Pleomorphic carcinoma of the lung: clinicopathologic characteristics of 70 cases. Am J Surg Pathol. 2008;32:1727-1735. [PMID: 18769330 DOI: 10.1097/PAS.0b013e3181804302]

Pulmonary sarcomatoid carcinoma: A rare case report, diagnostic dilemma and review of literature

RATIONALE

Pulmonary sarcomatoid carcinoma (PSC), a rare tumor, comprises 0.1% to 0.4% of all malignant lung tumors. Given the rarity of PSC, its clinical course, therapeutic guidelines, and patient outcomes remain largely unknown. Therefore, it is imperative to alert clinicians to this extremely rare and instructive early-onset cancer.

PATIENT CONCERNS

This report describes a 28-year-old woman with PSC, who was initially misdiagnosed with Whipple's disease. A conclusive diagnosis of PSC was made following careful clinical examination, imaging, and histopathological evaluation of the patient's biopsy sample. Radiological imaging revealed multiple nodules and mass formations in the left upper lobe of the patient's lung, with the largest measuring of 5.4 × 3.2 cm.

DIAGNOSIS

Histopathological examination indicated the presence of a malignant neoplasm associated with necrosis suggestive of sarcoma, which was pathologically staged as cT4N1M1.

INTERVENTIONS AND OUTCOMES

A regimen of doxorubicin and ifosfamide was administered therapeutically, resulting in a stable disease state.

LESSONS

The rarity and tumor origin challenge the diagnosis, which emphasizes the imperative role of histological examination, immunohistochemistry, and flow cytometry in achieving an accurate diagnosis. This report summarizes the existing publications to provide a comprehensive overview of PSC, including its clinical manifestations, radiographic imaging, pathologic features, diagnostic challenges, treatment strategies, and prognosis, and aims to improve the understanding of PSC.

Autopsy findings in a rare case of pleomorphic carcinoma in a patient on dialysis

Pleomorphic lung cancer is a very rare type of cancer and very few cases have been reported in the literature. We present a case of pleomorphic lung cancer in a patient with history of IgA nephropathy on hemodialysis.

Pulmonary Sarcomatoid Carcinoma: What Makes This Rare Lung Cancer So Challenging?

Pulmonary sarcomatoid carcinoma (PSC) is a rare and aggressive subtype of non-small cell lung carcinoma (NSCLC). This case report describes a 55-year-old male with a significant smoking history who initially presented with left hemiplegia. Imaging studies revealed brain metastases and a spiculated parenchymal lung nodule in the left apical region. Histopathological examination confirmed PSC through a CT-guided biopsy. The patient's condition rapidly deteriorated, leading to death before the initiation of planned palliative chemotherapy. This report highlights the diagnostic challenges and poor prognosis associated with PSC, emphasizing the need for further research into effective treatment strategies.

2021 WHO Classification of Lung Cancer: Molecular Biology Research and Radiologic-Pathologic Correlation

The 2021 World Health Organization (WHO) classification system for thoracic tumors (including lung cancer) contains several updates to the 2015 edition. Revisions for lung cancer include a new grading system for invasive nonmucinous adenocarcinoma that better reflects prognosis, reorganization of squamous cell carcinomas and neuroendocrine neoplasms, and description of some new entities. Moreover, remarkable advancements in our knowledge of genetic mutations and targeted therapies have led to a much greater emphasis on genetic testing than that in 2015. In 2015, guidelines recommended evaluation of only two driver mutations, ie, epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) fusions, in patients with nonsquamous non-small cell lung cancer. The 2021 guidelines recommend testing for numerous additional gene mutations for which targeted therapies are now available including ROS1, RET, NTRK1-3, KRAS, BRAF, and MET. The correlation of imaging features and genetic mutations is being studied. Testing for the immune biomarker programmed death ligand 1 is now recommended before starting first-line therapy in patients with metastatic non-small cell lung cancer. Because 70% of lung cancers are unresectable at patient presentation, diagnosis of lung cancer is usually based on small diagnostic samples (ie, biopsy specimens) rather than surgical resection specimens. The 2021 version emphasizes differences in the histopathologic interpretation of small diagnostic samples and resection specimens. Radiologists play a key role not only in evaluation of tumor and metastatic disease but also in identification of optimal biopsy targets. ©RSNA, 2024 Test Your Knowledge questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Common clinicopathological and immunological features of sarcomatoid carcinoma across organs: A histomorphology-based cross-organ study

Sarcomatoid carcinoma (SC), which can occur in any organ, is a rare disease. To elucidate common characteristics of SC beyond organs, we evaluated clinicopathological and immunological features of SC defined by the single histological criterion beyond organs compared to randomly matched conventional carcinoma (non-SC) adjusted for the disease stage. Immunological features were assessed by multiplex immunohistochemistry, comparing immune cell density in tumor tissues and tumor programmed death-ligand 1 (PD-L1) expression. A total of 101 patients with SC or non-SC (31 lung, 19 esophagus, 22 pancreas, 15 liver, 4 bile duct, 6 kidney, 2 uterus and 2 ovary) were identified among 7197 patients who underwent surgery at our institute (1997-2020). SC was significantly associated with worse survival (HR: 1.571; 95% CI: 1.084-2.277; P = .017). The frequency of postoperative progression within 6 months was significantly higher for SC patients (54% vs 28%; P = .002). The immune profiling revealed the densities of CD8+ T cells (130 vs 72 cells/mm2 ; P = .004) and tumor-associated macrophages (566 vs 413 cells/mm2 ; P < .0001) and the tumor PD-L1 expression score (40% vs 5%; P < .0001) were significantly higher in SCs than in non-SCs. Among 73 SC patients with postoperative progression, multivariate Cox regression analysis showed that immunotherapy tended to be associated with favorable survival (HR: 0.256; 95% CI: 0.062-1.057; P = .060). Collectively, SCs shared clinicopathological and immunological features across organs. Our study can initiate to standardize the pathological definition of SC and provide a rationale for the investigation and development for this rare disease in a cross-organ manner.

Pathologic features and clinical treatment of sarcomatoid intrahepatic cholangiocarcinoma

The current study examined sarcomatoid intrahepatic cholangiocarcinoma (S-iCCA). S-iCCA was a more aggressive subtype of intrahepatic cholangiocarcinoma (iCCA). Early detection and complete resection of tumors are very important. Reported here is a case of S-iCCA, and the diagnosis and treatment of S-iCCA are discussed. The patient underwent a tumor resection and was treated with chemotherapy and molecularly targeted drugs after surgery. The clinical pathologic features and treatment of S-iCCA are discussed based on the literature. An immunohistochemical examination revealed positivity for cytokeratin 7 (CK7), CK-pan, vimentin, and CK19 and negativity for hepatocyte paraffin 1 (HepPar-1) in sarcomatoid cells. This case suggests that the particular molecular characteristics of sarcomatoid cells have great clinical diagnostic value, and comprehensive treatment of S-iCCA based on surgery is described.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis

INTRODUCTION

Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC.

MATERIALS AND METHODS

In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery.

RESULTS

Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001).

CONCLUSIONS

This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

Preoperative CT findings and prognosis of pulmonary sarcomatoid carcinoma: comparison with conventional NSCLC of similar tumor size

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is a rare subtype of non-small cell lung cancer (NSCLC) but differs in terms of treatment strategies compared with conventional-NSCLC (c-NSCLC). However, preoperative CT differentiation between PSC and c-NSCLC remains a challenge. This study aimed to explore the CT findings and prognosis of PSC compared with c-NSCLC of similar tumor size.

METHODS

Clinical data and CT findings of 31 patients with PSC and 87 patients with c-NSCLC were retrospectively analyzed. Clinical data included sex, age, and smoking history. CT findings included tumor size, tumor location, calcification, vacuole/cavity, pleural invasion, mean CT value, and low-attenuation area (LAA) ratio. Kaplan‒Meier curves and log-rank tests were used for survival analysis. A Cox regression model was constructed to evaluate prognostic risk factors associated with overall survival (OS). The Spearman correlation among clinicoradiological outcomes were analyzed.

RESULTS

The mean tumor size of PSC and c-NSCLC were both 5.1 cm. The median survival times of PSC and c-NSCLC were 8 months and 34 months, respectively (P < 0.001). Calcification and vacuoles/cavities were rarely present in PSC. Pleural invasion occurred in both PSC and c-NSCLC (P = 0.285). The mean CT values of PSC and c-NSCLC on plain scan (PS), arterial phase (AP), and venous phase (VP) were 30.48 ± 1.59 vs. 36.25 ± 0.64 Hu (P = 0.002), 43.26 ± 2.96 vs. 58.71 ± 1.65 Hu (P < 0.001) and 50.26 ± 3.28 vs. 64.24 ± 1.86 Hu (P < 0.001), the AUCs were 0.685, 0.757 and 0.710, respectively. Compared to c-NSCLC, PSC had a larger LAA ratio, and the AUC was 0.802, with an optimal cutoff value of 20.6%, and the sensitivity and specificity were 0.645 and 0.862, respectively. Combined with the mean CT value and LAA ratio, AP + VP + LAA yielded the largest AUC of 0.826. The LAA ratio were not independent risk factors for PSC in this study. LAA ratio was negatively correlated with PS (r = -0.29), AP (r = -0.58), and VP (r = -0.66). LAA showed a weak positive correlation with tumor size(r = 0.27).

CONCLUSIONS

PSC has a poorer prognosis than c-NSCLC of similar tumor size. The mean CT value and LAA ratio contributes to preoperative CT differentiation of PSC and c-NSCLC.

A case of pulmonary pleomorphic carcinoma associated with cystic airspace

Lung cancer associated with a cystic airspace is frequently misdiagnosed or overlooked. Adenocarcinoma, followed by squamous cell carcinoma, is the most typical histologic type of lung cancer connected to a cystic airspace. Here we present the rare case of lung pleomorphic carcinoma associated with a cystic airspace. We encountered a 74-year-old Japanese man diagnosed by computed tomography (CT) as having a nodule outside a cystic airspace in the lung. Several previous CT images showed that the cystic airspace preceded the nodule. Postsurgery, pathology indicated a diagnosis of pleomorphic carcinoma. Since pulmonary pleomorphic carcinomas pursue an aggressive clinical course, their early detection may contribute to an improved prognosis. Our case demonstrated that pleomorphic carcinoma can arise with cystic airspaces. For early diagnosis of those aggressive lung cancers, chest physicians should carefully examine the walls of cystic airspaces on CT.

Pulmonary Pleomorphic Carcinoma Harboring EGFR Mutation Successfully Treated with Osimertinib: A Case Report

Pulmonary pleomorphic carcinoma (PPC) is well-known for its aggressive nature that is usually resistant to platinum-based chemotherapy. On the other hand, the efficacy of an immune checkpoint inhibitor-based regimen in PPC has been elucidated. PPCs harboring epidermal growth factor receptor (EGFR) mutations are extremely rare, and the efficacy of EGFR-tyrosine kinase inhibitors in PPC is limited compared to their efficacy in EGFR-mutated adenocarcinoma. A 43-year-old female patient presenting with a lung mass with multiple brain metastases, carcinomatous pericarditis, and multiple bone metastases was referred to our department. Transbronchial biopsy confirmed the diagnosis of PPC harboring an EGFR mutation with exon 19 deletion. Subsequently, she was treated with osimertinib, a third-generation EGFR-tyrosine kinase inhibitor, which resulted in partial response with shrinkage of the primary lesion and brain metastases. This partial response remained durable for 11 months with an ongoing regimen. The current case suggests that osimertinib would show promising effects as a first-line treatment for PPCs harboring EGFR mutations, as well as a reasonable sequence of therapy followed by immune checkpoint inhibitor-based regimens.

Epithelial-to-mesenchymal transition promotes immune escape by inducing CD70 in non-small cell lung cancer

INTRODUCTION

Epithelial-to-mesenchymal transition (EMT) is associated with tumor aggressiveness, drug resistance, and poor survival in non-small cell lung cancer (NSCLC) and other cancers. The identification of immune-checkpoint ligands (ICPLs) associated with NSCLCs that display a mesenchymal phenotype (mNSCLC) could help to define subgroups of patients who may benefit from treatment strategies using immunotherapy.

METHODS

We evaluated ICPL expression in silico in 130 NSCLC cell lines. In vitro, CRISPR/Cas9-mediated knockdown and lentiviral expression were used to assess the impact of ZEB1 expression on CD70. Gene expression profiles of lung cancer samples from the TCGA (n = 1018) and a dataset from MD Anderson Cancer Center (n = 275) were analyzed. Independent validation was performed by immunohistochemistry and targeted-RNA sequencing in 154 NSCLC whole sections, including a large cohort of pulmonary sarcomatoid carcinomas (SC, n = 55).

RESULTS

We uncover that the expression of CD70, a regulatory ligand from the tumor necrosis factor ligand family, is enriched in mNSCLC in vitro models. Mechanistically, the EMT-inducer ZEB1 impacted CD70 expression and fostered increased activity of the CD70 promoter. CD70 overexpression was also evidenced in mNSCLC patient tumor samples and was particularly enriched in SC, a lung cancer subtype associated with poor prognosis. In these tumors, CD70 expression was associated with decreased CD3⁺ and CD8⁺ T-cell infiltration and increased T-cell exhaustion markers.

CONCLUSION

Our results provide evidence on the pivotal roles of CD70 and ZEB1 in immune escape in mNSCLC, suggesting that EMT might promote cancer progression and metastasis by not only increasing cancer cell plasticity but also reprogramming the immune response in the local tumor microenvironment.

Clinicopathological characteristics, survival outcomes and prognostic factors in pleomorphic carcinoma: a SEER population-based study

Background

Pulmonary pleomorphic carcinoma (PPC) is a rare tumor, and it usually has an aggressive clinical course and poor prognosis. We aim to analyze the clinicopathological features, management and prognostic factors of pulmonary pleomorphic carcinoma.

Patients and methods

Using the surveillance, epidemiology, and end results (SEER) database, we identified 461 patients of pulmonary pleomorphic carcinoma from 2004 to 2014 including clinicopathological characteristics, treatment modalities and outcome data.

Results

The mean age of all PPC patients was 66 years and 58% of the patients were male. Most patients (80%) were white people, 53% were found in the right lung, and lesions were mostly observed in upper lobe (56%). The median overall survival was 9 months and overall 1-, 3- and 5-year survival rate was 45%, 29%, 23%. In Kaplan–Meier analysis, age, marital status, tumor primary site, gender, laterality, SEER summary stage, chemotherapy and surgery were associated with overall survival. Patients received surgery or chemotherapy had a better OS for patients with PPC. Multivariate Cox analysis revealed that SEER summary stage, age, surgery and chemotherapy were found to be independently associated with the OS. Surgery could significantly prolong survival in patients with localized stage and regional stage (HR = 0.120, 95% CI 0.038–0.383, p < 0.001; HR = 0.351, 95% CI 0.212–0.582, p < 0.001) while it did not have great impact on survival in patients with distant stage (p = 0.192). Chemotherapy decreased risk of death by 46% (HR = 0.544, 95% CI 0.393–0.752, p < 0.001) for patients with distant stage, whereas chemotherapy did not confer survival benefits to patients with localized stage and regional stage. But radiation did not have great impact on survival of patients with different stages in this study.

Conclusions

PPC mostly occurred in white people, with a median age of 66 years, and men were more susceptible to this disease. The SEER summary stage, age, surgery and chemotherapy were independently associated with prognosis. Surgery should be considered for the PPC patients with localized stage or regional stage, and chemotherapy should be recommended for the treatment of patients with distant stage.

Ringed fluorodeoxyglucose uptake predicted poor prognosis after resection of pulmonary pleomorphic carcinoma

Background

Pulmonary pleomorphic carcinoma (PPC) is a relatively rare and poorly differentiated non-small cell carcinoma. This study aimed to investigate the clinicopathological features including programmed cell death ligand 1 (PD-L1) expression status in patients with PPC who underwent curative resection.

Methods

We retrospectively studied 29 consecutive patients who had undergone anatomical lung resections for PPC. Perioperative and pathological variables, including radiological findings, were investigated to define prognostic factors.

Results

Overall survival (OS) rates were 71.8% at 1 year and 60.0% at 5 years. Disease-free survival (DFS) rates were 54.8% at 1 year and 43.6% at 5 years. Univariate analysis revealed that ringed fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) (p = 0.003), a cavity in the tumor on CT (p = 0.004), and tumor size (> 40 mm) (p = 0.014) were poor prognostic factors for OS. Regarding DFS, ringed FDG uptake (p = 0.002), a cavity on CT (p < 0.001), tumor size (p = 0.007), and pleural invasion (p = 0.014) were poor prognostic factors. PD-L1 expression was not a prognostic factor.

Conclusion

This study showed for the first time that ringed FDG uptake on PET/CT is a poor prognostic factor of PPC. PD-L1 expression status was not related to the prognosis.

Trial registration The study was approved by the Kobe City Medical Center General Hospital’s ethics board (No. 20112) on August 20, 2020.

High programmed death ligand 1 expression in carcinomatous components predicts a poor prognosis in pulmonary pleomorphic carcinoma

PURPOSE

This study reviewed the clinicopathological characteristics and programmed death ligand 1 (PD-L1) expression of 46 patients with pulmonary pleomorphic carcinoma to better understand its clinical behavior and factors affecting the survival.

METHODS

Data of patients with pulmonary pleomorphic carcinomas resected in our institution were retrospectively reviewed. The tumors were classified as carcinomatous or sarcomatous according to the tissue components. Pathological characteristics were evaluated on hematoxylin and eosin-stained sections. The percentages of tumor cells with membrane staining for PD-L1 in carcinomatous and sarcomatous components were determined.

RESULTS

We reviewed data of 46 patients (41 males, 5 females; median age 70.5 years old, range 36-83 years old). Most patients with pulmonary pleomorphic carcinoma expressed PD-L1 (80.4%), and the proportion of PD-L1 expression in tumor cells was significantly higher in sarcomatous components than in carcinomatous components. In univariable analyses, high p-stage (III), necrosis on pathological findings, and high PD-L1 expression in carcinomatous components (≥ 50%) were poor prognostic factors for the overall survival. In multivariable analyses, high PD-L1 expression in carcinomatous components was significantly associated with a poor prognosis after surgery.

CONCLUSIONS

High PD-L1 expression in carcinomatous components was significantly associated with a poor prognosis after surgery.

The Prognosis of Pulmonary Sarcomatoid Carcinoma: Development and Validation of a Nomogram Based on SEER

Background: The rarity of pulmonary sarcomatoid carcinoma (PSC) and the lack of prospective clinical trials have led to limited knowledge of its clinical characteristics. This study aimed to evaluate the survival and prognostic factors of PSC and to build a nomogram for clinical practice. Methods: Eligible patients diagnosed from 2010 to 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. We compared the clinical characteristics and survival times of PSC patients with those of lung adenocarcinoma (LADC) and lung squamous cell carcinoma (LSCC) patients. We also used univariate and multivariable Cox regression to estimate mortality hazard ratios among patients with PSC, while a visual nomogram was established to judge the prognosis. Discrimination, calibration, clinical utility, and reproducibility were validated by Harrell's concordance index (C-index), the area under the curve (AUC), calibration curves, and decision curve analysis (DCA). Results: A total of 400 PSC patients (0.42%) were identified in the SEER database, whereas 58 474 and 33 637 patients were diagnosed with LADC and LSCC, respectively. Age, T stage, grade, surgery, and radiation were shown to be significant prognostic factors in the Cox regression analyses and were included in the nomogram as predictors. The C-index of the nomogram in the validation set was 0.759. The AUC also demonstrated the good performance of the nomogram, and DCA demonstrated its good clinical applicability. Conclusion: We established a novel nomogram to predict the prognosis of PSC, which can help clinicians make tailored decisions and adjust follow-up management strategies, and can provide accurate and individualized survival predictions.

Robust response of pulmonary pleomorphic carcinoma to pembrolizumab and sequential radiotherapy: A case report

Pulmonary pleomorphic carcinoma (PPC) is a rare type of non-small cell lung cancer (NSCLC) with a more aggressive clinical course and a worse outcome than other types of NSCLC. Pembrolizumab, a monoclonal antibody targeting programmed cell death-1 (PD-1), has been approved as the first-line treatment for advanced NSCLC with robust PD-L1 expression in at least 50% of tumour cells, without epidermal growth factor receptor gene (EGFR) mutations or anaplastic lymphoma kinase gene (ALK) rearrangement. Here, we report the case of an 81-year-old man with multiple comorbidities who was diagnosed with PPC and showed a robust response to pembrolizumab followed by radiation therapy without adverse effects. In the absence of randomized clinical trials for PPCs, our case report demonstrates the potential application of pembrolizumab and radiation therapy for the treatment of PPCs.

Beta-HCG secretion by a pulmonary pleomorphic carcinoma: A case report

Ectopic secretion of beta-subunit of human chorionic gonadotropin (β-HCG) in pulmonary pleomorphic carcinoma is remarkably rare. Such unusual ectopic hormone production by lung cancer may be initially misinterpreted as extragonadal choriocarcinoma or germ cell tumor.

We report a 56-year-old postmenopausal female, smoker, who presented a 5-month history of progressive dyspnea, dry paroxysmal cough, and significant weight loss. She was referred by a local hospital with the preliminary diagnosis of gestational trophoblastic neoplasia due to a rapidly growing thoracic tumor with persistently elevated serum β-HCG. Computed tomography of the chest showed a lung mass in the right upper lobe associated with homolateral pleural effusion. Positron emission tomography showed pathological 2-[¹⁸F]FDG uptake at the mass lesion. Biopsies were performed. Histological examination described pleomorphic carcinoma with positive immunostaining for β-HCG. The serum levels of β-HCG were also elevated indicating ectopic secretion. The patient had rapid clinical deterioration and deceased before chemotherapy initiation.

Only a few cases of paraneoplastic β-HCG secretion have been reported in the literature. Previous studies suggested that the ability to secrete β-hCG in tumors may correlate to some extent to chemoresistance; thus, it might be useful as a prognosis marker.

Case report: Postoperative abdominal recurrence of pulmonary pleomorphic carcinoma showed a dramatic response to S-1 after pembrolizumab

The patient was an 80-year-old woman with combined pulmonary fibrosis and emphysema. She was diagnosed with pulmonary pleomorphic carcinoma in the right upper lobe, which relapsed 18 months after the operation. Computed tomography showed a mass in contact with the posterior wall of the lower part of the stomach. The patient was treated with two cycles of pembrolizumab, but the disease progressed. She was treated with S-1 as second-line therapy, resulting in tumor-shrinking after two cycles. Progression was not observed over the next twelve months. We report a rare case involving S-1 after immune checkpoint inhibitor treatment.

The importance of medical treatment before surgery in pleomorphic carcinoma of the lung: A case series study

Introduction and importance

Pleomorphic carcinoma of the lung is a rare malignant epithelial tumor. Due to its rarity, its clinicopathological characteristics are not clear, and there is no defined therapeutic path for this type of tumor.

Case presentation

We retrospectively analyzed the medical and pathological reports of 8 patients who underwent surgical resection for pleomorphic carcinoma between 2007 and 2010.

Clinical discussion

Eight patients were analyzed (7 males and 1 female, mean age 60). All patients underwent CT scans, and the average diameter of the nodules was 56 mm. Four patients were also investigated with FDG-PET with hypermetabolic activity in all four cases. In four patients, the carcinomatous component was adenocarcinoma (all with sarcomatoid component of spindle cell and giant cell carcinoma), although in two patients, it was squamous cell carcinoma (one with spindle cell and one with giant cell). In the two remaining patients, one showed a non-small cell carcinoma with giant cell carcinoma, and the other was a non-small cell carcinoma and squamous cell carcinoma with spindle and giant cell carcinoma. All cases were treated with surgical resection. Only two patients underwent neoadjuvant chemotherapy. At the time of data analysis, only one patient treated with neoadjuvant chemotherapy was alive.

Conclusion

The prognosis for these patients with a diagnosis of pleomorphic carcinoma undergoing surgery is generally better than those not treated with surgical resection, however the survival remains poor. Although with low number of patients, our research would suggest to consider neoadjuvant chemotherapy an appropriate approach for improving the outcomes before surgery.

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Pleomorphic carcinoma of the lung

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Rare malignant epithelial tumor

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Clinicopathological characteristics unclear

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Not defined therapeutic path

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Neoadiuvant chemotherapy improves the prognosis.

Clinicopathological, gene expression and genetic features of stage I lung adenocarcinoma with necrosis

OBJECTIVES

The purpose of this study was to investigate the clinicopathological, gene expression and genetic features of stage I lung adenocarcinoma with necrosis.

METHODS

We retrospectively reviewed 521 cases with pathologic stage I lung adenocarcinoma resected by lobectomy and lymph node dissection. We calculated the ratio of tumor necrotic area by digital image analysis and investigated the relationship between tumor necrosis and prognosis. Furthermore, we analyzed the differentially expressed genes between cases with and without necrosis using The Cancer Genome Atlas Lung Adenocarcinoma (TCGA-LUAD) dataset. Using whole exon sequencing data (n = 97), we examined whether tumor necrosis correlates with single nucleotide variants (SNVs) and driver mutations.

RESULTS

Eighty four (16%) cases of the study cohort had tumor necrosis. The presence of necrosis significantly correlated with poorer prognosis (5-year overall survival: 91.9% vs. 75.4%, p < 0.001; 5-year recurrence-free survival: 86.0% vs. 59.0%, p < 0.001); however, the ratio of necrotic area did not correlate with prognosis. In multivariable analysis, invasive component size, vascular invasion, and tumor necrosis were independently associated with a higher risk of recurrence (hazard ratio, 1.652; 95% confidence interval, 1.033-2.641; p = 0.036). Gene expression analysis of TCGA stage I lung adenocarcinoma revealed enrichment of biological processes, such as cell cycle and response to hypoxia, in cases with necrosis. The cases with tumor necrosis had more SNVs than those without tumor necrosis (p = 0.027), especially in smokers.

CONCLUSION

Stage I lung adenocarcinoma with tumor necrosis has worse prognosis than that without, and has distinctclinicopathological features in terms of gene expression and genetic features.

Comprehensive molecular profiling of pulmonary pleomorphic carcinoma

Information regarding the molecular features of pulmonary pleomorphic carcinoma (PPC) is insufficient. Here, we performed next-generation sequencing to determine the genomic and transcriptomic profiles of PPC. We sequenced the DNAs and RNAs of 78 specimens from 52 patients with PPC. We analyzed 15 PPC cases to identify intratumoral differences in gene alterations, tumor mutation burden (TMB), RNA expression, and PD-L1 expression between epithelial and sarcomatoid components. The genomic alterations of six cases of primary tumors and corresponding metastatic tumors were analyzed. KRAS mutations (27%) were the most common driver mutations, followed by EGFR (8%), and MET (8%) mutations. Epithelial and sarcomatoid components shared activating driver mutations, and there were no significant differences in CD274 expression or TMB between the two components. However, PD-L1 was highly expressed in the sarcomatoid component of several cases compared with the epithelial component. Primary and metastatic tumors shared oncogenic mutations among genes such as KRAS and TP53, and additional alterations including NOTCH4 mutations were specifically identified in the metastatic regions. Our data suggest that therapies targeting activating driver mutations may be effective for patients with PPC and that immune checkpoint inhibitors of PPC may be recommended after careful assessment of PD-L1 expression in each epithelial and sarcomatoid component.

Pleomorphic carcinoma of the lung: Prognostic models of semantic, radiomics and combined features from CT and PET/CT in 85 patients

Introduction

To demonstrate semantic, radiomics, and the combined risk models related to the prognoses of pulmonary pleomorphic carcinomas (PCs).

Methods

We included 85 patients (M:F = 71:14; age, 35–88 [mean, 63 years]) whose imaging features were divided into training (n = 60) and test (n = 25) sets. Nineteen semantic and 142 radiomics features related to tumors were computed. Semantic risk score (SRS) model was built using the Cox-least absolute shrinkage and selection operator (LASSO) approach. Radiomics risk score (RRS) from CT and PET features and combined risk score (CRS) adopting both semantic and radiomics features were also constructed. Risk groups were stratified by the median of the risk scores of the training set. Survival analysis was conducted with the Kaplan-Meier plots.

Results

Of 85 PCs, adenocarcinoma was the most common epithelial component found in 63 (73 %) tumors. In SRS model, four features were stratified into high- and low-risk groups (HR, 4.119; concordance index ([C-index], 0.664) in the test set. In RRS model, five features helped improve the stratification (HR, 3.716; C-index, 0.591) and in CRS model, three features helped perform the best stratification (HR, 4.795; C-index, 0.617). The two significant features of CRS models were the SUVmax and the histogram feature of energy ([CT Firstorder Energy]).

Conclusion

In PCs of the lungs, the combined model leveraging semantic and radiomics features provides a better prognosis compared to using semantic and radiomics features separately. The high SUVmax of solid portion (CT Firstorder Energy) of tumors is associated with poor prognosis in lung PCs.

Tongue swelling as a manifestation of tongue metastasis from pulmonary sarcomatoid carcinoma: A case report

BACKGROUND

Sarcomatoid carcinoma is a rare subtype of non-small-cell lung cancer, commonly associated with locally advanced disease, early metastasis, and poor prognosis. Tongue metastasis from lung cancer is a rare condition that may occur in advanced stage of the disease.

CASE SUMMARY

The patient was a 70-year-old female with a history of resected pulmonary sarcomatoid carcinoma (PSC) who presented with subacute tongue swelling, imparting the clinical impression of a lingual abscess. However, histologic examination of the partial glossectomy revealed a high-grade, poorly differentiated spindle and epithelioid carcinoma consistent with metastatic PSC.

CONCLUSION

Although uncommon, clinicians should be cognizant of the possibility of a metastatic process to the tongue mimicking a benign or inflammatory process. A high index of suspicion for metastatic disease should be maintained when tongue swelling is observed in patients with a known history of PSC.

Utility of Immunohistochemistry for MUC4 and GATA3 to Aid in the Distinction of Pleural Sarcomatoid Mesothelioma From Pulmonary Sarcomatoid Carcinoma

CONTEXT.—

Distinguishing pulmonary sarcomatoid carcinoma from pleural sarcomatoid mesothelioma is challenging because of overlapping histology, immunophenotype, and clinical features. Reliable immunohistochemical markers to aid in this distinction would be very valuable. Recent studies have proposed that MUC4 expression is common in sarcomatoid carcinoma but not in sarcomatoid mesothelioma, with the converse pattern reported for GATA3.

OBJECTIVE.—

To further explore the utility of MUC4 and GATA3 in distinguishing pulmonary sarcomatoid carcinoma from sarcomatoid mesothelioma.

DESIGN.—

Well-characterized cases of sarcomatoid carcinoma (n = 32) and sarcomatoid mesothelioma (n = 64) were included. Diagnoses were confirmed by thoracic pathologists with incorporation of immunophenotype, clinical, and radiographic features. Whole-tissue sections were stained for GATA3 and MUC4.

RESULTS.—

Patients with sarcomatoid carcinoma and sarcomatoid mesothelioma had similar mean age and male predominance. GATA3 was positive in 63 of 64 sarcomatoid mesotheliomas (98%; 42 diffuse, 16 patchy, 5 focal), and 15 of 32 sarcomatoid carcinomas (47%; 3 diffuse, 8 patchy, 4 focal). MUC4 was positive in 2 of 64 sarcomatoid mesotheliomas (3%; 1 patchy, 1 focal), and in 12 of 32 sarcomatoid carcinomas (38%; 5 diffuse, 6 patchy, 1 focal).

CONCLUSIONS.—

Diffuse GATA3 expression favors sarcomatoid mesothelioma over sarcomatoid carcinoma, which rarely shows diffuse expression (sensitivity and specificity of diffuse staining 66% and 94%, respectively). Focal and patchy GATA3 expression is observed in both tumor types, and therefore is not helpful in this distinction. Sensitivity of MUC4 for sarcomatoid carcinoma was low in our cohort, positive in only 38% with frequent patchy staining, but it was quite specific.

Combination of Pembrolizumab With Platinum-containing Chemotherapy for Pleomorphic Carcinoma of the Lung

BACKGROUND/AIM

Pleomorphic carcinoma of the lung is a rare, highly malignant subtype of lung cancer, with a more aggressive clinical course compared with other types of non-small-cell lung cancer (NSCLC). Platinum-containing chemotherapy has been the standard therapy for patients with NSCLC and pembrolizumab is one of the novel and reliable agents for these patients.

CASE REPORT

We herein report the case of a 60-year-old man with advanced chemo-naïve pleomorphic carcinoma of the lung who was successfully treated with a combination of pembrolizumab with platinum-containing chemotherapy.

CONCLUSION

In the absence of definitive clinical trials, which are unlikely to be performed due to the rarity of this tumor, our case demonstrates the potential utility of the combination of pembrolizumab with platinum-containing chemotherapy. Our result also suggest that this combination of therapy may be key to the treatment of pleomorphic carcinoma of the lung.

Prognostic impact of the tumor immune microenvironment in pulmonary pleomorphic carcinoma

INTRODUCTION

Pulmonary pleomorphic carcinoma (PC) is a rare non-small cell lung carcinoma (NSCLC) and is characterized by sarcomatoid and NSCLC components. This study aimed to characterize the association between immune microenvironmental factors and clinicopathological characteristics of PC.

METHODS

Eighty consecutive PC patients who had undergone complete surgical resection were enrolled. We calculated the immunohistochemical staining scores for E-cadherin, vimentin, programmed death ligand 1 (PD-L1), and carbonic anhydrase IX in cancer cells and counted the numbers of CD204-positive tumor-associated macrophages (TAMs) and Foxp3-, CD8-, and CD20-positive tumor-infiltrating lymphocytes (TILs). We also examined the association between these scores and the prognostic outcomes.

RESULTS

The staining score for PD-L1 in cancer cells and the number of CD204-positive TAMs in the sarcomatoid component were significantly higher than those in the NSCLC component; E-cadherin score in the sarcomatoid component was significantly lower. Patients with high PD-L1 expression in the NSCLC component had significantly longer overall survival (OS) and recurrence-free survival (RFS) than those with low PD-L1 expression in the NSCLC component (OS: p = 0.001, RFS: p = 0.038). Multivariate analysis revealed that high PD-L1 expression in the NSCLC component was an independent favorable prognostic factor for OS (p = 0.018), whereas high PD-L1 expression in the sarcomatoid component was not. The number of CD8-positive TILs was significantly higher in the high PD-L1 expression group than in the low expression group (NSCLC components: p < 0.001).

CONCLUSION

High PD-L1 expression in the NSCLC component may be associated with a favorable prognostic value in pulmonary PC.

A predictive model for identifying candidates for adjuvant chemotherapy based on recurrence risk profile of resected, node-negative (N0) non-small cell lung cancer

Background

The decision for administering adjuvant chemotherapy (AC) in completely resected node-negative non-small cell lung cancer (NSCLC) is guided by likelihood of disease recurrence or death based on tumor, node, metastasis (TNM) stage. However, within each TNM stage are sub-groups of patients that are more or less likely to relapse than stage alone predicts.

Methods

In this retrospective cohort study, prospective data from 394 consecutive patients who underwent complete resection of node-negative NSCLC without adjuvant therapies, between 2002 and 2019 was retrospectively analyzed. Independent tumor and host risk factors for recurrence were subjected to multivariate analysis to develop a predictive risk model distributing patients into low-risk or high-risk categories.

Results

Recurrence risk was independently predicted by a neutrophil:lymphocyte ratio (NLR) of ≥3.5 [hazard ratio (HR), 1.9; 95% confidence interval (CI), 1.1–3.5], visceral pleural invasion (HR, 2.2; 95% CI, 1.3–3.8), histopathology other than adenocarcinoma or squamous cell (HR, 2.6; 95% CI, 1.2–5.5) and tumor size >33 mm (HR, 3.9; 95% CI, 2.3–6.7). The specific combination of risk factors contributed to a score for a risk model which classified 9% of Stage I and 69% of Stage ≥II patients as high-risk. The predicted 5-year disease-free survival (DFS) for high-risk and low-risk patients as scored by the predictive model was 30% and 85%, respectively.

Conclusions

Our readily reproducible, low-technology model, developed from individually validated tumor/host risk factors, identified sub-groups of resected node-negative NSCLC patients at significantly discordant risk of recurrence to their TNM stage category.

Phase II study of durvalumab and tremelimumab in pulmonary sarcomatoid carcinoma: KCSG-LU16-07

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is rare with a poor outcome and is resistant to conventional cytotoxic chemotherapy. The efficacy and safety of durvalumab and tremelimumab for treating recurrent or metastatic PSCs were assessed by a nonrandomized, open-label, phase II study.

METHODS

A total of 18 patients with recurrent or metastatic PSC received 1500 mg of durvalumab and 75 mg of tremelimumab every four weeks, followed by 750 mg of durvalumab every two weeks until the disease progressed, or an unacceptable toxicity level was reached. The primary endpoint was the objective response rate (ORR). The secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity. Genomic profiling of PSC by next-generation sequencing (NGS) and determination of peripheral blood lymphocyte subsets using flow cytometry were performed for exploratory analysis.

RESULTS

A total of 15 out of 18 patients were evaluated for the analysis of the primary endpoint. At the data cutoff point, the ORR of 26.7% (95% confidence interval [CI]: 7.8-55.1) was achieved with the median follow-up duration of 12.0 months (range, 8.4-16.1). Median PFS and OS were 5.9 months (95% CI: 1.1-11.9) and 15.4 months (95% CI: 11.1-not reached), respectively. Treatment-related adverse events (AEs) of any grade were reported in 16 patients; the most common AEs were pruritus (n = 5), pneumonitis (n = 4), and rash (n = 4). Treatment was discontinued in two patients due to AEs of grade ≥ 3.

CONCLUSIONS

Durvalumab and tremelimumab demonstrated clinical benefit with a prolonged survival and manageable toxicity profile in patients with recurrent or metastatic PSC.

Non-small cell lung carcinomas with a minor sarcomatoid component and pleomorphic carcinomas are associated with high expression of programmed death ligand 1

Pleomorphic carcinomas are known to be highly programmed death ligand 1 (PD-L1) positive non-small cell lung cancer (NSCLC) types. However, the level of PD-L1 expression in lung carcinomas with a minor sarcomatoid component, comprising less than 10 % of the tumor mass, has not been determined yet. We hypothesized that NSCLC with a minor sarcomatoid component is more closely related to pleomorphic carcinomas in terms of PD-L1 expression than to NSCLC types without sarcomatoid features. The surgical resections from 690 lung carcinoma patients were retrospectively analyzed for the presence of PD-L1 by means of immunohistochemistry using the 22C3 PharmDx assay. The tumor proportion score system was applied to quantify the level of PD-L1 expression. Membranous staining present in ≥ 1 % of tumor cells was chosen as the cut-off to define a positive result for PD-L1 expression. Tumors were allocated into one of four subgroups: "adenocarcinoma", "squamous cell carcinoma", "pleomorphic carcinoma", or "NSCLC with a minor sarcomatoid component". PD-L1 expression in pleomorphic carcinomas (26/32, 81.3 %) and in the subgroup of NSCLC with a minor sarcomatoid component (35/46, 76.1 %) was identified in a comparable proportion of cases. Pleomorphic carcinomas were significantly more often PD-L1 positive than adenocarcinomas (p < 0.001) or squamous cell carcinomas (p = 0.0015). Accordingly, the proportion of PD-L1 expressing NSCLC with a minor sarcomatoid component was significantly higher than that of the adenocarcinoma (p < 0.001) or squamous cell carcinoma (p = 0.002) subgroup. In summary, we identified a presumable new subgroup of highly PD-L1 positive neoplasms within the NSCLC spectrum that is related to pleomorphic carcinomas in terms of PD-L1 expression. Further investigation regarding genetic relation and mechanism of PD-L1 expression in these two NSCLC categories is recommended.

Pulmonary pleomorphic carcinoma presenting as undifferentiated non-small cell carcinoma with giant cells: A case report and review of literature

Pulmonary pleomorphic carcinoma (PPC) is a poorly differentiated non-small cell lung carcinoma, including squamous cell carcinoma, adenocarcinoma, or undifferentiated non-small cell lung carcinoma with at least 10% spindle and/or giant cells. Here, we report a case of PPC showing undifferentiated non-small cell lung carcinoma with giant cells. A 71-year-old man with dyspnea underwent right lobectomy because of a mass in the right upper lobe of the lung. A 5.0 × 3.0 × 1.5 cm-sized tumor was identified; microscopically, the tumor composed of undifferentiated large sized tumor cells admixed with syncytial tumor giant cells and emperipoletic giant cells. Immunohistochemically, the tumor cells were reactive for pan-cytokeratin, but negative for P40, thyroid transcription factor 1 (TTF-1), and vimentin. The tumor cells were also positive for 3 clones of programmed death-ligand 1 (PD-L1). The clinical and histologic findings supported the diagnosis of an undifferentiated non-small cell lung carcinoma with giant cells, which is a subtype of pulmonary pleomorphic carcinoma. Unfortunately, after surgery, multifocal lymph node metastasis was identified in radiologic examination. Only palliative chemotherapy was administered to the patient, although he was indicated for immunochemotherapy. Pulmonary pleomorphic carcinoma is known to have a poor prognosis, even in early stages of the disease, therefore, we should be careful in the diagnosis to ensure optimal treatment.

Next-Generation Sequencing Analysis Identified Genomic Alterations in Pathological Morphologies of 3 Cases of Pulmonary Carcinosarcoma

Background

Pulmonary carcinosarcomas (PCSs) are a heterogeneous group of non-small-cell lung carcinomas (NSCLCs) with aggressiveness and a poor prognosis. Although genetic mutations of some common lung cancer subtypes have been extensively studied, the molecular characteristics of PCSs and the existence of abnormal target genes are unknown.

Methods

In this study, the clinical and molecular characterization in 3 pulmonary sarcomatoid carcinomas (PSCs) were presented using microscope analysis and next-generation sequencing (NGS) analysis.

Results

The results revealed a carcinosarcomas subtype presenting squamous cell carcinoma and sarcoma components in all 3 cases. NGS analysis showed that 182, 316 and 230 shared mutations were detected between sarcoma and lung carcinoma from 3 patients. Two identical alterations in two genes (CSMD3 and RYR3) that were all shared by the two components in 3 patients. Tumor suppressor gene TP53 (5/6, 83%) showed the highest mutation frequency for driver genes here. Additionally, we focused on an LYST mutation which was mainly present in the sarcoma components. Moreover, the clonal evolution and signature analysis confirm that lung squamous cell carcinoma and sarcoma in each PCS patient may have come from a common ancestor, and mutagenesis was possibly related to indirect effects of tobacco, age or other unknown factors.

Conclusion

Our results indicate that genetic analysis and molecular targeted therapy are necessary for the identification and treatment of these rare lung tumors. CSMD3 and LYST, as common mutation genes, may be a potential therapeutic target in PCS.

Analysis of targeted somatic mutations in pleomorphic carcinoma of the lung using next-generation sequencing technique

BACKGROUND

Pleomorphic carcinoma (PC) of the lung is a rare type of lung cancer with aggressive characteristics and a poor prognosis. Because it is rare, the molecular characteristics of PC remain unclear.

METHODS

A gene mutation analysis was performed using next-generation sequencing (NGS) in patients with PC of the lung who had undergone surgical resection.

RESULTS

A total of nine patients were enrolled in the study. All the patients were male and eight had a history of smoking. Eight tumors contained spindle cells and three contained giant cells. Mutations considered significant were found in eight of the nine patients: in TP53 in five patients, in MET in two patients, and in ALK, ERBB2, PIK3CA, APC, NF1, and CDKN2A in one patient each. No EGFR mutation was detected in our analysis. Co-mutations were detected in three patients: TP53 with MET and NF1, TP53 with ERBB2, and PIK3CA with CDKN2A.

CONCLUSIONS

TP53 mutations were detected most frequently in PC of the lung with NGS analysis. Different co-mutations were seen in several specimens.

KEY POINTS

Significant findings of the study This study demonstrates that mutations in the TP53 gene are frequently found and co-mutations are sometimes found in pleomorphic carcinoma of the lung using genomic profiling analysis. What this study adds Our results will help to analogize the genetic characteristics and potential target of molecular-targeted agents of pleomorphic carcinoma of the lung.

Clinicopathological Analysis of 17 Surgically Resected Pulmonary Pleomorphic Carcinoma Cases

OBJECTIVES

To determine the outcomes and prognostic factors associated with pulmonary resection of pulmonary pleomorphic carcinoma (PPC).

METHODS

During 2008-2017, 17 patients underwent pulmonary resection for primary PPC at the Saitama Cancer Center, Japan. We investigated clinicopathological characteristics and outcomes of these cases. Overall survival (OS) and disease-free survival (DFS) rates were determined using Kaplan-Meier method and compared using log-rank test. Univariate analysis was performed to identify prognostic factors.

RESULTS

The 5-year OS and DFS rates were 27.2% and 51.0%, respectively. The median follow-up period was 30.8±24.9 (3.6-92.8) months after pulmonary resections. Patients with disease-free interval (DFI) <1 year of resection had poorer prognosis than those without (p = 0.001). Patients with N2 status and adenocarcinoma components had significantly poorer disease-free prognosis than their counterparts (p = 0.021 and p = 0.019, respectively). Univariate analysis revealed that DFI <1 year was an unfavorable prognostic factor for OS (p = 0.005); N2 pathological status and presence of adenocarcinoma components were unfavorable prognostic factors for DFS (p = 0.038 and p = 0.036, respectively).

CONCLUSION

PPC patients with an adenocarcinoma component and N2 pathological status may have an earlier relapse and poorer prognosis than their counterparts. Further assessment of cases may help clarify the predictors of PPC.

The role of spread through air spaces (STAS) in lung adenocarcinoma prognosis and therapeutic decision making

Spread through air spaces (STAS) was included as a novel pattern of invasion in lung adenocarcinoma by the World Health Organization in 2015. Since then, multiple studies have investigated the association of STAS with clinicopathological and molecular features and its implication in the prognosis of early stage lung cancer patients undergoing different surgery types. The aim of this comprehensive review is to present current data on the role of STAS and its perspective in lung adenocarcinoma management.

A case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment

Background

Generally, primary pulmonary pleomorphic carcinoma is resistant to treatment and has a poor prognosis. We report a case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment.

Case presentation

A 74-year-old man with a history of emphysema, pneumoconiosis, and chronic bronchitis presented with left lung nodule and left adrenal tumor based on computed tomography. We suspected clinical T1bN0M1b, stage IVB lung cancer. Adrenalectomy of the left adrenal tumor yielded a definitive diagnosis of pleomorphic carcinoma. Chemotherapy was performed despite the spontaneous regression of lung lesions. Since lung lesions re-enlarged 11 months after adrenalectomy, the left lower lobe was partially resected followed by chemotherapy. The lung lesion was the primary lesion of the adrenal tumor. There was no recurrence 100 months after the lung resection.

Conclusions

The patient experienced long-term survival after multidisciplinary treatment. Both multidisciplinary treatment and immunological mechanisms caused spontaneous regression of the primary lesion.

Prognostic factors for sarcomatoid carcinomas of lung: A single-centre experience

Background:

Although lung sarcomatoid carcinomas (LSCa) arised from the epithelial tissue, they have very distinctive features than other non-small cell lung carcinomas in terms of histopathology and survival. It constitutes 0.1%–0.4% of all lung cancers. The aim of our study is to evaluate the survival analysis of LSCa in a single thoracic surgery clinic and to determine the prognostic factors.

Materials and Methods:

It was a retrospective cohort study. After the approval of the local ethics committee, a total of 34 patients who were operated in our department between January 2010 and December 2018, whose pathologies were reported as sarcomatoid carcinoma was included in the study. The patients were analyzed by age, gender, presence of necrosis in the histopathological examination, tumor stage, tumor diameter, and tumor location.

Results:

There were 28 males and 6 females. The median age was 60 years (range: 36–80 years). The median survival was 42 months (32.6–52.2 months), and the 5-year overall survival was 33.6%. Significantly negative prognostic factors were tumor diameter and tumor stage (P = 0.003 and 0.001, respectively). Median disease-free interval (DFI) was 38 months (27.3–49.1 months), and 5-year DFI was 32.6%.

Conclusion:

LSCa are highly heterogeneous epithelial malignancies, and it has worse survival than other epithelial cancers. Relatively, satisfactory results can be obtained in these tumors with surgical treatment.

Approaches to Tumor Classification in Pulmonary Sarcomatoid Carcinoma

Pulmonary sarcomatoid carcinoma (PSC) is a heterogeneous category of primary lung cancer accounting from 0.3% to 3% of all primary lung malignancies. According to the most recent 2015 World Health Organization (WHO) classification, PSC includes several different variants of malignant epithelial tumors (carcinomas) histologically mimicking sarcomas showing or entirely lacking a conventional component of non-small cell lung cancer (NSCLC). Thus, this rare subheading of lung neoplasms includes pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, pulmonary blastoma, and carcinosarcoma. A diagnosis of PSC may be suspected on small biopsy or cytology, but commonly requires a surgical resection to reach a conclusive definition. The majority of patients with PSC consists of elderly, smoking men with a large, peripheral mass characterized by well-defined margins. However, presentation with a central, polypoid endobronchial lesion is well-documented, particularly in pleomorphic carcinoma and carcinosarcoma showing a squamous cell carcinoma component. As expected, PSC may pose diagnostic problems and immunohistochemistry is largely used when pathologists deal these tumors in routine practice. Indeed, PSC tends to overexpress molecules associated with the epithelial-to-mesenchymal transition, such as vimentin, but the panel of immunostains also includes epithelial markers (cytokeratins, EMA), TTF-1, p40 and negative markers (e.g., melanocytic, mesothelial and sarcoma-related primary antibodies). Although rare, PSC has increased their interest among oncologist community for different reasons: a. identification of the epithelial-to-mesenchymal phenomenon as a major mechanism of secondary resistance to tyrosine kinase inhibitors; b. over-expression of PD-L1 and effective treatment with immunotherapy; c. identification of c-MET exon 14 skipping mutation representing an effective target to crizotinib and other specific inhibitors. In this review, the feasibility of the diagnosis of PSC, its differential diagnosis and novel molecular findings characterizing this group of lung tumor are discussed.

Uncommon Types of Lung Carcinoma With Mixed Histology: Sarcomatoid Carcinoma, Adenosquamous Carcinoma, and Mucoepidermoid Carcinoma

CONTEXT

- Lung tumors are histologically heterogeneous, but classification of lung carcinoma has prognostic impact and increasingly, specific molecular correlates.

OBJECTIVE

- To update the gross, microscopic, and molecular pathology of unusual lung carcinomas to assure accurate classification. In entities with mixed histology, the recognition of specific features or rare patterns is critical to diagnosis. These diagnoses can identify tumors with aggressive clinical behavior, and diagnostic pitfalls can therefore result in underdiagnosis of these already rare entities. Incorrect classification of more indolent tumors into the more aggressive categories can also occur. In the area of molecular pathology, these unusual tumors have a specific spectrum of molecular alterations.

DATA SOURCES

- PubMed searches for lung and sarcomatoid carcinoma, pleomorphic carcinoma, blastoma, carcinosarcoma, and adenosquamous and mucoepidermoid carcinoma were undertaken and this information was integrated with clinical experience of the author.

CONCLUSIONS

- These uncommon carcinomas have specific clinicopathologic features, and attention to their gross and microscopic pathology leads to classification with important associated molecular findings.

Single pembrolizumab treatment causing profound durable response in a patient with pulmonary pleomorphic carcinoma

We report a case of a 73-year-old man diagnosed with pulmonary pleomorphic carcinoma who showed profound durable response after a single treatment with pembrolizumab. The patient underwent a diagnostic workup in our hospital due to a hoarseness of voice. Chest computed tomography revealed a massive pulmonary tumor in the left upper lobe and multiple nodules in the both lung fields. Histological examination of a transbronchial lung biopsy specimen revealed pulmonary pleomorphic carcinoma. First-line treatment with pembrolizumab was discontinued after a single administration due to treatment-related pneumonitis. However, durable response has been observed over 17 months to date.

Pulmonary Spindle Cell Carcinoma: A Rare Case Report

Spindle cell carcinoma is a rare pulmonary malignancy. The prognosis and treatments are unclear, with limited literature available. Here, we report a man who underwent bronchoscopy with an endobronchial biopsy after complaining of dyspnea on exertion. Computed tomography (CT) chest showed a 10 x 3 cm mass in the right upper lobe. Biopsy revealed spindle cell carcinoma, and he was referred to hematology for chemotherapy. He was lost to follow-up recently.

Perioperative chemotherapy is not associated with improved survival in stage I pleomorphic lung cancer

OBJECTIVES

Pulmonary pleomorphic carcinoma represents an understudied, rare, and aggressive histologic subtype of non-small cell lung cancer. Better understanding of rare disease subtypes allows for improved individualization of patient care. This study aimed to evaluate current trends in treatment and survival of pleomorphic carcinoma.

METHODS

The National Cancer Database was used to identify patients with staged, pleomorphic carcinoma and adenocarcinoma between 2004 and 2015. Patient characteristics and treatments were compared using χ² tests. Cox proportional hazard models examined survival by stage after controlling for confounders. Propensity score matched Kaplan-Meier curves estimated survivor functions stratified by stage. Differences in survival following treatment for stage I pleomorphic carcinoma with surgery alone versus surgery plus chemotherapy were compared with Cox proportional hazard models and Kaplan-Meier survival curves.

RESULTS

One thousand four hundred eight patients with pleomorphic carcinoma and 607,561 patients with adenocarcinoma were identified. Pleomorphic carcinoma accounted for 0.1% of all non-small cell lung cancers. Pleomorphic disease had poorer overall 5-year survival compared with adenocarcinoma for stages I through IV (49.4% vs 59.1%, 34.5% vs 43.8%, 16.9% vs 28.4%, and 5.7% vs 7.8%, respectively; P < .0047 for all). Perioperative chemotherapy was used more frequently for pleomorphic disease (17.5% vs 6.1%; P < .001). For stage I pleomorphic cancer, treatment with surgery alone (n = 253) and surgery with chemotherapy (n = 57) had overall 5-year survival rates of 55.2% and 53.7%, respectively, and were not significantly different (P = .2868).

CONCLUSIONS

Pulmonary pleomorphic carcinoma is rare and aggressive, with worse survival when compared with adenocarcinoma. Perioperative chemotherapy has not demonstrated significant survival benefits in stage I pleomorphic cancer.

Dramatic response to nivolumab after local radiotherapy in pulmonary pleomorphic carcinoma with rapid progressive post-surgical recurrence

Pulmonary pleomorphic carcinoma (PPC) is resistant to anticancer drug treatment, outcomes are poor, and no standard therapy has been established. High PD‐L1 expression has been found in PPCs, suggesting the possible efficacy of an immune checkpoint inhibitor (ICI) in cancer immunotherapy; however, this approach requires further investigation through case accumulation. Herein, we report a case of rapid recurrence and progression of PPC early after surgery in a 70‐year‐old male ex‐smoker. Surgery was performed for lung cancer of the right lower lobe, and a pathological examination indicated primary PPC with high PD‐L1 expression (tumor proportion score: 90%). Because systemic metastasis recurred only six weeks after surgery, nivolumab was administered as second‐line treatment. Marked tumor regression was observed on imaging after three cycles, revealing a near complete response. Palliative radiotherapy was applied to the bone metastasis region for pain relief before nivolumab was administered. This case suggests that an ICI can have an effect on PPC and that the efficacy of ICIs may be enhanced by radiotherapy‐induced abscopal effects.

An Epithelial-to-Mesenchymal Transcriptional Switch Triggers Evolution of Pulmonary Sarcomatoid Carcinoma (PSC) and Identifies Dasatinib as New Therapeutic Option

PURPOSE

Pulmonary sarcomatoid carcinoma (PSC) is a rare and aggressive form of NSCLC. Rarity and poor characterization have limited the development of PSC-tailored treatment protocols, leaving patients with inadequate therapeutic options. In this study, we investigated the gene expression profile of PSCs, with the aim to characterize the molecular mechanisms responsible for their evolution and to identify new drugs for their treatment.

EXPERIMENTAL DESIGN

A training set of 17 biphasic PSCs was selected and tested for the expression of a large panel of 770 genes related to cancer progression using NanoString technology. Computational analyses were used to characterize a PSCs-gene specific signature from which pathways and drivers of PSC evolution were identified and validated using functional assays in vitro. This signature was validated in a separate set of 15 PSCs and 8 differentiated NSCLC and used to interrogate the cMAP database searching for FDA-approved small molecules able to counteract PSC phenotype.

RESULTS

We demonstrated that the transcriptional activation of an epithelial mesenchymal transition (EMT) program drives PSC phylogeny in vivo. We showed that loss of the epithelial-associated transcription factor (TF) OVOL2 characterizes the transition to sarcomatoid phenotype triggering the expression of EMT promoting TFs, including TWIST and ZEB and the expression of the membrane kinase DDR2. Finally, using a drug repurposing approach, we identified dasatinib as potential inhibitor of the PSC-gene expression signature and we confirmed in vitro that this drug efficiently restrains proliferation and reverts the sarcomatoid-associated phenotype.

CONCLUSIONS

Our data provide new insights into PSC evolution and provide the rationale for further clinical studies with dasatinib.

Effective combined therapy with ramucirumab for advanced pulmonary pleomorphic carcinoma

Pulmonary pleomorphic carcinoma (PPC) is a rare disease with a poor prognosis. Most patients with PPC are refractory to chemotherapy, whereas good responses to platinum-based chemotherapy in combination with the anti-angiogenesis agent bevacizumab have been reported. An 82-year-old man was diagnosed with PPC with a clinical stage of T3N0M0, coincident with primary lung adenocarcinoma in an early stage. We chose single-agent chemotherapy with docetaxel as an initial treatment, but both the primary adenocarcinoma and two PPC lesions in the right lung were enlarged after one treatment cycle. We subsequently started treatment with ramucirumab and docetaxel, and thereafter, the disease showed a good partial response. Here, we report the first case of advanced PPC that was effectively treated with chemotherapy and the anti-VEGFR-2 antibody ramucirumab. These observations suggest a potential therapeutic strategy for patients with PPC.

Pulmonary Sarcomatoid Carcinomas: A Review

Pulmonary sarcomatoid carcinomas belong to a group of neoplasms that remain incompletely understood. They are rare tumors of the bronchopulmonary system that incorporate a wide range of neoplasms that by definition contain a sarcomatoid component characterized by spindle or giant cells. Such classification has led to a heterogenous tumor category that includes neoplasms with different clinical, morphologic, and prognostic features. To date, the histopathologic diagnosis of pulmonary sarcomatoid carcinomas does not require the use of ancillary testing and is based on light microscopic criteria alone. However, with recent advances in immunohistochemical and molecular methods, it is becoming increasingly clear that pulmonary sarcomatoid carcinomas represent poorly differentiated or "dedifferentiated" variants of conventional non-small cell carcinomas with similar immunophenotype and molecular signatures. This review summarizes the latest insights and concepts of these unusual tumors and outlines future directions with emphasis on tumor classification and patient management.