Coexistence of esophageal granular cell tumor and squamous cell carcinoma: a case report

Esophageal granular cell tumor and eosinophils: a multicenter experience

Background

Esophageal granular cell tumor (eGCT) is rare, and the recent literature suggests a link between eosinophilic esophagitis (EoE) and eGCT. The aim of our study was to determine if EoE or other disorders associated with eosinophilia are consistently associated with eGCT.

Methods

We retrospectively searched pathology databases of three academic institutions from 1999 to 2018 for eGCTs. The archived slides and medical records were reviewed.

Results

From 294,855 esophagogastroduodenoscopy procedures, 45 patients (17 males and 28 females) with eGCTs were identified. The patients (30–73 years in age, median 50) had eGCT 0.2–2.0 cm in size (average 0.71). Thirteen had a history of gastroesophageal reflux disease, 5 had Barrett esophagus/goblet cell metaplasia and 1 had EoE. Thirty-four eGCTs had intralesional eosinophils (14 with peak > 10 eosinophils/400x hpf); of these, 21 also had eosinophils in lamina propria (9 with peak > 10 eosinophils/hpf). eGCT with atypical features (including nuclear enlargement and prominent nucleoli) were more likely to have increased eosinophils in non-epithelial compartments than those without atypia. Pleomorphism and spindled cells were seen in 3 eGCT cases (mean peak intralesional eosinophils: 43 per hpf); 2 of these had goblet cell metaplasia. We found no association between EoE and eGCT, p = 0.5966, (95% C.I. 0.0276, 6.5389, Fisher’s exact test). Instead, most patients had gastroesophageal reflux disease or Barrett esophagus.

Conclusion

Eosinophilia, common in eGCT and adjacent stroma, likely drives atypical/reactive histologic features, but a pathogenic relationship between eosinophil rich inflammatory conditions and eGCT has not yet been established.

Esophageal Granular Cell Tumor: A Case and Review of the Literature

Granular cell tumors (GCTs) are rare and benign tumors that can occur at any anatomical site. GCTs are thought to originate from nerve cells, particularly Schwann cells. Their name derives from the fact that an accumulation of cytoplasmic lysosomes imparts the tumor with a granular appearance. They are most commonly observed in the oral cavity, skin and subcutaneous tissue, breast, and respiratory tract. GCTs rarely affect the gastrointestinal tract. We report a 56-year-old female with a medical history of human immunodeficiency virus, hepatitis C, and cholelithiasis, who presented with abdominal pain. Upper endoscopy revealed a 1 - 2 cm solitary yellowish appearing nodule just distal to the GE junction. Biopsy of the nodule followed by histopathology was positive for S100, but negative for pancytokeratin immunostains. PAS staining highlighted cytoplasmic granules, further supporting the diagnosis of gastrointestinal GCT.

Progress in research of esophageal granular cell tumors

Esophageal granular cell tumor is a rare benign soft tissue tumor with malignant potential, and its histogenesis remains unclear. Since clinical manifestations lack specificity, the diagnosis depends on endoscopy, endoscopic ultrasonography, pathology and immunohistochemistry. Esophageal granular cell tumors have the potential of malignant transformation and are easily confused with leiomyoma and interstitialoma. At present, the treatment of this disease has not yet reached a consensus. This review aims to elucidate the histogenesis, clinical manifestations, diagnosis, treatment and prognosis of esophageal granular cell tumors.

Esophageal granular cell tumor: Clinical, endoscopic and histological features of 19 cases

Esophageal granular cell tumors (GCTs) are rare and often misdiagnosed. To demonstrate their clinicopathological features, the present study reports 19 cases and reviews the literature. There were 11 female and eight male esophageal GCT patients with a median age of 42.0 years. All the tumors were solitary. The majority of patient indications for endoscopy (89.5%) were non-specific and endoscopic therapy was performed in 17 cases with a relapse in one case after a 12-month follow-up. The endoscopic appearance of esophageal GCT was variable and the majority of tumors (80.0%) were located in the middle and lower esophageal segments. The size of the tumors ranged from 0.4 to 2 cm in diameter and the surface was white-gray, pink or yellow. Nine patients underwent an endoscopic ultrasound exam, eight of which demonstrated hypoechoic echostructures with a smooth margin and intracavity growth features. One case was derived from the muscularis propria layer with an irregular margin and intra- and extra-cavity growth features. The histological features could mimic other tumors and immunohistochemical stains are usually positive for S-100, periodic acid-Schiff, neuron-specific enolase and nestin. Three cases indicated pleomorphism and Ki-67 was locally positive. Esophageal GCTs are rare and endoscopic ultrasound features are variable. Immunohistochemical staining may aid in the diagnosis.

[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.

The unique simultaneous occurrence of a squamous cell carcinoma and a granular cell tumor of the tongue at the same site: a histological and immunohistochemical study

We report a case of a 47-year-old man with a granular cell tumor (GCT) of the tongue colocalized with a squamous cell carcinoma. To our knowledge, this is the first case to be reported in the literature with such an association. Furthermore, we performed an immunohistochemical analysis with p63 to distinguish pseudoepitheliomatous hyperplasia from invasive squamous cell carcinoma. Clinicians and pathologists must be made aware of this potential diagnostic pitfall so that the workup of a tongue lesion does not end prematurely with a benign diagnosis of granular cell tumor with overlying pseudoepitheliomatous hyperplasia.

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.