Carcinosarcoma of the uterus: immunohistochemical and genetic analysis of clonality of one case

Inter‑component immunohistochemical assessment of proliferative markers in uterine carcinosarcoma

In the scientific literature, a selected number of reports have investigated the impact of proliferative activity on the development and progression of uterine carcinosarcomas (UC). The aim of the present retrospective study was to compare the immunohistochemical proliferation markers [Ki67, proliferating cell nuclear antigen (PCNA), minichromosome maintenance complex component 3 (MCM3), and topoisomerase IIα (topoIIα)] assessment in both components of UC. A total of 30 paraffin-embedded slides of UCs, obtained from patients who underwent surgery between January 1, 2006, and December 31, 2020, were analyzed. Medical records and clinicopathological data of patients were reviewed. Formalin-fixed, paraffin-embedded tissue sections were immunostained with monoclonal antibodies against Ki67, PCNA, MCM3 and topoIIα. Ki67-positive nuclear immunoreactivity was reported in 20 (67%) and 16 (53%) UC carcinomatous and sarcomatous components, respectively. In the epithelial component, Ki67 positive staining was related to the International Federation of Gynecology and Obstetrics (FIGO) stage (P=0.025), and histological grade (G1 vs. G2/G3, P=0.031). Nuclear PCNA reactivity was observed in 18 (60%) and 16 (53%) carcinomatous and sarcomatous components, respectively. Notably, all four cases with omental metastases were PCNA-positive, and a relationship between staining pattern and the existence of metastases was of significant value (P=0.018). MCM3-positive nuclear staining was found nearly twice as high in the carcinomatous (n=19; 63%), compared with the sarcomatous (n=11; 37%) component, respectively, and MCM3 expression in the epithelial component was related to clinical stage (P=0.030), and the existence of omental metastasis (P=0.012). In addition, out of the 30 UCs, 17 (57%) and 13 (43%) showed topoIIα positivity in the carcinomatous and sarcomatous UC components, respectively. A significant relationship between protein immunoreactivity and FIGO stage (P=0.049), and omental metastasis (P=0.026) was revealed to exist. However, no significant differences between expression of proliferation markers and clinicopathological features in the sarcomatous UC component were identified. Finally, a significant correlation between each protein immunohistochemical staining was demonstrated, particularly in the sarcomatous UC component. Collectively, a combined analysis of Ki67, PCNA, MCM3, and topoIIα may provide more detailed information of cell-cycle alterations determining the heterogeneity of uterine carcinosarcomas.

In-depth molecular profiling of the biphasic components of uterine carcinosarcomas

Uterine carcinosarcoma is a clinically aggressive malignancy composed of a mix of carcinomatous and sarcomatous elements. We performed targeted next-generation sequencing of 27 uterine cancer and sarcoma genes together with immunohistochemical analyses of selected proteins in 30 uterine carcinosarcomas. This included 13 cases in which the distinct carcinoma and sarcoma components were sequenced separately and 10 cases where the metastatic tumours were analysed in addition to the primary tumours. We identified non-synonymous somatic mutations in 90% of the cases, with 27 of 30 cases (90%) harbouring TP53 alterations. The PI3K pathway was the most commonly mutated signalling pathway with mutations identified in PIK3CA, PTEN, PIK3R1, and/or PIK3R2 in two-thirds of the cases. Mutations in FBXW7, PPP2R1A, ARID1A and KRAS were demonstrated in a minority of cases. In cases where the carcinomatous and sarcomatous components were separately analysed, most of the mutations identified were present in both components, indicating a common origin for the two components. Furthermore, the same TP53 alterations and/or PI3K pathway mutations seen in the primary tumours were also identified in the metastatic sites. Overall, carcinosarcomas exhibited heterogeneous molecular features that resemble the heterogeneity seen in endometrial carcinomas, with some showing endometrioid carcinoma-like and others showing serous carcinoma-like mutation profiles. While patients with serous-like tumours presented more frequently with advanced-stage disease compared to patients with endometrioid-like tumours, there was no statistical difference in outcome between the two groups. Our results provide insights into the oncogenesis of uterine carcinosarcoma and identify targetable mutations that represent early oncogenic events. The findings of the different molecular types of uterine carcinosarcoma that parallel the different molecular types in endometrial carcinoma may have future treatment implications with targeted therapies.

Uterine carcinosarcoma: A review of the literature

OBJECTIVE

Uterine carcinosarcomas (UCSs) are aggressive tumors previously considered to be sarcomas, but now recognized as malignancies composed of metaplastic transformation of epithelial elements. Much of the management for UCS has been extrapolated from studies of endometrial carcinomas and sarcomas. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis and management of women with UCS.

METHODS

MEDLINE was searched for English language literature on UCS with a focus on the past 20years. Given the rarity of this tumor, studies were not limited by design or number of reported patients.

RESULTS

UCS is biologically a de-differentiated endometrial carcinoma with its own pathogenesis and molecular profile. It commonly presents with extrauterine disease which can be identified by comprehensive surgical staging. Most UCS patients are candidates for adjuvant chemotherapy. The role of radiation is less clear. Combination therapy, while commonly used, has not been studied in depth. The high recurrence rate and poor overall survival for UCS suggest an ongoing need for clinical trials for UCS specifically.

CONCLUSIONS

UCS represents a distinct subtype of uterine malignancy, and should be studied as such via focused clinical trials.

Serum CA 125, CA 15-3, CEA, and CA 19-9: a prognostic factor for uterine carcinosarcomas?

PURPOSE

There is a controversy in the literature regarding the role and the prognostic significance of serum markers in uterine carcinosarcomas (CSs). We attempted to determine the utility of serum CA 125, CA 15-3, CA 19-9, and CEA as prognostic factors and disease follow-up in patients with CS of the uterus.

METHODS

Thirty-seven patients with CS of the uterus were included in this study. Information regarding demographic, clinical, pathologic, tumor marker data (CA 125, CA 19-9, CA 15-3, and CEA both pre- and postoperatively) treatment and outcome information was obtained, followed by Statistical analysis.

RESULTS

The mean follow-up period was 3.5 years. None of the study serum markers showed significant association with the outcome. Greater hazard was found for cases that staged from IIIA to IV compared to those staged from IA to IIB (HR = 4.75, 95 % CI: 1.99-11.3). Also, greater hazard was found for adenosquamous histological type compared to the other histological types. When multiple Cox regression analysis with stepwise approach was implied, it indicated stage as the only significant factor for the outcome. Elevated CA19-9 was more frequent in cases with heterologous sarcoma (p = 0.036).

CONCLUSION

In this retrospective study, none of the preoperative serum tumor markers, neither epithelial component, histological type, nor grade showed a significant association with prognosis. This null finding may have significant implications in the common clinical practice; given that there is a controversy in the literature regarding the role and the significance of the prognostic significance of serum CEA, CA 125, CA 19-9, and CA 15-3.

Primary malignant mixed müllerian tumor of the peritoneum a case report with review of the literature

Malignant mixed Müllerian tumor is a rare malignancy of the genital tract and extremely uncommon in extragenital sites. This report describes a case of malignant mixed Müllerian tumor arising in the lower peritoneum of a 72-year-old female patient. The patient presented with ascites, lower abdominal mass and pleural effusion. The serum level of CA125 was elevated. At operation a diffuse carcinosis associated with tumor mass measuring 20 × 15 × 10 cm in the vesicouterine and Duglas' pouch were found. The uterus and the adnexa were unremarkable. Histopathology revealed a typical malignant mixed Müllerian tumor, heterologous type. The epithelial component was positive for cytokeratin 7 and vimentin whereas the mesenchymal component was positive for Vimentin, S100 and focally for CK7. The histogenesis of this tumor arising from the peritoneum is still speculative. Based on the previous reports and the immunohistochemical analysis of our case, we believe that this is a monoclonal tumor with carcinoma being the "precursor" element. Nevertheless, further molecular and genetic evidence is needed to support such a conclusion.

Tissue microarray analysis of hormonal signaling pathways in uterine carcinosarcoma

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Pathology of uterine malignancies

This overview covers epithelial, stromal and mesenchymal malignancies of the body of the uterus, excluding the cervix. The distinction of type I and type II endometrial adenocarcinoma with the morphological variants of this tumour is discussed and some molecular aspects are explored. The concept of carcinosarcoma representing a metaplastic adenocarcinoma of the endometrium that behaves more like a carcinoma than a sarcoma is explained. Some types of mixed epithelial and stromal neoplasm are described and contrasted with carcinosarcoma. The concept of stromal sarcoma and high-grade uterine sarcoma is described and an outline of malignant smooth muscle tumours of the uterus includes a description of smooth muscle tumours of uncertain malignant potential and worrying benign smooth muscle lesions.

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.

Serum CA125 predicts extrauterine disease and survival in uterine carcinosarcoma

OBJECTIVE

The purpose of this study was to determine the clinical utility of CA125 measurement in patients with uterine carcinosarcoma (CS).

METHODS

Ninety-five consecutive patients treated for CS at a single institution were identified. All 54 patients who underwent preoperative CA125 measurement were included in the study. Data were abstracted from the medical records. Tests of association between preoperative CA125 and previously identified clinicopathologic prognostic factors were performed using Fisher's exact test and Pearson chi-square test. To evaluate the relationship of CA125 elevation and survival, a Cox proportional hazard model was used for multivariate analysis, incorporating all of the prognostic factors identified by univariate analysis.

RESULTS

Preoperative CA125 was significantly associated with the presence of extrauterine disease (P<0.001), deep myometrial invasion (P<0.001), and serous histology of the epithelial component (P=0.005). Using univariate survival analysis, stage (HR=1.808, P=0.004), postoperative CA125 level (HR=9.855, P<0.001), and estrogen receptor positivity (HR=0.314, P=0.029) were significantly associated with survival. In the multivariate model, only postoperative CA125 level remained significantly associated with poor survival (HR=5.725, P=0.009).

CONCLUSION

Preoperative CA125 elevation is a marker of extrauterine disease and deep myometrial invasion in patients with uterine CS. Postoperative CA125 elevation is an independent prognostic factor for poor survival. These findings indicate that CA125 may be a clinically useful serum marker in the management of patients with CS.

Sarcomatoid eccrine porocarcinoma: report of two cases and a review of the literature

Eccrine porocarcinoma is an uncommon sweat gland malignancy. To the best of our knowledge, there has been no report in the English literature of porocarcinoma with predominantly undifferentiated sarcomatous change. We present two cases of sarcomatoid eccrine porocarcinoma associated with a benign poroma. Case 1 pertained to an 82-year-old woman with an ulcerated chest wall tumor, and Case 2 was that of a 74-year-old woman who presented with an ulcerated plaque in the lower leg. Case 1 showed an unusual pseudo-angiosarcomatous morphology with spindle cells dissecting through collagen bundles and forming vascular like channels. Case 2 revealed high-grade malignant spindle cells with focal evidence of ductal differentiation. In both the cases, benign poromatous elements were histologically evident. Immunohistochemistry performed showed pancytokeratin positivity in spindle cells of both lesions. Epithelial membrane antigen and carcino-embryonic antigen positivity in the malignant ductal elements and focal smooth muscle actin staining of the spindle cells were demonstrated in Case 2. A brief review of relevant literature is presented.

Sarcomatoid Basal Cell Carcinoma—Predilection for Osteosarcomatous Differentiation

Primary cutaneous carcinomas rarely show heterologous malignant mesenchymal differentiation. We report 11 cases of sarcomatoid basal cell carcinoma (BCC) with osteosarcomatous differentiation. The patients (7 men and 4 women) ranged in age from 61 to 92 years (median 75 y). The tumors presented as exophytic nodules (0.3 to 7 cm) on the head (n=6), upper limb (n=3), and lower limb (n=2). All lesions were completely excised. Seven patients were alive without evidence of disease (follow-up interval 5 to 24 mo) and 1 patient died of unrelated causes at 7 months without evidence of disease. On histology, the tumors were dermal in location with 2 cases showing focal subcutaneous involvement. Ten tumors were well-circumscribed and 1 tumor showed focally infiltrative edges. Ten tumors revealed conventional BCC associated with varying proportions of osteosarcomatous and undifferentiated sarcomatous stroma. Transition from neoplastic epithelial to mesenchymal cells was seen in 8 cases. One case showed a purely osteoclastic giant cell rich malignant mesenchyme, interpreted as representing early stages of osteosarcomatous transformation. Previously unreported in sarcomatoid BCC, the mesenchymal component of another two cases displayed predominant malignant giant cell tumor like areas and 1 further case disclosed areas reminiscent of telangiectatic osteosarcoma. Pancytokeratins (AE1/3 and MNF116) and smooth muscle actin stained occasional undifferentiated sarcomatous cells in 2 and 3 tumors, respectively. MNF116 and EMA were focally positive in osteosarcomatous tumor cells of 1 case. Although the follow-up interval is short, our data suggest an excellent prognosis for polypoid and exophytic sarcomatoid BCC after complete surgical resection.

Spindle cell carcinoma of head and neck: an immunohistochemical and molecular approach to its pathogenesis

BACKGROUND

Spindle cell carcinoma (SpCC) is a rare microscopic type of cancer of the mouth and oropharynx. Although SpCC is thought to arise from squamous cell carcinoma (SCC), it carries a worse prognosis.

AIM

To find out the difference in immunohistochemical expression of cytokeratin, vimentin and smooth-muscle actin, and mutational alterations in the K-ras oncogene between the two tumours, in an attempt to characterise SpCC.

METHODS

Immunohistochemical analysis was performed by standard avidin-biotin complex method in 35 cases each of SpCCs and SCCs. DNA extracted from paraffin wax-embedded tumours was used for PCR followed by single-strand conformation polymorphism for mutational analysis of K-ras exon 1 and exon 2.

RESULTS

In the SpCC group, cytokeratin positivity was significantly higher in epithelial areas (52.2%) than in spindle cell areas (16.1%), whereas vimentin was more positive in spindle cell areas (18.7%) than epithelial areas (2.7%). Cells intermediate between epithelial and spindle cell areas were consistently positive for both cytokeratin and vimentin. Cytokeratin was found to be significantly more positive in SCC (72.6%) than the squamous component and spindle cell component of SpCC. In this study, no mutation was detected in the K-ras gene of either the SpCC or SCC group.

CONCLUSIONS

The spindle cell component of SpCC is intermixed with cells that are morphologically mesenchymal but express dual antigen-positivity characteristic of epithelial (cytokeratin) and mesenchymal (vimentin) cells. These, possibly, are cells in transition suggesting that SpCC may be a sarcomatous metaplasia of SCC.

Cutaneous carcinosarcoma: adnexal vs. epidermal types define high- and low-risk tumors. Results of a meta-analysis

OBJECTIVE

We report four cases of cutaneous carcinosarcoma (CS) and perform a meta-analysis of the cutaneous CS literature.

RESULTS

CS occurred in elderly patients (mean of 80 years) on sun-damaged skin, and were keratotic papules of short duration. They did not recur after excision. CS exhibited basal cell carcinoma mixed with atypical fibroxanthoma cell populations. Immunophenotyping revealed vimentin+/keratin- spindle cells and vimentin-/keratin+ epithelial cells. Three cases exhibited p53 protein expression of both carcinomatous and sarcomatous components. Literature review identified 38 cases of cutaneous CS that could be broadly classified into two distinct groups. Epidermal-derived (basal or squamous cell carcinoma epithelial component) CS arose on the sun-damaged skin of the head and neck of elderly males (mean age 72 years) and had a 70% 5-year disease-free survival. In contrast, adnexal CS (spiradenocarcinoma, porocarcinoma, proliferating tricholemmal cystic carcinoma, or matrical carcinoma) occurred in younger patients (mean age 58 years), showed recent growth in a long-standing nodule and had a 25% 5-year disease-free survival. Age less than 65 years, recent growth, long-standing skin tumor, and tumor size greater than 2 cm significantly correlated with poor outcome.

CONCLUSIONS

Cutaneous CS is an aggressive skin cancer with high risk for advanced disease. Significant risk factors exist whose identification will allow for better management of CS patients.

Gliosarcoma with epithelial differentiation: immunohistochemical and molecular characterization. A case report and review of the literature

Few reported cases of gliosarcomas or glioblastomas with epithelial-like areas exist. Most cases were originally diagnosed as metastatic carcinoma. Focal expression of glial fibrillary acidic protein has helped characterize these tumors as having a glial origin. We report a case of gliosarcoma with multifocal, extensive areas of well-differentiated carcinoma; demonstrating squamous and glandular differentiation. The expression of glial fibrillary acidic protein and epithelial phenotype were mutually exclusive. We performed extensive immunohistochemical analyses and comparative genotypic analysis using microdissection to secure representative glial and epithelial components. Loss of heterozygosity was analyzed with a panel of 12 polymorphic microsatellite markers designed to indicate allelic loss and situated in proximity to known tumor suppressor genes located on chromosomes 1p, 9p, 10q, 17p and 19q. We found comparable patterns of acquired allelic loss between the glial and carcinomatous components, strongly supporting the monoclonal origin of this neoplasm. This case represents an extreme form of phenotypic divergence in a malignant glioma, and constitutes a difficult diagnostic challenge. This heterogeneity reflects the potential for a range of phenotypic expression in malignant gliomas that needs to be recognized. We suggest microdissection genotyping as a molecular technique to better characterize these tumors.

Sarcomatoid carcinoma of the head and neck: molecular evidence for evolution and progression from conventional squamous cell carcinomas

The underlying events associated with the development of sarcomatoid head and neck squamous carcinoma and the biologic significance remain unknown. To investigate the genetic events involved in the evolution of this entity, comparative analysis of matched microdissected epithelial and sarcoma-like components from 11 primary sarcomatoid carcinomas was performed using microsatellite markers. Nine markers on chromosomes 4p, 9p, and 17p regions (3 per each chromosomal region) were selected based on their informativeness, small product size, and the high alterations in head and neck squamous carcinomas. In this study, loss of heterozygosity (LOH) in at least one marker in either component was noted in all 11 tumors, and instability was found in 10 instances (six in 3 paired specimens and four in the sarcomatoid area only). Concordant results in both components were found in 58 (79.5%) reactions (37 LOH and 21 retention of heterozygosity), and paradoxical findings were noted in 15 instances (20.5%). The latter included LOHs in only two conventional epithelial components and 13 sarcomatoid components. Both keratin-positive and -negative sarcomatoid tumors had a comparable frequency of LOH. The most frequently altered markers in both components were D9S168 and D9S171 (75% each) and D4S1587 (66%). The sarcomatoid components manifested distinctly high alterations at marker D17S520 on chromosome 17p. Our study supports: 1) an evolution of sarcomatoid carcinoma from the conventional epithelial-type, 2) a malignant nature of the sarcomatoid component, and 3) that molecular progression is associated with the sarcomatoid transformation.

Cancer-testis antigen expression in uterine malignancies with an emphasis on carcinosarcomas and papillary serous carcinomas

The cancer testis (CT) family of antigens are expressed in certain malignant neoplasms and are silent in normal adult tissues, except for the testis. Expression of 2 members of this family, MAGE-A4 and NY-ESO-1, has been described recently in germ cell tumors, malignant melanomas, certain carcinomas and sarcomas. Our study is the first to describe the expression pattern of CT antigens in uterine neoplasms. Ninety-eight cases of uterine neoplasms, including 41 endometrioid, 19 papillary serous and 7 clear cell carcinomas, 22 carcinosarcomas and 9 endometrial stromal sarcomas were studied. Immunohistochemistry was carried out with the 57B monoclonal antibody that recognizes predominantly the MAGE-A4 antigen in paraffinized tissues and the D8.38 antibody that recognizes NY-ESO-1. MAGE-A4 expression was found to be present in 12% of the endometrioid adenocarcinomas, 63% of the papillary serous carcinomas and 91% of the carcinosarcomas. Within the tumor population the extent of MAGE-A4 expression was highest in the carcinosarcomas. In 12 of 22 positively staining carcinosarcomas more than 50% of the tumor cells expressed MAGE-A4. NY-ESO-1 expression was seen in 19% of the endometrioid adenocarcinomas, 32% of the papillary serous carcinomas and in 45% of the carcinosarcomas. CT antigen immunoreactivity was observed in both the carcinomatous and sarcomatous components of the carcinosarcomas and strong correlation between MAGE-A4 and NY-ESO-1 expression was present in individual cases. In summary, strong MAGE-A4 expression and to a lesser degree NY-ESO-1 expression is characteristic of the vast majority of uterine carcinosarcomas and a major subset of papillary serous carcinomas. These results suggest that CT antigen expression by these tumors may represent a novel target for immunotherapy.