Multidisciplinary therapy for granulocyte-colony-stimulating factor producing carcinosarcoma of the esophagus: report of a case

Oesophageal carcinosarcoma: a rare neoplasm of the oesophagus

Oesophageal carcinosarcoma (OCS) is a rare oesophageal cancer, expressing both carcinomatous and sarcomatous elements. Although believed to have a better prognosis, no standard guidelines exist for its diagnosis and management. We report a case of a 60-year male presenting with progressive dysphagia and weight loss. Endoscopy and contrast-enhanced computed tomography of the chest revealed a large polypoidal intraluminal growth at the mid-oesophagus. Endoscopic biopsy revealed a sarcoma of the oesophagus. The patient underwent McKeown minimally invasive oesophagectomy. Final histopathology was suggestive of OCS. Postoperatively, the patient received adjuvant chemoradiation. At 20-month follow-up, he was asymptomatic with no radiological evidence of recurrence.

G-CSF in tumors: Aggressiveness, tumor microenvironment and immune cell regulation

Granulocyte colony-stimulating factor (G-CSF) is a cytokine most well-known for maturation and mobilization of bone marrow neutrophils. Although it is used therapeutically to treat chemotherapy induced neutropenia, it is also highly expressed in some tumors. Case reports suggest that tumors expressing high levels of G-CSF are aggressive, more difficult to treat, and present with poor prognosis and high mortality rates. Research on this topic suggests that G-CSF has tumor-promoting effects on both tumor cells and the tumor microenvironment. G-CSF has a direct effect on tumor cells to promote tumor stem cell longevity and overall tumor cell proliferation and migration. Additionally, it may promote pro-tumorigenic immune cell phenotypes such as M2 macrophages, myeloid-derived suppressor cells, and regulatory T cells. Overall, the literature suggests a plethora of pro-tumorigenic activity that should be balanced with the therapeutic use. In this review, we present an overview of the multiple complex roles of G-CSF and G-CSFR in tumors and their microenvironment and discuss how clinical advances and strategies may open new therapeutic avenues.

The controversy of esophageal carcinosarcoma: A case report and brief review of literature

RATIONALE

Esophageal carcinosarcoma (ECS) is defined as a relatively rare malignant neoplasm with both epithelial carcinomatous and sarcomatous components. Besides, there were so many various controversies in ECS. This article describes a case of ECS that was effectively treated with radical esophagectomy and adjuvant chemotherapy. Also, we discuss the presentation, differential diagnosis, treatment, and prognosis of ECS.

PATIENT CONCERNS

A 58-year-old man presented with a history of progressive dysphagia and precordial pain after swallowing for 1 month.

DIAGNOSIS

Esophagogastroduodenoscopy (EGD) revealed a large polypoid neoplasm that occupied the esophageal lumen 30 to 34 cm from the incisors. On the characteristic morphology, clinical symptom and biopsy findings, the ECS was the primary considerated. Computed tomography (CT) examination demonstrated no radiological evidence of metastatic disease.

INTERVENTIONS

The patient underwent an Ivor Lewis esophagectomy, coupled with adequate lymph node dissection (2-field lymphadenectomy). ECS was confirmed by pathology report of postoperative. Then, the patient underwent adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine.

OUTCOMES

The patient remained alive without tumor recurrence at 24 months after multidisciplinary therapy.

LESSONS

It is generally treated by surgery, radiotherapy, and chemotherapy according to the protocols used for other esophageal cancers (EC). However, there is no recommended clinical treatment for ECS because of the rarity of the disease. Esophagectomy with extended lymphadenectomy followed by adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine may be recommended treatment for ECS. Chemotherapy regimen with docetaxel, oxaliplatin, and capecitabine may be a suitable adjuvant therapy for ECS.

Esophageal carcinosarcoma that disappeared pathologically by palliative radiotherapy alone

Only a few cases of esophageal granulocyte-colony-stimulating-factor (G-CSF)-producing esophageal carcinosarcoma are reported, and patients with G-CSF-producing tumors are typically considered to have poor prognosis. An 89-year-old man was examined for low-grade fever and dysphagia. Chest computed tomography revealed a huge 80-mm tumor on the thoracic esophagus without direct invasion to surrounding organs. Esophagogastroduodenoscopy (EGD) showed a huge mass occupying the esophageal lumen with a superficial flat lesion. Histopathological examination revealed that the tumor was composed of bizarre giant cells and pleomorphic spindle cells with hyperchromatic nuclei. Laboratory data showed aberrant elevation of leukocyte and neutrophil counts and G-CSF levels. The tumor was finally diagnosed as a G-CSF-producing esophageal carcinosarcoma, stage II (T2N0M0, Union for International Cancer Control-TNM Classification of Malignant Tumors, 8th edition). Considering his general condition, we performed palliative radiotherapy (45 Gy/15 fr) alone after consultation with surgeons and radiation oncologists. Follow-up EGD demonstrated the disappearance of the tumor, and the histological assessment of biopsy specimens confirmed no evidence of malignancy. The leukocyte count and G-CSF levels decreased within normal range. This is a very rare case of G-CSF-producing esophageal carcinosarcoma in which a pathologically complete response was achieved using palliative radiotherapy alone.

Metastatic esophageal carcinosarcoma comprising neuroendocrine carcinoma, squamous cell carcinoma, and sarcoma: A case report

RATIONALE

Esophageal carcinosarcoma generally comprises 2 histological components: squamous cell carcinoma (SqCC) and sarcoma. Esophageal carcinosarcoma comprising 3 components is extremely rare and no reports have described therapeutic effects for this disease with metastasis.

PATIENT CONCERNS

A 76-year-old man with dysphagia presented to a local clinic. Gastrointestinal endoscopy revealed a polypoid tumor in the middle esophagus and he was referred to our hospital.

DIAGNOSIS AND INTERVENTIONS

Thoracoscopic esophagectomy with super-extended (D3) nodal dissection and gastric tube reconstitution was performed, which resulted in carcinosarcoma comprising neuroendocrine carcinoma (NEC), SqCC, and sarcoma. Pathological stage was T1bN1M0 stage IIB according to the TNM Classification of Malignant Tumors-7th edition. The NEC component was observed in lymph node. At 47 days after surgery, lymph nodes, liver, and bone metastasis appeared, and tumor markers such as ProGRP and NSE were elevated. Combination chemotherapy with cisplatin and etoposide (EP) adapted to NEC was performed.

OUTCOMES

The patient showed complete response within 4 cycles of chemotherapy. However, the disease recurred 5.5 months after the final course of EP chemotherapy.

LESSONS

A therapeutic strategy based on assessment of which component caused metastasis might be important for metastatic carcinosarcoma comprising 3 components, although more accumulation of data about the efficacy of chemotherapy is necessary. Moreover, elucidation of the mechanisms underlying generation of carcinosarcoma is expected in the future.

Preoperative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for locally advanced esophageal carcinosarcoma: a case report and review of the literature

Background

Esophageal carcinosarcoma is a relatively rare malignant neoplasm composed of both epithelial carcinomatous and mesenchymal sarcomatous elements. There is no recommended clinical treatment for esophageal carcinosarcoma because of the rarity of the disease. This report describes a case of esophageal carcinosarcoma that was effectively treated with docetaxel, cisplatin, and 5-fluorouracil as preoperative chemotherapy.

Case presentation

A 73-year-old man had a chief complaint of dysphagia with epigastric pain. Esophagogastroduodenoscopy (EGD) revealed a polypoid neoplasm combined with an infiltrative ulcer that exhibited a mixture of squamous cell carcinoma and spindle cell sarcoma histologically. Computed tomography findings showed swollen lymph nodes in the mediastinum and around the cardia. We diagnosed esophageal carcinosarcoma cT3N1M0 cStage III. After preoperative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil, the patient underwent thoracoscopic esophagectomy with three-field lymph node dissection. Histological findings revealed that the sarcomatous component had completely disappeared and the carcinomatous component was only confined by the basement membrane with scar formation of the muscularis propria. Mural fibrotic lesions were observed in several resected regional lymph nodes. Hence, immediately after preoperative therapy, the esophageal carcinosarcoma was diagnosed as ypTisN0M0 fStage I. The patient remained alive without tumor recurrence at 12 months after the operation.

Conclusions

A review of the literature revealed that there is still no established therapeutic strategy for locally advanced esophageal carcinosarcoma, especially against the sarcomatous component. We herein provide the first report in which the sarcomatous component showed a complete response to preoperative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil. Preoperative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil followed by esophagectomy with extended lymphadenectomy may achieve definitive treatment for locally advanced esophageal carcinosarcoma.

Severe neutrophilic leukocytosis as a progression marker in granulocyte colony-stimulating factor-producing squamous cell carcinoma of the esophagus

There are very few reports of esophageal carcinoma producing granulocyte colony-stimulating factor (G-CSF). G-CSF-producing esophageal squamous cell carcinoma is an extremely aggressive carcinoma. Leukocyte counts, neutrophil counts, and serum C-reactive protein levels may be markers of its progression.