Squamous cell carcinoma variants of the head and neck

Spindle Cell Carcinoma of the Ocular Adnexa: A Case Report and Literature Review

A 68-year-old woman was seen in oculoplastic consultation with a medial canthal lesion initially diagnosed as an atypical fibroxanthoma. On excisional biopsy, she was found to have a spindle cell carcinoma, which is a rare and reportedly more aggressive form of squamous cell carcinoma. We highlight the surgical technique of biopsy and reconstruction, the detailed histologic and immunohistochemical analysis required for accurate diagnosis, considerations for adjuvant treatment, and suggestions for systemic workup and surveillance. This case adds to the small body of available literature on primary spindle cell carcinoma of the ocular surface and ocular adnexa, which we have summarized. We hope that as more data becomes available, there will be clearer diagnostic and treatment algorithms for this uncommon presentation.

Basaloid squamous cell carcinoma in the mandibular alveolus: A rare case report with differential diagnosis

ABSTRACT

Basaloid squamous cell carcinoma (BSCC) is a distinct, high-grade variant of oral squamous cell carcinoma (OSCC) with a poor prognosis. In the head and neck region, the most common sites are the epiglottis, piriform sinus, and tongue base. Other less common sites include the floor of the mouth, oral mucosa, palate, tonsils, nasopharynx, and trachea. In the present report, the unusual case of a 69-year-old male is presented; the patient exhibited ulceroproliferative growth involving the lower alveolus. Incisional biopsy was done and the hematoxylin and eosin-stained sections revealed tumor islands with dysplastic oral epithelial cells invading the underlying connective tissue as islands, cords, and nests. The presence of palisading basaloid cells with a central area of comedo necrosis and keratin formation on the islands revealed the diagnosis of BSCC. Immunohistochemistry demonstrated positive staining for proliferative cell nuclear antigen (PCNA) and pan-cytokeratin. The patient is still under treatment and follow-up.

A rare presentation of orbital spindle cell carcinoma a case report and brief review of the literature

BACKGROUND

To describe a case of orbital spindle cell carcinoma which presented with limbal ischemia and briefly review the literature.

METHODS

Retrospective case report and brief literature review.

RESULTS

A 61-year old man presented with blepharoptosis, periorbital pain, decreased vision and limbal ischemia. He did not mention any previous illness and did not take any kind of drugs. Imaging revealed an orbital mass that was positive for SMA, Vimentin and CD99 and negative for S100. We treated the patient with chemotherapy and followed him for other complications that occurred throughout disease course.

CONCLUSION

Spindle cell carcinomas are a rare variant of squamous cell carcinoma (SCC) with dual malignant histologic differentiation of squamous and mesenchymal cells. Few cases of orbital spindle cell carcinoma have been reported, which have been either secondary to distant metastasis or regional spread. In this study, we have reported the first case of primary orbital spindle cell carcinoma presenting with limbal ischemia. Further studies are needed to describe the different clinical presentations and management strategies of this rare clinical entity.

Comprehensive analyses of intraoral spindle cell carcinoma: A rare disease entity revisited

OBJECTIVE

The present study was aimed to comprehensively characterize the epidemiological, clinicopathological characteristics, treatments, and prognosis of intraoral spindle cell carcinoma (SpCC).

MATERIALS AND METHODS

Patients diagnosed with intraoral SpCC at our institution in the past 15 years (2005-2019) were screened from inpatient disease registry. All relevant data concerning patients with intraoral SpCC were retrieved. Previous reports about intraoral SpCC with adequate clinicopathological data in both English literature and Chinese literature were collected. Eligible cases were further reviewed and pooled for statistical analyses.

RESULTS

Six patients (5 females and 1 male; average age: 59 years) with intraoral SpCC were histopathologically diagnosed and surgically treated at our institution. The literature review identified another 63 published cases from 34 articles. Most cases were presented in the fifth to seventh decade of life with a male preponderance. Gingiva (23/69, 33.3%) was the most common site followed by the tongue (19/69, 27.5%) and buccal mucosa (8/69, 11.6%). Complete surgical ablation remains the primary treatment option. Tumor size, pathological grades, cervical node metastasis, and distant metastasis were significantly associated with reduced survival.

CONCLUSIONS

Intraoral SpCC is an uncommon and aggressive malignancy with dismal prognosis. Much attention and effort are needed to characterize this rare entity and improve its clinical outcomes.

Prognostic significance of head and neck spindle cell carcinoma

BACKGROUND

Our study investigates the prognostic significance of spindle cell histology on overall survival (OS) of conventional head and neck squamous cell carcinoma (HNSCC).

METHODS

The 2004 to 2017 National Cancer Database was queried for patients with head and neck spindle cell carcinoma (HNSpCC) (n = 1572) or HNSCC (n = 242 697) of the oral cavity, major salivary glands, sinonasal tract, oropharynx, hypopharynx, and larynx treated with curative intent.

RESULTS

Patients with HNSpCC presented more frequently with higher-grade tumors and cN0 disease than those with HNSCC (p < 0.001). In the oral cavity, the HR for death for SpCC compared with SCC was 1.33 (p < 0.001). In the oropharynx, the HR for death for SpCC compared with SCC was 1.47 (p = 0.028).

CONCLUSIONS

After adjusting for patient, tumor, and treatment characteristics, SpCC histology had an independent adverse prognostic effect on OS in the oral cavity and oropharynx. SpCC histology does not necessarily portend poorer survival in all HNSCC.

LEVEL OF EVIDENCE: 4

NUT Carcinoma, an under-recognized malignancy: a clinicopathologic and molecular series of 6 cases showing a subset of patients with better prognosis and a rare ZNF532::NUTM1 fusion

NUT carcinoma (NC) is a rare malignancy with aggressive clinical behavior, defined by rearrangements involving the NUTM1 gene locus. This entity is often under recognized and its diagnosis may be challenging. In this study, we describe a subset of patients that, despite the molecularly proven diagnosis of NC, show improved outcome. In addition, we describe one case with the novel ZNF532::NUTM1 fusion. All cases of NC diagnosed from 2013 to 2022 in our department were retrieved. FISH using dual color bring-together probes and next-generation sequencing assay were performed to characterize the fusions involving NUTM1. Amongst 6 patients identified, 5 were male with a median age of 35.6 years. Four patients had primary tumor in the head and neck region (2 ethmoid sinus, 1 parotid gland, 1 lacrimal gland); 1 in the mediastinum, and another presented with femoral bone tumor. In all cases, the initial diagnoses were not NC. The cases showed different morphological patterns, including monomorphic, rhabdoid and pleomorphic appearance. One case showed pseudopapillary pattern. By immunohistochemistry, all tumors showed squamous differentiation and ≥ 50% of neoplastic cells with nuclear positivity for NUT antibody. One case expressed WT1 (C-terminus) and other showed chromogranin positivity. Genetic study revealed a BRD4::NUTM1 fusion in all head and neck cases, BRD3::NUTM1 in mediastinum case, and ZNF532::NUTM1 fusion in the femur bone case. They were treated with surgical resection plus chemo and radiotherapy. The median overall survival was 23.11 months (1.6-83.3 mo) and the median disease free survival was 14.86 months (0-54.4 mo). The patients with longer overall survival were one with a lacrimal gland primary (83.3 months) and other with a parotid lesion (31.9 months). Both patients were primarily treated with complete surgical resection. Anatomic location may be directly related to the overall survival in NC cases. Resectability of the lesion is also an important factor related to survival. Pathologists should include NC in the differential diagnosis of any poorly differentiated and undifferentiated monomorphic malignancy, regardless of its anatomic location.

The association of long non-coding RNA in the prognosis of oral squamous cell carcinoma

BACKGROUND

Oral cancer is considered one of the most prevalent cancers in India. This is mainly because India suffers from high usage of tobacco, which is one of the main causative agents of oral cancer, and lacks proper health and sexual hygiene in rural areas.

DISCUSSION

Non-coding RNAs are reported to be involved in the various mechanism and causality of cancer. Numerous reports have identified viable prospects connecting non-coding RNA (ncRNA) with cancer. Specific ncRNAs like long non-coding RNA or lncRNAs are recently being prioritized as potential associations in the cause of cancer.

CONCLUSION

This review aims at presenting a concise perspective on the basics and the recent advancements of the lncRNA research pertaining specifically to oral cancer, its recurrence, and the future possibilities of knowledge it might possess.

Candida albicans Enhances the Progression of Oral Squamous Cell Carcinoma In Vitro and In Vivo

Oral squamous cell carcinoma (OSCC) is associated with oral Candida albicans infection, although it is unclear whether the fungus promotes the genesis and progression of OSCC or whether cancer facilitates fungal growth. In this study, we investigated whether C. albicans can potentiate OSCC tumor development and progression. In vitro, the presence of live C. albicans, but not Candida parapsilosis, enhanced the progression of OSCC by stimulating the production of matrix metalloproteinases, oncometabolites, protumor signaling pathways, and overexpression of prognostic marker genes associated with metastatic events. C. albicans also upregulated oncogenes in nonmalignant cells. Using a newly established xenograft in vivo mouse model to investigate OSCC-C. albicans interactions, oral candidiasis enhanced the progression of OSCC through inflammation and induced the overexpression of metastatic genes and significant changes in markers of the epithelial-mesenchymal transition. Finally, using the 4-nitroquinoline 1-oxide (4NQO) murine model, we directly correlate these in vitro and short-term in vivo findings with the progression of oncogenesis over the long term. Taken together, these data indicate that C. albicans upregulates oncogenes, potentiates a premalignant phenotype, and is involved in early and late stages of malignant promotion and progression of oral cancer. IMPORTANCE Oral squamous cell carcinoma (OSCC) is a serious health issue worldwide that accounts for 2% to 4% of all cancer cases. Previous studies have revealed a higher yeast carriage and diversity in oral cancer patients than in healthy individuals. Furthermore, fungal colonization in the oral cavity bearing OSCC is higher on the neoplastic epithelial surface than on adjacent healthy surfaces, indicating a positive association between oral yeast carriage and epithelial carcinoma. In addition to this, there is strong evidence supporting the idea that Candida contributes to carcinogenesis events in the oral cavity. Here, we show that an increase in Candida albicans burden promotes an oncogenic phenotype in the oral cavity.

The Histopathology of Oral Cancer Pain in a Mouse Model and a Human Cohort

Oral cancer patients often have severe, chronic, and mechanically induced pain at the site of the primary cancer. Oral cancer pain is initiated and maintained in the cancer microenvironment and attributed to release of mediators that sensitize primary sensory nerves. This study was designed to investigate the histopathology associated with painful oral cancers in a preclinical model. The relationship of pain scores with pathologic variables was also investigated in a cohort of 72 oral cancer patients. Wild-type mice were exposed to the carcinogen, 4-nitroquinoline 1-oxide (4NQO). Nociceptive (pain) behavior was measured with the dolognawmeter, an operant device and assay for measuring functional and mechanical allodynia. Lesions developed on the tongues and esophagi of the 4NQO-treated animals and included hyperkeratoses, papillomas, dysplasias, and cancers. Papillomas included lesions with benign and dysplastic pathological features. Two histologic subtypes of squamous cell carcinomas (SCCs) were identified-SCCs with exophytic and invasive components associated with papillary lesions (pSCCs) and invasive SCCs without exophytic histology (iSCCs). Only the pSCC subtype of tongue cancer was associated with nociceptive behavior. Increased tumor size was associated with greater nociceptive behavior in the mouse model and more pain experienced by oral cancer patients. In addition, depth of invasion was associated with patient-reported pain. The pSCC histology identifies 4NQO-induced tongue cancers that are expected to be enriched for expression and release of nociceptive mediators.

Knowing the unknown in oral squamous cell carcinoma: An observational study

Introduction

Conventional oral squamous cell carcinoma (OSCC) is relatively easy to diagnose on histopathology, as it comprises dysplastic epithelial cells with variable degrees of squamous differentiation. Different grading systems have been employed in grading OSCC based on its dysplastic features and host response. Some unusual features such as clear cell change, epithelial-mesenchymal transition (EMT), stromal hyalinization, stromal desmoplasia, perineural invasion, vascular invasion, tissue eosinophilia, giant cells, and tertiary lymphoid follicle formation are evident in OSCC histologically but have not yet been accounted in any grading systems of OSCC except perineural and vascular invasion.

Aim

The aim of the present study was to identify these uncommon features and to correlate them with different grades of OSCC.Materials and Methods:This study was conducted on 100 histopathologically confirmed OSCC cases retrieved from the archives of our department. They were graded on the basis of Broder's grading system and were reviewed for the features mentioned above. Data collected were subjected to statistical analysis.

Results

Clear cell change, EMT, foreign body giant cells, and tumor giant cells were observed in 13%, 20%, 1%, and 3% of cases, respectively. We found stromal desmoplasia in 15% and stromal hyalinization in 9% of cases. Tissue eosinophilia, tertiary lymphoid follicle formation, and perineural invasion were observed in 12%, 3%, and 2% of cases, respectively. Vascular invasion was not evident in any of the cases examined.

Conclusion

The incidence of the unusual features was 7.8% in our study.

Sarcomatoid Carcinoma in the Head and Neck: A Population-Based Analysis of Outcome and Survival

Objectives

To characterize sarcomatoid cell carcinoma (SaC) in head and neck, explore the value of radiotherapy (RT) and chemotherapy, and build a nomogram to predict the prognosis.

Study Design

Retrospective cohort study.

Methods

In total, 559 patients diagnosed with head and neck SaC from 2004 to 2015 were included from the Surveillance, Epidemiology, and End Results program. All the cases were divided into training (N = 313) and validation (N = 246) cohorts according to the year of diagnosis. The cases were analyzed on the age, site, sex, race, T stage, N stage, M stage, surgery, RT, and chemotherapy. Cancer‐specific survival (CSS) and overall survival (OS) were compared among disease‐related categories. The parameters significantly correlated with CSS were used to construct a nomogram.

Results

The multivariate analysis showed that age, T stage, N stage, and M stage were significantly correlated with CSS and OS. Overall, RT was correlated with improved CSS for Stage T3–4 and Stage N1–3. The subgroup analysis showed that RT was correlated with CSS in the Stage N1–3 patients after surgery while chemotherapy indicated an improved survival for Stage T3–4 and N1–3 patients without surgery. The prognostic nomogram was constructed and had a powerful discriminatory ability with the C‐index of CSS: 0.711.

Conclusion

Late‐stage head and neck SaC patients unfit for surgery need comprehensive treatment based on chemotherapy, and patients with node metastasis require adjuvant RT after surgery. Generally, RT might improve the survival of late‐stage patients. A reliable and powerful nomogram was established that can provide an individual prediction of CSS for head and neck SaC.

Level of Evidence

3 Laryngoscope, 131:E489–E499, 2021

Clinical features, treatment, and survival outcome of primary pulmonary NUT midline carcinoma

Objective

NUT midline carcinoma (NMC), a rare type of squamous cell carcinoma, is genetically characterised by NUT midline carcinoma family member 1 (NUTM1) gene rearrangement. NMC can arise from the lungs; however, there is no standard for the management of primary pulmonary NMC. This study aimed to confirm the clinical features and report the treatments, especially with immune checkpoint inhibitors (ICIs), and outcomes of patients with primary pulmonary NMC.

Methods

A retrospective review of patients with primary pulmonary NMC was performed in the First Affiliated Hospital of Guangzhou Medical University between January 2015 and December 2018. Clinical manifestations as well as radiographic and pathological findings were recorded. Whole-exome sequencing (WES), a predictor for ICI response, was used to determine the tumour mutational burden (TMB). Treatments, especially by immune checkpoint blockade, and patient survival were analysed.

Results

Seven patients with primary pulmonary mass (four men and three women) with a mean age of 42 years (range, 23–74) who were diagnosed with NMC according to NUT immunohistochemistry staining were included for analysis. One patient had a rare fusion of CHRM5-NUTM1 by tumour sequencing. A wide range of TMB (1.75–73.81 mutations/Mbp) was observed. The initial treatments included chemotherapy (5/7, 71.4%), surgery (1/7, 14.3%), and radiotherapy (1/7, 14.3%). Five patients (5/7, 71.4%) received ICIs (programmed cell death protein 1 [PD1]/programmed cell death ligand 1 [PDL1] monoclonal antibody) as second- or higher-line treatments. The median overall survival (OS) was 4.1 months (range, 1.5–26.7 months).

Conclusions

Patients with primary pulmonary NMC have a poor prognosis and chemotherapy is often preferred. Checkpoint immunotherapy is a good option as the second- or higher-line treatment. TMB seems to be not associated with OS.

NUT Carcinoma: Clinicopathologic features, pathogenesis, and treatment

NUT carcinoma (NC) is a rare, aggressive subtype of squamous cell carcinoma defined by rearrangement of the NUTM1 (aka NUT) gene. NC is driven by NUT-fusion oncoproteins resulting from chromosomal translocation, most commonly BRD4-NUT. This is a nearly uniformly lethal cancer affecting patients of all ages, but predominantly teens and young adults. The cell of origin is unknown, but NC most commonly arises within the thorax and head and neck. NC typically consists of sheets of monomorphic primitive round cells that can exhibit focal abrupt squamous differentiation. Diagnosis of NC is easy, and can be established by positive NUT nuclear immunohistochemical staining. Though characterization of the NUTM1-fusion gene is desirable by molecular analysis, it is not required for the diagnosis. The increasingly widespread availability of the NUT diagnostic test is leading to increasing diagnoses of this vastly underdiagnosed disease. The NUT midline carcinoma registry (www.NMCRegistry.org) serves as a central repository that has provided the main source of clinical and outcomes data for NC. Currently there is no effective therapy for NC, however small molecules directly targeting the BRD4 portion of BRD4-NUT, termed BET bromodomain inhibitors, have shown activity.

Outcomes and patterns of failure of sarcomatoid carcinoma of the larynx: The Mayo Clinic experience

OBJECTIVES/HYPOTHESIS

Sarcomatoid carcinoma is a rare variant of squamous cell carcinoma of the head and neck. No consensus exists on its management. Our aim was to present our outcomes.

STUDY DESIGN

Retrospective study. Median follow-up 45 months.

METHODS

There were 38 patients with pathologically confirmed sarcomatoid carcinoma of the larynx treated at the Mayo Clinic from 1990 to 2014. Statistical analysis of overall survival (OS), progression-free survival (PFS), and local control (LC) were conducted using the Kaplan-Meier method.

RESULTS

The majority of patients were elderly males (92%) with a smoking history (74%) presenting with early-stage disease (71%). Surgery alone was the primary treatment in 27 patients (71%). Nine patients (25%) were treated with adjuvant radiation due to initial stage or high-risk pathologic features. Median radiation dose to the primary/surgical bed was 65 Gy (range, 60.3-75.0 Gy). A total of 15 patients (39%) had tumor recurrence, majority being local (n = 12). Sixty percent (n = 9) had multiple local recurrences. Five-year OS, PFS, and LC were 63%, 46%, and 72%, respectively. Subgroup analysis by stage I versus higher stages (II-IV) showed an OS of 80% versus 43% (P = .030), PFS of 65% versus 18% (P = .003), and LC of 84% versus 57% (P = .039).

CONCLUSIONS

Sarcomatoid carcinoma of the larynx is rare, and frequently presents at an early stage in older men with history of smoking. Based on our outcomes and patterns of failure, it appears early-stage tumors are treated appropriately with single-modality therapy, whereas more advanced tumors require multimodality therapy. Validation in a larger cohort is warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:373-377, 2018.

Sinonasal spindle cell carcinoma presenting with bilateral visual loss: A case report and review of the literature

Spindle cell carcinoma (SpCC) is a rare variant of squamous cell carcinoma (SCC). SpCC of sinonasal origin is relatively rare and more aggressive than normal SCC. It most commonly involves the maxillary sinus, and rarely the sphenoid sinus. The present study reports a case of sphenoid sinus SpCC presenting with bilateral visual loss. Following endoscopic sinus decompression surgery, the patient was referred to the Oncology Department for a staging workup, and subsequently received concurrent chemoradiotherapy; however, the vision of the patient was not recovered, despite treatment. To the best of our knowledge, this is the first reported case of synchronous inverted papilloma of the sphenoid sinus and SpCC presenting with optic nerve compression.

Synchronous squamous cell carcinoma and diffuse large B-cell lymphoma of the head and neck: the odd couple

We report the case of an 81-year-old male with synchronous recurrent cutaneous squamous cell carcinoma (SCC) metastatic to the parotid and diffuse large B-cell lymphoma of the head and neck. These malignancies necessitated integrated multidisciplinary treatment within a short time period. Superficial parotidectomy was followed by chemotherapy for lymphoma. The subsequent radiation treatment plan combined both sequential boost to treat the SCC surgical bed to a higher dose compared with the lymphoma, and dose-painting intensity-modulated radiation therapy (IMRT) to differentially dose the areas at risk. The treatment was tolerated well. The restaging scans demonstrated no evidence of either lymphoma or SCC. This case highlights the importance of combined modality treatment for two concurrent aggressive malignancies in the head and neck region. Radiation treatment planning incorporated both sequential boost and dose-painting IMRT to integrate comprehensive treatment for both malignancies.

[Spindle Cell Carcinoma of the Head and Neck: A Report of 6 Cases]

Spindle cell carcinoma of the head and neck is a rare neoplasm. We at Kyushu Cancer Center experienced 6 cases of spindle cell carcinoma which accounted for 0.9% of all cases of head and neck squamous cell carcinoma. These cases presented with the characteristic clinical presentation, such as a particular form (polypoid and exophytic) and difficulty of pathological diagnosis. For treatment, surgery was performed in the main, but in one case of hypopharyngeal cancer chemoradiotherapy was undertaken. Spindle cell carcinoma exhibits a poor prognosis, compared with the other squamous cell carcinomas. However for the moment, 4 of 6 cases are surviving, and disease free. We will require long-term monitoring of these cases.

Disease-Specific Survival with Spindle Cell Carcinoma of the Head and Neck

Objectives

(1) Determine factors influencing survival in patients diagnosed with spindle cell carcinoma (SpCC), a rare variant of head and neck squamous cell carcinoma (SCC). (2) Compare survival of patients with SpCC to those with conventional SCC.

Study Design

Retrospective cohort study.

Setting

Surveillance, Epidemiology, and End Results 18 database (years 2004-2009).

Subjects and Methods

Among patients receiving treatment for a single primary in the oral cavity, oropharynx, hypopharynx, or larynx, 118 subjects with SpCC and 18,298 subjects with SCC were identified with complete data for the variables of age, sex, grade, tumor size, stage group, and TNM stage. Disease-specific survival curves were compared. Univariate and multivariate analyses were used to examine the effects of each factor on survival over all sites and within each of 3 sites.

Results

Univariate analysis of the combination of the 3 anatomic subsites showed survival with SpCC was worse than with conventional SCC ( P < .001). Three-year disease-specific survival with SpCC was 49.5%, and 5-year disease-specific survival was 40.2%. Compared with conventional SCC, survival was worse for SpCC of the oral cavity ( P < .001) and oropharynx ( P < .001) but no different for the larynx and hypopharynx site ( P = .15). Multivariate analysis identified age ( P = .02), tumor size ( P = .006), and M stage ( P < .001) as the only variables significantly affecting survival with SpCC. All variables significantly affected survival with conventional SCC.

Conclusions

Spindle cell carcinoma carries a worse prognosis than SCC. Larger tumor size, older age, and metastatic disease portend worse survival with SpCC of the head and neck.

Spindle Cell Carcinoma of the Upper Aerodigestive Tract

Objectives:

We sought to better characterize spindle cell carcinoma (SpCC) of the upper aerodigestive tract, a rare and aggressive variant, through comparison of a large cohort of head and neck SpCCs against a cohort of conventional head and neck squamous cell carcinoma (SCC) patients.

Methods:

We compared epidemiologic and clinicopathologic characteristics of 341 SpCCs with 67 882 SCCs of the head and neck, drawing data from the SEER national database. We also compared disease-specific survivals (DSS) for SpCC and SCC based on tumor site and mode of treatment.

Results:

SpCCs were predominantly laryngeal (46.4%, P < .001) and were more likely to be high grade ( P > .001). SpCCs were also more likely than SCCs to present at an early stage ( P < .001 to P < .05). Rates of distant metastasis were similar between the tumor types. DSS was similar between SpCCs and SCCs, although site-specific survival rates were higher for SpCCs of the larynx ( P = .017) and lower for those of the oral cavity ( P = .008).

Conclusion:

SpCC of the head and neck is more likely than SCC to present at an early stage, with fewer nodal metastases. Survival rates appear to depend on anatomic site as well.

Acantholytic squamous cell carcinoma in upper aerodigestive tract: histopathology, immunohistochemical profile and epithelial mesenchymal transition phenotype change

Acantholytic squamous cell carcinoma is a rare variant of squamous cell carcinoma in the mucosa of upper aerodigestive tract. Histomorphologically, acantholytic squamous cell carcinoma may lose the typical features of conventional squamous cell carcinoma and mimic other epithelial or mesenchymal malignancies due to advanced acantholysis and dyskeratosis. Because of its rarity, information of prognosis, pathologic features and immunohistochemical profiles is limited. We have studied clinicopathologic features and immunohistochemical profiles of four acantholytic squamous cell carcinoma cases arising from upper aerodigestive tract. Clinical results indicate an aggressive biologic behavior. Morphologically, all tumors revealed significant acantholysis with separation of tumor cells and intratumoral spaces. The tumor cells were highly pleomorphic and growth patterns were variable. In immunohistochemical studies, all tumor cells revealed positive reactions for AE1/AE3 and p63 supporting a squamous epithelial origin. In contrast to conventional aerodigestive squamous cell carcinoma, acantholytic squamous cell carcinoma showed significant reductions of cytokeratin19, E-cadherin and concomitant up-regulation of vimentin expression. Both morphologic features and immunohistochemical profiles indicate that acantholytic squamous cell carcinoma has acquired an epithelial mesenchymal transition phenotype. However, in contrast to other solid malignant tumors, the epithelial mesenchymal transition phenotype change in acantholytic squamous cell carcinoma is not limited to the invasive front of the peripheral tumor but, rather, diffusely involves entire neoplastic lesion. In addition, because cytokeratin 19 staining is attenuated, this would be an insensitive marker for following up and/or in detecting disseminated tumor cells in cases of acantholytic squamous cell carcinoma in upper aerodigestive tract.

Sinonasal tract mucoepidermoid carcinoma: a clinicopathologic and immunophenotypic study of 19 cases combined with a comprehensive review of the literature

Primary sinonasal tract mucoepidermoid carcinomas (MEC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. The design of this study is retrospective. Nineteen cases of MEC included 10 females and 9 males, aged 15-75 years (mean, 52.7 years); males, on average were younger by a decade than females (47.2 vs. 57.7 years). Patients presented most frequently with a mass, obstructive symptoms, pain, and/or epistaxis present for a mean of 12.6 months. The majority of tumors involved the nasal cavity alone (n=10), maxillary sinus alone (n=6), or a combination of the nasal cavity and paranasal sinuses (n=3) with a mean size of 2.4 cm. Most patients presented at a low clinical stage (n=15, Stage I & II), with only 4 patients presenting with Stage III disease. Histologically, the tumors were often invasive (bone or perineural invasion), with invasion into minor mucoserous glands. Surface involvement was common. The neoplastic cells were composed of a combination of squamoid cells, intermediate cells, and mucocytes. Cystic spaces were occasionally large, but the majority were focal to small. Pleomorphism was generally low grade. Necrosis (n=5) and atypical mitotic figures (n=6) were seen infrequently. Over half of the tumors were classified as low grade (n=11), with intermediate (n=4) and high grade (n=4) comprising the remainder. Mucicarmine was positive in all cases tested. Immunohistochemical studies showed positive reactions for keratin, CK5/6, p63, CK7, EMA, and CEA in all cases tested, while bcl-2 and CD117 were rarely positive. GFAP, MSA, TTF-1, and S100 protein were non-reactive. p53 and Ki-67 were reactive to a variable degree. MEC need to be considered in the differential diagnosis of a number of sinonasal lesions, particularly adenocarcinoma and necrotizing sialometaplasia. The patients were separated into stage I (n=9), stage II (n=6), and stage III (n=4), without any patients in stage IV at presentation. Surgery occasionally accompanied by radiation therapy (n=2) was generally employed. Six patients developed a recurrence, with 5 patients dying with disease (mean, 2.4 years), while 14 patients are either alive (n=9) or had died (n=5) of unrelated causes (mean, 14.6 years). MEC probably arises from the minor mucoserous glands of the upper aerodigestive tract, usually presenting in patients in middle age with a mass. Most patients present with low stage disease (stage I and II), although invasive growth is common. Recurrences develop in about a third of patients, who experience a shorter survival (mean, 6.5 years). The following parameters, when present, suggest an increased incidence of recurrence or dying with disease: size ≥ 4.0 cm (P=0.034), high mitotic count (P=0.041), atypical mitoses (P=0.007), mixed anatomic site (P=0.032), development of recurrence (P=0.041), high tumor grade (P=0.007), and higher stage disease (P=0.027).

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.