma of the head and neck mucosal region: a clinicopathologic review of 103 cases from a tertiary referral cancer centre

Sarcomatoid carcinomas are biphasic tumors proven to be monoclonal dedifferentiated forms of conventional squamous carcinomas. This study evaluates their clinicopathologic characteristics in head and neck mucosal sites and the problems in distinguishing them from other spindle cell tumors. A total of 103 cases with a confirmed diagnosis of sarcomatoid carcinoma accessioned in the pathology department of a tertiary referral cancer centre over a period of 7 years (2004-2010) were studied. An algorithm used for their diagnosis is presented. Ages of the patients were 22-90 years (median 53 years), and male:female ratio was 3.7:1. Site distribution was oral cavity (n = 65, 63.1%), larynx (18, 17.5%), oropharynx/hypopharynx (12, 10.7%), maxilla (6, 5.8%) and metastatic nodes (2, 1.9%). A large number of patients (95%) presented with a mass lesion of less than 1 year duration. Histopathologically, epithelial differentiation was evident on morphology in 48 (46.6%) cases, only on IHC in 34 (33%) cases, and in 21 (20.4%) no epithelial differentiation was seen. Typically, tumors were polypoidal (92, 89.3%) and ulcerated (95, 92.2%) with cells arranged predominantly in fascicles (59, 57.3%) or storiform pattern (17, 16.5%) amidst collagenous (50, 48.5%) or myxoid matrix (35, 34%). Anaplasia (2+/3+) and mitosis >10 per 10 HPF were noted in 96 (93.2%) cases. IHC was done in 82 cases; 55 (66.7%) showed positivity for epithelial markers with aberrant expression of mesenchymal markers in 43 (41.7%). Diagnosis of sarcomatoid squamous carcinoma is challenging because of overlapping histopathological features with other spindle cell tumors. Understanding their clinicopathologic characteristics facilitates their diagnosis and appropriate clinical management.

A spindle cell carcinoma presenting with osseous metaplasia in the gingiva: a case report with immunohistochemical analysis

BACKGROUND

Spindle cell carcinoma (SpCC) is a rare, high malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of conventional SCC component and malignant spindle shape cells with sarcomatous appearance.

METHODS

A case of Spindle cell carcinoma with bone-like calcified materials, occurring at the mandibular molar region of 71-years-old Japanese male patient was presented with gross finding, histological findings and MRI image. To identify the characteristics of the bone-like materials, immunohistochemistry were performed.

RESULTS

Histologically, the cancer cells were composed of spindle cells and epithelial cells which form nests with prominent keratinization. Histological findings showed typical histology of the SpCC, however, as an uncommon finding, spatters of calcified, bone-like materials were observed in between the cancer cells. Immunohistochemistry revealed that cancer cells were positive for cytokeratins and vimentin to a varying degree and negative for Desmin, S-100, Osteopontin, BMP-2 or BMP-4. These findings implied that the calcified materials were formed by metaplasia of the stromal cells.

DISCUSSION

Bone-like materials formation by osseous and/or cartilaginous metaplasia of the stroma in the carcinoma has been reported. However, the detailed mechanism of these metaplasia and affection on the clinical feature, prognosis and therapies are not well established. In summary, we presented an unique case of SpCC, which has not been described in the literature.

Urothelial Carcinoma and its Variants

Bladder cancer is the ninth most common cancer worldwide, and the most common malignancy affecting the urinary tract, with approximately 330,000 new cases and more than 130,000 deaths per year. Bladder cancer is primarily attributable to smoking, which accounts for 65% of male and 30% of female cases in some developed countries. Other major risk factors include analgesic abuse, some types of chemotherapy, occupational exposure to chemicals, and in Egypt and some Asian regions, endemic infection with Schistosoma haematobium. Approximately 90% of bladder tumors are classified as urothelial carcinoma (UC), also referred to as transitional cell carcinoma (TCC), and are believed to originate from transformation of the normal urothelium. UCs often exhibit elements of squamous or glandular differentiation. The spectrum of microscopic forms of urothelial carcinoma has been expanded recently to include several histologic variants, the recognition of which is important to avoid diagnostic misinterpretation, to predict outcome, and to guide the selection of the most appropriate therapeutic approach. This article reviews characteristic pathologic features and key clinical aspects of UC and its most common variants.

Salivary gland carcinosarcoma: oligonucleotide array CGH reveals similar genomic profiles in epithelial and mesenchymal components

In this study, we present a case of parotid gland de novo carcinosarcoma. Salivary gland carcinosarcoma (or true malignant mixed tumor) is a rare biphasic neoplasm, composed of both malignant epithelial and malignant mesenchymal components. It is yet unclear whether these two phenotypes occur by collision of two independent tumors or if they are of clonal origin. To analyze the clonality of the different morphologic tumor components, oligonucleotide microarray-based comparative genomic hybridization (oaCGH) was performed on the carcinoma and the sarcoma entity separately. This technique enables a high-resolution, genome-wide overview of the chromosomal alterations in the distinct tumor elements. Analysis of both fractions showed a high number of DNA copy number changes. Losses were more prevalent than gains (82 and 49, respectively). The carcinomatous element displayed more chromosomal aberrations than the sarcomatous component. Specific amplifications of MUC20 (in mesenchymal element) and BMI-1 (in both elements) loci were observed. Overall homology between the two genomic profiles was 75%. DNA copy number profiles of the epithelial and mesenchymal components in this salivary gland carcinosarcoma displayed extensive overlap, indicating a monoclonal origin. Since losses are shared to a larger extent than gains, they seem to be more essential for initial oncogenic events. Furthermore, specific amplifications of a mucin and a Polycomb group gene imply these proteins in the tumorigenesis of carcinosarcomas.

Molecular genetic findings in two cases of sarcomatoid carcinoma of the ureter: evidence for evolution from a common pluripotent progenitor cell?

The current World Health Organization classification recommends the usage of the term sarcomatoid carcinoma (SC) for all biphasic malignant neoplasms of the urinary tract exhibiting morphologic and/or immunohistochemical evidence of epithelial and mesenchymal differentiation. While most SC have been described in the urinary bladder, ureteral SC are extremely rare tumors. Here, we report on the clinical, morphological, and molecular biological findings of two cases in this unusual location. The genetic alterations investigated by comparative genomic hybridization in the epithelial and the mesenchymal component of both cases showed considerable but not complete overlap. Moreover, in spite of many morphological differences between the two cases, both cases shared some genetic gains and losses. Our findings are compatible with the concept that SC originates from a common pluripotent progenitor cell with a potential for epithelial and mesenchymal differentiation.

Sarcomas and sarcomatoid tumor after radiotherapy of oral squamous cell carcinoma: analysis of 4 cases

Radiation-induced sarcoma (RIS) or postirradiation sarcoma has been reported rarely as a long-term complication of radiation therapy (RT). We report 4 cases of oral sarcomas or sarcomatoid tumors with a rather short latency period after radiotherapy of the prior OSCC. Histopathological evaluation and immunohistochemical study were performed using a panel of markers including vimentin, cytokeratin, S-100, desmin, myoglobin, HHF-35, p53, and p16. All reported cases were positive for vimentin and negative for cytokeratin. Two cases were positive for myoglobin, desmin, or HHF-35, and were probably myogenic origin. One case was possibly a fibrosarcoma and the subclassification of the other one was not specified. Diverse expression of p53 and p16 was further observed in these 4 cases. Report of the complicated clinical processes and the analysis of genetic markers of these cases provide useful clinical and pathogenetic insights of mesenchymal malignancies associated with a status post OSCC radiation.

Detection of Residual Tumor Cells in Bladder Biopsy Specimens: Pitfalls in the Interpretation of Cytokeratin Stains

Some patients who have had prior bladder biopsies or transurethral resections undergo a repeat resection within several months for various reasons. The detection of a few residual tumor cells in bladder specimens with prior biopsy site changes can be challenging based on histology alone. Immunohistochemistry for cytokeratins may be used as an adjunct in this situation. We have noted several cases in which keratin stains were performed and positive cells were noted, raising the issue as to whether the cytokeratin positive cells were residual tumor cells or stromal cells. Immunohistochemistry for a panel of antibodies [AE1/AE3, CAM 5.2, high molecular weight cytokeratin, smooth muscle actin (SMA), desmin, and anaplastic lymphoma kinase (ALK)] was performed on 29 cases of bladder biopsies with prior biopsy site changes. Of 29 patients, 25 had a prior history of bladder tumor: 17 had invasive high-grade urothelial carcinoma (T1, 5 cases; T2, 11 cases; T3,1 case); 7 had noninvasive high-grade papillary urothelial carcinoma; 1 had noninvasive low-grade papillary urothelial carcinoma). One of the patients with noninvasive high-grade papillary urothelial carcinoma and one of the patents with invasive high-grade urothelial carcinoma had associated carcinoma in-situ. Four patients had prior benign bladder diagnoses: cystitis cystica et glandularis; polypoid cystitis; follicular cystitis; and neurogenic bladder with benign prostate hyperplasia. Of the 29 cases, 6 (21%) had cells with staining for at least 2 of the cytokeratin markers. Cytokeratin (CK) AE1/ AE3 was positive for cells in 8/29 cases (28%). In 6 of these cases, cells displayed a spindle cell and 2 cases a more epithelioid morphology. CAM 5.2 was positive in cells in 5/29 cases (17%); 3 of the cases had spindle cell and 2 cases epithelioid morphology. High molecular weight cytokeratin was expressed in cells in 2/29 cases (7%) with 1 case having spindle cell and 1 epithelioid morphology. SMA was positive in cells with a spindle cell morphology and negative in the more epitheloid cytokeratin positive cells. Desmin was positive in 3/6 keratin positive spindle cells and negative in keratin positive epithelioid cells. ALK was negative in all the cases. Three cases with spindle cell morphology and positivity for at least 1 of the keratins and SMA stains were interpreted as aberrant keratin expression in myofibroblastic cells based on the staining and the morphology of the spindle cells. Another 3 cases with concurrent staining for at least 1 of the keratins, SMA and desmin were consistent with smooth muscle cells on the basis of their cellular morphology. Another 2 cases had cells, which expressed at least 2 CK markers but did not express SMA, desmin, or ALK and a more epithelioid morphology. These cells were interpreted as residual tumors cells. When interpreting CK stains for the detection of residual tumor cells, one should pay attention to the nature of the cells and not assume all CK staining cells are residual tumor cells.

Differential diagnosis of laryngeal spindle cell carcinoma and inflammatory myofibroblastic tumor--report of two cases with similar morphology

Background

Spindle cell tumors of the larynx are rare. In some cases, the dignity is difficult to determine. We report two cases of laryngeal spindle cell tumors.

Case presentation

Case 1 is a spindle cell carcinoma (SPC) in a 55 year-old male patient and case 2 an inflammatory myofibroblastic tumor (IMT) in a 34 year-old female patient. A comprehensive morphological and immunohistochemical analysis was done. Both tumors arose at the vocal folds. Magnified laryngoscopy showed polypoid tumors. After resection, conventional histological investigation revealed spindle cell lesions with similar morphology. We found ulceration, mild atypia, and myxoid stroma. Before immunohistochemistry, the dignity was uncertain. Immunohistochemical investigations led to diagnosis of two distinct tumors with different biological behaviour. Both expressed vimentin. Furthermore, the SPC was positive for pan-cytokeratin AE1/3, CK5/6, and smooth-muscle actin, whereas the IMT reacted with antibodies against ALK-1, and EMA. The proliferation (Ki67) was up to 80% in SPC and 10% in IMT. Other stainings with antibodies against p53, p21, Cyclin D1, or Rb did not result in additional information. After resection, the patient with SPC is free of disease for seven months. The IMT recurred three months after first surgery, but no relapses were found eight months after resurgery.

Conclusion

Differential diagnosis can be difficult without immunohistochemistry. Therefore, a comprehensive morphological and immunohistochemical analysis is necessary, but markers of cell cycle (apart from the assessment of proliferation) do not help.

Histogenesis of sarcomatoid urothelial carcinoma of the urinary bladder: evidence for a common clonal origin with divergent differentiation

The histogenesis of sarcomatoid urothelial carcinoma, a rare neoplasm with bidirectional epithelial and mesenchymal differentiation, has been a matter of controversy. To clarify its origin, we analysed the status of X-chromosome inactivation in sarcomatoid urothelial carcinomas from 10 female patients and examined losses of heterozygosity (LOH) in these specimens and in additional 20 tumours from male patients. Six polymorphic microsatellite markers where genetic alterations occur frequently in early or advanced stages of urothelial carcinomas, including D3S3050, D8S261, IFNA, D9S177, D11S569 and TP53, were investigated in the current study. The identical pattern of non-random X-chromosome inactivation in both carcinomatous and sarcomatous components was identified in five of eight informative female patients, and the remaining three informative cases showed a random, but concordant, pattern of X-chromosome inactivation. The concordant X-chromosome inactivation results in all eight informative cases support the concept of a monoclonal origin of both components of this biphasic neoplasm. Among the tumours demonstrating loss of heterozygosity, high incidences of an identical pattern of allelic loss between carcinomatous and sarcomatous components were identified in genetic alterations associated with early carcinogenesis: 86% at D8S261, 78% at D11S569, 75% at D9S177 and 57% at IFNA. In contrast, concordant LOH patterns were less frequently observed for microsatellites related to advanced carcinogenesis: only 40% at D3S3050 and 40% at TP53. The significant overlap of loss of heterozygosity supports a monoclonal cell origin and suggests that clonal divergence may occur during tumour progression and differentiation. Divergent patterns of discordant allelic loss of microsatellite markers imply that heterogeneous pathogenetic pathways may exist in the evolution of this enigmatic neoplasm.

Sarcomatoid carcinoma with osseous differentiation in the bladder

INTRODUCTION

Bladder sarcomatoid carcinoma is a very rare variant of transitional cell carcinoma. With disputed nomenclature, the tumor has been described previously under a variety of names such as sarcomatoid carcinoma, pseudosarcoma, malignant mixed mesodermal/Müllerian tumor, metaplastic carcinoma and spindle cell carcinoma. This malignancy represents 0.3% of all bladder tumors and has an aggressive behavior yielding a poor prognosis despite radio and chemotherapy.

CASE REPORT

An 81 y/o man presented with a transitional cell carcinoma and underwent a transurethral resection. Adjuvant onco-BCG was introduced. After 9 months of follow-up, a local tumoral recurrence occurred and a new transurethral resection revealed sarcomatoid carcinoma with osseous elements. A radical cystoprostatectomy was then carried out.

Sarcomatoid carcinomas of the lung—are these histogenetically heterogeneous tumors?

Sarcomatoid carcinomas (SC) of the lung are a heterogeneous group of nonsmall cell lung carcinomas (NSCLC) containing a sarcoma or sarcoma-like component. SC may represent an epithelial neoplasm undergoing divergent tissue differentiation originating from a single clone. Epithelial-mesenchymal transition (EMT) best describes the origin of the spindle and giant cells. We aimed to define chromosomal aberrations within the subgroups of SC and if EMT does play a role in SC. Twenty-two SC were investigated by chromosomal comparative genomic hybridization (CGH). Immunohistochemical staining was performed with antibodies for E-cadherin, Vimentin, c-Fos, c-Jun, Snail, TGFbeta1, Notch1, beta-catenin, Glycogen synthase kinase 3beta (GSK3beta), and Fascin. Gains occurred more frequently than losses (70.5 vs 29.5%). The shortest regions of overlap were gains on chromosomes 8q and 7 followed by 1q, 3q, and 19, supporting the common origin of the different subtypes of SC. The immunohistochemical staining suggests that the sarcomatoid components of SC might have undergone EMT, not triggered by the signaling pathways Notch1, Snail, and TGFbeta1, but probably initiated by an upregulation of c-Jun and a consecutive overexpression of Vimentin and Fascin. The Wnt-pathway was not deregulated because combined membrane and cytoplasmic reactivity for beta-catenin and GSK3beta was observed.

Carcinosarcoma of the colon: report of a case with morphological, ultrastructural and molecular analysis

BACKGROUND

Carcinosarcoma of the colon is a rare histopathological entity with uncertain histogenesis, that shows both epithelial and mesenchymal malignant differentiation. Carcinosarcoma rarely affects the gastrointestinal tract and only few cases are reported in the colon. Herein we describe a carcinosarcoma of the ascending colon, with morphological, ultrastructural and molecular analysis.

CASE PRESENTATION

An 81-year-old man was hospitalised for asthenia, weight loss and iron-deficiency anaemia. The patient underwent colonoscopy and adenocarcinoma was diagnosed by endoscopic biopsy. A right hemicolectomy was performed and, during surgical operation, liver metastases were detected. Histological examination of the surgical specimen revealed areas of both carcinomatous and sarcomatous differentiation, completely separated by fibrous septae. The sarcomatous component exhibited areas of smooth muscle and osteoblastic differentiation, with focal osteoid material deposition. Molecular analysis conducted separately on the epithelial and mesenchymal components revealed the same p53 gene mutation (R282W in exon 8) and identical polymorphisms in p53 exon 4, in EGFR exons 20 and 21, and in c-kit exon 17. Microsatellite markers analysis revealed a common loss of heterozygosis on 18q. Overall, the data are consistent with a common origin of the two tumor components. The patient was treated with 8 cycles of oral capecitabine (1250 mg/m2 twice a day for 14 days repeated every 28 days) and two years after surgery is alive with liver metastases.

CONCLUSION

Carcinosarcoma of the colon is a rare tumour with both epithelial and sarcomatous components. Molecular analysis of the current case suggests the histogenesis from a common cell progenitor.

Sarcomatoid carcinoma of the parotid gland with apparent metastasis of epidermoid elements to cervical lymph nodes

A case of sarcomatoid carcinoma of the parotid gland is described in a 47-year-old male. Despite radical surgery and postoperative chemoradiation therapy, a distant metastasis occurred 1 month after treatment. The primary site was composed of well-differentiated squamous cell carcinoma intermingled with spindle-shaped malignant mesenchymal cells. Immunohistochemical studies showed that keratin was present in both epithelial cells and spindle cells, whereas vimentin was present in spindle cells and absent in epithelial cells. Two lymph nodes were metastasized by the epidermoid component. The origin of the sarcomatoid component and the differential diagnosis from malignant mixed tumours are discussed.

True carcinosarcoma of the esophagus

Most esophageal carcinosarcomas are diagnosed as so-called carcinosarcoma, in which individual elements may be derived from a single common ancestor cell, and there have been a few reports describing true carcinosarcoma originating from two individual stem cells. We describe a case of esophageal carcinosarcoma exhibiting neoplastic osteoid formation. Immunoreactivity for vimentin and p53 was limited to only the sarcomatous component and was absent in the carcinomatous component. Furthermore, a point mutation in exon 7 of the p53 gene was observed only in the sarcomatous component. Both sarcoma and carcinoma cells distinctively metastasized to different lymph nodes. These observations led us to diagnose the esophageal tumor as a true carcinosarcoma.

Alternative epithelial markers in sarcomatoid carcinomas of the head and neck, lung, and bladder-p63, MOC-31, and TTF-1

Sarcomatoid carcinomas are rare malignancies which represent poorly differentiated epithelial tumors that may be difficult to recognize as such. While some cases may have obvious epithelial areas, the sarcomatoid areas are poorly distinguishable from true sarcoma at the light microscopic level and, by immunohistochemistry, often show only limited staining for traditional epithelial markers such as cytokeratin or epithelial membrane antigen. This can be particularly problematic for diagnosis on small biopsy specimens. We sought to assess the diagnostic utility of several immunohistochemical markers of epithelial differentiation including p63, MOC-31, and thyroid transcription factor-1 on sarcomatoid carcinomas of the head and neck (19 cases; 'spindle cell carcinomas'), lung (19 cases), and urinary bladder (11 cases). These results were compared to immunohistochemistry for the traditional epithelial markers pan-cytokeratin and epithelial membrane antigen. Staining for p63 showed the greatest diagnostic utility, positive in 63, 50, and 36% of head and neck, lung, and urinary bladder sarcomatoid carcinomas, respectively. p63 stains were positive in many cases where immunohistochemistry was negative for both pan-cytokeratin and epithelial membrane antigen. All three alternative markers were quite specific for epithelial differentiation, each staining less than 10% of the control group of 73 various primary and metastatic sarcomas, melanomas, and benign spindle cell lesions. In conclusion, immunostaining beyond traditional pan-cytokeratin and epithelial membrane antigen may have diagnostic utility in this context.

Primary Carcinosarcoma of the Helix of the Ear

We report our histologic and immunohistochemical findings in a rare case of cutaneous carcinosarcoma involving the helix of the ear. The tumor exhibited cellular features of both basal cell and squamous cell carcinoma and a malignant mesenchymal component that was consistent with malignant fibrous histiocytoma. The epithelial component exhibited a positive immunohistochemical reaction to cytokeratin and a negative reaction to vimentin, whereas the mesenchymal component showed a positive immunohistochemical reaction to vimentin and a negative reaction to cytokeratin. To the best of our knowledge, this is only the third reported case of a carcinosarcoma of the ear and the second case in which it developed on the helix.

Mammary carcinoma provides highly tumourigenic and invasive reactive stromal cells

The progression of a lesion to a carcinoma is dependent on the engagement of 'reactive stroma' that provides structural and vascular support for tumour growth and also leads to tissue reorganization and invasiveness. The composition of reactive stroma closely resembles that of granulation tissue, and myofibroblasts are thought to play a critical role in driving the stromal reaction of invasive tumours as well as of physiological wound repair. In the present work, we established a myofibroblast-like cell line, named A17, from a mouse mammary carcinoma model in which tumourigenesis is triggered in a single step by the overexpression of HER-2/neu transgene in the epithelial compartment of mammary glands. We showed that although they derived from a tumour of epithelial origin and did not express HER-2/neu transgene, their subcutaneous injection into the backs of syngeneic mice gave rise to sarcomatoid tumours which expressed alpha-smooth muscle actin at the invasive edge. The expression of cytokeratin 14 suggested a myoepithelial origin but immunophenotypical profile, invasive and neoangiogenic potential of A17 cells and tumours showed many similarities with the reactive stroma that occurs in wound repair and in cancerogenesis. Our results suggest that epithelial tumours have the potential to develop highly tumourigenic and invasive reactive stromal cells and our cell line represents a novel, effective model for studying epithelial-stromal interaction and the role of myofibroblasts in tumour development.

Gemcitabine and cisplatin following surgical treatment of urinary bladder carcinosarcoma

The clinical case of a 73-year-old man with a history of transitional cell carcinoma of the bladder, an ulcerated mass on the left hemitrigone and left hydronephrosis who underwent radical cystoprostatectomy and urinary diversion followed by cisplatin-gemcitabine chemotherapy is presented. Pathological examination revealed a biphasic mixed tumor characterized by an epithelial and a mesenchymal component. At 24 months of follow-up the patient is alive and free from recurrent disease, with good quality of life and preserved renal function. Carcinosarcoma is highly aggressive and often has a dismal outcome regardless of treatment. Among all the studied prognostic factors, pathological stage is the main predictor of survival. The outcome of our patient suggests that the relatively well tolerated gemcitabine-cisplatin regimen after surgical treatment of invasive carcinosarcoma of the bladder might improve the currently dismal prognosis of selected elderly patients.