Carcinosarcoma of the colon: report of a rare tumor

Colorectal Carcinoma With Sarcomatoid Components: Report of 15 Cases and Literature Review of an Exceedingly Rare Carcinoma Subtype

Colorectal carcinoma with sarcomatoid components (which includes so-called carcinosarcomas and sarcomatoid carcinomas) is a rare subtype with 50 reported cases in the literature and overlapping criteria with undifferentiated carcinoma. We collected and described 15 cases from 10 men and 5 women, with a mean age of 66 years. Symptoms included abdominal pain and gastrointestinal bleeding. Most tumors presented in the rectosigmoid region, with a mean size of 8.2 cm. The sarcomatoid component, on average, represented 58% of the tumors and took many forms, including spindled (10 cases), anaplastic (9 cases), and rhabdoid (3 cases); one case showed osteoid matrix. Tumor budding was usually high, and tumor-infiltrating lymphocytes were usually low. The sarcomatoid component was keratin-positive in 10 cases. One case showed loss of mismatch repair protein expression, and 2 cases showed SMARCA4 loss (1 also with SMARCA2 loss). Molecular testing identified mutations in KRAS (n=1), NRAS (n=2), BRAF (n=2), APC (n=1), and TP53 (n=1) in a few cases. Tumors often presented at advanced stage, with 11 cases pT4, 9 cases with nodal metastases, and 7 cases with distant metastases. Follow-up was available for 10 cases (median: 2 months), with 2 alive without disease, 3 alive with disease, and 5 dead. Our findings roughly corresponded with those in previously reported cases. Colorectal carcinoma with sarcomatoid components is rare and aggressive, with a poor prognosis for many patients. We suggest that spindled cells, anaplasia, heterologous elements, and/or a component with definable sarcomatous lineage be used to distinguish colorectal carcinoma with sarcomatoid components from undifferentiated carcinoma.

Sclerosing encapsulating peritonitis causing fatal bowel obstruction

Sclerosing encapsulating peritonitis (SEP) is a rare condition characterised by a fibrotic peritoneal membrane encasing loops of bowel often resulting in obstruction. We present a case of SEP complicated by non-resolving small bowel obstruction in the context of prior malignancies and surgical complications. A literature review on SEP was performed to outline potential aetiologies, diagnostic investigations and treatment strategies that may be considered in the management of this disease.

SMARCA4-deficient rectal carcinoma with a sarcomatoid component: a case report

A new classification of SMARCA4-deficient tumors was proposed recently for thoracic malignancies, and the tumors have some histopathological characteristics similar to those of carcinosarcoma. We encountered a case of SMARCA4-deficient rectal carcinoma with a sarcomatoid component. A 46-year-old man presented to our hospital with a prolapsing anal mass. Colonoscopy revealed an irregular, nodular, and elevated lesion in the rectum, and the biopsy revealed a moderately differentiated adenocarcinoma. Abdominoperineal resection of the rectum was performed. A macroscopic image of the resected specimen showed a complex tumor 3.5 cm × 3 cm in size with a papillary protrusion and an irregular ulcerative lesion. Histopathological examination revealed that the tumor was composed of moderately/poorly differentiated adenocarcinoma and atypical spindle cells. The adenocarcinoma component was positive for epithelial markers (AE1/AE3 and carcinoembryonic antigen) and showed deletion of SMARCA2 and SMARCA4, while the spindle cells expressed mesenchymal markers (α-smooth muscle actin and vimentin). The pathological diagnosis was poorly differentiated adenocarcinoma with a sarcomatoid component, pT3N2bM0, stage IIIc. Although our case had histological characteristics of carcinosarcoma, immunostaining revealed a deficiency of SMARCA4. This case presented a SMARCA4-deficient colorectal carcinoma with a sarcomatoid component, which was histopathologically similar to carcinosarcoma.

Loss of CDX2 in colorectal cancer is associated with histopathologic subtypes and microsatellite instability but is prognostically inferior to hematoxylin-eosin-based morphologic parameters from the WHO classification

BACKGROUND

Immunohistochemical loss of CDX2 has been proposed as a biomarker of dismal survival in colorectal carcinoma (CRC), especially in UICC Stage II/III. However, it remains unclear, how CDX2 expression is related to central hematoxylin-eosin (HE)-based morphologic parameters defined by 2019 WHO classification and how its prognostic relevance is compared to these parameters.

METHODS

We evaluated CDX2 expression in 1003 CRCs and explored its prognostic relevance compared to CRC subtypes, tumour budding and WHO grade in the overall cohort and in specific subgroups.

RESULTS

CDX2-low/absent CRCs were enriched in specific morphologic subtypes, right-sided and microsatellite-instable (MSI-H) CRCs (P < 0.001) and showed worse survival characteristics in the overall cohort/UICC Stage II/III (e.g. DFS: P = 0.005) and in microsatellite stable and left-sided CRCs, but not in MSI-H or right-sided CRCs. Compared with CDX2, all HE-based markers showed a significantly better prognostic discrimination in all scenarios. In multivariate analyses including all morphologic parameters, CDX2 was not an independent prognostic factor.

CONCLUSION

CDX2 loss has some prognostic impact in univariate analyses, but its prognostic relevance is considerably lower compared to central HE-based morphologic parameters defined by the WHO classification and vanishes in multivariate analyses incorporating these factors.

Sarcomatoid Carcinoma of the Transverse Colon With Extremely Aggressive Brain Metastases

Introduction

Sarcomatoid carcinoma (SC) is a rare subtype of malignant neoplasm with a poor prognosis that involves both carcinomatous and sarcomatous components. Although it may develop in various organs, SC in the large intestine has rarely been reported. It is not rare for patients with SC to have distant metastasis, reflecting its highly aggressive oncologic features, but cases with brain metastasis on initial visit are rare. In this report, we described a case of SC in the transverse colon with brain metastases whose initial symptom was neurological disorder, and reviewed 31 reported cases of SC.

Case presentation

A 70-year-old man was admitted to our hospital with the chief complaints of gait disorder and severe dizziness. Head magnetic resonance imaging revealed tumor masses in the anterior lobe and cerebellum. A large tumor in the transverse colon was detected by colonoscopy and abdominal enhanced computed tomography (CT), and was diagnosed as undifferentiated adenocarcinoma by histology. Laparoscopic extended right hemicolectomy was performed to remove the obstruction, and the resected specimens revealed an invasive tumor consisting of a mixture of carcinomatous and sarcomatous components. According to the immunopathological study, the patient was diagnosed with SC. The clinical course was extremely aggressive, and the patient died on the 28th postoperative day because of disease progression.

Conclusion

To the best of our knowledge, this is the first case of SC in the transverse colon with a neurological disorder derived from brain metastases. This experience may contribute to the guidance regarding proper therapeutic options for SC.

Colonic Carcinosarcoma: Report of a Rare Colorectal Malignancy and Review of Literature

Colonic carcinosarcoma is an extremely rare tumor composed of mixed malignant epithelial and mesenchymal cells. Due to its rarity, its pathogenesis is poorly understood, and there are no specific guidelines for its treatment.

Morphology Matters: A Critical Reappraisal of the Clinical Relevance of Morphologic Criteria From the 2019 WHO Classification in a Large Colorectal Cancer Cohort Comprising 1004 Cases

The 2019 World Health Organization (WHO) classification of colorectal carcinoma (CRC) profoundly reclassified CRC subtypes and introduces tumor budding as a second major grading criterion, while condensing conventional grade into a 2-tiered system. So far it remains largely unexplored how these parameters interact with each other and whether they truly have an independent impact on patient prognosis. We reclassified a large single-center cohort of 1004 CRCs spanning 2 decades for adjusted WHO grade (low vs. high), tumor budding (Bd1/Bd2/Bd3), and CRC subtype (adenocarcinoma not otherwise specified, micropapillary, mucinous, serrated, medullary, adenoma-like, signet-ring cell, mixed adenoneuroendocrine carcinoma/neuroendocrine carcinoma, undifferentiated) according to the criteria of the 2019 WHO classification. We investigated the interaction of these parameters, their connection to stage/microsatellite status, and their significance for patient survival in the different subgroups. Specific subtypes other than adenocarcinoma not otherwise specified represented one third of all CRCs and were unevenly distributed throughout stage and microsatellite subgroups. Subtypes, WHO grade and tumor budding profoundly impacted all survival parameters (P<0.001 for all analyses), with CRC subtypes and tumor budding-but not WHO grade-being stage-independent prognosticators for all survival comparisons. WHO grade had very limited prognostic value in CRC subtypes, while tumor budding retained its strong prognostic impact in most scenarios. Accurate delineation of CRC subtypes introduced in the 2019 WHO classification provides strong stage-independent prognostic information, arguing that they should be considered in pathology reports and in clinical trials. Of the morphology-based grading schemes included in the 2019 WHO, tumor budding outperforms WHO grade.

A case of 18 years disease-free survival after combined pancreatoduodenectomy and hemicolectomy for carcinosarcoma of the transverse colon

BACKGROUND

Ascertaining the origin of large tumors located in the region of the pancreas head and adjacent mesocolon can pose a challenge preoperatively. En bloc pancreatoduodenectomy with hemicolectomy is often required towards curative tumor resection (R0) of malignant tumors in this region.

CASE PRESENTATION

Herein we report a case of a 48-year-old man with two contiguous masses each 5 cm in size, located in the pancreatic head. The masses were detected incidentally by abdominal ultrasonography at an annual health check. Endoscopic biopsies revealed inflammation with no malignancy. Cross-sectional imaging showed the tumor direct invasion of the uncinate process of the pancreas, and the third portion of the duodenum. Based on imaging, a malignant submucosal tumor originating from mesenchymal cells in the mesentery of the transverse colon was made preoperatively. The mass required en bloc pancreatoduodenectomy, right hemicolectomy, and resection of the superior mesenteric vein. The final pathology was carcinosarcoma of the transverse colon. The patient survived 18 years after surgery without recurrence.

CONCLUSIONS

Malignant tumors located in the region of the pancreas head should be considered for an en bloc curative tumor resection and adjuvant chemotherapy treatments offered that might be beneficial for carcinosarcoma.

Primary carcinosarcoma of the ureteropelvic junction associated with ureteral duplication: A case report

RATIONALE

Primary carcinosarcoma of the upper urinary tract is rare. Ureteral duplication is one of the most common urinary tract malformations. Additionally, the association between ureteral duplication and malignancy is unknown. To the best of our knowledge, no cases of malignant tumors diagnosed as carcinosarcoma with ureteral duplication have been reported. We herein report the case of a patient with carcinosarcoma of the ureteropelvic junction associated with incomplete ureteral duplication.

PATIENT CONCERNS

A 60-year-old Japanese woman presented with painless gross hematuria. She had a history of total hysterectomy and chemotherapy for endometrioid carcinoma 5 years before. She had no history of occupational chemical exposure.

DIAGNOSES

Radiographic imaging revealed right incomplete ureteral duplication, hydronephrosis, and a polypoid tumor in the ureteropelvic junction of the lower moiety of the right kidney. Urine cytology showed a small amount of degenerated atypical epithelial and nonepithelial cells. The transureteral biopsy specimen showed dysplastic urothelial cells and atypical myoid spindle cells. These findings were indefinite for malignancy.

INTERVENTIONS

The patient underwent right nephroureterectomy. Pathological examination of the resected tumor showed a biphasic neoplasm composed of carcinomatous and sarcomatous components. The sarcomatous component was immunohistochemically positive for vimentin, desmin, h-caldesmon, and α-SMA and negative for pancytokeratin (AE1/AE3), low molecular weight cytokeratin (CAM 5.2), EMA, E-cadherin, GATA3, uroplakin 2, and p63. Based on these findings, we diagnosed the tumor as carcinosarcoma.

OUTCOMES

The postoperative course was uneventful. No additional therapy was administered. The patient has remained alive without recurrence for 21 months since surgery.

LESSONS

Carcinosarcoma can arise from ureteral duplication. Although the majority of carcinosarcomas of the upper urinary tract are diagnosed at an advanced stage and have a poor prognosis, some can have a less aggressive course. Further studies are needed to determine the association between ureteral duplication and malignancy.

Sarcomatoid Carcinoma Manifesting as Recurrent Rectal Cancer and Mimicking Radiation-Induced Extraskeletal Osteosarcoma: A Case Report

Here, we report an unusual case of sarcomatoid carcinoma mimicking extraskeletal osteosarcoma that manifested as recurrent rectal cancer. Five years earlier, a 76-year-old male patient had undergone neoadjuvant chemoradiotherapy followed by a laparoscopic low anterior resection due to adenocarcinoma of the rectum. He was admitted because of pain in the anus and left hip. He underwent abdominal computed tomography that revealed a newly developed left perirectal mass with gluteus maximus invasion measuring up to 8 cm, and therefore, an abdominoperineal resection was performed. Histologically, the tumor revealed sheets of spindled or epithelioid cells, an absence of gland formation, mucicarmine and periodic acid-Schiff stain negativity, and prominent intercellular deposits of osteoid-like calcified tissue. Tumor cells were diffusely immunoreactive for vimentin and cytokeratins. Ultrastructural examination demonstrated microvilli on the surface or within intercellular spaces. In this report, we also discuss the possible pathogenesis as well as the differential diagnosis.

Carcinosarcoma of the Rectum: Report of a Rare Colorectal Malignancy and Review of the Literature

Carcinosarcoma (CS) is a rare mixed mesodermal malignancy most commonly affecting the female reproductive organs, respiratory tract, head, and neck. Though infrequent, it may affect the gastrointestinal tract, most often the oesophagus and only very rarely the rectum. Histologically, it is composed of two distinct elements of epithelial and mesenchymal origin. Clinically, it is a very aggressive tumour with many patients presenting with metastatic lymph nodes or distant metastases at the time of diagnosis. Prognosis is poor despite intervention with the majority of patients dying within six months. Due to the rarity of this condition, there are no specific treatment guidelines presently available. We describe the case of an 80-year-old patient with carcinosarcoma of the rectum with discussion of the immunohistochemistry and review the available literature pertaining to this rare presentation.

Carcinosarcoma in the cecum

Carcinosarcoma of the colon is rare. Seventeen cases have been reported in the English literature. Most cases occurred in the left side of the colon. Indeed, there is only one reported case of cecal carcinosarcoma. Carcinosarcoma has a tendency to distantly metastasize and shows dismal prognosis. We report a case of carcinosarcoma in the cecum and review the literature describing colonic carcinosarcoma.

Sarcomatoid carcinoma of colon: extremely poor prognosis

Colonic sarcomatoid carcinomas are known to be extremely rare tumors, with only 22 cases reported either as sarcomatoid carcinomas or carcinosarcomas in the literature. The known characteristics are rapid growth, a high recurrence rate, and an extremely poor prognosis. Herein we report a case of a patient who had a sarcomatoid carcinoma of the sigmoid colon and died only 22 days after surgery due to rapid tumor growth.

Carcinosarcoma of the Sigmoid Colon: Report of a Case

Our case was a 65-year-old male, with the chief complaints of diarrhea and abdominal distention. Three years earlier, the patient had undergone transcatheter arterial embolization and radiofrequency treatment based on a diagnosis of hepatocellular carcinoma due to hepatitis B by another doctor. In October 2007, the patient developed diarrhea and increased abdominal distention. In December, CT examination conducted by the previous doctor revealed a 20-cm tumor within the pelvis. The patient was diagnosed with sigmoid colon cancer based on barium enema examination using gastrografin, and was introduced to our hospital for treatment. He was diagnosed with low-differentiated carcinoma by biopsy of the colon during endoscopy and underwent sigmoidectomy based on a diagnosis of sigmoid colon cancer. The tumor had infiltrated the bladder, and a tumorectomy was conducted through partially combined resection. The tumor was a huge lesion occupying the inside of the lumen, and histopathological findings revealed that the tumor, the main part of which lay beneath the mucous membrane, had a transitional image composed of both spindle-shaped atypical cells and sarcomatoid shape. The result of immunostaining was CK7(+), CK20(-), AFP(-), and the patient was diagnosed as having carcinosarcoma of the colon. Carcinosarcoma of the colon is a malignant tumor with poor prognosis, and the mean survival period in past reports was approximately 6 months. The patient was treated with FOLFIRI+Bevacizumab therapy according to chemotherapy for colon cancer, but he was refractory to the therapy.

Carcinosarcoma on ascending colon found by bowel perforation: a case report

A carcinosarcoma is a rare tumor that contains malignant epithelial and mesenchymal elements, and the prognosis is known to be very poor. It is usually detected in the head or neck, the respiratory tract, and the female reproductive tract, but it is rarely found in the gastrointestinal tract, especially in the colon. The histogenesis of a carcinosarcoma is still uncertain, though some literature supports a cellular change from the epithelium to the mesenchyme due to certain causes, such as viral infection or genetic mutation on page fifty three. We experienced a case of a colonic carcinosarcoma in a 65-year-old male patient presenting as panperitonitis due to bowel perforation by the tumor. A right hemicolectomy with lymph node dissection was performed. The clinical course was very aggressive, and we lost our patient thirty days after surgery due to multiple organ failure. Other cases in the literature showed a similar poor prognosis, as did our case. Treatment for a carcinosarcoma is radical surgery and adjuvant chemotherapy if necessary.

Carcinosarcoma of the Colon: A Rare Cause of Colovesical Fistula

Carcinosarcomas are relatively rare tumors composed of both carcinomatous and sarcomatous components. The most common sites involved by this tumor are the head and neck, respiratory tract, uterus, ovaries, and fallopian tubes. Within the gastrointestinal tract this tumor most often occurs in the esophagus, followed by the stomach. Carcinosarcomas are very aggressive tumors associated with a poor prognosis. The first case of carcinosarcoma of the colon was reported in 1986. The case reported here is the only one involving an associated colovesical fistula.

Carcinosarcoma of the rectosigmoid colon in a 13-year-old girl

Reported herein is an unusual case of carcinosarcoma of the colon. A 13-year-old girl was transferred to Chonbuk National University Hospital, Korea with a known pelvic mass. CT and magnetic resonance imaging confirmed a large pelvic mass. A sarcoma was diagnosed following colonoscopic biopsy. An ultra-low anterior resection with pelvic lymph node dissection was performed. The tumor consisted of a well-differentiated adenocarcinoma showing strong immunoreactivity to epithelial markers (pancytokeratin, cytokeratin 7, cytokeratin 19, cytokeratin 20, epithelial membrane antigen, and CEA) and a sarcomatous lesion with strong diffuse vimentin expression but no immunoreactivity to any of the six epithelial markers. Carcinosarcomas of the colon are extremely rare, and all reported cases involve adults. To the authors' knowledge, this is the first reported case of a carcinosarcoma of the colon in a child.

Evidence for colorectal sarcomatoid carcinoma arising from tubulovillous adenoma

Sarcomatoid carcinomas of the colorectum are rare tumors that display both malignant epithelial and stromal components. Clinically, they are aggressive tumors with early metastasis. Due to their infrequent occurrence, the pathogenesis is poorly understood. We report a case of a 52-year-old woman who presented with a rectal mass and intermittent hematochezia. Superficial biopsies during colonoscopy revealed a tubulovillous adenoma with high-grade dysplasia. Endoscopic ultrasonography confirmed an invasive nature of the mass, and deeper biopsies revealed the presence of neoplasm with mixed histological components. The surgically-excised specimen demonstrated the presence of poorly differentiated spindle cells underneath the tubulovillous adenoma and an intermediate stage of invasive adenocarcinoma. Based on the histological appearance and immunohistochemical studies, a diagnosis of sarcomatoid carcinoma was made. Only nine cases of sarcomatoid carcinomas of the colorectum have been reported to date. As a result, the terminology and pathogenesis of sarcomatoid carcinoma remain speculative. To the best of our knowledge, this is the first report of co-existence of sarcomatoid carcinoma and invasive adenocarcinoma with tubulovillous adenoma; all stages represented within the same tumor. This observation supports the “monoclonal theory” of pathogenesis with an adenoma-sarcoma progression with or without an intermediate stage of carcinoma.

Carcinosarcoma of the spleen: literature review of a very rare tumour

Carcinosarcomas are rare tumours, which have both epithelial, and connective tissue elements. They are most commonly seen in the female genital tract. Rarely they arise from the gastrointestinal tract. We report a case of Carcinosarcoma arising as a primary in the spleen of a male aged 60yrs. The most unique feature of this tumour is the presence of osteosarcomatous element. This report highlights the importance of clinical awareness of such rare tumours and gives a brief overview on presentation, probable aetiology, diagnosis and management with literature review of carcinosarcoma.

Carcinosarcoma of the colon: report of a case with morphological, ultrastructural and molecular analysis

BACKGROUND

Carcinosarcoma of the colon is a rare histopathological entity with uncertain histogenesis, that shows both epithelial and mesenchymal malignant differentiation. Carcinosarcoma rarely affects the gastrointestinal tract and only few cases are reported in the colon. Herein we describe a carcinosarcoma of the ascending colon, with morphological, ultrastructural and molecular analysis.

CASE PRESENTATION

An 81-year-old man was hospitalised for asthenia, weight loss and iron-deficiency anaemia. The patient underwent colonoscopy and adenocarcinoma was diagnosed by endoscopic biopsy. A right hemicolectomy was performed and, during surgical operation, liver metastases were detected. Histological examination of the surgical specimen revealed areas of both carcinomatous and sarcomatous differentiation, completely separated by fibrous septae. The sarcomatous component exhibited areas of smooth muscle and osteoblastic differentiation, with focal osteoid material deposition. Molecular analysis conducted separately on the epithelial and mesenchymal components revealed the same p53 gene mutation (R282W in exon 8) and identical polymorphisms in p53 exon 4, in EGFR exons 20 and 21, and in c-kit exon 17. Microsatellite markers analysis revealed a common loss of heterozygosis on 18q. Overall, the data are consistent with a common origin of the two tumor components. The patient was treated with 8 cycles of oral capecitabine (1250 mg/m2 twice a day for 14 days repeated every 28 days) and two years after surgery is alive with liver metastases.

CONCLUSION

Carcinosarcoma of the colon is a rare tumour with both epithelial and sarcomatous components. Molecular analysis of the current case suggests the histogenesis from a common cell progenitor.

Rectal carcinosarcoma: A case report and review of literature

A 60-years old male was admitted to our department for investigation of constipation and hypogastric discomfort intensified during defecation of a few weeks duration. The cause proved to be a rectal carcinosarcoma that was treated by abdominoperineal resection and postoperative chemo-radiotherapy. The patient died 6 months later due to hepatic failure, showing evidence of disseminated disease. In general colonic carcinosarcomas constitute a rare category of malignant neoplasms whose nature is still incompletely understood. No specific treatment guidelines exist. Surgery is the mainstay of treatment and regardless of the addition of adjuvant therapy the prognosis is very poor. Systematic genetic analysis may be the clue for understanding the pathogenesis of these mysterious tumors.

Radiology-Pathology Conference: carcinosarcoma of the colon

Carcinosarcomas are very uncommon tumors, which are comprised of both malignant epithelial and mesenchymal elements. They occur most commonly in the head and neck, respiratory tract, and female reproductive organs. In the gastrointestinal tract, they are most often found in the oropharynx, esophagus, and, to a lesser extent, in the stomach. Carcinosarcomas rarely originate from the colon, but when they do, they are extremely aggressive malignancies. We report the radiologic and pathologic findings of a patient with a carcinosarcoma believed to have arisen from the colon and which involved the adjacent mesentery and omentum.