Association of multiple granular cell tumors and squamous carcinoma of the esophagus: case report and review of the literature

Coexistent Squamous Cell Carcinoma and Granular Cell Tumor of Head and Neck Region: Report of Two Very Rare Cases and Review of the Literature

Granular cell tumor (GCT), a relatively rare neuroectodermal tumor occurring most often in the head and neck region, is not uncommonly associated with pseudoepitheliomatous hyperplasia of the overlying surface epithelium, which may be at times nonreadily distinguishable from well-differentiated squamous cell carcinoma (SCC). To the best of our knowledge, only a handful of coexisting SCC and GCT, mostly described in the esophagus, have been reported in (the current) literature so far. We herein report 2 new cases of coexisting GCT and SCC of the head and neck region, located, respectively, in larynx and tongue; comment on their clinical, imaging, and pathologic features; and discuss their management. In the present work, we also review the literature concerning this association to contribute to the head and neck pathologists' and surgeons' awareness regarding the possibility of this association for an adequate surgical excision and a better management of these patients.

Lingual squamous cell carcinoma surrounded by granular cell tumor

The granular cell tumor (GCT) is an uncommon, benign lesion with a preference for subcutaneous sites. In the head and neck, the tongue is the most common site, followed by the larynx. We experienced a case of a 27-year-old woman with lingual squamous cell carcinoma (SCC) surrounded by GCT. The pathological findings established that the lesion was SCC covered by GCT in the midline of the tongue. The size of the mass was very small, however, so we excised it in a diamond shape. There is an interesting association between GCTs and other malignant neoplasms. However, no causal relationship between GCT and these other carcinomas has been established. Here we report on an SCC coexisting with GCT at the same site as a median tongue lesion and review the literature.

[Granular cell tumor of the esophagus: description of an infrequent benign tumor]

Granular cell tumors (GCT) are infrequent tumors first described by Abrikossoff in 1926. Gastrointestinal involvement occurs in about 6% of GCT, the esophagus being the most frequent location. These tumors are usually benign and asymptomatic and are usually found incidentally when an upper gastrointestinal endoscopy is carried out for another reason, showing an isolated polyp or sessile submucosal nodule, covered by intact yellowish mucosa and with firm consistency. Endoscopic ultrasonography has significantly improved the diagnosis of these lesions. Nowadays endoscopic mucosectomy is the treatment of choice of esophageal GCT with a low frequency of complications. Histologic analysis of the surgical specimen shows specific characteristics such as positivity for S-100 protein. We present two new cases of esophageal GCT that were diagnosed recently and discuss the most relevant features of this infrequent disease.

Esophageal granular cell tumor colliding with intramucosal adenocarcinoma: a case report

We report a case of a granular cell tumor colliding with intramucosal adenocarcinoma of the esophagus. A 58-year-old white was found to have a 5 mm nodule in the distal esophagus detected by upper gastrointestinal endoscopy performed as part of the workup of long standing reflux. Endoscopic biopsies revealed intramucosal adenocarcinoma arising in the setting of Barrett’s esophagus. The adenocarcinoma infiltrated a granular cell tumor also present at the nodular site. Endoscopic mucosal resection using Duette band ligation and hot snare electrocautery was performed. Margins were negative for both tumors, and endoscopic surveillance for recurrence is planned.

Multifocal granular cell tumor presenting as an esophageal stricture

INTRODUCTION

Granular cell tumors are uncommonly found in the gastrointestinal tract with slow progression and are usually benign though they may have propensity for malignant transformation. Initially attributed to neuronal origin through immunohistochemistry, there has been controversy with increasing reports of granular cell tumors of non-neural origin.

CASE REPORT

We report a case of multifocal granular cell tumor involving the esophagus and stomach in a young female with history of dysphagia for 9 years with worsening symptoms. She had been managed at another facility with repeated dilations for presumed benign peptic stricture. Radial endosonography (EUS) of the proximal end of stricture showed a posterior submucosal esophageal mass that was heterogeneous and invaded into the muscularis propria. Fine-needle aspiration (FNA) showed large cells with granular cytoplasm along with spindle nuclei. Cells were initially checked for CD117 stain alone and found to be negative. A follow-up CT-guided core needle biopsy revealed similar granular cells that were positive for S-100. She underwent a two-stage transhiatal esophagogastrectomy as the tumor circumferentially involved the cervical esophagus and was adherent to the trachea and recurrent laryngeal nerve bilaterally. At surgery, there were two additional foci palpable in the proximal stomach.

DISCUSSION AND CONCLUSION

As these tumors may have potential for malignant transformation and locoregional invasion, they should be considered while evaluating submucosal lesions of the esophagus even in young patients. A large number of granular cell tumors may be missed in the absence of S-100 staining, which should be requested when granular cells are seen on cytology obtained by EUS FNA as this can be a minimally invasive diagnostic modality for these tumors. Other foci should be sought at surgery as they have a propensity for locoregional spread.

Esophageal granular cell tumor covered by intramucosal squamous cell carcinoma: report of a case

We report a case of a granular cell tumor (GCT) covered by squamous cell carcinoma (SCC) in the esophagus. A 69-year-old Japanese man was admitted to our hospital for treatment of superficial esophageal cancer detected by upper gastrointestinal endoscopy. Endoscopic examination revealed a shallow ulcer in the esophagus, 28-32 cm from the incisor teeth. The pathological findings of a biopsy of the lesion were moderately differentiated SCC. Thus, we performed partial esophagectomy with two-field (thoraco-abdominal) lymph node dissection. Microscopic examination of the surgical specimen revealed intraepithelial SCC with minimal invasion, and a GCT, 3 x 1 mm in size, in the submucosa just beneath the SCC. Cytoplasmic granules in the GCT were positive for periodic acid-Schiff. Immunohistochemically, the GCT was strongly positive for S-100 protein. To our knowledge, this is the first published report of a GCT covered by SCC in the esophagus.

Esophageal granular cell tumor and eosinophilic esophagitis: two interesting entities identified in the same patient

We illustrate the case of a 41-year-old male with allergic manifestations since childhood. He sought medical attention for intermittent, progressive dysphagia from which he had been suffering for a number of years, having felt the sensation of a retrosternal lump and a self-limited obstruction to the passage of food. Endoscopy detected a submucosal tumor in the upper third of the esophagus, which was typified, via biopsy, as a granular cell tumor with benign characteristics and probably responsible for the symptoms. Two years later, the patient sought medical attention once again as these symptoms had not abated, hence digestive endoscopy was repeated. This revealed stenosis of the junction between the middle and lower thirds of the organ which had not been detected previously but was passable under gentle pressure. Eosinophilic esophagitis was detected after biopsies were taken. Esophageal manometry identified a motor disorder affecting the esophageal body. Following three months of treatment using fluticasone propionate applied topically, the symptoms went into remission, esophageal stenosis disappeared and the esophageal biopsies returned to normal. This is the first documented case of the link between granular cell tumors and Eosinophilic esophagitis, two different disorders which could cause dysphagia in young patients.

Granular cell tumors of the esophagus: report of five cases and review of diagnostic and therapeutic techniques

Granular cell tumors (GCT) of the esophagus are stromal lesions originating from the Schwann cells of the submucosal neuronal plexus. Although they are very infrequent, they constitute the second largest cause of non-epithelial tumors in the esophagus after leiomyomas. These tumors are generally benign, although a certain number of malignant, aggressive cases have been reported. Diagnosis requires that this possibility be ruled out before deciding on which course of therapeutic action to take as well as familiarization with the relevant indicators. GCT linked synchronically or metachronically to other malignant neoplasias of the esophagus have also been described, but the actual extent of this association is uncertain. This report describes five cases of GCT recently diagnosed as incidental findings following endoscopic exploration. All of these were benign and were treated conservatively. The article discusses new aspects relating to the diagnosis of these lesions and the role carried out by endoscopic ultrasonography in their characterization, both at preliminary diagnosis and monitoring levels. No standard therapeutic guidelines exist for the management of GCT, but endoscopic treatment without invading the muscularis propria layer would be used for symptomatic patients, creating histopathological doubts requiring research on the entire organ. Endoscopic therapeutic techniques are analyzed (resection with forceps or diathermy handles, yttrium-aluminum-garnet laser ablation, alcohol injection) in esophageal GCT, which have overtaken surgery in most cases due to their efficiency, greater safety and fewer complications.

Granular cell tumor of hypopharynx: report of a rare case

Granular cell tumor is a rare tumor, probably of Schwann cell origin. The head and neck are most frequently affected, but hypopharyngeal lesion is extremely rare. We report the seventh case of hypopharyngeal granular cell tumor. Immunohistochemical staining for S100 protein is helpful for the correct diagnosis. There is some possibility of malignancy despite absence of histological evidence, thus the treatment is exclusively surgical resection. The microlaryngoscopic approach is feasible for hypopharyngeal lesions in most cases. Recurrence can occur even after appropriate resection.

Granular cell tumours of the gastrointestinal tract: expression of nestin and clinicopathological evaluation of 11 patients

AIMS

Granular cell tumours (GCTs) in the gastrointestinal (GI) tract are rare, with few series reported in the literature. Nestin is a recently identified intermediate filament protein that is expressed in neuroectodermal stem cells and skeletal muscle progenitor cells and has been shown to be expressed in gastrointestinal stromal tumours (GISTs) and GI schwannomas. Herein, we describe the clinicopathological and immunohistochemical features of 11 GI GCTs, introducing nestin as an additional marker that identifies these tumours.

METHODS AND RESULTS

The archives of the departments of pathology at London Health Sciences Centre (London, Ontario) and St Michael's Hospital (Toronto, Ontario) were searched for GCTs occurring in the GI tract, yielding 11 cases. Histological features were assessed and immunohistochemistry was performed with S100 protein, nestin, glial fibrillary acidic protein (GFAP), CD34, desmin, CD117, and inhibin-alpha. Charts were reviewed for clinical information. Ages at diagnosis ranged from 31 to 73 years; there were six males and four females. All GCTs were solitary, six in the oesophagus, three in the caecum, one in the rectum and one perianal. Most lesions were discovered incidentally. The size of the GCTs ranged from 4 mm to 30 mm. All were submucosal, typically firm, with a white-yellow appearance. Histologically, the GCTs showed moderate cellularity, predominantly solid growth with areas of nesting. While lesional cells were mainly plump and polygonal, areas of spindling were present in several tumours, more frequently in the colorectum. Margins were circumscribed. Nuclei were round to oval, with even chromatin and small nucleoli. Mitoses were rare to absent and necrosis was absent in all cases. Staining with periodic acid-Schiff, with diastase predigestion, showed globular and diffuse positivity within the cytoplasm. Moderate to strong expression of S100 protein and nestin was observed in 11 of 11 and seven of seven tumours, respectively. GFAP, CD34, desmin, CD117 and inhibin-alpha were negative. While patients were variably managed with resection or observation, all remain clinically well, without disease progression.

CONCLUSIONS

Although rare, GI GCTs have characteristic clinicopathological features. Nestin may be a useful immunohistochemical marker for identifying these tumours; the presence of this persistent stem cell cytoskeletal filament within GI GCTs suggests that these lesions may arise from a multipotential stem cell in the GI tract.