Adenosquamous carcinoma in the biliary tract: association of the proliferative ability of the squamous component with its proportion and tumor progression

Primary Squamous Cell Biliary Carcinoma With Liver Metastasis Is Rare but Malicious

Primary squamous cell carcinoma (SCC) of the liver is quite rare, and to our knowledge, very few cases have been reported in the literature. The exact pathogenesis of the disease is unestablished; however, it is mostly reported to be associated with hepatic cyst, Caroli's disease, hepatolithiasis, hepatic cirrhosis, and hepatic teratoma. We report a case of a 50-year-old woman with no prior medical history initially, who presented with postprandial epigastric and right upper quadrant pain that continued to worsen and was associated with early satiety, nausea, and weight loss of 25 pounds over 2 months, which prompted further evaluation by her primary care physician. Magnetic resonance imaging (MRI) examination a month later revealed a large heterogeneous area measuring 8.5 × 2.4 × 7.4 cm in the inferior right hepatic lobe with heterogeneous enhancement and involvement of the gallbladder, concerning for cholangiocarcinoma. Given radiographic findings, she underwent a computed tomography (CT)-guided core biopsy of the liver, which showed a necrotic malignant tumor favoring adenocarcinoma and was also found to have germline BRCA mutation. A positron emission tomography (PET) scan revealed a large partially necrotic fluorodeoxyglucose (FDG) avid mass, possibly arising from the gallbladder fossa with an invasion of both lobes of the liver and probable involvement of a portion of the ascending colon. There was no gross evidence of distant metastatic disease. The patient underwent staging laparoscopy prior to initiating chemotherapy, and another biopsy was done, which returned in favor of SCC, with immunohistochemical stains being positive for cytokeratin (CK)19, Ber-EP4 (epithelial antigen recognized by Ber-EP4 antibody), and P40 (DeltaNp63); while negative for CK7, CK20, caudal-type homeobox 2 (CDX-2), paired box 8 (PAX-8), and mucicarmine. The patient started platinum-based chemotherapy due to germline BRCA mutation. However, due to complications associated with therapy and the progression of the disease, the patient eventually chose hospice. Primary SSC remains an unexplored aggressive malignancy that carries an overall poor prognosis. Diagnosis can be challenging and requires high clinical suspicion due to the scarcity in specific laboratory workup. Pathological diagnosis remains the gold standard; however, it also carries its own challenges. Treatment is usually case-oriented, and definitive protocols have yet to be established.

Rare histotypes of epithelial biliary tract tumors: A literature review

Adenocarcinoma represents the most frequent biliary tract cancer. However, other rare histotypes can be found in the biliary tract, such as cholangiolocellular carcinoma, cholangiocarcinoma with ductal plate malformation pattern, adenosquamous carcinoma, mucinous carcinoma, signet ring cell carcinoma, clear cell carcinoma, mucoepidermoid carcinoma, lymphoepithelioma-like carcinoma, and sarcomatous cholangiocarcinoma. These cancer types account for less than 10 % of all the already rare biliary tract tumors. Yet, they represent a relevant issue in everyday clinical practice, given the lack of therapeutic recommendations and the overall scarcity of data, mainly deriving from isolated small center-specific cohorts of patients.The shifts of such histotypes from the most common ones reflect genetic and molecular differences, determine changes in clinical aggressiveness, and suggest a possible variability in sensitivity to the standard treatments of biliary adenocarcinomas. The consistency and degree of these variables are still to be solidly demonstrated and investigated. Therefore, this paper aims to review the current literature concerning very infrequent and rare epithelial biliary tract cancers, focusing our attention on the clinical, molecular, and immunohistochemical features of these tumors.

An overview of extrahepatic cholangiocarcinoma: from here to where?

Extrahepatic cholangiocarcinoma (eCCA) contains perihilar cholangiocarcinoma and distal cholangiocarcinoma both of which can arise at any point of the biliary tree and originate from disparate anatomical sites. Generally, the incidence of eCCA is increasing globally. Though surgical resection is the principal treatment of choice for the early stages of eCCA, optimal survival remains restricted by the high risk of recurrence when most patients are present with unresectable disease or distant metastasis. Furthermore, both intra- and intertumoral heterogeneity make it laborious to determine molecularly targeted therapies. In this review, we mainly focused on current findings in the field of eCCA, mostly including epidemiology, genomic abnormalities, molecular pathogenesis, tumor microenvironment, and other details while a summary of the biological mechanisms driving eCCA may shed light on intricate tumorigenesis and feasible treatment strategies.

Epidemiology and survival outcomes in adenosquamous carcinoma: a population-based study

BACKGROUND

The relationship between the location of the primary tumor and survival of adenosquamous carcinoma (ASC) remains poorly understood. This study aimed to evaluate the impact of primary tumor location on the survival outcome of patients with ASC.

METHODS

Patients with ASC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database with ≥ 150 cases per tumor location. The Kaplan-Meier method was used to generate survival curves and differences among them were compared using the log-rank test. On the other hand, Cox proportional hazards models were used to evaluate factors that had independent predictive effects on cancer-specific survival (CSS).

RESULTS

A total of 14,829 eligible patients with ASC were included in this study. Lung and bronchus ASC accounted for 51.1%, followed by the cervix uteri (17.0%), corpus uteri (13.9%), pancreas (4.9%), esophagus (3.1%), gallbladder (2.5%), stomach (2.2%), colon and rectum (2.0%), head and neck (1.8%), and breast ASC (1.3%). The 5-year CSS of breast, cervix uteri, colon and rectum, corpus uteri, esophagus, gallbladder, head and neck, lung and bronchus, pancreas, and stomach ASC was 76.9%, 66.0%, 34.8%, 72.9%, 12.0%, 10.8%, 45.0%, 24.7%, 4.3%, and 17.3%, respectively. COX analysis demonstrated that the primary tumor location was an independent prognostic factor for CSS. Besides, the breast, uterine corpus, and cervix as well as head and neck ASC were significantly associated with better prognosis, while pancreas and gallbladder ASC were significantly associated with poor CSS; stomach and colorectal were roughly the same as ASC prognosis.

CONCLUSION

Our study showed that the CSS of patients with ASC depends on the location of the primary tumor. Besides, tumor location is an important factor that should guide the use of chemotherapy and radiation.

Therapeutic Effect and Prognosis of Biliary Tract Tumor Transformation

Biliary tract tumor is a common malignant disease in clinical practice. Its incidence rate and mortality rate are high, which seriously endangers the health of the people. At present, gastrointestinal surgery is mainly used to treat patients at home and abroad. This paper discusses the main risk factors of biliary tract cancer transformation, analyzes its prognostic characteristics and clinical efficacy, and compares them by comprehensive evaluation methods such as observation group control method, blood routine examination and treatment. The results are as follows: the postoperative adverse reactions in the control group are more obvious than those in the experimental group. There were no obvious clinical manifestations or adverse reactions in the experimental group. The therapeutic effect of biliary tumor transformation can effectively help patients improve their quality of life. Through the prognosis recovery of biliary tract tumor transformation treatment, the health level of patients in the experimental group was higher than that in the control group.

Adenosquamous Carcinoma of the Distal Common Bile Duct: A Case of a Rare Type of Cholangiocarcinoma

Introduction

Adenosquamous carcinoma (ASC) is a rare subtype of the conventional adenocarcinoma of the bile duct. The clinico-pathological characteristics of this entity are poorly understood partly due to its rarity.

Case Summary

A 67-year-old ASA II male presented with obstructive jaundice subsequently complicated by cholangitis. CT abdomen showed dilatation of the intra and extrahepatic biliary tree. Endoscopic retrograde cholangiopancreatography revealed a stricture with a mucosal growth at the ampulla of Vater. He had a pancreaticoduodenectomy and the distal common bile duct tumour identified in the specimen was on histology an adenosquamous carcinoma (ASC) of the extrahepatic bile duct.

Discussion

ASCs are considered to have more aggressive tumour biology compared to adenocarcinomas. The presence of a squamous component at the invasive front relates to its poor prognosis. Surgery is the curative option, but with a high propensity for early recurrence and distant metastases. The scarcity of reports on the clinicopathological course of ASC have resulted in a lack of standardised care pathways.

Conclusion

A better understanding of the clinicopathological characteristics, biological behaviour and disease progression of ASC will aid therapeutic options and prognostication.

Comparative Outcomes of Adenosquamous Carcinoma of the Gallbladder: an Analysis of the National Cancer Database

BACKGROUND

A paucity of data exists regarding adenosquamous carcinoma of the gallbladder, a histology comprising under 10% of gallbladder cancer diagnoses. The aim of this study is to characterize the clinicopathological features of these tumors utilizing a population-based dataset compared with gallbladder adenocarcinoma.

METHODS

We identified patients with gallbladder adenosquamous and adenocarcinoma from the National Cancer Database from 2004 to 2015. Patient demographics, tumor characteristics, treatment regimens, and overall survival were analyzed between the groups.

RESULTS

We identified 13,158 patients: 12,455 (95%) with a diagnosis of gallbladder adenocarcinoma and 703 (5%) with adenosquamous carcinoma. Adenosquamous tumors were larger, poorly differentiated, and presented with Stage III/IV disease (75% vs 69%, p < 0.001). Overall 1-, 3-, and 5-year survival for adenosquamous and adenocarcinoma were 24%, 11%, and 9% vs 37%, 16%, and 11%, respectively (p < 0.001). Following surgical resection, adenosquamous carcinoma had more positive margins (31% vs 25%, p < 0.001), and median overall survival was 10.3 months vs 20.5 months for adenocarcinoma (p < 0.001). Overall survival at 1-, 3-, and 5-years for surgically resected adenosquamous and adenocarcinoma were 43%, 23%, and 18% versus 63%, 35%, and 25%, respectively (p < 0.001). In resected adenosquamous carcinoma, positive lymph nodes and margins were associated with worse survival, while adjuvant chemoradiation (HR 0.457, 95% CI 0.31-0.69, p < 0.001) was associated with improved survival.

CONCLUSION

Adenosquamous gallbladder cancer presented with larger tumors at advanced clinical stages when compared with adenocarcinoma. Overall survival was worse for adenosquamous tumors both overall, and following curative intent resection. Adjuvant chemoradiation was associated with improved survival in adenosquamous tumors.

Concomitant adenosquamous carcinoma and cystadenocarcinoma of the extrahepatic bile duct: A case report

BACKGROUND

Infiltrative adenosquamous carcinoma (ASC) of the extrahepatic bile duct is reported infrequently, which is an unusual variant of the ordinary adenocarcinoma. The simultaneous development of ASC and cystadenocarcinoma in the extrahepatic biliary tree is rare. In addition, the accurate preoperative diagnosis of concomitant carcinoma in the multiple biliary trees at an early stage is often difficult. Thus, awareness of the risk of the multiplicity of biliary tumors is perhaps the most important factor in identifying these cases.

CASE SUMMARY

Here, we report a case of a 63-year-old female with jaundice, who was referred to Shuguang Hospital because of abdominal pain for 1 mo. An abdominal contrast-enhanced computed tomography revealed a type I choledochal cyst and intraluminal masses suggestive of adenoma of the common bile duct. In addition, a preoperative diagnosis of a concomitant Klatskin tumor and type I choledochal cyst was made. The patient underwent anti-inflammatory therapy, followed by radical surgery due to hilar cholangiocarcinoma and resection of the choledochal cyst. Examination of the surgical specimen revealed a papillary tumor of the common bile duct, which arose from the malignant transformation of a pre-existing cystadenoma. Histologic examination confirmed a special type of cholangiocarcinoma; the tumor in the hilar bile duct was an ASC, whereas the tumor in the common bile duct was a moderately differentiated cystadenocarcinoma. The patient showed rapid deterioration 8 mo after surgery.

CONCLUSION

Although concomitant ASC and cystadenocarcinoma of the extrahepatic bile duct is difficult to diagnose before surgery, and the prognosis is poor after surgery, surgical resection is still the preferred treatment.

Adenosquamous carcinoma of the bile duct: a population-based study

Introduction

Adenosquamous carcinoma (ASC) of the bile duct is a rare diagnosis with poorly understood clinicopathological characteristics and disease progression, so identification of the features associated with ASC patient survival is warranted.

Materials and methods

A population cohort study was performed using prospectively extracted data from the Surveillance, Epidemiology and End Results (SEER) database for patients with histological diagnoses of ASC of the bile duct from 1973 to 2013.

Results

A total of 106 patients with ASC of the bile duct were included (mean age 68.1±13.5 years). Lesions from 58 patients were in the extrahepatic bile duct and 34 were located at the ampulla of Vater. Fifty-seven patients were categorized with a regional stage, 15 had localized disease, and 30 had distant disease. Most (60.4%) patients received cancer-directed surgery, and radiation was performed in 14.1% of cases. The 1-year, 2-year, and 5-year overall survival (OS) for patients with ASC of the bile duct was 30.1%, 11.3%, and 3.7%, respectively. Cancer-directed surgery offered 10 additional months of OS for patients with ASC of the bile duct and median OS was 14.0, 6.0, and 6.0 months for ampulla of Vater, extrahepatic bile duct, and intrahepatic bile duct cases, respectively. A multivariate Cox analysis showed that lesions in the ampulla of Vater (HR=0.51, 95% CI 0.26–0.99) and having surgery (HR=0.34, 95% CI 0.14–0.81) were independent protective prognostic factors for these patients.

Conclusion

Cancer-directed surgery and a primary lesion site of the ampulla of Vater may suggest favorable prognosis for patients with ASC of the bile duct.

A case of primary squamous cell carcinoma of the gallbladder with local invasion of the liver and peritoneum, and metastasis to the omentum

Primary squamous cell carcinoma of the gallbladder is a rare entity that comprises approximately 1%-3% of all primary gallbladder cancers. We report the case of a 37-year-old woman who was diagnosed with a locally invasive squamous cell carcinoma of the gallbladder. Surgical pathology revealed a predominantly squamous cell carcinoma composition of the tumor with a few microscopic foci of adenocarcinoma (<1% of tumor). We discuss pertinent clinical features, risk factors, and imaging characteristics to prompt early diagnosis and treatment, which will ultimately lead to improved patient outcomes.

Rapid progression of a granulocyte colony-stimulating factor-producing liver tumor metastasized from esophagogastric junction cancer: A case report and literature review

The current study presents the case of a 72-year-old woman with a rapidly enlarged liver metastasis from esophagogastric junction (EGJ) cancer, accompanied by progressive leukocytosis (47,680/µl) and elevated serum granulocyte colony-stimulating factor (G-CSF; 779 pg/ml). The patient underwent right hemihepatectomy 26 months after a total gastrectomy. On the seventh post-operative day the patient's leukocyte count and serum G-CSF level decreased to 4,280/µl and ≤19.5 pg/ml, respectively. Histologically, the lesion was a well to moderately differentiated adenocarcinoma similar to the primary lesion. Therefore, this tumor was clinically diagnosed as a G-CSF-producing liver metastasis from EGJ cancer, although immunohistochemical staining for G-CSF was negative. A right pulmonary nodule detected simultaneously with the hepatic mass was resected four months following the hepatectomy and was diagnosed as a pulmonary metastasis. The patient's leukocyte count was normal at the time of her initial surgery for EGJ cancer, and her clinical course varied for different metastatic sites. The liver metastasis was accompanied by progressive leukocytosis and elevated serum G-CSF and demonstrated rapid tumor growth during a six-month period, whereas the non-G-CSF-producing pulmonary metastasis grew slowly during the same period. In addition 21 reported cases of G-CSF-producing upper gastrointestinal tract cancer were reviewed to elucidate the clinicopathological features of this disease.

Combined Adenosquamous and Large Cell Neuroendocrine Carcinoma of the Gallbladder

Large cell neuroendocrine carcinoma (LCNEC) of the gallbladder is extremely rare and usually combined with other type of malignancy, mostly adenocarcinoma. We report an unusual case of combined adenosquamous carcinoma and LCNEC of the gallbladder in a 54-year-old woman. A radical cholecystectomy specimen revealed a 4.3×4.0 cm polypoid mass in the fundus with infiltration of adjacent liver parenchyma. Microscopically, the tumor consisted of two distinct components. Adenosquamous carcinoma was predominant and abrupt transition from adenocarcinoma to squamous cell carcinoma was observed. LCNEC showed round cells with large, vesicular nuclei, abundant mitotic figures, and occasional pseudorosette formation. The patient received adjuvant chemotherapy. However, multiple liver metastases were identified at 3-month follow-up. Metastatic nodules were composed of LCNEC and squamous cell carcinoma components. Detecting LCNEC component is important in gallbladder cancer, because the tumor may require a different chemotherapy regimen and show early metastasis and poor prognosis.